Therapeutic Factors in
Occupational Therapy
Groups
Janet Falk-Kessler, Christine Momich,
Sharla Perel
Key Words: activity groups. group
process. occu pational therapy in
psychiatry. task groups
A survey was administered to patients and their
therapists in an attempt to assess which tberapeutic
factors were perceived as helpful in occupational
therapy groups. The patients' responses were com-
pared to their tberapists 'jar similarities and d~{ler­
ences. Hath groups highly valuedfactors ofgroup co-
hesiveness, instillation of hope, and interpersonal
learning. The therapists also valued gUidance and
identification, which the patients did not. Least ual-
ued by the patients were gUidance, existential/ac-
tors, and identification; least ualued hy the thera-
pists were self-understanding, family reenactment,
and existential factors.
Janet Falk-Kessler, MA, OTR, is Assistant Professor in Clini-
cal Occupational Therapy, College of Physicians and Sur-
geons, Columbia University, 630 West 168th Srreet, New
York, New York 10032.
Christine Momich, MS, OTR, is an Occupational Therapist,
lnrerdisciplinary Cenrer for Child Development, Rego
Park, New York. At the time of this study, she was an occu
parionaI therapy graduate student at Columbia University,
New York, New York.
Sharla Perel, MS, OTR, is an Occupational Therapist, Sraten
Island Hospital, Staten Island, New York. At the time of
this study, she was an occupational therapy graduate S[ll'
dent at Columbia University, New York, New York.
This article was accepted/or publication!uly 8, 1990.
The Americanjoumal a/Occupational Therapy
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ccupational therapists have used groups as
O their preferred modality in psychosocial
settings since the origin of the profession
(Bruce & Borg, 1987). During the 1960s, leading
theorists in occupational therapy began to focus on
the dynamic forces occurring in groups as important
curative agents (Fidler, 1969; Mosey, 1986). These
dynamic forces typically encompass the interpersonal
interactions within group settings and often reflect
the intra member relationships, the member-leader
interactions, and the degree of cohesiveness within
the group (Bennis & Shepard, 1974; Bion, 1959;
Yalom, 1985) When group dynamics are working ef-
fectively, they allow for the emergence of factors that
will promote therapeutic change.
With the recognition of the importance of group
dynamics in treatment comes the inclusion of this
material in occupational therapy curricula. Sixty-three
percent of educational programs in occupational ther-
apy offer courses in group dynamics, with the re-
maining programs incorporating this material into
other courses (Barris, 1985). Despite the overwhelm-
ing reliance on and attention to groups in educational
settings and as a treatment modality in psychiatric oc-
cupational therapy, very little research has focused on
the dynamics within occupational therapy groups. In-
stead, occupational therapists rely on theory and re-
search by professionals from other disciplines (Howe
& Schwartzberg, 1986), which is typically based on
student study groups, encounter groups, and group
psychotherapy (Bennis & Shepard, 1974; Bion, 1959;
Yalom,1985) Research is often focused on the group
members' interactions and on the therapeutiC factors
identified by Yalom (1970, 1985) that group members
perceive to be helpful. These therapeutic factors, con-
sidered to be prerequisites to growth and change, are
shown in Table 1.
Although therapeutic factors have been identified
as important in occupational therapy groups (Howe &
Schwartzberg, 1986; Stein & Tallant, 1989), little re-
search on them exists Identification of therapeutic
factors in occupational therapy groups would aid ther-
apists in planning effective interventions and would
aid instructors in planning effectively for occupational
therapy courses. The purpose of the present study was
to examine which therapeutic factors in occupational
therapy groups were perceived as helpful by patients
and therapists.
Literature Review
The use of groups as a therapeutiC tool in occupa-
tional therapy was first described in 1922 by Meyer
(1977). As precursors to present-day occupational
therapy groups, collective activities programs grew
out of the Moral Treatment movement of the 19th
59
 Table 1 peer group environment. This emphasis continued
Therapeutic Factors 8 well into the next decade.
Factor Definition Sample Statement When neuroleptic drugs were introduced in the
Altruism Giving of oneself to "Putting others' 1950s and psychiatric symptoms were better con-
help others. needs ahe"d of trolled, patients were able to function in social set-
mine."
Catharsis Relieving of "Getting things off
tings. This in turn gave rise to a shift in the focus of
emotions by my chest." group therapy: Therapists were able to use groups to
expressing one's address the individual's therapeutic goals rather than
feelings.
Universality Recognizing shared
just socialization (Howe & Schwartzberg, 1986). In
"Learning I'm not
feelings and that the only one with the 1960s, treatment groups began to focus on the
one's problems are my type of interpersonal relationship between the patients and
not unique. problem; we're all
the therapiSt. During this time, the role of activity as a
in the same boat."
Existential Accepting that the "Recognizing that shared, common task was viewed as a means of learn-
factors responsibility for life is at times ing through doing and discussion. Fidler (1969)
change comes unfair and unjust."
from within
stated that "task accomplishment is not the purpose of
oneself. the group but hopefully the means by which purpose
Self- Discovering and "Learning why I is realized" (p. 45). Group treatment flourished at this
understanding accepting the think and feel the
(insight)
time with the development of community mental
unknown parts of way I do (that is,
oneself. learning some of health programs to address the needs of deinstitu-
the causes and tionalized psychiatric patients.
sources of my
Throughout the 1970s and 1980s, economic fac-
problems)."
Family Understanding "Being in the group tors brought about by recession led to reduced hospi-
reenactment through the group was, in a sense, talization and programming funds. As a result, a more
experience what it like reliving and
economical treatment of patients led to the develop-
was like growing understanding my
up in one's family. life in the family in ment of behavioral, skills-oriented groups, which
which J grew up." continue today as the model for treatment groups for
Guidance Accepting advice "Group members' psychiatric patients (Howe & Schwartzberg, 1986).
from other group suggesting or
members. advising Participation in occupational therapy groups has been
something for me shown to improve interpersonal skills (DeCarlo &
to do."
Mann 1985; Mumford, 1974), and involvement in oc-
Identification Benefiting by "Trying to be like
imitating positive someone in the cupational therapy programs has been shown to in-
behaviors of other group who was crease the effectiveness of aftercare programs in the
group members. better adjusted treatment of the patient with chronic mental illness
than I "
Instillation of Experiencing "Seeing that other (Linn, Caffey, Klett, Hogarty, & Lamb, 1979; May,
hope optimism through group members 1976)
observing the improved
Despite the trend toward the use of groups in
improvement of encouraged me.
others in the group. psychiatric occupational therapy, only two studies
Interpersonal Receiving feedback "Learning how I have examined what patients perceive as useful.
learning- from group come across [()
These studies have noted that what patients value in
input members others."
regarding one's their groups is often different from what therapists
behavior. view as beneficial (Burton, 1984; Vaughan &
Interpersonal Learning successful "Improving my skills Prechner, 1985). For example, although therapists
learning- ways of relating to in getting along
output group members. with people." may deSign a group to focus on issues and tasks re-
"(Yalom, 1970, 19H5)
lated to community reentry, patients identify "making
things" and "passing the time" as reasons for atten-
dance (Burton, 1984).
century as a means to develop socially acceptable be- What patients and therapists view as therapeutic
havior in persons with mental illness and, ultimately, is important to examine and has been extensively
to focus on vocational goals (Howe & Schwartzberg, studied in the area of group psychotherapy. Building
1986). Reviewing the history of occupational therapy on research that examined what therapeutic mecha-
groups, Howe and Schwartzberg noted that by the nisms were operational in groups (Berzon, Pious, &
mid-1930s, group work was viewed as a curative tool Farson, 1963; Dickoff & Lakin, 1963), Yalom (1970,
rather than simply as a means to meet the economic 1985) compiled an inventory of therapeutic factors
needs of a hospital or to keep patients occupied. that served as the organizing principle of research on
Group activities were viewed as proViding opportuni- the perceptions of group therapy effectiveness. Thera-
ties for socialization among psychiatric patients in a peutic factors reflect those qualities that are inherent

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 in groups and that patients value Examples of these
include feeling accepted by others (cohesion), learn-
ing how to relate to others (interpersonal learning,
output), and feeling optimistic about one's potential
(instillation of hope). A complete listing is shown in
Table 1.
Therapeutic factors are defined as "mechanisms
of change" that "occur through an intrinsic interplay
of various gUided human experiences" (Yalom, 1985,
p. 3). Different factors achieve importance at various
times in a group's development and help to facilitate
the change process. Although these factors do not
necessarily have individual significance, it is their in-
terrelationship that gives strength to the dynamic pro-
cess of group therapy.
When examining the perceived helpfulness of
therapeutic factors within group settings, one must
note that it is still the individual's singular experience
within the group that determines what that individual
values. Nevertheless, group participants' views reveal
striking similarities on which factors are particularly
helpful.
Yalom's initial study (1970) revealed that inter-
personal learning, catharsis. group cohesiveness, and
self-understanding were most valued by group
members who were inpatients. This study has been
adapted and replicated by a variety of researchers for
use in both inpatient psychiatric groups (Butler &
Fuhriman, 1980; Leszcz, Yalom, & Norden, 1985; Ma-
caskill, 1982; Marcovitz & Smith, 1983; Maxmen,
1973; Schaffer & Dreyer, 1982; Steinfeld & Mabli.
1974) and outpatient psychiatric groups (Butler &
Fuhriman, 1980, 1983; Leszcz et a!., 1985; Long &
Cope, 1980; Rohrbaugh & Bartels, 1975; Weiner,
1974). These studies confirmed that the four factors
most valued were interpersonal learning, catharsis,
cohesiveness, and self-understanding.
Group therapists tend to value the factors of fam-
ily reenactment and identification (Yalom, 1985).
Yalom concluded that the establishment of appro-
priate goals based on valued therapeutic factors
should be the first step for any therapist forming a
new therapy group. Compatibility of factors is impor-
tant because "when therapists emphasize therapeutic
factors that are not compatible with the needs and
Method
Sample
The sample was chosen from four occupational ther-
apy groups selected from three psychiatric day treat-
ment centers affiliated with Columbia University's
College of Physicians and Surgeons in New York, New
York. Each was a long-term, ongoing thematic group
led by an occupational therapist. A thematic group
focuses on the performance of skills and behaviors
related to a specific activity (Mosey, 1986). The
groups in this study were designed to develop either
task or social skills. Patient membership in these
groups was stable. The patients from these groups
were eligible to participate in the study if they met the
following criteria: (a) fluent in English, (b) not ac-
tively psychotic, and (c) able and Willing to partici-
pate in a written survey.
This selection process yielded a total of 36 sub-
jects: 28 patients and 8 therapists. Of the latter, 2 were
men and 6 were women; 2 had bachelor's degrees and
6 had master's degrees; and the average number of
years working in mental health was 4.6. Of the 28
patients, responses of 19 were used in the final re-
sults; the remaining surveys were either incorrectly
filled out or incomplete. Demographic data of the
patients are shown in Table 2.
Instrument and Scoring
This study used a survey and format developed by
Maxmen (1973). The study involved the use of (a) a
general questionnaire to gather demographiC infor-
mation and assess general attitudes toward group
therapy and (b) five schedules, each with 12 state-
ments (factors), which subjects were to rank from
most helpful (1) to least helpful (12). Examples of
such statements are shown in Table 1.
A point value was assigned to each ranking; for
Table 2
Demographic Data on Patients (n = 19)
Occupational Therapy
Group
Patient Category A B C D Total

capacities of the group members then obViously the Sex

female 2 2 3 0 7 (37.0%)
therapeutic enterprise will be derailed: patients will Male 4 4 1 12 (63.0%)
3
become bewildered and resistant; therapists, discour- Age (in years)
aged and exasperated" (Yalom, 1985, p. 106) 20-29 3 2 0 0 5 (26.0%)
30-39 2 2 0 1 5 (260%)
Our objectives in the present study were (a) to 1 1 1 6 (32.0%)
40-49 3
identify within occupational therapy groups the thera- 50-59 0 1 I 1 3 (J60%)
peutic factors considered by patients and occupa- M 313 368 478 430 384
Diagnosis
tional therapists to be most and least helpful and (b) Schizophrenia 6 1 2 14 (74.0%)
5
to ascertain whether patients who attend dilferent oc- Depression 0 0 0 1 1 (50%)
cupational therapy groups value the same therapeutic Bipolar disorder 0 0 2 0 2 (10.5%)
Other psychosis 0 1 1 0 2 (105%)
factors.

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 example, factors ranked firsl, that is, as mOSl helpful,
received 12 points. A cumulative score was derived by
adding the pOints aSSigned to a particular factor on all
five schedules. Thus, the highest possible cumulative
score for anyone factor was 60; the lowest possible
score,S.
Replicating the procedure used by Maxmen
(1973), we classified the cumulative scores as most
helpful (cumulative score of 40 to 60 points), moder-
ately helpful (cumulative score of 30 to 39 points),
and least helpful (cumulative score of 5 to 29 points).
This procedure of classification prOVided a matrix
from which our study could be compared with Max-
men's study.
Data Analysis
Therapeutic factors were ranked according to the
mean value of the cumulative score for each factor.
The data were then analyzed with the Kruskal-Wallis
ranking of variables for the total group and the Bon-
ferroni correction for each factor.
Results
Eighteen of the 19 patients and all 8 of the therapists
believed that their group was helpful; only 1 patient
reported the group to be harmful. Each survey was
then analyzed to determine which therapeutic factors
were perceived as helpful and whether there was
agreement between patients and therapists on these
factors. Table 3 proVides a summary of the relative
importance of all 12 factors.
The patient sample ranked group cohesiveness,
interpersonal learning-output, and instillation of
hope as most helpful and identification, existential
factors, guidance, and catharsis as least helpfu I (see
Table 3). When comparing the rank order of the thera-
peutic factors (see Table 4), we found significant dif-
ferences between total patients and tOtal tl1erapists in
their ranking of family reenactment (p < .001), exis-
tential factors (p < .05), and identification (p < .05).
No significant differences were found between the
patients' and therapists' rankings for the remaining
factors.
Because the aggregate data are based on the four
occupational therapy groups in combination, that is,
total patients, one would expect the perceptions
within each group to reflect the combined rankings.
In general, this occurred. Most notable was the high
value placed on group cohesiveness and instillation
of hope by patients from each of the four occupational
therapy groups and the high value placed on inter-
personal learning-output by patients from three of
the occupational therapy groups. Most of the thera-
pists also ranked these factors highly. In one group,
however, there was a discrepancy between the pa-
tients' and the therapists' views of group cohesiveness
and interpersonal learning-output; the patients val-
ued cohesiveness more highly than did their thera-
pists, and the therapists valued interpersonal learn-
ing-output more highly than did their patients. Instil-
lation of hope and guidance were among the top four
factors valued by both the patients and the therapists
in this occupational therapy group.
Within each occupational therapy group, there
was more variation between patients' and therapists'
rankings of those factors that differed significantly
when the groups were pooled. Because of the general

Table 3
Helpful Factors in Occupational Therapy Groups
Percentage of Patients (n : 19) Percentage of Therapists (n : 8)

Most Moderately Least MOSl Moderately Least

Therapeutic Helpful Helpful Helpful Helpful Helpful Helpful
factor' (40-60 pts.) (30-39 pts.) (5-29 pts) (40-60 pts.) (30-39 piS.) (5-29 piS.)
Group
cohesiveness 680 16.0 16.0 50.0 250 250
Interpersonal
learning-output 320 520 16.0 625 375 0.0
instillation of
hope 26.0 580 160 37.5 ')0.0 12.5
Universality 210 580 21.0 0.0 500 50.0
Guidance 160 320 520 75.0 12.5 125
Fan1ily
reenactment 160 52.0 320 0.0 125 87.5
Altruism 160 530 31.0 25.0 500 250
Catharsis 11.0 37.0 520 250 375 37.5
Interpersonal
learning-input 10.0 ')8.0 32.0 37.5 375 25.0
Self-understanding 5.0 630 32.0 125 00 875
Identification ')0 210 74.0 2')0 50.0 25.0
Existential faclols 0.0 370 630 0.0 0.0 100
---------------
'(YaIom, 1970,1985)

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january 1991, Volume 45, Number 1
 Table 4
Rank Order of Therapeutic Factors Based on Average Cumulative Score
Rank (Cul1lubrive Score)
------
Towl Patients from Palienlb from Patients from Pa[ienlS from
Therapeutic Total Patients Therapists Group A Group B Group C Group 0 Total Subjects h
Factor" (11=19) (II = 8) (n = 6) (II = 6) (n = 4) (II = 3) (N = 27)
----
Group
cohcsiveness I (452) 3 (401) 2 (83) I (425) J (50.0) I (450) I (423)
Interpersonal
learning-output 2 (72) I (423) I (92) 2 (39.7) 8 (05) 4 (373) 2 (38.7)
Instillation of
hope .3 (62) -i (75) 5 (323) 3 (357) 2 (40O) 3 (400) 3 (66)
Universal it) -I (343) 9 (283) 7 (20) 405.5) 3 (345) 5 (363) 6 (325)
Family
reenactment" , 5 (32 H) I] (193) 8 (310) 8 (29.3) 5 (33 5) 2 (423) 10 (28.8)
lnterrersonal
learning-input 6 C,19) 5 (70) 3 (3-13) 5 (33) II (268) 7 (31O) 4 (33-i)
Self·understandi ng --; (315) 10 (250) -i (3.~7) 10 (282) 7 (320) 6 (533) 9 (296)
Altruism 8 (11) 802.8) 5 (23) 7 (307) 6 (32.5) JO (273) 8 (316)
Catharsis 8 (311) 7 (334) 10 UOH) 6 (33.5) 9 (295) 9 (290) 7 C.317)
Guidance' 10 (294) 2 (418) 8 (310) 9 (29.5) ~ (338) 12 (200) 5 (330)
Existel1lial
faclors* * 11 (27]) 12 (]7 9) 11 (268) 12 (252) to (28.0) 8 (300) 12 (243)
Idelllificalion" 12 (23H) 6 (35~) 12 (26.0> 11 (26.3) 12 (19 ..3) J I (203) 11 (272)
- - - - _..- ------- ---- ---
.1(Yalom, 1970. 1985) hThe Kruskal-\'(/;t1lb ranking of '·ariahles was used for the to[al subjects group . The l·hisquare test showed this rank
order [0 he significant at the .05 levcl .
• p = .07 "p < .05. "'J) < .001

consistency between the groups when eXZlmined incli-
vidual!y or collectively for the most and least helpful
f<lCtors, the following discussion is based on the ag-
gregate data.
Discussion
Similarities of Perceptioll
Group cohesiveness, interpersonal learning-output,
and instillation of hope were the factors that were
consistently most valued by all subjects in this study.
In the psychotherapy literature reviewed by Yalom
(1985), cohesiveness is identified as most helpful by
various patient populations. Because group cohesive-
ness involves and reflects the attractiveness of a group
and the development of trust and belonging within a
group, its significance as a condition that allows for
growth and change cannot be overemphasized. As a
positive correlate to successful group therapy (Yalom,
1985), cohesive factors may be a prereqUisite for the
therapeutic effect of activities (whether they be
geared toward social or task skills), the result of in-
teractions of patients around activities, or both. Activi-
ties proVide a common focus around which group
members can relate. This common focus may be the
first step in the development of emotional ties that
Freud (1921/1961) noted to be an essentiZlI compo·
nent in groups.
Interpersonal learning-output, which involves
learning to relate to others, is often an implication or
explicit goal of occupational therapy groups such as
those in the present study. The subjects· selection of
this factor as helpful suggests that the communication
of goals that are appropriate to patients· needs was
clear. The selection of interpersonal learning-output
rather than input also suggests an emphasis on and
appreciation for behavioral change rather lhan in-
creased insight. This emphasis may reflect the social
and behavioral emphasis of day treatment centers.
The underlying importance of social relationships in
any group setting is implied by these findings. Be-
cause research has shown that task groups can be
more effective than verbal groups at improving social
skills (DeCarlo & :Mann, 1985; Howe & Schwartzberg,
1986; Mumford, 1974), it is important to retain the
focus of interpersonal learning-output in activity
groups.
Instillation of hope, the third factor highly valued
by all subjects, is a necessary condition for growth and
change in psychotherapy groups (Yalom, 1985). In
psychiatric rehabilitation, hope promotes a future ori-
entation for patients (Anthony, Cohen, & Cohen,
1984) This belief is consistent with the goals of the
occupational therapy groups in the study; goals are
oriented toward the development and maintenance of
skills necessary for presenl and future community
(e.g., family, work) interaction Group activities allow
patieOls to explore aml develop those necessary skills
and behaviors
If exploration proVides a foundation for the de-
velopmeI1l of competence and achievement (Reilly,
1974), il is not surprising that a feeling of hopefulness
would also be fostered. The significance of hopeful-
ness as a therapeutic factor in activity groups reflects

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 the role played by affective elements in any behav-
ioral change These affective elements may arise from
the inherent qualities associated with activities
(Boyer, Colman, Levy, & Manoly, 1989; Cynkin, 1979;
Fidler & Fidler, 1978) A feeling of hope, as with a
feeling of belonging, can provide an impetus for
learning and change. Because these qu::dities were
important to the patients in our study, they could be
used to enhance the effect of group dynamics, even in
activity groups that focus on skill development or be-
havioral change.
Cohesiveness, interpersonal learning-output,
and hope must therefore he viewed as significant
therapeutic factors that are interdependent. Without
the inter;Jction among these three components, thera-
peutic goals may not be achieved.
Differences in Perception
As previously stated, in one occupational therapy
group there was a difference in how the patients and
their therapists viewed the factors of cohesiveness
and interpersonal learning-output. This particular
group was the only occupational therapy group with
goals focused on both social skill development and
specific task skill development. Although the goals
spanned two areas, it appears likely that (a) the pa-
tients were unclear about the group's goals or (b) the
patients focused on goals that met their personal
needs regardless of what was being emphasized.
The way in which the patients and therapists
viewed the least helpful factors varied. The therapists'
rankings may reflect their explicit and implicit group
goals as well as their leadership style, whereas the
patients' rankings may reflect what they find helpful
in the group, which is not necessarily a group goal.
When patients' and therapists' rankings are compati-
ble, it suggests that the group's goals are appropriate,
the patients' needs are being met, and communica-
tion is clear. It might, however, suggest that the thera-
pist's bias has affected the group's responses (Lieber-
man, 1972). A significant discrepancy in rankings
raises the question of whether therapeutic factors are
being appropriately emphasized. Four of the factors
in this study reflect such a discrepancy: gUidance,
identification, family reenactment, and existential
factOrs.
The difference in how patients versus therapists
ranked gUidance 00 vs. 2, respectively), for example,
may be explained as a difference in labeling. The
feedback and interventions that therapists perceive as
gUidance may be seen by patients as a means of learn-
ing to approach others more successfully (interper-
sonal learning-output). Another explanation may be
that advice is valued more by its giver than by its
receiver. Finally, while therapists may feel it is im-
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portant to encourage group members to advise each
other, the members themselves may not.
Identification was also ranked differently by ther-
apists and patients (p <05). Sevemy-hve percent of
the patients ranked thiS factor in the least helpful cate-
gory (this concurs with other research [Marcovitz &
Smith, 1983; Maxmen, 1973; Yalom, 1985]), giving it a
rank of 12, whereas 75% of the therapists viewed it as
moderately to most helpful, giving it a rank of 6. The
reasons for this finding may be similar to those for
gUidance.
The definitions of these factors (identification
and guidance) involve learning from peers. With
identification, group members become the role
models. Although this is typically stressed by occupa
tional therapy group leaders as a desired component
of the group's process, the value of role modeling
behavior may be greater for the role model (interper-
sonal learning-output) than for the other members.
Another explanation for this discrepancy may be that
the value of factors such as identification and gUid-
ance may be unconscious; patients, therefore, may not
recognize its helpfulness, while therapists do.
A third factor that was ranked differently by pa-
tients and therapists was family reenactment. In other
studies, patients viewed this factor as among the least
helpful (Maxmen, 1973; Yalom, 1985), whereas thera-
pists often valued it highly (Yalom, 1985). In our sam-
ple, the reverse occurred. Because none of the four
occupational therapy groups was based on an analyti-
cal frame of reference, transference issues that are
implied by this factor are not focused on. The thera-
pists, therefore, wou ld not be expected to select state-
ments related to family reenactment as particularly
helpful. Two thirds of the patients, however, did. This
might have been related to a difference in interpreta-
tion of the statements representing this factor. In psy-
chiatric rehabilitation, the need to increase patients'
dependency on the program is the first step toward
independence (Anthony et aI., 1984). Possibly, the
patients' rankings of family reenactment statements
may reflect this dependency, and the fact that patients
view the day treatment center almost as a surrogate
family. Rather than focusing on transference issues,
therefore, the patients are focusing on their sense of
belonging to the day treatment center; thus, family
reenactment may be another expression of group
cohesiveness.
Existential factors, the fourth therapeutic factor to
be viewed differently by the patients and therapists in
this study (p < .05), was ranked low by both groups
(the patients ranked it 11; the therapists, 12). Despite
the low ranking by the patients, 37% of the patients
considered it to be moderately helpful (see Table 3).
Tbe patients' moderate valUing of existential factors is
supported by other research (Leszcz et a!., 1985;
January 1991, Volume 45, Number 1
 Maxmen, 1973; Yalom, 1985), The existential state-
ments in the survey relate to issues of control, that is,
the need to be able to take responsibility for oneself
and for ooe's actions and to understand that there are
some things in life over which we have no control.
Although therapists may not identify this as a specific
group goal, it is certainly an implied objective of the
groups and of the day treatment ceoter in gen-
eral. Some patients recognize this and value its
importance.
Similarities Witb Other Studies
Similarities of our findings with those of other studies
are striking. Despite differences in diagnoses, treat-
ment settings, and group format, certain therapeutic
factors are consistently operational In Yalom's
(1985) review of psychotherapy grou ps, co hesiveness
and interpersonal learning are most valued by pa-
tients, which was the finding in our study A compari-
son of perceptions of helpful therapeutic factors
among the patients in our study with those of I'vlax-
men's (1973) study reveals that subjects from barh
studies highly valued cohesiveness and instillation of
hope. Yalom (1985) noted that perceptiofls of helpful
therapeutic factors depend on elements such as pa-
tients' diagnoses, treatment settings, and stages in a
group's development. Yet these are the very elements
thal distinguished the two study samples from one
another: Maxmen's subjecrs were from a short·term
inpatient se[[ing and participated in a psychotherapy
group characterized by rapid membership turnover,
and few of his subjects were diagnosed as having
schizophrenia The subjects in our study were long-
term partiCipants of day treatment centers, were in
occupational therapy groups char:lCterized by ongo
ing and stable membership, and were diagnosed as
having schizophrenia. The perception of patients
from both studies that cohesiveness and instillation of
hope are most helpful suggests that these particular
factors carry a universal importance thal belies group
differences
Implications
The findings from this study suggest th:J.t therapeutic
factors, as defined by Yalom (1970,198'5), are in faet
valued in psychiatric occupational therapy tre3tmcnt
groups. Occupational therapists net'd to be :I\vare of
the value of these factors and the role they pby in a
group's dynamics.
Factors that arc valued by palients can and should
be used to promote specific gmll achievenwnr By
being aware of what the patie11l pel-ceives as helpful,
the occup3tional therapist can ensure thallile group's
goals and methods appropriately address patients'
needs. If therapists are unaware of what patient~ per-
The American journal o/Occupatiolial Therapy
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ceive as helpful, or if therapists rely on an underval-
ued factor in their methods to achieve particular
goals, then the group may become unattractive and,
therefore, unsuccessful.
The specific relationship between therapeutic
factors and aerivities was not a focus of this study, The
study findings, however, suggest that a relationship
may exist. Activities can be used to facilitate the devel-
opment of helpful therapeutic factors, and therapeutic
factors can be used to maximize the inherent or pre-
scribed therapeutic effect of the activities. The thera-
peutic potency of occupational therapy groups may
result from this dynamic interaction between activi-
ties and therapeutic factors. Further research needs to
be done in this area
Finally, the importance of these therapeutic fac-
tors in groups should not be limited to mental health
settings. Their value may enhance the achievement of
treatment goals in other specialty areas; this should be
t'xplored further in other studies.
Study Limitations
A number of limitations need to be considered \\Then
evaluating the results of this study The overall sample
size and the small size of e3ch occupational therapy
group did not permit in-depth statistical analysis. Be-
cause the sample was limited to chronic psychiatric
patients at day treatment centers, the results cannot be
generalized to occupational therapy groups within
other settings or with other populations. The data
collection instrument used in the present study was
lengthy and rather complex. Although the patients
were able to accurately complete the survey, perhaps
a simpler survey would have yielded more accurate
results
Conclusion
The perception of therapeutic factors in activity
groups is an important consideratiun, because it is
these factOrs that allow change to occur Although this
study had:.1 limited number of subjt'cts, it is probably
not coincidental that the patients' must valued thera-
peutic factors in the occupational therapv groups sur-
veyed corresponded with those valued by patients in
group psychotherapy Principles of group dyn,lInics
transcend profeSSional disciplines, and it is important
to understand and apply these concepts to occupa-
tional therapy. Particularly salient in the present study
was the value placed on group cohesiveness hy the
patients, which suggests that the development and
maintenance of group cohesiveness is the condition
for the groups' therapeutic effect The results of this
study also suggest a strong interaction betwt'en the
factors of cohesiveness, hopt', and interpersonal
learning and group efficacy; it is these three factors
65
 that patients and therapists considered to be most
helpful. ..
Acknowledgments
We thank the patients and therapists who participated in this
study; ]errold Maxmen, Mo, for his generous support; Fran-
cine Cournos, Mo, Barbara Bouley, OTR, Barbara Henryson,
OTR, and Anne Robinson, OTR, for their cooperation; and
Edith Flaster and the Center for Clinical Research at Co-
lumbia University, New York, New York.
This paper is based in part on a presentation given in
April 1989 at the 69th Annual Conference of the American
Occupational Therapy Association in Baltimore, Maryland.
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January 1991, Volume 45, Number 1