SYSTEMS CONCEPTS AND WORKING IN GROUPS
Kathleen R. Tusaie
EXPECTED LEARNING OUTCOMES
After completing this chapter, the student will be able to:
1. Describe systems theory, including the major concepts
2. Discuss the relationship of General Systems Theory to nursing theories
3. Apply systems theory thinking to psychiatric-mental health nursing
4. Define group therapy
5. Identify key concepts related to group therapy, including those from systems theory
6. Explain the 11 curative factors of a therapeutic group
7. Describe the content of a supportive and insight-oriented group
8. Discuss how family is considered a specialized type of group
9. Describe the use of a genogram in family assessment
10. Identify the relationship between interpersonal based therapy and group and family therapy
Lines of resistance
Normal line of defense
Consider the following situation:
Three blind people encountered an elephant. The first touching an ear stated, “It is a large, rough thing, wide, and broad like a rug.” The second holding the trunk stated, “No, it is a straight hollow pipe.” While the third holding the front leg replied, “It is mighty and firm like a pillar.” Given these individuals’ ways of knowing, they will never know an elephant. (Old Sufi story)
From the individual perspective, each person’s statement is correct. Yet, instinctively, the individuals know that the truths expressed by each person are incomplete truths and cannot ever wholly describe the elephant. Systems theory provides a framework to see the whole elephant.
Using systems theory or systems thinking provides a means for thinking about the larger picture and holds the potential for treatment planning leading to higher levels of functioning. It does not produce “quick fixes.” How an individual thinks not only determines what he or she sees, but also what he or she does. This chapter provides an overview of General Systems Theory and exposes the reader to systems thinking. It reviews examples of how systems theory is reflected in nursing theory. The chapter discusses groups, group therapy, and family therapy as they relate to systems theory and systems thinking with examples of applications to each. Exercises are integrated throughout this chapter to facilitate understanding of personal experiences within systems thinking and its relevance to psychiatric-mental health nursing practice.
GENERAL SYSTEMS THEORY
Biologist Ludwig von Bertalanffy proposed a General Systems Theory in 1928 to provide a way of thinking that could be applied across professional boundaries and promote holistic thinking. Rather than reducing a system (human body) to the components of its parts (cells), systems theory focuses on the interactions of its parts and the nonlinear, dynamic pattern of those interactions. General Systems Theory has diverse applications, including engineering, philosophy, mathematics, computer modeling, ecology, management, nursing, psychotherapy, and others.
A SYSTEM is any group of components sufficiently related to identify patterns of interaction (Kuhn, 1996). A change in any component induces a change in one or more other components of the system and in the system as a whole. No component of the system can be understood out of the context of the way it interacts with other components. Thus, the system is more than a sum of its parts (Figure 9-1).
von Bertalanffy (1968) described two major types of systems: closed and open. Closed systems are those in which the components are isolated from the environment. In contrast, open systems are those in which the components interact with the environment and with the other components of the system. Thus, the system is dynamic and ever-changing. How Would You Respond? 9-1 provides an example of an open system.
A system is a group of components that interact, such that a change in one component affects the other components and the system overall. Using systems theory or systems thinking provides an opportunity to look at the “bigger picture” and promotes treatment planning that ultimately can lead to higher levels of functioning.
Systems Theory and Nursing Theory
Theory provides a systematic way of viewing the world to describe, explain, predict, or control it. Theories are created by experienced practitioners who make abstractions from large collections of facts and concepts. The practice of psychiatric-mental health nursing is derived from theory that has been tested through research to produce evidence for practice. There is an intertwining, circular relationship among theory, practice, and research. Nursing theorists who have built on General Systems Theory are briefly reviewed here.
Systems thinking is not new to nursing. The basic elements in any description of nursing include not only person and health, but also the environment (Fawcett, 1984). The environment the person emerges from and returns to is considered across several nursing theories. For example, Florence Nightingale’s (1859) broad view of nursing included creating the right environment for the patient’s natural, reparative powers to act, as well as awareness of the influences of socio-political-religious issues on nursing practice (Reed & Zurakowski, 1996). As nursing continued to evolve, other theorists began to address environment as having a major impact on a person. The Theory, Science of Unitary Human Beings, developed by Martha Rogers (1970, 1992) reflects an open system model. In her model, Rogers describes the person as an energy field inseparable from the environment with continuous and mutual interaction between the two. As a result, both the person and environment experience changes at the same time and in the same manner. The person is described in the context of an environment resulting in constant change as well as the continuous evolution of the change itself. Thus, the person is viewed as a unified whole that is more than and different from the sum of the parts. Rogers (1970) describes the professional practice of nursing as seeking to understand patterns of interactions between person and environment and working “with” the patient for “ … realization of maximum health potential” (p. 122). This is an important statement because it emphasizes that patients are active participants who make choices rather than passive recipients of nursing care.
HOW WOULD YOU RESPOND? 9-1:
THINKING IN SYSTEMS
Review Figure 9-1. Place yourself as the person at the center of the system. Then insert the names of people or groups to complete the surrounding circles for family and friends, community, country, and the world.
Now think of a recent event in your community, country, or the world.
CRITICAL THINKING QUESTIONS
1. How did you respond to this event? What effect did it have on you? How were others affected?
2. Was the system stressed, disturbing the usual balance and homeostasis?
3. What did you notice about coping and adaptation for yourself? For others in the system? For the system overall?
4. If the imbalance or disruption was too great, what developed or occurred?
Systems thinking is not new to nursing. The environment has been a major component of many nursing theories.
Another nursing model that applies systems theory is Neuman’s Systems Model (2002). This model is based on concepts of stress and coping (Lazarus & Folkman, 1984) and General Systems Theory (von Bertalanffy, 1968). The whole person (client) system is defined as the person in interaction with the internal and external environment. Each client system is a unique composite of factors and characteristics within a given range of possible responses. The central core of the client system includes basic survival factors common to all, such as normal temperature, genetic structure, and organ functioning. This central core is surrounded by circles that function as LINES OF RESISTANCE. These lines represent the internal factors that an individual uses to help defend against stressors. Extending out further from the core is the next level of circles, or the NORMAL LINE OF DEFENSE. This normal line of defense, or usual response to stressors, represents the individual’s usual state of wellness. According to Neuman, the normal line of defense is flexible and dynamic with the ability to expand or contract as needed in response to stressors. She further describes stressors as known, unknown, and/or universal. Each differing stressor has the potential, alone or in combination, to disturb the stability of the system. When a stressor penetrates the normal lines of defense, protective factors within the lines of resistance are activated to protect the central core’s functioning. In other words, the entire client system is constantly in a dynamic process of input, output, feedback, and compensation with the goal of maintaining balance.
Neuman identified specific nursing interventions to retain or maintain system stability. Thus, primary, secondary, or tertiary prevention are possible interventions that can be used in the model (Neuman, 2002). Primary prevention, or wellness promotion and disease prevention, represents expanding the normal line of defense, strengthening the flexible line of defense, or decreasing the possibility of encountering stressors before their invasion. Interventions described as secondary prevention, or treatment of symptoms, are focused on strengthening the lines of resistance to protect the core of the system. Interventions such as prompt detection of symptoms and early treatment are examples. Tertiary prevention indicates adjustive processes or readaptation, such as sleeping or learning new coping skills, taking place as the system begins to return to a balanced state of wellness. Once balance is achieved, these processes then begin to function as primary prevention interventions, demonstrating a circular pattern of interventions.
The system described by Neuman’s model may be the individual person, a family, a group, or a community. In addition, application of this model has been described across all nursing specialties, as well as across disciplines and internationally (Neuman, 2002).
Systems Theory and Psychiatric-Mental Health Nursing
The brief overview of systems thinking previously provided argues that a system perspective has always been present in the discipline of nursing. However, the definition of system and environment has varied. These broad theorists have provided a framework for thinking about psychiatric-mental health nursing.
Consider this example. During an inpatient hospitalization, Mr. Davis, an individual experiencing auditory and visual hallucinations, has been stabilized with medications, a structured environment, and one-to-one interactions with nurses. The primary focus of the nurse–patient interactions has been to establish trust and to emphasize the importance of medication to minimize the distress experienced with the hallucinations. This is a very appropriate, evidence-based approach and Mr. Davis is discharged with decreased symptoms. However, within several weeks, he is readmitted to the inpatient unit. How is this exacerbation of symptoms explained? From a snapshot or reductionist explanation, the individual stopped taking his medications and symptoms returned. This would not be incorrect. However, this view is limiting because it only provides a narrowed view or “quick fix” for the problem. It does not explain the whole experience for this patient. Using systems thinking, Mr. Davis would be viewed as a person who does not live in isolation. Rather, he is part of the family system, the community, and world as a whole. There would be awareness of the interactions among the family who have been encouraging the patient to not take his medications, possibly because they are too expensive or because they cause adverse effects. In addition, Mr. Davis has resumed chain-smoking cigarettes, which interferes with the absorption of the medications. His lack of any daily routine, the consumption of only fast food and snacks at home, combined with living in a high crime neighborhood are all possible interacting factors leading to his current situation. Thus, the use of systems thinking promotes comprehensive, holistic care.
GROUPS AND GROUP THERAPY
Individuals are members of multiple groups. A GROUP refers to any collection of two or more individuals who share at least one commonality or goal, such that the relationship is interdependent. Applying systems theory, a group is a set of components that work together to achieve a function or purpose. Groups may be formal or informal. Formal groups are structured and have authority. Informal groups typically address personal needs.
Psychiatric-mental health nurses are members of multiple groups, both formal and informal. Professional or more formal group affiliations may include the clinical group of students in the psychiatric-mental health nursing rotation, the student body of a college of nursing, all student nurses belonging to Student Nurses Association, club memberships, as well as work-related groups such as the treatment team in the place of employment. More informal group memberships focus on casualness and personal needs. These include family, friends, or even a small informal group in the work setting. (Note that the family is a specialized type of group and is discussed later in the chapter using the Bowen Family Systems Model  as the framework. The focus of the discussion here is on THERAPEUTIC GROUPS, groups used to promote psychological growth, development, and transformation.) GROUP THERAPY is the process by which group leaders with advanced educational degrees and experience provide psychotherapy to members to improve their interpersonal functioning.
Two or more people together functioning interdependently form a group. Family is a specialized type of group.
Types of Therapeutic Groups
Therapeutic groups may be categorized as open or closed systems based on membership. Open groups are ones in which new members can join and old members can leave at different times. Members are welcome to attend the group meetings at any time in the individual’s recovery as well as at any stage of the group’s development. Open groups typically are ongoing, which permits their availability of access to a greater number of individuals. Unfortunately, new members joining an open group face a disadvantage in that they have yet to form relationships already present in existing group members. Thus, cohesiveness may be less. An example of an open group is Alcoholics Anonymous (AA), one of the most successful approaches for maintaining sobriety today.
Closed groups are ones in which membership is limited to those members involved when the group initially forms. No new group members can join. If an old member leaves, no new member comes in to take his or her place. For example, if a closed group initially started out with eight members, and two members leave the group, the group remains with only six members. This approach facilitates more group cohesiveness, safety, and interpersonal learning. An example of a closed group is an insight-oriented psychotherapy group meeting for 90 minutes a week for 12 weeks as part of an outpatient practice. When the 12 weeks are over, the group disbands. Then another group starts again, with new members being accepted for the specified time frame.
Another way to classify groups is related to the group’s purpose and goals. These may include therapeutic insight-oriented groups and supportive groups. Insight-oriented groups are characterized by increased process, focusing on the interpersonal relationships among members and their communication patterns and styles to foster the development of better perception into one’s self. Generally, these groups are less structured and require leaders prepared at the gradual level of education.
Supportive groups have a specific content and structure and are often led by nurses (Kurtz, 2013). More structure and less process characterize the supportive group. Some of these include education groups, recreation groups, socialization groups, or reality orientation with older adults (Kurtz, 2013; Thompson, Parahoob, & Blair, 2014). In structured environments such as inpatient or partial hospitalization programs, goal-planning groups, which meet in the morning to set goals for the day and then again before bedtime to review goal achievement, are examples of supportive groups.
Self-help groups are also considered a supportive group. This type of group usually consists of persons coping with a particular problem. Some self-help groups include AA, National Alliance for the Mentally Ill (NAMI), Overeaters Anonymous (OA), groups of individuals with a specific diagnosis such as a cancer support group (Breitbart et al., 2015), Alzheimer’s support group for caretakers, or diabetic support groups. Self-help groups offer acceptance, mutual support, and help in overcoming maladaptive behaviors. Although controversial, web-based self-help groups are showing promising results. Issues involving problem drinking, smoking, depression, anxiety, and work-related stress have all demonstrated positive change following involvement in a web-based self-help program (Griffiths, Farrer, & Christensen, 2010).
A final classification for types of groups is based on setting, an important consideration for group therapy. Therapeutic groups classified by setting are inpatient or outpatient. Current inpatient treatment has shifted dramatically from the history of prolonged stays in remote state hospitals to brief, often repeated, hospitalizations in small acute general hospital units. Although the core of group therapy remains the same, adaptations are necessary for the acute inpatient setting. Yalom (2005) has discussed these adaptations in great detail and they are summarized in Table 9-1.
Several methods have been used to adjust to these issues. Often, inpatient groups are categorized by level of functioning, organizing the groups as lower functioning and higher functioning groups. Shifting the time frame is another adjustment strategy. This shift necessitates that the group leader provides structure and participation by members in each session. There is no time to be passive and allow group cohesion to develop. Inpatient groups may also be influenced by incidents on the unit because group members are living together. Thus, by shifting the time frame, an aftercare group available immediately after discharge from the inpatient setting could be developed. Then the inpatient, aftercare, and outpatient groups would be seen as continuous and complementary.
Groups may be classified by membership as open or closed, by purpose as insight oriented or supportive, and by setting as inpatient or outpatient.
Group Process and Group Dynamics
Individuals participate in a group process even if they are unaware of that participation. GROUP PROCESS refers to interaction among group members. GROUP DYNAMICS refers to the forces that produce patterns within the groups as the group moves toward its goals. As mentioned previously, a group results any time two or more people are together and interdependent. Interdependence of group members is the key difference between a group and a collection or aggregate of individuals. Interdependence involves a common task or purpose that has brought the people together, some characteristic shared in common, and a pattern of interaction established among the people.
Curative Factors of Groups
Expectations are different for each type of group member. However, common factors operate in all types of groups. These factors, called CURATIVE FACTORS (Yalom, 2005), describe the patterns of interaction in a therapeutic group. Using Neuman’s model and the group as the system of focus, the curative factors are the central core necessary for the survival of the group.
INPATIENT THERAPEUTIC GROUPS
OUTPATIENT THERAPEUTIC GROUPS
Overlap of therapies may result in competition for patients. Administrative staff makes decisions about group frequency, duration, optional or mandatory attendance, and group leadership.
Leader makes decisions about group membership, procedures, and functions independently.
Patient acuity is greater, which limits the cognitive abilities of patients to participate.
Patients are better able to participate due to a lessened illness acuity.
Shorter or briefer lengths of stay lead to a new patient in every group session.
Group membership is more consistent.
Yalom (2005) identified 11 categories of curative factors:
1. Instillation of hope
3. Imparting of information
5. Corrective recapitulation of the primary family group
6. Development of socialization techniques
7. Imitative behavior
8. Interpersonal learning
9. Group cohesiveness
11. Existential factors
These curative factors are interdependent. However, some factors take on a more significant role at different times during the group process depending on the group’s purpose, time frame, and stage of development.
Yalom identified 11 curative factors that are interdependent within a group. They are the central core necessary for group survival.
Instillation of Hope
Feeling hopeful is necessary in all types of therapy. In group therapy, hope or optimism that the therapy will be helpful often keeps the person involved until the other curative factors develop. Literature on the mechanisms by which optimism promotes mental and physical health and studies indicating that optimism can be increased through psychotherapy—individual as well as group—is extensive (Magyar-Moe, Owens, & Scheel, 2014; Seligman, 1998).
Being hopeful is also an important factor in the group leader or facilitator. Believing that the group process is beneficial and important is necessary for an effective outcome. During the first group meeting or preceding the meeting, the leader may share positive expectations and enthusiasm for the group experience with prospective members. However, this optimism must be genuine to be effective.
In addition to the group leader or facilitator’s optimism, other techniques are used to encourage optimism. When identifying group members, including individuals who are further along in the process of treatment and recovery as well as individuals who are in their initial session may be beneficial. This allows more experienced members to offer encouragement and advice as well as to role model healthier behavior during the group process. Self-help groups such as AA place emphasis on instillation of hope in several ways. For example, all members tell their stories of falling into alcoholism and the awful consequences, followed by recovery and healthier, happier living without alcohol. Instillation of hope is very influential in the beginning group to maintain attendance and participation.
As group members continue to feel hopeful, they begin to develop the belief they are not alone and not so different from others in the group. This belief leads to a feeling of connectedness and safeness within the group sessions. Often patients have poor social skills and experience interpersonal conflicts within many settings, thus leading to lack of personal connectedness and validation in their lives. The experience of universality has been described as a “welcome to the human race” (Yalom, 2005). For example, in an adolescent outpatient psychotherapy group, one young girl who was crying disclosed that she had been arrested for shoplifting. The group members validated her embarrassment and then several shared that they had also attempted to shoplift to see if they could get away with it and stated, “That’s what we do, we push the limits, that’s part of being a kid.” The sharing of information helped the patient feel less distressed. It then led to a discussion involving the importance of thinking about consequences before acting and what could be learned from this experience.
The experience of universality may also happen during individual therapy, but there is less opportunity for validation. For example, a patient shares information about his inability to keep up with his employment responsibilities following the death of his mother. Following a discussion of the experienced difficulties, the nurse normalizes the difficulties by stating that “it is common to have difficulty functioning when grieving” and the patient begins to feel less self-critical. A similar message from not only the nurse but also group members is often more powerful. Thus, the patient experiences universality and maintains hope.
Imparting of Information
This curative factor includes didactic information provided by the leader or facilitator, as well as advice and suggestions offered by group members. Providing information about mental health and illness or other topics is an important factor. The discussion at the beginning of this chapter presented the innate need of all people to explain experiences in some way. The ability to understand the source and meaning of symptoms provides a sense of cognitive control and relieves some of the uncertainty and anxiety experienced by an individual with symptoms of psychiatric-mental health disorders. Knowledge is power. Providing information also conveys a sense of interest and caring that contributes to this curative factor.
Undergraduate nurses are often leading educational groups that focus on diagnoses, medications, or coping skills. Although imparting information is an important curative factor, no factor operates in isolation. In other words, using part of the group session to provide information and part of the session for discussion to encourage activation of other curative factors such as altruism, hope, socialization techniques, interpersonal learning, group cohesiveness, and catharsis is most effective. Activation of curative factors is necessary for an effective outcome from the group therapy session.
Patients are enormously helpful to each other during group therapy sessions. They offer support, suggestions, and insight, and share similar issues. Frequently, patients will listen more readily to another group member than the nurse or therapist because the therapist is considered a paid professional. However, another member can be counted on to be more truthful and practical (Yalom, 2005). Sometimes, an individual will resist suggestions or even participation in a group because “we will pull each other down” or “I won’t have time to talk.” However, this usually represents a hidden message that the individual believes he or she has nothing to offer and may require additional work in individual sessions.
Altruism also is associated with the belief that helping others increases one’s self-esteem. If an individual can offer something of use to another, his or her feelings of uselessness are decreased. In addition, self-preoccupation and absorption with one’s own problems may be decreased. The therapeutic group teaches the lesson that decreasing self-absorption provides a different view of their world.
The Corrective Recapitulation of the Primary Family Group
Patients come to group being shaped by their experiences in their families. Group therapy resembles family structure: Group members may interact with leaders as they did with parents and interact with members as they did with siblings. Often, these communication patterns are dysfunctional. Using the therapeutic group format, members can learn more effective and functional communication patterns. (Family patterns are discussed in more detail at the end of this chapter.)
Development of Socialization Techniques
The development of basic social skills is a curative factor present in all groups to varying degrees. For example, a group session with individuals who have been institutionalized for years preparing for community reintegration would directly address the development and practice of social skills such as maintaining eye contact, carrying on a conversation, and use of polite comments. However, a group of divorced women planning to re-enter the dating scene would focus on different issues. Involvement in any group holds the potential to learn how to communicate and interact with sensitivity and empathy, and with less judgmental approaches. These skills can only improve social functioning in the world.
Individuals commonly pick up or imitate behaviors of social groups. This may involve walking, talking, dressing, or thinking like others. Sometimes, it may involve something as simple as a haircut or something more involved such as adding coping strategies observed in the group. A group member may try on a new behavior to break up old patterns during the process of change.
Interpersonal learning is an important and complex curative factor. Frequently referred to as insight, interpersonal learning reflects an understanding of the patterns in behavior, and thinking and working through feelings.
Interpersonal learning is bidirectional. In other words, what is learned in the world is carried into the group and what is learned in the group is carried into the world. Thus, an adaptive spiral is set into motion, as described by Neuman’s circular pattern of interventions. More specifically, Yalom (2005) described a pattern of interpersonal learning in a therapeutic group. First, a member displays a behavior. Next, through feedback and self-observation, the impact of the behavior on others’ feelings and opinions about him is recognized.
The person also recognizes the impact of the behavior on the opinion that he has of himself. Finally, the individual takes responsibility for the creation of his interpersonal relationships in conjunction with an awareness that he can make changes.
A group leader can use specific techniques when intervening to facilitate interpersonal growth. These include offering feedback on a specific behavior in the group, encouraging self-observation, and reinforcing the transfer of learning.
Cohesiveness in group therapy is similar to the therapeutic relationship in individual therapy. This sense of “we-ness,” solidarity, or attractiveness of the group for its members is not only a curative factor, but a necessary condition for effective group therapy. Groups differ in the degree of cohesiveness. Factors that promote group cohesiveness are highlighted in Box 9-1. Those with higher levels of cohesiveness will attend regularly, provide support, defend the group rules, be more accepting of members, and feel greater security and relief from tension in the group.
The group leader can do much to promote cohesiveness. Selection of members and discussing group rules, being a technical expert, and serving as a role model of therapeutic communication are a few examples of fostering group cohesiveness.
Members of a group learning how to express feelings and being able to verbalize what is bothering them is a powerful aspect of a therapeutic group. Without catharsis, a group would be more of an academic, sterile experience. However, it is important to remember that catharsis alone is not adequate for an effective group. Interaction of the curative factors is necessary.