Learning Multiple Family Therapy Through Simulated Workshops

Our former method of teaching Multiple Family Therapy (MFT) was to have a beginner progress through at least five steps, each with a minimum duration of twelve weeks. The progression was from silent observer, to operator of the video camera, to active observer, to cotherapist, to therapist; this process frequently took two years. We now believe that MFT can be learned through role-playing in simulated MFT workshops. The advantages of these workshops are:

In writing about what we actually do in a workshop using role-playing and emphasizing nonverbal communication, we find the written word lacking in power to communicate the process. It's similar to doing family therapy supervision from only an audio tape — the words are just one dimension of the experience. We hope the chronological account of an actual workshop of simulated MFT will mitigate the deficiencies of these written words.

Getting MFT Simulations Started

Our ideal size in negotiating for a workshop is about 25 with an upper limit of 35. If the number of participants approaches 35, the group should be divided into families with more individuals in each family e.g., 6 families of approximately 6 each versus 8 families of 4. We have done a workshop with as many as 9 families but this proved difficult just to remember all of the characters and who belonged to which family.

We have also learned to predict a dropout rate of 20 to 30 per cent, which seems to approximate real MFT, in which some members and families do not return each week. This drop-out rate will also vary with selection and preparation of participants, in a similar fashion to selecting patients for group therapy (1). In our experience workshop participants do not drop out of the simulations and remain in the workshop. We have encountered slight resistance to role-playing but as with actual MFT this is easily overcome with constant, gentle, firm pressure.

We negotiate for a duration of one to five days for each workshop with an ideal of two to three days. Longer workshops allow the participants to get more into their roles and approximate more closely the intensity of actual MFT. They also enable the leaders to cover many issues, which can simulate a one- to two-year time period of MFT. An important factor in selecting workshop duration is the stamina of the leader, as the simulations can be very strenuous.

After defining the group size and time parameters, the MFT workshops can begin. Our treatment of theory in the workshop is similar to the way we handle historical facts with families, ie, integrated throughout the workshop rather than explored in depth at the very beginning. Thus, we begin a workshop with a brief (fifteen to thirty minutes) theoretical introduction, including from the start the many pitfalls of the modality and the personal reflections of the leaders.

Next we move rapidly to subdivide the large workshop group into families based on the color of their clothes, yielding, e.g., a red, brown, blue, green and white family with the simulated kids removing their shoes. It is only necessary to assign participants roles of mother, father, aunt, son, etc.

A suggestion of who the identified patient is —“Your daughter cannot decide if she wants to be a nun or a street walker — and the “family” is off in a matter of minutes to simulating years of psychopathology. Professionals seem very eager to role play and they will frequently choose their most difficult cases.

Before too much chaos develops, we begin a simulation of the first MFT session. We advocate several exercises to facilitate early cohesiveness and identification with subgroups. It is useful to have mothers and fathers come to the center of the room and discuss what kind of spouses and parents they are. This gets Mr. Brown thinking about himself as a father along with Mr. Red, Mr. Blue, and Mr. Green, rather than only as a member of the Brown family. The kids can also be brought together in the center of the room — first the group defined by their families as “good,” then a second group defined as “bad.” In both workshops and actual MFT, the “bad kids” rapidly gain a great deal of support from each other, and “bad” can be redefined as “having more fun.” There is a lot of polarization around this specific issue and the stage is set for a working-through phase.

In the initial sessions of a workshop (as well as MFT itself), it is important for people to physically get off their seats and begin paying attention to nonverbal clues and visual images, using such techniques as sculpting. We set a goal of at least one exercise per session to achieve some kind of movement and to decrease intellectualization. To include children and keep their interest, it is necessary to do more than just talk. Shifting chairs frequently helps to keep everyone alert, and we continually look for ways to physically subdivide people into new groups, eg., moving the entire group into one of four corners representing mad, glad, sad, and afraid. Other exercises have been previously published (2).

What to Expect in the Middle

In thinking about the middle of the simulated workshop, we became aware of an airplane-flight analogy, ie, the hardest parts are taking off and landing. In the middle, the workshop seems to flow, and our experiences with actual MFT groups seem to have prepared us for almost anything. Some turbulence inevitably develops, and although there are predictable content areas such as affairs, incest, grieving, drug abuse and others, there is always a unique, individualized unfolding of perplexing family conflicts.

During the workshop, we model our style of cotherapy interaction. Our age and experience present a discrepancy, so we model a complementary, father-son relationship with mutual respect and consideration. Besides each other, we can draw on participants in the workshop from previous years in places where MFT workshops have become an annual event. This process of involving experienced workshop members is parallel to utilizing actual MFT family members with the greatest group longevity as cotherapists and for living proof that families can and do change. More than one family has remained for a couple of sessions past their expected termination date to help engage a new family.

Usually during a workshop, we are asked to consult on ongoing MFT groups. Our most frequent encounter has been with discouraged leaders who lack flexibility, represented by either closed-ended or homogeneous groups, both of which lead to “dull” MFT. If, for example, five Jewish lawyers bring their families together, we have found it natural to discuss Jewish law and much more difficult to explore parent-child interaction and marital conflicts. The leaders have also frequently become discouraged because of unrealistic expectations, especially in beginning and maintaining a MFT group. Merely to recruit five families to “go public” in a group is challenging. To rapidly build cohesion and not have individuals feel lost in a crowd is also difficult.

We stress that establishing an MFT group and training program is frequently discouraging and, when a group finally takes off, a couple of families may drop out. Institutional resistance is ever present, and most colleagues will remain very skeptical.

One of our more successful consults was to an ongoing MFT group at Topeka State Hospital in Kansas. A three-member co-therapy team was conducting a closed-ended group, and they specifically requested some separate consultation time “behind closed doors.” When they were convinced to allow the consultation to be fish-bowled in front of the entire workshop, their protectiveness and secretiveness became readily apparent to everyone, with a resultant mushrooming of ideas for future directions and an obvious revitalization of the treatment team.

Following the consultation and questions from participants, we return to another simulated session. The stage is set only in terms of what number session the group is in and a hint at the process, eg., polarization is beginning to occur around the generation gap. Sometimes, especially after lunch, fatigue sets in for both participants and workshop leaders making it difficult to get back into the role. It is especially easy at these times for confusion to occur around whether people are in or out of roles. Here it is imperative for us as leaders to be clear when we are stopping and breaking roles for a clarification or explanation. This process in simulated MFT models frequent interruptions for clarification or explanation in actual MFT.

In general, the addition of role-playing makes simulated MFT in these workshops even more difficult for us than running an MFT group. One author (JR) has encountered more headaches and personal emotions in simulations than in actual MFT, especially around areas of adequacy as a therapist and personal grief. The death of his father became vivid when a participant was struggling with the actual loss of a brother dying of cancer while she simulating a grieving process in her simulated family.

How to End “Healthily”

Simulations by professionals offer the advantages of rapid recovery as the workshop approaches its conclusion. Professionals have a great need to help people and to show that what they do is helpful; thus incredibly severe pathology is rapidly resolved making the workshop leaders look very effective and talented. In summing up, it can be impressive to sculpt families showing how they first presented to the group and where they ended. Many structural changes become obvious in only a couple of minutes.

Another important part of the ending is debriefing. Since MFT roles have inevitably touched on many reality issues, debriefing is essential. It is also necessary to get professionals out of roles, especially important for those who will continue to work together. Paricipants are asked what it was like to be in their roles, who they are now, and if they are truly out of role again. Even after spending considerable time in this process, it is still necessary frequently to take someone aside after the workshop who is not responding in a spontaneous manner and talk him down.

The other part of closing is to assess the results of both simulated MFT workshops and actual MFT. The subjective opinion of the therapists is not enough (3). When feedback from the workshop group is elicited, the variance of response is astonishing. Realistically, the entire group can never be satisfied, but it is possible to satisfy the majority. Throughout the workshop, it is to be hoped that those individuals and simulated families who are dissatisfied with specific exercises and sessions will become involved and learn in a satisfying way at other times. From the workshops it appears that simulators of subassertives and schizophrenics are at high risk for chronic dissatisfaction. Here the role seems to double bind the simulator into feeling abandoned yet unable to mention it. In fact, in MFT, these specific clients need the closest scrutiny not to become lost and may be the most vulnerable clients for deleterious effects from MFT.

Our workshops have stimulated an increased interest and involvement with MFT in many of the participants. Topeka, Kansas City, and Holland have all been revisited, and all are continuing MFT one year later with an increasing number of MFT groups, increasing workshop attendance, and snowballing enthusiasm.