Family, Couple, and Group Therapy
The phenomena of emotional bonding, role enactment, communication, sexuality, and the broader system that provides the context for a relationship become the focus of couple therapy when conflict occurs.
Interest in the family of the psychiatric patient has blended over the years to interest in the family as the psychiatric patient. This conceptual focus on the family as a whole instead of one individual member is the key element of the family therapy approach.
Groups are a crucial part of life experience for people…. They constitute a potent force for the prevention and remediation of personal and social problems.
—Brill, Levine, & Brill, 2001
Learning objectives
After studying this chapter, you should be able to:
Describe at least three alternatives to the traditional nuclear family.
Articulate the developmental stages of the family according to Duvall’s theory of the family life cycle.
Compare and contrast characteristics of functional and dysfunctional families.
Explain the development of couple, family, and group therapy.
Explain the purpose of couple, family, and group therapy.
Analyze four different modes of family therapy, stating the role of the therapist in each mode.
Compare and contrast the goals of couple and family therapy.
Develop a couple or family assessment guide.
Formulate a list of the common nursing diagnoses applicable to families participating in family therapy.
Construct a genogram and explain its usefulness in family therapy.
Recognize the advantages of group therapy.
Identify at least six factors considered to be essential components of group therapy.
Construct the stages of group development in group therapy.
Compare and contrast the nurse–therapist’s role in couple, family, and group therapy.
Key Terms
Autocratic group leader
Brief couples therapy
Closed groups
Contextual therapy
Couple therapy
Democratic group leader
Dysfunctional families
Families
Family therapy
Group therapy
Healthy functioning family
Laissez-faire group leader
Marital-relations therapy
Object-relations therapy
Open groups
Families are groups of individuals who interact, support, and influence each other in performing basic functions. They are an integral part of society, bound together by intense and long-lasting ties of past experience, social roles, mutual support, and expectations. The family constitutes an interactive milieu in which the exchange of information among individual members continually occurs. The term couple is used to describe two adults who have a close or intimate relationship. They may be heterosexual or homosexual, single, married, or in a same-sex union. The term group is used to describe at least three individuals who gather together to share or discuss common problems or concerns.
This chapter focuses on the application of couple, family, and group therapy as they relate to the psychosocial needs of clients, families, or significant others. The role of the nurse–therapist is also discussed.
Overview of Families
Families have undergone many changes in the last 50 years. Various lifestyles and arrangements have emerged. Historically, “family” referred to the traditional nuclear family, that of father, mother, and children. Today, alternatives to this traditional nuclear family include single-parent households, blended families involving the remarriage of one parent to someone who may or may not have children, extended families that include the presence of other relatives, and cohabitation between nonmarried persons. Families may consist of married or nonmarried, homosexual or heterosexual couples and may include children.
All family members influence one another as they interact and support each other in performing basic functions necessary for the family’s well-being. As women continue to join the workforce in greater numbers, changes occur in child care, childrearing practices, and role sharing. In a dual-career family in which both husband and wife work, the husband must assume some roles that mothers and wives traditionally performed. These changes in the traditional nuclear family have made it necessary for parents to teach their children new skills to help them cope in today’s society.
The family also influences personal development. In the family setting, members learn how to relate to and communicate with others. If the family has a positive influence on its members, they will develop a sense of self-worth and positive self-esteem, ultimately becoming productive members of society. Conversely, poor parenting skills, ineffective role-modeling, and the inability of parents to communicate effectively may have negative influences on family members. As a result of these negative influences, family members often have difficulty adjusting to the expectations of society.
The Family Life Cycle
The family is a developing system that must progress in the proper manner for healthy child development. According to Duvall’s (1984) theory, there are predictable, successive stages of growth and development in the life cycle of every family. Each stage is characterized by specific tasks to be achieved. These family developmental tasks refer to growth responsibilities achieved by a family as a unit and by individual developmental requisites. However, individual developmental needs and family tasks may not always agree, possibly leading to conflict and resulting in poor interpersonal relationships, the development of individual emotional problems, or a family crisis. Duvall identified eight stages of the family life cycle. Table 15-1 summarizes each of Duvall’s eight stages, including the age and school placement of the oldest child, which affects the responsibilities of the family members. An understanding of these stages provides the nurse with guidelines for analyzing family growth and health promotion needs and the ability to provide therapeutic intervention when conflict arises.
Healthy Functioning Families
Finding research on the so-called “normal” family is difficult, although much is published about dysfunctional or pathogenic families. However, healthy families demonstrate specific characteristics:
The ability to communicate thoughts and feelings
Parental guidance in determining the functioning level of the total family
In addition, the healthy family expects interactions among its members to be unreserved, honest, attentive,
and protective, whereas interactions in the unhealthy family tend to be reserved, guarded, or antagonistic (Goldenberg & Goldenberg, 2003).
and protective, whereas interactions in the unhealthy family tend to be reserved, guarded, or antagonistic (Goldenberg & Goldenberg, 2003).
 Table 15.1 Duvall’s Eight Stages of the Family Life Cycle | ||||||||||||||||||
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In the healthy functioning family, no single member dominates or controls another. Instead, there is a respect for the individuation of other family members and their points of view and opinions, even if the differences lead to confrontation or altercation. Family members participate in activities together, unlike members of dysfunctional families, who tend to be isolated from one another, possibly trying to control others in the family. Although power is found in healthy families in the parent coalition (union or alliance), it is not used in an authoritarian manner. Children are allowed to express opinions, negotiations are worked out, and power struggles do not ensue. Good communication patterns are paramount (Goldenberg & Goldenberg, 2003).
A healthy functioning family encourages personal autonomy and independence among its members, but individuality is not obscured. Family members are able to adapt to the changes that occur with normal growth and development and to cope with separation and loss.
In a healthy functioning family, each family member typically progresses through specific stages of development, which include bonding, independence, separation, and individuation. Ego boundaries are clearly developed. By the time members reach adolescence, they begin to function more independently. Increased independence requires an adjustment in the relationship of all family members. However, family members should not function so independently of each other that the family system is impaired or the rights of individual family members are violated. Otherwise, distress in the family can result. Other problems that may cause distress include marital disharmony, differing childrearing techniques, and the acute physical or emotional illness of a member. See Supporting Evidence for Practice 15-1 for an overview of the effect of cardiac disease on the family.
Supporting Evidence for Practice 15.1: Adaptations by Client and Family During Illness
Problem Under Investigation
The effects of a medical diagnosis—coronary artery disease—on the life of a client and the client’s family
Summary of Research
A literature review of 13 research studies published between the years of 1982 and 2000 focused on family adaptation and interventions after a cardiac event. Research revealed that certain themes prevailed within the family unit, including increased anxiety, fear, and mood disturbances; changes in family roles and functioning; and struggles to reduce lifestyle risk factors. Interventions for the clients and families included support groups to provide them with information about coronary artery disease; decrease isolation and anxiety; and share problems, experiences, and solutions. Although individual outcomes such as increased self-esteem, increased self-efficacy, and lowered anxiety occurred, family outcomes were mostly unaffected. Researchers concluded that family functioning during the acute and recovery phases of coronary artery disease involves many complex issues, and families may require interventions of greater intensity and longer duration.
Support for Practice
Recognizing the effect of any serious illness on family functioning is a key nursing responsibility. Nursing interventions for clients with serious medical conditions such as coronary artery disease should address family adaptations and role changes during the acute and recovery phases.
Source:
Van Horn, E., Fleury, J., & Moore, S. (2002). Family interventions during the trajectory of recovery from cardiac event: An integrative literature review. Heart & Lung, 31, 186–98.
Dysfunctional Families
Like mental health and mental illness, family functioning occurs on a continuum. Healthy families can become dysfunctional under stress when issues of power persist and go unresolved; no identified leader or parent helps take control and establish some sense of order. Instead, the family experiences chaos, which results from leadership that may be changing from one member to another over short periods. Control or power is attempted through intimidation instead of open communication and negotiation. The lack of leadership
sometimes makes it difficult to determine who fulfills the parental role and who fulfills the child’s role. This confusion encourages dependency, not autonomy, and individuation is not enhanced. In contrast, the sharing of similar thoughts and feelings among all family members is viewed as family closeness rather than a loss of autonomy (Goldenberg & Goldenberg, 2003).
sometimes makes it difficult to determine who fulfills the parental role and who fulfills the child’s role. This confusion encourages dependency, not autonomy, and individuation is not enhanced. In contrast, the sharing of similar thoughts and feelings among all family members is viewed as family closeness rather than a loss of autonomy (Goldenberg & Goldenberg, 2003).
In dysfunctional families, communication is not open, direct, or honest; usually, it is confusing to other family members. Little warmth is demonstrated. All these experiences tend to undermine each member’s individual thoughts, feelings, needs, and emotions so that they are regarded as unimportant or unacceptable. Also, in dysfunctional families, children and adults may perform roles that are inappropriate to their age, sex, or personality. For example, the mother of a 7-year-old daughter and a 3-year-old son may expect the daughter to take care of the son and help prepare meals. This expectation can create distress in the daughter because of the amount of responsibility being placed on her, and because she is being forced to fulfill the role of a mother. If such expectations persist, it could result in a dysfunctional family system.
Culturally Diverse Families
Culture influences family functioning in many ways. Established cultural traditions give families a sense of stability and support from which members draw comfort, guidance, and a means of coping with the problems of life (Andrews & Boyle, 2003). The ability to communicate through the use of the same language is necessary if one is to understand cultural diversity. Duvall’s stages of the family life cycle do not apply to all cultures because of differences in family and kinship systems, social life, political systems, language and traditions, religion, health beliefs and practices, and cultural norms. It is imperative for the nurse–therapist to consider these differences when assessing family members for therapy to avoid labeling a family as dysfunctional because of cultural differences.
History of Family and Couple Therapy
In the 1950s, psychotherapists began looking not only at individuals with problems, but also at the pattern of relationships that corresponded with couple and family problems. These psychotherapists included Murray Bowen, Nathan Ackerman, Salvador Minuchin, Jay Haley, and Virginia Satir. They began changing their approach from treating only the individual to including the couple or family, to help increase therapeutic effectiveness. This change in therapeutic approach was based on the belief that until the pattern of the couple or family was changed, the individual’s behavior would remain fixed.
This approach corresponds with another method: viewing the family as a system of relationships, such as that between brother and sister or mother and daughter. Each member of the family must be able to communicate in a productive and healthy way with other members in the system. If there is a breakdown in the system, all members are affected. Thus, a change or disruption in one family member affects the family system and all its members.
When a disruption occurs, members may participate in individual, couple, family or group therapy. Individual therapy was addressed in Chapter 14. Following is a discussion of family, couple, and group therapy.
Family Therapy
Family therapy is a method of treatment in which family members gain insight into problems, improve communication, and improve functioning of individual members as well as the family as a whole. This type of therapy is particularly useful when the family system does not perform its basic functions adequately. Issues such as dysfunction or the acting out of a child, marital conflict, or intergenerational relationship problems can be improved through family therapy. The client in family therapy is considered the family system as a whole, rather than any individual member.
Family therapy differs from individual therapy. Family therapy assumes that outside or external influences play a major role in personality development and the regulation of members’ lives. In individual therapy, however, it is believed that internal or intrapsychic thoughts, feelings, and conflicts are the major components of personality development (Goldenberg & Goldenberg, 2003).
Traditionally, in family therapy, the person who seeks treatment is considered the client. If the problem is primarily within the individual and he or she is motivated to change, individual treatment can be helpful and can improve behavior. If the client’s behavior is symptomatic of a dysfunctional family system, however, improvement may not be as significant or last as long. Some family therapists believe that if one individual
in a family system changes self-functioning, this will eventually have an impact on the functioning of the family, and positive changes will occur in the entire system. Other family therapists believe that if the person who is symptomatic improves, regression to old patterns of behavior or to other dysfunctional behaviors can occur if the family has not changed also. In some situations, family members who are resistant to change become more dysfunctional as the person who seeks treatment responds favorably to therapy.
in a family system changes self-functioning, this will eventually have an impact on the functioning of the family, and positive changes will occur in the entire system. Other family therapists believe that if the person who is symptomatic improves, regression to old patterns of behavior or to other dysfunctional behaviors can occur if the family has not changed also. In some situations, family members who are resistant to change become more dysfunctional as the person who seeks treatment responds favorably to therapy.
As the family works through problems, each individual member’s role(s) should become clear. Sometimes scapegoating occurs. The family needs to maintain a “sick” person in the family, or a scapegoat, to aid in denying the family pathology. Once the family is able to perceive this scapegoating, family therapy focuses on family problems instead of on the individual who was the scapegoat (Cohen & Lipkin, 1979).
Approaches to Family Therapy
Jones (1980) and Sadock and Sadock (2003) describe several orientations or approaches to family therapy. A brief description of the more common approaches follows.
Integrative Approach
Nathan Ackerman, a trained psychoanalyst, considered by some to be the grandfather of family therapy, 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 goals of therapy are to identify and remove the pathogenic or intrapersonal conflict, improve communication and problem-solving, and promote more healthy relationships within the family (Jones, 1980; Sadock & Sadock, 2003). For example, a family of five is having financial difficulty resulting from 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.
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 (Jones, 1980; Sadock & Sadock, 2003).
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 (Bowen, 1994).
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 oneself, 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.
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 (Titleman, 1998).
Structural Approach
Structuralists, like the well-known 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 (Jones, 1980).
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 (Sadock & Sadock, 2003).
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 (Jones, 1980; Sadock & Sadock, 2003).
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. Therapy 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.
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 (Jones, 1980).
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 social 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 (Jones, 1980
contract may be established for this purpose (Jones, 1980
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