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Cognitive Behavioral Therapy: Group Settings Versus Family Settings
Cognitive Behavior Therapy (CBT) has proven to be an effective evidenced based psychotherapy for many individuals with psychological and emotional disorders in both family and group therapy settings as it is in individual settings (Landa, Mueser, Wyka, Shreck, Jespersen, Jacobs, … Walkup, 2016; Patterson, 2014). The paramount goal of CBT is to modify the maladaptive thinking of individual in the group so that they can better adjust in their perceptual, affective, and behavioral domains, interaction, and relationships (Wheeler, (Ed.), 2014). However, unlike in individual psychotherapy, where an individual’s thinking can be challenged directly, family and group sessions presents the dilemma of involvement of others whose definition of a problem may be at variance (Yalom and Leszcz, 2005). Furthermore, the issues of privacy, confidentiality, and honest exchange can present additional obstacles (Patterson, 2014; Wheeler, (Ed.), 2014).
In the light of this, determining if family or group CBT is appropriate for any individual or groups of individuals should be based on thorough assessment of the environment or contest in which communication take place (Wheeler, (Ed.), 2014; Yalom and Leszcz, 2005). The family provide the primary socializing environment for people of all cultures. Maladaptive behaviors in individuals can therefore be seen as a product of that family dysfunction (Gomes, Cordioli, Bortoncello, Braga, Gonçalves, Heldt, 2016). Family structure, hierarchy, alliances, boundaries, and communication patterns provide the context in which interaction that provide a feedback loop (negative or positive) take place (Selles, Belschner, Negreiros, Lin, Schuberth, McKenney, … Stewart, 2018; Gomes et al, 2016; Landa et al, 2016). Family CBT may be useful in families with multigenerational dysfunctional thinking patterns, feeling of a sense of guilt for the suffering of another, severe differentiation, triangulation of members, or role conflict, such as in post-traumatic stress disorder (PTSD), Obsessive compulsive disorders (OCD), and psychosis (Selles et al, 2018; Gomes et al, 2016; Landa et al, 2016).
A combination of cognitive and behavior approach is used to redirect the thinking of family members in more realistic way about the peculiar dysfunctions of the family, such as role differentiation, obsessions, entrenched behavioral responses, structures and subsystems, and communication patterns to produce second-order changes. Methods may include cybernetics, role reversal, acting out an escalation of dysfunction or the desired state, and exploiting the family feelings and reaction. When family members accept certain symptoms as normal, this may in effect reestablish dynamic family equilibrium in interaction (Sheehan and Friedlander, 2015),
Group CBT on the other hand can be used for therapeutic and preventive intervention in varying populations. Often shared symptomatology or diagnosis are the bases for group formation. At other times, groups may be formed around sociocultural identities. Whatever is the underlying reason for the group formation, proper assessment is necessary for setting, group membership, ground rules, development of goals and objectives (Selles, Belschner, Negreiros, Lin, Schuberth, McKenney, … Stewart, 2018). Psychoeducation of group members is done to introduce member to issues of rules, norms, gals, privacy, confidentiality and the limitation thereof (Mulia, Keliat, and Wardani, 2017). Unlike in family therapy, where embers have shared concerns and relative involvement in each others life, members of the group may not see how the group may be helpful to them.
It is therefore the responsibility of the leader or therapist to ensure that curative/therapeutic factors, such as, building hope, encouraging and guiding group interaction, emotional expression, real time awareness of the impact of interaction and communication patterns on individual in the session are addressed in a way that real but non-patronizing way (Patterson, 2014; Wheeler, (Ed.), 2014; Yalom and Leszcz, 2005). During psychoeducation, integrative factors including group cohesion, universality of issues and cohesiveness should be emphasized. Conflicts which may arise in groups should be considered as unique opportunity for social learning (Mulia, Keliat, and Wardani, 2017; Patterson, 2014; Yalom and Leszcz, 2005).
In a small-scale study conducted by Landa, Mueser, Wyka, Shreck, Jespersen, Jacobs, … Walkup, they found that group CBT did not only reduce psychotic symptoms in adolescents with predisposition to psychosis, but the “family members showed significant improvements in use of CBT skills, enhanced communication with their offspring, and greater confidence in their ability to help” (2016, p. 511). Another study by Mulia, Keliat, and Wardani (2017), showed significant improvement in anxiety in drug addicted inmates, using the Hamilton Anxiety Scale (HAM-A) post treatment with CBT compared to routine nursing intervention.
The media from Week 5 highlights some of the challenges of using cognitive behavioral therapy for groups. The clients (Ms. Johnson) who had been traumatized by sexual abuse could not at the time see the usefulness of therapy despite reassurance from peers. Self-blame was a central team for members of the group and that can be confronted with CBT.
I attended a group therapy session where, a patient was prematurely discharged from group therapy due to inability to follow rules. He has dysfunctional overcompensation for his internalized self-blame and maladaptive response to deal with his anger and feeling of inadequacy (Webb, Hirsch, Visser, and Brewer, 2013). His daughter was sexually abused by his younger brother while he was incarcerated, and he has not forgiven himself or his brother for what happened to his only daughter. Presently, he is overprotective of his daughter and excessively tax himself financially and otherwise to meet and exceed every irrationally perceived need of his daughter. Family CBT was recommended for him and his daughter before his premature discharge from the group therapy session.
In such situation a dyad type family CBT can be more beneficial than a group CBT therapy.
References:
Gomes, J. B., Cordioli, A. V., Bortoncello, C. F., Braga, D. T., Gonçalves, F., & Heldt, E. (2016). Impact of cognitive-behavioral group therapy for obsessive-compulsive disorder on family accommodation: A randomized clinical trial. Psychiatry Research, 246, 70–76. https://doi-org.ezp.waldenulibrary.org/10.1016/j.psychres.2016.09.019
Landa, Y., Mueser, K. T., Wyka, K. E., Shreck, E., Jespersen, R., Jacobs, M. A., … Walkup, J. T. (2016). Development of a group and family-based cognitive behavioural therapy program for youth at risk for psychosis. Early Intervention in Psychiatry, 10(6), 511–521. https://doi-org.ezp.waldenulibrary.org/10.1111/eip.12204
Laureate Education (Producer). (2013c). Johnson family session 3 [Video file]. Author: Baltimore, MD.
Mulia, M., Keliat, B. A., & Wardani, I. Y. (2017). Cognitive behavioral and family psychoeducational therapies for adolescent inmates experiencing anxiety in a narcotics correctional facility. Comprehensive Child & Adolescent Nursing, 40, 152–160. https://doi-org.ezp.waldenulibrary.org/10.1080/24694193.2017.1386984
Patterson, T. (2014). A Cognitive Behavioral Systems Approach to Family Therapy. Journal of Family Psychotherapy, 25(2), 132–144. https://doi-org.ezp.waldenulibrary.org/10.1080/08975353.2014.910023
Selles, R. R., Belschner, L., Negreiros, J., Lin, S., Schuberth, D., McKenney, K., … Stewart, S. E. (2018). Group family-based cognitive behavioral therapy for pediatric obsessive compulsive disorder: Global outcomes and predictors of improvement. Psychiatry Research, 260, 116–122. https://doi-org.ezp.waldenulibrary.org/10.1016/j.psychres.2017.11.04
Sheehan, A. H., & Friedlander, M. L. (2015). Therapeutic alliance and retention in brief strategic family therapy: A mixed-methods study. Journal of Marital and Family Therapy, 41(4), 415–427. doi:10.1111/jmft.12113