Scandinavian Journal of Psychology, 2012, 53, 523527

DOI: 10.1111/sjop.12020

Personality and Social Psychology

Development of sense of coherence during two group interventions
HO
NEN,1 PETRI NA
A
TA
NEN,2 ASKO TOLVANEN3 and KATARIINA SALMELA-ARO4
KARI KA
1

Department of Psychology University of Jyvaskyla, Jyvaskyla and Reflekta Ltd, Finland

Department of Psychology University of Jyvaskyla, Jyvaskyla, Finland
3
Department of Psychiatry, Helsinki University Central Hospital,Helsinki, Finland
4
Helsinki Collegium for Advanced Studies, University of Helsinki, Helsinki, Finland
2

Kahonen, K., Naatanen, P., Tolvanen, A. & Salmela-Aro, K. (2012). Development of sense of coherence during two group interventions. Scandinavian
Journal of Psychology 53, 523527.
Burnout is a serious occupational hazard. This study investigated the possibility to develop an effective salutogenic group intervention among employees
suffering from severe burnout symptoms. Participants consisted of employees aged 31 to 59 years working in different public service occupations, such as
police officers, tax officers, (and other public service officers), and assigned to three different groups: analytic (N = 25), psychodramatic (N = 24) and
controls (N = 28). The intervention comprised 16 separate days over a nine-month period. Changes in sense of coherence (SOC) were measured four times
with the 13-item Orientation to Life Questionnaire during the intervention and at six-month follow-up, and analyzed by general linear model (GLM) and
using Cohens d to estimate effect sizes. Change in SOC between the three groups was statistically significant (F(4,148) = 2.65, p = 0.036). The
psychodrama group showed a higher increase in SOC than the analytic group during the intervention, while the improvement in the analytic group was
significant during the six-month follow-up. Total effect size from baseline to follow-up was in the analytic group 0.71, in the psychodrama group 0.47, and
in the control group from baseline to end of intervention 0.09. The results show that it is possible to improve SOC by group intervention in the
occupational healthcare context. The dialogue-based analytic method and action-based psychodramatic method differ in their specific effects.
Key words: SOC, sense of coherence, group intervention, group psychotherapy, group analysis, psychodrama, occupational healthcare, burnout, stress,
salutogenesis.
Kari Kahonen, University of Jyvaskyla, Department of Psychology and Reflekta Ltd., Raakkatie 47, Iittala 14500, Finland.
E-mail: kari.kahonen@reflekta.fi

INTRODUCTION
Burnout is a chronic stress syndrome which develops gradually as
a consequence of a prolonged stress situation. It is a serious threat
for both individual employees and the public sector economy in
Finland (Ahola, Honkonen, Isometsa et al., 2006). In this study
we tried to develop a salutogenic group intervention to reduce the
risk for burnout. Feldt, Kinnunen and Mauno (2000) showed in
their study the major role of a good organizational climate for
enhancing sense of coherence (SOC), and consequently wellbeing. We wanted to know if it is possible to enhance SOC irrespective of organizational climate. We would then have two main
strategies to tackle the threat of burnout in the occupational
healthcare context, both on the individual and organizational
levels. SOC was selected as an indicator of effect because of its
positive correlations with well-being and health (see later). A salutogenic approach can also be seen as more positive than a pathogenic approach. In this study we compare and contrast the
positive effects on SOC of two types of group interventions.
Antonovsky (1987) argued that good health is not simply the
absence of pathology, but that the presence of positive, protective
factors is essential to promote good health. Antonovsky developed
a theory and a research perspective that he called salutogenesis
(Antonovsky, 1987). Rather than seeking the mechanisms underlying illness (pathogenesis), he tried to identify the origin of
health (salutogenesis) (Antonovsky, 1979, 1987). The salutogenic
model is based on the premise that stress and difficulties are integral elements of human existence. Korotkov (1998) stated that
everyone is under an imminent heightened pressure toward
entropy or chaos caused by various external and internal bodily

stressors. The salutogenic paradigm focuses on the resources and

strategies that are order restoring and enable successful coping
with pathogenic factors in life (Korotkov, 1998). Antonovsky
(1979, 1987) developed the concept of sense of coherence (SOC)
as central part of his theory. Sense of coherence consists of three
components: comprehensibility, manageability and meaningfulness (Antonovsky, 1987). Comprehensibility refers to
whether or not inner and outer stimuli make sense to us in terms
of being coherent, ordered, cohesive, structured and clear. Manageability refers to the extent to which we feel resources are at
our disposal to help meet the demands posed by the stimuli to
which we are exposed. Meaningfulness refers to whether we can
perceive lifes difficulties as welcomed challenges worthy of
an investment of energy, engagement and dedication rather than
as a burden that we would prefer to avoid. Meaningfulness is the
motivational component of the concept. The aim of this study was
to investigate whether is it possible to improve SOC by group
interventions designed to enhance the ability to work in occupational healthcare.
Several studies have found positive associations between SOC
and mental health (Bowman, 1996; Sammallahti, Holi, Komulainen & Aalberg, 1996). Among caregivers of patients with Alzheimers disease (Bias, 1998) as well as among patients with
rheumatoid arthritis (Callahan & Pincus, 1995; Hawley, Wolfe &
Cathey, 1992), SOC serves a protective function against depression and perceived stress associated with facing a chronic illness.
Greater SOC has been associated with better adaptation to disability (Rena, Moshe & Abraham, 1996) among Canadian adults with
stronger subjective assessments of health (Hood, Beaudet &
Catlin, 1996). In psychotherapy patients, SOC was negatively

2012 The Authors.

Scandinavian Journal of Psychology 2012 The Scandinavian Psychological Associations. Published by Blackwell Publishing Ltd., 9600 Garsington
Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA. ISSN 0036-5564.

524 K. Kahonen et al.

correlated with self-report measures of perceived stress, trait anxiety, and current depression (Frenz, Carey & Jorgensen, 1993). In
a systematic review of SOC and health, Flensborg-Madsen,
Ventegodt and Merrick (2005) concluded that SOC is highly
related to psychological aspects of health but that there is not a
strong association with physical health. Konttinen, Haukkala and
Uutela (2008) found in their population-based study, with SOC
tertiles and health, that the variation at the low end (SOC13 < 61) was more strongly associated with the health variables
than the variation at the high end (SOC-13 > 71). As a whole,
these findings suggest that individuals with high SOC perceive
less stress and experience less psychological disturbance in the
context of challenging life events (Weissbecker, Salmon, Studts,
Floyd, Dedert & Sephton, 2002). Kivimaki, Feldt, Vahtera, and
Nurmi (2000) cited an additional 26 cross-sectional studies that
linked SOC to physical complaints, mental health, and role functioning.
Antonovsky (1979) viewed SOC as an enduring attitude that is
developed between childhood and age 30, and that is less likely to
change. He theorized that only a profound change in social or cultural influences or living conditions, such as emigration, the birth
of a child, changes in marital status or employment, would be
likely to alter SOC.
Only a few studies have investigated whether it is possible to
enhance sense of coherence by therapeutic interventions. There
are at least two controlled trials that have shown significant
positive changes in SOC. The Mindfulness-Based Stress Reduction (MBSR) program was the first randomized prospective trial
to demonstrate enhancement of SOC through a psychosocial
intervention (Weissbecker et al., 2002). Another randomized controlled trial with significant improvement in SOC consisted of
(salutogenic-based talk-therapy groups of persons with mental
health problems) which met weekly for 1.5h over 16 weeks
(Langeland, Riise, Hanestad, Nortvedt, Kristoffersen & Wahl,
2006). The authors found that treatment was helpful in increasing
coping in the recovery process among people with a mental
disorder. In a study of 405 patients who had received long-term
psychoanalytically-oriented psychotherapy, a significant improvement in SOC was observed (Blomberg, Lazar & Sandell, 2001).
However, a non-controlled trial, in which an 8-week multidisciplinary group-intervention program with a salutogenic approach,
focusing on somatic as well as psychological reactions and
developed for patients reporting hypersensitivity to electricity,
failed to demonstrate significant improvement in SOC (Hillert,
Savlin, Berg, Heidenberg & Kolmodin-Hedman, 2002).
But how is a group intervention able to achieve a positive effect
on SOC? Amirkhan and Greaves (2003) studied the mechanism
by which SOC can bring about health benefits. They found two
main mechanisms: perceptual and behavioral. Through the perceptual mechanism SOC caused people to view stressful events as
more comprehensible, manageable, and meaningful, and through
the behavioral mechanism SOC caused people to be more prone
to fight than flight in their dealings with life stressors. They also
verified that this coping pattern was effective in preventing
depression and stress-related illness. Finally, they stated that it
may be possible to intervene via the behavioral mechanism, shaping stress responses towards the efficacious coping style associated with a strong SOC. We assume that a group intervention is

Scand J Psychol 53 (2012)

ideal for enhancing both the perceptual and the behavioral mechanism. In a group with nine other people who also have a rich
experience of working life, the individual has the opportunity to
learn to see difficulties in a more constructive and coherent way.
Such a group can also generate more flexible and creative
solutions on how best to behave in critical situations.

THE PRESENT STUDY

The aim of this study was to develop a salutogenic group intervention in the occupational healthcare context by answering the
following research questions: (1) Is it possible to improve sense
of coherence by group interventions of two different kinds (group
analytic and psychodramatic)? and (2) Does SOC develop differently as a result of these two methods?
We hypothesized (H1) that it would be possible to obtain significant improvement in SOC during a nine-month group psychotherapy intervention. We also hypothesized (H2) that the group
analytic method and psychodrama method would have a different
effect on SOC. The psychodrama method is more directed by
the group coordinator, the issues for study in the group are given
by the group coordinator, various tools are provided to help
participants express their thoughts, and the participants learn
relatively quickly to use the method. The group analytic method
is based on group-centred discussion, where the coordinator does
not supply the issues for study, but the group has to create them
by itself, the participants may only express themselves in words,
and it takes more time to learn the method. We hypothesized (H3)
that SOC would improve faster and more in the psychodrama
groups during the intervention, and that even if the intervention
was relatively short compared to the three-years typically used in
group analytic psychotherapy, the effect on the SOC would be
stronger after the six-month follow-up in the group analytic
groups.

METHOD
Participants
Three different groups were formed with a total of 94 participants. The
criterion for inclusion was suffering from severe burnout symptoms, as
measured by the Bergen Burnout Inventory (Matthiesen, 1992). In the
first phase, 62 subjects suffering from severe burnout were randomly
selected into eight intervention groups (four group analytic and four
psychodrama). In the second phase, 32 subjects were selected for the
control group. They were able to consult an occupational physician and
a psychologist if needed, and they had a possibility to participate in the
same kind of intervention after this trial. Two phases were used as it was
deemed unethical to leave participants suffering from severe burnout to
be kept waiting for therapy to begin. All the participants were recruited
via their occupational healthcare service in the Helsinki area between
August 1998 and January 2000. The intervention groups consisted of
employees aged 33 to 59 years (Mean = 48, 73% women, 27% men)
working in different public service occupations such as police officers
and tax officers. Ages in the control group ranged between 31 and
58 years (mean = 47, women 78%, men 22%).
The subjects were randomly selected for the therapy groups as follows: (1) men, who were in the minority, were selected first, followed
by; (2) people working in the same organization; and then (3) the rest.
Thus, an equal distribution of men and the avoidance of confidentiality
problems among people in the same organizations were guaranteed.

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Scandinavian Journal of Psychology 2012 The Scandinavian Psychological Associations.

Sense of coherence in group interventions

Scand J Psychol 53 (2012)

Next, these groups were randomized into eight intervention groups: four
analytic groups, eight members in each group, and four psychodrama
groups, eight members in two groups and seven members in the other
two groups. Every subject received an in-depth introduction to the study
and they were asked to give their written permission for the results to be
used in scientific research.
Of the 32 subjects in the analytic groups and 30 subjects in the
psychodrama groups, seven of the analytic subjects and six of the
psychodrama subjects were absent from at least 30% of meetings and
were excluded from final results. Four control subjects were excluded
because of incomplete measurements.

Intervention
The interventions consisted of 16 separate days with an interval of two
weeks between each, and with four sessions on each day of one and half
hours each with one-hour lunch break and two half-hour coffee breaks.
The process began in March and ended in December, with summer break
of eight weeks in July and August. The follow-up day took place six
months later in June. The follow-up day followed the same timetable as
the intervention days. The group analytic groups were coordinated by a
female and a male analyst; both were physicians and group analysts. The
psychodrama groups had two female coordinators one of whom was a
psychologist and the other a physiotherapist. All coordinators were middle-aged and had many years experience in occupational health care and
coordinating groups.
A common issue in both group methods was to investigate the balance
between work, social life (including family life) and personal hobbies. In
terms of general resistance resources, these three basic dimensions support each other, meaning that if someone faces serious conflicts in his
occupational domain, a functional social life and important personal hobbies may be enough to prevent burnout. Another common issue was to
investigate participants personal values, beliefs, attitudes and patterns of
behavior, especially those exposing to conflicts in their work. This connects both the perceptual and behavioral mechanisms of SOC (Amirkhan
and Greaves, 2003).
The group analytic method (Foulkes & Anthony, 1990) was based on
free floating discussion. In the beginning it is important to build a safe
and familiar atmosphere in which every group member can express his
or her personal thinking. The first goal is on the collective level in group
analysis, and it is successfully reached when a group member feels that
this is my group, I want to be and I am part of it. The second goal is
on the projective level, and concerns the expression of the feelings and
ideas awakened in the group, the reasons for these feelings being solely
outside the world (one-way reason-result relation). At this level there is
nothing much to do because the reasons are outside. The third goal is on
the level of transference, where the group member becomes conscious of
his or her own subjective inner world, its continuing development in the
complex relationship between past history and the present. The world
becomes more open and relational, and more hope and possibilities to
adapt are evoked. Typically, a group analytic therapy process comprises
one or two sessions a week over three years, hence this intervention was
markedly less intensive and shorter (than the average).
The psychodrama method was based on many different kinds of
psychodramatic techniques (Blatner, 1996). In the beginning, cards and
figures were used to help the group members express their feelings and
idea. After this warm-up various socio- and psychodramatic techniques
were used. Drawing, music and writing were used to investigate and
express the group members inner worlds. Muscle relaxation and
exercises using the imagination were used in the last session of the day.
During the intervention, every participant had the possibility to be the
protagonist of the day, that is, to use the whole group and coordinators
to investigate through psychodrama something of crucial importance to
him/herself.
The role of the coordinators differed in these two methods. In the psychodrama groups they sought to advance the group work by giving more
direction, and being generally active and helpful, while in the analytic
groups they were more passive and less supportive. The group analytic

525

method is thus more frustrating in the beginning, because it takes more

time to learn to communicate without access to the aids used in the psychodramatic approach. A psychodrama group stays dependent on coordinators, while the analytic group becomes more and more independent.

Measurements
To measure sense of coherence, the 13-item Orientation to Life Questionnaire (Antonovsky, 1987) was completed by the participants before the
beginning of therapy, in the middle of the therapy (in the summer break)
and at the end of therapy. Two intervention groups completed the same
scale once more the follow-up day six months post intervention.
This scale consists of three dimensions. Comprehensibility (five questions): Has it happened in the past that you were surprised by the
behavior of people whom you thought you knew well, Manageability
(four questions): Has it happened that people whom you counted on
disappointed you? and Meaningfulness (four questions): Do you have
the feeling that you dont really care about what goes on around you?
The participants were asked to answer the questions on a seven-point
semantic differential scale with two anchoring phrases (e.g., 1 = never
and 7 = always). After reversing the scores of the five negatively
worded items, the total sum score ranged from 13 (low SOC) to 91 (high
SOC). At the baseline, the Cronbachs a for the SOC scale was 0.90, at
the second measurement (middle) 0.85, at the third (end) 0.81 and at the
fourth (follow up) 0.83. The SOC-13 measure has relatively high structural validity and high stability (Feldt, Leskinen, Kinnunen & Ruoppila,
2003), and a high level of reliability and content, face and construct
validity (Antonovsky, 1993, Callahan & Pincus, 1995).

Statistical analyses
In the first research question, in which the level and development of
SOC across three measurements between two intervention groups and
one control group were compared, the general linear model (in this study
GLM always refers to the multivariate approach to repeated measures
ANOVA) was used. The analysis was continued with pairwise comparison using GLM to explore which of the groups differ in change across
the three measurements. Differences are further tested using repeated
contrast to show whether the differences in change are detected between
the first and second measurements or between the second and third measurements. Finally, GLM was used to analyze whether the change in the
mean score of SOC of the group analytic group and the psychodrama
group was different between the end of the intervention and the followup six-months later. Cohens d was used to estimate the effect size of
the change in SOC (the difference between two means divided by a
pooled standard deviation at baseline).

RESULTS
The means and standard deviations of SOC measured three times
for the group analytic, psychodrama and control groups are shown
in Table 1. The GLM analyses show, that the change in SOC,
measured three times during the nine-month group psychotherapy
intervention (at the beginning, middle and end), between the three
groups was statistically significant (F(4,148) = 2.65, p = 0.036).
Pairwise group comparisons revealed, that the change across the
three measurements differed between the psychodrama and control groups (F(2,49) = 4.03, p = 0.024), the psychodrama group
showing a significantly better improvement in SOC (mean from
3.81 to 4.33, effect size 0.67; see Table 1) between the second
and third measurements (F(1,50) = 7.78, p = 0.007). A significant
change across the three measurements was also observed between
the group analytic and psychodrama groups (F(2,46) = 3.00, onetailed p = 0.030), with the psychodrama group showing

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526 K. Kahonen et al.

Scand J Psychol 53 (2012)

Table 1. Changes in SOC (means, standard deviations and effect sizes) in

three groups (group analytic, psychodrama and control)
Mean

SD

Effect size

Group analytic (N = 25)

baseline
3.41
middle
3.56
end
3.69
follow-up
3.96

0.73
0.90
0.62
0.80

0.19
0.17b
0.35c
0.71d

Psychodrama (N = 24)
baseline
3.91
middle
3.81
end
4.33
follow-up
4.27

0.64
0.59
0.78
0.76

0.13
0.67b
-0.08c
0.45d

Control (N = 28)
baseline
middle
end

0.94
0.89
0.88

0.10
0.19b
0.09e

3.91
3.83
3.98

Notes: Effect size = the difference between two means divided by a

pooled standard deviation at baseline. abaseline vs. middle; bmiddle vs.
end; cend vs. follow-up; dbaseline vs. follow-up; ebaseline vs. end

significant better improvement between the second and third

measurements (F(1,47) = 6.00, p = 0.018). No significant difference in change in SOC was observed between analytic and control
groups. The repeated measures GLM shows that the change from
the end of the intervention to the six-month follow-up differed
between analytic and psychodrama groups (F(1,47) = 4.35,
p = 0.042). This change in SOC was statistically significant only
in the analytic group, which showed an increased SOC score
between the end of the intervention and the six month follow-up
(mean from 3.69 to 3.96, effect size 0.35; see Table 1). The
total effect size from baseline to follow-up was 0.71 in the
analytic group and 0.47 in the psychodrama group, and from
baseline to end of the intervention 0.09 in the control group (see
Table 1).

be explained by the nature of this particular method. Compared to

the psychodramatic group, the coordinators in the analytic group
transfer a lot more responsibility to the group as a whole and to
the group members as individuals, for example, by simply sitting
in a circle and trying to develop a dialogue between the group
members. This can be frustrating in the early stages, and as our
results demonstrated, SOC improved more slowly in the analytic
than in the psychodrama group. It is very interesting that once
SOC started to improve in the analytic group it also continued
during the six-month follow up. Langeland et al. (2006) discussed
the fact that it was difficult to determine whether the improvement
in SOC in their study was a specific or non-specific effect of their
talk-therapy group intervention, and whether another type of therapy in addition to a control group should be used to shed light on
this. Using two different therapy methods, dialogue-based analytic
therapy and action-based psychodrama we were able to elicit
effects and differences specific to these two methods. This is
important, as it offers guidelines for developing future group
interventions. Action-based experimental technique in early stages
of the intervention are highly recommended by this study, while
to achieve a long lasting effect it is important during the intervention to shift step by step away from acting towards dialogue and
the transfer of responsibility for the group dynamic from the
coordinators to the group members.
These results and differences between the two group methods,
group analytic and psychodrama, raise at least the following speculations. First, the present study indicates, that because it is possible to enhance SOC by a group intervention, this should be
considered an important strategy alongside improvement in the
organizational climate (Feldt et al., 2000) when seeking to prevent
occupational burnout. Second, it is possible to enhance SOC by a
relatively short group intervention among employees suffering
burnout symptoms. Instead of costly clinical rehab programs,
cost-effective interventions close to the workplace can be developed in the occupational healthcare context. Third, it would be
very useful to try to combine the two methods, to achieve a faster
start-up, as in the psychodrama group, and a long lasting late
effect as in the analytic group.

DISCUSSION
The study supported our hypothesis (H1) that it is possible to
improve SOC in an occupational healthcare context by means of a
group intervention. An improvement took place during the second
half of the nine-month intervention in the psychodrama group and
during the six-month follow-up in the analytic group, which supported our second hypothesis (H2). While these two different
intervention methods did not differ significantly in their total
effect between baseline and follow-up, their different positive
slopes are very interesting. As we hypothesized, the psychodramatic method resulted in a more rapid improvement than the
analytic method, while the analytic method had a long lasting
effect, which continued post intervention. The more active and
supportive role of the coordinators and use of various experimental techniques, such as drawing pictures, using postcards, music,
the imagination, socio- and psychodrama, and relaxation techniques, in the psychodrama group proved to enhance more rapid
development, although the effect was not found to be progressive
at follow-up. The analytic group got off to a slow start, which can

LIMITATIONS AND FUTURE DIRECTIONS

The present trial also has its limitations. The number of participants was relatively low, and we were only able to randomize
them into the two different intervention groups but not into the
control group. More controlled randomized trials are needed to
verify these findings. Another limitation of the present research
was that it did not include qualitative data analysis to help explain
the quantitative results; hence it is suggested that further research
uses a qualitative or mixed methods design. It is important to
investigate simultaneously different intervention methods to determine the differences and effects specific to them. Because group
interventions are much more economical than individual ones,
and because groups contain not only the professional competence
of their coordinators but also the huge life experience of all the
other group members, rehabilitation programs of this kind should
be enhanced in both the occupational and common healthcare
contexts. However, it is important to bear in mind that to be effective and safe the group intervention should not be used without

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Scandinavian Journal of Psychology 2012 The Scandinavian Psychological Associations.

Sense of coherence in group interventions

Scand J Psychol 53 (2012)

properly educated and competent coordinators, as groups can also

be affected by powerful destructive forces if these are not recognized and controlled for.
The study was financially supported by the Finnish Work
Environment Fund. We are very grateful to the group coordinators
Tuula Grandell, Tarja Miikkulainen and Marja Saarnio.

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Received 9 December 2011, accepted 12 September 2012

2012 The Authors.

Scandinavian Journal of Psychology 2012 The Scandinavian Psychological Associations.