Multiple-Family Therapy:
A Model For Social Worker's
At Children's Homes

©1994 By John Howe MSW, CCSW

I. What Is It?
Multiple Family Group Therapy (MFGT) involves working with a collection of families, including the families identified patient, in a group setting. It combines the power of group process with the systems focus of family therapy. MFGT is ideally suited to working with families facing similar problems i.e. schizophrenia, chemical dependence, domestic violence, sexual abuse, having a child in out-of-home placement, etc.

II. Why Do It?
A. More Curative Power
Quite simply because MFGT is more powerful, supportive and empowering than single family therapy. A multi-family group offers the following curative factors usually not present, or not present as strongly in single family therapy:
1) universality - in a group the family learns that they are not alone, other families have similar problems and concerns;
2) hope - the group can give families hope as they see other families learn, change and grow and as they receive support and encouragement from other families;
3) empowerment - as families find themselves able to care for and help other families, they increase their own sense of competence and power;
4) support/acceptance - the group becomes a support network where families can feel accepted just as they are - flawed just like all families - and friendships develop between families that continue outside of and beyond the group;
5) imitation learning - families learn through identification with other families and through modeling behaviors observed in other families (more on this later);
6) experimentation - the group becomes a safe place to experiment with, practice and get feedback on new skills and ways of relating before using them in real life; and
7) increased commitment to change - by attending and involving themselves in group families are publicly committing themselves to change and exposing themselves to subtle social pressures and personal dissonance pressures that encourage change.

B. More Avenues for Learning With Less Resistance
Additionally, MFGT offers a family more avenues for learning and growth, with less resistance, than they would get in therapy by themselves. Families come into family therapy with their resistances to each other well established and we all know about the resistances inherent in the therapist-client relationship. In MFGT family members can "see" themselves in other families and learn vicariously through observation and modeling without the resistance a direct approach often entails. Identification with members of other families who share the same family role or issues also takes place overtly through direct sharing and support. This allows for learning between peers as opposed to from the therapist which again involves less resistance and tends to be reciprocal and empowering to both. Also, family members often "hear" from someone else -usually a person sharing the same or opposite role in another family - something they can't seem to hear from a person in their own family. And, again, this takes place on a peer to peer level with the benefits already noted. Finally, MFGT simply involves more people than single family therapy which translates into more points of view, more observations, more experiences, more opportunities for relationships and more opportunity for connecting with someone from whom you can learn or something you're ready to learn.

C. Therapist Ease and Economy
MFGT, because of the shared experiences and boosted learning mentioned above, is also in many ways easier for the therapist than working with a single family. Much of the therapeutic work is done by the group members. It is also more economical, allowing a therapist to see more families in less time.

D. Smoother Transition to Self-Help and Other Support Groups
Finally, participation in MFGT is good preparation for and helps families or family members transition into participation in ongoing self-help support groups such as Parents Without Partners, Tough Love, CHADD, Al-Anon, Nar-Anon, Al-Ateen, Alcoholics or Narcotics Anonymous, etc.

III. How Do You Start A Multiple Family Therapy Group?
A. Selection and Recruitment
1. Who should attend?
Multiple Family Group Therapy was initially developed by Dr. H. Peter Laqueur in his work with hospitalized schizophrenic patients in the 1950's. Since then it has been used in working with chemically dependent persons, with hospitalized psychiatric patients regardless of diagnosis and with families troubled by domestic violence and/or sexual abuse. In reviewing the literature on MFGT with these populations the following contraindications were found:
a) actively psychotic members should not be included in group,
b) families within which explosive violence is common and where family members have either not owned the problem or not evidenced an ability to control the violence should not be included,
c) families with sexual abuse where the family is not ready to deal publicly with it should not be included, and
d) currently intoxicated family members should not participate in group.

The common threads seem to be that individuals who would be disruptive to the group or dangerous to others in the group should not be included and that families who are not ready to publicly deal with a problem, where that problem is the focal point for the group, should not be included. Other than these there are few apparent contraindications to participation in MFGT.

MFT groups tend to be composed of families facing similar issues or problems but not to be selected based upon other variables such as race, socioeconomic status, diagnosis, family constellation, etc. Homogenous issues - chemical dependence, having a schizophrenic family member, having a child in out-of-home care, etc. - and heterogeneous make up seems to be the standard approach.

Groups do differ in terms of who from the family is included and in how many families are included in the group. Typically at least everyone living in the home with the identified patient is included in the lable "family" and invited to group. However, some groups have also included other concerned and involved family members or relatives not living in the home and some groups have included anyone else who is concerned, involved and willing to make the commitment to attend. We have typically invited everyone living in the home with the youth in care but have also in specific situations extended this to include others - relatives and non-relatives - where they appear to play a major role in the "families" functioning. So far for us this has included grandparents, aunts, cousins, fiancés, mothers' boyfriend and foster parents. We do not include both divorced parents and their new spouses or love interests together in the same group (we tried this and found the situation too tense to be productive) but have involved the ex-spouses alone and the new couples in separate groups.

The age of participants can be a factor. We have experimented with allowing small children and babies in-group. When the group is small and there are only one or two small children this does not seem to create major problems although there are distractions. However, when the group is large or the number of infants and small children large the distractions become too great for productive group functioning. Based upon this we have set our minimum age for participation at eight, finding this creates minimal problems.

2. How do you recruit families?
Most agencies offer MFGT consider it to be an essential element in their overall care or treatment program rather than an adjunctive service for family members. Based upon this families are involved and expectations for their participation in MFGT are set from the beginning of an agencies contact with the family or identified patient. The earlier in care the family is recruited the better the likelihood of their agreement to participation in MFGT.

In recruiting families we stress that their involvement is essential in order to maximize the chances for successful treatment or care for their child. When families are not involved treatment or care is less successful. Also stress that you need everyone's input in order to get a clearer idea of the problem's. Always ask to speak directly with any family member reluctant or refusing to attend. For the approach our agency uses see the handout entitled - Rationale for Family Program.

B. Structuring and Staffing
1. Group Size
Groups either reported in the literature or that we are aware of have ranged from four to five families to the group to one program that runs a group with an unlimited number of families involved. The
norm seems to be four to seven families per MFT group
. We have done group with as many as 13 families but the four to seven range seems more workable. This creates a group large enough for the curative factors noted above to become operational yet small enough to ensure that each family has the opportunity for group attention and involvement.

2. Frequency and Length of Group
The
norm here seems to be weekly meetings 1 1/2 to 2 hours in length. We do know of programs that meet once weekly for a full day and programs that meet all day for a full week. Due to time and distance constraints on our families, We have chosen to run our groups only once a month on a Saturday. On this day we do two two hour groups with a break for a potluck lunch in between. Additionally, we supplement our groups with individual family sessions as needed.

3. Setting
You need a room
large enough to have space in which to move around. Individual, moveable chairs are preferred to couches, love seats, etc. A circular seating arrangement with each family sitting together is best.

4. Open vs. closed Groups
The
norm here seems to be open ended groups including families at various stages in treatment in each group. With this approach new families coming into group are socialized to group and to the systems approach by "older" families who are familiar with group process speed the new families involvement in group and readiness to work. Also with this approach new families are able to see and hear about other families at various stages of recovery and to celebrate in the successes of families who are preparing to leave group. This can increase the new families hopefulness about the possibility for positive changes in their own family. Additionally, this approach allows new families to begin group right away without having to wait for a new group to form before they can begin. We have chosen to use the open ended approach.

5. Staffing
The
norm here is for co-therapists as opposed to single therapists although this is more costly for the agency. This is the approach we have used. As with any co-therapy it is necessary for the therapist to agree upon how they will work together. We typically have one therapist responsible for leading the group with the other therapist in an observer and support role available as requested by the lead therapist. They trade off this role from group to group. However, as each therapist has families that they are assigned to as the primary therapist, when this family is working the primary therapist does the work with the family, even if they are not the lead therapist for that session, and the other therapist plays a support role.

C. Starting UP: Forming and Norming
The first priorities when starting a multi-family group include orienting the families to the purpose of group and how group works, establishing a bond with the parents (if one of the children is the identified patient) or the spouse/significant other (if one of the couple is the identified patient), helping the families get to know and become relaxed around each other, and establishing a therapeutic atmosphere
. The latter involves creating a climate of concern, confidentiality, trust, acceptance, respect and fun. As the group evolves so will its work/change ethic

Please refer to the handout of our orientation material including our rules for group. (For copies email John.) We started our group with a morning orientation for parents followed by an afternoon of outdoor group challenge activities for all the families designed to get them used to interacting with each other and working together. During the morning of our second session we oriented the residents and their siblings separately from their parents while we did a sharing activity with the parents designed to help them get to know each other and to get them used to sharing moderately intimate material with each other. That afternoon we continued our outdoor challenge and group building activities with all the families. The third session we did an inner circle/outer circle sharing exercise around feelings about placement in the morning and played favorite family games in the afternoon. By the fourth session we were ready to begin actual family work. Over the course of these sessions our staff modeled, taught and stroked behaviors consistent with our group norms.

IV. How Do You Run A Multiple Family Therapy Group?
A. Therapist Role
The therapist role in MFGT is very much like the therapist role in any group therapy. Because most of the therapy and benefits of MFGT come from the group itself, the therapist overriding responsibility is the development and maintenance of a healthy functioning group. This is an ongoing process requiring a knowledge of the stages of group development and of group process. Once actual family work begins the therapist also has the usual therapeutic responsibility of facilitating this process but does so with the added resources of the group. It is because of this dual focus, one on developing and maintaining the group and two on doing family therapy, that having a co-therapist can be so valuable in MFGT.

B. Stages of Group Development
1. Forming
2. Storming
3. Norming
4. Performing
5. Transforming

C. Steps of Any Given Group
1. Social/Warming UP
2. Problems/Focus Selection
3. Working
4. Summarizing/Wrapping UP
5. Recapitulation of 2-4
6. closure and Wrap-Up for Session

D. Recurrent Issues/Anxieties in Group Interaction
In or Out (Belonging)
Top or Bottom (Control/Influence)
Distant or Close (Intimacy)

E. A Model For Thinking About Therapist Interventions in Group (modified from the work of Arthur Cohen and R. Douglas Smith in The Critical Incident In Growth Groups)

1. Levels of Therapist Intervention
Individual
Interpersonal
Individual Family (or Family Segment)
Between Families (or Segments of Families)
Group

Treatment goals focus on helping an individual family function better; however, because you are working with a multi-family group, you also have the goal of establishing and maintaining a functioning group. This requires that many of your interventions, especially early in the development of the group, be focused at the group and between families levels. also, to maintain a working group, it is important that after working with any subset of the group that you allow processing - comments, observations, etc. - by the whole group.

2. Types of Therapist Intervention
Conceptual - verbal, meaning offering interventions such as clarifying, summarizing, interpreting, reframing, story telling, teaching, etc.

Structured - assigning or creating a specific activity or task as a vehicle for discovery, learning or practice of a skill such as a yes/no dialogue, a role play, setting up an enactment between family members, etc.

Experiential - (therapist use of self) self-disclosure of personal experiences triggered by what is happening in group or giving personal feedback to an individual, family or the group as a whole designed to encourage disclosure, intimacy, sharing or growth.

3. Intensity of Therapist Intervention
Low
Medium
High

Intensity is defined as the intended impact of the intervention not its actual impact. The intensity level is determined by the degree of intended confrontation. The most intense interventions are usually experiential interventions directed at the individual level. The least intense interventions are usually cognitive interventions aimed at the group level. The chosen intensity level of a therapist intervention depends on the stage and climate in group, the quality of the therapist relationship with the individual, family or group and on the history and success of prior interventions. Generally the earlier in the development of the group and the earlier in the relationship the less intense the chosen intervention. As the group enters the working stage, as relationships become more trusting and genuine and the degree to which less intense interventions haven't worked the chosen intensity of interventions tends to increase.

4. Choosing an Intervention

a. Context
What stage is the group in developmentally?
At what point in this session is the group?
What is the group climate?

b. Specific Events, Issues and Anxieties Requiring Choice
What specifically is happening?
What group issues are involved? Overtly? Covertly?
What family or individual issues are involved? Overtly? Covertly?
What are the families goals?
What is your strategy for achieving these?

c. Intervention Chosen
Level
Type
Intensity

d. Outcome of Intervention

5. Therapy is an art not a science, we each develop our own unique styles and each family and multiple family group has its own unique flavor so doing MFGT cannot be reduced to a formula or do this/do that instructions. However, we can offer some suggestions.

Deal with group issues before family issues.

Deal with family issues before individual issues.

Use less intense interventions early in group and early in your work with a family.

Use the least intense intervention necessary to achieve your goal and make sure you've joined before you challenge.

Use the group and the family. If possible always get another family member or a group member to say or do something rather than saying or doing it yourself.

Keep the parents in charge of their children in group. Ask them to deal with problems or to give help if needed.

Do model, actively teach and stroke behavior consistent with your group norms and tactfully and caringly challenge any behaviors contrary to them.

Always keep missing family members (those not present in group) in your and the families awareness through the use of empty chairs, stand ins, etc.

F. Therapeutic Activities Unique to or Ideally Suited to MFGT

1. Fish bowling (all traditional family therapy techniques - sculpting, drawing, role playing, enactment's, etc. - can be done inside the fish bowl and be observed and processed by the group).

2. Inner Circle/Outer Circle (a between families intervention allowing members from different families who occupy the same family role to interact together while being observed by the rest of the group who then is involved in processing and responding to this interaction).

3. Interfamily Role Play/Enactments (a between families intervention allowing members from different families to interact together as if they were in the same family).

4. Reflecting Team (an experiential intervention allowing the therapist to talk together and make observations about the group and the families involved in it).

END

 

John Howe is Director of Youth and Family Services at Youth Homes, Inc., Charlotte, NC.

He and his team of four Social workers at Boy's and Girl's Homes at Lake Waccamaw in NC, (John Howe, Bill Morrison, Becky Wray, Stokes Smith and Jimmie Tutor) pioneered this model for ten years.

The MFGT Resource Center has a two hour videotaped interview with John and his Social Worker Team. For information email the resource center.

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