5group family

8/2/2019 5Group Family

1/6


2/6

[PAPER3:PSYCHOTHERAPYGROUP&FAMILYTHERAPY] 2

SPMM COURSE 2010

techniques, imitative behaviour, interpersonal learning, group

cohesiveness, catharsis and existential factors. Of these, cohesiveness,

and learning from feedback are valued positively though other factors

may also be important.

Bions group dynamics:According to Bion, whenever a group gets derailed from its task, it

deteriorates into one of three basic states: dependency, pairing, or fight-

flight.

In dependency, members of the group become dependent on each other

to elicit protection. Fight or flight reaction refers to either attacking

therapist or totally withdrawing and retreating. Pairing refers to the

group illusion that some miraculous rescue might take place from

individual partnerships within the group. A 4th basic assumption was

introduced by Hopper - called massification/aggregation where a rigid

fusion of identities lead to loss of individuality, or extensive withdrawal

leads to loss of mutual dependence.

Group alliance refers to the quality of the relationship that develops

between each individual member and the therapist. Group cohesion

refers to the sense that the group is working together towards a common

goal. Group coherence is a more evolved group state where the group

goes beyond cohesion and becomes self evolving and able to work though

conflicts. Positiveidentification refers to an unconscious group

mechanism in which a person incorporates the characteristics and the

qualities of the group. Catharsis refers to the process by which mere

expression of ideas and conflicts is accompanied by an emotional

response which produces a sense of relief.

Factors influencing communication in a group matrix: (Foulkes, 1964)

1. Mirroring2. Exchange3. Free floating discussion4. Resonance5. Translation

The above mostly applies to a psychodynamic group setting.

Homogeneous groups include members who are comparable in age,

diagnosis, background etc. Heterogenous groups include people of

varying categories.Closedgroups have a fixed number and composition of patients. If any

group member leaves, no new members are included. In opengroups no

fixed limit exists for number of members; membership is more democratic

and new members can come in whenever someone leaves.

Psychodrama

Founded by Jacob Moreno Therapeutic dramatization of emotional problems is the main

principle employed.

The director is the leader/therapist he/she is an activeparticipant with catalytic function. High involvement of therapist isrequired.


3/6

[PAPER3:PSYCHOTHERAPYGROUP&FAMILYTHERAPY] 3 The protagonist is the patient with emotional conflict. An auxiliaryego is another group member representing someone

significant in the protagonists life. Other members of the

psychodrama act as the audience group.

Soliloquy is the monologue like recital of thoughts and feelings Role reversal refers to the exchange of the patient's role for therole of a significant person The double refers to the auxiliary ego acting as the patient The multiple double refers to several egos acting as the patient Mirror technique refers to an auxiliary ego imitating the patient and

speaking in proxy.

The four major principles on which a therapeutic community is based

are exemplified by the Henderson hospital model. According to this model,

the major components are (mnemonic CPD-R)

1. Communalism (Staff are not separated from inmates by uniformsor behaviours, mutual helping and learning occurs)

2. Permissiveness (tolerating each other and realising unpredictable

behaviour can happen within the community)

3. Democratisation (shared decision making and joint running of

the unit) and

4. Reality confrontation (self deception or distortions from reality

are dealt with honestly and openly by all members without formalities).

Corrective emotionalexperience was seen by Alexander as the central

part of change secondary to psychotherapy. Processes that take place in a

therapy setting give the patient an opportunity to reflect on their pastexperiences and make necessary behavioural or cognitive and emotional

changes to reduce ones difficulties.

Kaplan & Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry, 10thEdition. Lippincott Williams & Wilkins 2007

Gelder et al (Ed). New Oxford Textbook of Psychiatry. Oxford University Press 2000.

Family therapies:

Family unit & Psychiatry:

Family is essentially the most basic social unit and microcosm of an

individual. Family systems have been studied in detail with respect to

schizophrenia especially.

Lidz studied family systems described two schizophrenogenic family

patterns:

Marital schism: Here a family is in a state of disequilibrium due to

repeated threats of parental separation. Parents downgrade roles of each

other, and may even attempt to collude with children and exclude

partners. In marital skewfamily is at an equilibrium that is skewed and

achieved at an expense of distorted parental relationship. One parent may

be dominant and other submissive, making the marriage a stable fit.


4/6


SPMM COURSE 2010

Wynne and colleagues described certain communication patterns that

may relate to later development of perceptual and thought disorders

linked to schizophrenia. Pseudo-hostility and pseudo-mutuality

refers to the disjointed or fragmented communication where the child is

forced to accept and develop a pattern of communication that will negateand deny the existence of meaningless relationships in the family.

Bateson described the double-bindrelationship where superficial verbal

communications contradict the behavioural and deeper communications

passed between members of the family. These mixed messages keep a

growing child in a double bind (cannot be correct either way) which can

later increase the risk of psychosis.

The concept of schizophrenogenic-mother was coined by Freida

Fromm-Reichmann. These mothers were described to be 'rejecting,

impervious to the feelings of others, rigid in moralism concerning sex andhad significant fear of intimacy'. A similar concept was popular for

sometime with regard to autism where mothers were blamed to be

refrigerator mothers who defrosted just enough to produce a baby

but remained emotionally cold, inflexible and lacking warmth in parental

relationship. This theory has been widely discussed and refuted as no

proof exists to support this claim.

All of the above four family functions are disputed in being causally

related to schizophrenia. There is no experimental evidence to support

these claims and any small data regarding the above theories are rather

poorly reproducible.

Social reactivity of mental illness:

Social etiology of negative symptoms of schizophrenia was explored by

Wing & brown. They surveyed asylums (Mapperley Hospital at

Nottingham, Netherne in south London and Severalls in Essex) that

existed in the late fifties and concluded that social poverty and lack of

stimulation were very much related to the severity of blunted affect,

poverty of speech, and social withdrawal these were termed as clinical

poverty. But such relationship was found to be weak in a reappraisal in

1990. (Curson et al, 1992). It was also feared that too much stimulation

could provoke positive symptoms in these patients. Thus social reactivity

was seen as an important phenomenon in schizophrenia.

Expressed emotions:

Expressed emotions concept was developed by Brown & Rutter in 1966 as

a part of the Camberwell Family Interview (audiotaped interview with

carer), and later modified by Vaughn & Leff in 1976. The ratings were

based on content and prosodic aspects and emphasis of speech. Five

measures are considered;

1. Critical comments2. positive remarks3. emotional over involvement4. hostility


5/6

[PAPER3:PSYCHOTHERAPYGROUP&FAMILYTHERAPY] 55. emotional warmth

The final scores of emotional over involvement, critical comments and

hostility were the most predictive measures for relapse. CFI is a long

interview process where individual members of a family are interviewed

(including the patient). If one relative is classified as high EE relative, thefamily is classified as a high EE family. It was found that ratings based on

interviewing parents singly had the most predictive value. A Five Minute

Speech sample (FMSS) measure was introduced as a substitute but it

tends to underestimate EE. But FMSS was more useful for measuring

professional or staff carers level of EE.

Worldwide the proportion of high EE in schizophrenia carers is 52%.

Lowest rates are found in India and other developing nations. The

strength of association between relapse and EE is identical for both

genders though the data on female cases is less. Major meta-analysis on

EE data found that for patients living in situations

rated as showing highexpressed emotion the relapse rate was 50%, whereas in the low

expressed emotion group the rate was 21%. In the majority of the

studies, high expressedemotion was predictive of relapse in symptoms of

schizophrenia9 months later for both genders. A large amount of face-to-

face contact (more than 35 hours per week) with a relative with a high

expressed emotion score increased the risk of relapse,but in households

with a low expressed emotion score, high levelsof contact appeared to be

protective.

Significant cultural differences exist in EE data. Hashemi & Cochrane

carried out a population-based normative study for expressedemotion and

found that Pakistani families in the UK were more

likely to be rated ashigh expressed emotion than White families, indicating that components

such as emotional overinvolvement may be cultural rather than

pathogenic traits.

Hashemi, A. H. & Cochrane, R. (1999) Expressed emotion and schizophrenia: a review of

studies across cultures.International Review of Psychiatry, 11, 219224

Bebbington & Kuipers, 2003. Schizophrenia and psychosocial stresses. In Schizophrenia,

Hirsch & Weinberger (Ed). Blackwell; Oxford.

Curson DA, et al. Institutionalism and schizophrenia 30 years on. Clinical poverty and the

social environment in three British mental hospitals in 1960 compared with a fourth in

1990. British Journal of Psychiatry 1992; 160: 230-241.

Models of family therapies:

1. Psychodynamic modelsEmphasize individual maturation in the context of the family system

Therapists seek to establish an intimate bond with each family member

Family sculpting refers to family members physically arranging themselves in ascene depicting individual view of relationships.

2. Bowens model (family systems approach) emphasizes ones ability to retainindividual self in the face of familial tension. The degree of enmeshment is

analysed here.


6/6


SPMM COURSE 2010

An emotional triangle is a three-party system where closeness of two members

(in either positive or negative sense) tends to exclude a third. This hot triangleleads to symptom formation. Here therapist maintains minimal emotional contact

with family members.

Bowen also found a tool to analyse history of families across generations calledthe genogram.

3. Structural model (Minuchin) views family as a structure built of

interpersonal relationships. Such a structure will have hierarchy of power

(parents in charge of children), firm boundaries and rules. Families functionparticularly well when these family structures are intact. Disrupted structure leads

to disrupted communication.

Method for restoring family structure uses simultaneous individual and familytherapy.

4. Strategic systemic therapy (Haley) believes that symptoms are maintained

by behaviours that seek to suppress them at first place. For example, the womanwith depression with low self-esteem may elicit her partner's over-protectiveness,

a solution that perpetuates the presenting problem. A strategic systemic therapist

uses reframing or positive connotation which is relabeling of negativelyexpressed feelings or behavior as positive using a new frame of reference. This is

the major strategy used by narrative therapists. A domino effect wherein if oneproblem is properly addressed, it leads to reduction or resolution of other

problems may explain the rationale behind strategic therapy.

5. The Milan systemic approach (Palazzoli) gives great emphasis on circular

and reflexive questioning. In a circular fashion each family member is asked to

comment and reflect on each others response.

Paradoxical therapy (Gregory Bateson): Therapist makes the patient

intentionally engage in the unwanted behavior (called the paradoxical

injunction) e.g. avoid a phobic object or perform a compulsive ritual. Thiscounterintuitive approach can provide new insights for some patients.Psychoeducational approaches refer to relatives being educated about the

causes and course of their family member's psychiatric illness.

Asen, E. Outcome research in family therapy. Advances in Psychiatric Treatment (2002). 8,

pp. 230238

5group family

Documents