III - Family Psychology & Family Psychiatry - Psychotherapy
Organisation of Benexperiential Psychotherapy
Here, the discussion will be concerned with the interview termed “family group therapy”. This is the basic interview in family psychiatry. Nevertheless, other types of interviews will be employed from time to time. Work should be flexible. The appropriate interview procedure is employed according to the dictates of the situation at a particular moment in time. Flexibility is the keynote. Circumstances may sometimes dictate that only a particular interview procedure is possible, but one aspires to the most appropriate at a particular time in a particular situation.
Types of interview
- Individual interviews.
- Dyadic interviews involving any two people and the therapist.
- Family group interviews involving the whole family (this may sometimes be a partial family group).
- Multiple family groups – the present family may get together with related families, such as preceding, collateral or succeeding families. The group may consist of a number of unrelated families.
- General groups – these consist of members of unrelated families and have many variants, depending on gender, vocation, type of problem, etc.
Comparison of Family Group Therapy with Individual Therapy
Family group therapy has some features in common with individual therapy. But in family group therapy the number of relationships is greater, the therapist is part of a web of communication and he addresses himself to the “collective psyche” of the family. The great advantage of family group therapy is that in the group there is a built-in corrective to misinformation by an individual by the sifting and re-evaluation of the others. Furthermore, it is possible to deploy assets not only in the therapist, but also in the family itself.
Comparison between Family Group Therapy and General Group Therapy
General group therapy treats together a number of individuals from unrelated families. Groups may be male, female or mixed. They may meet formally for intensive therapy, or informally in a club setting. One or more therapists may be employed, and the clinical material is interpreted according to the school of thought of the therapists. The aim is to bring profit to each individual in the group.
The family group has a strong identity which reaches from the Past and extends into the Future. It existed as a group before therapy, and will go on after it. It is a heterogenic group of both sexes and of all age groups. It is subject to strong influences from the extended family group. Its members have learnt rigid patterns of behaviour and communication, in relation to one another. Each member of the family has strong meaning for the others. Powerful emotions can be aroused in it, for good or evil. The strength and cohesiveness of a family group often become strikingly apparent when it is attacked from outside. The aim of therapy is to change the collective psyche of the family.
Flexibility in therapy
It must be emphasized that family group therapy is but one procedure of benexperiential psychotherapy, which in turn is only one part of family therapy. The use of family group therapy alone seriously limits the treatment of the family. Benexperiential psychotherapy, vector therapy and preventive psychiatry are complementary, and the most effective family therapy employs all these procedures simultaneously.
The therapeutic needs at a given moment can be met by a flexible approach ready to utilise whatever is appropriate. Thus, individual and family group psychotherapeutic procedures may be employed together, or family group therapy and vector therapy, or family group therapy and dyadic therapy, etc. Whenever possible, the whole family must be involved in the treatment process; this does not mean just for family group therapy alone, but applies to all the therapies appropriate to the task at that time.
Treatment may have to proceed with an individual, or with only a part of the family; this may be so because of inability to involve the whole family or because of the dictates of the treatment situation at that moment. But if only a part of a family is under treatment, the rest of the family is not overlooked, and the aim does not change; to adjust the whole family is still the target.
With the consent of the family group, family members can see the therapist alone, but with the understanding that, whenever possible, material relevant to family life must be reintroduced to the group. The therapist applies no pressure; he concentrates on producing security which makes revelation possible to the rest of the family. The therapist, of course, does not allow himself to be used against the family, or to show special favour to any one member. Whenever misunderstanding threatens, it pays to subject the situation to the scrutiny of family discussion; capacity to understand is often greater than imagined. There is no doubt that an experienced family therapist is more comfortable in family therapy than in individual or dyadic therapy, where there is always anxiety lest unseen family members are not taken into account.
The following illustrates the need to be flexible in family group therapy and to allow fragmentation when required:
A father, mother and daughter meet together for family group therapy. At one moment father becomes silent, anxious and restless; the group makes no progress. The father then asks that he be allowed to see the therapist alone. When he does so, he relates that some time ago he had an involvement with a third person. He ends by wondering whether this information should be imparted to the family group.
Discussion may show that two plans should be considered: (i) that the material imparted is of no significance to the rest of the family or (ii) that it is of significance to the wife, who, the patient feels, may suspect the situation. He asks for a meeting between the therapist, the wife and himself, as he feels that the matter needs resolution. Husband, wife and therapist meet – dyadic therapy. Again the couple wonders whether the information should be imparted to the family group. They decide that the event has no significance for the adolescent daughter, and they do not wish to introduce the material to the group. Or they may decide that the daughter may already suspect this relationship, is worried about it, and the matter should be divulged. Thus, the therapist, mother and daughter meet to discuss the situation. Thereafter, family group therapy continues.
Selection of families
Few units are so well staffed as to be able to apply family group therapy to all their families. Thus, selection becomes necessary. In general, units deploy their facilities to give optimum value to the community. Therefore the families selected are those with a degree of disturbance likely to respond, in a reasonable period of time, to the treatment offered by the facilities available. Families with young children have a degree of priority. They have young parents; young parents have not been emotionally ill as long as older people, and thus respond more readily to treatment. The younger the children when treatment is established, the more they profit. The number of children in the family is a factor in selection; the greater their number, the greater the benefit that will accrue to society by improving their emotional health. In all families, whatever the degree of disturbance, efforts should always be made to bring relief to the children, the young generation and the generators of new families; we must invest in the future.
To make priorities when so many require help is a trying matter. But if the number under therapy exceeds the resources of a particular institution the standard of therapy can deteriorate to the point that no one receives effective therapy. When allowance has been made for administration, staff contact, meetings (and excessive conferencing is a sign of inexperience and inefficiency), reports, course attendance, teaching and investigation, a possible therapeutic weekly period of 40 hours can easily become 20 hours. This means that ten families receive two hours from a therapist if seen weekly, or 20 families if seen fortnightly – less contact than this is not valuable. Thus, interview therapy is exceedingly expensive of time and money. A clinic with five therapists might have 400 families referred to it, but be able to offer therapy to 100 families for two hours a fortnight or 50 families for two hours a week. If a clinic is wasteful enough to use two co-therapists, the number of families receiving treatment would drop to 50 families if seen fortnightly, or 25 families if seen weekly. Thus, selection of families is imperative.
It is still a matter for amazement that some clinics aspire to give all patients a complete form of psychotherapy; they end up in a scramble to cope that means superficial, wasteful therapy.
Normally, the best deployment of facilities involves selecting a few families for complete antecedental psychotherapy, a larger number for focal antecedental psychotherapy, and the largest number for actuality psychotherapy and vector therapy. Vector therapy has revolutionised the effective use of time and is usually the procedure that gives the best rewards for the time and resources available. However, the lengthier methods continually unearth new knowledge and techniques that can then be applied to the shorter methods.
Some “hard core” or “problem” families in small number are invaluable as teaching media for trainees. Thus a few should be in the treatment programme. Some help is given and the reward for this in understanding the mechanics of family life is enormous.
Senior staff members of an institution should constantly remind staff of the cost of time. Endless discussion and counterdiscussion, often purposeless, can go on. The greater the time spent on this, usually the less effective the therapists. It is a measure of the need to question whether the right staff members have been selected. Naturally, some time must be spent on structured, fruitful staff communication.
Home or clinic setting
Family therapy usually takes place in an out-patient clinic. Few clinics offer a service in the family’s home. It is held by some that therapy in the clinic is a less artificial situation than therapy in the home, where it creates embarrassment to the family by provoking the interest of neighbours, and where distractions are many. Therapists feel safer in their own clinic setting and claim that it offers a controlled environment, which makes diagnosis easier. Others claim that the home, as the family’s natural setting, is more revealing, that it is easier to collect family members together there, and that it offers less distractions than a clinic. Probably the main determining factor in choice of setting is the time factor; it saves therapeutic time to bring the family to the clinic and this time is always at a premium. The family doctor, family nurse and family social worker, on the other hand, may find the home to be the best platform.
Home versus clinic setting is not a key factor in therapy. Given the right therapist, the all-important communication can ensue in any setting.
The clinic setting
The family group usually meets in the clinic setting. They can meet informally in a comfortable circle of chairs, or seated round a table. All members of the family of any age group, including infancy, are present. Less than one-and-a-half hours is unlikely to be worthwhile, and more than two-and-a-half hours is likely to be exhausting. About two hours is the average period for a group meeting. Family groups should, if possible, meet once a week and no less frequently than once a fortnight. There are times when a longer meeting with rest pauses may be indicated – even for a whole day. These longer sessions are useful for dealing with a crisis, or when the family has reached a point where it feels able to resolve a particularly difficult situation. This is a modification of the multiple impact therapy developed by the Galveston, Texas, group of workers; they brought a family into a residential setting for a once-and-all therapy with a stay of two to three days.
The room should be restful and quiet. Lighting should allow easy visibility, while being subdued and not harsh or revealing. All the chairs should be of equal height and size; the therapist claims no privilege. There should be playing material and reading material for the children. All need access to a toilet. A profitable arrangement can be to plan evening sessions for families unable to get together during the day.
Size of group
In family group therapy, concern should be with individuals who have emotional significance as a group. This, most commonly, is the nuclear family. But a blood tie is of secondary importance to an emotional tie. The family group in therapy should consist of those who are involved together in an emotionally significant way. Thus, the functional rather than the legal or physical group is important. For example, in a particular set of circumstances a lodger may be a more important father figure than a husband; a nanny may be a more important mother figure than the natural mother. Thus, added to the nuclear family, there may be grandparents, siblings, relatives, neighbours, friends, acquaintances, servants, etc. Always, the approach should be flexible – in the course of therapy the group may need to shrink or expand.
This applies at two points. Firstly, retaining information in the family group and, secondly, dealing with confidence as it concerns one family member within the group.
Families need to be assured that information will be kept confidential. Information must be assumed to belong to the person who gives it. It is imparted because only in so doing can the help needed be received. If it is communicated to others outside the family by the therapist, it must be with the clear understanding and permission of the family or the particular family member. Thus any recordings or notes must be made with their agreement and the anonymity of the family must be protected when they are used outside the immediate therapeutic situation, eg in teaching and writing. To fail means poor communication and ineffective therapy.
Within the family group, an individual may have information he wishes to impart to the therapist only. Similar “special information” relationships develop naturally within the family. The need for this is respected. While a particular family member’s right to communicate alone with the therapist must be maintained, its handicapping effect on therapy must be pointed out. With increasing confidence, more and more information is thrown into the common pool by the family members. Especially in early interviews, the family group cannot produce complete security and thus complete communication. To force it beyond what the relationship in the group can stand creates greater insecurity and impedes progress.
Given the agreement of the family, the interview can be recorded by sound or video tape. As a means of expediting day-to-day therapy, recording on tape and video has a limited part to play. Seldom does a therapist have time to consult a two-hour tape before engaging on another session. If this were done as a routine the number of families helped by a team of five therapists in one year and seen once fortnightly could shrink by half to 50 families! However, there are times when a family will profit from having a previous session played to it on tape and discussing it. More usually, the part played covers some especially significant part of the interview. Thus, any of its tapes should be accessible to a family, but the playback used with discrimination, eg a family member may not yet be secure enough to stand the revelation that in an interview he gives himself away so clearly. Again, one family member may use a section of tape to score off another member. Therapy aims to teach that such hostility is unnecessary.
The great value of recording interviews is in research and teaching, and not in routine therapy.
The prime channel of communication within the family group is speech. However, much more occurs which has meaning to the family. The seating arrangements can reflect divisions and coalitions in the family. Posture and gesture may convey what is felt and perhaps what an individual might wish to do, or how he would like to be regarded, his aspirations, and his defences. At first the therapist may find it difficult to understand both the verbal and the non-verbal communications, as families have idiosyncrasies. He must, with time, become attuned to the language of that family. The role of non-verbal communication has already been stressed as a major part of the skills of the therapist.
One or multiple therapists
Another matter of organisation is that concerning the choice of one therapist or several. Usually, economy dictates the choice of one only. At first, therapists new to the field have difficulty in shifting loyalty from one person to a group. Yet, all have had experience of such a loyalty within their own families; such a shift is possible once the group idea is grasped and habit given time to work. Having a number of therapists carries the danger of each forming an attachment to an individual family member and setting up rivalries. On the other hand, if more therapists are introduced there is more dilution of family disturbance. It has been argues that a number of therapists are collectively wiser and more skilled. But an experienced individual therapist should have the skill to manage alone. The greatest problem in having multiple therapists, and the final argument for one therapist, is maintaining adequate communication between a group of therapists; one therapist is usually of one mind, and comes from one preceding family.
Much profit comes in teaching from bringing a trainee into a family interview if this is tolerable to the family. Skills can be maintained by therapists playing video tapes of their therapy to colleagues for comment.
When a family has a member with psychopathology springing from a preceding family, then that preceding family should always be involved if it is accessible. It is much easier to resolve difficulties in the past if the past can be made present. Resolving the past through the imprint of the past life in the individual is more difficult. The preceding family is seen with its family member from the present family or jointly with the present family – depending on what is required. Even two preceding families or collateral families may be included. This latter is a form of multiple family therapy.
The effectiveness of family group therapy is dependent on a number of factors: (i) The less the degree of family disturbance, the more rewarding, of course, is the therapy – with our present knowledge, even the best therapists may have difficulty in resolving a severe degree of family emotional disorders. (ii) Problems of the Present resolve very satisfactorily – problems with deep roots in the Past are resistant. (iii) In general, the younger the family members, the more effective the therapy. (iv) Recent acute situations resolve more easily than long-standing, chronic situations.
Even in the most resistant families, family group therapy can be a valuable technique in conjunction with vector therapy; insight can develop to the point when the family can accept adjustment which will change the pattern of intra- and extra-family dynamics in its favour.
Equally good results can be obtained with all clinical categories, including the psychonotic, the psychopath, the alcoholic and the delinquent. In the writer’s experience, family group therapy is not a profitable procedure for “process” schizophrenia.
What constitutes resolution will depend on the target set. Targets could be:
- Relief of the presenting symptom in the presenting family member.
- Resolution of psychonosis in the presenting family member.
- Resolution of psychonosis in all family members to make the family harmonious in present circumstances.
- Resolution to the point when the contribution of this family to the foundation of succeeding families will be healthy.
- Complete resolution of psychonosis throughout the family to guarantee harmony under all ordinary circumstances.
Clearly (1) is much easier to achieve than (5), which is only occasionally attempted.
A routing follow-up contact with the family can reinforce previous procedures, offer continuing support, and may, with the detachment of time, allow a realistic appraisal of the extent and techniques of clinical effort. If investigation and diagnostic procedures are carefully followed, the family indicators will have been carefully recorded before therapy. Following therapy, the family can be reassessed as to the state of its indicators and a comparison made with its pre-therapy phase.
There are few good follow-up studies of family group therapy. Problems of evaluation, which are considerable in individual psychotherapy, are even greater in family psychotherapy. Often family group therapy amounts to an evaluation of family dynamics without any clear benefit to the family, analysis without reconstruction. Allowance must also be made for the fact that factors change by time alone; chance may change the pattern of adverse vectors to their advantage and the longer the therapy (and thus, time) the more likely this is to happen.
However, careful research could show that family group therapy is not only the most potent form of therapy, but also has, in most situations, a clear advantage over individual therapy.
There are a number of indications for the use of individual interviews.
- An individual person is the referred patient and the rest of the family refuse to co-operate.
- The referred patient is a single person and it is not immediately possible to involve the preceding family.
- The referred patient is an individual with a problem that does not involve the rest of the family – but later it may be necessary to involve the preceding family.
- The referred patient does not see at first that the present family is involved.
- Having started with a family or dyadic interview, a family member requests an individual interview for clarification of what appears to him to be a personal problem.
- One family member may alone show psychonosis of a severe degree. To cope with his experience in his preceding family, individual interviews run alongside the family group therapy. This may be a prelude to involving his preceding family.
It is not necessary to elaborate on the procedure of an individual interview here, as its main features are similar to those of family group therapy. Usually, interviews last 50 to 60 minutes but may be usefully prolonged at significant points in the therapy. The individual may be of any age group = child, adolescent, middle aged or of old age.
It may be useful to briefly outline the steps in the therapy of children.
In the Institute of Family Psychiatry, a child psychotherapist undertakes the investigation and treatment of the child patient in collaboration with the family’s psychiatrist. Together psychiatrist and child therapist outline the project for a particular child.
The first aim is usually to establish rapport by the use of much play material. Thereafter, systematic observation of the child takes place in the play situation; this gives a base line for comparison later on.
Play diagnosis follows. The aim here is to encourage the child to reveal his problems as he knows them and also to express what he knows about himself and his relationships within the family, the school and the neighbourhood. A young child can only communicate through play; an older child may spontaneously verbalise to the therapist. The play medium appropriate to the child’s age, sex and inclination is supplied. It is usual to corroborate information obtained through one medium by that disclosed by another. There is a systematic evaluation of the child’s family life.
Play therapy is the final technique and is employed for one of the following reasons: (i) to support the child while the parents are receiving treatment; (ii) to support the child when the family environment cannot be changed, or when he cannot be separated from it; (iii) to help separate the child from his family, either for short or lengthy periods; (iv) to make a lasting change in the child’s personality. The relationship between therapist and child is the most potent therapeutic medium. Within the safety of this relationship, the child expresses his fears, guilt, hate, and, sharing these with the therapist, is encouraged to healthier reactions.
Child psychotherapy is at its most effective when undertaken as part of family therapy.
Adolescents are particularly sensitive to such matters as being regarded as adults, confidentiality, and the relationship between the therapist and their parents. It is often wise to commence therapy with the adolescent in individual interviews. When rapport is established the advisability of a family group interview is discussed. He will need reassurance that any matter that has passed between therapist and adolescent can be kept confidential as long as he wishes. The aim and organisation of the family group interview is also the subject of preparation.
A dyadic interview is an interview that includes a dyad in the family – these can vary greatly, but the commonest of those that include the marital couple, parent and child, or two siblings.
Indications for a dyadic interview include:
- The referred patient may be a couple and it may be necessary to start with them before including the rest of the family as they do not see that the rest of the family is implicated.
- They may alone be available. They may have no children or immediate relatives.
- Other family members may refuse to co-operate.
- At a given moment in family group therapy a particular relationship may require special attention.
- A dyad may have a problem that does not include the other family members.
Sometimes before embarking on dyadic interviews it is wise to see each person individually. The right moment to bring them together can be gauged after preparation. Again when the situation requires it, they can receive individual interviews and this is made clear to them in the preparation. The bringing together must not be over-hasty. Some interviews may be too traumatic – one or the other member may not be ready for harsh revelations, rapport may suffer or he may move out of therapy. Family members sometimes cope with one another by being secretive, withholding information or saying little. These coping mechanisms must not be pushed aside until both partners are secure enough to deal with the consequences.
Multiple family therapy
Here, a number of families come together for therapy. Multiple family therapy is of two types:
- The families are related, eg starting with the present family, either a preceding family or collateral or succeeding families are brought in. They can be immensely valuable in either benexperiential psychotherapy or in vector therapy. The clan has assets and resources, and these can come into play. Naturally, the process is not undertaken without the understanding and preparation of the presenting family.
- Unrelated families. These are less useful. Each family has its unique historical background and a psychonosis arising out of it. These preceding families are not available and the crucial past situations cannot be dealt with. Each family is anxious to receive help for its own problems.
Such groups are most useful when discussing general problems of living which are of common interest. It has been argued that disturbed families can help one another. In general, disturbed families, like disturbed individuals, are not effective therapeutic agents. The other families are particularly prone to pick up the unhealthy reactions. Such families are not very understanding, and less so than a well selected and trained therapist. Normally, families profit from contact with healthy families. There would be more profit in mixing healthy and unhealthy families – with a preponderance of healthy ones. But healthy families usually see no good reason for being used in this way. It should be remembered that the larger the group, the more diluted it is. Furthermore, the larger the group, the less often can one member of it talk in a given period of time. As in all groups, there is an optimum size for useful communication. The group should probably not exceed seven persons.
General group therapy
These groups include a number of people from different families. They are organised in various ways:
- By age – groups of children, or adolescents, middle aged, aged.
- By sex – groups of men or women.
- Mixed sex groups.
- Economic, social or religious groups.
- Groups, all of whom have common syndromes, eg agoraphobia, asthma, fetishism, etc.
Activities can be very varied – some groups revolve round discussion, or dancing, teaching, art, etc. Some groups have a number of activities and take on the features of a club. All are of value in a supportive way.
The most useful groups are those in which a number of healthy people are able to exert a precise effect on a small number of sick people. Naturally, the younger the patients the more rapid the change. Thus groups are especially useful for infants (day nurseries, play groups, children’s clubs, adolescent’s clubs, etc.). Here we impinge on vector therapy, to be discussed later.
Even larger groups are useful (i) for their supportive effect, (ii) for discussion of general problems of living, and (iii) as a means of diagnosing and having access to vulnerable people.
However, they are not a very potent therapeutic milieu for advanced ill-health because:
- Each member of the group has a different preceding family unique to him.
- Attitudes from the past interfere with the present family, who cannot be dealt with as that family is not there – nor its preceding family.
- Each member is an epitome of its own family and each strives for expression.
- The amount of collective psychopathology is great, but there is no common interest in dealing with it.
At this point we also touch on group relations in in-patient care, and this will be discussed under vector therapy.