We have described various individual therapy approaches in which the patient’s or client’s descriptions of relationship and interpersonal problems are explored. However, there are a number of therapies that work directly with these problems, not just through the patient’s recall. Some, such as couples and family therapy, directly involve all the individuals affected. Group therapy offers direct opportunities for feedback in interactions with others, with constructive challenges in the here-and-now on how to go about things differently. There are also more interactive therapies such as art and music therapy, which can be provided either with groups or individuals. These particularly suit patients who are less clear about what their problems are, or who might struggle to express them verbally.
There are countless variations of these more active therapies. In this chapter we will describe the practice of systemic family therapy, couples therapy, and group therapy, which are now widely established. We will also briefly introduce the practice of psychodrama, art therapy, and music therapy.
Freud is all nonsense; the secret of neurosis is to be found in the family battle of wills to see who can refuse longest to help with the dishes.
Julian Mitchell, quoted by Robin Skynnerin
One Flesh, Separate Persons
We are all born into ‘the hands of others’, the cradle of the family. Salvador Minuchin, an influential early family therapist, describes families like this:
In all cultures, the family imprints its members with selfhood. Human experience of identity has two elements: a sense of belonging and a sense of being separate. The laboratory in which these ingredients are mixed and dispensed is the family, the matrix of identity.
Robin Skynner wrote that the best way to learn how to create a happy and healthy family was to have been born into one. That way we learn how to ‘find satisfaction in harmonious relationship to one another’. Aware of the enormous creative potential of the family it is not surprising that, when it becomes disordered, it possesses an equal potential for destruction.
Family therapy is often used when the referred patient is a child or adolescent. Originally, family therapists perceived the child’s disturbance more as a marker of a family disturbance, but this is no longer necessarily so. A referral for family therapy does not imply that the family is considered responsible for the patient’s problems, more a recognition that severe emotional problems can, and do, involve everyone in the family. For example, the families of younger patients with anorexia nervosa are usually offered therapy, and this has been found to be helpful. Nobody really knows what causes an individual girl to become anorexic, but a severe, life-threatening illness in a young person is bound to disrupt any family. Few who work with anorexia nervosa believe that the family ‘causes’ anorexia, and the therapy is aimed at finding ways to cope with the disorder for all involved.
The same would apply when the identified patient is seen by an adult mental health team, whether dealing with the painful consequences of a psychotic disorder in a member of the family or when an ‘adult child’ has become ‘stuck’ at home.
When families are struggling to find a healthy balance, systemic family therapy offers them an opportunity to take a step back and think together. It provides a chance to review patterns that might have become fossilized and find ways to renegotiate and change them. Family therapy aims to understand and intervene in the whole relationship context, rather than just with the problems of the member initially identified as the patient. Freeing up patterns at an early stage can bring prompt relief for all involved. Such freeing up can also prevent family members being burdened with restrictive family ‘scripts’ or myths.
Family therapy aims to improve the family’s capacity to communicate clearly and openly with one another, exposing it to new perspectives and ideas. It is not so preoccupied with specific solutions for specific problems—problems arise constantly in all families—but with changing the family’s style of interacting and operating. Family dynamics are immensely powerful, so the therapy aims to channel this energy in a more healthy direction. Clarifying communication clears away obstructions to the developmental stages that all families have to go through, and so allows its members to grow and move on.
Family therapists are very active and use a number of tried and tested ‘tools’. One is the genogram (see ). This is a family tree, usually drawn up at the beginning of therapy. It outlines diagrammatically all the family members and their relationships to each other, and usually covers the last three generations. This helps the family see itself in context and with a wider perspective. Intergenerational patterns can emerge with startling clarity in this shared exercise.
Examining the genogram helps the family and the therapists to undertake what is called a script analysis. This is rarely done in a particularly formal manner, but involves working out the rules, spoken or more often unspoken, that govern how they relate. Four family ‘scripts’ are usually identified: the circumstantial script is what all the members know about their family history, and on which they base their overall behaviour; the assumptive script describes beliefs about, and emotional attitudes towards, their roles, both within the family and in the outside world; the delivered script is what they actually say to one another, the words they use to convey these assumptions; and finally the subscript is what we hold back from expressing, whether deliberately or not. This nevertheless continually affects our interactions, and all the more powerfully so for being unspoken.
In family and group therapies the participants are both agents and observers. So while the mother and her son Simon may be at loggerheads in a session over his recent truancy, the father and his sister Naomi observe how they constantly interrupt one another, ramping up the tension despite their best efforts to calm the situation down.
Collaborative team working is another striking feature of systemic family therapy, usually with two therapists working together. In some settings other members of the team may watch from behind a two-way mirror, even phoning in advice to the therapists! Obviously this only happens with the full agreement and consent of the family, and mainly in training settings. However, it demonstrates a remarkable break with psychotherapy’s usual insistence on intimacy and confidentiality. So why does it happen? Family scripts can be inordinately powerful, with a whole set of well-entrenched routines devoted to keeping things as they are. It takes intense, concerted effort for therapists to get into this system enough to obtain a good grasp of it. Yet they also have to remain something of an outsider to be able to ‘shake it up’ and create new experiences and a space to reflect. Conjoint work ensures that therapists can be both agents and observers. It also means that their working relationship can model more constructive and less defensive ways of interacting, such as when they ask each others’ opinions or discuss their different experiences of what is going on.
Family therapists demonstrate a stance of neutrality by seeking out the views of each family member and taking them equally seriously. They often use a circularity of enquiry, turning to each member of the family individually as well as addressing the family as a whole. In the mother and son scenario outlined above, the therapists might try and loosen the stalemate as follows:
TO FATHER: How do you think your wife feels when she’s going on at Simon?
TO SIMON: While you’ve been having these school problems, have you noticed any other changes in the family?
TO NAOMI: What do you think happens to Simon when he has these rows with your mum?
TO MOTHER: If this were a stage with characters in a play, where do you think Naomi feels herself to be at the moment?
TO THE WHOLE FAMILY: What are things like for you as a family at the moment? How would you like it to be? What would you each need to do differently to get there? Who would be most likely to try it out?
Here we can see similarities with solution-focused therapy, and many aspects of family scripts have an overlap with the reciprocal roles of CAT (see ). In common with most psychotherapy approaches, therapists aim to help reframe difficulties. Family therapists are known for their irreverence and tend to do this in a playful manner, where family members often find themselves laughing out loud. The aim is to show that rather than keep repeating ‘more-of-the-same’ sequences, things can be done differently, while not trying to achieve any ‘right’ way to do them.
Many things happen all at once in family therapy, and each member may have a different experience of it, so family therapists often write therapeutic letters in which they summarize what went on in the session. With the agreement of the family, these letters can also be a way of involving and communicating with other systems engaged with the family, such as school or a nursing team. This is particularly important as other professionals may inadvertently be maintaining or exacerbating a family’s difficulties. Their responses, while entirely well-intentioned, may get in the way of change. A school nurse trying to support Simon by allowing him off lessons might need to understand that him telling his mother each evening that he had been in the sick bay was getting in the way of them getting to the root of their difficulties. Systemic work sometimes involves bringing more distant family members or other professionals into the sessions.
Couples and marital therapy are more commonly available than family therapy. RELATE (previously called the Marriage Guidance Council) is best known in the UK for this, but almost all countries have similar organizations. The approach is very similar to family therapy, although it is not so common to have two therapists. Where there are, they are usually one man and one woman, and their collaboration in the sessions acts as a potent modelling experience.
Problems in relationships can have their roots in difficulties each partner may have had earlier in their lives. Institutions such as the Tavistock Centre in London employ a psychodynamic approach to understanding how this impacts on the couple in the present, but couples therapy usually restricts itself to altering the style of communication and focuses more on the present and the future. Couples, like families, have no shortage of grievances about each other, and the therapy has to get beyond the ‘blame game’. The therapy often uses homework exercises—‘get a babysitter, go out to somewhere you like, just the two of you’—to review in the next session. Sometimes prescribing what not to do is more important: ‘talk for an hour planning a holiday together without mentioning the last two disasters’. This approach is used extensively in sex therapy, where prohibiting intercourse for a set period can remove inhibiting performance anxiety or prevent tensions building up. This can free up the warmth and intimacy that is needed for eventually making love and enjoying it.
As its name implies, group therapy involves several people together. Unlike family therapy these individuals do not generally know each other before coming to the group. Groups usually consist of between six and eight members plus the therapist (two co-therapists is quite common). They meet in the same place at the same time, usually for about ninety minutes once a week. The emphasis is on what goes on in the group, and members are asked not to meet outside. If they do meet (which almost invariably happens), they should be sure to report it back.
Group therapy is traditionally composed of individuals with a range of problems—anxiety, depression, phobias, relationship difficulties, etc. This range of problems and individuals (men and women, different ages, varying life experiences) makes the group a microcosm of ordinary life. It means that the full range of possible difficulties and conflicts is likely to occur in the group over time.
Therapists have to balance the diversity needed to provide a rich experience with ensuring that the group members have enough in common to gel. It is particularly important not to have one or two members who are clearly outliers. You don’t want a single retired member in a group of twenty-year-olds, or someone with a dramatically different level of education or income to the rest of the group. It should be a spread of life-experience, not a random hotchpotch.
Not all groups are drawn from such a diverse population. Groups are also used extensively for individuals who share a similar problem such as eating disorders, addiction, or depression. Their advantage is that they can learn about different ways of coping. They are very supportive, as members realize they are not alone with their difficulties and can identify with each other’s struggles. They can also be challenging, as members will know all the tricks and be able to confront the person using them.
Group analysis applies psychoanalytic principles within the group. This involves a blank screen therapist who interprets emerging themes in terms of unconscious processes, including an exploration of group transference. It was one of the earliest group therapies, and established the basic expectations. These include the size of the group, with members sitting in a circle so that they can easily see each other, the duration of therapy (usually between one and two years), and the concept of what is called a slow-open group. Only rarely in analytic groups do members all start and finish at the same time—most join ongoing groups. As well as being practical, this has several real advantages for patients, such as being able to observe how other members deal with the end of their therapy before doing it yourself. Turnover needs to be modest so that group members can gain trust in each other and have the opportunity to pursue issues for a decent length of time.
Overall, however, the only predictable feature of group therapy is that it involves a group of people. Other than a belief that more can be learned by sharing and in the importance of confidentiality and boundaries, there is no single theory or set of rules or practices. Groups can range from an analytical group for well-heeled intellectuals through to structured CBT groups for psychopaths in high-security prisons. Having said that, most group therapy encompasses a common set of processes.
Irvin Yalom, a leading exponent of group psychotherapy, identified three underlying assumptions in group therapy. First, the central importance of interpersonal relationships for a robust sense of self. Second, that we can develop less distorted and more gratifying relationships through corrective emotional experiences. And finally, that the social microcosm of a group provides an ideal setting for relearning. As in life around us, group members will sooner or later recreate the same interpersonal universe they have always inhabited. A patient, abandoned by her mother and adopted into a high-achieving family with two children, had always felt of less value, that she was never going to fit in or be good enough. Finding it hard to trust relationships, she attacked them, creating the very rejection she feared. On joining a group she was antagonistic, instigated rows, and was often on the verge of leaving the group. Only this time round she was able to observe and change old patterns by using feedback from the other group members.
Group therapy offers an opportunity to get a better alignment between how we see ourselves and how we actually come across and are experienced by those around us. As Robert Burns put it, ‘Wad some power the giftie gie us, to see ourselves as others see us.’ A corrective emotional experience requires a new experience which is emotionally vivid, and where the emotions are clearly expressed. In a safe and supportive group feelings like anger or dislike can be expressed and feedback given honestly and openly. The ceiling doesn’t fall in after all, the anticipated catastrophe does not materialize, and relationships are not destroyed. The second, and crucial, aspect of the experience is its cognitive processing, when group members can reflect on it. It is not enough just to feel something strongly, we need to make sense of the experience and see how it could change our future relationships.
Yalom also outlined several specific therapeutic factors in groups. These vary for different group members and over time, but tend to reinforce each other. Group cohesiveness is the foundation on which the group work rests. It corresponds to the therapeutic relationship in individual therapy, but includes the relationships of group members to one another, with the therapist, and also to the group as a whole. It is what makes the group attractive and keeps members attending, especially during the unfamiliar early phase. It makes the group feel comfortable and welcoming, similar to Carl Rogers’ unconditional regard. Therapists and members have to work to sustain it. For the young adopted woman it made all the difference that she was warmly welcomed, was helped to say something about herself early on, and was not interrupted. Most importantly other group members found what she said helpful and told her so.
Upon this solid platform rests a range of therapeutic factors. Installation of hope arises from seeing that others with similar problems seem to be overcoming them. Universality is the sense that ‘we’re all in the same boat’. It reduces loneliness and shame, giving a sense of belonging to those who might otherwise withdraw from social contact. Imparting of information, such as the physical consequences of their habits in an eating disorder group, can make a surprising difference. A lack of basic knowledge and uncertainty are much more common than we often assume, and they make us anxious and less able to cope. The act of giving advice or information also demonstrates that others have our well-being at heart.
In groups, therapeutic activity does not originate from the therapist alone, but occurs naturally between group members. The sense of altruism this generates can be particularly therapeutic, as group members find they have something to offer others rather than constantly feeling like they are a burden. Collectively, these processes enable members to share events and feelings they have rarely, if ever, told anyone about. Making such revelations can constitute another therapeutic factor, the cathartic experience.
Group members invariably bring old family conflicts and historical preoccupations into the group (see ), but the power of the group lies in the melting pot of the here-and-now. This is where the real interpersonal learning takes place. It is here that members become aware, through feedback and self-observation, of what they do to others and how, in turn, this rebounds on them. It is also where people can learn to see that they have the power, and ultimately the responsibility, to do something about it.
It’s not all hard work. The group is a place to experiment with new ways of being and relating to others. These can be discovered by simply imitating others or by becoming aware of new feelings and ideas in the group. Groups provide an unparalleled opportunity to discover new and surprising aspects of yourself and your abilities. Simply accepting an offer of a tissue when talking about something upsetting can be liberating, just as finding yourself doing the same for another group member can be cathartic.
The group therapist will always return the attention of the group to the here-and-now, to the purpose of the group, and to the reason why each member is there. In addition to attending to what is being said, he will notice how things are expressed as well as enquiring into the why. With his experience the therapist also listens out for what is not being said or is being avoided, such as competitiveness or envy.
The therapies we will outline here occupy a special place in health services. They are all registered therapies, but in practice they often straddle the boundary between psychotherapy and a therapeutic activity. They may lack the specific characteristics of psychotherapy, such as an explicit agreement between a therapist and patient on the specific problems of an individual, and a relatively formal and tailored plan based on a detailed assessment. Obviously this is not a hard-and-fast divide—many psychotherapies are fairly open-ended in their initial goals, and individuals often discuss in detail what they want to gain from drama or music therapy, especially if provided in specialist settings or in private practice. In our experience however, it is rare for these therapies to be offered or sought independently of other treatment programmes within general mental health services.
Psychodrama was initially created by Jacob Moreno in the early 1900s. He was equally frustrated with the overly formal, analytical approach of psychoanalysis, and with the strictures of the drama and theatre of his day. He stressed the need for spontaneity and improvisation to explore internal conflicts and painful memories, and to resolve unfinished business. Although it is group-based, psychodrama is essentially an individual approach, with one protagonist taking centre stage in each session. The group members are allotted different roles—for example, someone’s powerful father figure—or act out different responses, such as one person challenging and another being more submissive. It has been widely used to explore family conflicts.
A typical session involves a number of people, helped by a ‘director’, to enable the protagonist to enact emotionally important scenarios of his choosing. After a warm-up to focus and enter a creative frame of mind, scenes are acted out. The protagonist is centre stage, but he can also invite others to take up his role (mirroring) or act as a double to put into words feelings he may only be dimly aware of, or be avoiding. Role plays and role reversals expand self-knowledge and perspective. The wind-up involves a discussion in which all the participants offer observations from the perspective of their allotted roles.
Drama therapy is a term used rather loosely to cover the use of drama to promote emotional awareness and personal growth. There have been a number of successful initiatives in prisons, as it recommends itself to men who are not used to talking about their feelings. Plays usually touch on the issues that matter powerfully to us, and often in dramatic and violent forms. Both acting and watching allows prisoners to identify with, and express their feelings through the actions of characters in a play.
Music therapy emerged in both the UK and the US in the aftermath of World War II in treatment programmes for soldiers recovering from physical and emotional injuries. It can be supportive and resource-building, but in Europe it is primarily psychodynamic, with musical improvisation at its core.
In a typical music therapy session therapist and client play together, in both senses of the word. The therapist will encourage the client to express her feelings through jointly creating music. Interacting with the therapist in this process, the client will often reveal her patterns of relating, initially with no need for words. No previous musical experience is needed. Instruments are generally provided, such as piano, guitar, drums, or xylophone, which are easy to use and highly expressive. The therapist is active and interactive, inviting an inhibited individual to exaggerate and let go of their feelings, or with others to contain and vary the expression of theirs. This can then be further explored through role play and discussion. The aim is to gain a fuller and less intellectual experience of the self, and to improve social interaction.
Music, perhaps more than any other art form, has the capacity to affect our emotions and mood. Even as infants we respond to the elements of music (timbre, pitch, volume, rhythm), and these still affect us as adults. Music’s capacity to link with our more primitive or freer responses is used to full effect in music therapy. It is commonly used to help with communication difficulties in autism and learning disabilities, in reminiscence and orientation work with adults with dementia, with those recovering from strokes, and also in child and adolescent settings.
Art therapy has its roots both in art and in psychotherapy. It is used in two quite different ways, each prioritizing one of these origins. The first relies on the healing power inherent in the creative act of simply making art. The second uses the patient’s art as the basis for interpretation in a more traditional psychotherapeutic format. What is created artistically is explored to enhance self-awareness and insight. Art therapy originally drew directly on psychoanalysis, but it became a profession in its own right in the mid-20th century. It can be used with individuals or groups.
In an art therapy session the aim is not to produce beautiful art, but rather to use a range of materials to create an image or a picture that speaks for an experience or a feeling state. As with music therapy it removes the reliance on words, but initially may have to overcome inhibitions: ‘I’m no good at art’ or ‘I can’t draw’. After the creative part of a session, time is usually spent discussing the personal meaning of what has been created or the materials used. Over time, or through a sequence of images, new meanings can be discovered or alternative feelings and identities experimented with.
All the interactive therapies we have described in this chapter make use of direct interpersonal experiences. This makes it possible to bypass some of the defences we described earlier, or at least for them to be identified and worked with at an early stage and with real immediacy.
We started this book with formal psychoanalysis, and have moved through time-limited therapies, CBT and counselling, to interactive therapies. We hope we have provided an overview of psychotherapy in its many different forms and current models. In the final chapter we will consider where psychotherapy goes next, and the challenges it faces in that process.