Other Forms of Psychotherapy for Major Depression - Group, Family and Couples Therapy

Rashmi Nemade, Ph.D., Natalie Staats Reiss, Ph.D., and Mark Dombeck, Ph.D.

As the name suggests, group therapy (including family and couples therapy) is a form of treatment involving a small group of individuals, generally between 4 and 12 in number, who meet regularly to talk, interact, and discuss problems with each other. Therapy groups are typically run by one or more group therapists who keep the group organized and on track therapeutically. Therapy groups can be highly structured in nature (with specific goals set for each meeting) or flexible (group members discuss whatever is important). Groups are often set up to address particular therapy agendas. For instance, a therapy group might address men's issues, or women's issues, or focus on anger management, social anxiety, or chronic illness support. Participants are typically invited into the group based on the degree to which they fit the profile of an ideal member (e.g., having issues that the group is designed to address; being the right gender, etc.) and how likely it is that they may be able to contribute to the group as a whole.

However they are structured, most therapy groups have some basic ground rules that are usually discussed during the first session. Individuals are usually asked not to share what goes on in therapy sessions with anyone outside of the group. This rule protects the confidentiality of the other members and encourages people to be open and honest in their comments. Group members may also be encouraged to avoid seeing other members socially outside of therapy because of the harmful effect it might have on the dynamics of the group.

The emphasis on the patient-therapist relationship in individual forms of therapy is, in group therapy, replaced with an emphasis on patient's relationships with other patients. Group therapists set agendas within the therapy setting, but they are most happy when they are able to get out of the way and allow group members speak to one another directly. Patients are often more receptive to feedback they get from peers than they are to feedback they get from therapists who are often perceived as authority figures.

In a group therapy session, members are encouraged to openly and honestly discuss the issues that brought them to therapy. They try to help other group members by offering their own suggestions, insights, and empathy regarding discussed problems. A well functioning therapy group offers its members a safe and secure place where they can discuss and work out problems and emotional issues. Participants gain insight into their thoughts and behavior by listening to peers who are struggling with similar issues, by offering support and feedback to peers, and by accepting the support and feedback of other members.

Group therapy is often an ideal therapeutic environment for people who are having interpersonal difficulties, including depression (and anger and social anxiety problems, etc.), as the therapy is inherently interpersonal in nature. Affected group members usually benefit from the social interactions that are a basic part of the group therapy experience.

Group therapy provides a sense of identity and social acceptance for some participants. It can be very comforting to realize that other depressed people have similar symptoms, emotional issues, and life stressors. Learning how others cope with depressive symptoms provides new strategies or ideas that people can try in their own lives. Group interactions can also offer people unique insight into their own behavior, and provide immediate feedback about the success of new skills. For instance, many people are not aware of their negative body language (tendency to slump, look down, sit with crossed hands and feet, etc.) or style of communication unless it is pointed out to them directly. Group members may also offer one another social support by providing each other with words of encouragement and empathy. Lastly, by helping others in the group work through their problems, members can gain a personal sense of self-esteem.

As is the case with individual therapy, group therapies may draw on different psychological theories. For example, a depressed person may participate in a cognitive behavioral group that uses the meetings as a workshop for teaching cognitive restructuring and similar exercises involved in monitoring and changing thoughts and behavior. Alternatively, a group might be run more dynamically in nature and focus on interpersonal relationships, both at home and within the group itself. Sometimes, group therapy is used as a way to transition people out of individual therapy. Groups can also be a cost effective way to continue therapy after insurance benefits run out (group therapy sessions usually cost substantially less than individual therapy sessions). Group therapy is probably not helpful as a sole therapy for severely depressed individuals (unless it occurs in the context of a larger therapeutic program). However, research suggests that cognitive behavioral group therapy can be very effective for people with mild to moderate depression.

Family and Couples Therapy

Couples therapy occurs when intimate relationship partners (married or otherwise) enter therapy together. Family therapy occurs when an entire family comes for therapy. Both of these forms of therapy tend to take a Family Systems approach to therapy. Therapists working from this approach treat the entire unit in front of them (e.g., the entire couple; the entire family) as the patient, and the individual members of these social groups are seen as components of that single patient. Though entry of couples and families into therapy may be motivated by problems that a single individual within the couple or family is having, the family systems therapist will tend to view the identified problem as a problem shared by all system members. In this way of doing therapy, a husband's depression is considered, at least in part, as a symptom of something going wrong with the relationship, and not simply something going wrong with the husband.

Family therapy and couples therapy sessions delve into the details of the interactions between partners, or family members as a core component of treatment. Both therapies examine the role of the depressed member in the overall psychological well-being of the family (or couple), as well as the role of the family (or couple) in creating depressive symptoms. Both family therapy and couples therapy aim to identify and then change destructive relationship patterns that may be contributing to the system's difficulties. For instance, if a family has been scapegoating one of it's members, and that member has become depressed, the therapist will call attention to this scapegoating behavior. If one spouse is enabling the other's abuse of alcohol, and both spouses are depressed, the therapist will call attention to this dysfunction too. Family and couples therapy can also uncover hidden issues and/or teach people new strategies for dealing with emotions and behavior.

Family and couples therapy isn't generally viewed as a good primary means of obtaining therapy for depressed individuals, but it can be an excellent adjunctive therapy strategy, as depressed individuals are both affected by and affect their relationship partners. Family or couples therapy is most useful when a person's depressive symptoms are: 1) seriously jeopardizing his or her marriage and family functioning, and/or 2) clearly being caused (or maintained) by dysfunctional marital and family interaction patterns. Patients with mood disorders have a very high rate of divorce. Many people (approximately 50%) report that they would not have married their spouse if they knew that he or she would develop a mood disorder. Family and couples therapy, therefore, can be a crucial and effective component of treating depression.

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