Some Relationships between Group Process and Mental Health Phenomena in Theory and Practice

Though the focus on interpersonal interaction is a powerful therapeutic factor in group therapy, traditional chemical dependency therapy groups generally fail to employ the interactional group orientation. An interactional approach can be effectively applied to alcoholics if the following guidelines are observed: (1) recovery is always accorded priority, (2) the patient accepts identification as an alcoholic, (3) anxiety is carefully modulated, (4) the proper distinction is made between what the alcoholic is and is not responsible for, (5) the therapist is thoroughly familiar with Alcoholics Anonymous language, steps, and traditions. It is important that therapists not permit misperceptions of A.A. to be used as therapy resistance and that they be able to harness the wisdom of A.A. for psychotherapeutic ends. Group therapists must also be prepared to deal with common themes arising in the treatment of the alcoholic patient: idealization, devaluation, externalization, defiance, grandiosity, conning, and avoidance.     

J.L. Moreno: An Unrecognized Pioneer of Family Therapy

J.L. Moreno's fundamental and pioneering contributions to the development of group therapy, encounter, transactional analysis, and especially psychodrama are well known. However, most family therapists seem unacquainted with the fact that from his earliest writings in 1923 J.L. Moreno developed an interactional view of psychotherapy that in 1973 already resulted in formulations of a true systems orientation and very concrete ideas about marital therapy, family therapy, and network therapy. He probably is the first (1937!) therapist that actually involved a husband's lover in conjoint marital therapy. His general theoretical formulations about the pathology of interpersonal relations as well as his practical suggestions for the therapy of the interpersonal relations seem to be insufficiently known to workers and researchers in the field of family therapy.     

Communicational Styles and Interaction of Alcoholics and Their Wives

The following hypotheses, derived from an interpersonal-interactional theory of alcoholism were investigated: (1) The alcoholic uses a style of communication characterized by responsibility avoidance, when interacting with his wife; (2) The wife of the alcoholic uses a more direct, responsibility-accepting style of communication than her husband, when interacting with him; (3) The interaction between an alcoholic and his wife is marked by (a) an inability to function as a unit for mutual benefit, and (b) rigidity of complementarity and/or escalation of symmetry. These hypotheses were tested by placing twenty married couples with alcoholic husbands and twenty normal control couples in an interactional game-playing situation. Hypotheses 1, 2, and 3a were confirmed. It was found that alcoholic couples use the escalation of symmetry pattern (hypothesis 3b). Additional findings on competition, dominance, and interactional rigidity are discussed.     

Dynamically oriented group therapy with alcoholics: Making it work despite the prevailing bias

A bias exists in the psychiatric community against dynamically oriented group therapy with alcoholics. The basis for this bias lies primarily in negative experiences of practitioners who have attempted to use traditional therapy with alcoholic patients who continued to drink. At Appleton Outpatient Clinic, we have found that dynamically oriented group therapy is a highly suitable treatment modality for alcoholic patients when negative biases of treators can be addressed and when initial preparatory work is done with patients. This preparatory work includes: (a) building a working alliance around abstinence and providing adequate supports to make this possible; (b) explicit contracting that establishes clear treatment goals and consequences should the goals not be met; (c) preparatory short-termgroup experiences.This paper was presented at the 1988 annual meeting of the American Group Psychotherapy Association.     

Does family therapy produce change? an overview of outcome studies

Summary Families were randomly assigned to one of two forms of conjoint marital therapy: an insight-oriented treatment (n=10) or a problem-solving intervention (n=10.). The results on self-report measures of family functioning indicate that the problem-solving intervention produced more favorable changes after three months. However on long-term follow-up after a year, this more positive effect did not apparently persist, since the insight treatment group reported better results. Experienced therapists did better than inexperienced therapists in the insight treatment condition, but level of experience did not make a difference in the problem-solving intervention. A group of eight families who dropped out of the insight treatment group provided data on correlates of premature termination. Several of the practical obstacles to implementing an experimental design in a clinic setting are illustrated by the research.As we develop more sophisticated methodology, we hope that is the near future family therapy researchers will be better able to state which type of approach is more effective for whom and under what circumstances. A review of current studies of family therapy outcome research indicates that family therapy seems to be as effective as individual psychological treatment.     

Techniques of Structural Family Assessment: A Qualitative Analysis of How Experts Promote a Systemic Perspective

The trajectory of assessment in structural family therapy moves from a linear perspective, in which problems are located in the identified patient, to an interactional perspective, in which problems are seen as involving other members of the family. Minuchin, Nichols, & Lee (2007) developed a 4‐step model for assessing couples and families consisting of: (1) broadening the definition of the presenting complaint to include its context, (2) identifying problem‐maintaining interactions, (3) a structurally focused exploration of the past, and (4) developing a shared vision of pathways to change. To study how experts actually implement this model, judges coded video recordings of 10 initial consultations conducted by three widely recognized structural family therapists. Qualitative analyses identified 25 distinct techniques that these clinicians used to challenge linear thinking and move families toward a systemic understanding of their problems. We discuss and locate these techniques in the framework of the 4‐step model.     

Stability/Instability in the Alcoholic Marriage: The Interrelationships Between Course of Alcoholism,Family Process,and Marital Outcome

Thirty-one alcoholic families who were originally studied in home, multiple-family group, and laboratory settings were reassessed two years later to determine course of alcoholism and degree of marital stability. This paper presents data comparing baseline alcohol consumption and family interactional behavior at home with subsequent alcoholism and marital stability outcomes. Findings suggest that the relative degree of stability/instability in these marriages is best understood as a function of the “goodness-of-fit” between the relative predictability of drinking on the part of the identified alcoholic and the family's characteristic pattern of interactional behavior at home.     

The use of the self in group leadership: a relational perspective

This article, written from a relational perspective, describes a shift that is taking place in the thinking of many psychodynamically oriented psychotherapists regarding the practice of therapy and the implications it has for group therapists. The shift, from one-person to two-person and multi-person theory, has particular importance for group leaders since it recommends making the subjective involvement of the therapist in the interactional field of the group much more a part of the treatment process. Theory and research on the use of countertransference, non-interpretive interventions, humor, and spontaneity by the leader are reviewed and vignettes are presented to illustrate the application of these ideas. Guidelines regarding the application of such ideas in group therapy are also discussed.     

Change: How do we recognize it?

The paper seeks to examine the working assumptions that guide us as therapists engaged in the attempt to facilitate change in families. It summarizes a piece of preliminary research based on the responses of a group of therapists working in different agencies. A questionnaire on change was developed and given to the therapists followed by a group discussion.
The results suggest that therapy teams, and families, have common sense ideas about:

• the beginning, and end of a period of change;

• types of change—those falling into four categories; of behavioural, structural, communication and experiential.

Our results suggest that difficulties in therapy may be associated with a failure amongst the therapists in a team to negotiate their mutual assumptions about change. In addition the process of therapeutic change is seen as involving a negotiation between the family and the therapists about what will count as change.
The data were gathered from a group of therapists attending a local meeting of the Association for Family Therapy in Plymouth.     

Objective Evaluation of the Process and Effects of Analytic Group Psychotherapy with Adolescent Girls

This article, written from a relational perspective, describes a shift that is taking place in the thinking of many psychodynamically oriented psychotherapists regarding the practice of therapy and the implications it has for group therapists. The shift, from one-person to two-person and multiperson theory, has particular importance for group leaders since it recommends making the subjective involvement of the therapist in the interactional field of the group much more a part of the treatment process. Theory and research on the use of countertransference, noninterpretive interventions, humor, and spontaneity by the leader are reviewed and vignettes are presented to illustrate the application of these ideas. Guidelines regarding the application of such ideas in group therapy are also discussed.     

Commonsense about Psychoanalysis by Rudolph Wittenberg

Obstacles are described that constrain or block the full implementation of Yalom's model of inpatient group psychotherapy. These obstacles include situational constraints that are imposed by the temporal, spatial, and organizational structures of many treatment settings, and attitudinal constraints that consist of therapist and patient resistances to the implications and demands of the model. Recommendations are provided that have proven useful for overcoming these obstacles. They address such issues as: (1) patient confusion with here-and-now focus, (2) tendencies toward therapist-centered interaction, (3) the apparent irrelevance of interactional groups for many patient presenting problems, (4) insufficient time to accomplish interactional goals, and (5) the inability of patients to engage in group processing.     

Observations Of Conjointly Hospitalized “Alcoholic Couples” During Sobriety And Intoxication: Implications For Theory and Therapy

This paper presents clinical data from a research study designed to examine the relation between alcohol consumption and interactional behavior in “alcoholic couples.” The central innovative feature of the study was the simultaneous admission to an inpatient setting of up to three couples, one or both members of which was alcoholic. The in-patient experience was part of an intensive, six-week, multiple-couples, group-therapy program. During hospitalization couples were encouraged to reproduce as closely as possible their usual drinking patterns and interactional behavior. Therapists utilized observations of interactional behavior during intoxication and sobriety to formulate central interactional and psychological issues for each couple. The authors utilized these same observations to develop the interactional model of alcoholism in families that is presented in detail in this paper. This model is an extension of earlier work delimiting an interactional theory of alcoholism based on general systems concepts. Two extensive case histories are presented to illustrate both theoretical issues and the treatment process.     

Practice-based evidence: patients who did not respond to group analysis

Evidence-based psychotherapy is typically based on treatment outcome for the "average" patient in aggregate designs; reports on individual non-responders are rarely published. In this observational study, we explored factors that might have contributed to non-response in long-term dynamic group psychotherapy. Eight patients (14%) who did not change were compared with 48 treatment responders on clinical variables, and their case stories were retrospectively scrutinized for explanatory factors. The non-responders had less initial distress, stayed for shorter durations in therapy, and were more dissatisfied with their group and therapists. Based on detailed case stories, attempts are made to tease out idiographic hypotheses why each patient did not change during group analysis.     

Alcoholism: etiologies proposed and therapeutic approaches tried

Alcohol, probably the most popular mood-altering drug, has frightening consequences when abused. Genetic factors and sociocultural influences contribute to alcoholic behavior. Study of endocrines, neurotransmitters, and neuropeptides may reveal biological markers to help identify those at risk for alcoholism. Drinking patterns are often based on the expectation of alcohol's mood-altering quality. The focus of treatment has expanded to include not only drinking behavior but also emotional, social, and vocational adjustment. Controlled drinking has proved effective for some, so that complete abstinence is no longer the sole goal of therapy. Behavioral, martial, group and individual, outpatient and inpatient therapy, and drugs as adjuncts, all help some alcoholics, but none is a cure for all. Answers still lag behind questions but researchers have registered some advances that challenge therapists to enlarge therapeutic approaches to fit the multifaceted picture of alcoholism.     

Therapists’ and clients’ perceptions of routine outcome measurement in the NHS: A qualitative study

Primary objective: This is the first qualitative study that elicited the perceptions of both psychological therapists and their clients in the use of Clinical Outcomes in Routine Evaluation with computer software (CORE‐Net), where instant visual feedback for session tracking was given on a computer screen in the therapy room at each therapy session. The study also examined how therapists viewed its potential value in supervision and provides suggestions for improving training. Research design: The study adopted a convenience sample of four therapists in a primary care counselling setting (PCC – General Practitioner referrals) who were experienced in using CORE‐Net, and five therapists in an NHS employee/occupational support counselling service (OH) who had just begun to use CORE‐Net for session tracking with 10 of their clients. Method: A qualitative methodology was used and interview data were collected from the therapists via focus groups; the clients were interviewed individually face to face. All data was analysed inductively. Findings: The study identified six overarching themes: (i) therapists were initially anxious and resistant; (ii) therapists adapt ‘creatively’; (iii) outcome measures help the client/therapist relationship; (iv) clients perceive visual measures as helpful; (v) CORE scores inform supervision; and (vi) proper and ongoing training/support of therapists is necessary. The main limitations are comparability of data and the generalisabilty of results. Conclusions: The implementation of routine outcome measurement (ROM) is a challenge but can be made easier with proper training and supervision. Clients appear happier than their therapists when routine outcome measurement is used.     

Treatment of alcoholic couples in outpatient group therapy

This paper summarizes special issues that group leaders are likely to encounter when adapting their skills to outpatient group therapy with alcoholic couples. More specifically, the paper: (a) discusses the advantages of treating alcoholic couples in a group as opposed to individual couple's therapy; (b) outlines the parameters of a couples group with alcoholic members that differentiate it from working with other kinds of couples in group; and (c) provides guidelines and techniques for tackling some of the specific kinds of problems and situations that arise.This paper was presented at the Annual Meeting of the American Group Psychotherapy Association, New York City, February, 1985.The author wishes to acknowledge the contribution of Geraldine Alpert, Ph.D., whose thoughtful comments and discussion helped to crystallize the concepts presented.     

A Summary Report of the Cost-Effectiveness of the Profession and Practice of Marriage and Family Therapy

This purpose of this paper is to provide a summary of the cost-effectiveness research for the profession and practice of marriage and family therapy. Studies based on four sources of data were considered: (1) a western United States HMO covering 180,000 subscribers; (2) the Kansas State Medicaid system with over 300,000 beneficiaries; (3) Cigna, a large Unites States health insurance benefits management company with more than nine million subscribers; and (4) a marriage and family therapy training clinic in the western United States serving approximately 300 individuals and families a year. Results from the studies support the potential for a medical offset effect after couple or family therapy, with the largest reduction occurring for high utilizers of health care. The studies also show that covering family therapy as a treatment option and marriage and family therapists as a provider group is not associated with significantly higher treatment costs. An application of cost-effectiveness methodology to medical family therapy is also considered.     

To be in touch

This study examined the constellation of interaction structures – repetitive patterns of interactions between patient and therapist over the course of treatment – that emerged in the psychodynamic therapy (PDT) of a child diagnosed with borderline personality disorder and treated by two doctoral student therapists. Identification of these interaction structures can inform therapists of what might be expected from patients with particular symptom or behaviour patterns and how interactions change over time. This study also examined each session’s adherence to three session prototypes: PDT, cognitive-behavioural therapy (CBT) and reflective functioning (RF) process. The Child Psychotherapy Q-Set (CPQ) is a 100-item instrument that assesses the processes within a single psychotherapy session. Items reflect a wide range of therapist attitudes and behaviours, patient attitudes and behaviours and interactions between therapist and patient. Experts used the CPQ to define PDT, CBT and RF process session prototypes. The results suggested that four distinct interaction structures could be identified and that their constellations differed between the two therapists and also differed over time within each treatment. Therapists were more structured and accommodating early on in their treatments and more interpretive later. Prototypical PDT process was more prominent in the sessions than RF process, which in turn was more prominent than CBT process. Unique therapeutic processes are at work in every dyad, despite holding the patient and theoretical orientation constant. An effective treatment in one dyad might not work in another due to therapist-specific and dyad-specific effects.