NIGHTINGALE INSTITUTE OF NURSING,

NOIDA

PEER PRESENTATION

ON

GROUP THERAPY AND FAMILY THERAPY

(SUBJECT: MENTAL HEALTH NURSING)

SUBMITTED TO: SUBMITTED BY:

MS. GLORY TRIPATHY MS. DHAIRYA ARORA

LECTURER MSC(N) 1st year
NIN,NOIDA NIN, NOIDA
GROUP THERAPY:
INTRODUCTION:
It is less time-consuming procedure in which 10 people can be treated at one time. Joseph
Pratt uses it first in 1905 on tuberculosis patient. Group therapy may utilize psychoanalytic,
supportive, transactional or behavioral approaches. over the years many types of group
therapies have emerged like self help groups(alcoholics anonymous for alcoholics, weight
watchers for obese) transactional analysis groups, psychodrama,etc.
DEFINITION:
IT is a form of treatment in which carefully selected, emotionally ill persons are placed into
groups ,guided by a trained therapist for the purpose of changing the maladaptive behavior of
the individual member.
PURPOSES:
1. To intervene in psychopathology.
2. To reveal ,examine and resolve distortions in interpersonal relationships.
3. To improve the skill of relating to others.
4. To learn coping styles.
CHARACTERISTICS OF GROUP THERAPY:
1. When people come into a group and interact freely with other group members, they usually
recreate those difficulties that brought them to group therapy in the first place. Under the
direction of the group therapist, the group is able to give support, offer alternatives, and
comfort members in such a way that these difficulties become resolved and alternative
behaviors are learned.
2. The group also allows a person to develop new ways of relating to people.
3. During group therapy, people begin to see that they are not alone and that there is hope and
help. It is comforting to hear that other people have a similar difficulty, or have already
worked through a problem that deeply disturbs another group member.
4. Another reason for the success of group therapy is that people feel free to care about each
other because of the climate of trust in a group. As the group members begin to feel more
comfortable, you will be able to speak freely. The psychological safety of the group will
allow the expression of those feelings which are often difficult to express outside of group.
You will begin to ask for the support you need. You will be encouraged tell people what you
expect of them.
5. In a group, people probably will be most helped and satisfied if they talk about their
feelings. It is important for them to keep in mind that they are the one who determines how
much they disclose in a group. No one is forced to tell anyone, deepest and innermost
thoughts.
THERAPEUTIC FUNCTIONS OF GROUP THERAPHY:
1 . imparting of information:
Psycho education /health education information that are structured and planned are given
through lecture method in the group.
2. Instillation of hope: Helps the client maintain faith in the therapeutic modality. The client
is optimistic he believes he will get better.
3.Universality: Client learns that others in the group have problems ,thought and feelings
similar to his own.
4.Altruism:Is the process of client s’ aiding or helping each other. The act of giving to others
becomes therapeutic for the giver, which increases the self esteem of the giver.
5.Correctives recapitulation of the primary family group:
Means that the client is influenced in therapy group by his history. Initially in group therapy
the client is influenced in therapy group by his history. Initially in group therapy the client
perceives the behavior of other members as being like his siblings and the behavior of the
therapist as being like his parents have in the past the client begins to gain insight into his
own behavior.
6. Development Of Socializing Techniques:
Role play and feedback in group therapy helps to develop social skills.
7.Imitative Behavior:
The client identifies with the healthier aspects of the other members and the leader and gains
growth imitation.
8. Interpersonal Learning:
The client learns to profit from the therapeutic use of anxiety when anxiety is minimized the
client relates more openly he learns to trust, to expose himself ,to give of himself ,to expect
from others ,to test reality ,and therefore to experience growth .
9.Group Cohesiveness:
Relates to bonding the feeling of “we instead of “I” .cohesiveness is demonstrated through
attendance and ability of the group to communicate positive and negative expressions to each
other without the group disintegrating.
10. Catharsis:
IS The expression of feelings deep emotions and anxiety provoking problems in the group .
this enables the client to find a practical solution.
11. Existential Factors:
The group is able to help individual members take directions of their own lives and to accept
responsibility for the quality of their existence.
SETTINGS:
Group therapy can form part of the therapeutic milieu of a psychiatric in-patient unit or
ambulatory psychiatric Partial hospitalization (also known as Day Hospital treatment) .In
addition to classical "talking" therapy, group therapy in an institutional setting can also
include group-based expressive therapies such as drama therapy, psychodrama, art therapy,
and non-verbal types of therapy such as music therapy. Group psychotherapy is a key
component of Milieu Therapy in a Therapeutic Community. The total environment or milieu
is regarded as the medium of therapy, all interactions and activities regarded as potentially
therapeutic and are subject to exploration and interpretation, and are explored in daily or
weekly community meeting.
A form of group therapy has been reported to be effective in psychotic adolescents and
recovering addicts. Patient groups read a novel or collectively view a film. They then
participate collectively in the discussion of plot, character motivation and author motivation. .
Under the guidance of the therapist, defense mechanisms are bypassed by the use of signifiers
and semiotic processes. The focus remains on the text rather than on personal issue.
PHYSICAL CONDITIONS THAT INFLUENCE GROUP DYNAMICS:
 Seating : the physical conditions for the group should be set up so that there is no barriers
between the members. For eg a circle of chairs is better than chairs set around a table.
Members should be encouraged to sit in different chairs each meeting. This openness and
change creates an uncomfortableness that encourages anxious and unsettled behaviours
that can then be explored within the group.
 Size: various authors suggested different range of size as ideal group interactions: 4to 7
(Huber 1996) 2 to 15 (Sampson & marthas 1990) and 4 to 12 (clark 1994) . group size
does not make a difference in the interaction among members. The larger the group the
less time is devot to individual member. In larger group aggressive individual are most
likely to heard where as quieter members may be left out discussion . the larger group
provides more opportunities for individual to learn from other members. The wider range
of life experience and knowledge provides a greater potential for effective group problem
solving.
 Membership: whether the group is open ended or close ended is another condition that
influence the dynamics of the group process. Open ended groups are those in which
members leave and others join at any time while the group exists. The continuous
movements of members in and out of the group creates the type of uncomfortableness.
These type of group held in short term inpatient unit or in long term facilities as well as.
Closed groups are fixed frame. All members join at the time of group organized and
terminate at the end of designated time period. These groups are composed of individual
with common issues or problems they wish to address.
 Dealing with challenging group behaviors: problematic behaviors occur in all groups.
They can be challenging to the most experienced group leaders and frustrating to new
leader . in dealing with any problematic behaviors the leader must remember to support
the integrity of the individual members and the group as whole.
 Monopolizer: some people monopolize group by talking others. It causes anxiety among
the members. Within few sessions person relaxes no longer attempts to monopolize the
group. The leader support the group in establishing rules that allows everyone to
participate . the leader can interrupts monopolize by acknowledging the members
contribution.
 Yes , but: some people agree with suggestions from others but they add ,yes but”and
give several reasons so leader must avoid problem solving for the member and encourage
the person to develop his or her own solutions.
 Disliked member: in some group members dislikes one particular member so in this
situation leader must move the member to better match group. Whether the person stay
or leave the leader must stay neutral and avoid displaying negative and non verbal
behaviors that indicate he or she too dislikes the group member. Or leader must show
respect for disliked member and acknowledging his contribution.
 The silent member: the member who does not participate in group discussion the leader
must respect the person silent nature and get to know the member and understand the
meaning of the silence before encouraging interactions.
 Group conflict; groups experienced conflict. The leader must decide it is a natural part or
addressing any issues. Member to member conflict can be handled but leader to member
conflict is more complicated. The leader can use conflict resolution strategies but should
be sensitive to the power differential between leader role and member role.
TYPES OF GROUP THERAPY:
1.Task Groups: Task groups are designed to accomplish a particular task. The emphasis of
these groups is on decision making and problem solving . they often have specific goals to
accomplish and a deadline for completion of the work.
2.Self Help Group:Groups organized around a common experience are labeled self –help
group.eg alcoholics anonymous, smoking cessation group and numerous groups related to
specific health problems . they may not receive consultation from a health care provider .
although some self-help group are established and organized by professionals the groups are
run by the members alone and often do not have a designated leader. Leadership evolves with
in the group depending on the need that arises.
3.Educational Groups:The goal of teaching group is to provide information.eg child birth
preparation ,patient education groups, medication groups and psychoeducation group .
inservice education for staff are also included in this category.
4.Supportive Therapy Group:The primary goal of supportive therapy group is to help the
members cope with life stress. The focus is on dysfunctional thoughts ,feelings and behavior .
it has value for patient of all ages and with both medical and psychiatric diagnoses.
5. Psychotherapy Group:The goal of psychotherapy group is the treatment of emotional
,cognitive , or behavioral dysfunction. Group techniques and processes are used to help
members learn about their behavior with other people and how to relates to core personality
traits. The intent is for members to change their behavior ,not just to understand oa seek
support for it.
6. Brief Therapy Group:The purpose of brief therapy group is to focus on the actions
participants can take to improve their current situation .these group target what can be done
now to change a patient problem solving approach and help the patient implement more
adaptive coping skills. The establishment of recognized and self sustaining group program is
greatly facilitated by advanced planning ,well thought out structure and clearly stated goal.
7.Intensive Problem –Solving Groups:These are designed for 6to 10 patients each working
on the identification and resolution of specific target problems ,goals, and problem solving
strategies related to an individual treatment plan . they based on cognitive ,behavioral , and
interpersonal therapy models implemented in a structured problem solving format. The goal
is to identify and clarify the problem ,explore alternatives solutions and get action oriented
commitments for change. The therapist act as a leader ,techer, and coach whose purpose is to
teach group members the interpersonal skills needed to solve the problems identified in their
treatment plans.
8. Multidisciplinary Team:Nurses are often members of multidisciplinary teams consisting
of psychiatrists psychologist, social worker, and so on. the pooling of all of these resources
allows for efficient use of available resources for the benefit of the patient. One drawback of
these groups is the tension that can be manifested between the different professional
disciplines because of status issue, communication issue, leadership issues conflict for whose
is the leader.
9.Activity Groups:It is designed to enhance the psychological and emotional well being of
patients . task include drawing ,exercise to music, arts and crafts, reviewing current events.
The benefits that have been reported from the participation of patient in such group activity
groups include the expression of positive and negative feelings and the greater acceptance of
oneself.
10. Peer Support Groups:It is effective way of professional to share the stress and problems
related to their work. group purposes may include case consultation ,sharing information,
about educational opportunities providing information about management skills, and
decreasing professional isolation.
ACCORDING TO THE PURPOSES:
1. Psychoanalytic Group Therapy:Group communication is focused on the here level of
unconscious ,semiconscious and conscious material .the group focuses on interpretation
of dreams ,free association, and other latent content produced in the group. The therapist
turns these experiences into conscious, healthy learning experience for the client.
2. Transactional Analysis:The three ego states of the individual the parent ,the child ,and
the adult –are examined in TA group.
3. Rational Emotive Therapy :It aims to maximize a person rational thinking.
4. Gestalt Therapy:It emphasizes self expression, self exploration, and self awareness in
the patient .clients and therapist focus on the every day problem and try to solve them.
5. Interpersonal Group Therapy:It explore the members anxiety and stress and their
effects on the individual . it is believed that anxiety from interpersonal relationship is
reduced or relieved through interpersonal support.
6. Psychodrama Group:It explore the truth through dramatic methods. During
psychodrama the client produces a topic to be explored .the therapist directs the subject
through role playing of scenes related to the topic and incorporates the use of therapeutic
ideas in the action. The audience experiences the feeling and identifies with the action on
the stage .a catharsis occurs for the subject and also for the audience.
7. Encounter Groups:It aims at the bringing personal change as a result of deeply felt
experiences.
8. T –Groups:The goal is to verify experimentally the T- group method . this involves the
study of groups norms , roles , communication distortions, and the effect of authority on
behavior patterns personality and coping mechanisms. Group members receive feedback
by exposing themselves to others in the group and they also experiment with new or more
productive behavior.
9. Community Support Groups:Provides identification ,clarification ,understanding ,role
modeling ,feelings of togetherness, and group cohesion. They help prevent the individual
member from feeling lonely and isolated. They help the members decrease levels of stress
and increase level of self acceptance . the members develop new or more effective
patterns of behavior.
10. Marathon Group:The term Marathon group refers to the amount of concentrated time
the participants spend together as a group. These sessions may last from 12 hours to 2,3
or more days, allowing short period away from the group for sleeping and eating . these
groups have a clearly stated goal of personal change or growth of participants. Size of
group -8-10 members duration of each session 1-2 hours frequency everyday or 3 days in
a week depending on the purpose.
PHASES OF GROUP DEVELOPMENT :Groups, like individual move through phases of
life cycle development .ideally ,groups will progress from the phase of infancy to advanced
maturity in an effort to fulfill the objectives set forth by the membership. Unfortunately as
with individuals some group fixed in early developmental levels
and never progress or experience periods of regression in the developmental process. Three
phases of group development are:
Phase 1 Initial Or Orientation Phase:
 Group activities:The leader and member works together to establish the rules that will
govern the group .(eg when and where meetings will occur the importance of
confidentiality, how meetings will be structured) goals of the group are established .
members are introduced to each other.
 Leader expectations: The leader is expected to orient members to specific group
processes, encourages members to participant without disclosing too much too soon ,
promote environment of trust and ensure that rules established by the group do not
interfere with fulfillment of the goals.
 Member behavior:In phase 1 ,members have not yet established trust and will respond
to this lack of trust by being overly polite. There is a fear of not being accepted by the
group . they may try to get on good side of the leader with compliments and confronting
behaviors. A power struggle may ensue as members compete for their positions in the
pecking order of group.
Phase 2 Middle Or Working Phase:
 Group activity:During the working phase ,cohesiveness has been established has been
established with in the group. This when the productive work toward completion of the
task is undertaken .problem solving and decision making occur within the group . in the
mature group ,cooperation prevails and differences and disagreements are confronted and
resolved.
 Leader expectations:The role of leader diminished and become more one of facilitator
during the working phase. Some leadership functions are shared by certain members of
the group as they progress towards resolution. The leader help to resolve conflict and
continues to foster cohesiveness among the members while ensuring that they do not
deviate from the intended task or purposes for which the group was organized.
 Member behavior:At this point trust has been established among the members. They
turn more often to each other and less often to the leader for guidance . they accept
criticism from each other using it in a constructive manner to create change.
Phase 3 Final Or Termination Phase:
 Group activity:The longer a group has been in existence ,the more difficult termination
is likely to be for the members. Termination should be mentioned from the onset of group
formation. It should be discussed in depth for several meetings prior to the final session.
A sense of loss that precipitates the grief process may be evident particularly in the
groups that have been successful in their stated purpose.
 Leader expectations:In the termination phase the leader encourages the group members
to reminisce about what has occurred within the group to review the goals and discuss the
actual outcomes and to encourage members to provide feedback to each other about
individual progress within the group. The leader encourages members to discuss feelings
of loss associated with termination of the group.
 Member behaviors: Members may express surprise over the actual materialization of
the end . this represents the grief response of denial which may then progress to anger .
anger toward other group members or toward the leader may reflect feelings of
abandonment. These feelings may led to individual members discussions of previous
looses for which similar emotions were experienced. Successful termination of group may
help members develop the skills needed when losses occur in the other dimensions of
their lives.
MEMBERS ROLES:
Benne And Sheates identifies three major types of roles of individual play within
membership of the group. These are
1. Complete the task of the group.
2. Maintain or enhance group processes.
3. Fulfill personal or individual needs.
Task roles and maintenance roles contribute to the success or effectiveness of the group.
Personal roles satisfy needs of the individual members sometime to the extent of interfering
with the effectiveness of the group.
PREPARATION : The patient is prepared for the group therapy sessions by explaining the
processes to which the patient will exposed ,emphasizing the need to be open and honest with
co- patient and finally ,alerting the patient to the possibility that he may likely be questioned
by group members explicitly share his problem to develop self knowledge about illness.
CRITERIA OF PATIENT TO BE INCLUDED IN GROUP THERAPY:
1. Ability to communicate .
2. Willingness to share his problems with others.
3. Motivation to change.
4. Patient with authority anxiety .
5. Patient using defense mechanism of projection, repression, denial, suppression,
transference reactions.
FACTORS CONTRIBUTING TO GROUP THERAPY:
1. Faith in the treatment procedure.
2. Universality (similar problems are seen in the others)
3. Direct guidance for the problem.
4. Altruism (patient offer each other support ,reassurance, suggestion, and insight)
5. Development of socializing skills.
6. Imitative behavior (imitation of a healthy behavior ,especially therapist is identified as a
role model and patients imitates the therapist.)
7. Catharsis (ventilation of emotion)
8. Conflict resolutions.
9. Acceptance of the reality
10. Group cohesiveness(attractiveness that members have for their group and other members)
11. Interpersonal learning.
THERAPEUTIC TECHNIQUES USED IN GROUP THERAPY:
1. Approval: -
condoning or encouraging an attitude, feeling or action
2. Acceptance: -
An attitude or a relationship that recognizes the worth of a person without imply either
approval of particular behavior or personal affection.
3. Clarification: -
Restatement by another in what is hoped to be clearer terms of the substance of what the
client has said.
4. Exploration: -
A shift from considering one aspect of a situation to considering other.
5. Identification: -
Delineating specific factors for the purposes of understanding or clarifying.
6. Interpretation:-
Finding or explaining the meaning or significance of the information.
7. Information giving:-
Stating facts about a problem.
8. Encouraging expression of feelings or ideas:-
Indication in some way that it is permissible or desirable to talk about feelings or ideas.
9. Reassurance :-
Offering the client confidence of a favorable outcome through suggestion, through
persuasive arguments or through comparing similar cases.
10. Support :-
giving comfort ,approval or acceptance.
11. Intervention:-
An action that directs or influences the client behavior.
12. Understanding:-
Indicating verbally or nonverbally that you know or comprehened what the client is
communicating and what he is feeling.
13. Reflection:-
Repeating back to the client what he has said mirroring his statements.
14. Listening :-
Concentrating on the clients communication without interruption.
15. Teaching:-
Helping the client learn specifies in relation to events and behavior.
16. Silence:-
The use of no verbal or spoken words.
17. Structuring:-
Shaping the content of the group meetings.
18. Limit –setting:-
Deciding how far group members and the group may go before the therapist ceases or
restricts to a point ,the behavior ,activity , or verbal expression of members.
19. Transference and counter transference:-
Transference occurs when the client attributes characteristics and the behavior of the
family member to the therapist. And counter transference occurs when therapist responds
in a negative manner to the client transference. The clarification of this distortion with
the client helps to create a therapeutic process of learning.
20. Themes:- The area of discussion that recur or relate one group session to another and
then explore the meaning of these themes.
ADVANTAGES OF GROUP THERAPY:
1. Members profit by hearing other members discuss their problems. This discussion
decreases the members feeling of isolation alienation, and uniqueness, and encourages him to
share his feeling and problems.
2. Opportunity to explore specific styles of communication in a safe atmosphere, where they
can receive feedback and can undergo change.
3. Learns multiple way of solving problems from other group members and group exploration
helps them to discover new ways of solving problems.
4. The group provides for its members understanding, confronting and identification, with
more than one individual.
5.Group therapy allows people to receive the support and encouragement of the other
members of the group. People participating in the group are able to see that there are others
going through the same thing, which can help them feel less alone.
6.Group members can serve as role models to other members of the group. By seeing
someone who is successfully coping with a problem, other members of the group can see that
there is hope and recovery is possible. As each person progresses, they can in turn serve as a
role model and support figure for others. This can help foster feelings of success and
accomplishment.
7.Group therapy is very cost effective. Instead of focusing on just one client at a time, the
therapist can devote his or her time to a much larger group of people.
8.Group therapy offers a safe haven. The setting allows people to practice behaviors and
actions within the safety and security of the group.2
9.By working in a group, the therapist can see first-hand how each person responds to other
people and behaves in social situations. Using this information, the therapist can provide
valuable feedback to each client.
DISADVANTAGES:
1. Individual privacy is destroyed.
2. Resistance and reluctant to change.
3. Therapist at times dominant or as if he is giving individual therapy.
NURSES’ ROLES IN GROUP THERAPY:
Nurses explore the use of groups as a teaching method , a therapeutic method ,a therapeutic
tool with clients and a form of peer group supervision. Nurses participates as a leader in
many formal and informal group therapies, including resocialisation, reeducation, supportive
therapy, psychoanalytic therapy, family therapy, couple therapy etc.
Leader roles are :
1. group task roles.
2. group building and maintenance role.
3. individual roles.
Group task roles:
To identify group problems and select methods to solve those problems.
 Suggests new ideas.
 Seeks clarification.
 Ask for opinion to what the group is undertaking.
 Gives information shares experiences in relation to the group problems.
 Give opinion by stating ideas and values about group suggestions.
 Clarifies how ideas can work.
 Orients the group on target by defining where the group is in relationship to its goal.
 Evaluates the accomplishment of the group in relation to its task.
 Motivates the group to greater productivity.
 Record the productive discussion.
Group building and maintenance roles:
To strength , regulate and perpetuate the group members to function as whole group.
 Encourage and accepts the contributions of others.
 Reconciles differences between group members.
 Admits error to maintain group harmony.
 Keeps communication open and provides encouraging remarks.
 Sets group goals and evaluate the functioning of the group.
 Observes the group discussion , gives feedback and interprets.
 Assumes more of an audience role but gives the feeling of being with group.
Individual role:
 To meet the needs of the group members it hampers group functioning that need to be
aware of .
 Expresses aggressions, which deflates the status of individual and group accomplishment.
 Resists progress by arguing or disagreeing beyond reason.
 Calls attention to himself/ herself through boasting and pointing out achievements.
 Give self confession by expressing feelings and ideology not related to the group but uses
the group as audience.
 Demonstrate individuals lack of involvement.
 Asserts authority superiority in manipulating the group.
 Seeks helps from group.
 Tries to have own biases and prejudices.
Basic roles of nurses:
 Determine setting and size of the group.
 Choose frequency and length of group sessions.
 Select a therapist for the group.
 Formulates policy on group therapy with other therapeutic modalities.
 Formulating appropriate goals.
 Selecting patients who can perform the group task.
 Preparing patients who can perform group task.
 Preparing patients for group therapy.
 Explaining group members to maintain confidentiality of group discussion.
 Identify and resolve common problems.
 Fix up time for the subsequent sessions.
 Maintain attendance of group members.
 Arrange for guard ship during session for uninterrupted discussions.
 Maintain strict discipline and confidentiality over the informations that are discussed in
the session.
 Assists the group members for progressing and completing the task home assignments.
 Monitor the group members behavioral changes prior to and after group therapy sessions.
 Prepare the group member physically to attend group therapy session continuously by
attending to his needs like medication, nutritional needs and elimination need, personal
hygiene.
RESEARCH
ARTICLE
Behavioural group therapy for obsessive–compulsive disorder in Norway. An open
community-based trial  Behaviour Research and Therapy, Volume 48, Issue 6, June 2010,
Pages 547-554
Åshild Tellefsen Håland, Patrick A. Vogel, Birgit Lie, Gunvor Launes, Are Hugo Pripp,
Joseph A. Himle
Abstract: The aim of the current study was to test the effectiveness of ERP-based 12 weeks
group therapy for OCD patients in a community-based, general Norwegian outpatient clinic.
The sample consisted of 54 patients diagnosed with OCD. The Yale-Brown Obsessive–
Compulsive Scale (Y-BOCS), the Beck Depression Inventory (BDI) and the Spielberger
State Anxiety Inventory (STAI-S) were administered before treatment, after treatment and at
3- and 12-month follow-ups. Analyses with mixed models for repeated measurements
showed that group behavioural therapy offered to OCD patients significantly improved
ratings of obsessive–compulsive symptoms, depression and anxiety. These improvements
were maintained at 3- and 12-month follow-ups and an additional reduction in obsessive–
compulsive symptoms was observed from post-treatment to 3-month follow-up. However, the
delayed effect of therapy was no longer present at 12-month follow-up. The results also
revealed that the patients had a lower chance for an increased outcome category (e.g. from
unchanged to improved or recovered) with high scores on STAI-S at the given observation
times (post-treatment, 3- and 12-months follow-ups). Depressive symptoms (BDI) at post-
treatment and follow-ups had no significant influences on the three categories of outcome for
OCD. In conclusion, the results indicate that behavioural group therapy can successfully be
delivered to patients with considerable comorbidity in a real world setting conducted by
therapists with limited training in the CBT.
FAMILY THERAPY:
INTRODUCTION
Family is the most powerful primary social system or primary social group, to which
a person ever belongs. For example-birth, childhood, puberty, marriage and death, etc.
Family therapy is a form of group therapy in which the client and his or her family
members participate. Regardless of the origin of the problem, and regardless of whether the
clients consider it an "individual" or "family" issue, involving families in solutions is often
beneficial. This involvement of families is commonly accomplished by their direct
participation in the therapy session. The skills of the family therapist thus include the ability
to influence conversations in a way that catalyzes the strengths, wisdom, and support of the
wider system.
Family therapy is a form of psychotherapy designed to assess and treat various
psychiatric disorders through-
• An understanding of how the interactional dynamics of the family relates to individual
psychopathology
• Mobilization of the family's inherent strengths and functional resources
• Restructuring of maladaptative family behavioral styles and
• A strengthening of family problem solving behaviors
Family therapy works through social negotiation. It involves determining what the family
wants, how they see the problems, what they think wrong and what is within their capacity to
alter.
Therapist enters the family at relationship level not at the individual level.
Shift from individual deficit model to relationship deficit model. All behavior occurs in
context, and that context determines what you do in therapy.
DEFINITION
Family therapy may be defined as any psychotherapeutic endeavor that explicitly focuses on
altering the interactions between or among family members and seeks to improve the
functioning of the family as a unit, or its subsystems, and/or the functioning of individual
members of the family.
Family therapy is used to refer to both specific family interventions and a broader conceptual
framework for intervention that include specific family interventions and a broader
conceptual framework for interventions that include family centered treatment, family/couple
psychotherapy, family skill building, multiple family groups and in home support.
STAGES OF FAMILY DEVELOPMENT
Carter and Golddricj (1999) have identified six stages that describe the family life cycle.
These stages are-
1. THE SINGLE YOUNG ADULT-
- Tasks include forming an identity separate from parents, establishing intimate peer
relationships & advancing toward financial independence.
- Problems arise when either the young adult or the parents encounter difficulty terminating
the interdependent relationship that has existed in the family of origin.
2. THE NEWLY MARRIED COUPLE-
- Tasks include establishing relationships with members of extended family, and making
decisions about having children.
- Problems arise if either partner chooses to cut themselves with his/her family of origin or
when the couple chooses to cut themselves off completely from extended family.
3. THE FAMILY WITH YOUNG CHILDREN-
- Tasks include making adjustments within the marital system to meet the responsibilities
associated with parenthood while maintaining the integrity of the couple relationship,
sharing equally in the tasks of childbearing, and integrating the roles of extended family
members into the newly expanded family organization.
- Problems arise when parents lach knowledge about normal childhood development and
adequate patience to express themselves through behavior.
4. THE FAMILY WITH ADOLESCENTS-
- Tasks including the level of dependence so that adolescents are provided with greater
autonomy and freedom to make independent decisions or when parents are unable to
agree and support each other in this effort.
5. THE FAMILY LAUNCHING GROWN CHILDREN-
- Tasks include reestablishing the bond of dyadic marital relationship, realigning
relationship to include grown children, in-laws and new grandchildren, accepting
additional care-taking responsibilities and eventual death of elderly parents.
- Problems can arise when feeling of loss and depression become overwhelming in
response to departure of children from home, when parents are unable to accept their
children as adults etc.
6. THE FAMILY IN LATER LIFE-
- Tasks includes new social roles related to retirement and possible change in socio-
economic status, accepting some decline in physiological functioning, dealing with death
of spouse and confronting and preparing for one’s own death.
- Problems arise when older adults have failed to fulfill the tasks associated with earlier
levels of development and are dissatisfied with the way their lives have gone.
MAJOR VARIATIONS IN FAMILY LIFE CYCLE DEVELOPMENT
1. DIVORCE
 Stages of family life cycle of divorce include deciding to divorce, planning the breakup
of system, separation and divorce.
 Tasks include accepting one’s own part in the failure of marriage, working
cooperatively on custody & visitation of children & finance, realigning relationship with
extended family and mourning the loss of marriage relationship & intact family.
2. REMARRIAGE
 Stages of family life cycle include entering the new relationship, planning the new
marriage & family and remarriage and reestablishment of family.
 Tasks include making a firm commitment to confront complexities of combining two
families, facing fears, realigning relationship with extended families to include new
spouse & children.
 Problems arise when there is a blurring of boundaries between the custodial and
noncustodial families.
3. CULTURAL VARIATIONS
 It is difficult to generalize about variations in family life cycle development according to
culture. Cultural diversity does not exist, however, and nurse must be aware of possible
differences in family expectations related to Sociocultural beliefs.
FUNCTIONS OF FAMILY
The various functions of family are:
1. MANAGEMENT- Use of decision making power for all family activities, rule making,
provision of financial & other support, successful negotiations with future planning.
2. BOUNDARY FUNCTION- Clear boundaries define the roles of members within family
and allow for differences among members. Diffused boundaries are blending together the
roles, thoughts and feelings of individuals; rigid boundaries prevent family members from
trying out new ideas.
3. COMMUNICATION- Healthy communication within family encourages its members to
express their feelings or emotion appropriately, therefore helps the family members to
solve their problems.
4. SUPPORT- Healthy family are concerned with each other’s needs (physical &
emotional), they feel support from those around and are free to grow and explore new
roles and facets of their personalities.
5. SOCIALIZATION- socialization skills are learnt within the family. People learn how to
interact, negotiate & plan, adopt coping skills.
6. BIOLOGICAL FUNCTION- Replacement of species through the propagation of progeny.
Family is the medium where the sex relations are controlled and regulated.
7. PSYCHOLOGICAL- Love, belongingness, affection, intimate relationship, sympathy,
security, attention, emotional satisfaction, care of offspring, sexual relationship etc. will
be attained through family.
8. EDUCATION- mother is the first teacher & primary care giver. Child’s personality &
character formation will be attained through family.
9. RECREATION
10. RELIGIOUS FUNCTION- child learns values, moral, ethics, honesty, traditions etc.
11. SOCIAL & CULTURAL FUNCTION- get togethers with people belonging to different
cultures and believes.
APPROACHES TO FAMILY THERAPY
Several different approaches or orientations to family therapy have been identified:
1. Integrative Approach-
 Nathan Ackerman, a trained psychoanalyst, used the integrative approach, including
both individual and family as a cluster. He focused on family values. Ackerman
believed in interlocking pathology, which occurs when an individual's problems are
entwined into a neurotic interaction with the family and social environment.
 Therapists using the integrative approach consider the interactions between the person
and his or her social environment and give equal weight to the internal and external
influences.
 The family needs to share concern for each member's welfare. A problem arises when
interpersonal conflict is internalized by the client and it becomes an intrapersonal
conflict.
 The overall goal of therapy is to remove the pathogenic intrapersonal conflict and
promote more healthy relationships within the family.
 For example, a family of five is having financial difficulty due to poor money
management. The husband internalizes blame because he is the primary wage earner and
head of the household; thus he develops the intrapersonal conflict of guilt. During
family therapy, the wife and children admit to excessive spending and the husband's
intrapersonal conflict of guilt is resolved.
2. Psychoanalytic Approach-
 Therapists using the psychoanalytic approach base many of their views on Freud's work,
believing that family members are affected by each member's psychological makeup.
 Individual behaviors are regulated by the family's feedback system. Problems arise
when there is an internalization process or introjection of parental figures. For example,
unresolved conflicts between first- and second-generation family members are
internalized (lived out) or projected onto family members in current marital or parental
relationships. Simply stated, a 40-year-old woman who observed her mother's difficulty
relating to a rigid husband has difficulty relating to her husband when he disciplines
their teenage children. She has unconsciously incorporated or internalized an aspect of
her mother's personality into her own.
 Psychoanalytic therapy is intensive over a long period and focuses on cognitive,
affective, and behavioral components of family interaction.
 One goal is to guide the family members who exhibit pathology into clarifying old
misunderstandings and misinterpretations between themselves and parents and members
of the family of origin and establishing an adult-to-adult relationship.
3. Bowen Approach-
 Murray Bowen's approach to family therapy or family systems therapy views the family
as consisting of both emotional and relational systems. Bowen believed that an
individual's behavior is a response to the functioning of the family system as a whole.
 One concept from Bowen's theoretical approach is the differentiation of self-concept.
This refers to the degree that an individual is able to distinguish between the feeling
process and the intellectual process in one's self, thereby making life decisions based on
thinking rather than on feeling.
 Other concepts include the identification of emotional triangles or three-person
interactions in a family, the importance of intergenerational family history in
understanding dysfunction, and the role of anxiety on functioning of the individual and
the family.
 Dysfunction in the family is related to the method in which families as a whole respond
to anxiety. Processes that can be used to handle anxiety include projection to a child,
conflict between spouses, and dysfunction in an individual spouse.
 Therapy using this approach focuses on guiding one or more family members to become
a more solid, defined self in the face of emotional forces created by marriage, children,
or the family of origin. Ultimately the result is to gain the clarity and conviction to carry
through one's own positions, such as a parent, spouse, or dependent child.
4. Structural Approach-
 Structuralists, like Salvador Minuchin, view the family as a system of individuals. The
family develops a set of invisible rules and laws that evolve over time and are
understood by all family members. A hierarchical system or structure develops in the
family.
 Problems arise if family boundaries become enmeshed (tangled with no clear individual
roles) or disengaged (individual detaches self from the family). Problems also arise
when a family cannot cope with change.
 The structural therapist observes the activities and functions of family members.
Therapy is short term and action oriented, with the focus on changing the family
organization and its social context.
 A holistic view of the family is developed, focusing on influences that family members
have on one another.
 Guidance is given toward developing clear boundaries for individual members and
changing the family's structural pattern.
5. Interactional Or Strategic Approach-
 The interactional or strategic approach, pioneered by Virginia Satir and Jay Haley, uses
communication theory as the foundation.
 In this approach, the therapist studies the interactions between and among family
members, recognizing that change in one family member occurs in relation to change in
another family member.
 Family members develop a calibration or rating and feedback system so that
homeostasis is maintained.
 Interactionists agree with structuralists that a set of invisible laws emerges in the family
relationship, and that problems arise if these family rules are ambiguous.
 When power struggles develop in a family, strategies employed to control the situation
may provoke symptoms. These symptoms are interpersonal, with at least one family
member contributing to the dysfunction of another.
 Therapy is based on the concept of homeostasis. According to this concept, as one
member gains insight and becomes better, another family member may become worse.
 Communication is considered the basis for all behavior.
 Deals with the interpersonal relationships among all family members and focuses on
why the family is in therapy and what changes each member expects. The family thus
helps set goals for the treatment approach.
6. Social Network Or Systemic Approach
 Some therapists believe that the family operates as a social network. They believe that
healing comes from social relationships.
 Problems ensue if the family social network loses its ability to recover quickly from
illness or change.
 A systems approach is used, but is not clearly defined. The growth model is used to
understand emotional difficulties that arise during different stages of development.
 Therapy emphasizes the natural healing powers of the family. It involves bringing
several people together as a social network. For the first few meetings, this may
encompass people who are outside of the family, but who have similar ideals and goals.
 Family members are helped to set goals for optimal outcomes or solving of problems.
7. Behaviorist Approach
 Behaviorists believe that the family is a system of interlocking behaviors, that one type
of behavior causes another.
 They deny internal motivating forces, but believe individuals react to external factors
and influences.
 The individual learns that he or she obtains satisfaction or rewards from certain
responses of other individuals. Behavior is thus learned.
 Problems arise when maladaptive behavior is learned and reinforced by family
members, who respond either positively or negatively. Sometimes a particular behavior
is exhibited to gain attention.
 Therapy includes interpreting family members' behavior but not necessarily changing it.
However, restructuring interpersonal environments may bring about change. Thus,
therapy is based on an awareness process as well as on behavioral change.
 Therapeutic approaches using principles of learning theory are taught. Approaches are
direct and clearly stated. In an effort to bring about change, positive reinforcement is
given for desired behavior.
 The family is involved in goal setting for desired outcomes, and a contract may be
established for this purpose.
AIMS OF FAMILY THERAPY
• To address and reduce dysfunctional behaviors and psychiatric symptomatology of
individual family members in the matrix of interpersonal relationship
• To solve intra family relational conflict and conflict between the family and its
extended family and social environment.
• To mobilize family resources and identify maladaptative family problem solving
behaviors in the service of addressing the family‘s present complaints
• To enhance the perception and fulfillment by one another‘s emotional needs
• To improve family problem solving and communication skills
• To strengthen the capacity of individual members and the family as a whole to cope
with major life stressors and traumatic events, including chronic psychiatric and
physical illness.
• To promote appropriate role relationship between the sexes and between the
generations.
INDICATIONS OF FAMILY THERAPY
 Problems in relationship within family (e.g. marital discord, existence of
communication or generation gap)
 Interdependence of symptoms (wife depression being contingent on the husband alcohol
consumption and vice versa)
 Development of stress in other family members improves amember (development of
depression in wife following husbands giving up drinking, leading to his improved
participation in family matters.
 Disorganized and disrupted families
 Present of a lot family psychopathology
 Inadequate family structure
 Most of the family engaged in ASPD activities.
 Family experiencing a transactional stage of family life cycle.
 No improvement occurs with individual therapy.
 Other indications- psychosis, schizophrenia, depression, anxiety disorders, substance
abuse, childhood psychiatric disorders, bipolar disorders, psychosomatic disorders etc.
CONTRAINDICATIONS OF FAMILY THERAPY
(A) Family Factors:
• If key family members are unavailable for geographical or other reasons or are
completely unmotivated to become involved in the treatment.
• Families having major psychopathology in more than one family member.
• When the family is referred by an agency such as a court or school. In such cases
there may be hidden agenda for example- To provide a child from being expelled
from a school, rather than any real wish to change.
• Due stigma care giver of the mental illness patient does not want to participate in the
therapy
(B) Therapist Factors:-
• Lack of commitment
• Inflexibility
• Therapist having problems similar to the patient’s problem
• Lack of empathy and adequate training
• Therapist having social relation with the client.
TYPES FAMILY THERAPY
1. Individual Family Therapy
 Each family member has single family therapist; they work out on specific issues that
have been defined by individual members; occasionally they meet along with their
therapist to observe how each member is relating to one another in solving the issues.
2. Single Family Therapy
 Generally for nuclear families
 Family interaction is the main focus
 Therapist observes the family interaction pattern & helps to clesrly define problems
and suggests the ways/ solutions and helps to implement the activities, evaluates its
effects and if required, modified strategies are taken.
3. Couple/ Marital Therapy
 The therapist observes the family patterns, interaction, communication style, each
partner’s goal, hopes and expections and suggests certain methods to solve the
problems.
 Partners have to recognize and report each others similarities and differences. Certain
time will be allotted to resolve the issues; repeated counselling sittings may be
required.
4. Multiple Family Group Therapy
 In this family, 4-5 families meet weekly to discuss about their problems & dealing
the issues which are common to them.
5. Multiple Impact Therapy
 It is focused on developing social skills and working together as a family and with
other families within the community. Several families will live together and deal with
pertinent issues related to each family member in context of the group.
6. Network Therapy
 It includes 40-60 members like family members, friends, neighbours, well- wishers
etc. who invested in the outcome of the current crisis. Thus therapy may be
conducted within the family or in community itself.
FAMILY ASSESSMENT
Assessment is a crucial step in any family related problem solving process. Holman has
suggested comprehensive frame work for family assessment which outlines following five
major areas which need to be investigated:
(A) PROBLEMS
A clear understanding of the nature of the problem is essential in deciding
how to deal with it. Some of the aspects are:
• Nature, origin, duration and urgency of the problem
• Patient’s perception and reaction to it
• Other family member’s perception and response to the problem
• Is any attempt made by the family members & patient to solve the problem.
• Involvement of other system in the environment.
(B) UNDERSTANDING OF THE REFERRAL
 Who referred to your client and why? What were their expectations? What
expectations did they communicate to the family? Whether the referral is routine
process and of no major import? Or whether all or some family members were
consider the need of treatment?
 It’s also important to find out if clients have been in treatment elsewhere? What
happened?
(C) IDENTIFING THE SYSTEMATIC CONTEXT
 Emphasis on current familial and extra familial context of the client.
(D) STAGES OF THE FAMILY LIFE CYCLE
(E) FAMILY STRUCTUTRE
 Regardless of what approach a therapist takes, it’s wise to understand something
about the family’s structure .What are the actual functioning subsystems and what the
nature of boundaries between them is. is the nature of the boundary around the couple
or the family? What triangles are present? Who plays what roles in the family?
Communication pattern within family?
AREA OF THE FAMILY ASSESSMENT
Following area we should assess:
• Family socio- demographic details
• Family organization or type (What type of family i.e. joint or nuclear)
• Family boundaries ( external & internal; Open, closed, diffused)
• Leadership pattern and Decision making process (Functional, nominal, autocratic ,
democratic & participation in the decision making process)
• Role functioning
• Communication Pattern (Direct vs indirect, switchboard, double blind, paradoxical)
• Coping pattern (Adequate or inadequate)
• Reinforcement pattern (Healthy or unhealthy)
• Cohesiveness
• Social support system (Adequate or inadequate)
• Family rituals
• Family burden
• Marital quality of patient
• Family significant life events
• Family member’s attitude towards other family members
• Patient’s attitude towards family members
FAMILY INTERVENTIONS
 Encouraging active participation in treatment and rehabilitation.
 Increasing knowledge by psychoeducation regarding disease process, treatment and
management of patient.
 Skill building programmes in identifying signs and symptoms of aggravating
condition, side effects of medications etc to equip the family in better management of
patient.
 Couple therapy to build togetherness by balancing intimacy and autonomy.
 Family bereavement to help the family deal with losses faced and emotional
challenges brought by grief.
 Parent skill building to provide parents with skills to nurture and protect their
children, to train parents to deal with challenging children and to help children
develop social skills.
 Can be delivered at schools, OPD, IPD, homes, offices, courts, church etc.
 Nurses, Psychiatrists, Psychologists, Social Workers can provide it. However, the
delivery of family & couple therapy requires advanced training and supervision.
CONDUCTION OF FAMILY THERAPY
 Prepare a comfortable seating arrangement and room for conducting therapy.
 Maintain confidentiality.
 The number of sessions depends on the situation, but the average is 5-20 sessions.
 Introduce self and purpose and topic of discussion.
 Review previous therapy’s summary.
 Family therapist usually meets several members of the family at the same time. It has
the advantage of making differences between the ways family members perceive
mutual relations as well as interaction patterns in the session apparent both for the
therapist and the family.
 Therapy interventions usually focus on relationship patterns rather than on analyzing
impulses of the unconscious mind or early childhood trauma of individuals.
 Encourage the family to solve problems rather than looking upto therapist.
 Family therapists are relational therapists; they are generally more interested in what
goes between people rather than in people.
 Depending on circumstances, a therapist may point out to the family interaction
patterns that the family might have not noticed; or suggest different ways of
responding to other family members.
 These changes in the way of responding may then trigger repercussions in the whole
system, leading to a more satisfactory systemic state; it should be noted though, that
some family therapists tend to be as interested in individuals as in systems.
 Family therapists help in the maintenance and/or solving of problems rather than in
trying to identify a single cause.
 A causal focus can be experienced as blaming by some families and is with many
issues of questionable clinical utility.
 Problem should be discussed keeping in mind all therapeutic communication
techniques,
 Problems should be discussed based on a mutual understanding and goal setting by
therapist and family.
 Review the day’s communication and decisions or objectives achieved.
 Inform the family about the next topc of discussion, time, venue and duration of
therapy.
 Terminate the session.
NURSING PROCESS IN FAMILY THERAPY
ASSESSMENT-
 Family system, subsystems & individuals
 Information related to Sociocultural issues, past medical & mental illness, family
interaction, pattern of family life cycle, multi-generational issues, developmental
crisis, parenting skills, problem-solving, limit-setting
NURSING DIAGNOSIS-
The problems related to relational problems, abuse or neglect or bereavement has to be
identified, like
 Impaired judgment
 Impaired parenting
 Interrupted family process
 Sexual dysfunction
 Strain of care giver
 spiritual distress
 Defect in utilization of defense mechanisms
PLANNING-
 Determine the immediate & long-term needs of family
 Formulate goals & interventions
 Help family to learn about illness, medications, situational support, available
resources, measures for improvement
INTERVENTIONS-
 Counselling, using problem- solving approach, to meet immediate difficulty
 Case management, Psychoeducation, Referrals, Emotional support, Guidance &
counselling, Community resources
EVALUATION-
 Observe whether family is able to cooperate in provision of care
 Need to reduce therapist visit
 Implementation of modified strategies in counselling sessions
RESEARCH
ARTICLE
UTILIZING SPIRITUAL ECOGRAMS WITH NATIVE AMERICAN FAMILIES AND
CHILDREN TO PROMOTE CULTURAL COMPETENCE IN FAMILY THERAPY
This study advances the knowledge base in therapeutic settings by examining the
cultural consistency, strengths, and limitations of using spiritual ecograms to conduct
spiritual assessments with Native American families and children. Over the past decade, the
field of marriage and family therapy has reflected a demand for more culturally competent
services. Given the importance of spirituality for many Native Americans, spiritual ecograms
appear to offer family therapists a structure through which to integrate spirituality into the
therapeutic dialogue. Spiritual ecograms can also allow the family or child's participation in
planning for their future in a natural, interactive way. The findings of this study represent an
initial step at helping family therapists utilize spiritual ecograms in their work with Native
American families and children.

BIBLIOGRAPHY
 Townsend Mary C, “ Psychiatric Mental Health Nursing” fifth edition Philadelphia :F.A
Davis 2006.
 Marry Ann Boyd, “Psychiatric Nursing Comtemporary Practice’’ Wolters Kluwer
publication 4th edition, 2008.
 Stuart W. Gail; Laraia T. Michele, Principles and Practice of Psychiatric Nursing, 8th
Edition, New Delhi: Elsevier Publications, 2005.
 Videbeck L.Sheila, Psychiatric Mental Health Nursing, 2nd Edition, 2005.
 Shives, Louise Rebraca, Basic Concepts of Psychiatric-Mental Health Nursing, 6th
Edition, Lippincott Williams & Wilkins, 2005.
 Srevanni R “ A guide of mental health nursing “ jaypee publication 3 edition page no
114-115
 Kaplan I. Harold, Sadock J. Benjamin, Synopsis of Psychiatry, William and William
Publications, 8th Edition,2002, Pp-2584 - 259
 Lalitha K., Mental Health and Psychiatric Nursing, 1st Edition, Banglore: VMG Book
House, 2007.
 Limb, Gordon E, Hodge, David R, Utilizing Spiritual Ecograms With Native American
Families And Children To Promote Cultural Competence In Family Therapy. Journal of Marital
and Family Therapy. 2011.
(http://findarticles.com/p/articles/mi_qa3658/is_201101/ai_n56828380/pg_9/?
tag=content;col1)
 Park, Soo Kyung; Kim, Jae Yop; Cho, Choon Bum, Prevalence of Internet addiction and
correlations with family factors among South Korean adolescents.(Report). Family
Therapy. 2009.
(http://www.highbeam.com/doc/1G1-214101782.html)
 P. N. Suresh Kumar and Biju Thomas , Family intervention therapy in alcohol
dependence syndrome: One-year follow-up study. Indian Journal of Psychiatry. 2007.
49(3): 200–204.
(http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2902094/)