Psychotherapy II

Notes and Important Topics

Dr. Anganabha Baruah
• What is Psychotherapy
• • Psychotherapy for Families, Couples, Groups
• • Introduction to General Systems Theory
• • Systems Approach in Family therapy
• • Minuchin (Structural)
• • Bowen (Intergenerational)
• • Haley and others (Strategic)

• Other Family Therapy Approaches

• • Narrative Therapy
• • Solution Focused Therapy
• Integrated Approach
• Applicability of Individual Therapy Model (Psychodynamic, Cognitive Behavioral,
Humanistic/Existential)
Background of Family Therapy
• Family therapy is psychotherapeutic treatment of the family to bring
about better psychological functioning.
• Freud & Other Psychoanalysts: Early childhood experiences are
structured by family
• Interdisciplinary Systems Theory: the interactions and processes of
parts of a whole.
• Early Marriage Counselling: Friends, Doctors, Clergy
• What could be some issues that required therapy back then??
• Mothers were seen as the cause of problems; less focus on the father.
• Since 1950s there was a shift from blaming parents for children’s
problems to helping parents and children relate better to each other.
• Nathan Ackerman was the initiator of family therapy as a whole unit.
• Research on Family of Schizophrenic patients revealed a lot of
behaviour patterns in families. (Double bind, marital schism and
marital skew, Pseudo mutuality)
Family Theories of life Cycle
• Evelyn Duvall’(1977)
• Joanne Stevenson (1977)
General Systemic Approach
• Family is situated within a subsystem.
• 1. Feedback Loop- Reciprocal Interaction and its effect. Each
member's actions affecting and being affected by others
• 2. Circular Questions- Indirect questions to explore the feelings,
response patterns of the other family members.
• 3.Boundaries
• 4. Intergenerational Patterns
• 5. Joining.
• General Systems Theory: a systems theory perspective, each family is a
part of a larger system, a neighborhood, which is again a part of a larger
system, a town, and so forth.
• Norbert Wiener (1948) a mathematician; computers; wrote of feedback
mechanisms that were essential in the processing of information.
• • Von Bertalanffy’s (1968) à work in biology and medicine; explored the
interrelationships of parts to each other and to the whole system.
• • When his general theoretical approach is applied to family therapy how
the family functions as a whole unit.
• • From a systems theory perspective each family is a part of a larger
system a neighbourhood, a town a district a country a continent.
• Importance of feedback and Homeostasis.
Theory of Family Systems (Murrey Bowen)
• the family’s emotional system and the history of this system as it may be
traced through the family dynamics of the parents’ families and even
grandparents’ families.
• Self differentiation (Clarity between thought and feelings)
• Triangulation (bring in a third persons to reduce stress)
• Emotional system (two people with less clarity will create conflict)
• Family projection.
• Emotional Cutoff (isolation)
• Multigenerational transmission process
• Sibling Position of the parents
• Societal regression.
Therapeutic Techniques
• Evaluation interview: understanding the triangulation, projection,
emotional system, generational patterns.
• Genogram and interpretation to see generational pattern
• Detriangulation
• Differentiation
• Emotional Connection rebuilding

• https://youtu.be/ImAJJCzILK8
Structural Family Therapy
• Structural therapy, developed by Salvador Minuchin, helps families by
dealing with problems as they affect current interactions of family
members.
• How families operate as a system and their structure within the
system are the focus of Minuchin’s work.
Concepts in Structural Family Therapy
• Family structure. rules that have been developed over the years to
determine who interacts with whom.
• Family subsystems. For a family to function well, members must work
together to carry out functions. The most obvious subsystems are those of
husband–wife, parents–children, and siblings.
• Boundary permeability. Both systems and subsystems have rules as to who
can participate in interactions and how they can participate. These rules of
interaction, or boundaries, vary as to how flexible they are.
• Alignments and coalitions. In responding to crises or dealing with daily
events, families may have typical ways that subsystems within the family
react. Alignments refer to the ways that family members join with each
other or oppose each other in dealing with an activity. Coalitions refer to
alliances between family members against another family member.
Therapeutic Process
• Family mapping. Whereas Bowen uses the genogram to show
intergenerational patterns of relating, Minuchin uses diagrams to
describe current ways that families relate. (Boundaries, Coalition etc.)

• Accommodating and joining. The therapist joins the family system

and try to accommodate their pattern of interaction.
• Enactment. By instructing the family to act out a conflict, the
therapist can work with problems as they appear in the present
rather than as they are reported.
• Intensity. Changing the pattern of how a message is given change can
be facilitated.
• Changing boundaries. As the therapist observes the family interacting
they use boundary marking to note boundaries in the family. To
change boundaries, therapists may rearrange the seating of the family
members and change the distance between them or side with one
party who have less power.
• Reframing. There are several ways to see an event or situation or to
reframe it. The therapist may wish to give a different explanation so
that a constructive change can occur in a family situation.
Strategic Therapy
• Concerned with treating symptoms that families present, Haley
(1923–2007) takes responsibility for what occurs in treatment and
designs approaches for solving family problems.
• Haley observes the interaction among family members, attending
particularly to power relationships and to the ways parents deal with
power.
• a communication from one person to another is an act that defines
the relationship.
• Symptoms are reflected through communication as metaphors. My
stomach hurts; (I need Attention).
• The therapist sets goals for the session.
• There must be sufficient information so that therapists can plan
strategies to reach goals.
• Because the presenting problem is the focus of strategic therapy,
tasks to alleviate the problem or symptom are its cornerstone.
• Straightforward tasks. When strategic family therapists judge that the
family they are trying to help is likely to comply with their
suggestions, they may assign a straightforward task. By talking with
the family and observing family boundaries and subsystems, the
therapist will be able to help the family accomplish its goals.
• Paradoxical Task:

• Asking to repeat the same behaviour that one need help with by
giving a rationale.
Experiential Therapy
• Dysfunctional behaviour is hindrance to growth. People try to suppress their
emotions by creating Emotional deadness.
• Whitaker and Keith (1981) described the beginning, middle, and ending phases of
therapy.
➢In the beginning phase, there is a battle for taking initiative in developing a
structure, such as determining who is going to be present at the therapy sessions.
➢In the middle phase, Whitaker worked actively on family issues, bringing in
extended family when appropriate. To bring about change, he used
confrontation, exaggeration, or absurdity. When he picked up an absurdity in the
patient, he built upon it until the patient recognized it and could change her
approach.
➢The ending phase of therapy deals with separation anxiety on the part of the
family (and therapist) and the gradual disentanglement from each other’s lives
• Experiential family therapists who do not consider techniques
important may advocate at least a few of these processes in
conjunction with the use of their personality.
• Among the most widely used structured therapeutic responses are
those that were originated by Virginia Satir. They include modeling of
effective communication using “I” messages, sculpting, choreography,
humor, touch, props, and family reconstruction.
Humanistic Approach
• Virginia Satir (1916–1988) attended to the feelings of family members
and worked with them on day-to-day functioning and their own
emotional experiences in the family.
• One of Satir’s contributions to family communications was the
identification of five styles of relating within the family (Satir, 1972):
the placater, weak and tentative, always agreeing; the blamer, finding
fault with others; the superreasonable, detached, calm, and
unemotional; the irrelevant, distracting others and not relating to
family processes; and the congruent communicator, genuinely
expressive, real, and open. Satir’s emphasis on communication style
influenced her selection of therapeutic interventions.
• Chronology: Satir always met with the entire family, helping them to
feel better about themselves and each other. One approach was a
family life chronology in which the history of the family’s
development was recorded. This chronology included how spouses
met, how they saw themselves in relationship with their siblings, and
their expectations of parenting.
• Family reconstruction, an experiential approach including guided
fantasy, hypnosis, psychodrama, and role playing.
• Family sculpting, in which family members were physically molded
into characteristic poses representing a view of family relationships.
Integrative Approach to Family Therapy
• The current practice of family therapy reflects a creative approach on
the part of family therapists who integrate transgenerational,
structural, strategic, experiential, and many other family therapies.
• Because many therapists come to family therapy after having been
trained as individual therapists, they are likely to combine their
training with family systems therapy.
• Therapists may mix individual, couple, and family sessions in
treatment. There is currently a greater focus on use of concepts
rather than theory. Thus, “differentiation” (Bowen), “enactment”
(Minuchin), and genograms may be used by therapists of many
orientations.
Individual Family Therapy Models
• Psychoanalysis (Past experiences, Interactions, unconscious)
• Adlerian Therapy (Conflict in family, birth order, Style of life in family)
• Existential Therapy (awareness about self and around the world)
• Person-centered Therapy (Self-concept, Positive regards, empathy)
• Behavior Therapy ( Contingency management, Rewards and
punishment)
• Cognitive Therapy (Faulty though pattern, irrational beliefs)
• Reality Therapy (Choices, wants, needs, autonomy)
• Feminist Therapy (Gender role and expectation, stereotypes)
Coping Strategies of the family
Types of Family
Common Factors of Family Therapy

• 1. Extratherapeutic factors (40%).

• 2. Therapy relationship factors (30%).
• 3. Expectancy, hope, and placebo factors (15%). “
• 4. Model and technique factors (15%).
 Problems for beginning Family Therapist
•Overemphasis on
1) Details
2) Trying to make everyone happy
3) Verbal expression

Underemphasis on
1) Structure
2) Not showing care and concern
3) Letting the family work on their problems
Structure of the Therapy session
1. Pre session planning (during appointment taking and after).
2. Initial sessions (Rapport, understanding the family patterns)
3. Observation & Assessment (Triangulation, subsystems, coalition)
4. Connecting and involving the family members
5. Reinforce positive change
6. Use of humor
7. Evidence of change in the family
8. Termination and Follow up.
Challenges of Psychotherapy in Indian Setting
• In the 1950s, Nand acknowledged the ‘split’ of psychiatrists into
biologically-oriented and analytically-oriented.
• Later, many others later observed that psychotherapy, as practiced
in the West, might be suitable only for those living in cosmopolitan
cities of India and not for majority of the population.
• Surya and Jayaram pointed out that the Indian patients are more
dependent unlike Western patients.
• There is a tendency for dissociation between thinking, feeling and
acting and may block the process of psychotherapy.
• Neki discussed confidentiality and privacy in the Indian context
and opined that these terms do not even exist in Indian Languages
and, in the socio-cultural context; the concepts of privacy could
severe people from interdependent society.

• Dependence/interdependence.
• Lack of psychological sophistication.
• Social distance between the doctor and the patient.
• Religious belief in rebirth and fatalism.
• Guilt attributed to misdeeds in past life.
• Confidentiality.
• Personal responsibility in decision making.
• There is paucity of literature related to psychotherapy process and
outcome research undertaken in our country.
Emotion Focused Therapy
• Emotion-focused treatment was developed as an empirically
informed approach to the practice of psychotherapy grounded in
contemporary psychological theories of functioning.
• It has developed into one of the recognized evidence-based
treatment approaches for depression and marital distress as well as
showing promise for trauma, eating disorders, anxiety disorders, and
interpersonal problems.
• A major premise of EFT is that emotion is fundamental to the
construction of the self and is a key determinant of self-organization.
• EFT talks about emotional schemas that are created in form of neural
networks in brain.
• During the period of memory consolidation or reconsolidation,
emotional memory can be disrupted.
Emotional Assessment
• Primary Emotion (deeper emotions) & Secondary emotion (reaction to
primary emotion)

• EFT intervention is based on two major treatment principles: the provision

of a therapeutic relationship and the facilitation of therapeutic work.
• The relational style is person-centered, which involves a way of being with
patients characterized by entering the client’s internal frame of reference
and empathically following the client’s experience.
• This is combined with a more guiding, process-directive gestalt therapy
style
• MARKERS AND TASKS
• A defining feature of EFT is that intervention is marker guided and
process directive.
• 1. Problematic reactions expressed through puzzlement about
emotional or behavioral responses to particular situations. For
example, a client saying “on the way to therapy I saw a little puppy
dog with long droopy ears and I suddenly felt so sad and I don’t know
why.”
• 2. An unclear felt sense in which the person is on the surface of or
feeling confused and unable to get a clear sense of his or her
experience: “I just have this feeling, but I don’t know what it is.”
• 3. Conflict splits in which one aspect of the self is critical or coercive
toward another aspect. For example, a woman in therapy says, “I feel
inferior to them; it’s like I’ve failed and I’m not as good as you.”
• 4. Self-interruptive splits in which one part of the self interrupts or
constricts emotional experience and expression, “I can feel the tears
coming up, but I just tighten and suck them back in; no way am I going to
cry.”
• 5. An unfinished business marker in which the statement of a lingering
unresolved feeling toward a significant other such as the following said in
a highly involved manner, “my father, he was just never there for me. I
have never forgiven him; deep down inside I don’t think I’m grieving for
what I probably didn’t have and know I never will have.”
• 6. Vulnerability, a state in which the self feels fragile, deeply
ashamed, or insecure, “I just feel like I’ve got nothing left. I’m
finished. It’s too much to ask of myself to carry on.”
Focus of Therapy
• Emotional Awareness
• Naming a feeling in words helps decrease amygdala arousal. Once people
know what they feel, they reconnect to their needs and are motivated to meet
them.
• Emotional expression
• There is a strong human tendency to avoid expressing painful emotions.
• Regulation.
• Things such as identifying triggers, avoiding triggers, identifying and labeling
emotions, allowing and tolerating emotions, establishing a working distance,
increasing positive emotions, reducing vulnerability to negative emotions, self-
soothing, breathing, and distraction improve coping.
• Reflection.
• In addition to symbolizing emotion in words, reflection on emotional
experience helps people make narrative sense of their experience.
• Transformation.
• Probably the most important way of dealing with emotion in therapy
involves the transformation of emotion
Techniques
• Validation
• Chair Technique
• Reflection
• Reframing
Marital Therapy Case Study (Indian Context)
• Shalini and Vikram were wedded through arranged marriage.
• They stay with their in-laws
• Initially Shalini had a very close relationship with her MIL
• But after her sister in law came to visit the relationship was disrupted.
• Vikram was disengaged in all these issues and Shalini developed
depression.
Interventions used
• Asking the clients to spend time together alone
• Asking the couple to stay away from the family
• In individual session with Shalini the idea of separation was suggested
• Then she started to focus on the positives of the marriage (Support of
grandparents for her children, Vikram being a good father)
• Shali was advised to express how she felt about the change in
relationship with the MIL and they formed an alliance and became
the “two reasonable people in the family”
Things to Consider in Couples Therapy
• Freedom to choose mate in influenced by various factors
• Gender role expectation

• Common Relationship Issues

• Communication Problems
• Conflict Resolution Difficulties
• Trust Issues
• Intimacy and Emotional Distance
Historical Background of Couples Therapy

• 1.Early 20th Century: Freudian Influence

2. Mid-20th Century: Behavioral Approaches
3.1960s-1970s: Systemic Approaches
4.1980s-1990s: Integration of Theory and Techniques
5. Late 20th Century-Present: Emphasis on Emotion and Attachment
6.Technology and Accessibility
•
 Marital Life Cycle (Nichols, 1988)
• Commitment (desire to continue the relationship)
• Caring
• Communication (the ability to share meanings, verbally and nonverbally/
symbolically)
• Conflict and compromise (the extent the partners are able to recognize
and deal with the disagreements)
• Contract (set of expectations and explicit, implied, or presumed
agreements held by the partners)
• Goals of Couples Therapy
• Improve Communication
• Strengthen Connection and Intimacy
• Resolve Conflicts in a Constructive Way
• Rebuild Trust
• Effective Communication
• Active Listening Techniques
• "I" Statements for Expressing Feelings
• Non-Verbal Communication Awareness
• Avoiding Blame and Criticism
• Challenges in Couples Therapy
• Resistance to Change
• Individual Issues Impacting the Relationship
• Cultural and Societal Influences
• Dealing with Disparities in Commitment
Gottman Couples Therapy
• The Gottman Method is a form of couples-based therapy that draws
on the pioneering studies of relationships by psychologist John M.
Gottman and clinical practice conducted by John Gottman and his
wife, psychologist Julie Gottman.
• Their method is based on observations of thousands of couples,
demonstrating that there is a real science to having a happy and
healthy relationship.
Relationship True or False?
• 1. neurosis or personality problems ruin marriage
• 2. common interests keep people together:
• 3. reciprocity keeps a good relationship:
• 4. Avoiding conflict will ruin your marriage:
• 5. Affairs are the root causes of divorce:
• 6. Men are not biologically built for marriage
• 7. Men and women are from different planets
Antidotes for Four Horseman
• Criticism (Use if I statements. “I feel that..)
• Defensiveness (Taking responsibility. I could have done that)
• Contempt (Appreciation. Thanks for trying)
• Stonewalling (Taking a break to cool down)

• Techniques
• Using appreciation for each other
• Have stress reduction conversation with your partner (wash cloth
moments)
• The goals of Gottman Method Couples Therapy are

❑to disarm conflicting verbal communication,

❑increase intimacy, respect, and affection,
❑remove barriers that create a feeling of stagnancy in conflicting
situations, and
❑create a heightened sense of empathy and understanding.
Skills to Manage Conflict
• 1. Use softened, Gentle Start-up
• 2. Repair and De-escalation
• 3. Physiological Self soothing
• 4. Accept What You Cannot Change (understanding your partner’s
way of thinking)
• 5. Accept Your Partner’s Influence
• 6. Compromise
Skills to Repair relationship post-affair
• 1. Atonement
• 2. Attunement
• 3. Attachment
CBCT
• Cognitive-behavioral couple therapy (CBCT) aims at assisting romantic
partners who report distress in their relationship.
• Over the years, CBCT has been extensively evaluated in treatment
outcome studies, which have repeatedly concluded in its
effectiveness for decreasing couple distress and dissatisfaction as well
as for addressing communication or problem-solving difficulties.
• Studies have also found that such improvements seem to be
maintained for up to 2 years by most couples.
• The origins of CBCT stem mainly from Stuart’s work on behavioral
exchanges between partners.
• He based his analysis of couple interactions on learning principles and
social exchange theory, postulating that individuals’ evaluation of
their relationships would depend on the ratio of benefits to costs,
resulting from positive and negative exchanges with others.
• Successful relationships could be differentiated from dysfunctional
ones by the frequency of positive and negative behavioral exchanges.
Assessment Interview
• The assessment phase of CBCT is typically formed of three parts: one
or two couple sessions in which both partners are present and one
individual session with each partner followed by a feedback session
for the couple.
• During the first couple session, the therapist presents his or her
qualifications, theoretical orientation as well as the objectives and
structure of CBCT.
• The therapist informs the patients that this is a couple therapy
process where he/she would not be forced to keep a secret from one
partner during treatment.
• The therapist will then meet with each partner separately in order to
gather information on their personal history as well as their current
psychological and social functioning.
Examples of Skills Training
• Communication Skill ( I feel sad when you do not tell me about your
plans to come home late and Maybe I am not your priorities).
• Conflict resolution ( Brainstorming common solutions)
• Cognitive Restructuring (there are no concrete signs that indicate that
you would cheat on me… I think I’m just afraid of losing you.)
• Tolerating Differences.
Group Therapy
• In group therapy, five to ten people meet face-to-face with one or
more trained group therapists and talk about what is troubling them.
• Members also give feedback to each other by expressing their own
feelings about what someone says or does.
• This interaction gives group members an opportunity to try out new
ways of behaving and to learn more about the way they interact with
others.
• What makes the situation unique is that it is a closed and safe system.
• The content of the group sessions is confidential; what members talk
about or disclose is not discussed outside the group.
Benefits of Group Therapy
• Exploring issues in an interpersonal context more accurately reflects real
life.
• Group therapy provides an opportunity to observe and reflect on your own
and others’ interpersonal skills.
• Group therapy provides an opportunity to benefit both through active
participation and through observation.
• Group therapy offers an opportunity to give and get immediate feedback
about concerns, issues and problems affecting one's life.
• Group therapy members benefit by working through personal issues in a
supportive, confidential atmosphere and by helping others to work through
theirs.
• Common misperceptions about Group Therapy:
• 1. "I will be forced to tell all of my deepest thoughts, feelings and secrets
to the group.“ (You control what, how much, and when you share with
the group.)
• 2. "Group therapy will take longer than individual therapy because I will
have to share the time with others. (Listening to others, commonality)
• 3. "I will be verbally attacked by the leaders and by other group
members.“ (opportunity to receive feedback from others in a supportive
environment)
• 4. "Group therapy is second-best to individual therapy.“ (Group therapy is
recommended when it is the most effective method to help you. )
• 5. "I have so much trouble talking with people, I'll never be able to share
in a group.“ (People open up more in supportive space).
Ground rules for Group Therapy
• 1. If you are going to miss a session, please let one of the leaders of the group know.
• 2. The group meeting times have been set by the group leaders, and you are asked
to adhere to those times.
• 3. Having a feeling and acting on it are two different actions. Acting out your
feelings (on self or others) is not acceptable. The way we most respect ourselves
and others is by experiencing feelings and then allowing ourselves to talk about
them.
• 4. It is your responsibility to talk about your reasons for being in the group.
• 5. Group sessions are confidential. Members and leaders are bound ethically and
legally not to disclose the contents of the sessions in any way that could identify
members of the group. Remember, we are building trust and safety.
• 6. If you should decide not to continue in the group, it is preferred that you come to
the group to say goodbye.
• 7. Interactions between members outside the group can affect relations inside the
group; therefore we ask that you discuss these interactions, if they occur, in the
group.
History of Group Therapy
1.Early Influences (1900s-1930s):
Sigmund Freud, the founder of psychoanalysis, played a significant role in the early development
of group therapy. He conducted informal group sessions with his patients to explore interpersonal
dynamics and gain insights into individual behavior.
2.The Work of Jacob Moreno (1920s-1930s):
Jacob L. Moreno, a Viennese psychiatrist, is often credited as the father of group psychotherapy.
He developed psychodrama, a therapeutic technique that involved role-playing and dramatic
enactment within a group setting. This approach laid the foundation for modern group therapy
methods.
3.World War II and Post-War Era (1940s-1950s):
During and after World War II, the demand for mental health services increased significantly.
Group therapy gained popularity as a cost-effective way to provide treatment to large numbers of
veterans dealing with post-traumatic stress disorder (PTSD) and other psychological issues.
4.Encounter Groups (1950s-1960s):
In the 1950s and 1960s, encounter groups emerged as a prominent form of group therapy. These
groups focused on personal growth, self-awareness, and interpersonal relationships. Pioneers like
Carl Rogers and Fritz Perls contributed to the development of humanistic and experiential
approaches within group therapy.
5.T-Groups and Sensitivity Training (1960s-1970s):
T-groups, or "training groups," became popular in the business and organizational context
during this period. These groups aimed to improve communication, leadership, and
interpersonal skills among participants. Sensitivity training was a related approach that
emphasized emotional awareness and empathy.
6.Group Therapy in Mental Health Settings (1980s-Present):
Group therapy continued to be a common treatment modality within mental health settings.
Various therapeutic approaches, such as cognitive-behavioral, dialectical-behavioral, and
psychoeducational, have been adapted for group settings to address a wide range of mental
health issues.
7.Support and Self-Help Groups (1980s-Present):
Support groups and self-help groups, often facilitated by mental health professionals or peers,
have become an essential part of the mental health landscape. These groups provide
individuals with a sense of community and shared experiences while addressing specific issues
like addiction recovery, grief, and chronic illness management.
8.Modern Developments (2000s-Present):
With advances in technology, online group therapy and teletherapy have gained prominence,
allowing individuals to participate in group therapy sessions remotely. This accessibility has
expanded the reach of group psychotherapy.
Groups are divided in the basis of
• 1. Therapeutic Goals (overcoming drink or drugs dependency or
coming to terms with Cancer)
• 2. Skills Building (Anxiety Management, Anger management skills
training).
Types of Groups
• Psychoeducational Groups: These groups focus on providing information and education about a
specific psychological issue or skill development. For example, a group may focus on teaching
coping strategies for anxiety or anger management.

• Support Groups: Support groups are designed to provide emotional support and validation for
individuals dealing with similar challenges or conditions. They can be particularly helpful for
people facing issues such as grief, addiction recovery, or chronic illness.

• Interpersonal Process Groups: These groups focus on exploring and improving participants'
interpersonal relationships and communication skills. Members share their thoughts, feelings,
and experiences within the group, and the therapist helps analyze and address interpersonal
dynamics.

• Cognitive-Behavioral Groups: These groups utilize cognitive-behavioral therapy (CBT) techniques

in a group setting. Participants learn to identify and change negative thought patterns and
behaviors that contribute to their psychological issues.
• Dialectical Behavior Therapy (DBT) Groups: DBT is a specialized form of CBT that focuses on
emotion regulation, distress tolerance, interpersonal effectiveness, and mindfulness. DBT groups
help individuals develop these skills to manage their emotions and relationships better.

• Psychodynamic Groups: These groups explore unconscious thoughts and feelings and their
impact on current behavior. Participants may delve into their past experiences and relationships
to gain insight into their current challenges.

• Family Therapy Groups: Family therapy groups involve family members and can be particularly
useful in addressing family-related issues, such as conflicts, communication problems, or the
impact of a family member's mental health condition.

• Art or Expressive Therapy Groups: These groups use creative arts, such as painting, music, or
drama, as a means of expression and healing. Participants can explore their emotions and
experiences through artistic mediums.
• Mindfulness and Meditation Groups: These groups focus on mindfulness and meditation
practices to help participants reduce stress, increase self-awareness, and improve emotional
regulation.

• Process-Oriented Groups: Process groups focus on the here-and-now experiences of group

members. Participants explore their emotions, thoughts, and interactions within the group as
they happen, helping them gain insight into their patterns of behavior and communication.

• Substance Abuse or Addiction Recovery Groups: These groups are designed to support
individuals in their journey to overcome substance abuse or addiction. They often incorporate
elements of relapse prevention and coping strategies.

• Trauma Recovery Groups: These groups are specifically tailored for individuals who have
experienced trauma, such as post-traumatic stress disorder (PTSD) groups. They provide a safe
space for processing and healing from traumatic experiences.
Stages in Group Therapy (Tuckman)
• Forming: In this initial stage, group members come together, get to
know each other, and establish the purpose and goals of the group.
There is often a sense of politeness and uncertainty as members try
to understand their roles and responsibilities within the group.

• Storming: During the storming stage, conflicts and disagreements

may arise as group members begin to assert themselves and their
ideas. This stage is characterized by debates, power struggles, and
challenges to the group's direction. It is a crucial phase for the group
to establish its norms and resolve conflicts.
• Norming: As the group works through the conflicts and differences that
surfaced during the storming stage, it enters the norming stage. In this phase,
group members start to develop a sense of cohesion, trust, and cooperation.
They begin to establish common rules, values, and procedures for working
together.

• Performing: The performing stage is when the group is functioning at its

highest level of productivity and effectiveness. Group members have resolved
their conflicts, have a clear understanding of their roles, and are committed to
achieving the group's goals. Collaboration is at its peak during this stage.

• Adjourning (or Mourning): Not all group models include this stage, but
Tuckman added it later to acknowledge the eventual dissolution of groups. In
the adjourning stage, group members prepare to disband as the project or
task comes to an end. There may be feelings of sadness or loss as members
reflect on their accomplishments and relationships within the group.
• Popular Group Theories
• • Adlerian Group Counselling
• • Person Centred Group Cpunseling
• • Psychodramma
• • CBT Group Counseling
• • Bion’s Analytical Group
• • Yalom’s Interperosnal Group
• Yalom’s 11 Therapeutic (curative) factors
• • Therapeutic change -- complex process -- occurs through an intricate interplay of human
experiences ie. “therapeutic factors.”
• • therapeutic experience into eleven primary factors:
• • 1. Instillation of hope
• 2. Universality
• 3. Imparting information
• 4. Altruism
• 5. The corrective recapitulation of the primary family group 6. Development of socializing techniques
• 7. Imitative behavior
• 8. Interpersonal learning
• 9. Group cohesiveness
• 10. Catharsis
• 11. Existential factors
• Interpersonal Learning (Yalom)

• • Therapist Plays an Essential Role

• • Analogous to Insight, Working through Transference, Corrective
• Emotional Experience
• • Therapy Task Shift from dysfunction to gratifying & distortion free IPR
• • Understood w.h.o 3 concepts (forms the premise of IPR Learning:

• 1. The importance of interpersonal relationships

• 2. The corrective emotional experience
• 3. The group as social microcosm

• Interpersonal Learning (Yalom)

• 1. The importance of interpersonal relationships
• • Jown Bowlby, William James, Harry Stack Sullivan
• • Sullivan’s Interpersonal Model of Psychotherapy (self Concept based
• on perceived appraisals)
• • Parataxic distortions parataxic distortion occurs in an interpersonal situation when one person relates to another not
• on the basis of the realistic attributes of the other but on the basis of a personification existing chiefly in the former’s own fantasy.
Case Study
• Patient Demographics:

• Group Size: 8 participants (age range: 25-45)

• Gender: 4 females and 4 males
• Cultural Backgrounds: Diverse, including various regional, religious,
and socio-economic backgrounds
• Clinical Diagnoses: All participants met the criteria for Generalized
Anxiety Disorder (GAD) and Major Depressive Disorder (MDD) as per
the DSM-5.
• Intervention Techniques:

• Cultural Sensitivity: The group therapy sessions were culturally sensitive and tailored
to the Indian context. This involved acknowledging cultural values, norms, and
beliefs while avoiding ethnocentrism.

• Psychoeducation: The program began with psychoeducation about anxiety and

depression, aiming to reduce stigma and improve participants' understanding of
their conditions.

• Cognitive-Behavioral Techniques: The core of the intervention was based on

cognitive-behavioral techniques. Participants learned to identify and challenge
negative thought patterns and behaviors contributing to their anxiety and
depression.

• Mindfulness and Meditation: Given the prevalence of mindfulness practices in India,

mindfulness and meditation exercises were integrated. Participants practiced
mindfulness techniques to develop emotional regulation skills.
• Supportive Group Dynamics: The group format fostered mutual support and
understanding among participants. Sharing experiences and coping strategies
helped reduce isolation and provided a sense of community.

• Interpersonal Skill Building: Interpersonal difficulties often exacerbate

anxiety and depression. Group members worked on improving
communication, conflict resolution, and assertiveness skills.

• Homework Assignments: Participants were given homework assignments to

practice skills learned in sessions and monitor their progress. This
encouraged active engagement in the therapeutic process.

• Cultural Storytelling: Participants were encouraged to share personal stories,

myths, or cultural narratives related to mental health and coping. This helped
normalize discussions around mental health and reduce stigma.
• Challenges:

• Stigma: Despite efforts to reduce stigma, some participants still faced

societal and familial resistance to seeking mental health treatment.

• Cultural Diversity: Managing diverse cultural backgrounds required

sensitivity to different beliefs and practices. The therapist needed to
balance universal therapeutic principles with cultural nuances.

• Attendance: Ensuring consistent attendance was challenging due to

participants' work and family obligations.
• Results:

• At the end of the 12-week program, significant improvements were

observed in the participants' self-reported anxiety and depression
scores. Qualitative feedback indicated increased awareness, improved
coping skills, and a sense of belonging among the group members.
Several participants reported reduced social isolation and improved
family relationships.
• Interpersonal group psychotherapy is a form of group therapy that
was developed by Dr. Irvin D. Yalom, a renowned psychiatrist and
psychotherapist.
• This approach is rooted in existential and humanistic psychology and
focuses on the importance of interpersonal relationships in
understanding and resolving psychological and emotional issues.
• Definition: Interpersonal group psychotherapy is a therapeutic
approach that involves a small group of individuals who come together
to discuss their thoughts, feelings, and experiences, with an emphasis
on how they relate to one another within the group.
• The primary goal is to explore and improve interpersonal
relationships, enhance self-awareness, and address individual and
collective psychological challenges.
• Techniques:
1.Interpersonal Process Analysis: Group members are encouraged to openly
discuss their interactions and reactions to one another. For example, if a
group member feels neglected by another, they would express their
feelings, and the group would explore the dynamics of this interaction.
2.Feedback: Giving and receiving honest, constructive feedback is a crucial
technique. Group members share their observations and reactions to each
other's behaviors. For instance, a group member may say, "I noticed that
when you talked about your family, you became very defensive, and I feltit
was shut out."
3.Role Play: Sometimes, role-playing exercises are used to help group
members practice new ways of interacting or responding to specific
situations.
• Challenges:
• Resistance: Some group members may resist sharing their feelings or
opening up to others.
• Conflict: Conflict within the group can be challenging to manage.
• Confidentiality: Maintaining confidentiality in a group setting can be
difficult.
• Balancing Time: Balancing the needs of multiple group members
within a session can be a challenge.
• Case Study (Indian Context): there is an interpersonal group therapy session
consisting of members from diverse cultural backgrounds.
• One member, Ravi, struggles with work-related stress and has difficulty
expressing himself.
• During a session, he talks about his frustration with his colleagues. Another
member, Priya, offers feedback, saying she noticed Ravi often seems
reserved and that this might be contributing to his workplace difficulties.
• In this case, the therapist and the group can explore Ravi's interpersonal
style and help him understand how it affects his relationships at work.
• The group might discuss cultural factors that influence their communication
styles and how they can adapt to work effectively together.
 Narrative Couple Therapy
Narrative Therapy: Narrative therapy, developed by Michael White and
David Epston, is the foundation of Narrative Couple Therapy. This
approach emphasizes that people are not defined by problems but
rather by the stories they create to make sense of their lives. In the
context of couples therapy, the focus is on the stories that each partner
tells about their relationship.
• Philosophical Background:
• Postmodernism: Narrative therapy is deeply influenced by postmodern
philosophy, which challenges the idea of objective truth and reality.
Postmodernism suggests that our understanding of the world is shaped by
language, culture, and context. Therefore, it's essential to acknowledge and
work with the multiple subjective realities and narratives people construct
about their lives.
• Social Constructionism: This is another foundational concept in narrative
therapy. It asserts that our understanding of reality is co-constructed
through social interactions and language. People don't have inherent, fixed
identities or problems; instead, these are constructed through dialogue
and cultural norms.
• They challenged traditional therapy models by emphasizing the
importance of language, narrative, and social constructs in shaping
one's sense of self and reality. In the context of couples therapy,
narrative therapy evolved to address the relational aspects of these
constructs.
Techniques of Intervention
• Externalizing the Problem:
• Technique: Externalizing the problem involves separating the issue
from the individuals in the relationship. It helps the couple view the
problem as an entity outside themselves, making it easier to address
collaboratively.
• Example: In a case where a couple is struggling with communication
issues, the therapist might ask them to give a name to this problem,
such as "The Silent Wall." By externalizing the issue, the couple can
work together to address "The Silent Wall" rather than blaming each
other.
• Re-authoring Stories:
• Technique: Re-authoring helps couples reframe their narratives by
highlighting exceptions to the problem and identifying strengths and
resources within the relationship.
• Example: In a case where a couple constantly argues about finances,
the therapist may encourage them to recall instances when they
successfully managed their finances together. This helps the couple
rewrite their financial narrative with a focus on their strengths in
handling money.
• Reflecting on Personal Narratives:
• Technique: The therapist encourages each individual to explore their
personal narratives and how they contribute to the relationship's
dynamics.
• Example: In a case study where one partner often feels neglected, the
therapist might ask them to reflect on their own narrative about
abandonment and how it might affect their perception of the
relationship. This reflection can help the individual understand how
their past experiences influence their current feelings.
• Mapping Relationship Patterns:
• Technique: The therapist helps the couple identify recurring patterns
in their interactions and narratives, allowing them to see how these
patterns impact their relationship.
• Example: In a case where a couple struggles with trust issues, the
therapist can create a diagram or map illustrating the cycle of
mistrust, where one partner's suspicion triggers defensive behavior in
the other. By visualizing this pattern, the couple can work on
interrupting it.
• Restorying Conversations:
• Technique: Couples are encouraged to have conversations that allow
them to express their preferred or preferred alternative narratives
about their relationship.
• Example: In a case where a couple frequently argues about household
chores, the therapist may facilitate a conversation where each partner
describes their ideal vision of how responsibilities should be shared.
This helps in co-creating a more balanced narrative of their household
dynamics.
Case Study
• Background: Raj, a 35-year-old software engineer, and Priya, a 32-
year-old school teacher, have been married for six years. They come
from different cultural backgrounds; Raj is from Northern India, and
Priya is from Southern India. They live in a cosmopolitan city and have
a 4-year-old daughter, Meera. Over time, they have experienced
increasing conflict and tension in their marriage.
• Presenting Issues: Raj and Priya frequently argue about various
aspects of their relationship, including their parenting styles, financial
decisions, and cultural differences. Raj feels that Priya's family is too
involved in their lives, and Priya feels Raj is neglecting their cultural
traditions. Their communication has become strained, and they have
difficulty connecting emotionally.
Externalizing the Problem:
1. The therapist, Dr. Sharma, starts by externalizing the problems in their relationship.
Instead of framing the issues as "Raj's anger" or "Priya's stubbornness," Dr. Sharma
helps them see these as external challenges they are facing together.
2. Example: Dr. Sharma says, "It seems like there's a third entity in your relationship -
the constant tension between your cultural backgrounds. Let's talk about how this
'cultural tension' affects you both."
Mapping the Narrative:
1. Dr. Sharma encourages Raj and Priya to tell their individual stories and experiences
within the relationship. This allows them to express their feelings and perspectives.
2. Example: Raj shares, "I feel like I'm always expected to follow Priya's cultural
traditions. It's stifling." Priya responds, "I'm just trying to keep our traditions alive,
but Raj never shows interest."
Re-authoring the Narrative:
1. Dr. Sharma helps them re-author their relationship narrative. Instead of
focusing on blame, they work together to create a new story that
incorporates their cultural differences as strengths rather than obstacles.
2. Example: Dr. Sharma says, "Let's explore how you can blend your traditions in
a way that honors both your backgrounds. What values from each culture do
you want to pass on to Meera?"
Remembering and Reconnecting:
1. The therapist guides Raj and Priya in recalling positive memories and shared
experiences to rekindle emotional connection.
2. Example: They reminisce about the times they enjoyed celebrating each
other's cultural festivals and the happiness it brought them.
Outsider Witnessing:
1. Dr. Sharma brings in the perspective of external "witnesses" like family and
friends to provide feedback and alternative viewpoints.
2. Example: Priya's cousin, Anjali, shares her view on how cultural traditions
have positively impacted her own relationship, which gives Priya a fresh
perspective.
Outcomes: Over several sessions, Raj and Priya gradually start to see
their cultural differences as a source of enrichment rather than conflict.
They develop strategies to create a more inclusive and harmonious
environment for their family, incorporating elements from both
cultures. Their communication improves, and they report feeling more
connected and supported by each other.
• Resistance to Change: Couples may be resistant to exploring their narratives
or may be unwilling to change the stories they've constructed about their
relationship. This resistance can hinder the therapeutic process.

• Communication Issues: Poor communication is often a primary reason for

seeking couples therapy. It can be challenging for couples to express
themselves effectively and for therapists to facilitate productive dialogue.

• Emotional Intensity: Couples therapy can bring out intense emotions and
conflict. Managing these emotions, ensuring both partners feel heard, and
preventing escalated conflicts can be difficult.

• Power Imbalances: Some couples may have power imbalances that affect
their ability to engage in a balanced narrative therapy process. Therapists
must address these imbalances to create an equitable environment.
• Trauma and Past Experiences: Unresolved trauma or past experiences can
affect how couples perceive their relationship narratives. These underlying
issues may need specialized attention alongside narrative therapy.

• Limited Perspective: Therapists and couples may have limited insight into the
narratives they've constructed, making it difficult to identify the root causes
of issues.

• External Stressors: External stressors, such as financial difficulties, work-

related stress, or family issues, can impact a couple's ability to engage fully in
therapy and may need to be addressed alongside the narrative work.

• Individual Needs vs. Relationship Needs: Couples therapy must balance

addressing individual needs and the needs of the relationship itself. Finding
this balance can be challenging.
• Length of Therapy: Narrative therapy can be time-consuming and may take
longer than some other therapeutic approaches. Maintaining motivation and
commitment over the course of therapy can be difficult for some couples.

• Therapist Competency: Not all therapists are trained in narrative therapy,

and finding a skilled therapist can be a challenge for couples seeking this
approach.

• Cultural and Diversity Sensitivity: Narrative therapy may not always consider
the cultural and diversity factors that can shape a couple's narrative.
Therapists need to be sensitive to these aspects.

• Maintaining Change: Even if couples successfully revise their relationship

narratives, they may struggle to maintain those changes once therapy
concludes.
Feminist Therapy
• Feminist therapy is a therapeutic approach that emerged in the late
1960s and 1970s as part of the broader feminist movement. It
focuses on the unique experiences and challenges faced by women
and seeks to address gender-related issues in therapy. The
philosophical background of feminist therapy is rooted in feminist
theory and principles, which emphasize gender equality and the
recognition of the social, cultural, and political influences that shape
women's lives.
• Philosophical Background:
1.Feminist Principles: Feminist therapy is based on the principles of feminism,
which include a commitment to gender equality, social justice, and
empowerment of women. It recognizes that women have been historically
oppressed and seeks to address the impact of this oppression on mental health
and well-being.
2.Social and Cultural Context: This approach emphasizes the importance of
understanding the broader social and cultural context in which individuals live. It
acknowledges that gender roles and stereotypes can contribute to psychological
distress and that societal norms can perpetuate gender-based discrimination.
3.Intersectionality: Feminist therapy recognizes that women's experiences are
diverse and can be influenced by various intersecting factors, such as race, class,
sexual orientation, and disability. It aims to be inclusive and attentive to these
intersecting identities.
• How It Works:
1.Empowerment: Feminist therapy focuses on empowering clients to make
informed choices and regain control over their lives. Therapists often act as
allies, helping clients recognize and challenge oppressive systems and
beliefs.
2.Exploration of Gender Roles: Therapists encourage clients to explore their
beliefs and experiences related to gender roles and stereotypes. This
exploration can help clients understand how societal expectations may have
influenced their self-concept.
3.Shared Decision-Making: In feminist therapy, the therapist and client work
collaboratively. The client is encouraged to actively participate in setting
therapeutic goals and making decisions about the therapeutic process.
4.Deconstructing Patriarchy: The therapy process may involve deconstructing
patriarchal norms and examining how they have affected the client's self-
esteem, relationships, and life choices.
5.Validation and Support: Therapists offer validation and support for clients'
experiences, emphasizing that their feelings and concerns are legitimate.
• Challenges:
1.Critique and Resistance: Not all clients may be open to a feminist perspective,
and some may resist or critique the approach. This can challenge therapists to
adapt their methods to meet the needs and preferences of their clients.
2.Intersectionality Complexity: Addressing the diverse experiences of women
due to factors like race, class, and sexual orientation can be complex and
require a nuanced approach. Therapists need to be aware of these
complexities.
3.Cultural Sensitivity: Feminist therapy's Western origins may not fully address
the cultural nuances of clients from non-Western backgrounds. Cultural
sensitivity and adaptation are essential.
4.Limited Research: While feminist therapy has been influential, there is a
relatively limited body of empirical research on its effectiveness compared to
more traditional therapeutic approaches.
5.Gender Role Expectations: In some cases, clients may hold deeply ingrained
beliefs about traditional gender roles and may be resistant to challenging
these beliefs.
• Case Study: Reena and Sanjay - Applying Feminist Couples Therapy in
an Indian Context
• Background: Reena (30) and Sanjay (32) have been married for five
years. They reside in an urban area in India and have a two-year-old
daughter. Reena works as a software engineer, while Sanjay is a
marketing manager. The couple has been experiencing conflicts and
communication issues.
• Session 1: Initial Assessment and Establishing Rapport
• The therapist, begins the first session by creating a safe and non-judgmental
space for Reena and Sanjay. She emphasizes that her approach is based on
feminist principles, aiming to address issues of power and equality within the
relationship.

• Technique 1: Psychoeducation
• Therapist educates the couple about the feminist perspective in therapy,
which focuses on examining societal and cultural factors that influence gender
roles and power dynamics. She highlights how these factors may impact their
relationship.
• Reena shares her frustration about managing household chores and parenting
while working full-time, feeling overwhelmed and unappreciated. Sanjay
expresses his concerns about Reena's emotional distance and the lack of
intimacy in their relationship.
• Session 2: Unpacking Gender Roles
• Dr. Meera explores how traditional gender roles influence their
relationship dynamics and assigns them homework to list their daily
responsibilities.
• Technique 2: Role Reversal Reena and Sanjay are asked to switch roles
for a day. Reena takes on the role of the breadwinner, and Sanjay
assumes the responsibility of childcare and household chores. This
exercise helps them empathize with each other's experiences.
• Reena finds it challenging to balance work and home life, understanding
the stress Sanjay feels. Sanjay appreciates the effort it takes to manage
household responsibilities and childcare.
• Session 3: Reconstructing Communication
• The couple discusses their communication patterns, which often lead
to arguments.
• Technique 3: Reflective Listening Dr. Meera introduces reflective
listening, where one partner speaks while the other listens and then
summarizes what they heard. This technique encourages active and
empathetic communication.
• Reena: "I feel unappreciated when you don't notice my efforts." Sanjay:
"I didn't realize how much you do. I'm sorry."
• Session 4: Challenging Patriarchy
• Dr. Meera explores how patriarchal values have affected their
relationship. She highlights the importance of creating an equitable
partnership.
• Technique 4: Power Mapping The couple is asked to draw a power
map, showing how they perceive power and control in the
relationship. This visual aid helps identify areas where power
imbalances exist.
• Reena realizes that in certain aspects of their relationship, Sanjay has
more power, while in others, she does. They discuss strategies to
rebalance power.
• Session 5: Setting Goals and Empowerment
• The couple discusses their vision for the future.
• Technique 5: Empowerment Statements Dr. Meera encourages Reena
and Sanjay to express their goals for a more equitable and fulfilling
relationship. They create empowerment statements to guide their
actions.
• Reena: "I want a partnership where we share responsibilities and
appreciate each other." Sanjay: "I want to be a more involved father
and support Reena in her career.“
• Follow up
Books and Materials
• Already shared in Classroom
• Please do additional research for depth of the topics