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Group therapy:

Group methods were developed in the early 20th century following observations of beneficial group effects in TB patients. Group therapies can be classified

according to the objectives of the group and how the group is led or managed (leadership). Highly specific target oriented groups include structured groups for drug use or alcohol use, activity groups like occupational therapy groups etc. These groups have high level of leader input. Psychodrama, music therapy, systems centred groups are some less specific therapies but are highly directed by the leader or therapist. Problem solving therapy and psycho educational groups are highly specific but have low level of therapist activity. Support groups, art therapy, interpersonal therapy and groups like Tavistock model analytic groups have low level of leader activity and have low specificity with respect to treatment goals.
Types of groups: a) Activity groups- used for patients who are unsuitable for other group activities. Focuses may be art, computing and gardening. It is mainly used in LD, chronic psychosis, and other disorders with functional impairment. b) Support groups-peer support in LD, Chronic illness and also for those caring for others. c) Problem-focused groups-alcohol dependence, drug dependency, sexual deviancy d) Psychodynamic groups-Aim of lasting change through exploratory therapy e) Behavioural groups e.g. for phobia therapy

Foulkes is considered to be one of the founders of group therapy. According to Foulkes, the network of all individual mental processes, the psychological medium in which they meet, communicate and interact, can be called the matrix. The matrix is the hypothetical web of communication and relationship in a given group. It is the common shared ground which ultimately determines the meaning and significance of all events in the group. Foulkes identified two forms of the matrix the foundation matrix refers to the commonalities that exist among a group of total strangers even before they convene to meet at a group; for example, common characteristics of the human species, language, culture etc. This is called as fundamental mental matrix (foundation matrix). To this their closer acquaintance and their intimate exchanges add consistently so that they also form a current, ever moving ever developing dynamic matrix. Foundation matrix is a precondition for the later evolving dynamic or group matrix. Yaloms curative factors: Yalom cited 11 curative' factors responsible for change in groups. The curative factors include instillation of hope, universality, imparting information (feedback), altruism, corrective recapitulation, socialisation

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techniques, imitative behaviour, interpersonal learning, group cohesiveness, catharsis and existential factors. Of these, cohesiveness, and learning from feedback are valued positively though other factors may also be important. Bions group dynamics: According to Bion, whenever a group gets derailed from its task, it deteriorates into one of three basic states: dependency, pairing, or fightflight. In dependency, members of the group become dependent on each other to elicit protection. Fight or flight reaction refers to either attacking therapist or totally withdrawing and retreating. Pairing refers to the group illusion that some miraculous rescue might take place from individual partnerships within the group. A 4th basic assumption was introduced by Hopper - called massification/aggregation where a rigid fusion of identities lead to loss of individuality, or extensive withdrawal leads to loss of mutual dependence. Group alliance refers to the quality of the relationship that develops between each individual member and the therapist. Group cohesion refers to the sense that the group is working together towards a common goal. Group coherence is a more evolved group state where the group goes beyond cohesion and becomes self evolving and able to work though conflicts. Positive identification refers to an unconscious group mechanism in which a person incorporates the characteristics and the qualities of the group. Catharsis refers to the process by which mere expression of ideas and conflicts is accompanied by an emotional response which produces a sense of relief.
Factors influencing communication in a group matrix: (Foulkes, 1964) 1. Mirroring 2. Exchange 3. Free floating discussion 4. Resonance 5. Translation The above mostly applies to a psychodynamic group setting.

Homogeneous groups include members who are comparable in age, diagnosis, background etc. Heterogenous groups include people of varying categories. Closed groups have a fixed number and composition of patients. If any group member leaves, no new members are included. In open groups no fixed limit exists for number of members; membership is more democratic and new members can come in whenever someone leaves. Psychodrama Founded by Jacob Moreno Therapeutic dramatization of emotional problems is the main principle employed. The director is the leader/therapist he/she is an active participant with catalytic function. High involvement of therapist is required.
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The protagonist is the patient with emotional conflict. An auxiliary ego is another group member representing someone significant in the protagonists life. Other members of the psychodrama act as the audience group. Soliloquy is the monologue like recital of thoughts and feelings Role reversal refers to the exchange of the patient's role for the role of a significant person The double refers to the auxiliary ego acting as the patient The multiple double refers to several egos acting as the patient Mirror technique refers to an auxiliary ego imitating the patient and speaking in proxy. The four major principles on which a therapeutic community is based are exemplified by the Henderson hospital model. According to this model, the major components are (mnemonic CPD-R) 1. Communalism (Staff are not separated from inmates by uniforms or behaviours, mutual helping and learning occurs) 2. Permissiveness (tolerating each other and realising unpredictable behaviour can happen within the community) 3. Democratisation (shared decision making and joint running of the unit) and 4. Reality confrontation (self deception or distortions from reality are dealt with honestly and openly by all members without formalities). Corrective emotional experience was seen by Alexander as the central part of change secondary to psychotherapy. Processes that take place in a therapy setting give the patient an opportunity to reflect on their past experiences and make necessary behavioural or cognitive and emotional changes to reduce ones difficulties.
Kaplan & Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry, 10th Edition. Lippincott Williams & Wilkins 2007 Gelder et al (Ed). New Oxford Textbook of Psychiatry. Oxford University Press 2000.

Family therapies: Family unit & Psychiatry: Family is essentially the most basic social unit and microcosm of an individual. Family systems have been studied in detail with respect to schizophrenia especially. Lidz studied family systems described two schizophrenogenic family patterns: Marital schism: Here a family is in a state of disequilibrium due to repeated threats of parental separation. Parents downgrade roles of each other, and may even attempt to collude with children and exclude partners. In marital skew family is at an equilibrium that is skewed and achieved at an expense of distorted parental relationship. One parent may be dominant and other submissive, making the marriage a stable fit.

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Wynne and colleagues described certain communication patterns that may relate to later development of perceptual and thought disorders linked to schizophrenia. Pseudo-hostility and pseudo-mutuality refers to the disjointed or fragmented communication where the child is forced to accept and develop a pattern of communication that will negate and deny the existence of meaningless relationships in the family. Bateson described the double-bind relationship where superficial verbal communications contradict the behavioural and deeper communications passed between members of the family. These mixed messages keep a growing child in a double bind (cannot be correct either way) which can later increase the risk of psychosis. The concept of schizophrenogenic-mother was coined by Freida Fromm-Reichmann. These mothers were described to be 'rejecting, impervious to the feelings of others, rigid in moralism concerning sex and had significant fear of intimacy'. A similar concept was popular for sometime with regard to autism where mothers were blamed to be refrigerator mothers who defrosted just enough to produce a baby but remained emotionally cold, inflexible and lacking warmth in parental relationship. This theory has been widely discussed and refuted as no proof exists to support this claim. All of the above four family functions are disputed in being causally related to schizophrenia. There is no experimental evidence to support these claims and any small data regarding the above theories are rather poorly reproducible. Social reactivity of mental illness: Social etiology of negative symptoms of schizophrenia was explored by Wing & brown. They surveyed asylums (Mapperley Hospital at Nottingham, Netherne in south London and Severalls in Essex) that existed in the late fifties and concluded that social poverty and lack of stimulation were very much related to the severity of blunted affect, poverty of speech, and social withdrawal these were termed as clinical poverty. But such relationship was found to be weak in a reappraisal in 1990. (Curson et al, 1992). It was also feared that too much stimulation could provoke positive symptoms in these patients. Thus social reactivity was seen as an important phenomenon in schizophrenia. Expressed emotions: Expressed emotions concept was developed by Brown & Rutter in 1966 as a part of the Camberwell Family Interview (audiotaped interview with carer), and later modified by Vaughn & Leff in 1976. The ratings were based on content and prosodic aspects and emphasis of speech. Five measures are considered; 1. Critical comments 2. positive remarks 3. emotional over involvement 4. hostility
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5. emotional warmth The final scores of emotional over involvement, critical comments and hostility were the most predictive measures for relapse. CFI is a long interview process where individual members of a family are interviewed (including the patient). If one relative is classified as high EE relative, the family is classified as a high EE family. It was found that ratings based on interviewing parents singly had the most predictive value. A Five Minute Speech sample (FMSS) measure was introduced as a substitute but it tends to underestimate EE. But FMSS was more useful for measuring professional or staff carers level of EE. Worldwide the proportion of high EE in schizophrenia carers is 52%. Lowest rates are found in India and other developing nations. The strength of association between relapse and EE is identical for both genders though the data on female cases is less. Major meta-analysis on EE data found that for patients living in situations rated as showing high expressed emotion the relapse rate was 50%, whereas in the low expressed emotion group the rate was 21%. In the majority of the studies, high expressed emotion was predictive of relapse in symptoms of schizophrenia 9 months later for both genders. A large amount of face-toface contact (more than 35 hours per week) with a relative with a high expressed emotion score increased the risk of relapse, but in households with a low expressed emotion score, high levels of contact appeared to be protective. Significant cultural differences exist in EE data. Hashemi & Cochrane carried out a population-based normative study for expressed emotion and found that Pakistani families in the UK were more likely to be rated as high expressed emotion than White families, indicating that components such as emotional overinvolvement may be cultural rather than pathogenic traits.
Hashemi, A. H. & Cochrane, R. (1999) Expressed emotion and schizophrenia: a review of studies across cultures. International Review of Psychiatry, 11, 219224 Bebbington & Kuipers, 2003. Schizophrenia and psychosocial stresses. In Schizophrenia, Hirsch & Weinberger (Ed). Blackwell; Oxford. Curson DA, et al. Institutionalism and schizophrenia 30 years on. Clinical poverty and the social environment in three British mental hospitals in 1960 compared with a fourth in 1990. British Journal of Psychiatry 1992; 160: 230-241.

Models of family therapies:

1. Psychodynamic models Emphasize individual maturation in the context of the family system Therapists seek to establish an intimate bond with each family member Family sculpting refers to family members physically arranging themselves in a scene depicting individual view of relationships. 2. Bowens model (family systems approach) emphasizes ones ability to retain individual self in the face of familial tension. The degree of enmeshment is analysed here.

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An emotional triangle is a three-party system where closeness of two members (in either positive or negative sense) tends to exclude a third. This hot triangle leads to symptom formation. Here therapist maintains minimal emotional contact with family members. Bowen also found a tool to analyse history of families across generations called the genogram. 3. Structural model (Minuchin) views family as a structure built of interpersonal relationships. Such a structure will have hierarchy of power (parents in charge of children), firm boundaries and rules. Families function particularly well when these family structures are intact. Disrupted structure leads to disrupted communication. Method for restoring family structure uses simultaneous individual and family therapy. 4. Strategic systemic therapy (Haley) believes that symptoms are maintained by behaviours that seek to suppress them at first place. For example, the woman with depression with low self-esteem may elicit her partner's over-protectiveness, a solution that perpetuates the presenting problem. A strategic systemic therapist uses reframing or positive connotation which is relabeling of negatively expressed feelings or behavior as positive using a new frame of reference. This is the major strategy used by narrative therapists. A domino effect wherein if one problem is properly addressed, it leads to reduction or resolution of other problems may explain the rationale behind strategic therapy. 5. The Milan systemic approach (Palazzoli) gives great emphasis on circular and reflexive questioning. In a circular fashion each family member is asked to comment and reflect on each others response. Paradoxical therapy (Gregory Bateson): Therapist makes the patient intentionally engage in the unwanted behavior (called the paradoxical injunction) e.g. avoid a phobic object or perform a compulsive ritual. This counterintuitive approach can provide new insights for some patients. Psychoeducational approaches refer to relatives being educated about the causes and course of their family member's psychiatric illness.
Asen, E. Outcome research in family therapy. Advances in Psychiatric Treatment (2002). 8, pp. 230238

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