One Flew Over the Cuckoo’s Nest Essay Example for Free

One Flew Over the Cuckoo’s Nest Essay One Flew Over the Cuckoo’s Nest published in 1962 is a fiction novel by Ken Kesey. The novel is set in an Oregon asylum and serves as a study of the institutional practice and the human mind. Its curious approach lays the foundation for a discussion concerning truth, as not each event described by the narrator is possible truth in the book’s reality, such an evaluation is made by the reader. One Flew Over The Cuckoo’s Nest is the creation of both the personal experiences of the author, Ken Kesey, and the particular culture in which it was written. Kesey developed the novel as he attended Stanford University as a graduate student in their Creative Writing program as the winner of a Woodrow Wilson Fellowship. The novel was partly inspired by Kesey’s part-time job as an orderly in a Palo Alto veterans’ hospital. It was moreover as a student at Stanford where Kesey started participating in experiments for the psychology department that involved the exercise of LSD. This use of LSD had driven Kesey to have hallucinations while working as an orderly. Kesey imagine seeing a large Indian mopping the flooring of the hospital; this hallucination prompted Kesey to include the character Chief Bromden as the novel’s narrator. â€Å"What is the character of Bromden? How he regain his sanity? † A tall, half-Indian patient in the ward, Chief Bromden is the patient who has been considered the longest in the institution. Even though others believe that he is deaf and mute, Chief Bromden instead prefer not to speak, originally for the reason that others ignored him and then out of fear of Nurse Ratched. Chief Bromden is said to be the narrator of the novel. With the aid of McMurphy, he started to speak once more and reassert himself against Nurse Ratched and her workers. Chief Bromden speaks to McMurphy and sooner overcomes his schizophrenia throughout his influence, distinguishing himself for the physical giant and mistreated man he has always been. Chief Bromden’s background has had an intense impact on his character. Society never treated him with the respect every person deserved, and not being competent to face up to it, he was forced into hiding out in a mental institution. The abandon from society all through his life turned the Chief into a paranoid, unconfident and reserved man. The reader gets a quick look of Chief Bromden’s paranoia in the start of the novel. General Discussion The One Flew Over The Cuckoo’s Nest novel in some sense structures a bridge between the bohemian beatnik movements of the 1950s and the 1960s counterculture movement. Kesey was significantly motivated by the beatnik culture around Stanford, and in the novel Kesey deals with a number of themes that would be important in the counterculture movement, as well as notions of freedom from repressive authority and a more liberated observation of sexuality. Kesey himself became an extremely influential counterculture figure as piece of the Merry Pranksters. Chief Bromden is a half American Indian. His father was a chief named Tee Ah Millatoona, which referred as The-pine-that-stands-tallest-on-the-mountain. That is why he is capable of using the title chief. He took on his mother’s last name of Bromden. He spent his growing up stage in the Columbian gorge. The chief is massive and tall and would appear very unapproachable and threatening to those who meet him. He was committed to the hospital institution and has been there for longer than anybody else, for over 15 years. Chief Bromden was put in there after World War two. The chief was an electricians assistant in a training camp prior to the army shipped him off to Germany. It is possibly due to working with electronics and the added tension of going to war that has led the chief to have such a harmful preoccupation with electronics. The chief has led everybody in the hospital, both staff and patients to think he is deaf and dumb. As a young child he was for all time ignored, by fellow students and adults, this could have been for the reason that he was so strange looking, being half American Indian and appearing so big and threatening yet being quite shy. I had to keep acting deaf if I wanted to hear at all Chief Bromden said. He felt abandoned by his peers all through life and so as an adult decided that as people acted like he was invisible he might as well vanish, It wasnt me that started acting deaf, it was people that first started acting like I was too dumb to hear or see or say anything at all Chief Bromden said. So acting to be deaf and dumb was most likely a defense mechanism. For him, his silence is also exceptionally potent. As he is capable to hear all that went on in the meetings where the doctors and nurses talk about the future of the patients. The doctors and nurses dont hesitate to declare anything in front of him for the reason that they assume he cant hear. Chief Bromden said They dont bother not talking out loud about their hate secrets when Im nearby because they think Im deaf and dumb. The process and experiences that Chief Bromden has to go through in order to regain his sanity is discussed below. In the first chapter, Kesey sets up the formation of the mental institution where the novel takes place. The authority figure is obviously Nurse Ratched, as yet known merely as Big Nurse, a woman whose character seems hardly human. Kesey makes the whole thing about Nurse Ratched mechanical and automated, such as her robotic movements and accurate speech. She is a representation of bureaucracy and authority in general. Conversely, even within this first chapter there are signs that behind this apparently inhuman facade there is some great instability. Chief Bromden appears to believe that Nurse Ratched is ready to snap at the black boys at any minute, and her big breasts, the one absurd part of her appearance, illustrate that she is unable of fully separating herself from typical human characteristics. The black boys, the workers at the institution, serve Nurse Ratched out of terror; on the other hand, their most well-known characteristic is an absolute hatred for all around them. Unlike Nurse Ratched, they are cruel, if only for the reason Nurse Ratched is incapable of feeling any satisfaction from the pain she inflicts. This makes them a more immediate threat to patients such as Chief Bromden, but also more at risk. They go through from the same human failings that Nurse Ratched has concealed. Even though Chief Bromden is the narrator of the tale, his descriptions cannot be entirely trusted. He is clearly unreliable, as shown when he hallucinates the Air Raid and the fog machine. The fog symbolizes Bromden’s own mental clarity; it will reappear whenever Chief Bromden turn into less stable and recede every time he becomes more coherent. It is significant that Chief Bromden is silent, for he stands for the more passive elements of society that submit to authority which is Nurse Ratched. In chapter three having illustrates the support staff of the hospital, Chief Bromden turns to the patients who occupy the institution. The majority of the patients are Acutes, meaning that they have the likelihood for rehabilitation and release, but Bromden makes the significant point that they also have the risk of becoming worse for the reason of their stay at the hospital, as established by Ruckly and Ellis. Kesey makes obvious the lines of disagreement between McMurphy and Nurse Ratched. Nurse Ratched signifies rules and order, while McMurphy symbolizes anarchy and disobedience. Yet a more significant characteristic that McMurphy displays is showmanship. In this chapter he grasps for attention, acting like a politician on a campaign stop. This trait will cause McMurphy to be an easy target for those in the institution, mainly Nurse Ratched. Chief Bromden releases the critique of the mental institution in One Flew Over the Cuckoo’s Nest to a bigger societal critique. The social criticism of the events in the novel generally entails the idea that the institution is a microcosm for the entire society, but Kesey moreover makes the precise connection between the institution and other societal organizations. The mental institution is intended to repair damage done by schools, churches and families, however operates under the similar conditions as these organizations and hence suffers the same problems. In chapter six Chief Bromden’s suggestion that Nurse Ratched can direct the clocks at the ward show that Chief Bromden is frequently unreliable as a narrator, but nonetheless remains constant with Ratched’s domineering and controlling personality. Harding, the president of the patients’ council and a college graduate, continues to serve as an expository device; it is he who gives details to McMurphy the causes for various events at the institution, such as the music. Kesey establishes another contrast between McMurphy and Nurse Ratched in this chapter. His confrontation with Nurse Pilbow, one of Ratched’s nurses, underscores that Ratched signifies sexuality, as compared to the passionless and reserved Nurse Ratched. In chapter seven, this chapter once again serves to demonstrate that Chief Bromden is an unreliable narrator. Even though several of the details of his observation are true, others are mainly fantasy; Bromden worries that the workers are using the Vegetables for terrible experiments and will do the same to him. On the other hand, Kesey makes it unquestionably clear that Bromden is having a hallucination in this chapter when Mr. Turkle, the night watchman, wakes him. In chapter twelve Kesey demonstrates these chapters in short succession. Two of these include little more than a paragraph. This serves to show the disjointed nature of Chief Bromden’s observations. He presents only short glimpses of events that transpire in the institution, none of which include any great importance. The most significant point that Chief Bromden makes is that the ‘insanity’ as illustrated by the fog is a comfort for the patients. It permits them to recede from the complexities of reality that McMurphy wants them to face. In chapter fifteen Kesey uses Chief Bromden mainly as a narrator who illustrates external conditions, and hardly gives insight into Chief Bromden’s own psychology. On the other hand, in this chapter Kesey gives several indication of the origin of Chief Bromden’s psychological problems. Bromden relates the imaginary ‘fog machine’ of the mental institution to the fog that surrounded him throughout wartime. This point out that Chief Bromden probably suffers from shell-shock caused by his war experience, and it is this shell-shock which driven him to lose his grip on sanity. Kesey in addition gives a similar psychological deconstruction of Billy Bibbit. The beginning of Billy Bibbit’s problems leads to a strict Freudian interpretation. He is the creation of a domineering mother who controls his all action, as well as deciding which woman is suitable for him to marry. That the first word Billy Bibbit stuttered was ‘mama’ is an obvious indication that she is the cause of his problems. His mother’s obvious collaboration with Nurse Ratched is additional evidence that Billy’s mother is the cause of most of his troubles. McMurphy assumes the part of a revolutionary in this chapter. When he rebels against Nurse Ratched by breaking from the recognized schedule to watch the World Series, McMurphy at last abandons the rules and regulations of the ward. This rebellion take place, though, only after it is obvious that McMurphy cannot take part in the apparently democratic system that Nurse Ratched controls. This is a significant point, for it reveals that McMurphy is not a casual anarchist bent on breaking down any system of governance, but rather a man driven to rebellion by an unjust system around him. Even though Nurse Ratched’s claim that the vote is democratic, her vote consists the Chronics, who have no capability to make a rational choice required of voting. This guarantees that Nurse Ratched can keep the status quo, despite the clear support for McMurphy. When McMurphy shatters from his schedule to watch the World Series, he makes an ultimate break from the ‘government’ of Nurse Ratched. It is a revolutionary measure on the level of the institution. The vote for the World Series is a defining moment for Chief Bromden, for it is the first point through which he reasserts himself as a functioning person. He does this in the course of his vote for McMurphy, the first ultimate, responsive action that Chief Bromden takes throughout the novel, and continues this pattern when he unites with McMurphy and the other Acutes in the protest against Nurse Ratched. This underscores a foremost theme of the novel, the importance of rational choice. It is the capability to choose that determines one’s status as a rational human being. One Flew Over the Cuckoo’s Nest in a very important sense centers on the conflict between McMurphy, who characterizes this capability for choice, and Nurse Ratched, who does not permit persons to determine decisions for themselves. In chapter sixteen the fog that Chief Bromden declares to see is a symbol of his incoherence and incapacity to assert himself, therefore when Bromden makes the decision to join the other men in dispute of Nurse Ratched, the fog vanish. This decision comes at a cost, on the other hand; by making choices Chief Bromden becomes susceptible, as he realizes. He loses the protection of the fog for the privileges of human choice. Chief Bromden’s choice to present himself once again as deaf and dumb is a strategic move that serves both himself and, for the narrative intentions of the story, Kesey. Bromden uses the perception that he is deaf and dumb as a scheme to deflect harassment by the black boys, but this perception also permits Chief Bromden access to circumstances such as the staff meeting that would usually remain secretive. Kesey grants Bromden access to the staff meeting to gives better insight into both Nurse Ratched and the perceptions of McMurphy. In chapter seventeen Kesey demonstrates the change in Chief Bromden in this chapter, when the character awakes and watches the dog outside the window. This shows that Chief Bromden is now more aware of the outside world. He can conceive of existence outside of the institution, as he could not before. McMurphy is the primary cause of this change. In chapter twenty four Chief Bromden’s stories about his childhood reveal that he, like Harding and Billy Bibbit, undergoes to some degree from a domineering female figure. Like Billy Bibbit, Chief Bromden is frightened by his mother, whom he describes as â€Å"twice as tall† as his father, who was himself a big man. Chief Bromden point out that his mother dominated both him and his father, causal to the problems that both faced. It is from his father that Chief Bromden developed the thought of the Combine. The story that Chief Bromden tells McMurphy supplies a huge deal to a psychological analysis of the character. He appears to be deaf and dumb mainly for the reason that he has been frightened by others around him, whether heartless inspectors or his domineering mother. However Chief Bromden reasserts himself once McMurphy proves him some degree of kindness and respect. Chief Bromden is possibly the best example that Kesey provides of the beneficial effect that McMurphy has on the patients in the institution. Kesey indicates later even when McMurphy discusses the control panel in the tub room. He gives Chief Bromden the thought that he might be able to raise the control panel and throw it all the way through the window, permitting an escape. The one question that remains is what will induce Chief Bromden to carry out this action. In chapter twenty seven Nurse Ratched does achieve a victory over McMurphy in this chapter, but whatsoever victory she has will be short-term. The shock treatment does not radically affect Chief Bromden; he rapidly regains a sense of lucidity subsequently and returns to rationality. More significantly, the nurse who treats McMurphy’s wounds makes the significant point that other nurses are contradicted to Nurse Ratched’s behavior. Even though Nurse Ratched keeps a tight grip on her specific ward, she is susceptible within the very institutional structure she uses against her patients. In chapter Twenty-Nine the final chapter of One Flew Over The Cuckoo’s Nest culminates in a pyrrhic triumph for Nurse Ratched but a final triumph for the martyred McMurphy. The argument between the two characters aligns on sexual lines, as set up by the disagreement between Nurse Ratched and Billy Bibbit that instantaneously precedes it. McMurphy’s attack on Nurse Ratched results an exact exposing of the Big Nurse. Once again the sexual connotations are tough, for when he attacks her he reveals her breasts, the one sign of her femininity. This also relates back to Harding’s previous suggestion that sex is the cure for Nurse Ratched; this chapter demonstrates that, if it is not the cure, it is surely a potent weapon against her. The outcome of this fight, nevertheless, is the final dehumanization of Nurse Ratched. When she proceeds to the ward, she is incapable of speaking and hence has lost a foremost sign of humanity. This neatly parallels Chief Bromden, who in the path of the novel recovers his voice and his humanity. McMurphy apparently loses his battle against Nurse Ratched when she commands a lobotomy for him, but the victory is hollow; she loses power over the ward as the other patients free themselves of her grip and willingly leave the hospital. This moreover fits in well with the Christian symbolism of the novel; even though McMurphy dies for his reason, his disciples leave the hospital to live in accordance to his teachings. They achieve the strength and the liberty to make independent choices that McMurphy proposed. Chief Bromden best exemplifies this. Throughout the course of the novel he has regained his voice, and he makes the ultimate step in the direction of self-realization at the novel’s end. By moving the control panel, Chief Bromden fulfills McMurphy’s desires and reasserts himself as a member of society.

Hummingbirds :: Biology Animals Birds

Hummingbirds are stunning creatures, but their future can be bright only if they have plenty of flowers for food and trees for shelter. Unfortunately, human population grows too fast for the hummingbirds' habitats. Once a person knows more about these charming animals, they will find the forests a richer place to protect. Hummingbirds are the smallest and most brilliantly colored birds. Their aerial maneuvers fascinate all. Hummingbirds are promiscuous animals, and families generally consist of a single mother and two baby chicks. It all starts during mating season, when a male tries to attract a female. He may hover in front of her showing off his gorgeous wings, tail, beak and plumage. If she isn?t interested she just flies away. If he wins her affection, they will sleep together one night. In the morning they?ll fly away in separate directions and probably never meet again. Males obviously take no part in raising the young. Two white pea-sized eggs are generally laid, several days apart. The hummingbird mother works very hard to care for her young. The two chicks are born naked, blind, and smaller than bumblebees, but they grow quickly. By the time they are three to four days old, their eyes open, and the mother continues feeding them. The duration of nesting period is fourteen to thirty-one days depending on the food available and the strengths of the chicks and the mother. When they are ready for fledging, the chicks may be 4.5 grams while their exhausted mother is down to 2.5 grams after the feat of raising her young. After a month or so, the hummingbirds leave their nest and master flying quickly and easily. They are continued to be fed because they end up wasting a lot of time mistaking hats, signs, and other bright objects for flowers. The average life span of a hummer is probably three to five years. The record has been twelve years. There are about three-hundred and twenty different species, and the Bee Hummingbird is the smallest. 8 cm is not only half of the length of my pen, but also the length of the largest hummingbird, the Giant Hummingbird. The beak and tail tend to make up half of their small length. Most hummingbirds have ten tail feathers. These tails come in 2 a variety of shapes, and depending on the way the sunlight hits it, these tail feathers may flash red, gold, purple, or black.

Behaviour Research and Therapy Essay

Abstract Cognitive-behavior therapy (CBT) for Social Phobia is effective in both group and individual formats. However, the impact of group processes on treatment efï ¬ cacy remains relatively unexplored. In this study we examined group cohesion ratings made by individuals at the midpoint and endpoint of CBT groups for social phobia. Symptom measures were also completed at the beginning and end of treatment. We found that cohesion ratings signiï ¬ cantly increased over the course of the group and were associated with improvement over time in social anxiety symptoms, as well as improvement on measures of general anxiety, depression, and functional impairment. In conclusion, ï ¬ ndings are consistent with the idea that changes in group cohesion are related to social anxiety symptom reduction and, therefore, speak to the importance of nonspeciï ¬ c therapeutic factors in treatment outcome. r 2006 Elsevier Ltd. All rights reserved. Keywords: Social phobia; Social anxiety disorder; Group c ohesion; Cognitive-behavior therapy Introduction Social phobia is characterized by an excessive fear of social or performance situations, during which a person may be scrutinized, judged, embarrassed, or humiliated by others. Evidence-based psychosocial treatments for social phobia have primarily come from a cognitive-behavioral orientation and include various combinations of four main components: (1) exposure-based strategies, (2) cognitive therapy, (3) social skills training, and (4) applied relaxation (for reviews, see   administered in either individual and group formats (e.g., Heimberg, Salzman, Holt, & Blendell, 1993; Turner, Beidel, Cooley, Woody, & Messer, 1994). However, the mechanisms of change, and effective ingredients of these treatments remain relatively understudied. Researchers have compared group and individual treatments for this condition, although evidence regarding the relative effectiveness of each approach has been inconsistent (see Scholing & Emmelkamp, 1993; Stangier, Heidenreich, Peitz, Laut erbach, & Clark, 2003; Wlazlo, Schroeder-Hartwig, Hand, Kaiser, & Munchau, 1990 for direct comparisons of individual and group cognitive-behavioral treatment for social  ¨ phobia). However, for some patients, group treatment may offer a number of advantages over individual treatment. For example, group treatment provides an opportunity to marshal group processes (e.g., encouragement, support, and modeling from other group members) that may aid in teaching cognitive strategies and facilitating exposure exercises. Further, there may be nonspeciï ¬ c effects that arise as a result of the relationships that form amongst group members that may contribute to therapeutic outcome. We decided to investigate how these group processes, particularly group cohesion, may be related to treatment outcome in cognitive-behavior therapy (CBT) groups for social phobia. Within the group therapy literature, one putative mechanism of change is that of group cohesion (Yalom, 1995). However, the construct of group cohesion has deï ¬ ed ready operational deï ¬ nition, especially with more technique-driven interventions like CBT. For example, a broad deï ¬ nition proposed to explain group cohesion is ‘‘the resultant of all forces acting on all the members to remain in t he group’’ (Cartwright & Zander, 1962, p. 74) or, in simpler terms, how attractive a group 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 levels of cohesion are presumed to have a higher rate of attendance, participation, and mutual support, and to be likely to defend group standards much more. Further, Yalom (1995) believes that group cohesion is necessary for other group therapeutic factors to operate. Researchers studying this construct have also included concepts such as a sense of bonding, a sense of working towards mutual goals, mutual acceptance, support, identiï ¬ cation, and afï ¬ liation with the group (e.g., Marziali, Munroe-Blum, & McCleary, 1997). Clearly then, cohesion is purported to be a critical ingredient for change and therefore would be expected to predict symptomatic outcomes. Some researchers investigating the relationship between group cohesion and treatment outcome have found positive results. Although some of these studies have investigated other nonspeciï ¬ c therapeutic factors as well (i.e., the therapeutic alliance), the present discussion will focus on ï ¬ ndings related to group cohesion processes. Studies have found that group cohesion is related to pre-treatment levels of symptomatic distress, 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 signiï ¬ cantly correlated with treatment outcome and patients who made therapeutic gains reported a high level of group cohesion that began shortly after the ï ¬ rst few sessions. In contrast, unsuccessful patients did not experience a high level of group cohesion at any time. Overall, these studies suggest that group cohesion may play a role in facilitating therapeutic change, though negative ï ¬ ndings also exist (e.g., Gillasp y, Wright, Campbell, Stokes, & Adinoff, 2002; Lorentzen, Sexton, & Hà ¸glend, 2004; Marziali et al., 1997). In the CBT literature, researchers are increasingly paying attention to nonspeciï ¬ c therapeutic factors contributing to treatment outcome (e.g., Ilardi & Craighead, 1994; Kaufman, Rhode, Seeley, Clarke, & Stice, 2005). One of the ï ¬ rst studies in this area was conducted by Hand, Lamontagne, and Marks (1974) in treatment groups for individuals presenting with agoraphobia. They found that members of the group in which cohesion was speciï ¬ cally fostered demonstrated 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). Other ï ¬ ndings from the CBT treatment literature include greater group cohesion ratings predicting lower physical and psychological abuse at follow-up in abusive men (Taft, Murphy, King, Musser, & DeDeyn, 2003), higher levels of group cohesion being signiï ¬ cantly 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 indicate that group cohesion may play some role in facilitating change or enhancing long-term beneï ¬ ts in CBT-based treatments. Although it is not yet clear what factors are relevant for fostering group cohesion, certain disorders may present more challenges than others. For example, given that social phobia involves an intense fear of scrutiny from other people, these individuals may present with barriers to forming a collaborative alliance, such as poor social skills, extreme sensitivity to evaluations, or social avoidance (Woody & Adessky, 2002). Only one study thus far has examined the development 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 using Heimberg’s (1991) protocol for group CBT for social phobia and had clients rate group cohesion using the Group Attitude Scale (GAS; Evans & Jarvis, 1986). The GAS measures the clients’ degree of attraction 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 approaches might need to be further reï ¬ ned in order to more fully understand the degree to which group format and group process variables may add an important element to therapeutic outcome. It is important to note that the measure of group cohesion used by Woody and Adessky (2002) deï ¬ nes the construct unidimensionally. The GAS was designed to measure only attraction to group, deï ¬ ned as ‘‘an individual’s desire to identify with and be an accepted member of the group’’ (Evans & Jarvis, 1986, p. 204). Examples of items include: ‘ ‘I want to remain a member of this group,’’ ‘‘I feel involved in what is happening in my group,’’ and ‘‘In spite 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 both intrapersonal elements (e.g., group member’s 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 aspects of cohesion that are important for making 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 assess a number of different constructs thought to be related to group cohesion. The Group Cohesion Scale-Revised (GCS-R), developed by Treadwell, Laverture, Kumar, and Veeraraghavan (2001), taps into several different aspects of group cohesion including: interaction and communication (including domination and subordination), member retention, decision-making, vulnerability among group members and consistency between group and individual goals. This self-report questionnaire has been shown to be both reliable and valid for detecting changes in group cohesiveness during the process of group development (Treadwell et al., 2001). Clients with a principal diagnosis of Social Phobia were treated and, based on the preceding literature, we explored: (1) group cohesion development during the course of the group and (2) the relationship of group cohesion to treatment outcome, broadly deï ¬ ned to include not only social phobia symptoms, but the overall experience 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 signiï ¬ cantly related to positive treatment outcome (i.e., symptom reduction). Method Participants There were a total of 34 outpatient individuals in this study. The average age of participants was 36 years (range 19–64 years; 19 female, 15 male). All individuals reported symptoms meeting criteria for a principal diagnosis (i.e., the diagnosis causing the most distress or impairment) of Social Phobia, as determined by the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders—4th edition (SCID-IV; First, Spitzer, Gibbon, & Williams, 2001). One individual also had symptoms meeting criteria for a co-principal primary diagnosis of Dyssomnia Not Otherwise Speciï ¬ ed. For 32 of the participants, the social phobia was generalized (i.e., occurring in most social situations), whereas for the other two 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 additional mood disorder (Major Depressive Disorder, 47%; Bipolar Disorder, 6%; Dysthymic Disorder, 3%), 62% had one or more additional anxiety disorder (Speciï ¬ c Phobia, 47%; Generalized Anxiety Disorder, 26%; Obsessive Compulsive 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 Speciï ¬ ed, 6%; Cannabis Dependence, 6%; Paraphilia Not Otherwise Speciï ¬ ed, 3%; Intermittent Explosive Disorder, 3%; Impulse Control Disorder Not Otherwise Speciï ¬ ed, 3%). The values for the anxiety disorders sum to greater than 100% as several participants had multiple anxiety disorders. Measures Depression Anxiety 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 experienced over the past 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, lack of interest/involvement, anhedonia, and inertia. The Anxiety scale (DASS-21-A) measures autonomic arousal, skeletal musculature effects, situational anxiety, and the subjective experience of anxiety affect. The Stress scale (DASS-21-S) measures difï ¬ culty relaxing, nervous arousal, and a tendency to become easily upset/ agitated, irritable/over-reactive, and impatient. Strong internal consistency with a clinical sample has been demonstrated with the DASS-21 (a’s ranging from .87 to .94), and the factor structure is well supported (Antony, Bieling, Cox, Enns, & Swinson, 1998). Construct validity of the three scales has also been demonstrated (see Brown, Chorpita, Korotitsch, & Barlow, 1997). In the current sample, reliability was acceptable at pre-treatment for the Depression (a  ¼ :91), Anxiety (a  ¼ :87), and Stress (a  ¼ :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 recreation (e.g., sports), passive recreation (e.g., reading), ï ¬ nances, relationship with partner, sexual and family relations, other social relations, self-expression/self-improvement, religious expression, and community and civic involvement. For each item, an individual rates the intrusiveness on a scale for 1–7 with higher scores 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  ¼ :87). Social Phobia Inventory (SPIN; Connor et al., 2000). The SPIN is a 17-item questionnaire designed to assess symptoms of social phobia. Each item measures the severity of a particular symptom during the past week, using a ï ¬ ve-point scale ranging from 0 (not at all) to 4 (extremely). It consists of three subscales: fear, avoidance, and physiological arousal. The SPIN has been shown to have good empirical support (Antony, Coons, McCabe, Ashbaugh, & Swinson, 2006; Connor et al., 2000) and enables the assessment of a wide range of social anxiety symptoms, making it an ideal measure for generalized social phobia. The total score 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  ¼ :92) and a combined sample of individuals meeting criteria for Social Phobia (Generalized Type), Panic Disorder with Agoraphobia and Obsessive-Compulsive Disorder (with a  ¼ :95) (Antony et al., 2006; Connor et al., 2000). It has also been shown to have good test–retest reliability (r  ¼ :86, po:001), convergent and discriminant validity as well as being able to distinguish 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 changes in the severity of social phobia following cognitive-behavior treatment (Antony et al., 2006). In the current sample, pre-treatment reliability was acceptable (a  ¼ :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 usually feel free to share information,’’ ‘‘There are usually feelings of unity and togetherness among the group members,’’ and ‘‘Many members engage in ‘back-biting’ in this group.’’ This scale was recently revised (Treadwell et al., 2001) in order to modify one item, discard another item, and change the wording of the anchor points. In a validation study, internal consistency (as measured by Cronbach’s 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  ¼ :84) and at treatment endpoint (a  ¼ :79), and the reliability of the change score was .56 (Williams & Zimmerman, 1996). Procedure All individuals completed a 10-session CBT treatment group for social phobia.1 Treatment administered was based on protocols described 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 ï ¬ ve–eight patients per group. A total of 11 groups were included in the study. It should be noted that initially 76 individuals were enrolled in these 11 groups. However, of these 76 individuals, there were only 67 individuals from whom any measures were received at all (i.e., nine individuals did not return any data). In order to conduct the analyses that will 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 last session of each group. Questionnaires assessing symptom severity (i.e., the DASS-21, IIRS a nd SPIN) were completed prior to the beginning of group treatment as well as during the last session of each group. Data analysis Multilevel regression analyses (i.e., generalized mixed modeling) using the software program HLM 6 (Raudenbush, 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 maximum likelihood estimation instead of least squares. Before examining change over time in the outcome variables and GCS, intraclass correlations (ICCs) were estimated to examine the interdependence of data due to nesting (see Herzog et al., 2002). The intraclass correlation depicts how much variance in the outcome variable is due to within-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 missing. Missing values for a particular scale item were replaced by calculating the mean 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 section of moderate to severe social phobia patients typically seen in an acute outpatient clinic, presenting with anxiety disorders and related problems.

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