Burlingame, G. M., McClendon, D. T., & Yang, C. (2018). Cohesion in group therapy: A meta-analysis. Psychotherapy, 55, 384-398.
Many writers consider group cohesion to be one of the most important concepts in group psychotherapy and that is a pre-requisite for positive patient outcomes. That is, patients in a group must feel a bond with the group and its members, must value the relationships in the group, and must see the group experience as a vehicle by which to achieve the change that they want. As Burlingame once noted, over time cohesion has become synonymous with the therapeutic relationship in group therapy. Although an important concept, cohesion has been elusive to define partly because of the complexity of group therapy itself. From the patient’s point of view, relationships in group therapy can take on three structural aspects in the form of member to member, member to group, and member to leader interactions. And so, cohesion may refer to the quality of the member’s relationship: to other members, to the group as a whole, and/or to the group leader. By “quality of group relationships”, clinicians and researchers often mean the positive affective bond (warmth, empathy, attraction, compatibility, trust) and working relationship (consensus on tasks and goals, willingness to work) that members have with other members, the group as a whole, and/or the group leaders. In this meta-analysis, Burlingame and colleagues identified 55 group therapy studies including over 6,000 patients that investigated the cohesion – outcome relationship. The average correlation of cohesion to patient outcomes in the 55 studies was statistically significant, r = .26 (95% CI [.20, .31], p = .01), suggesting a moderate effect. Leaders who had an interpersonal orientation had the highest cohesion – outcome relationship (r = .48), although leaders of other theoretical orientations also posted statistically significant but lower values. A greater group process orientation (r = .36), emphasizing greater interactions among group members (r = .36), composing groups of members with similar diagnoses or problems (r = .23), and groups lasting more than 20 sessions (r = .41) also each produced significantly higher cohesion – outcome correlations.
The group cohesion – outcome relationship is highly reliable and suggests that clinicians of all theoretical orientations should routinely assess and enhance group cohesion to improve patient outcomes. Ways of increasing cohesion include emphasizing member to member interactions in a group, and discussing group processes as they occur. These processes may be related to members interacting with other members, with the group as a whole, or with the leader. In particular, group therapists should promote a positive emotional climate by handling conflict and avoidance when it arises in the group. This takes particular skills, training, and knowledge in group therapy processes, and so it is important for therapists to be aware of current practice guidelines for group therapy.
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