Chapter 14: Family and Group Therapy
All individuals are born into some form of family (even if adopted) and that the family
often determines how an individual understands or copes with events.
Dates back to the 1950s. Therapists began to realise that patients that were beginning
to cope would go back to their families and just regress. Idea of ‘sick family unit’.
Idea of identified patient who was manifesting troubled behaviour maintained by
problematic transactions within the family or between the family and the outside world.
Early ideas of family effects came from study of schizophrenia
• Schizophrenia was thought to come from lack of warmth/caring by the primary
caregiver (usually the mother)
o Terms ‘refrigerator mother’ or ‘schizophrenogenic mother’
o Has since been disproved
• Has since been considered that it may result from pathological family interactions
or mixed communication signals over time
Bateson viewed family as cybernetic system: regulatory systems that operate by
In 1950s, idea of nuclear family: composed of husband wife and offspring – two or more
children, divided pretty much equally between genders
• Changes in the world have made this pretty much inaccurate now
Family: two or more people related by birth, marriage, or adoption residing in the same
Household: all people who occupy a housing unit regardless of relationships
Things that can affect family tensions:
• Socioeconomic status (SES): person’s position in society as determined by
income, wealth, occupation, education, place of residence, and other factors
• Social class: divided into three categories – upper, middle, lower class
Another issue is ‘What is a normal family?’
• What differentiates a normal family from a dysfunctional family is the absence of
violence – any violence = unhealthy family o Lack of violence doesn’t necessarily mean healthy
• Enmeshed family: organization in which boundaries between members are
blurred and members are over involved in one another’s lives
• Disengaged family: organization with overly rigid boundaries, in which members
are isolated and feel unconnected to one another; family has few interactions
with one another
o Normal means no disengaged/enmeshed
• Family alliances are an issue too
o Dyad: alliance between two people in a family situation; communication is
often better between the two than in the larger family unit
o Triad: three person alliance; communication is better within this
o Often in conflict with each other
Confidentiality is huge issue because there is more than one person involved.
• Confidentiality is still in place but it needs to be explained more clearly
Clinical neuropsychologist must ensure that the family does not use the diagnosis within
therapy to label one member of the family as the only one that is having difficulties
Clinical neuropsychologist can use structured interviews to gain information,
behavioural scales to collect observational data, assessment tools to garner information
If individual assessment tools will be sued, ethical issues discussed earlier must also be
Stages of Family Therapy
Step 1 Introduction
• From first contact, Clin. Neuro. must work towards a working alliance
Step 2 Confidentiality
• Need to establish limits so that people can feel comfortable to talk
• Family members are not ethically/legally bound to maintain confidentiality
Need to decide about delivery • New family therapists often have difficulty trying to make sure everyone gets
Step 3 Intake info
• Info about identified patient is available at the beginning but not so much about
rest of family
• Can do private interviews but can be problematic they can get info that people
wouldn’t disclose to the group but then they become secret keepers – which
makes objectivity hard
• If information is found out in group, individual might hold back info
Step 4 Bringing in the rest of the family to the identified patient’s difficulties
• Spreading the problem: bringing information to all of the family members
• Making the family aware that they contribute to the functioning or non-functioning
of the family unit
• Need to know their role in the perpetuation of the identified patient’s difficulty
Ways to include the family:
• Ask the family why they think they’re there
o A lot of time there are resentment or anger
o Want to make sure it’s known that it’s not their fault that they’re in therapy
• Planned warm-up strategy
o “How does your family communicate? Pick a topic and show me”
• Development of family rules
o Aim is to force the family members to think how each person affects the
behaviour of others
o Rules should be generated by the family but can be prompted by the
Theories of Family Therapy
Object Relations Family Therapy
Based on psychodynamic views and concepts.
Therapists contend that the need for a satisfying relationship (i.e. another person) is the
fundamental motive in life. • Perspective individuals bring memories of loss or un-fulfillment from childhood,
defined as introjects: implies that the individual brings memories of loss or
unsatisfying childhood relations into adult relationships which are likely to cause
Argue that individuals unconsciously relate to one another in the present largely on the
basis of expectations formed during childhood.
Therapists help family members gain insight into how they internalized objects intrude
on current family relationships. Goal is awareness within the family of unresolved
introjects. Once this is achieved, development of understanding of how these issues
have caused current family issues.
Tend to have largest number of sessions.
Family Systems Family Therapy
Based on work of Murray Bowen.
Conceptualized family as an emotional unit, network of interlocking relationships that
are best understood when analyzed with a multigenerational framework.
Looks at various systems or grouping within the family of procreation but also the family
Members with the strongest affective connections (fusion) with the family are the most
vulnerable to personal emotional reactions to family stress. The degree to which an
individualized separate sense of self, independent from the family (differentiation of self)
occurs is correlated with the ability to resist being overwhelmed by emotional reactivity
in the family.
Tends to work well with families which are on the enmeshed side.
Takes some from psychodynamic but focuses on the ability of the individual to be both a
member of the family and also an individual with a clear sense of identity.
Structural Family Therapy
Focuses on family organization and the rules which govern transactions.
Symptoms are viewed as means of diffusing conflict, diverting attention from more basic
• Symptoms are maintained by a family structure unable to adapt to changing
environmental or developm