The International Journal of Psychosocial Rehabilitation

The Impact of Group-as-a-Whole Work on a Severely Mentally Ill,
Institutionalized Population: The Role of Cohesiveness

Diana J. Semmelhack, Psy.D., L.C.P.C.
Midwestern University

Larry Ende, Ph.D, MSW

Clive Hazell, Ph.D., L.C.P.C.
DeVry University

Dr. William Hoffman, Ph.D
University of Illinois

Tanya Gluzerman, M.A.
Doctoral Candidate

Semmelhack  DJ, Ende  L, Hazel  C, Hoffman W & Gluzerman  T  (2009). The Impact of Group-as-a-Whole Work on a Severely Mentally Ill,
 Institutionalized Population: The Role of Cohesiveness
. International Journal of Psychosocial Rehabilitation. Vol 13(2).   25-37

Dr. Diana Semmelhack is an Associate Professor in the Department of Behavioral Medicine at Midwestern University.  Dr. Clive Hazell is a Senior Professor at DeVry University.  Dr. Larry Ende has a Ph.D. in English and a Master’s Degree in Social Work.  He is a therapist and group specialist in Chicago, Illinois. Dr. Hoffman is Director of Research in the Department of Anesthesia at the University of Illinois, Chicago.  Tanya Gluzerman, M.A. is completing her doctoral studies at Midwestern University.

Acknowledgement: The authors would like to offer special acknowledgement to New Beginnings Community Services, Inc. (NBCS) and The National Alliance for the Mentally Ill (NAMI), DuPage County, IL for their contributions to this article.

Correspondence: Diana Semmelhack, Psy.D., L.C.P.C., Department of Behavioral Medicine, Midwestern University, 555   31st , Downers Grove, IL  60515 E-mail:

This study explores the impact of a group-as-a-whole (Tavistock) processing group on 11 severely mentally ill patients in a long- term care facility.  We assess the influence of the group-as-a-whole model in developing group cohesiveness and reducing anxiety and depression for members.  Research indicates that group cohesiveness is a necessary precondition for effective therapy (Dion, 2000; Yalom, 2005).  The process of depersonalization characteristic of institutionalized settings makes cohesiveness even more critical to therapy in these settings (Rosenhan, 1973).  In our study, the experimental group, the group receiving group-as-a-whole treatment, showed a significant increase in group cohesiveness and a significant decrease in anxiety. The control group, a comparable group but without group-as-a-whole treatment, showed no significant changes at all.

Widespread opinion says that severely mentally ill clients reap no benefit from deep psychological processing.  Some attribute this absence of benefit to the lack of ego strength of severely mentally ill clients, their lack of capacity for insight, or to a general lack of relevance or usefulness of clinical depth psychology. Our study supports the conclusion that under certain conditions these clients do benefit from deep psychological processing.  This conclusion offers  hope given the intense needs of this highly isolated and neglected population.

We are also responding here to a need for empirical research. We need this kind of research on the clinical use of depth psychology, especially concerning the severely mentally ill. There is a lack of empirical research based on depth psychology partly because it is difficult to do such research. It is difficult, for example, to measure and interpret subjective states, as opposed to concrete behaviors. In addition, there is a lack of research on how group-as-a-whole work can be used with the severely mentally ill (Hazell, 2005). Most of the work available on the group-as-a-whole methodology involves qualitative descriptions of group process, not empirical studies conducted with control groups (Leszcz, Yalom, & Norden, 1985).

In this study, we hypothesize that the “group-as-a whole” therapeutic model (a deep processing model of group therapy) contributes to the development of group cohesiveness, which leads to positive therapeutic outcomes, including a reduction in anxiety and depression, in the treatment of a severely mentally ill, institutionalized population. As background, we will first discuss three of the study’s components: 1) the concept of group cohesiveness and its importance. To begin with, we have found cohesiveness important here because of the isolation experienced by the severely mentally ill, 2) the “group-as-a-whole” therapeutic model, and 3) some reflections on the need for this model in responding to the severely mentally ill population. Indeed, our study emerged out of the attempt to meet the deep and extensive needs of this population, a population whose entire treatment often consists of little more than medication monitoring.

Group Cohesiveness
Group cohesiveness, according to Yalom, Houts, Zimerberg, & Rand (1967), predicts  successful outcomes in group therapy. The development of cohesiveness appears to have a
curative effect (Yalom, 2005).  Marmarosh et al (2005) concurs, finding that cohesiveness is a primary group factor, “ ‘directly related to curative group factors such as “collective self-esteem” (the self-esteem one gains by being a member of a group) and “hope for the self” (similar to optimism)”.  What is group cohesiveness? Bion said (1951) that we are group animals at war with our groupishness. While as group animals we desire to be in groups, we also fear groups and what they can do to us and others. There is a field of forces that each human being must negotiate—forces pulling us towards the group and forces pulling us away from the group. The net effect of this force field results in the individual’s level of membership or belonging to a group. When this force field is aggregated across all of the members of a group, one could call the result the group’s cohesiveness. For Bion, to come to grips with these group phenomena is to begin to understand the dynamics of a group. Thus the concept of cohesiveness stands at the center of his work and also of much of the work done by those he influenced.  Bion’s perspective on cohesiveness suggests the complexity of the concept and the difficulty of measuring it.

Following Bion, other researchers have examined ways of increasing cohesiveness (Burlingame et al 2001), while still others have wrestled with the fact that the concept of cohesiveness is multifaceted or potentially multifactorial.  Dion (2000) provides an excellent review of the multiple conceptualizations of the concept of cohesiveness in an attempt to shift it from the field of forces concept that we find in Bion (1951) and Lewin (1935, 1936) to a multifactorial dimension. In so doing he helps locate different forms of cohesiveness as they relate to different measures. Dion finds Carron’s (1988) model a useful template and uses it to postulate cohesiveness that may emanate from social factors, task factors, attraction and integration. He further identifies cohesiveness that may result from the cognitive processes of self-categorization as elaborated by Hogg (1992). Again, we wish to emphasize the complexity of measuring cohesiveness.

Because we discovered that all of the participants in the experimental group had experienced trauma, we considered the relationship between  trauma and group cohesiveness.  In this regard, we found the writing of Hopper (2003) to fit the patterns that we observed. Hopper theorizes that when a group contains a significant amount of serious trauma amongst its members there are two adaptive mechanisms that are frequently observed. These two mechanisms he derives in part from Tustin (1981). Hopper calls them forms of “incohesiveness.” In the first form, the members seem to retreat into their private shells. There is a hyper-individuality, a minimization of emotional contact, and a shunning of interpersonal merger. A metaphor captures the “feel” of this group: it is a constellation of billiard balls—highly separated, bouncing off of one another, but never changing in their internal structures. They have become closed systems. Trauma, in this kind of “incohesiveness,” results in an autistic-like lack of contact in the group. At the other extreme, trauma in a group may result in the adaptation of “massification/aggregation.” In this form, the group behaves as if it were an undifferentiated mass. This is the polar opposite form of incohesiveness. There is a feel of merger or fusion, as if boundaries between self and other in the group have been obliterated. One might feel that there is a high level of cohesiveness in the group, but it is important to recognize that this cohesiveness depends on a covert agreement  that there should be little or no self-other differentiation. Our concern with these dynamics of incohesiveness concerns the unworked trauma in the group. The  forms of incohesiveness under discussion theoretically dissolve as the members work through the trauma (Hopper, 2003).  

What we can see, even from such a brief review as the foregoing, is that cohesiveness as a concept is: (a) probably very important in the way it affects group outcomes  (b) complex insofar as it is an aggregate of opposing forces (Bion, 1951), apparently multifactorial, and has different effects on groups at different stages of group development (Dion 2000), and (c) needs further research, despite the fact that some valiant efforts have already been made.  Despite these difficulties, we decided to measure cohesiveness in this study (Evans & Jarvis, 1986) and its potential impact on anxiety and depression.    

The Group-as-a-Whole Model                        
The importance of cohesiveness to group therapy pertains to those who work in the Tavistock (group-as-a-whole) tradition because implicit in this very mode of working is the assumption that there exists a group to which everyone in the room belongs by virtue of being connected to the “group mentality” (Bion 1951). The very wording of the “consultations” from the group-as-a-whole oriented consultant (e.g., “The group is engaging in a fantasy that only one member is feeling angry right now”) assumes a high degree of unconscious cohesiveness regardless of the stated sentiments of the group members.

In the Tavistock model, consultant interpretations address processes operating outside the current awareness of the group.  Thus, the model involves some integration of psychodynamic theory.  The exact nature of the theory is not prescribed, but one frequently finds elements of traditional psychodynamic and object relations theory in Tavistock consultations (Hazell, 2005). As an example, a consultant operating in the Tavistock tradition might perceive a group that discusses a trip to a restaurant as possibly avoiding the task at hand.  A possible group-as-a-whole interpretation might be, “This group is anxious about addressing something in this room and wishes to move far away from it, to go out to eat so to speak rather than to address it.”  In this case, the consultant was made aware of the group’s flight from the task by the focus of various members’ comments on events outside of the group’s process.  The consultant’s interpretation was designed to bring the focus of the group’s discussion back to the dynamics emerging in the here and now.  Sometimes, as in the groups under consideration in this study, this task is yoked to another task, such as the examination of interpersonal relationships.

We believe that the curative gains noted in our first study (Semmelhack, Hazell, & Hoffman, 2008)  at least partially result from the development of cohesiveness through the group-as-a-whole methodology.   The consultant’s interpretive approach, which emphasizes the group-as-a-whole versus any individual member, reinforces a sense of interconnectedness, even if this sentiment is not overtly expressed by group members.  Furthermore, the group appears to reduce its propensity for scapegoating due to the discussion of this issue. This contributes to the creation of an atmosphere conducive to sharing and confronting painful issues.  An increased capacity to confront and work through these issues ultimately suggests an increased sense of cohesiveness and may contribute to a reduction in anxiety and depression. We were therefore not surprised that the current study indicates that the group-as-a-whole method increases group cohesiveness.

The Need for This Treatment
The group-as-a-whole treatment model shows special promise for helping the severely mentally ill in nursing home settings (the context of our study). In the United States, the population of individuals diagnosed with severe mental illness residing in these facilities is growing (Many of these clients are under the age of 65) (Jervis, 2002). Institutionalized settings such as nursing homes have a depersonalizing and dehumanizing effect, in essence creating a sense of “incohesiveness” (Rosenhan, 1973).  Many nursing homes create environments which provide routine care limited to maintaining medication compliance. The dramatic sense of “incohesiveness” fostered in these settings leaves clients either isolated with few opportunities to engage in authentic interpersonal relationships, or as part of an amalgamated mass with little sense of individuality.  This institutionalized mass is often labeled the “patients” or the “mentally ill residents.”  Either isolation or “massification” negatively impacts on an individual’s sense of emotional well-being, contributing to anxiety and depression.  Yet the treatment focus is typically medication management with few opportunities for clients to explore their need for positive relationships, or the impact of isolation on their psychological well-being (Edelson, 1970a; 1970b).  Group-as-a-whole treatment may relieve some of the anxiety and depression that the mentally ill face in the nursing home environment.

It is astonishing to discover the tragic reality of how many nursing home residents have been abused and need treatment for trauma. Studies consistently show a 50-80% prevalence rate of physical and sexual abuse among individuals who later acquire a diagnosis of mental illness (Stefan, 1996).  According to Briere (2004), 35-70% of institutionalized female mental health clients have sexual abuse histories.  From a treatment perspective, these histories are frequently ignored. We need to provide treatment modalities other than medication management to address the abuse and neglect histories of institutionalized individuals.     

Finally, the group-as-a-whole model may be useful for treating the severely mentally ill in many places besides nursing homes. This is both because most environments encourage the isolation of this group and because the members’ isolation is part of their inner world as well as their relation to the external world.    

The Study
The groups studied (experimental and control) took place in a nursing home with more than 350 male and female adult clients, all of whom had been given a major Axis I diagnosis according to the Diagnostic and Statistical Manual of Mental Disorders Text Revision (DSM-IV-TR) (American Psychological Association, 2000).  The population ranged from 40 to 90 years of age.  The average stay in the facility was 5 years (D. Nelson, personal communication, June 19, 2007).  Individuals residing in the facility had few treatment options other than attending medication management groups and participating in activities such as bingo and cooking class (these are seen as treatment options).  

Twenty clients were referred for participation in the experimental group by the social services department.  Potential members were interviewed by the group's consultant (a licensed clinical professional counselor and clinical psychologist).  In 45-minute interviews with each referred member, the investigator described the purpose and structure of the group and asked members if they were willing to sign a consent form. 

Among the 20 individuals who were referred, 11 consented to participate.  These 11 severely mentally ill members had been given Axis I diagnoses as follows:  three with paranoid schizophrenia, two with major depression, four with schizoaffective disorder and two with bipolar I disorder. None of the participants had an Axis II diagnosis. All of them had experienced childhood trauma, including sexual, emotional, or physical abuse, or neglect. Additionally, they all had made at least one suicide attempt. (The pervasive histories of trauma and suicide attempts reported among members, as suggested, is shocking. Clearly, there is a serious need here for therapy and research.) The membership ranged in age from 30 to 78.  All members had at least average intelligence, which had been measured upon admittance into the facility through the administration of a Kaufman Brief Intelligence Test (K-BIT) (Kaufman & Kaufman, 1990).      Members of the control group were selected from the same nursing home population. They were matched with the experimental group for gender, age and intelligence.  Additionally, members of the control group had similar Axis I diagnoses.  They showed an absence of Axis II diagnoses, as well as a history of suicide attempts and trauma.  Control group members were not engaged in any form of group psychotherapy other than a medication management group and participated in activity groups, including bingo and cooking class.

The final sample consisted of 23 clients (10 men and 13 women) with Axis I diagnoses living in a long- term care facility.  The sample was divided into two groups, control (5 men and 7 women) and experimental (5 men and 6 women).  All participants were European American.  Instruments: Beck Depression Inventory-Second Edition (BDI-II) (Beck, Steer & Brown, 1996).

This self-report measure required participants to rate how they felt over the past two weeks regarding 21 depressive symptoms and attitudes, including sadness, loss of pleasure, and self- dislike.  The participants rated each item on a 4-point scale from 0 (currently not experiencing that symptom/attitude) to 3 (experiencing a high degree of that symptom/attitude).  Each participant's score was acquired by totaling all 21 items.  In terms of reliability, Groth-Marnat (2003) showed high levels of internal consistency for the BDI-II (α =.91) in a psychiatric population.  Beck et al. (1996) found a significant test-retest correlation of .92 (p < .001).  Studies have found support for the validity of the BDI-II.   For example, the assessment of content, discriminant, concurrent, and factor analysis with psychiatric patients has been favorable (Groth-Marnat, 2003). With regard to convergent validity, the BDI-II was assessed by administration of the BDI-1A and the BDI-II to two sub-samples of psychiatric patients (Beck et al., 1996).  The administration of the two versions yielded a significant correlation of .93 (p <.001). Beck Anxiety Inventory (BAI) (Beck & Steer, 1993).

Participants were asked to read a series of 21 common symptoms of anxiety, including feeling hot, unable to relax, and nervous.  They were asked to rate the degree to which they had been bothered by each symptom over the past week, including the day of testing, utilizing a  4-point scale ranging from 0 (not at all) to 3 (severely).  Total scores were obtained by adding each participant's ratings on all 21 items.  Reliability measures for the BAI show high levels of internal consistency (α = .92) with psychiatric populations (Hewitt & Norton, 1993).  Beck, Epstein, Brown and Steer (1988) also found test-retest reliability to be significant, noting the correlation between intake and 1-week BAI scores to be r = .75 (p < .001).  Studies have supported the test as a valid measure of anxiety with psychiatric patients, and they have considered the test to have appropriate discriminant validity with other measures of anxiety (Beck et al., 1988).  An analysis of concurrent validity showed 1) a correlation of the BAI of .51 (p<.001) with the Hamilton Anxiety Rating Scale--Revised  and 2) a correlation of .the BAI of .51 (p < .001) with the anxiety subscale of the Cognition Checklist.  The correlation between the BAI and the BDI was r = .48 (p < .001) (Beck, et al., 1988).

Cohesiveness was measured by a modified version of the Group Attitude Scale (Evans & Jarvis, 1986).  The questionnaire consists of a 20- item self-report study.  The items on the instrument relate to several aspects of cohesiveness, including attractiveness, belongingness, task identity, popularity, and well- being. They thus address the broadness of the concept of cohesiveness.   The measure required the participants to respond to statements such as, "People in my work group work together well," and, "I feel like I am really part of my group" before and after the ten week treatment period by placing an "X" on a continuous scale labeled from 0 to 100.  Specifically, members of the control and experimental groups were asked to indicate how they felt about group membership at the time the measure was administered. In several studies of the original Group Attitude Scale the measure coefficient alpha has ranged from .90 to .97 in various points in the lives of groups studied.    The validity and reliability data obtained to date on the scale suggest that the instrument has promise as a measure of attraction/ sense of belonging to a group (Evans & Jarvis, 1986). 

Structure of the group.  In this study, boundaries in terms of structure, task and role were clearly stated for the membership verbally and in writing during an introductory session. The group was held at the same time each week for a 60-minute period in the counseling room. It ran for 10 weeks.  Members had an opportunity to exit at any point during the 10-week period.  However, all 11 original members remained in the institution and opted to participate in the group for the 10-week period.  As outlined in our earlier study (Semmelhack, Hazell & Hoffman, 2008), a 10-week module consisted of four types of activities:  the Opening Activity, the Here and Now Activities, the Discussion Activity and the Application Activity.  

The Opening Activity (session one) was designed to orient group members to the task at hand and the roles in the group, to review basic concepts concerning groups and to reinforce the importance of confidentiality. The goal for each session was for members to increase group connectedness. This was to be done by exploring together group-as-a-whole events.  The Here and Now Activities (sessions two through five and seven through nine) constituted the major work of the group, in which members learned about themselves and the group through direct participation in the intra/inter psychic group process. (Unlike in traditional psychodynamic therapy, in group-as-a-whole work the unconscious is explored as it manifests itself in the here and now.) A member might come to discover, for example, a role she has been unconsciously playing in the group and its effects on how others respond to her.  The intensity of affect expressed by members during these activities required a 30-minute tension-reduction period immediately after each session.  During this period, the consultant was available for one-to-one consults with members who experienced painful affect during the preceding group session.  The Discussion Activity (session six) served as a container of painful affect that could emerge due to severe psychopathology and obstruct the task (Hazell, 2005).  In this session, the consultant and observer were prepared to step out of role and address members' questions directly.  (Ordinarily, the consultant interprets group activity, but does not directly discuss it. This contributes to the members' active, increasing interpretation of their own experience in the group.) The Application Activity (session ten) focused on applying experiences in the group to experiences that members have in other groups to which they belong.  

The formal roles in the group included those of consultant, observer, member and external consultant (Semmelhack, Hazell & Hoffman, 2008).  The consultant (a licensed clinical professional counselor and clinical psychologist) had the task of attempting to make contributions to the group that would further the goal of increasing connectedness. These contributions were intended to be interpretations of group dynamics taking place outside the awareness of the group. The observer (a graduate student) remained silent throughout the sessions and simply observed the group's process to gain a better understanding of what goes on in any group (Hazell, 2005).  

Group members participated with the same goal as the consultant. Ultimately, it was hoped, a decreased sense of isolation would contribute to an increased sense of group cohesiveness and positive therapeutic outcomes including a reduction in depression and anxiety.  The outside expert (external consultant), who had no direct contact with group members, helped the consultant to deal with transference and counter-transference issues through the weekly analysis of transcripts of the group's process.

Administration of study measures.  Participants in the treatment group were given the BAI (Beck & Steer, 1993; Beck, Epstein, Brown & Steer, 1988), BDI-II (Beck, Steer & Brown, 1996) and cohesiveness measure (Evans & Jarvis, 1986) by a member of the social services department before the group began (Time 1).  The group ran for 10 weeks, at the conclusion of which participants were again given the BAI, the BDI-II (Time 2) and the cohesiveness measure.  A member of the social services department distributed the tests to group members immediately after the end of the ten week module. She collected the completed tests within 2 hours after the end of the group.  

Statistical Analyses
Data are reported as mean + standard deviation.  Changes in anxiety, depression and cohesiveness over the ten week treatment were evaluated by paired t-tests.  Correlations between the change in cohesiveness and the final depression and anxiety measures were determined by Pearson Product Moment correlations.         

The effect of group treatment on depression, anxiety and cohesiveness is shown in figure 1.  In the control group there was no significant change in depression, anxiety or cohesiveness  over 10 weeks. In the experimental group there was a trend for depression to decrease during the 10 week treatment period, but this trend was not significant.  There was a significant decrease in anxiety and a significant increase in cohesiveness during the treatment interval. These results indicate that during 10 weeks of treatment with group-as- a- whole therapy anxiety decreased and cohesiveness increased.

Figure 1 BDI-II, BAI and cohesiveness scores in control and experimental groups at baseline and after 10 weeks of treatment.

 Mean + SD. * = P < .05 compared to 0 weeks within each group. There was a significant decrease in anxiety and an increase in cohesiveness in the experimental group with 10 weeks of treatment.

As a measure of test-retest reliability, Cronbach's alpha was evaluated for depression, anxiety and cohesiveness scores before and after the 10 week period in both groups considered together. For depression alpha was .56, anxiety: alpha = .58, cohesiveness: alpha = .41. Considering the small sample size, these results suggest that scores were consistent for individuals from the first to the second measure.

In addition to measuring the changes in depression, anxiety and cohesiveness over 10 weeks, we also determined the interaction of these measures within individuals. There was a significant negative correlation between the change in cohesiveness from 0 to 10 weeks and the anxiety level of each patient at the end of 10 weeks (fig 2). In addition, the change in cohesiveness was negatively correlated to the final level of depression at the end of the study.

Figure 2 Final anxiety scores

Final anxiety scores (top graph) and depression scores (bottom graph) at 10 weeks of treatment plotted as a function of the change in cohesiveness from 0 to 10 weeks. Pearson product moment correlation is given with significance level. Both anxiety and depression scores at the end of 10 weeks of treatment were correlated with the change in cohesiveness.

Doing group psychotherapy may improve a severely mentally ill, institutionalized patient’s affective state over time (Semmelhack, Hazell & Hoffman, 2008).  The current study explored the effects of group-as-a-whole processing on the development of a sense of cohesiveness as well as on symptoms of anxiety and depression in 11 severely mentally ill institutionalized clients over 10 weeks, utilizing BDI-II, BAI and a modified Group Attitude Scale as measurements.  Members of the experimental group showed a significant decrease in anxiety and a significant increase in cohesiveness across the 10 week treatment period.  There was no significant improvement in depression.  Individual depression and anxiety scores for each patient at the end of the study were also negatively related to their cohesiveness scores. This suggests that higher depression and anxiety levels in individual patients may inhibit their ability to fully interact in the treatment process.  These results are consistent with Yalom et al.’s (1967) perspective that the degree of cohesiveness evident in a psychotherapy group contributes directly to therapeutic outcomes.  The current findings with respect to anxiety and depression are consistent with our earlier research over a 30-week period (Semmelhack, Hazell & Hoffman, 2008).

Our study responds to the depersonalizing effect of being held in an institutional setting, which contributes to a sense of “incohesiveness.” Members isolate and cannot bring about a sense of interpersonal connectedness, or they lose their individuality by becoming enmeshed in a mass labeled “patients,” or the “mentally ill residents.”  In either case, there is not the development of a sense of cohesiveness thought to be critical for a positive therapeutic outcome (Yalom, 1967).  The findings in our study point to the utility of the group-as-a whole model in fostering a sense of cohesiveness.

A cohesive group appeared to evolve in this study, contrary to the assumption that the “group-as-a- whole" approach does not facilitate psychological growth with this population (Nichols & Taylor, 1975).  Nichols and Taylor suggest that the Tavistock focus on the whole group versus the individual more likely increases than decreases anxiety in the group participants. This assumption has now been challenged by research findings suggesting that the group-as-a-whole model may in fact facilitate the population’s capacity to acknowledge feelings as well as their ability to foster positive interpersonal relationships (Hazell & Semmelhack, 2001; Semmelhack, Hazell & Hoffman, 2008).

As stated earlier, the group-as-a-whole method contributes to cohesiveness through its interpretive style, which, emphasizing the whole group versus any given individual in the group, assumes a high degree of unconscious cohesiveness.  The consistent use of group-as-a-whole interpretations in response to comments made by individuals highlights the notion of a “group mentality” (Bion, 1951). The interpretive reinforcement of the unconscious dimension of the group’s interconnectedness may lead to its enhancement and ultimately the explicit recognition of cohesiveness by group members.   Lastly, the emphasis on the whole group versus any individual member may reduce the possibility of being scapegoated, thus making the group a safer place to share painful thoughts, feelings and memories. This in turn may increase cohesiveness further. 

Study Limitations
Reactivity given the repeated measure design of this study may have been a potential weakness influencing outcomes. For example, results may have been influenced by the fact that over time members gained a familiarity with the tests given and awareness that they were part of a study. Client mood may also have been influenced by other activities or events in clients’ lives.  It is also possible that the increased attention given to the experimental group impacted positively on the outcome measures rather than the intervention itself. A confounding variable could have been the presence of an observer.  However, because she remained silent, the observer most likely had a limited effect on outcomes.  Another weakness of the study is the small sample size because it may have attenuated our ability to see significant differences between groups. The fact that the results with respect to anxiety were consistent with our earlier study, however, is important to note when considering this limitation. Because group participants were not ethnically diverse, the ability to generalize the results to diverse populations is limited. Lastly, we recognize that cohesiveness is a very complex variable and that the measure utilized may have been limited in its capacity to identify the dimension of cohesiveness linked with therapeutic change.  (Hornsey, M.; Dwyer, L & Tian,O, 2007).

There is a need for new treatment options for severely mentally ill individuals in long- term care facilities.  This population is growing and there are few therapies available other than medication management. The intense depersonalization and isolation which this population suffers from likely contributes to anxiety, depression and the experience of alienation.  Ultimately, it is hoped that the group-as-a-whole approach facilitates the evolution of a safe context for the task of developing greater group cohesiveness. To further support the efficacy of the model presented, more research is needed.  The results need replication.  We need studies exploring the impact of a longer treatment period on the development of group cohesiveness. And finally, the utility of the model with diverse populations of severely mentally ill clients needs to be explored. 


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