Behaviour Research and Therapy Essay

AbstractCognitive-behavior therapy (CBT) for kind phobic neurosis is effective in twain loose radical and various(prenominal) dos. However, the impact of sort out processes on discourse efcacy remains comparatively unexplored. In this study we experimentd host gumminess ratings made by individuals at the center field and abrogatepoint of CBT impacts for mixer phobic neurosis. Symptom cards were withal perfect at the beginning and end of manipulation. We tack together that cohesiveness ratings signi hobotly cast upd everyplace the course of the class and were associated with good severally(prenominal) everyplace prison term in affable dread emblems, as substantially as improvement on measures of general perplexity, drop-off, and functional impairment. In conclusion, ndings are consistent with the idea that reassigns in free radical coherency are relate to amicable misgiving symptom littleening and, therefore, speak to the importance of non specic remedy factors in handling out arise. r 2006 Elsevier Ltd. entirely rights reserved. Keywords fond phobic neurosis Social disturbance derange sort cohesiveness Cognitive-behavior therapy trigger Social phobic neurosis is characterized by an extravagant fear of genial or action situations, during which a person may be scrutinized, judged, embarrassed, or humiliated by some others. Evidence- base psycho hearty words for affectionate phobia get primarily come from a cognitive-behavioral orientation and entangle various(a) combinations of four main comp hotshotnts (1) characterisation-based strategies, (2) cognitive therapy, (3) friendly sk lightheadeds training, and (4) use relaxation (for reviews, see  administered in either individual and congregation formats (e.g., Heimberg, Salzman, Holt, & angstrom unit Blendell, 1993 Turner, Beidel, Cooley, Woody, & adenylic acid Messer, 1994). However, the mechanisms of spay, and effective ingredients of these handlings remain comparatively understudied. Researchers hold back compared root word and individual sermons for this condition, although evidence regarding the relative effectiveness of each greet has been inconsistent (see Scholing & vitamin A Emmelk adenine, 1993 Stangier, Heidenreich, Peitz, Lauterbach, & Clark, 2003 Wlazlo, Schroeder-Hartwig, Hand, Kaiser, & Munchau, 1990 for direct comparisons of individual and convention cognitive-behavioral interference for kind phobia). However, for virtually patients, crowd discourse may offer a sub collectable of advantold ages over individual interference.For example, collection discourse provides an opport angiotensin-converting enzyme to marshal merging processes (e.g., encouragement, reinforcer, and framework from other meeting portions) that may assist in teaching cognitive strategies and facilitating exposure exercises. Further, there may be nonspecic effects that arise as a result of the descents that form amongst assembly processs that may contri furthere to remediation government issue. We decided to check into how these meeting processes, particularly root cohesiveness, may be relate to handling aftermath in cognitive-behavior therapy (CBT) radicals for brotherly phobia. Within the assemblage therapy literature, iodine putative mechanism of change is that of free radical cohesion (Yalom, 1995). However, the construct of sort out cohesion has deed ready operating(a) denition, especially with more technique-driven interventions like CBT. For example, a broad denition proposed to explain mathematical root word cohesion is the resultant of all forces acting on all the genus Phalluss to remain in the classify (Cartwright & Zander, 1962, p. 74) or, in simpler terms, how attractive a convocation is for the members who are in it (Frank, 1957).Yalom (1995) conceptualizes group cohesion as the we-ness that is felt amongst the group members. Groups with higher lev els of cohesion are pre sum of moneyed to soak up a higher rate of attendance, participation, and unwashed support, and to be likely to defend group standards untold more. Further, Yalom (1995) believes that group cohesion is incumbent for other group therapeutic factors to operate. Researchers analyze this construct take also take on concepts such as a perceive of bonding, a adept of working towards unwashed goals, mutual acceptance, support, identication, and afliation with the group (e.g., Marziali, Munroe-Blum, & McCleary, 1997). intelligibly then, cohesion is purported to be a full of invigoration ingredient for change and therefore would be expected to predict symptomatic outcomes. or so researchers investigating the relationship amongst group cohesion and handling outcome have nominate appointed results.Although some of these studies have investigated other nonspecic therapeutic factors as considerablyhead (i.e., the therapeutic alliance), the set in telligence allow focus on ndings tie in to group cohesion processes. Studies have anchor that group cohesion is related to pre-treatment levels of symptomatic di punctuate, improved self-esteem and reduced symptomatoloty (e.g., Budman et al., 1989). A recent study by Tschuschke and Dies (1994) found that the level of group cohesion in the second half of a long-term psychoanalytic treatment for inpatients was signicantly correlated with treatment outcome and patients who made therapeutic gains describe a high level of group cohesion that began lightly after(prenominal) the rst a few(prenominal) seances. In contrast, unsuccessful patients did not get laid a high level of group cohesion at whatever clipping. Overall, these studies show that group cohesion may vivify a role in facilitating therapeutic change, though negative ndings also outlive (e.g., Gillaspy, Wright, Campbell, Stokes, & Adinoff, 2002 Lorentzen, Sexton, & Hglend, 2004 Marziali et al., 1997).In the CBT literature, researchers are increasingly paying solicitude to nonspecic therapeutic factors contributing to treatment outcome (e.g., Ilardi & Craighead, 1994 Kaufman, Rhode, Seeley, Clarke, & Stice, 2005). unity of the rst studies in this area was conducted by Hand, Lamontagne, and mark (1974) in treatment groups for individuals presenting with agoraphobia. They found that members of the group in which cohesion was specically fostered show greater improvement up to 6 months after treatment as compared to members of a less cohesive group who demonstrated a greater likelihood of relapse (see also Teasdale, Walsh, Lancashire, & Matthews, 1977, for a replication of these effects, albeit with weaker results). new(prenominal) ndings from the CBT treatment literature include greater group cohesion ratings predicting lower animal(prenominal) and psychological abuse at reappraisal in abusive men (Taft, Murphy, King, Musser, & DeDeyn, 2003), higher levels of group cohesio n organism signicantly related to decreased post-treatment systolic and diastolic blood pressure as well as improved post-treatment quality of life in cardiac patients (Andel, Erdman, Karsdorp, Appels, & Trijsburg, 2003). In addition, group cohesion ratings have been found to be associated with improvements on depressive symptoms at treatment midpoint, after controlling for initial depression level (Bieling, Perras, & Siotis, 2003). Overall, these studies advise that group cohesion may play some role in facilitating change or enhancing long-term benets in CBT-based treatments.Although it is not in time clear what factors are relevant for training group cohesion, certain disorders may present more challenges than others. For example, given that hearty phobia involves an intense fear of scrutiny from other people, these individuals may present with barriers to forming a cooperative alliance, such as poor social skills, extreme sensitivity to evaluations, or social avoidance (Woody & Adessky, 2002). Only one study thus far has examined the instruction of group cohesion and its relationship to outcome during a group CBT treatment of social phobia. Woody and Adessky (2002) treated individuals for social phobia in a group format utilize Heimbergs (1991) protocol for group CBT for social phobia and had clients rate group cohesion victimisation the Group spot carapace ( flub Evans & Jarvis, 1986).The turgidness measures the clients head of attractiveness to the group. Measurements were conducted at three points during treatment (sessions 2, 5, and 9) and indicated that group cohesion remained static over time. They also found that the level of group cohesion clients reported was in no way related to outcome. It was suggested that the constructs and measurement of group process in cognitive-behavioral preliminaryes might pauperization to be further rened in order to more fully recognize the degree to which group format and group process inc onstants may add an classical element to therapeutic outcome. It is important to take note that the measure of group cohesion use by Woody and Adessky (2002) denes the construct unidimensionally. The GAS was designed to measure only attraction to group, dened as an individuals appetite to identify with and be an accepted member of the group (Evans & Jarvis, 1986, p. 204). Examples of souvenirs include I want to remain a member of this group, I feel involved in what is happening in my group, and In shock of individual differences, a feeling of unity exists in my group. However, as discussed by Burlingame, Fuhriman, and Johnson (2002), elements of group cohesion may include some(prenominal) intrapersonal elements (e.g., group members sense of belonging and acceptance) as well as intragroup elements (e.g., attractiveness and compatibility felt among the group members).Therefore, by solely focusing on attraction to the group it is possible that the GAS fails to operationalize a spects of cohesion that are important for do therapeutic gains. The present study, therefore, examined the role of cohesion in group CBT for social phobia, using a measure that includes items that ostensibly valuate a number of different constructs persuasion to be related to group cohesion. The Group Cohesion Scale-Revised (GCS-R), developed by Treadwell, Laverture, Kumar, and Veeraraghavan (2001), lights-out into some(prenominal) different aspects of group cohesion including interaction and communication (including domination and subordination), member retention, decision- qualification, vulnerability among group members and consistency between group and individual goals. This self-report questionnaire has been shown to be both(prenominal) reliable and valid for detecting changes in group cohesiveness during the process of group development (Treadwell et al., 2001).Clients with a champion diagnosis of Social Phobia were treated and, based on the preceding literature, we ex plored (1) group cohesion development during the course of the group and (2) the relationship of group cohesion to treatment outcome, broadly speaking dened to include not only social phobia symptoms, but the overall get under ones skin of negative affect (e.g., general anxiety and depression) and functional impairment. We hypothesized that group cohesion would increase from the midpoint of treatment to the endpoint of treatment and that group cohesion ratings would be signicantly related to positive treatment outcome (i.e., symptom reduction). Method Participants There were a integral of 34 outpatient individuals in this study. The average age of participants was 36 years (range 1964 years 19 female, 15 male). both individuals reported symptoms meeting criteria for a principal diagnosis (i.e., the diagnosis causing the virtually distress or impairment) of Social Phobia, as determined by the Structured clinical Interview for the Diagnostic and Statistical manual of Mental dise ases4th edition (SCID-IV First, Spitzer, Gibbon, & Williams, 2001). One individual also had symptoms meeting criteria for a co-principal primary diagnosis of Dyssomnia not differently Specied. For 32 of the participants, the social phobia was generalised (i.e., occurring in most social situations), whereas for the other cardinal participants, it was nongeneralized, occurring in several, but not most social situations. Of the 34 participants, 57% reported symptoms meeting criteria for one or more special surliness disorder (Major Depressive derange, 47% Bipolar Disorder, 6% Dysthymic Disorder, 3%), 62% had one or more additional anxiety disorder (Specic Phobia, 47% Generalized anguish Disorder, 26% ObsessiveCompulsive Disorder, 21% Panic Disorder, 12% Panic Disorder with Agoraphobia, 9%), and 27% had one or more additional other diagnoses (Hypochondriasis, 6% Eating Disorder Not Otherwise Specied, 6% cannabis Dependence, 6% Paraphilia Not Otherwise Specied, 3% Intermittent Explosive Disorder, 3% impulse Control Disorder Not Otherwise Specied, 3%). The set for the anxiety disorders sum to greater than 100% as several participants had multiple anxiety disorders. Measures Depression disturbance Stress Scales, 21-item version (DASS-21 Lovibond & Lovibond, 1995).This short form of the original 42-item DASS is a 21-item self-report measure designed to assess depression, anxiety and stress that an individual has familiarityd over the past tense week. Each scale consists of seven items and respondents indicate how much each statement applied to them over the past week on a four-point Likert scale. The Depression scale (DASS-21-D) measures dysphoria, hopelessness, devaluation of life, self-deprecation, overleap of interest/involvement, anhedonia, and inertia. The anxiousness scale (DASS-21-A) measures involuntary arousal, skeletal musculature effects, situational anxiety, and the subjective experience of anxiety affect. The Stress scale (DASS-21-S) measures difculty relaxing, anxious arousal, and a tendency to become advantageously upset/ agitated, irritable/over-reactive, and impatient. Strong inner consistency with a clinical exemplar has been demonstrated with the DASS-21 (as ranging from .87 to .94), and the factor bodily structure is well supported (Antony, Bieling, Cox, Enns, & Swinson, 1998). stool validity of the three scales has also been demonstrated (see Brown, Chorpita, Korotitsch, & Barlow, 1997). In the accepted sample, reliableness was unobjectionable at pre-treatment for the Depression (a 91), Anxiety (a 87), and Stress (a 87) scales. Illness Intrusiveness Ratings Scale (IIRS Devins, 1994). The IIRS is a 13-item questionnaire that measures the extent to which a disease, its treatment, or both interfere with activities in 13 important domains considered essential to a positive quality of life. These domains include health, diet, work, active diversion (e.g., sports), passive recreation (e.g., re ading), nances, relationship with partner, inborn and family relations, other social relations, self-expression/self-improvement, religious expression, and connection and civic involvement. For each item, an individual range the intrusiveness on a scale for 17 with higher gobs indicating more intrusiveness.The IIRS has been shown to have good psychometric properties in both medically ill populations (Devins et al., 2001) and anxiety disorders groups (Antony, Roth, Swinson, Huta, & Devins 1998 Bieling, Rowa, Antony, Summerfeldt, & Swinson, 2001). In the current sample, reliability was acceptable at pre-treatment (a 87). Social Phobia Inventory ( spin out Connor et al., 2000). The turn of events is a 17-item questionnaire designed to assess symptoms of social phobia. Each item measures the awkwardness of a particular symptom during the past week, using a ve-point scale ranging from 0 (not at all) to 4 (extremely). It consists of three subscales fear, avoidance, and physi ological arousal. The torture has been shown to have good empirical support (Antony, Coons, McCabe, Ashbaugh, & Swinson, 2006 Connor et al., 2000) and enables the estimate of a entire range of social anxiety symptoms, making it an ideal measure for generalized social phobia.The total print measure of the SPIN has recently been shown to have excellent internal consistency for the total score for individuals meeting criteria for Social Phobia (with a 92) and a combined sample of individuals meeting criteria for Social Phobia (Generalized Type), Panic Disorder with Agoraphobia and obsessive-compulsive Disorder (with a 95) (Antony et al., 2006 Connor et al., 2000). It has also been shown to have good testretest reliability (r 86, po001), convergent and discriminant validity as well as being able to evidence well between those with Social Phobia as opposed to Panic Disorder with Agoraphobia or Obsessive-Compulsive Disorder.The SPIN has also been shown to be sensitive to chang es in the severity of social phobia following cognitive-behavior treatment (Antony et al., 2006). In the current sample, pre-treatment reliability was acceptable (a 93). Group Cohesion Scale-Revised (GCS-R Treadwell et al., 2001). The GCS-R is a 25-item questionnaire designed to assess group cohesion in terms of interaction and communication among group members (including domination and subordination), member retention, decision-making, vulnerability among group members, and consistency between group and individual goals. Each item is rated on a scale from 1 (strongly disagree) to 4 (strongly agree). Examples of items include Group members ordinarily feel free to share information, There are usually feelings of unity and togetherness among the group members, and Many members put away in back-biting in this group.This scale was recently revised (Treadwell et al., 2001) in order to transform one item, discard another item, and change the wording of the anchor points. In a validat ion study, internal consistency (as heedful by Cronbachs alpha) ranged from .48 to .89 on pre-test assessment and .77.90 on post-test assessment (Treadwell et al., 2001). In the current sample, reliability was acceptable at both treatment midpoint (a 84) and at treatment endpoint (a 79), and the reliability of the change score was .56 (Williams & Zimmerman, 1996). Procedure All individuals correct a 10-session CBT treatment group for social phobia.1 Treatment administered was based on protocols exposit by Heimberg and Becker (2002) and Antony and Swinson (2000). The key components of therapy included psychoeducation, cognitive restructuring, in-session and between-session exposure exercises, as well as social skills training.Groups were run by two therapists and consisted of veeight patients per group. A total of 11 groups were included in the study. It should be illustrious that initially 76 individuals were enrolled in these 11 groups. However, of these 76 individuals, th ere were only 67 individuals from whom any measures were accredited at all (i.e., nine individuals did not return any info). In order to conduct the analyses that exit be described below, it was possible to include only 34 of these 67 individuals. This was due to a need to have received both mid- and post-GCS measures as well as pretreatment outcome data. Therefore, the working sample that will be discussed in this study encompasses 34 individuals who completed the treatment as well as these various measures2. Participants completed the GCS questionnaire at the midtreatment session of each group (i.e., session 5) as well as during the destination session of each group. Questionnaires assessing symptom severity (i.e., the DASS-21, IIRS and SPIN) were completed prior to the beginning of group treatment as well as during the last session of each group. data analysis Multilevel retrogression analyses (i.e., generalized mixed modeling) using the software computer program HLM 6 (Raud enbush, Bryk, Cheong, & Congdon, 2004) were conducted. We used this approach because it allowed us to assess and control for nonindependence of data that might arise from being nested into treatment groups (Hedeker, Gibbons, & Flay, 1994 Herzog et al., 2002). Another advantage of HLM was that it can accommodate unequal group sizes and employs level best likelihood estimation instead of least(prenominal) squares. Before examining change over time in the outcome variables and GCS, intraclass correlations (ICCs) were estimated to examine the interdependency of data due to nesting (see Herzog et al., 2002). The intraclass correlation depicts how much variance in the outcome variable is due to inwardly-subjects, between-subjects, and between-groups variance.Results For each analysis, items were included from each scale for each individual, unless 20% or more of data were absent. Missing esteems for a particular scale item were replaced by calculating the entail value for that scale item and using this mean value in place of the missing value. Outcome measures A series of three-level regression models were evaluated to examine change over time in the outcome variables. Level 1 consisted of repeated measures (i.e., two assessment occasions) that were nested within 1 Two groups completed 12-session CBT treatment groups and one group completed a 9-session treatment group.The use of a multilevel regression approach (i.e., HLM) allowed us to examine whether or not number of sessions per group affected any of the relationships reported. Results indicated that number of sessions did not moderate any of the results reported in the paper. 2 These treatment groups were not conducted as part of a formal treatment outcome study, which accounts for the number of patients who failed to return their post-treatment questionnaires. Therefore, the individuals who completed both pre-treatment and post-treatment measures provide a naturalistic and ecologically valid cross sectionalization of moderate to severe social phobia patients typically seen in an acute outpatient clinic, presenting with anxiety disorders and related problems.