Evidence-Based Practices:
Shaping Mental Health Services Toward Recovery
Family Psychoeducation
Workbook
Chapter 6: The First and Second Psycho- educational Multifamily Group Sessions
The Format of the First and Second Sessions
During the first two multi-family group sessions, the goal is to quickly establish a partnership between all participants. The initial sessions are intended to build group identity and a sense of mutually shared interest before going on to discuss clinical and rehabilitation issues. This approach promotes inter-family and interpersonal social support.
Traditional multifamily therapy models emphasize expressing feelings, while risking negative emotional interactions among group members. These spontaneous initial techniques often spark conflict between family members, disagreement between families about the purpose of the group, and anger or confrontation with the leaders. People with schizophrenia and other serious mental illnesses often become overwhelmed and subsequently give up on the group. Similar reactions have been seen in minority groups with less experience in therapy and who simply do not understand the function or value of non-directed conversation among a group of strangers.
Since successful outcomes depend on at least one member of each family participating in the group for at least one year, it is important to avoid dropouts. Solving problems in the group depends on ideas being shared and accepted across family boundaries, so it is best to proceed slowly and take the time to develop trust and empathy. In situations where the family prefers to meet individually with a practitioner rather than join a multifamily group, or a multifamily group is not imminent, the practitioner should maintain the goal of developing a partnership with the family and consumer. This process is started in the joinings and continues through the single family sessions as the family and practitioner learn about one another, then learn to solve problems that interfere with the consumer’s progress in daily life.
The rationale for Making the First Two Groups Different
People need an opportunity to get to know one another apart from the effects of mental illness on their lives. The first and second group sessions are designed to help the participants and co-facilitators learn about each other and bond as a group.
Unlike traditional group process sessions, people in multifamily groups are encouraged to also talk about topics unrelated to the illness, such as their personal likes, dislikes, and daily activities. The first two sessions are especially important in this regard.
The Role of the Co- Facilitators in the First Two Groups
The co-facilitators act as good “hosts”. They make introductions, point out common interests and guide conversations to more personal subjects, such as personal histories, leisure activities, work, and hobbies. Practitioners act as role models. They demonstrate by their own example that people are expected to talk about topics other than the illness. This means practitioners should be prepared to share a personal story of their own.
Practitioners should pay close attention to each individual who speaks and thank him or her when they finish. It may be necessary for co-facilitators to prompt reluctant group members with questions or offer encouragement to talk more. It is also important for practitioners to understand that many people in the group may benefit from a slow conversational pace to better absorb information that they hear.
Tip: Multifamily Group Behavior
Practitioners who are trained in traditional group process models should not expect groups to interact in exactly the same way as in a group process setting.
The first session is not intended to be an opportunity to share deep emotions and feelings about the illness or about the group itself. This is a time for families to get to know each other and discover common interests, issues, and concerns.
The Design of the First Group
In the joining session, consumers and families learn that they are expected to meet with five to eight other families for 1 1/2 hour meetings every other week for at least six months, and then monthly for as long as families find it helpful.
The goal of the first group is for practitioners and family members to get to know each other in the best possible light.
Tip: Setting up the room
Chairs should be arranged in a circle or around a table so everyone can easily see and hear each other. The same setup should be used at every session. Once the problem-solving sessions begin, groups often like to be in a semicircle so they can see the blackboard or flip chart.
Refreshments, including decaffeinated beverages, should be available to allow relaxed interactions before and during the group. Co-facilitators should say at the start of the session that it is all right to move around, get a drink or go to the bathroom whenever necessary. Consumers, especially, should be made to feel they can leave the room whenever necessary.
Practitioners should think of this group in terms of any group of people who are meeting each other for the first time. The facilitators act like good hosts by guiding the conversation to topics of general interest, such as: where people live, where they were born and grew up, what kind of work people do both inside and outside the home, hobbies, how people like to spend their leisure time, recent movies they’ve seen, what plans people have for holidays or vacations, etc.
The co-facilitators begin by introducing themselves. Next, they welcome the entire group and remind them of the format of future groups. They might say: “This is our first meeting. We will meet every other Thursday at this time. We will work together for the next year or two. Our goal is to problem-solve ways of achieving more satisfaction with our family lives, work and social lives.”
Tip: Making the introductions
It is common for people to want to talk about the illness during their introduction. Co-facilitators can avoid this by modeling what sort of introduction is expected and by redirecting people: “This is the time for people to get to know each other. We will have time to talk about the illness later on.” Also, if families have joined thoroughly with one of the practitioners, they will feel less need to focus on illness during the first group.
The practitioner continues by setting the agenda for this particular group. He or she might say: “Tonight we will try to get to know each other since we will be working together for a long time. We will go around the room and each of us will say something about ourselves. It is understandable that people may want to talk about the effects of a mental illness. We will get to that at our next meeting. Tonight, we want you to talk about the rest of your life and the things about you and your family you are proud of. I would like to start by telling you about myself.”
When co-facilitators participate and talk about themselves, it allows them to act as members of the group and creates a feeling of partnership with the families. The practitioner’s goal is to provide a model for the group. For instance, a practitioner might say:
“Hi, my name is Margaret Hanson. Some of you have already met me, and some of you are meeting me for the first time tonight. I am a nurse and have worked in the community mental health center here for 15 years. I grew up in this area and my parents still live in the house I grew up in. I’m the mother of three teenage girls who keep my husband and me very busy and challenged! Even though the girls are growing up and going in different directions, we still like to do things together as a family. One of the things we like to do is go camping. Over the years, we’ve acquired a lot of equipment so the children could each invite a friend along on our trips. This summer, we’re planning a trip to the White Mountains, and we’re bringing along 2 large canoes since the girls are inviting friends. I especially enjoy these trips since I don’t do much of the cooking…my husband does! It’s so peaceful to camp and to spend time in a less harried environment. We have an old yellow lab that stays home when we go camping, but when we’re home, she likes to take me for a walk every morning, usually as the sun comes up! In my spare time, I enjoy gardening, scouting flea markets for “finds”, spending time with friends, sewing, and reading. Occasionally, my husband and I catch a movie, go out to eat with friends, or walk the beach when the tourists aren’t around. Well, that’s enough about me for now. I’m looking forward to getting to know all of you better as time goes by.”
Then the practitioner turns to the next person and continues around the circle, thanking each one after his or her contribution. The second practitioner sits halfway around the circle, and takes his or her turn in sequence.
Tip: Prompting
Co-facilitators sometimes have to prompt a group member who offers a minimal amount of information about him/herself. The practitioner asks questions to help the person give more details. For example, the practitioner may ask whether the person likes to watch TV (which shows?), read, follow the news, cook (what favorite recipes?), eat out (what restaurants?), listen to music, go to the movies (any recently that you liked?), follow sports (which teams?), do crafts, take walks (where?), belong to organizations (which one(s)?), go to church (where?), etc.
The guiding principles for this session are validation and positive reinforcement. It may be useful for practitioners to tell members that they should only share information they think others will view in a positive light. Unpleasant family background, like criminal activity, addictions, etc., is of little help in problem solving and, if presently under control, is not especially relevant.
Tip: Interruptions
The practitioner needs to interrupt when: a) a family member speaks for someone else, or b) a family member follows the natural impulse to talk about the effects of the illness. The practitioner can restate the purpose and format of this particular group. For example, the practitioner might say: “Right now I’d really like to hear about you “ or “It’s natural to want to talk about the illness and we’ll be getting to that soon. But now I’d like us to get to know each other.”
Co-facilitators should strive to point out similarities or common interests in the group. For example, he or she might say: “I notice that several of us like to go to the movies. Maybe sometime we can talk about our most recent favorite films.” This helps develop relationships and group cohesion.
It is also helpful to point out group members’ different approaches to solving problems. This diversity of ideas is one of the keys to success in problem solving in multifamily group sessions.
It is key that during this session, the leaders have thought through how this format may contradict cultural norms for one or several families and be prepared to adapt and explain the approach to them, allowing them to introduce themselves in whatever way would be culturally congruent. It greatly helps in this regard if at least one of the leaders represents that cultural population and can interpret both at the linguistic and social level, and make them feel comfortable and respected.
Tip: Sharing personal information
Practitioners may find it uncomfortable to share personal information, since this is a departure from the usual way of conducting groups. However, it is essential to create a friendly, comfortable atmosphere between practitioners and families.
It may be helpful for co-facilitators to rehearse with each other ahead of time. Think of a few superficial, but personal, stories about family or favorite activities or foods and be prepared to talk about these topics for about five minutes.
The Design of the Second Group
This group will focus more on how the mental illness has changed the lives of the people in the group. The co-facilitators should state clearly that the focus of the evening is “how mental illness has changed our lives.” In this session, the goal is to continue building trust among group members. This meeting is intended to help participants quickly develop a sense of a common experience of having a major mental illness or having a relative with a disorder. The mood of this session is usually less lighthearted than the previous session, but it is the basis for the emergence of a strong group identity and sense of relief.
Both practitioners welcome members to the group as they arrive, and direct them to the refreshments. To start the group, one practitioner outlines the agenda for the meeting. He or she begins by saying, “Thanks for being here tonight. Last time we spent time getting to know each other. Tonight, let’s begin by visiting with each other for 15 minutes. Then we will discuss how mental illness has affected us.”
The practitioner begins the socializing with a comment or question unrelated to the illness, and perhaps somewhat superficial, such as, “Did any of you see the rainbow on the way over here? It actually looked like a double rainbow, which I have only seen one other time.”
Tip: The importance of humor
Early on, it is helpful to introduce humor into the group dynamic. The practitioner should let group members know that it is okay to have fun and laugh, and should model this behavior as well.
It is important to begin groups by socializing. The practitioners should encourage participation by modeling, pointing out connections between people and topics, and asking questions. Also, they should feel free to join in the discussion, especially if the topic is relatively neutral and does not reveal sensitive personal information. Side conversations, interrupting, monopolizing, criticizing, complaining and speaking for others are discouraged with positive redirecting remarks, such as: “It’s hard for me to hear when more than one person is talking,” or “That’s interesting; I wonder if Mr. Smith has something to say about this,” or “Your wife says she thinks you’re over the flu. How long were you sick?”
After socializing, the practitioners proceed to the topic for this meeting. One of them might say, “Now it’s time for us to focus on our topic for the evening. Mental illness has touched all of our lives in some way and is the reason we are getting together on a regular basis. Tonight, we will each have a chance to share our personal story of how mental illness has impacted our life. You can share as much or as little as you would like, but also feel free to ask one another questions and to provide support to one another. I would like to start off by sharing my story.”
Tip: Difficulties of the second session
It may be difficult for group members to confide their problems. Co-facilitators need to work hard to encourage people to talk and to promote connections between people, such as similar problems, worries or stories. It may be necessary to ask questions to keep people talking.
Since group members will follow the practitioners’ examples, practitioners should share as much as possible about their own professional and personal experiences. Practitioners may want to share a story about a friend or family member with mental illness or talk about how they became interested in their work and how they have been affected by treating people with serious mental illnesses.
It is important to encourage group members to express any feelings that surface while discussing these difficult experiences, especially the feelings that families commonly have but are reluctant to talk about. These include anxiety, confusion, fear, guilt, anger, sadness, and grief.
When the practitioner finishes his or her story, he/she turns to the person in the next chair. “How has it been for you? How has mental illness affected your life?”
Some individuals may find it difficult to talk about their experiences. People can say as much or as little as they wish. After each person has briefly shared his or her story, the co-facilitator should thank him or her. This is a good time to point out any similarities to another group member’s experience. This group meeting may be the first time some families realize they are not alone.
Compared to the first meeting, the mood of this meeting is often sad, and there may be anger and frustration expressed as well.
The leaders also remind group members that during future meetings everyone will be working on solving problems like the ones expressed in this meeting and that similar issues have been successfully dealt with in previous groups. It is important to be optimistic and send people home with the sense that the group can and will help them.
At the end of the group meeting, the facilitator should remind members of the time and date of the next meeting. There should be 10 minutes or so to socialize before concluding the group. Practitioners should promote socializing at the end of the group and tie conversations into concrete topics, like weekend plans, recent movies seen, holiday plans, etc. The purpose of the socializing is to re-acquaint people with the art of small talk and to gain confidence in making interpersonal contacts.
Tip: Dealing with complaints
Sometimes group members will express their unhappiness with the consumer’s psychiatrist, the mental health system, or a particular institution. The practitioner should validate these feelings and experiences and ask for specific details. However, this discussion should not dominate the session. If group members start to talk about specific problems that they want to solve immediately, the practitioner helps them return to the agenda of the meeting by saying something like, “We will have an opportunity to solve problems at a later session.” Or, the practitioner might suggest meeting outside the group to discuss the problem.
Tip: Keeping the family up-to-date
Co-facilitators should share with the group any new research or information they come across. This includes articles, helpful strategies and medications.
Tip: Timeline for group meetings
These sessions are usually biweekly and become monthly after stability has been achieved. They continue for at least six months. Research has shown that two years is indicated for schizophrenic disorders.
Tip: Case management
Some groups have found it helpful to provide case management during the multifamily group sessions. It can be an effective way to deal with several families’ problems at one time.
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