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INTRODUCTION
There are a number of therapeutic factors in enhancing the efficacy of group psychotherapy, e.g., self-disclosure, interaction, acceptance, group cohesiveness, insight, catharsis, guidance, vicarious learning, instillation of hope, existential factor, and so on (1). Similarly, there have been numerous studies on therapeutic factors influencing the outcome of group psychotherapy (2, 3). Which factors are more important for the therapeutic outcome may differ with various dimensions such as the therapeutic approach, the type of disorders, and so on.
Recently, many researchers have demonstrated the effectiveness of Cognitive Behavioral Group Treatment (CBGT) for social phobia (4-8). Although research about CBGT is increasing gradually in Korea, there is still little research investigating the therapeutic factors of CBGT for social phobia, as compared to that of the international community. Currently, there are only a few cases of research detailing the therapeutic factors of group psychotherapy concerning panic disorder, conduct disorder, and the chronically mentally ill (9-12).
Our research seeks to broaden the research that is currently being conducted by examining the efficacy of the therapeutic factors which influence the outcome of CBGT for social phobia, by using Yalom's Curative Factors Questionnaire (13).
MATERIALS AND METHODS
Subjects
The subjects of this study were 50 outpatients who sought treatment for interpersonal or performance anxiety at the cognitive behavior therapy clinic of a university hospital. All patients were initially interviewed with the Anxiety Disorder Interview Schedule-Revised (ADIS-R) (14) and all met the DSM-IV criteria for social phobia (15). Patients who had a prior diagnosis of major depression, bipolar disorder, other anxiety disorders, psychotic disorder, and/or active alcohol or drug dependence were excluded. The patients must also have received a rating of 4 or greater on the ADIS-R Clinician's Severity Rating Scale, a 0-8 global rating scale that incorporates both the level of anxiety and the degree of functional interference in its assessment.
Twenty-six of the patients were male, and twenty-four were female. The mean age of the patients was 31.22 yr (SD=9.15; range=16-55), the average level of education was 14.28 yr (SD=2.10; range=11-18), and the mean age at onset was 17.19 yr (SD=6.54; range=5-40). Concerning marital status, 25 were single, 24 were married, and 1 was divorced. The mean duration of illness was 13.40 yr (SD=10.16; range=1-45). In pretreatment anxiety scores on the 9-point Clinician's Severity Rating (14), the mean score of patients was 6.62 (SD=0.88; range=5-8), i.e., moderate to severe anxiety level. Five patients were taking medication (mostly benzodiazepines) on an as needed basis, and the others were not taking medication at the time of the intake interview.
Treatment
Patients received CBGT in groups of 5-10 for ten weekly 2-hr sessions. The CBGT that was administered by the authors used the protocol developed by Heimberg et al. (16), consisting of several components: 1) Psychoeducation: a presentation of a cognitive-behavioral explanation of social phobia; 2) Cognitive restructuring: the training of patients in the skills of identification, disputation of problematic cognitions and dysfunctional beliefs, and developing alternative rational responses; 3) In-session exposure: exposure of patients to stimulations of anxiety-provoking situations during therapy sessions; 4) In vivo exposure: homework assignments for in vivo exposure to situations previously addressed in sessions.
Measurements
We used the Curative Factors Questionnaire to determine the most important therapeutic factor for each of the social phobics. Originally it was developed by Yalom (13), and consisted of total 60 items categorized into 12 factors. However, in this study, we used the abbreviated form consisting of 12 items; each describing one of the therapeutic factors. At the end of the program, patients were asked to rate the degree of helpfulness of each of the therapeutic factors on a 9-point scale, as they were perceived throughout the therapy.
Additionally, at the end of the program, patients were asked to rank which therapeutic component, among the four components of CBGT for social phobia (psychoeducation, cognitive restructuring, in-session exposure, in vivo exposure), was the most helpful during the treatment.
The criteria for improvement were as follows: 1) a decrease of 3 or more from pretreatment to posttreatment scores on the 9-point severity rating (0="no phobia present" to 8="very severely disturbing/disabling") of the Fear Questionnaire (17) as a self-rating of intensity of social fear; and 2) a decrease of 3 or more from pretreatment to posttreatment scores on the 9-point Clinician's Severity Rating as a clinician's rating. Patients who met both of these criteria were classified as 'more improved', and patients who did not meet both or either of the criteria were classified as 'less improved'.
Statistical analyses
All data were analyzed using the SPSS version 11.0 for Windows (SPSS Inc, Chicago, IL, U.S.A.). The chi-square test and independent t-test were conducted to compare the variables between the more improved group and the less improved group. The minimal limit of statistical significance was a p-value of <0.05.
RESULTS
A comparison of the therapeutic factors scores between more and less improved groups
Among the 12 factors, "Existential factor", "Interpersonal learning-output", "Guidance", and "Self-Understanding" showed higher mean scores among all the patients (6.44, 6.00, 6.00, 5.74, respectively) (Table 1).
Furthermore, we compared the therapeutic factors scores between the more improved patients and the less improved patients in order to examine which therapeutic factors could be more important to the outcome of treatment. As shown in Table 1, the more improved patients scored significantly higher in the factors such as "Interpersonal learning-output", "Guidance", "Universality", "Group cohesiveness" than the less improved patients (t=2.23, p<0.05; t=2.18, p<0.05; t=2.99, p<0.01; t=2.72, p<0.01, respectively).
A comparison of the therapeutic components evaluation between more and less improved groups
Fig. 1 presents the components patients in each group endorsed as the most helpful among the four therapeutic components, calculated as percentages. The results of the frequency analysis indicated that the most helpful component was cognitive restructuring, followed by psychoeducation, in vivo exposure, and in-session exposure, respectively.
Chi-square analysis indicated that the two groups differed significantly in the frequency of primary ranking for therapeutic components (χ2=26.22, p<0.01). Among the four components, only psychoeducation showed a statistically significant difference between the two groups (χ2=6.40, p<0.05). The other components did not show any statistically significant difference (Table 2).
DISCUSSION
The results of this investigation indicate that social phobic patients participating in CBGT rated "Existential factor", "Interpersonal learning-output", "Guidance", and "Self-Understanding" as being more helpful than the other factors. Moreover, it appears that the more improved patients rated "Interpersonal learning-output", "Guidance", "Universality", and "Group cohesiveness" as more beneficial than the less improved patients.
More specifically, the more improved patients gave prominence to contents such as "The group's giving me an opportunity to learn to approach others (Interpersonal learning-output)", "The doctor or group members suggesting or advising something for me to do (Guidance)", "Learning I'm not the only one with my type of problem- We're all in the same boat (Universality)", "Belonging to a group of people who understood and accepted me, so not feeling alone any longer (Group cohesiveness)." Therefore, it will be necessary to reinforce these therapeutic factors through CBGT of social phobia in order to obtain a more effective outcome.
According to many research papers about the therapeutic factors for outpatients in group therapy, the most commonly chosen therapeutic factors were "catharsis, self-understanding, interpersonal input, cohesiveness, and universality" (18-22), although these studies were not just for social phobic patients. The reason why our results somewhat differ from these previous results could derive in part from different therapeutic approaches. The therapeutic approaches in many previous research programs emphasized affectively charged, self-reflective interpersonal interaction; however, the therapeutic approach in this research highlighted more cognitive and behavioral aspects. So, our results may be indicative of which therapeutic factors are more important for the outcome of CBGT for social phobic patients.
In addition, this research examined which of the therapeutic components was most beneficial in CBGT for social phobia. Despite the fact that among the four components, only psychoeducation showed a statistically significant difference between the two groups in the frequency of primary ranking, the most helpful component for patients was cognitive restructuring.
It has been already demonstrated that correcting the patients' automatic dysfunctional thoughts in social situations should be the core therapeutic component in CBGT, and the fact that almost half of our patients in this study rated cognitive restructuring most helpful consolidated this result. Interestingly, the more improved patients rated cognitive restructuring as more helpful. In contrast, the less improved patients rated psychoeducation as more helpful. These results suggest that the development of rational and alternative thoughts through cognitive restructuring is essential in the treatment of social phobia.
Despite many significant findings, the present study has several limitations. First, the Yalom's Curative Factors Questionnaire in this study was an abbreviated form consisting of 12 items, for the convenience of administration. It will be necessary to use the original 60 item Questionnaire to acheive a more accurate result. Secondly, as a criterion for the classification of improvement level, this study adopted symptom severity ratings only by therapists and patients. Future studies should include various measures that may be useful for a more comprehensive evaluation of improvement.
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