1. Group and Family Therapy
Chapter 16
Group and Family Therapy

2. Group and Family Therapy
Group therapy and family therapy both feature multiple clients being treated together
However, they are quite distinct from each other, with separate histories and methods
We will consider them separately in this chapter

3. Group Therapy: An Interpersonal Emphasis
Most forms of group therapy strongly emphasize interpersonal interaction
Take advantage of the fact that the group therapy experience itself is based on interacting with other people
Irvin Yalom is a leader in this interpersonal approach to group therapy
Clients’ problems stem from flawed interpersonal relationship skills
If they can practice and improve on this with fellow group members, they can generalize lessons learned

4. Therapeutic Factors in Group Therapy
Instillation of hope
Universality*
Imparting information
Altruism
Corrective recapitulation of the primary family group
Development of socializing techniques
Imitative behavior
Interpersonal learning*
Group cohesiveness*
Catharsis
Existential factors
*More information is provided in subsequent slides for starred factors.

5. Therapeutic Factors in Group Therapy (cont.)
Universality
Clients realize that others share the same struggles (i.e., “We’re all in the same boat”)
Especially powerful in homogeneous groups
Group Cohesiveness
Feelings of interconnectedness among group members
Trust, acceptance, belongingness
Analogous to therapeutic alliance in individual therapy

6. Therapeutic Factors in Group Therapy (cont.)
Interpersonal Learning
The same interpersonal tendencies that contributed to the client’s problems will appear in the group context
Group members form relationships with each other and work to improve them, and those improvements will help with outside relationships eventually

7. Therapeutic Factors in Group Therapy (cont.)
Interpersonal Learning (cont.)
The group becomes a social microcosm for each client
Clients enact their own relationship pathology (without knowing it) in the group itself
Focus on the here-and-now
Discourage discussion of lives outside of therapy
Encourage discussion of relationships between group members in the current moment
Clients talk directly with each other about the way they behave toward each other

8. Practical Issues in Group Therapy
Group membership
Typically 5-10 clients
Open-enrollment groups—individuals leave or join at any time
Closed-enrollment groups—members start and finish together
Most individuals can be included, unless they can’t interact meaningfully with others and reflect upon that interaction
Psychosis, acute crisis, frequent absences are problematic
Many group therapists find that having 7 to 8 members in a group is ideal.

9. Practical Issues in Group Therapy (cont.)
Preparing clients for group therapy
Correct misconceptions
Provide realistic and encouraging data about outcome
Encourage helpful ways of participating
Some clients may mistakenly believe that group therapy is second-rate (in comparison to individual therapy), that they will be forced to immediately disclose intimate personal details to strangers, or that interacting with other people with psychological problems will somehow worsen their own symptoms.

10. Practical Issues in Group Therapy (cont.)
Developmental Stages of Therapy Groups
Initially, cautious and concerned about acceptance
Next, some jockeying for position in the social “pecking order”
Finally, cohesiveness emerges

11. Practical Issues in Group Therapy (cont.)
Cotherapists
Often, group therapy is conducted by a team of two therapists (rather than one)
Second set of eyes and ears can attend to client behaviors
Also, therapists can model healthy interaction
Cotherapy can be problematic when therapists are competitive, distrustful, or have incompatible therapy orientations
Cotherapists can facilitate recapitulation of the family group. With one male and one female cotherapist, for example, a group can evoke the same dynamics as a traditional family, and the way that clients from such families respond to each cotherapist—trusting one while fearing the other, for example—can shed light on their interpersonal tendencies with other important people in their lives.

12. Practical Issues in Group Therapy (cont.)
Socializing between clients
Extra-group socializing between clients (romantic or platonic) is a significant problem
Even when prohibited at the outset, it happens at times
Loyalty to friendship may exceed loyalty to group
Other group members can feel excluded

13. Ethical Issues in Group Therapy
Confidentiality
Clients should maintain confidentiality of fellow members, but difficult to enforce
Consequences of broken confidentiality can effect professional or personal life, as well as group climate of trust
Important to get group members to appreciate importance of this and commit to maintaining confidentiality at outset

14. How Well Does Group Therapy Work?
Not studied as extensively as individual therapy
Existing studies strongly suggest that group therapy is beneficial
About equal to individual therapy in most studies; slightly inferior in a few studies
Cohesiveness in group is a major contributor to successful outcome
Can be less expensive than individual therapy also

15. Family Therapy: The System as the Problem
When the family therapy movement initially arose in the mid-1900s, it was considered revolutionary
Psychological symptoms as a byproduct of dysfunctional families
One individual may exhibit symptoms, but the problem belongs to the entire system

16. Family Therapy: The System as the Problem (cont.)
Circular causality—events influence each other reciprocally
As opposed to linear causality, which is endorsed by individual therapists
Focus on communication patterns in families
Focus on functionalism of symptoms
Within family, symptoms may be adaptive
Circular causality is different from linear causality. Linear causality, which tends to be endorsed by individual therapists, suggests that events from the past cause or determine events in the present in a unidirectional or “one-way street” manner. That is, the way a parent treats a child influences the child’s subsequent behavior.

17. Family Therapy: The System as the Problem (cont.)
Homeostasis
Families regulate themselves by returning themselves to an emotional set point
Like a thermostat
A family member may sense that the family is reaching an uncomfortable state, and take action (feedback) to return it to comfort zone

18. Assessment of Families
Interviews and other methods as used in individual therapy are common
Ask who the family includes
Genograms
A pencil-and-paper method of creating a family tree that incorporates detailed information about the relationships between family members for at least three generations
Process and result can both be beneficial
See Figure 16.2 Genogram of the Simpsons.

19. Assessment of Families (cont.)
Family Life Cycle
A developmental theory for families, including seven stages
Leaving home
Joining of families through marriage or union
Families with young children
Families with adolescents
Launching children and moving on in midlife
Families in late middle age
Families nearing the end of life
Leaving home. Single young adults become independent and self-sufficient.
Joining of families through marriage or union. A new couple forms a new family system, and the spouse is incorporated into existing family systems.
Families with young children. Taking care of children; adjusting the marriage; and managing child-related, financial, and other responsibilities are among the primary tasks.
Families with adolescents. Parents provide children with increasing amounts of independence and may adopt caretaking roles for their own parents as well.
Launching children and moving on in midlife. Adjusting to the “empty nest,” managing relationships with children’s partners, and taking on the grandparent role are central.
Families in late middle age. Focus shifts to managing declining health, adopting to new roles in family and community.
Families nearing the end of life. Accept the realities and inevitability of death (one’s own and that of family members); frequently, reverse the caretaker roles between older and younger generations.
The list of variations to the traditional family on which the family life cycle is based is extensive: Divorced families, step-families, single-parent families, families with gay/lesbian members, families of diverse or blended ethnicities or religions, families with parents in nontraditional gender roles, nonmarried cohabitating couples, couples without children, families that have experienced an unexpected or premature loss, and families with many years between offspring are only some of the ways in which a family might not match the prototype.

20. Assessment of Families (cont.)
Conflict Tactics Scale (CTS)
Objective questionnaire used to assess violence and abuse in couples
Measures how individuals react when family conflicts arise
Speaking calmly, using insults, throwing objects, hitting others, etc.

21. Assessment of Families (cont.)
Identified patient
It can be critical for the family therapist to persuade the family that the problem is systemic rather than individual
This can be difficult when the family has attributed the problem entirely to one member (identified patient)

22. Family Therapy: Essential Classic Concepts
Family Structure
Unwritten rules by which a family operates
When flawed, problems in relationships and individuals may result
Family structure can be improved by focusing on subsystems within families and the boundaries between them
Should be neither enmeshed nor disengaged
Structural family therapists emphasize subsystems within families (parental subsystems, sibling subsystems, etc.) and boundaries between those subsystems. These boundaries should be permeable enough to allow emotional closeness between family members but rigid enough to allow for independence as well. If boundaries are too permeable, family members can become enmeshed; if they are too rigid, family members can become disengaged.

23. Family Therapy: Essential Classic Concepts (cont.)
Differentiation of Self
An appropriate degree of self-determination, or becoming your own person, is essential
Families that don’t allow this to happen can create problems for their members
Families remain emotionally fused, or an undifferentiated ego mass

24. Family Therapy: Essential Classic Concepts (cont.)
Triangles
When two people are in conflict, either one may try to bring in a third person to take their side
In families, this can be problematic, especially when the triangulated person is a child
Therapeutic goal is to encourage detriangulation and direct communication between two people at odds with each other

25. Family Therapy: Contemporary Approaches
Solution-Focused Therapy
Evolved from strategic family therapy
Emphasis on solving problems
Emphasis on the use of solution-talk rather than problem-talk
Make clients think about positive outcomes rather than unpleasant present situations
Emphasis on exceptions to current problems (times when better) and how they created these exceptions (to encourage them to create more exceptions)

26. Family Therapy: Contemporary Approaches (cont.)
Narrative Therapy
Highlights clients’ tendencies to create meanings about themselves and the events in their lives in particular ways
Stories we construct about our own lives are powerful influences on the way we experience new events
We “edit” our experiences to fit the story line
Revise stories and recast selves in more positive, heroic way; new events can be interpreted more positively

27. Ethical Issues in Family Therapy
Cultural competence
Family therapists should appreciate the cultural background of the families
Ethnicity
Religion
Other variables
Often, one family includes a blend of cultural influences
Members from different cultures
Varying levels of acculturation

28. Ethical Issues in Family Therapy (cont.)
Confidentiality
Can be difficult when one family member tells therapist something in private
Diagnostic Accuracy
DSM disorders apply to individuals, not families
If diagnosis is required, therapist who thinks system is flawed has a dilemma
Labeling identified patient with disorder can perpetuate the family’s tendency to blame one member
In general, it is best to set the ground rules for confidentiality during the initial informed consent process; that way, all family members understand up front that the family therapist will handle private conversations in a particular way.

29. How Well Does Family Therapy Work?
Methodological difficulties in measuring outcome of family therapy include the issue of which family members’ opinions should be solicited
Not as much outcome research as individual therapy, but existing research is very positive
Family therapy appears to work about as well as other modes of therapy
Empirical studies demonstrate that a strong therapeutic relationship is key