Multiple Family Group Therapy in a
Drug and Alcohol Rehabilitation Centre
©2008 By Gabriele Schaefer
(Gabriele Schaefer, Senior Lecturer, School of Social Sciences, Auckland University of Technology, Auckland, New Zealand; Email email@example.com; Ph. + 64 09-9219999 Ext. 8410. This article was published in ANZJFT, Vol 29 Number 1, 2008, pp 17-24)
In the last decade there has been increasing interest in working systemically with groups of families. Multiple family groups (MFGs) have been used in mental health settings with schizophrenia, eating disorders and drug and substance abuse. This article describes the MFG program used in Higher Ground Alcohol and Drug Rehabilitation Trust, a rehabilitation centre in Auckland, (New Zealand). Higher Ground provides an 18-week residential therapeutic program for people with a severe substance abuse disorder. The MFG in Higher Ground focuses on developing better communication patterns and better boundaries between family members, fostering mutual support, and promoting self-responsibility.
Keywords: multifamily therapy groups, substance abuse treatment
Alcohol and drug addiction is an increasing social problem that results in enormous costs for the abuser, their family, and the community (Bushman & Cooper, 1990; Cohn & Rotton, 1997). Research suggests that family members often play an important role in the lives of drug abusers and alcoholics (O’Farrell, 1989a, b; O’Farrell & Fals-Stewart, 1999; Blum, 1972; Kaufman, 1985). Researchers have identified a strong connection between disrupted family relationships and alcohol and drug addiction (Steinglass et al., 1987; Stanton et al., 1984; Stanton & Shadish, 1997). Alcohol and drug abuse colour all behaviour within a family system (Lederer, 1991). Lederer suggests some markers that distinguish alcoholic families from other families: these include reciprocal extremes of behaviour between family members, power imbalances in family organisation and lack of a model of normality. Some psychological factors that affect the alcoholic and their family include emotional withdrawal, and guilt. These factors can compromise the family’s ability to counter alcoholism’s destructive effects (Nace et al., 1982).
Edwards and Steinglass (1995) reported a meta-analysis of 21 studies of family involvement therapy. They concluded that:
• family therapy is helpful in motivating people with alcoholism to enter treatment programs
• family-involved treatment is marginally more effective than individual treatment
• moderate benefits are found when families are involved in relapse prevention.
Stanton and Shadish (1997) also conducted a systematic review and meta-analysis of outcome studies in drug abuse treatment and family therapy. This review, which included 15 studies, comparing family/couple therapy with non-family modalities, such as peer group therapy or individual counselling, showed superior results for family therapy. McLellan (1993) found that a comprehensive intervention package with a number of treatment components, including family therapy, is more effective than standard care. Based on these and other research findings, increasing numbers of therapeutic treatment centres have included family therapy approaches in order to address substance abuse in families.
Higher Ground as a Therapeutic Community
Higher Ground was established in 1989 in Auckland (New Zealand) and provides a 25-bed, four-month residential, 12Step-oriented therapeutic community for people with severe dependency on drugs and alcohol. The residents who were admitted to Higher Ground had a primary diagnosis of Substance Dependence Disorder. The diagnosis was made prior to admission by a trained and experienced social worker and reassessed by a clinician psychologist once admitted. The criteria were based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (2000) and included at least three or more of the following: tolerance to or withdrawal from the substance of choice, taking the substance in larger amounts and over longer periods than intended, unsuccessful attempts to reduce substance intake, a large amount of time spent on obtaining the substance or overcoming the aftereffects, reduced social activities as a direct result of substance use, and continued use despite negative consequences. Residents were required to be abstinent from alcohol and non-prescribed drugs, refrain from violent behaviour or theft, and refrain from sexual relationships between them while at Higher Ground. Violation of these rules resulted in dismissal from the facility. Residents were also encouraged to attend Narcotics Anonymous or Alcoholics Anonymous while they were residents at Higher Ground.
In the year ending 31 March 2002, 120 residents attended Higher Ground. The admission criteria included a primary diagnosis of substance dependence disorder. Residents were actively involved in the day-to-day running of the therapeutic community. Apart from completing daily routines, the residents attended therapy groups such as Relationships, Acknowledgement, Anger Management, and Settling. The aim of the Settling group was to resolve conflicts in the therapeutic community. All residents had an individual caseworker who conducted their assessments and was available for individual counselling. However, clients were expected to do most of their therapeutic work in group therapy, and only a limited time was offered for individual counselling. After residents finished the residential program, they were encouraged to return one evening per week for the aftercare program. In the year finishing 31 March 2002, 102 ex-residents attended the aftercare group program, and 111 accepted individual aftercare counselling (Steenhuisen, 2002).
Several terms are used to describe therapy involving more than one family conjointly. These include Family Group Therapy, Multiple Family Therapy, Family Group Counselling, Multiple Family Sessions, Family Meetings, and Partner Groups. The term Multiple Family Group was first used by Laqueur (1970). He and his co-workers (Laqueur et al., 1964) were the first clinicians to develop the idea of treating a number of families together. They initially worked in a hospital with patients who had schizophrenia. The focus of their work was to improve inter- and intra-family communication, because they hoped that this might help create more understanding for the family members. Laqueur and his group quickly realised that through the exchange of experiences and ideas with other family systems, the group participants were able to learn from each other. These early multi-family groups were described as ‘sheltered workshops in family communication’ (Laqueur et al., 1964). This work resulted in the establishment of more formal MFGs for patients with schizophrenia and their family members (Laqueur, 1972). Central to the effective facilitation of the groups are principles of restoring self-directed vicarious learning, improved communication skills and support (Kaufman & Kaufman, 1979; Kaufman, 1994). Asen and Schuff stated that
The rationale for MFGT (Multiple Family Group Therapy) is fairly obvious and not at all different from that underpinning many self-help groups: people who face similar problems can share their experiences and advise and support each other (2006: 59).
However, MFGT differs from self-help groups in that sessions or programs are structured by therapists who employ specific systemic techniques to facilitate change. Although the literature and research about MFGT is limited, it has become increasingly popular for the treatment of a number of conditions, for example alcohol and substance misuse, eating disorders, chronic physical illness, child abuse, and social and educational exclusion (Asen, 2002). Most publications on MFGs date between the 1970s (Alger, 1975; Bergen, 1973; Bowen, 1975; Hendrix, 1971; Kaufman & Kaufman, 1977; Laqueur, 1976; Laqueur et al., 1964; McKamy, 1976) and mid-80s (Anton et al., 1981; Clerici et al., 1988; Lovern & Zohn, 1982; Nichols, 1985; Kosten et al., 1986; Zimberg, 1982; McFarlane, 1982). McFarlane (1982), for example, developed a multi-family therapy program in a psychiatric hospital. He believed that families might learn from each other by seeing parts of themselves in others.
Between the mid- 1980s and the mid-1990s relatively little was published, followed by a renewed burst of interest in the last ten years (Boylin et al., 1997; Conner et al., 1998; Henggeler et al., 1991; Kooyman, 1993; McFarlane, 2002; Asen et al., 2001; Asen, 2002; Bishop et al., 2002; Eisler, 2005; Scholz et al., 2005; Asen & Schuff, 2006; Lemmens et al., 2003; Lemmens et al., 2007). However, most studies that have been conducted in the last ten years demonstrated that MFGs are either an effective treatment for various conditions or were favorably viewed in self-report studies. For example, Asen and Schuff (2006) state that MFGs are an effective family intervention in the treatment of individuals suffering from a psychotic disorder. Lemmens and his colleagues showed that the family discussion group for hospitalised depressed patients and their families helped them cope better with the depression and offered the therapeutic team an opportunity to broaden their interventions in supporting the families:
Probably the most important therapeutic concept of the group is based on bringing together different families suffering from depression, connecting them with each other in order to use their strengths and resources (2007: 52).
Scholz and his colleagues (2005) developed
a MFG in the Dresden Family Day Clinic for Eating disorders. They reported that
the MFG was rated ‘satisfactory’ by 40%, and ‘very satisfactory’ by 60% of the
parents and ‘satisfactory’ by 40% and a further ‘very satisfactory’ by 39% of
the patients. Colahan and Robinson (2002) also stated that patients in the Royal
Free Hospital community-oriented eating disorder service indicated that they and
their families viewed MFGs favourably. All of the cited studies identified that
the main components of MFGs are that families are able to learn from each other
and have the opportunity to improve their communication skills (see Kaufman &
1979; Asen, 2002).
A Model of Treatment
From 1997, the program has sought more effective ways to engage family members of residents. I facilitated MFGs in Higher Ground 1998–2002 as a psychologist and family therapist and was part of the team who developed the therapeutic format for the MFG, aiming to help families and residents to:
• create a support network for remaining alcohol and drug free
• improve their inter- and intra-family communication
• address some of the significant issues that prevented families and support networks from working together
• develop good boundaries and stop enabling behaviours, such as giving the addicted person more money
• address denial, defensive behaviours and past resentments in the family
• normalise painful family experiences and patterns
• assist problem solving.
Higher Ground employed a flexible and
eclectic approach to their MFG program. I observed that all therapists in the
program used McFarlane’s (1983) four types of therapeutic
interventions in multiple family therapy. ‘Self-triangulation’ relates to direct interactions between the therapists and the families, and includes conventional individual and family therapy interviewing techniques. ‘Group interpretation’ involves conventional group therapy skills such as labelling group process, inviting responses from individuals or subgroups. ‘Cross family linkages’ are communications directed towards the therapist to be redirected to family members. Therapists needed to think of themselves as catalysts, generating interactions between the families, who then do much of the work. ‘Inter-family management’ promotes relationships across family boundaries and requires the therapist to regulate the social bonds that have developed during the group process. Other Higher Ground interventions came from:
• psycho-education (such as giving information about various drugs, the 12-step program, communication skills training, and the disease model)
• cognitive behavioural therapy
• motivational interviewing
• structural family therapy
• feminist family therapy
• narrative family therapy (e.g. externalisation, normalisation, unique outcome, and so on)
• social learning theory.
Not surprisingly this sometimes led to conflicts over approaches and interventions, between staff in general and also between the two therapists who co-facilitated the group. For example, a number of family therapists did not feel comfortable with the disease model of addiction. They thought that labelling the person who experienced addiction as a lifelong ‘addict’ was unhelpful. By contrast, drug and alcohol counsellors often felt that the disease model reduced blame and helped the family to cope with addiction, particularly when the addicted person was male. More feminist-oriented family therapists felt at times that the 12step program of AA or NA was problematic for some of the resident women who had to acknowledge that they were powerless over their addiction. Generally these women already felt powerless in their families, with their partners and in society in general, and now they had to acknowledge that they were even powerless over their own addiction. Different counselling styles created ideological and interventional tensions for the therapists who facilitated the groups.
However, I never experienced open confrontations between therapists in the actual MFG. Sometimes therapists just made subtle comments that relativised the 12-Step program or the disease model. Nevertheless, it has to be emphasised that Higher Ground is not unusual with respect to employing therapists who use different therapeutic approaches. From the outset multiple family therapy has been a strange mix of group therapy and family therapy, psychodynamic practices and attachment theory (Asen, 2002). Hence it is not surprising that this blend of different approaches is reflected in the therapist’s therapeutic backgrounds. For example, Vetere and Henley (2001) described how couple and family therapy were integrated into a community alcohol service (CAS). They reported that one team member was a systemic psychotherapist and the other a group analytic psychotherapist. In addition, they had regular students on placement with backgrounds in both psychiatry and social work. Interestingly they did not report the difficulties or challenges that Higher Ground encountered at times. Thankfully therapists in Higher Ground were generally able to resolve their ideological differences in the debriefing sessions.
Therapists at Higher Ground quickly realised that clients did not find it easy to contact their family members and invite them to attend the MFGs. This is also reported by other authors, for example Stanton and Todd (1982b) and Van Deusen and his colleagues (1982) argued that clients were often hesitant to involve their families in their treatment. Hence, Higher Ground developed some strategies to involve families in Higher Ground:
• When clients first contacted Higher Ground they were invited to bring family members to the assessment interview and told that family involvement was an integral component of treatment. Prospective residents were informed that family members and significant others were strongly encouraged to attend the MFG.
• Within the therapeutic community the MFG was given a high status. New staff members were engaged to facilitate the MFG together with experienced staff members.
• Residents were sent home during the weekend or had their children staying in the community over the weekend in the second phase of the program, because this was believed to strengthen their bonds with their families. This allowed staff members to get to know the families, which further encouraged participation in the MFG (Steenhuisen, 2002).
The service scheduled the MFGs once a week, and invited every resident’s family members. After a period of experimentation, the therapeutic team decided that children and adolescents under the age of 16 should not attend the group so as not to expose them to the trauma that frequently had to be addressed in the groups. A family system was composed of a resident with one or more members of his/her family or significant others. This could be any member of the (extended) family in any combination (Steenhuisen, 2002). If residents did not have family members attending, they were encouraged to invite a support person — a friend, a sponsor from a 12-Step Fellowship, or a colleague.
Every Wednesday morning, the staff and residents met to discuss the preparations for the MFG that evening. According to the therapists, the residents were often anxious as they reported which family members and support people would attend with them that night. The reason for their fear was that discussing addiction and the behaviours such as prostitution, stealing and drug dealing was especially difficult in the presence of family.
In the evening before the groups started, residents, family, significant others and staff had a meal together. These dinners gave staff a good opportunity to meet everybody and hear what happened in their week. This informal meeting often lessened the anxieties for both residents and their relatives, and provided a ‘warm-up’ to the groups. Between 15 and 25 residents and between 9 and 30 family members attended, bringing the total of participants to between 24 and 50 per evening. The groups were split into three smaller groups of between 10 and 25 participants. A regular Higher Ground staff member and an external family therapist facilitated each smaller group. Average sessions lasted 90 minutes. A senior resident opened the MFG with a brief explanation of its objective. This resident also explained the confidentiality and behavioural rules for the MFG. After the introduction, one of the facilitators asked all participants to report briefly on important experiences during the previous week, and invited them to bring up issues for the MFG. Generally, the group focused on the ‘here and now’ of the clients’ life. If there was a need for residents to address issues from their past, then staff coached them on how to address these problems without making them the major focus of group attention for the whole session and referred them to individual family counselling sessions where necessary. Facilitators paid considerable attention to establishing a working alliance amongst all participants as quickly as possible, which was sometimes a challenge. As in many residential programs, group membership changed frequently, as residents either graduated from the program or were discharged. Residents’ family members or support persons changed as well. Naturally this had an impact on the issues that were brought forward and the general trust levels of the group.
Facilitators intervened if they believed that family members wanted to discuss sexual abuse or anything else too overwhelming for a member of their family to cope with. The therapeutic team decided that clients had to be properly resourced in order to discuss issues such as sexual abuse and that the MFG was not the right context to discuss this. If family members brought these matters up in the opening round they were referred to individual family sessions, or to external therapists. Each family system had a limited amount of time to explore their problems, which was another reason why therapeutic topics themselves had to be carefully monitored by the facilitators. Facilitators taught families to create good boundaries, develop good communication skills and recognise unhelpful enabling behaviours in the family system, all of which were named in the group objectives. When a family explored their difficulties, other families were invited to provide their observation and feedback in a respectful way. As mentioned above, therapists encouraged communication between the families, but sometimes residents and their support persons had to be coached on how to give feedback respectfully, without blaming or moralising. Generally, only some of the families had the opportunity to explore their concerns in any one session. In some cases, the facilitators discussed prior to the MFGs which families needed to address a particular problem. Naturally, some residents and their family members were more comfortable than others to discuss their difficulties, and the more silent families needed to be encouraged to share their experiences. Therefore the therapists had to exert a certain amount of control and monitor the therapeutic processes in the MFG carefully. When ‘old’ families told their story, this was often a source of encouragement for the ‘new’ families.
Sometimes residents and their support persons left the group in order to regulate the stress they were experiencing. The facilitators did not encourage this, but if it happened the residents had to spend time with a supervisor in the reception room, and be available for a discussion with a therapist after the group. If clients left precipitously and unexpectedly, one therapist usually followed them and assessed whether they were stable enough to join the group again, should spend time with a supervisor outside, or should leave Higher Ground (if they were a family member or an unrelated support person). Family members could leave Higher Ground at any time, but were generally contacted by a therapist the next day in order to make sure that they were emotionally stable.
After the sessions, participants were encouraged to have a hot drink. Often participants brought special foods or residents baked a cake. This process allowed further communication between residents and their families, and also provided a chance for the different families to bond. In many cases, family members were able to create support networks. The therapists who facilitated the aftercare program heard that families stayed in touch even after the resident graduated from Higher Ground.
After the group session finished, staff members wrote their reports on each resident in their group, debriefed and were available to talk with individual participants or families. Anything dramatic that happened in the MFG was noted in the relevant resident’s file so that caseworkers in Higher Ground could get in touch with the family member and address the issue with the resident during the following week.
In the 12 months ending 31 March 2001, a total of 239 family members or support persons and 120 residents attended the MFGs. Eighty-two (34%) family members or significant others attended the MFGs only once, and 93 (37%) attended between two and five times. Sixty-four family members (30%) attended between six and 24 times (Higher Ground Statistics, 2002). Higher Ground (Anderson, 2001) looked at the level of family or support person attendance at each MFG for each individual resident over the six months ending 31 March 2001. During this period 60 residents and 100 family members or support persons attended the MFGs. Twenty-six out of 60 residents always had someone attending the MFGs with them. Twenty residents had a person attending with them 70% to 90% of the time, and ten out of 60 residents had a person attending with them 10% to 60% of the time. Four residents had no family or support persons attending the MFGs, and of these four, two spent less than two weeks at Higher Ground before leaving prematurely. Anderson pointed out that the majority of residents had family members or support persons regularly supporting them in the MFG. The majority of residents in Higher Ground are European and only 10% are Maori and Pacific Island clients.
Advantages of MFGs
Therapists as well as clients reported improvements through the implementation of the MFG program:
• Often families are caught up in a repetitive pattern of interaction in which any change is difficult (see Colahan & Senior, 1995). The MFG format allows families to explore these entrenched interactions without feeling judged. It was certainly our team’s impression that families were more open to accepting advice and criticism from other suffering families than from professionals. In this way the group itself was an important therapeutic tool. The presence of several families reshaped all relationships in the group (see Lemmens, 2007: 52).
• Robert Steenhuisen and I conducted a study with residents and resident’s family members in 2001–2002. We were both employed in Higher Ground and were both interested in understanding the MFGs from the residents and the families’ perspective. Robert Steenhuisen interviewed 11 family members about their MFG experience. Most felt that the MFG experiences helped them to ‘move on’ and change old dysfunctional family patterns. I conducted nine interviews with residents and three interviews with ex-residents. Results indicated that all of the residents experienced positive changes in their relationships with their family members and partners. Participants explained that they had gained better communications skills and were able to integrate these skills into their relationships with their families and partners. They felt that they experienced more closeness with their families even if their family members did not attend the group very often. Our research was qualitative and therefore it is not possible to generalise the results. However, the results suggested that the therapeutic process was very useful for the participants of the MFGs we interviewed. More qualitative and quantitative research is needed to learn about how the therapeutic processes in the MFGs influence the group participants.
• This model considers the family as the central unit of care and acknowledges family members’ inherent need for support (Lemmens et al., 2007). Lemmens and his colleagues (2003) reported that families included in the treatment program might not only feel better understood and supported, but might gain a better insight into the patient’s problems, and might lead the therapeutic team to take a respectful attitude to the families, so that they could all work together in a more constructive way.
• The psycho-educational elements in the group process can help families to gain a better understanding of substance abuse and explain why their addicted family member behaved in a certain way. This increased understanding can then lead to more empathy and initiate a (usually slow) process of reconciliation. Family members can revisit and reconstruct their way of managing the addiction to alcohol and drugs, by not enabling their addicted family member any more.
• Multiple family therapy addresses ways in which the family members respond to conflict and can help to gradually eliminate destructive conflict behaviours such as passive aggressive communication, verbal abuse, and conflict withdrawal. The training in constructive communication behaviours teaches participants how to communicate effectively without blaming each other or avoiding each ther.
• Bishop and his colleagues (2002) pointed out that the social context of the groups could create the potential for highly therapeutic encounters for patients as well as for their relatives through the development of ‘surrogate’ relationships and ‘reverberating’ conversations in the multi-groups. For example, a family member may connect with another parent’s experience and that can help him/her to re-experience and re-evaluate his/her own situation and experience.
• The MFG sessions do not use as much therapist time as would be dedicated to families using the single-family approach alone (Anderson, 2001). Asen (2002) and Asen and Schuff (2006) explained that its cost-effectiveness in times of dwindling resources could partly explain the increasing popularity of the multiple family therapy approach.
Disadvantages of MFGs
• When a number of different families are in the same room, therapists are much less central than in other forms of therapy. Therapists tend to find it easier to work with multiple families if their training has exposed them to structural techniques such as ‘enactment’ and ‘intensification’ (Minuchin & Fishman, 1982). Obviously this can increase training and staffing needs for therapeutic services.
• Multiple family work sometimes can create complex dynamics between families, which can be challenging for the therapist. Examples might be animosity between two families, one family member dominating another family, or other group members. Additionally, substance abusers are often the most loyal children in the family, and can begin to feel disloyal to their family of origin when challenged by other clients about how unfairly their families had treated them (see Soyez et al., 2004). In this situation, staff members need to intervene by stimulating discussions about loyalty. This can then create a climate in which the residents’ defence of their families is reframed positively as loyalty. Therapists need to be trained in both family therapy as well as group therapy in order to cope with these situations.
• Therapists may feel confused about whether MFT is family therapy in a group or group therapy with families (Saayman et al., 2006). If therapists are only trained in one modality they may feel apprehensive about exposing themselves to other colleagues and appearing incompetent. Institutions may resist the investment of time, funding and resources in the development of MFGs. In Higher Ground it took both dedication and lengthy consultations and discussions to successfully implement the MFG program.
• Saayman and his colleagues (2006) wrote that practical issues include ensuring a consistent referral process and identifying families willing to discuss their problems in a group setting. In Higher Ground, it was a challenge to engage family members to attend the group. Residents were often ‘horrified’ by the prospect of having to confront their families in the MFG, and staff members frequently had to initiate the contact with the family members. We also encountered family members who did not want to have any contact with their substance-abusing relative, because they had experienced so much abuse from them in the past.
• Few systematic studies or random controlled trials to date provide a scientific evidence base for the efficacy of multiple family therapy. Consequently, multiple family therapy remains a largely ‘unexplored model’ although it has shown effectiveness in different settings (Thorngreen et al., 1998, see literature review).
MFGs are a specialised form of family therapy that can be successfully applied to treating alcohol and drug addiction. Although the literature on MFGs is relatively limited, professionals have tried since the 1950s to bring families together and get them to share their problems and find solutions. The majority of residents at Higher Ground had family members or other individuals regularly supporting them in the MFG. This is a success for Higher Ground, given how estranged many residents were from their families and how difficult it was for many to get in touch with their families again. Residents and family members reported that the MFGs helped them to build family networks, address boundary issues, facilitate better communication patterns and create more closeness with their families. This indicates that families can be successfully engaged in the treatment of substance abuse disorders in a residential program, and that MFGs can provide a good format for family healing and recovery.
I wish to acknowledge the assistance I received from Robert steenhuisen, Dr George Latham and Stuart Anderson. I also want to thank the Auckland University of Technology for its financial support for this project.
1 Individual family therapy sessions were available for residents who wanted to explore intimate details that were not appropriate to discuss in the MFGs, such as sexual abuse or severe childhood trauma. In the debriefing sessions after the MFGs, the therapists and the clinical director decided which residents and their families would benefit from individual family sessions. The family therapists who conducted the single-family sessions recorded the therapeutic process in the client’s file so that the facilitators of the MFGs could find out what happened in the individual family sessions. Again, this approach is quite common, e.g. the combination of MFGs and single family therapy sessions were also used by the Marlborough Family Day Unit in London (Asen, 2002).
2 Robert Steenhuisen was the director of Higher Ground and was not involved with clients therapeutically. As I explained above, I facilitated the MFGs but decided, out of ethical concerns, that I would interview only clients from other MFGs that were not known to me.
3 The results of my research will be published in 2009.
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