A Model for
Multiple Family Group Therapy
In Adolescent Inpatient

1995 By Nicholas A. Belsky, MSW

Multiple family group therapy can be an effective helping tool for families who have adolescent children with significant mental health problems requiring inpatient treatment. As Peter Laqueur has described multiple family group therapy, it combines the principles of family therapy and group therapy. A group of families come together with a treatment approach that is born of necessity.

In today's world of managed care and scarce community resources, necessity dictates that the impatient treatment of adolescents takes place in a shorter period of time. The multiplicity of conflicting messages from the mass media and numerous other assaults on the family unit tend to isolate families. It is no wonder that parents have problems developing the parenting and communication skills they need to help their children to grow up safely. In short, the inpatient therapist ends up with 3 to 10 days of treatment to help the adolescent family system to effect a coherent and manageable system of rules and consequences for people to live by. Herein, is a model of a type of multiple family group therapy which can be used to help families help themselves.

Goals of the
Multiple Family Therapy Group

The goals of the multiple family therapy group are:
1. To help each family member deal with his/her reality,
2. To improve communication between family members,
3. To change how the family works- i.e. to make it work better,
4. To help the therapist as a change agent, i.e. to share the group leadership experience with peers (cotherapists), nursing staff, trainees, and families.

Theoretical Assumption

The basic theoretical assumption of the multiple family therapy group is that the individual (adolescent) lives in the system (family) and the system maintains the symptoms of the individual and the family. The goal of treatment is to help the information flow freely within the family system to and from the outside world. The other assumption is that families tend to perpetuate problem behaviors as a form of metaphoric communication about themselves in relation to the outside world.

The symptoms reveal to the other systems how the family develops rules, roles, rituals and myths. These enable the other systems to identify how the family operates. The therapist experiences these communication styles as they occur and can intervene directly to effect change.

Major Principles

Major principles used in developing a mode of intervention in multiple family group therapy are:
1. When a family is in crisis all members are reacting to the crisis.
2. Symptoms are a way of avoiding responsibility and get the family stuck.
3. Families need to occasionally change their rules and roles; they need new ideas.
4. Problems that people have are between individuals, i.e. they are interactional in nature.
5. If a problem continues, it is because people are coming up with bad solutions. E.g. If a family member is drinking heavily, members try to control the drinker rather than take care of themselves or allow the drinker to fully realize the consequences of his/her drinking behaviors.
6. Therapeutic intervention is based on focusing on here and now interactions between members, one day at a time, one change at a time.
7. If one person changes his/her behavior-no matter how long the nature or origin, the problem changes.
8. Intervention is based with a minimum of emphasis on insight but more on reframing family interactions.
9. Intervention is based on building strengths as well as developing and reinforcing already existent problem solving skills of the various members.
10. Small changes are crucial; take care of the little things and the big things will take care of themselves.
11. People need and respond positively to getting credit for their efforts.
12. The solution to a problem is unique to each family.
13. Interventions emphasize the hierarchy of the family and it is the job of the therapist to empower the parents.
14. The family is encouraged to negotiate achievable and realistic goals.
15. The adolescent with the identified problem is to be joined by the therapist whose responsibility is to positively reliable the negative behaviors of the youth.
16. All family members need to be engaged by the group leaders, however, it is best to go with the one who is most ready to be open with the group leader.
17. Most important; Have fun!

Structure of the Group

Each multiple family therapy group leader has his/her own style, strengths, and biases which get incorporated into the group structure. The structure of this model group comes from the writers' 8 plus years of leading inpatient multiple family group therapy.

Each group starts with a circle of chairs to be filled. The group leader should always sit facing a clock, or have a watch, to be aware of the time. If there is more than one leader, they should not cluster together, and should sit so they can see each other directly and each can have a clear view of their section of the circle. Multiple family group therapy sessions tend to be longer than the average group session, and it is very useful to have some healthy food and drink available such as fruit and juice. Members are encouraged to be able to get up and move around a bit if they feel the need and are free to get up and get a bite to eat or drink as they see fit. At the beginning of the group session, members are reminded to go to the bathroom.

The leader starts the group by defining its structure and rules. He/she introduces him/herself, e.g. "I am Nick Belsky and I am a social worker on the unit," and people go around the circle identifying themselves. The leader allows that the group members will reintroduce themselves each time someone enters after the group starts. The leader announces the group rules.


Group Rules

The following are the minimal group rules that are used in this model of multiple family group therapy:
1. What we talk about is to be confidential. It is a small world and you never know who you will bump into and whom they know, for trust to develop in the group, members are asked not to talk to anyone outside of the group about the other families' business. Staff will communicate with each other about the group as part of treatment.
2. Family members and significant others are asked not to have any alcohol or drug use before coming to the group.
3. Members are asked to pay attention and give respect to each other when the other has the floor, with no side conversations. The meeting is emphasized as not to be used as a visiting hour but as a serious working group. If inpatients are interrupting and out of line, they will be issued one warning by the leader or staff present, and will be given consequences the second time there is a need for a warning.
4. Members are encouraged to share in the group. When a family is working on its identified issue, it is a rule that members of the group outside of that family cannot tell anyone in the family what to do or not to do, but to frame any interaction in the form of their sharing a similar experience of their own. When people come together to share of themselves, their feelings, their own personal insights, their sharing can be just as helpful and sometimes more helpful to each other than any therapist, doctor, or staff member. This rule is the same that is used in psychodrama groups. It is also emphasized that the group leader will from time to time, be directive and will be telling group members what to do as part of the therapy.

Obviously, families will be briefed about the group procedures previous to their attending and significant family members and others are encouraged to be included. Estimated time of the group is from 2 to 3 hours long depending on how many families attend. If an inpatient does not have his/her family present, he/she comes to group anyway, and is encouraged to share his/her perception of their family.

After the group rules are announced, each family is told to gather together and decide amongst themselves what family issue they will identify for their family to work on. They are given 5-10 minutes to come up with their issue. Each family voluntarily takes its turn as the group focus, and the group proceeds until all families present get their turn. When it is a family's turn, the group leader that is that family's identified family therapist leads the intervention with the family in the fishbowl. As each family works on their issue, the group leader encourages members of other families to share with the family similar experiences, feelings and insights. He/she also can give each family member homework to help the family make structural changes.


Role of the Group Leader

The group is open ended, based on the current patient population which will change from week to week. The leader does not have the luxury of an ongoing group process with the same group members and families to evolve into their functional roles and behaviors. Each group is its own existential entity. some families will have just one exposure to the group, and others from two to three groups. Consequently, this model presents the group leader as active, directive and as an authority figure. The leader is analogous to being a doctor on a M.A.S.H. unit, i.e. he/she has got to do it now, do it fast, and do it right. You might have no tomorrow.

A primary function of the group therapist is to get the family members from a point of talking about their problem to experiencing the problem and solving it uniquely. Psychodrama techniques are freely used to get people interacting. Role playing, enacting and reenacting situations, modeling, role reversals, back to back talking, talking to the empty chair, sculpting a family at home, setting up a genogram, taking a trip, among others, get people ito what happens between each other. Encouraging members to refrain from talking about a family member to saying things directly to each other is a primary intervention. Changing how people choose to seat and posture themselves (e.g. getting a teen in an enmeshed family to get out from sitting between the parents) is another experiential intervention.

The group leader encourages members to take responsibility for their feelings and behaviors. He/she corrects people when they externalize blame, or make statements such as "...he makes me feel this way," to making 'I' statements such as "...he does so and so, and "I" feel this way." In particular, the group leader helps the family member understand that it is a particular behavior that he/she does not like and not that a person is disliked. The leader encourages the member to get in touch with ambivalences through role playing each side of the ambivalence to discover that they have choices and different positions on issues. For example, a member can be encouraged to argue out in a role play a habitual problem solving technique that is losing its effectiveness with a new technique to give the new one some credibility.

The group leader encourages members from other families to help the family in the fish bowl by asking them to share any similar experiences and how they have resolved or not resolved their dilemmas. Often people with problems feel all alone and this sharing provides them with a feeling of belonging and not being alone. It is important to stop a group member from telling a person how to do something (and coming from a position of know it all and authority) and to teach them how to use their experiences as a way of connecting as equals. It is much better to offer an experience as a peer and have expertise given to you by others then to bestow it on oneself.

In this model, there is some allowance for self disclosure by the group leader, both as a way of being a role model of sharing to others, and as a way of humanizing the leader. Self disclosure is used only with self material that is familiar and safe to the therapist and is not used as a means of making the therapist superior to the group members, or as using the group to work out his/her own issues. It is the art of therapy to use relevant self disclosure as a form of joining with the client to help that client create his/her own solutions.

The group leader, most of all, needs to be supportive of and affirm each family's abilities to be positive and to have its own problem solving skills. People need to be encouraged to remember what has worked for them, and what good has taken place. Matthew Selekman's miracle question is often asked, "If you woke up next morning and a miracle was to occur what would it be? and how would you work it?" Michael White's technique of externalizing problems by asking "How good are you at inviting your parents to accept responsibility for your life: "or" Are you ready to run your life or will you let your habits do it for you?" Framing questions in this manner supports the individual to become his/her own change agent.

All in all, multiple family group therapy can do many things for distressed families. In the group, individuals share information, experiences and perceptions, which can be empowering to those who feel insignificant, increasing their self esteem. Hopefully, with the participation of many different family members in the group process, there is a decrease in the myth that the child is sick. A common goal of families is to work on their communication and to make it more clear. People begin to recognize the different levels of communication, to listen better, to look at the other and talk directly to him/her, and to check out unclear messages. With the different generations there to share, there is a demystification of what parents talk about, or what kids talk about. The therapist as well as any family member can serve as active role models and can show others skills in communicating. Often, there is a consensus about what behaviors are acceptable or unacceptable.


What the Patent's Experience

For the patient's, the multiple family therapy group provides the experiencing of their peers in their families. They get connected to each other in a real way and their families are not abstractions. The peer who talks about his relationship with his father to his co-patient is talking to a person who has experienced being with the father in the multiple family therapy group and has his/her own perceptions to share. The multiple family therapy group gives the patients and staff a focus to work on during the week after the group. The patients also have seen staff work together as authority figures in the group alongside their parents and hopefully begin to allow them more credibility (both staff and parents).


What the Families Experience

There is usually one major theme that occurs in each group. It may be alcoholism and enabling, mothering, abandonment, blended families, handling anger or grief, or how families deal with the separation-individuation needs of the members, etc. What they find is a multiplicity of solutions and that they are not alone. People discover that they don't need to be as isolated as before and that though their family is unique, it struggles with the same issues as other families, sometimes no better or worse. And a great feature of multiple family therapy group is that surprises occur. A boy who is angry and hates his dad, might connect to another boy's dad in the group. The interaction between the boy and the other's dad might free up an avenue of communication that had not been there before between father and son. A mother might reveal something of herself to another mother in the group that she never would have shared with her family and therefore gets to show her family another side of herself. Sometimes these small miracles happen.

Assigning Homework

From the here and now interactions of family members, it is the job of the group therapist to assign appropriate homework for people to work on outside to of the group. It is optional either to assign the homework to the family when it is in the fishbowl or to assign it at the end of the group. The rationale for homework is that a stuck group needs new things to do together. Examples of homework assignments used in previous groups are:
a) For parents to work out a new list of rules, consequences, and expectations for their children.
b) For family members to experience letting go of members by burning a photograph, an old piece of clothing, or to tear up a photo and distribute the pieces.
c) For members to experience reversals, e.g. for the dad to think like a woman one night or the sister to think like a man.
d) For each member to write up the same list, for all to compare lists and discuss their views together. e.g. for all to rank the members on who is the most concerned about drugs in the family.
e) For parents of suicidal children or children who seriously abuse drugs to plan their child's funeral, in order to get them connected to the grieving process the child's behaviors bring out.
f) For parents to celebrate their child's' return home from hospitalization by hiding a gift for the child to find, (or create their own celebration).
g) To use parents' differences instead of working out compromises, e.g. odd days dad's the boss, even days mom's the boss.
h) For members who have gaps of time in their relationship to write each other a letter describing their history during the missing time.
i) For kids and parents to write lists of activities they would like to do together.
j) For people to write up ways they control their anger or depression or anxiety.
k) for members to have practice phone calls or interactions where one person talks only and the other listens for 5-10 minutes, and later the listener feedbacks what was heard.
l) for members to attend appropriate groups that can be supportive to them, e.g. AA/NA, Alanon, Tough Love, OEA, ACO
A, Parents Anon. et.al. All these assignments and others provide the family with therapeutic rituals from which they can improve their functioning.

Training and Supervising

For the therapist, multiple family group therapy is a good opportunity to train others. When nursing staff attends the group, they get a perception of the identified patient as more than what they see in the hospital milieu, experiencing the child-in-the-family. They are also more able to deal with families at visiting hours because they are connected to each other as part of the multiple family therapy group. Nursing staff can learn family and group dynamics from the group leader and can also share their expertise in child care with parents. For family therapy students and interns, the supervision relationship includes the sharing of the group process. Students become collaborators with their supervisor reducing some of the hierarchy of supervision. The supervisor is in the group as a safety net to help and supplement the intern's interventions. The intern and the group leader-supervisor can share that each is not stuck with a family, i.e. they have each other as well as nursing staff as well as any group members who exerts leadership to share the "therapeutic" burden of being helpful.

Nicholas A. Belsky is a Psychiatric Social Worker at the Cheshire Medical Center, Adolescent Mental Health Unit, located at Keene, New Hampshire and he maintains a private practice providing individual, family and group treatment to adolescents and their families. He attends the social work Doctoral Program at the Boston College School of Social Work. Nick is married and has three children.

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