👨‍👩‍👧‍👦🤝 Group & Family Therapy

Chapter 8: Group and Family Therapy

Therapy is an intensive treatment that involves open therapeutic communication with participants who are willing to take part in therapy. Although individual therapy is an important treatment for mental illness, group and family therapies are also a part of the treatment plan for many clients in a mental health setting.

Leaders guide group and family therapy, and they can employ various leadership styles. Democratic leadership supports group interaction and decision making to solve problems. In group settings, more than one client can be involved. Therapy groups offer each client opportunities for growth and a feeling of belonging. Laissez-faire leadership progresses without any attempt by the leader to control the direction. In autocratic leadership, the leader completely controls the direction and structure of the group without allowing group interaction or decision making to solve problems.

Examples of group therapy topics include stress management, substance use disorders, medication education, understanding mental illness, and dual diagnoses.

Group therapy

Group process is the verbal and nonverbal communication that occurs during group sessions, including how the work progresses and how members interact with one another.

Group norm is the way the group behaves during sessions and, over time, it provides structure for the group. For example, a group norm could be that members raise their hand to be recognized by the leader before they speak. Another norm could be that all members sit in the same places for each session.

Hidden agenda: Some group members (or the leader) might have goals different from the stated group goals that can disrupt group processes. For example, three members might try to embarrass another member whom they dislike.

The dynamics of a group are affected by the group either being open or closed.

A nurse wants to use democratic leadership with a group whose purpose is to learn appropriate conflict resolution techniques. The nurse is correct in implementing this form of group leadership when demonstrating which of the following actions?

A

Observes group techniques without interfering with the group process.

B

Discusses a technique and then directs members to practice the technique.

C

Asks for group suggestions of techniques and then supports discussion.

D

Suggests techniques and asks group members to reflect on their use.

Group Membership

• A homogeneous group is one in which all members share a certain chosen characteristic (e.g., diagnosis or gender). Membership of heterogeneous groups is not based on a shared chosen personal characteristic. An example of a heterogeneous group is all clients on a unit, including a mixture of men and women who have a wide range of diagnoses.

• A subgroup is a small number of people within a larger group who function separately from the group.

• Groups can be open (new members join as old members leave) or closed (no new members join after formation of the group).

Components of Therapy Sessions

• Use of open and clear communication

• Cohesiveness and guidelines for the therapy session

• Direction toward a particular goal

• Opportunities for development of interpersonal skills, resolution of personal and family issues, and development of appropriate, satisfying relationships.

• Encouragement of the client to maximize positive interactions, feel empowered to make decisions, and strengthen feelings of self-worth

• Communication regarding respect among all members

• Support, as well as education regarding support topics (e.g., available community resources for support)

Focus and goals for individual, family, and group therapies

Group Therapy Goals

• Sharing common feelings and concerns

• Sharing stories and experiences

• Diminishing feelings of isolation

• Creating a community of healing and restoration

• Providing a more cost-effective environment than that of individual therapy

Concerns

• Privacy

• Not all members may receive equal attention.

• Personal opinions may be discouraged by group norms.

• Disruptive members can decrease a group's effectiveness.

Age Groups in Group Therapy

Children: Group therapy may be in the form of play while talking about a common experience.

Adolescent: Group therapy is especially valuable, as this age group typically has strong peer relationships. QPCC​​​​​​​

Older adult: Group therapy helps with socialization and sharing of memories.

Phases of Group Development

Planning Phase

Primary focus: Identify group characteristics like member inclusion, group name, seating configuration, and group schedule.

Responsibilities

• Consider group composition. For example, a client who is withdrawn may not interact well with a client who tends to probe other members.

• An overcrowded room may cause discomfort and anxiety while a large room for a small group does not encourage intimacy.

• A circular seating configuration emphasizes equality, especially when choosing a democratic leadership style.

Orientation Phase

Primary focus: Define the purpose and goals of the group.

Responsibilities

• The group leader sets a tone of respect, trust, and confidentiality among members. The group leader is active and provides the purpose of the group.

• Members get to know each other and the group leader.

• There is a discussion about termination.

Working Phase

Primary focus: Promote problem-solving skills to facilitate behavioral changes. Power and control issues can dominate in this phase.

Responsibilities

• The group leader uses therapeutic communication to encourage group work toward meeting goals.

• Members take informal roles within the group, which can interfere with, or favor, group progress toward goals.

• Cohesiveness has been established and the role of the leader is gradually diminishing.

Termination Phase

Primary focus: This marks the end of group sessions.

Responsibilities

• Group members discuss termination issues.

• The leader summarizes the work of the group and individual contributions.

• Members of a group can take on any of a number of roles.

• Feedback regarding the group therapy is elicited.

A nurse is assisting in planning group therapy for clients dealing with bereavement. Which of the following activities should the nurse include in the initial phase?

Select all that apply.

A

Encourage the group to work toward goals.

B

Define the purpose of the group.

C

Discuss termination of the group.

D

Identify informal roles of members within the group.

E

Establish an expectation of confidentiality within the group.

Roles

Maintenance roles: Members who take on these roles tend to help maintain the purpose and process of the group. For example, the harmonizer attempts to prevent conflict in the group.

Task roles: Members take on various tasks within the group process. An example is the recorder, who takes notes and records what occurs during each session.

Individual roles: These roles tend to prevent teamwork, because individuals take on roles to promote their own agenda. Examples include the dominator, who tries to control other members, and the recognition seeker, who boasts about personal achievements.

Group Characteristics

Characteristics can vary depending on the health care setting.

Acute mental health setting: Members can vary on a daily basis, and the focus of the group is on relief. Unit activities will directly impact the group, and the leader must provide a higher level of structure.

Outpatient setting: Members are often consistent, the focus of the group is on growth, external influences are limited, and the leader can allow members an opportunity in determining the group’s direction.

Virtual groups: Members meet remotely through teleconferencing technologies. This is ideal for members who have limited transportation resources or live in rural areas. Some challenges of virtual groups are difficulties reading nonverbal cues of communication, losing control of group settings, and a lack of full presence.

A nurse is working with an established group and identifies various member roles. Which of the following should the nurse identify as an individual role?

A

A member who praises input from other members.

B

A member who follows the direction of other members.

C

A member who brags about accomplishments.

D

A member who evaluates the group’s performance toward a standard.

Families and family therapy

Types of Families

Nuclear families include children who reside with married parents

Single-parent families include children who live with a single adult that can be related or nonrelated to the children

Adoptive families include children who live with parents who have adopted them

Blended families include children who live with one biological or adoptive parent and a nonrelated stepparent who are married

Cohabitating families include children who live with one biological parent and a nonrelated adult who are cohabitating

Extended families include children living with one biological or adoptive parent and a related adult who is not their parent (grandparent, aunt, uncle)

Other families include children living with related or nonrelated adults who are neither biological nor adoptive parents (grandparents, adult siblings, foster parents)

Family is the first system to which a person is attached and is the most influential system to which an individual will belong.

• Families go through various developmental stages. The roles the family members fulfill change throughout the stages. For instance, when adults become parents they care for and model behavior for their children. As children mature, they rely on their parents less. Later on, the parents may have to depend on their children to meet their needs.

• Families can have healthy or dysfunctional characteristics in one or more areas of functioning.

• Healthy family relationships support the well-being of each member of the family unit.

Areas of Functioning

Communication

Healthy families: There are clear, understandable messages between family members, and each member is encouraged to express individual feelings and thoughts.

Dysfunctional families

One or more members use unhealthy patterns, including the following.

• Blaming: Members blame others to shift focus away from their own inadequacies.

• Manipulating: Members use dishonesty to support their own agendas.

• Placating: One member takes responsibility for problems to keep peace at all costs.

• Distracting: A member inserts irrelevant information during attempts at problem solving.

• Generalizing: Members use overall descriptions (“always” and “never”) in describing family encounters.

Management

Healthy families: Adults of a family agree on important issues (rule making, finances, plans for the future).

Dysfunctional families: Management can be chaotic, with a child making management decisions at times.

Boundaries

Healthy families: Boundaries are distinguishable between family roles. Clear boundaries define roles of each member and are understood by all. Each family member is able to function appropriately.

Dysfunctional families

• Enmeshed boundaries: Thoughts, roles, and feelings blend so much that individual roles are unclear.

• Rigid boundaries: Rules and roles are completely inflexible. These families tend to have members who isolate themselves, and communication is minimal. Members do not share thoughts or feelings.

Socialization

Healthy families: All members interact, plan, and adopt healthy ways of coping. Children learn to function as family members, as well as members of society. Members are able to change as the family grows and matures.

Dysfunctional families: Children do not learn healthy socialization skills within the family and have difficulty adapting to socialization roles of society.

Emotional/Supportive

Healthy families: Emotional needs of family members are met most of the time, and members have concerns about each other. Conflict and anger do not dominate.

Dysfunctional families: Negative emotions predominate most of time. Members are isolated and afraid and do not show concern for each other.

Other Concepts Related to Family Dysfunction

Scapegoating: A member of the family with little power is blamed for problems within the family. For example, one child who has not completed their chores can be blamed for the entire family not being able to go on an outing.

Triangulation: A third party is drawn into the relationship with two members whose relationship is unstable. For example, one parent can develop an alliance with a child, leaving the other parent relatively uninvolved with both.

Multigenerational issues: These are emotional issues or themes within a family that continue for at least three generations (a pattern of substance use or addictive behavior, dysfunctional grief patterns, triangulation patterns, divorce).

Discipline

Disciplining children is a family behavior that can be healthy or dysfunctional. Setting limits on children’s behavior protects their safety and provides them with security. Discipline should be consistent, timely, and age-appropriate. Parents should administer discipline in private, when they are calm. Caregivers should be in unison on when and how to discipline.

Family Therapy

A family is defined as a group with reciprocal relationships in which members are committed to each other. Examples of families vary widely and are often nontraditional (e.g., a family made up of a child living with a grown brother and his partner). Areas of functioning for families include management, boundaries, communication, emotional support, and socialization. Dysfunction can occur in any one or more areas.

• In family therapy, the focus is on the family as a system, rather than on each person as an individual.

• Family data collection includes focused interviews and use of various family assessment tools.

• Nurses work with families to provide teaching. For example, an RN might instruct a family on medication administration or ways to help a family member manage their mental health disorder. QPCC​​​​​​​

• Nurses also work to mobilize family resources, to improve communication, and to strengthen the family’s ability to cope with the illness of one member.

• Multi-family therapy is an effective modality for families who are experiencing similar challenges. For example, two or more families learn new skills and share their experience of living with a family member who is diagnosed with a serious mental illness like schizophrenia.

A nurse on an acute mental health unit forms a group to focus on self-management of medications. At each of the meetings, two of the members conspire together to exclude the rest of the group. This is an example of which of the following concepts?

A

Triangulation

B

Group process

C

Subgroup

D

Hidden agenda

A nurse is assisting with a family therapy session. The younger child tells the nurse about plans to make the older sibling look bad, believing this will earn more freedom and privileges. The nurse should identify this dysfunctional behavior as which of the following?

A

Placation

B

Manipulation

C

Blaming

D

Distraction

Active Learning Scenario

A nurse is contributing to the plan of care for a family that is planning to begin therapy to improve the emotional and supportive aspect of the family unit. Use the ATI Active Learning Template: Basic Concept to complete this item.

Related Content: Identify the definition of a family.

Underlying Principles: Discuss the focus of family therapy.

Nursing Interventions

• Identify at least two outcomes for emotional/supportive functioning.

• Identify at least two interventions to assist the family during therapy.

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Active Learning Scenario Key

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