1. Couple Group Therapy: The Best of Both Worlds John Caffaro, Ph.D.
Distinguished Professor
California School of Professional Psychology
Los Angeles, California
@jvcaffaro

2. INTRODUCTION
John V. Caffaro, Ph.D.
Developing proficiency in “multi-person treatment” (i.e., group or couple therapy) as a primary modality of treatment is often ignored in traditional clinical training
There is even less consistency in the availability of couple group therapy training, with some programs placing a priority on the development of skills leading groups and others giving couples therapy greater attention
This presentation incorporates learning obtained from conducting a monthly couples group that combines differentiation-based couples therapy with an interpersonally-focused group orientation
However, evidence suggests that authenticity and self awareness in the hands of a competent clinician are particularly potent
Certain skills and general principles characterize work of the most effective clinicians and are, at least, partly independent of theoretical orientation (Duncan, Miller, Wampold, & Hubble, 2010; Wampold, 2001)

3. Describe the value of the group context for couples
INTRODUCTION
John V. Caffaro, Ph.D.
Learning Objectives
Describe the value of the group context for couples
Application of interpersonal integrative theory to couples group setting
Emphasize importance of here and now member-to-member interaction
Utilize video to demonstrate an initial full day meeting of a couples group in action

4. Interpersonal Group Therapy
KEY CONSTRUCTS
John V. Caffaro, Ph.D.
Basic Elements:
Interpersonal Group Therapy
Psychodynamic foundation
Understanding the past shows how and why the present is shaped in the way that it is
Resolution, however, must be found in current exchange with group leader or members, not in reconstruction of past
Change occurs when group member enacts a resolution of their conflicts in current relationship with group leader or group members

5. Engagement that Encourages Change
KEY CONSTRUCTS
John V. Caffaro, Ph.D.
Engagement that Encourages Change
Being affectively present and maintaining good contact provides the kind of interpersonal support that fosters group member growth
Being dependably available supports group member risk taking
Group events understood in terms of co-constructed experiences that emerge from interactions between leader and members and member-to-member

6. KEY CONSTRUCTS John V. Caffaro, Ph.D.
The Process Dimension
When group member participates in an experiential process, rather than being advised, reassured or interpreted, they are better prepared to make enduring changes
Capacity for change fueled by the personal significance of the therapeutic relationship
Instead, of trying to make things happen, group leader must focus on what is actually and presently happening

7. KEY CONSTRUCTS John V. Caffaro, Ph.D.
Prerequisites for
Effective Group Intervention
Must provide holding environment in group that allows group member to re-experience & integrate threatening emotions in safe group setting
“Follow the leader” and listen for patterns, themes, feelings that recur
Focus group inward, respond to affect and make group member an active participant in their own change process

8. KEY CONSTRUCTS
John V. Caffaro, Ph.D.
Group Cohesion…
Cohesion is largely regarded as a necessary condition of change in group therapy
Consensus investment in, and commitment to, the group by its members (Yalom & Leszcz, 2005; Davies, Burlingame, & Layne, 2006)
Trusting, cohesive group encourages—lends courage, as it were—to its members who now speak more easily about feelings and reactions that they previously had been careful to avoid

9. KEY CONSTRUCTS
John V. Caffaro, Ph.D.
Group Cohesion
Couples in the group eventually find they are struggling with universal issues of being a self-in-close connection
Relationships across (rather than within) couples are cultivated so that individuals develop in the presence of, not only in tandem with, their spouses
This helps break up collusive, stifling frozen roles that serve to stabilize expected characteristic behavior patterns in the couple system

10. therapeutic alliance embraces multiple relationships
KEY CONSTRUCTS John V. Caffaro, Ph.D. Expanded Concept of Group Cohesion
Requires interpersonal orientation where member-to-member interaction as important as interactions with leader
Members see and express things as well or better than the leaders; becoming therapeutic with other members is just as important as members taking help from leaders
Research supports position that the group rather than leader is most important for cohesion (Caffaro & Conn-Caffaro, 2003; Fuhriman & Burlingame, 2000; Fuhriman & Burlingame, 1994; Flowers, 1978)
Therapeutic alliance in group requires making contact with each individual as well as group-as-a-whole
therapeutic alliance embraces multiple relationships
group cohesion in 1st 30 min predicts strongest relationship to patient outcome (Budman, et al., 1989)

11. Multiple systemic levels of intervention Individual Interpersonal
KEY CONSTRUCTS
John V. Caffaro, Ph.D.
Isomorphism
Multiple systemic levels of intervention
Individual
Interpersonal
Subgroup
Group-as-a-whole
Ultimately, purpose of couples group is to cultivate individual growth in the presence of one’s spouse aided by peers and co-leaders
SYSTEMS CONSTRUCT- Define

12. VID #1 Impact on Couple of Being Moved by Group
John V. Caffaro, Ph.D.
Peggy & Nicole
Intervening with a pair in the group creates two subgroups: the pair and the remainder of the group
Identifying and working with their differences can serve a unifying function for the whole group
Interpersonal focus:
Possibility of working with more than one member at a time
Notion that group interaction is co-created underscores reciprocal nature of change
Clip begins with asking couple about the impact on them of the group’s overwhelmingly supportive feedback. ILLISTRATES POWER OF INTERPERSONAL AND INTRAPSYCHIC FOCUS

13. Group as-a-Whole Intervention…
VID #2 Group-as-a-Whole Intervention
John V. Caffaro, Ph.D.
Group as-a-Whole Intervention…
You can simultaneously say something to a group member & the group-as-a-whole which might be too direct or be experienced as shaming or critical if said directly to the individual
Group process begins when members allow their attention to shift away from their spouses, and begin to regard group members as something more than an audience or jury
Group serves witness function and helps hold members accountable to one another

14. Next clip demonstrates Group-as-a-Whole intervention
VID #2 Group-as-a-Whole Intervention
John V. Caffaro, Ph.D.
At first, members tend to focus on intra-couple issues in group and individuals remain subordinate to marriages
In time, [and considerable back & forth], members begin to feel as close to one another as they do to friends and siblings--group becomes a “third family”
Gradually, relationships of members with each other gain strength and influence--which is the whole purpose of group therapy
Next clip demonstrates Group-as-a-Whole intervention
Clip demonstrates the sort of heated conversation that might emerge re infidelity

15. Member-to-Member Interaction
VID #3 POWER OF MEMBER-TO-MEMBER INTERACTION
John V. Caffaro, Ph.D.
Member-to-Member Interaction
Development of cross-couple relationships among group members is crucial:
Cross-couple dyads often spur and nurture change in individuals first, and then couple systems
Unless focus can be drawn away from spouse, rigid patterns of the marriage are likely to prevail against efforts of the therapist
Once each couple has their turn in the spotlight, each spouse confronts the persuasive comments of peers about how he or she acts in the group: interpersonal evidence in more difficult to deny
Next clip illustrates power of member-to-member interaction to effect change in couple
Gurman (1975) understood long ago that positive outcome of couple group therapy rests upon the presence of improved couple interaction and not only indiv change
Understanding that it is experience rather than simply insight that leads to enduring change for clients is central to this framework
----- Meeting Notes (7/23/15 22:55) -----
power of confrontation and hostility channeled effectively in service of change

16. VID #4 GROUP DISCUSSION OF GENDER ROLES
John V. Caffaro, Ph.D.
“Women v. Men”
Participating in a group process elicits feelings about one’s unique identity with greater intensity than individual therapy (Salvendy, 1999)
In group, couples face peers who are different in a multitude of ways
Next clip demonstrates how contact between group members facilitates open dialogue re gender roles (i.e., male=dominant; women=submissive)
Clip picks up after conversation re submissive v. dominant traits has taken place.

17. VID #5 UNIVERSALITY
John V. Caffaro, Ph.D.
Universality
Self disclosure builds trust and the group begins to relate to common personal histories, and not stereotypes
Interpersonal disclosure in a heterogeneous group paradoxically leads to both a sense of belonging, and respect for differences
Creates common bond of support for all participants in the context of diversity—for example, the impact of one couple on another
Final clip illustrates awareness of universality of feelings re commitment and inspiration for personal growth
you see one couple (older) affectively connected to another (younger) in meaningful way

18. Our Co-leader Relationship
Strengths
We are both systemic thinkers
Senior clinicians with mutual respect
History of positive working relationship
Enjoy working together but each of us also feels capable of handling the group on our own

19. Sibling Dynamics and Co-Leading
Experienced and inexperienced therapists alike have difficulty creating satisfying co-leader relationships
Co-leader relationships enhanced through an understanding and examination of our own sibling relationships
Balance between autonomy & belonging; complementary & symmetrical behaviors thought to be crucial

20. Sibling Dynamics & Co-leading Degrees of Sibling Identification
Continuum illustrates co-leader characteristics as influenced by early sibling relationship dynamics
Focus on inclusion/exclusion and similarities/differences
Begins with family emphasizing similarities or differences; family values, flexibility of sib roles; etc

21. Close Id Close Identification Sibling Dynamics Sr./Jr. Positions
Older/Younger
Poor Conflict Reso Skills
Confluence or Fusion
Co-Leader Interaction
Sr./Jr. Positions
Difficulty w/Cooperation
Tendency Toward Minimizing Differences: Strong “We” v. “I”.
Can sometimes be assessed by level of complementarity in co-leader relationship
Do co-leaders retain ability to engage in behavior they deemphasize for the sake of complementarity?
E.g., nurturing therapist who never learns to be confrontive as co-leader

22. Distant Identification
Sibling Dynamics:
De-identification or Cutoff
Emphasis on Autonomy/Individuality
Rigid Sibling Roles
Co-Leader Interaction:
Maximizing Differences: “I” v. “We”
Absence of Mutuality/Shared Direction
Contra-distinct Roles/Gender Stereotypes
To the extent that therapist’s sense of self is tied up with being different from sibling, he or she may seek out cotherapists who allow them to “shine”
Struggles over “air time” between co-leaders comparable to sibs in FOO trying to dominate family conversations
John V. Caffaro, Ph.D.
Allison Conn-Caffaro, M.S.

23. Partial Identification
Idea is to strike balance between an overly close, and more distant co- leader professional relationship
“I” and the “We” balanced overall
Ability to be intimate, yet separate
Degree of healthy interdependence