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Chapter 3.5

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Overview
▪ 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.

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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

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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.

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Therapeutic Factors in Group Therapy

1. Universality
▪ Clients realize that others share the same struggles (i.e.,
“We’re all in the same boat”)
▪ Especially powerful in homogeneous groups

2. Group Cohesiveness
▪ Feelings of interconnectedness among group members
▪ Trust, acceptance, belongingness
▪ Analogous to a therapeutic alliance in individual therapy

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Therapeutic Factors in Group Therapy

3. 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.
▪ 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

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Practical Issues in Group Therapy

1. 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.

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Practical Issues in Group Therapy

2. Preparing clients for group therapy
▪ Preparing clients for group therapy
▪ Correct misconceptions
▪ Provide realistic and encouraging data about the 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 symptoms.

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Practical Issues in Group Therapy

3. Developmental Stages of Therapy Groups
▪ Initially, cautious and concerned about acceptance
▪ Next, some jockeying for position in the social “pecking order”
▪ Finally, cohesiveness emerges

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Practical Issues in Group Therapy

4. Co-therapists
▪ 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
▪ Co-therapy can be problematic when therapists are competitive,
distrustful, or have incompatible therapy orientations

❖ Co-therapists can facilitate recapitulation of the family group.

❖ With one male and one female co-therapist, for example, a group can evoke
the same dynamics as a traditional family, and the way that clients from such
families respond to each co-therapist—trusting one while fearing the other,
for example—can shed light on their interpersonal tendencies with other
important people in their lives.

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Practical Issues in Group Therapy

5. 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

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Practical Issues in Group Therapy

6. Confidentiality
▪ Clients should maintain the confidentiality of fellow members, but
difficult to enforce
▪ Consequences of broken confidentiality can affect professional or
personal life, as well as group climate of trust
▪ Important to get group members to appreciate the importance of this
and commit to maintaining confidentiality at the outset

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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 a group is a major contributor to a successful
outcome

▪ Can be less expensive than individual therapy also

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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

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Family Therapy:
The System as the Problem
▪ 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 the 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.

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Family Therapy:
The System as the Problem
▪ 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

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Assessment of Families
a. Interviews and other methods as used in individual
therapy are common

b. Ask who the family includes

c. 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.

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Assessment of Families
d. 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.

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Assessment of Families
d. Family Life Cycle
❖ Joining 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.

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Assessment of Families
d. Family Life Cycle
❖ 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.

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Assessment of Families
d. Family Life Cycle
❖ 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.

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Assessment of Families
e. 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.

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Assessment of Families
f. 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)

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Family Therapy:
Essential Classic Concepts
1. 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.

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Family Therapy:
Essential Classic Concepts
2. 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

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Family Therapy:
Essential Classic Concepts
3. 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

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Family Therapy:
Contemporary Approaches
1. 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)

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Family Therapy:
Contemporary Approaches
2. 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 storyline

▪ Revise stories and recast selves in a more positive, heroic way;

new events can be interpreted more positively

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Ethical Issues in Family Therapy

1. 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

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Ethical Issues in Family Therapy

2. Confidentiality
▪ Can be difficult when one family member tells the therapist something in
private

3. Diagnostic Accuracy
▪ DSM disorders apply to individuals, not families
▪ If the diagnosis is required, the therapist who thinks the system is flawed
has a dilemma

❖ Labeling identified patients with the 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 upfront that the
family therapist will handle private conversations in a particular way.

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How Well Does Family Therapy Work?

▪ Methodological difficulties in measuring the 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

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