Exploring concepts considered central to the effectiveness of group therapy in mental health care

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Exploring Concepts Considered Central to the Effectiveness of Group Therapy in Mental Health

Trina Skinner

Stenberg College

Working in Groups

PSYN 203-3 A

Debbie McCreedy

August 26, 2013


The following paper will serve as an introduction to four critical concepts central to the effective group therapy model. Each of the following concepts will be addressed in this paper. First, the concept of group cohesiveness will be explored. Second, this paper will offer a detailed discussion of therapeutic factors that contribute to the effectiveness of group work. Finally, the analysis of the stages of group development will be examined.

Exploring Concepts Considered Central to the Effectiveness of Group Therapy in Mental Health

This paper will attempt to provide a comprehensive analysis of some of the major concepts, theories, and practice where group therapy in mental health care is concerned. There are a vast number of variables that coincide in order to establish an effective therapeutic group setting. This paper will focus on three of the main precipitating factors as they apply to ensuring successful interaction within the group therapy model; ranging from the formative stages to the termination phase of the group. First, the theory of group cohesiveness will be explored. Second, an in-depth look at the therapeutic factors that influence group therapy effectiveness will be addressed. Finally, various stages of group development will be defined and elaborated on. In summary the essay to follow will provide a detailed concept analysis of the four elements of the group therapy model listed above.

Group cohesiveness is defined by Yalom & Leszcz (2005), as “the group therapy analogue to relationship in individual therapy” (p. 53). Similarly, an alternate resource explains that in considering the major reviews of cohesion introduced over a 30 year span, the general consensus indicates that a cohesive group environment is considered the "analogue of the good therapist-client relationship" (Braten, 1991, p. 39). The complex nature of group cohesiveness requires that specific preemptive conditions be considered where the therapeutic process of group cohesion is concerned (Skinner, 2013). Some of these significant preconditions are identified by (Braaten, 1991, p. 39) as: selection of suitable participants; a balanced group composition; and level of effectiveness related to orientation and training (p. 39).

Research on group cohesion is somewhat ironic in that the concept of cohesiveness has been extensively investigated in hundreds of research articles, however, it is noted that very little cohesion exists within the literature itself. This is likely due to the broad range of definitions, means of measurement, subjects, and diversified perspective (Yalom & Leszcz, 1991, p. 54-55).

Regardless of the difficulties in identifying a unified, global measure of cohesion and what the idealic picture of group cohesiveness looks like, it seems to be agreeable among most researchers in this field that the phenomenon plays a critical role in determining the strength , ability, and ultimately effectiveness of a group therapy program. Cohesiveness has been identified as “the total field of forces which act on members to remain in the group” (Gross & Martin, 1952, p. 555).

Some of these forces include level of appeal or affliction of one group member towards another and the variance of behavior and activities that are permitted within the group environment. Frank (1997) asserts that ‘mutual liking’ is also indicated as a strong source of increased group cohesion, however in contrast, he also explains that it is not necessary for group members to like one another in order to achieve cohesiveness (p. 66). “Individuals may have a strong sense of belonging to groups in the face of considerable mutual antagonism” (Frank, 1997, p. 66). Compare to the typical family unit for example; there are bound to be issues driven by envy, rivalry or competiveness amongst members, as well as other negative feelings, yet the familial unit generally remains intact (Frank, 1997. p. 66). In considering mentally ill participants in group therapy Frank (1997), explains that the patient who is mentally ill is “characteristically contemptuous of themselves and therefore each other” (p. 66). Frank attributes this manifestation of contempt in mentally ill patients to underdeveloped level of cognitive function resulting in self-centeredness and lack of genuine concern for their peers and fear of interaction with strangers as a residual effect of past traumas (Frank, 1997, p. 66).

All in all it remains to be seen that the concept of group cohesion continues to function within the realm of obscure and questionable guidelines based on the available research.

Secondly, an overview of the conceptual framework ‘therapeutic factors’ is presented. Yalom & Leszcz (1991), described therapeutic factors as the vehicle to promote therapeutic change by means of a complicated process “that occurs through an intricate interplay of human experiences” (p. 1). In this section the reader will be exposed to three contrasting accounts of what constitutes ‘therapeutic factors’ in group work. Yalom & Leszcz (1991), Lese & Macnair-Semends (1997), and Stuart & LaSalle (2009), each offer their personal accounts of which factors are considered fundamental to the successful group therapy process. Yalom & Leszcz (1991) base their views on a division of therapeutic experience into eleven core factors. These include: “Instillation of hope, universality, imparting information, altruism, the corrective recapitulation of the primary family group, development of socializing techniques, imitative behavior, interpersonal learning, group cohesiveness, catharsis, and existential factors” (p. 1-2).

In contrast, Stuart & LaSalle (2009) deliver a more concise list of primary factors promoting therapeutic change. In terms of an overall view of group therapy, Stuart & LaSalle (2009), assure that the group must share a distinct purpose within their own unique structure and identity. Each member, including the leader, contribute to the overall shared group purpose and these contributions are considered both oriented in ‘content and process’ (p. 594). Content refers to the sharing of personal experience amongst group members with the intention of supporting one another; whereas process functions to permit individualized feedback from other members of the group (including the leader), as to how each participant is perceived through interactions with their peers (Stuart & LaSalle, 2009, p. 594).

In terms of small groups, Stuart & LaSalle (2009), identify a more comprehensive list of eight essential components (factors) as per their viewpoint. These include: “structure, size, length of sessions, communication, roles, power, norms, and cohesion” (p. 595).

Further, Lese & MacNair-Semands (1997), challenge Yalom’s earlier work in this domain stating that although Yalom’s (1995) framework regarding ‘therapeutic factors’ determining outcome in group therapy has been accepted by psychologists who specialize in group work, no empirically based instrument that has the ability to assess all of Yalom’s proposed therapeutic factors in a singular measure currently exist (n.p.). Thus, the Therapeutic Factors Inventory (TFI) was established to produce a measure that was comprehensive while empirically-based as a method of assessment for ‘therapeutic factors’ in a specified group (n.p.). TFI scales were set to correspond with Yalom’s eleven therapeutic factors . In order to design the TFI, a context was developed as a result of literature reviews pertaining to Yalom’s work. Each of the factors were defined based on his theory work and subsequently numerous items generated (Lese & MacNair-Semands, 1997, n.p.). Lese & MacNair-Semands (1997). recruited seventy-seven participants, of which roughly half attended five-eight group therapy sessions and the other eight or more. Measurement was then initiated based on the TFI scales. Results reflected that items measured suggested ‘strong internal consistency’, indicating reliable measurements of therapeutic principles in this design, as well as those defined by Yalom. That being said, the majority of Yalom’s eleven factors correlated strongly with one another which could in turn suggest errors in measurement or inclusive factors (n.p.). In conclusion, Lese & Macnair-Semands (1997) suggest that based on the “systematic scrutiny Yalom's theory has undergone, that the intercorrelation of therapeutic factors may not imply that the concepts are meaningless, but that they are meaningless in isolation”.(n.p.).

Our final concept analysis of this paper is based on the various stages of group development. Group therapy, like individual therapy, facilitates growth and development. In contrast groups also possess the ability to cease in effectiveness and progression. According to Stuart & LaSalle (2010), every group is formed and developed by a selection of three interpersonal stages: “inclusion, control, and affection” (p. 597). Stuart & Lasalle (2010), also offer a comprehensive comparison and contrast between both Yalom’s and Tuckman’s framework of developmental group phases. Tuckman’s model is based on four phases of group work, forming, storming, norming, & performing. Yalom’s model of group developmental stages consists of orientiation, conflict, cohesive, and the working phase. The model of stages in group therapy exemplified by Stuart & Lasalle (2010) follows a format that consists of the pre-group phase, the initial phase, the working phase, and finally, the termination phase (p. 598). The description of each group phase and the tasks and interpersonal activity that correlate with each phase itself, is most accurately defined by Stuart & Lasalle (2010), as the authors draw parallels between the stages of group therapy regardless of what model we are analyzing. In the pre-group phase it is essential that a set of goals to be achieved in group therapy is constructed. The approach that the group leader takes is strongly fuelled by the purpose identified by the group itself. The selection of members, location and question of whether or not the group will be open or closed to new members once the group has been established, all these pre-group tasks and tactics are of great significance, as if a group starts out in a hazy and undirected, ill managed way, the therapeutic value for participants will likely be compromised. The initial phase is all about preparing the participant for group work. In this phase Yalom (2005), further divides it into three specific phases: orientation, conflict, and cohesive. It is noted that Yalom’s three phases highly correspond to Tuckman’s first three stages in developing a group: forming, storming, & norming. The orientation phase proposed by Yalom functions similar to Tuckman’s formative stage. The task associated with this stage is “to identify and boundaries regarding it” (Stuart &LaSalle, 2010, p. 598). The interpersonal activity that occurs within this stage includes relationship testing, the definition of ‘interpersonal boundaries’ is made clear. This initial phase tends to form a dependent relationship with the leader, other members, or pre-established standards. It is at this point early on in group work that the leader generate a sense of cohesion amongst group members (Stuart & LaSalle , 2005, p. 598). The next stage to follow consists of Yalom’s ‘conflict’ and Tuckman’s ‘storming’ phase. At this stage of initial development group members may become resistive to group work and influence by peers. The task identified for this phase is to assist members to become emotionally responsive to the task at hand. Not surprisingly, the interpersonal activity at this stage is internal group conflict (Stuart & LaSalle, 2005, p. 598). Onto the what Yalom has identified as the cohesive phase, deemed the norming phase in Tuckman’s model. During this phase of group work members resistance is headed and the task activity urges members to express their personal opinions concerning the task at had. Interpersonal activity at this stage consists of members taking on new roles, creating standards based on new group feelings; and arguably most important, group cohesiveness is established (Stuart & LaSalle, 2005, p. 598). Finally the working (Yalom) and performing stage (Tuckman) are addressed, It is at this stage when critical thinking and problem solving become active and members start looking towards the solution in the perceived problem. The expectation as far is that members will direct their cohesive energy towards completing the task undertaken by the group. In terms of interpersonal activity, interpersonal infrastructure of the group transforms into a tool in order to promote achievement of the identified task; it is at this point group roles increase in terms of flexibility and functionality (Stuart & LaSalle, 2005, p. 98).

In conclusion, the formative process of group therapy in mental health is one that is extremely complex and remains in a constant state of revolution. Although most psychologists that specialize in group work have a formative guideline established in which the progress and direction of the group can be measured and modified; the fact remains that a therapy group of any nature is established through interpersonal interaction amongst individuals and the unique personality traits and characteristics that each brings to the proverbial table. This paper provided a snapshot of three concepts critical to the group therapy model. Group cohesiveness, therapeutic factors in groups, and the various stages of group development have been subject to a brief conceptual analysis. The purpose of this paper is to educate the reader on a few of the concepts central to group work, this list is by no means exhaustive and hopefully inspires the reader to pursue further knowledge and experience on the dynamics of group therapy.



Braaten, L. (1991). Group cohesion: A new multidimensional model. Eastern Group

Psychotherapy Society. 15(1). 39-55. Retrieved from


Frank, J.D. (1997). Some determinants, manifestations, and effects of cohesiveness in therapy groups. Journal of Psychotherapy Practice and Research. 6(1). 63-70. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3330442/?tool=pmcentrez&rendertype=a bstract

Gross, N. & Martin, W. (1952). On group cohesiveness. American Journal of Sociology.

57(6).546-564. Retrieved from


Lese, K.P & MacNair-Semands, R. (1997). The Therapeutic Factors Inventory: Development of

a Scale. Education Resources Information Center (ERIC). Retrieved from


Stuart, G, LaSalle, P., & LaSalle, A. (2009). Recovery and psychiatric rehabilitation. In G. W.

Stuart, Principles and practice of psychiatric nursing (9th ed. (pp. 199-216). St. Louis, MO: Mosby Elsevier.

Yalom, I. D. & Leszcz, M. (2005). The Theory and Practice of Group Psychotherapy (5th Ed.).

New York,  NY: Basic Books 


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