This paper presents a systemic approach to group work with parents of patients with mental illness. Close relatives, especially mothers, act as the major carers for patients with psychosis. Patients’ families feel overwhelmed, most of them are isolated, and need support from mental health services. The parents group is an effective therapeutic intervention that helps families to cope with problems, improves the quality of relationships and can facilitate the return of a person with mental illness to recovery.
Key words :Family relations, interventions, psychosis, parent groups


As the duration of hospitalization is reduced and psychiatric patients return to their families after hospitalization, the needs of these families increase. The families feel overwhelmed, they experience grief, they have to cope with stigma and have a lot of concerns about a range of everyday problems.
In grief, they experience the feeling of loss and grieve for the loved one they knew. There is also a loss of expectations. Resolution of grief is also complicated by the stigmatization of mental illness. Since the diagnosis of mental illness is often concealed from those outside the family unit, it may not attract the same attention and support that an overt source of grief such as death would ensure.
Stigma exacerbates the sense of being different or feeling marginalized. Studies show that half the parents and spouses of recently hospitalized psychiatric patients concealed the hospitalization to some degree (Phelan et al, 1998). The hospitalisation of a female relative was more than twice as likely to be concealed than that of a male relative.
Mothers are more socially isolated than fathers because they invest more time in the care of the patient, and are affected more by his behaviors (Lefley, 1994). Siblings of psychotic persons feel resentment towards the patient because of the attention given by parents (Seltzer et. Al. 1997) as well as the overwhelming fear that “it can happen to me”, while they want to confirm that parents see them as “the good son/daughter.”
Chronicity plays a central role in the family dynamics. The relapses, crises and hospitalizations determine family life, which is dominated by concern about the prognosis, sorrow for the suffering patient, ignorance about how to cope with the manifestations of the disorder, feelings of inadequacy and failure as parents. They are often told that they do not have the right to feel anger or hostility towards the patient and they should offer unlimited devotion and care. They expect that the experts will disapprove of them (Johnson HC 1987). The same dynamic exists in families which have a member with special needs such as autism and other populations with chronic diseases (Johnson, 1986b).
The adjustment of these families to the emotional and social conditions of a chronic mental illness is hindered by the inherent dysfunctional relations. These dysfunctional relations within the family also affect the course of illness.
Many of these families have high degrees of enmeshment, rigidity and distorted hierarchies. They respond to changing conditions by intensifying old habits. They are usually isolated or in conflict with their environment. While they have internally unresolved conflicts, these families present themselves to the outside world as united.
The presence of the patterns of double bind (Bateson, 1956), pseudomutuality (Wynne, 1958), disqualifications (Watzlawick, 1977), avoidance to define the relationship (Haley 1990), power games (Palazzoli, 1978), and high degree of fusion and triangulation (Bowen, 1957) show that the illness is embedded in family dynamics, and this means that the family has greater resistance to therapeutic interventions.
Expressed emotion (EE) was a construct derived inductively from psychosocial research (Bertrando 2009) and it comprises emotionally over-involved attitudes and behaviours displayed by one or both parents to their schizophrenic offspring. Patients living in high-EE families have high relapse rates (Brown et al, 1972) and (Vaughn et Leff, 1976)

Multi-Family Group Therapy (MFGT) in psychosis.

Laqueur was one of the first users of MFGT in a hospital setting with psychotic patients. He reported that MFGT was cost-efficient, and produced change faster than therapy with individual families (Laqueur, 1976). Laqueur asserted that MFGT was distinct from other forms of therapy as it allowed the community to enter into therapy via other families.
Bowen (1976) applied his theoretical concept of triangles to groups of families as he focused on emotional interdependence between family members while other group members silently observed.
As a result of the evidence that expressed emotions (ΕΕ) affect the course of the disease and the relapse rates, psychoeducation programs directed to the family were implemented. Psychoeducational programs may take a number of formats, including therapy sessions with single families (Kuipers et al., 2002) and therapy sessions with multiple families (McFarlane, 2002). Psychoeducation programs provide family members with both information about schizophrenia and strategies for managing common problems, for reinforcement of medication compliance, training in stress management and problem-solving skills.
Formal psychoeducation and formal problem-solving approaches do not ‘fit in’ with systemic practices (Asen E. Schuff H.,2006). Psychoeducationalists hold that all the available knowledge about the illness, the treatment and the findings from the field of EE research (Leff and Vaughn, 1985) are ‘lessons’ which can be taught, so as to affect behaviours within the family, mainly those of carers in relation to the person with psychosis. Moreover, psychoeducation places its emphasis on the concept of illness and divides the family in two—the sane on one side, the ill on the other. Such polarization goes against the unity of the family and may have rather serious side effects (Bertrando 2009).
The Family team at the Marlborough Family Service in London developed a systemic model of multiple family Group therapy (MFGT) (Asen E. Schuff H.,2001). Drawing on their many years of experience of working with families, they adopted a structurally derived approach based on the organisation and development of family life. The model offers clear guidelines to the therapist for interventions on the hierarchies, boundaries, decision making and patterns of interaction and communication.

Parents group 

The psychiatric department of the General Hospital of Athens “G.Gennimatas”, in search of an effective therapeutic continuity after discharge, began implementing group therapy for parents of schizophrenic children who had been hospitalized in the clinic. This work with groups follows the systemic approach and is inspired by the parents’ and mothers’ groups conducted by G. and V. Vasiliou in the Athenian Institute of Anthropos. The therapists were trained in this institute and are experienced family and group therapists. Our approach to families with a member suffering from psychosis also includes elements derived from a multi-family therapy program in Marlborough Family Day Unit in London (Eia Asen 2001)
Group meetings are held on a weekly basis and include 15 participants. Before new members join the group, they undergo two to three single family sessions. Both parents participate in the group. However, there is the flexibility to include either only the mother, who is committed individually, or the father, whose attendance is not regular. Sessions start with a topic usually pertaining to understanding and handling emotional issues that arise in communication, interaction, and crisis management. Then the group is divided into subgroups so as to encourage higher participation, and the interaction becomes more complex. Parents from the same family are placed in different subgroups. Each subgroup reaches a conclusion. At the end, at the plenum the subgroups share their messages with other team members and arrive at a synthesis.
When the parents come for the first time in the group, they demand concrete answers at a cognitive level about the manifestation of the illness, the medication and side effects, recent advances in pharmacotherapy. Later they discover that they need to learn about themselves and about the changes they should effect so that the family can become more functional and more content.
Οur approach is based on the belief that families have many resources of their own. Our task is to facilitate the emergence of these resources and reinforce the family to make some positive changes.
We assure parents that we do not believe they are the cause of the “illness.” This relieves them because they expect that experts will disapprove of them again. This belief does not stem from the view that psychosis is purely a biological disorder with no interaction with the dynamics of family, but from the epistemological position that attributing blame to somebody for the illness is to adhere to the linear causality.
There are no ready recipes for dealing with behavior problems. The problematic behaviors are examined in the context where they arise. Not all behaviors derive from illness. For example, a mother asked what to do when her son swears at her. Upon probing, it transpired that her son attacked her verbally when she tried to dictate what his interests must be. For him, the problem was that the mother did not accept that the matter of interests is a personal one.
In problem solving and decision making we promote parents’ cooperation in order to work out their own solutions and block patterns of behavior in which they undermine each other. Whenever called upon to make decisions about a current topic, both recapitulate the whole history of their controversy.
Sometimes the wife will accuse the husband that he always leaves her to cope alone with the child, while the husband will respond by accusing her of never allowing him to relate to the child. Then we explore how she can find more functional ways to ask for help, or how the husband can stand by his opinion and not withdraw with the first frustration.
We clarify and strengthen the intergenerational boundaries of function, decision making and define the boundaries of privacy for young people as well as for adults who remain at home with their parents. One key goal is to achieve a greater degree of autonomy for the patient.
During the sessions we intervene to improve communication by improving clarity and congruence of communication patterns, ensuring that statements are completed and checking that each person has been understood.
The Group facilitators may take advantage of an interaction that occasionally emerges spontaneously within the group, so as to initiate enactment, intensification or playful exercises, develop alternative modes of resolving conflicts, such as developing empathetic listening, or urging to see one’s own role in the interpersonal processes.
We encourage parents to increase the number of relationships and get involved in social activities. This enables them to spread the emotional energy instead of concentrating their investment on one or two family relationships. By relieving the emotional fusion, more tolerance is facilitated. By increasing socialization, enmeshment loosens up.
There is often a close relationship between the isolation of the family from other intimate contacts and the patterns of overinvolverment in relationships within the family (Cooklin et al., 1997).
The question of meaning is of central importance to the conception of grief and chronicity. In the encounter with the loss of expectations and chronicity the family experience disruption in socially prescribed meanings in concepts of productivity, functional success and pursuit of excellence. It is in our considerations of, illness and adaptation that we are able to discover what is distinctive about the human. Humaneness transforms the approach to pain and gives new meaning to suffering and illness. We offer the meaning of adaptation as a movement of re-symbolization. Through symbolization they can positively deal with tragedy and limit.

Advantages of parent groups 

The group provides a framework for emotional support that comes from members of the same team. Bringing families together and encouraging them to make contact with one another expands their social network and counteracts isolation.
Our concern as facilitators is to encourage dialogue between members so that they share feelings and maintain their interest in each other. Thus we take care to create a positive, empathetic, non critical atmosphere of respect and encouragement. Questions like “what other group members think about the comments made by a parent, and how they feel“ promote interaction.
The therapeutic team’s continuous encouragement to parents to respond to one another and to comment on their observations creates a context for mutual reflection.
In the parent group context, couples benefit from their group therapy experiences. The group presents additional opportunities for them to address aspects of their functioning through the group process.
Parents exchanging their experiences and finding out that they have similar problems of living, can feel that they are “all in the same boat”. Joining other parents with similar feelings gives them a sense of solidarity and reduces some of the burden experienced by the carers. One father said “I come here to tell my pain, and I find others whose pain is greater” Additionally, they give and receive emotional support.
Peer support and peer criticism are known to be powerful dynamics that can promote change. Many people find it easier to use mutual support and feedback from fellow-sufferers than from staff. It seems more “credible” because these families all have direct painful experiences of similar issues.
In this way, there is active parental involvement in the management of their problems. The positive energy released in the course of such a therapeutic process activates the strengths of the family and injects hope.


To evaluate the effectiveness of the Parent group therapy modality, we created a self report questionnaire with 20 questions that evaluate five areas of family functioning: emotional exchange, communication, decision making, conflict resolution and crisis management. The questionnaire was administered after 18 months of participation in the group.
Parents reported increased tolerance, better comprehension, more openness and sharing and improvements in crisis management and decision making.
During the first four years of the group’s life, parents from 30 families participated. Patients whose parents participated in the group had longer relapse-free periods compared to the previous course of their illness, and in some cases relapse was treated without the need for admission to hospital. In two cases, patients who had been compulsorily admittedin the past, were hospitalized voluntarily for a short period.


With the move away from institutionalised care for psychiatric patients, the respite afforded by this care is being replaced by greater contact with families. If a patient is in regular contact with family members, it is reasonable to engage these relatives in the patient’s care.
Preliminary evidence suggests that parent groups is an effective intervention in psychosis. This aids family members not only in contributing to problem resolution but also in disengaging from family processes that maintain the identified patient’s problems. The approach is acceptable by the affected families, improves the relations between families and professionals and facilitates the rehabilitation of patients.
This approach can be further developed so that more families can benefit. It is a flexible interactive approach that can be expanded to the broader mental health service context.


Asen Eia, Dawson Neil McHugh Brenda. Multiply Family therapy: The Marlorough Model and its wider applications. Carnac Ltd. London (2001)
Asen Eia and Schuff Heiner: Psychosis and multiple family group therapy Journal of Family Therapy (2006) 28: 58–72
 Bateson G, D.Jackson, J. Haley J.H. Weakland: Towards a theory of schizophrenia. Behavioral sci. 251-264, 1956
Bertrando, Paolo, Surviving in Psychiatry as a Systemic Therapist, The Australian and New Zealand journal of family therapy Volume 30 Number 3 2009 pp. 160–172
Bowen M. Family participation in schizophrenia, Am.Psychiatric Association, Chicago,May 1957.
Bowen, M. (1976). Principles and techniques of multiple family therapy. In P. J.Guerin (Ed.), Family therapy, theory, and practice (pp. 388-404). New York: Gardner.
Brown, G. W., Birley, J. L., and Wing, J. K. (1972) Influence of family life on the course of schizophrenic disorders: a replication. British Journal of Psychiatry, 121(562), 241—58.
Cooklin, A., Bishop, P., Bruggen, J., Sturgeon, D.(1997) From patients to service systems: Family interventions training as a strategy of change in mental health care delivery.
Haley, Jay. Strategies of Psychotherapy. 2nd ed. Rockville: Triangle, 1990.
Johnson H.C. “Biologically based deficit in the identified patient: Indications for psychoeducational strategies: J. Marital and Family Therapy: Vol.13, No 4, 337-348, 1987
Johnson, H. C. (1986b). Family system scanner. New York: Paul Brenner Associates.
Kuipers, E. (2006) Family interventions in schizophrenia: evidence for efficacy and proposed mechanisms of change. Journal of Family Therapy, 28: 73–80.
Laqueur, H. P. (1976). Multiple family therapy. In P. J. Guerin (Ed.), Family therapy, theory, and practice (pp. 405-416). New York: Gardner.
Leff, J.P., & Vaughn, C.E. (1985). Expressed emotion in families. London: The Guilford Press.
Lefley, H.P. and Wasow, M. (ed) 1994, Helping Families Cope with Mental Illness, Harwood
McFarlane, W. R. (2002) Multifamily Groups in the Treatment of Severe Psychiatric Disorders. New York and London: Guilford Press.
Palazzoli M.S., Boscolo L., Cecchin G., Prata G.,: Paradox and Counterparadox, Jason Aronson 1978, London
Phelan JC, Bromet EJ, Link BG.: Psychiatric illness and family stigma. Schizophr Bull 1998; 24: 115-26
Seltzer, M. M., Greenberg, J. S., Krauss, M. W., Gordon, R. M., & Judge, K. (1997). Siblings of adults with mental retardation or mental illness: Effects on lifestyle and psychological well-being. Family Relations, 46,395–405.
Vaughn C, Leff J. The influence of family and social factors on the course of psychiatric illness. Br J Psychiatry 1976; 129: 125-37.
Watzlawick, Paul. How Real Is Real: Confusion, Disinformation, Communication. New York: Vintage-Random, 1977.
Wynne, L.C., J.M. Ryckoff, J. Day, S.I. Hirsch: “Pseudomutuality in the family relations of schizophrenics, Psychiatry, 21:205-221(1958)