r The Association for Family Therapy 2007.

Published by Blackwell Publishing, 9600 Garsington

Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA.
Journal of Family Therapy (2007) 29: 4968
0163-4445 (print); 1467-6427 (online)

Family discussion group therapy for major

depression: a brief systemic multi-family group
intervention for hospitalized patients and their
family members

Gilbert M.D. Lemmens,a Ivan Eisler,b

Lieven Migerode,c Magda Heiremand and
Koen Demyttenaeree
This paper describes a brief systemic multi-family group intervention for
hospitalized patients with major depression and their family members.
The presented treatment integrates elements of systemic therapy, social
constructionist and narrative concepts and the family systems-illness
model. It has further adapted a specific multi-family group format
combining marital group sessions and family group sessions. Similarities
and differences with other family interventions for depression are
discussed. The therapeutic foundations and goals, the organization, and
the therapeutic process are explained. A number of clinical vignettes are
presented to illustrate the treatment procedure. Although the first clinical
impressions about the usefulness of the family discussion group intervention are promising, the efficacy of the treatment awaits the completion
of a clinical trial that is currently underway.

Introduction
To date, the field of empirically supported psychosocial interventions
for major depression has largely been dominated by couple treatment
studies for depressed outpatients (Gupta et al., 2003; Keitner et al.,
a
Consultant in Psychiatry, Section of Family Therapy, Department of Psychiatry,
University Hospital Leuven, Kapucijnenvoer 33, 3000 Leuven, Belgium. Tel: 0032-(0)16.
33.26.20. E-mail: Gilbert.Lemmens@uz.kuleuven.ac.be
b
Reader in Family Psychology and Family Therapy, Section of Family Therapy,
Institute of Psychiatry, Kings College, University of London, UK.
c
Senior Lecturer in Family Therapy, Section of Family Therapy, Department of
Psychiatry, University Hospital Leuven, Belgium.
d
Senior Lecturer in Family Therapy, Section of Family Therapy, Department of
Psychiatry, University Hospital Leuven, Belgium.
e
Professor of Psychiatry, Department of Psychiatry, University Hospital Leuven,
Belgium.

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Gilbert M.D. Lemmens et al.

2003). Examples include studies of behavioural marital therapy

(Beach and OLeary, 1992; Emmanuels-Zuurveen and Emmelkamp,
1996; Jacobson et al., 1991; OLeary and Beach, 1990), conjoint
interpersonal therapy (Foley et al., 1989), emotion-focused therapy
(Dessaulles et al., 2003) and enhancing marital intimacy therapy
(Waring, 1994; Waring et al., 1995). Overall, these couple interventions for depression proved to be significantly better than no treatment at all and as good as better than empirically supported
individual alternatives when applied in cases of marital distress
(Beach, 2003; Cordova and Gee, 2001; Mead, 2002). Despite some
differences in the treatment models, most of these interventions tend
to focus exclusively on treating the depression by focusing on changing the marital relationship (Cordova and Gee, 2001). There is some
evidence that they indeed alleviate the depression by improving the
quality of the relationship (Beach and OLeary, 1992; Jacobson et al.,
1991; OLeary and Cano, 2001). Their basis stems predominantly
from the evidence of a strong association between depression and
marital dissatisfaction in both treatment-seeking and populationbased samples (Whisman, 2001).
A conceptually somewhat different approach is adopted by Jones
and Asen (Jones and Asen, 2002; Leff et al., 2000) in whose systemic
couple therapy the focus is not primarily in altering relational distress,
but to help the couple to better cope with the depression. They
conceptualize the depressive symptoms in interactional terms, which
means that close relationships are both influencing and being influenced by the patient and his or her depressive symptoms. Attention is
first paid to exploring the depression definition within its relational
context, before looking at other and wider patterns of interactions
and quality of life questions, and ending treatment with the discussion of possible treatment gains and relapse prevention.
The third group of couple/family interventions for depression are
the so-called psycho-educational multi-family group interventions
that have been used mostly for individuals treated as inpatients
(Anderson et al., 1986; Harter et al., 2002; Keitner et al., 2002; Keller
and Schuler, 2002; Swan et al., 2004). These interventions are mainly
based on the core concept of depression as a biologically based
vulnerability to stress. Their aim is to alter the psychosocial environment to fit more closely the specific needs and biological vulnerabilities of the depressed person and to meet the family members needs
for education, guidance and support, drawing on the research
evidence that major depression has an important impact on many
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51

areas of family life: the partners and the children (Benazon and
Coyne, 2000; Beardslee et al., 1983), the marital relationship (Coyne
et al., 2002), and the family and social functioning (Keitner and Miller,
1990). Most of these programmes start with some education about the
nature of depression (e.g. aetiology, symptoms and course) and its
pharmacological treatment, before focusing on enhancing problemsolving, communication and coping skills, and increasing social support. Thus, conceptually, this focus is quite different from the focus on
the marital relationship as in most couple interventions. Unfortunately, little empirical data about these interventions are available at
present (Keitner et al., 2002).
At the Anxiety and Depression Unit of the University Hospital
Leuven we have been faced with a population of severely depressed
individuals, and in keeping with the strong family systems orientation
of the service we have developed a multi-family group approach for
depression. Its main aims are to address not only the needs of the
patients but also the difficulties of the family members in dealing with
depression and the impact of the depression on the family unit. The
group programme originated from previous multi-family therapy
work with psychiatric patients (Lemmens et al., 2001, 2003a) and
chronic pain patients (Lemmens et al., 2003b, 2005). In this paper, the
therapeutic foundations and goals and the organization of the family
discussion group will be outlined. Treatment processes will be described and illustrated with clinical vignettes. A randomized clinical
trial investigating its effectiveness is currently being undertaken and
the results will be reported in subsequent publications.

Therapeutic foundation and goals

The integration of systemic and narrative concepts
In the family discussion group model, elements of systemic therapy,
social constructionist and narrative concepts, and the family systemsillness model of Rolland (1994, 2003) are integrated. Central to the
model is the notion that the family becomes increasingly organized
around the depression, affecting every family member, who at the
same time affects the depression and its presentation in the family
context. Families living with depression often react by trying to
accommodate family life to the challenges and demands of
the depression. Over time, this process of accommodation leads to
major changes in family life. The family becomes organized around
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Gilbert M.D. Lemmens et al.

depression-related behaviours and demands (a dominant story, a

problem-organized system), resulting in drifting away from other
priorities that have been previously important parts of their lives (a
thin non-illness description) (White, 1995). In our family discussion
group therapy as in systemic couple therapy, three phases can be
distinguished: (1) the focus on the depression and its context; (2) the
focus on wider patterns of interactions and normative relational
functioning; (3) consolidating treatment gains and relapse prevention.
The family systems-illness model offers within a normative framework a useful systemic view of family adaptation to depression as
a developmental process over time (Rolland, 1998, 2003). It means,
for example, that during the acute phase of the depression, family
members need to take over the household roles of the depressed
person. Similarly, in the recovery phase the patient gradually needs to
take up more appropriate roles and responsibilities. It is important
that the patient and the family members anticipate their different
responsibilities during the various phases of the depression. This
model also considers the family as the central unit of care and
acknowledges their inherent need for support. By including the
families in the treatment programme, they not only may feel supported and better understood, but their presence may lead to a
broader perspective on the patients problems and a respectful
attitude of the therapeutic team for the families, resulting in working
together better (Lemmens et al., 2003a).
Multi-family format
Probably the most important therapeutic concept of the group is
based on bringing together different families suffering from depression, connecting them with each other in order to use their strengths
and resources. It is a higher order goal in our model than the
provision of information or education to the families as in some
psycho-educational multi-family groups.
The group itself is an important therapeutic tool. The presence of
several families reshapes all relationships in the group. It makes one
view oneself and the other less individually, but more as part of a
couple or a family. The problem of a depressed person (Im
depressed, My husband is depressed) is automatically reframed to the
problem of a couple or a family (Were struggling with depression). The
group helps to dilute the potency of the relationships and the family
dynamics. In contrast to single couple therapy, the partners in the
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53

group tend to never interrupt each other when one is speaking. The
position of the therapists is also influenced by this phenomenon as the
group mainly organizes itself, and the therapists are only one part of it
and never fully in control of the treatment process.
Further, the group functions as a therapeutic social network of
which the majority of those participating families and clinicians do
not have a diagnosis that interferes with social interaction and joint
therapeutic efforts (McFarlane, 2002). It helps the families to re-enact
their forgotten social skills and to overcome social isolation, which
characterizes many families living with depression. The socially
appropriate (i.e. normative) interaction between the families in the
group may also promote more normative behaviour and communication within and across family boundaries. The multiple opportunities
for experiencing communality in the group help the families to feel
that they are not alone in struggling with depression, to realize that
their reactions, feelings and difficulties are normal, and to feel less
stigmatized by the problem (Asen and Schuff, 2006; Lemmens et al.,
2003b; Steinglass, 1998). The variety of different and similar stories
(depression-related as well as non-depression-related) between the
families help them to broaden their viewpoints, to generate different
perspectives (Leichter and Schulman, 1974) and to learn from others
experiences in coping with the individual and family problems (Eisler,
2005; Lemmens et al., 2003a). The group, which creates a microsociety with specific rules and values, brings the outside world into
the therapy and simultaneously makes the therapy more real and
humane.

Adaptations specific for depression

In order to draw on the demonstrated value of couple interventions
for depression, our customary format was changed to primarily a
multi-couple group with the inclusion of two planned sessions to
which the patients children were also invited. This has the advantage
that the parents/couples have the opportunity to speak more freely
and to address specific couple issues, and at the same time a clear
voice is given to their children in the two children sessions. The
inclusion of the children helps to more directly pay attention to their
needs and may lead, in a more preventive way, to better child outcome
by improving parenting skills, family functioning and the parents
understanding of their children (Beardslee et al., 1983, 1997; Sanford
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Gilbert M.D. Lemmens et al.

et al., 2003). The content of these sessions is completely focused on

child issues with the children as the main protagonists.
In the context of the treatment study the content and structure of
the sessions are guided by a treatment protocol. While this limits, to
some degree, the flexibility of the therapists, it helps to structure the
sessions in a clear way by finding, for example, a good balance
between the depression-related and other types (e.g. recovery or
family-related) of stories since the content varies with each session.
The six fortnightly sessions and the follow-up session after three
months also cover the acute phase (e.g. admission) as well as the
recovery phase of the depression (e.g. period after discharge from
hospital). The follow-up session functions as a kind of aftercare by
refreshing and consolidating the treatment gains and by additionally
supporting the families in dealing with current difficulties during the
recovery period (Miller et al., 2005). It is important to emphasize that
the family discussion groups take place in the context of a broader
treatment programme (described below) and their aim therefore does
not lie primarily in reducing the depressive symptoms of the patients.
Rather the aims are:
 to decrease the impact of depression on the family unit
 to support the family in coping with depression
 to help the families with adapting to the different stages of the
depression and the family life cycle
 to promote a better working alliance between the patient, the
family and the therapeutic team
 to create healthier stories about themselves, their relationship,
their lives instead of the dominant depression story
 to improve family functioning, communication and problemsolving within the family
 to support normal family processes within the family life cycle
and intergenerational context.

The organization of the family discussion groups

Background
At the Anxiety and Depression Unit of the University Hospital Leuven
patients aged between 18 and 65 years with anxiety and affective
disorders are treated using a bio-psychosocial illness approach. The
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55

treatment programme, which lasts about three months, is available on

an inpatient or day clinic base. It takes place in two phases: a
problem-analysis phase (first month) and the working through
phase. During each phase, specific therapeutic interventions are
offered to the patients, mostly in a group format and fewer individually. The therapeutic techniques and interventions within the programme draw on different conceptual therapeutic frameworks such
as non-verbal therapy, cognitive behavioural therapy, systemic therapy, pharmacological treatment and activation. For example, the
systemic therapy component includes a genogram group, communication training and a narrative group, a lecture about the impact of
depression on the family (Rolland, 1994), a single family meeting for
all newly admitted patients, a multi-family group for depressed young
adults and their parents (Migerode et al., 2005), and the family
discussion groups for cohabitating couples and their children described in this article.
Organization of the family discussion group
The inclusion criteria to participate in the group were: (1) having
major depression as defined by DSM-IV (American Psychiatric Association, 1994); (2) being involved in the treatment programme of the
unit, and (3) cohabitating with a partner for at least one year. No other
selection criteria were used. Information about the group was given to
all newly admitted patients during the lecture about depression and
the family.
Patients and family members were also encouraged to participate
by members of the clinical team on the unit. Because patients often
felt reluctant to give their family members the additional stress of
taking part in therapy, it was sometimes more difficult to convince
them to participate than their partners.
A depressed husband was in doubt about participating in the group.
When his wife visited him on the ward, the group therapist asked her if
she would like to participate in the group. She responded that she had
read the informed consent and wanted to participate. Then she turned
to her husband: Of course, only if you also agree. He responded: I agree.

A group cycle started after four to eight patients and their partners
gave written, informed consent to participate in this project. The
children of the patients were invited to participate only in sessions 2
and 5. A male family therapist/psychiatrist together with a female
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Gilbert M.D. Lemmens et al.

therapist led the sessions. An observation team in the room consisted

of about three or four mental health professionals from the unit and/
or trainees in family therapy. Therapists and observers did not change
during a group cycle.
A group cycle consisted of six fortnightly sessions and a follow-up
session three months after the ending of the group. The group
sessions were held in the evening. A session lasted about ninety
minutes with a break after sixty minutes. Each session was videotaped.
The content of each session was determined by the treatment
protocol.

The therapeutic process

As family and systemic therapists, the group therapists are interested
in the belief systems, the behavioural patterns, and the contextual and
constitutional factors of the families (Carr, 2000; Rolland, 1998, 2003).
This is reflected in the treatment protocol and in their choices of
interventions in the sessions. During the first session, the content of
the introductory questions focuses, for example, on different aspects
of the family structure and present/absent family members such as
their number, age and gender, the duration of the marriage, and
school or professional activities. A variety of family therapy techniques
are used during the sessions including reframing techniques, the
search for exceptions, focusing on competence and resilience,
on changing behaviour and interactions, the exploration of family
life-cycle issues, circular interviewing, past/future/here and now questions, externalization of the illness and using metaphors. Informationgiving about depression and its treatment occurs in a conversational
way and rather as part of the general exchange of the different
experiences of the group members, including the therapists, in which
the families are treated as useful experts and encouraged to share
their experiences, feelings and perceptions in order to develop a
database about family reactions to depression and to family issues.
The therapists act mainly as facilitators of the conversation process.
In order to achieve this, they stimulate connections between participants occupying analogous family, developmental and illness roles by
searching for a common denominator. This helps the families to feel
supported, that they are not alone in coping with the depression.
Simultaneously, differences between the group members are searched
for and acknowledged in the hope that new stories and new insights
will emerge, and a rather and-and stance will be adopted.
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After the brief elaboration or presentation of family problems or

issues of one family, similarities or differences are quickly searched for
in other families (Can your absent son also talk to you about the depression,
like Mary is talking to her father?, Did the admission come suddenly or was it
more or less predicted?). The therapists try to let the information
circulate as much as possible in the group and make sure that all
participants, patients as well as family members, can express their
experiences. The discussion will never take place with one individual
or one family alone, but the information is allowed to reverberate
throughout the group.
An important aspect of the group process is valuing listening and
witnessing other group members which is often as important (and
sometimes even more important) than speaking itself. Every speaker
automatically has an attentive audience. Listening to the external
dialogue in the group helps to create a more effective internal
dialogue within each group member, which in turn leads to more
realistic viewpoints about themselves and their relationships. When
the internal voices are in their turn externalized in the group, other
internal dialogues are stimulated, leading to new external conversations. The group functions automatically as a constantly changing
reflecting team, restoring meta-communication which is often difficult
to achieve in chronic depressive families.
The therapists may support this process by paying attention to nonverbal reactions of the group members such as nodding or smiling.
These non-verbal reactions are often external signs of an ongoing
internal dialogue. Simply pointing to them (I see you smiling) is mostly
sufficient to help to externalize the internal dialogue. The use of socalled embedded suggestive questions, which the therapist asks when
she suspects what is ongoing in the internal dialogue of the group
members, may also enhance this process. These questions, which
contain some implicit viewpoints concerning the depression, the treatment or the family functioning, introduce a range of different meanings
to the audience and help to open up the dialogue. For instance, the
question: How can your partner appeal for support to the extended family and
friends introduces several different ideas such as that isolation is not
necessary, that isolation often happens in the context of depression, or
that a partner may need support in dealing with the depression. Each
group member, picking up a particular meaning and bringing it back to
the group, helps to broaden the conversation. Illness-recognizing
questions (What is the impact of the depression on your life?, How does the
depression influence your relationship?) give recognition to the couples that
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Gilbert M.D. Lemmens et al.

the depression may have an impact on their lives and simultaneously

make room for discussion of the restraints of the depression without
stigmatization and blaming. Health-promoting questions (How are you
supporting your (non-depressed) partner?) bring back to attention healthy
characteristics of the person or the couple. It helps to put the depression
back into its place.
The treatment protocol provides a structured development of the
therapeutic process. Starting from talking about the impact of the
depression, it guides the therapists actions to gradually pay more
attention to non-depression-related stories and normal family functioning in the hope of finally creating better stories for the future. A
close look at the treatment protocol follows.
Impact of the depression/treatment on the family unit: couple (session 1) and
children (session 2)
After a brief introduction of the participants and an explanation of the
project, sessions 1 and 2 focus mostly on the impact of the depression
and/or treatment on the family unit, the familys coping mechanisms
and the outside help and support. In the beginning of the group
the therapists try to create a safe context for therapy by emphasizing
confidentiality and maintenance of appropriate boundaries. Each
group member is encouraged to contribute as much or as little to
the discussion as he or she wants, even to the point that he or she
remains silent for an entire session. We explain that listening
is as important as talking to the process of learning in these sessions.
In the childrens session this is repeated, and the parents are further
encouraged to value the courage of the children for talking
openly and not to penalize them afterwards. The absent children
are introduced by their parents and the therapists make sure their
voices remain present by letting the parents talk in their name.
Important questions asked by the therapists in both sessions are:
What is the impact of the depression on the family?, What are the reactions of
others?, From whom do you [partners, children] get support?, Do you [children]
have someone to talk to inside or outside the family?, Looking back, how did you
as a child try to have your own life and to leave home in the context of
depression?
The sessions with the children are completely focused on them,
content-wise by emphasizing child issues, and form-wise by letting
them do the talking. It creates a children fish bowl, forcing the
parents into a listening position and making the voices of the children
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more prominent and hopefully better heard by the parents without

actually using two different circles, as is more common with such a
technique (Bishop et al., 2002).
In a children session seven children, aged from 5 to 14 years, discussed
separately what they wanted to ask their parents or the therapists. The
following three questions were put forward: (1) How long will my parent
be depressed? (2) When will my depressed parent start doing some
leisure activities? (3) When will both my parents start going out without
us? After hearing these questions, a depressed mother mentioned that
she had quite a few hobbies. Her daughter responded: Right you are,
cooking, ironing, and vacuuming. All group members laughed. The
children explained further that they always had a great time when a
baby-sitter came and that each time, when the parents went out together,
they had the feeling that everything went well between them. Some
parents had not gone out without the kids for the past ten years. After
the ending of the group, the therapist received a letter from the abovementioned girl and her sister. Mummy and daddy went to Paris (just for one
day). In our opinion, it was a bit short. We hope that they are not going to use it as
an excuse for not going out the next three months. This would be wrong. Our
parents enjoyed the trip very much. Au revoir. Signed Daisy and Ann.

Couple issues (session 3)

During this session specific couple-related issues and perspectives are
discussed within and outside of the context of depression. Communication, problem-solving and competences in the relationship are
addressed. The discussion of gender issues and roles is often quite
lively and transcends the depression.
A husband mentioned that he never sees any dust. It is probably
something only women can see. All the women in the group reacted.
One husband mentions that his mood strongly depends on his wifes
mood. A patient explains that this may be because he is still young and
married for only a short time. When she was younger she had the same
problem. Being together with her partner for a longer time has helped
her to be more tolerant of her partner and has made the impact on the
relationship of one partner feeling bad less important. Being together is
what matters, she added.
A husband mentions that when his wife is depressed, he is more
careful in what and how he is talking to her. When she feels all right, he
communicates more freely and openly.

Themes as to how to find a good balance within the relationship,

how to accept ones partners differences, how to confront ones
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partner with something you are not agreeing on, how to have
arguments and end them constructively, how to struggle with the
isolation outside and even inside the relationship are common in these
groups. The discussion about normative relationship issues helps to
put the position of both the patient and the partner in another
perspective: the patient is seen more as a full member of the relationship and not primarily as being depressed, and the partner cannot
further hide his partnership because of the depression.
A husband mentions to the group that if his wife would be the same as
him, it would be much easier to discuss things, but, he added with a big
smile: There probably would be not a lot of talking.
After the discussion of some inadequate household activities of the
depressed wives, the therapist asks the patients which activities their
husbands find difficult to quit. One husband reads almost every book or
magazine that he finds at home, and there are a lot of them. Two
husbands were too preoccupied with their children. It was difficult for
them not to interfere when they were playing or to leave them with a
baby-sitter.

Partners often start to address each other more in the language of

becoming than acting in a more negative and cautious way (Wachtel,
2001).
A husband mentions that his wife is really making some efforts to
change. He knows that coming to the day clinic is not always easy for
her, but he appreciates her efforts in doing so. He has also noticed that,
at last, she has started to say no to other people.

Restoring family functioning: couple (session 4) and children (session 5)

Normative family processes are, despite the presence of the depression, supported by focusing on positive and common family issues
and by differentiating between normal family processes and the
depression. Further, the discussion enquires about adaptation after
discharge (Are there any changes within the family?), new balances in
relationships, the emergence of positive changes, new coping strategies, new solutions, new problem-solving, effects of positive changes
on family and others.
An adolescent explains to her parents that she no longer wants to
accompany them whenever they are going out. However, another
adolescent who goes to a boarding-school would like to do more things
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together with his parents during the weekend. Both adolescents place
their parents back in their parenting role despite the depression.
A son mentions that for the past two years there was little contact
between his mother and his sister. Recently, this had changed. His
depressed mother explains that she had simply phoned her daughter
and told her that she wanted to visit her. She had taken a very nice
bouquet of flowers with her. They had both enjoyed her visit very much.

Possible solutions or propositions, which the family members have

probably mentioned already a thousand times, can be commonly discussed in the group without an aggressive or defensive response from
the patients. It is probably the result of the patients already feeling a
little better at this stage of their depression having learned from the
different therapies of the unit, or the group format.
The therapist asks the family members what the patients need to start
doing in the future. An 8-year-old girl answers: My mother needs to start
working again in the supermarket. An adult son mentions that he and his
sisters are trying to convince his mother to start doing some leisure
activities. Because his mother has never had a job, a leisure activity
would help to bring the outside world into the family and increase her
social contacts. He adds that it would have been better if she had a job: It
would have been better for her social life and she would probably understand my
father much better if she had experienced herself that a job nowadays can be very
stressful.

The involvement of the children in the group creates further

therapeutic opportunities to discuss processes and dynamics within
the families. The spontaneity, the energy, the rebellious behaviour of a
normal adolescent can question the depression-related and familyrelated dynamics and processes.
One childless husband mentioned after a group session that the
presence of children itself created an anti-depressive atmosphere in
the group.
A father explains to the group that he is more cautions and careful with
his wife than his son. The son finds that his father needs to be a bit tougher
with his mother, because she can get very angry with him: He does not need
to tolerate her behaviour. The depressed wife tells the group that her
husband has always been a very gentle person: If her son is not agreeing
with her thats fine, but she likes her husband the way he is, he does not have to
change. Another depressed wife responds: You are right, this discussion could
bring our husbands to strange thoughts. All group members start laughing.
The therapist asks an adolescent daughter if her father could make a
stand against his wife. The daughter responds diplomatically that her
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mother is the leading lady of the house and that she as a daughter is
allowed to say a lot more to her mother than her father is. The latter
replies that his wife does not know how to deal with tough behaviour
towards her as she makes him clearly aware that he had better not
behave in such a way. He adds that he could say everything to his wife,
but it is never the right moment or in the right way. The therapist asks
the first husband if he wants to behave like his son. He responds that he
would like to learn it but that he finds it difficult. His wife quickly replies
that this is because of his gentle personality. The therapist asks the group
if there are other husbands present with a similar personality. Again,
there is a lot of laughter. A husband responds that he is quite different
from the other two husbands. Suddenly, a patient wonders if her
husband also might behave in a way that he thinks is the best to keep
things going smoothly between the two of them. After some further
discussion, the adolescent son mentions that if his father would behave
differently, it would have a good effect on his mother.

Relapse prevention (session 6)

This session tries to facilitate thinking about the future. The discussion
focuses on positive changes in their life (What things are going better in
your life, what things are still difficult?), recognizing and consolidating
treatment gains for patients, partners and the family (children) (In
which way have the partners changed?). Further, the couples are asked to
predict difficulties over the next weeks and months. Preventive
actions are discussed, as well as the possibility of relapse and adequate
measures for dealing with it (How will you know if things are getting
worse? What do you have to do to prevent a relapse?).
A patient has learned not to panic if she is having an off-day. Things
always go better after a while.
A wife mentions that she stopped being the therapist for her depressed
husband. It was not very helpful for the relationship.
A patient explains that things are getting a bit worse. She has started to
talk about her past to her therapist and it is upsetting her. Her husband
adds that despite the fact that she is more depressed, they can now
discuss things much more easily in comparison with a few months ago.

Often the discussion focuses on work. Questions are: When do you feel that
you are ready to start working again?, How important is a job in your life?
After five years of not working, a patient has started a job. His wife is
worried that he is working too hard and not having enough leisure
activities. The husband agrees, but he also mentions that he is already
handling the job much better than a few weeks ago.
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Follow-up session (session 7)

Session 7 focuses on how the families are taking up their lives (How
are you doing now?), what difficulties and gains they experience, and
what both the patients and partners, looking back, have learned about
the depressive episode (Did you learn something from this depressive
episode for yourself or the relationship?).
A female patient mentions that she learned that social contacts are
essential for her. It is something that she constantly needs to keep in her
mind.
A patient explains that she and her husband are doing more things
together, that her husband is also taking more initiatives such as
organizing a baby-sitter, that he is asking more often how she is getting
on, that he is more aware if things are getting worse.

For the unit, the follow-up session provides useful feedback on how
the patients are doing at the moment, what they have learned from
the admission, and how helpful the admission has been for them and
their families.

Some observations and dilemmas

Although most patients, family members and the therapeutic team are
enthusiastic about the groups, some limitations and dilemmas concerning the groups need to be raised.
Families
If patients are too depressed (e.g. a melancholic depressive state) to
respond in a group, they are advised to wait before starting the
group, although this is seen only as a temporary contra-indication.
Having suicidal thoughts is not a contra-indication for participation.
Most patients only start the group after the third or fourth week of
their admission to hospital. At this stage they are already feeling a little
better compared to the time of admission. However, it may be possible
that these patients and their family members would benefit from
starting the group earlier. To date we have found no specific contraindications for the participation of partners or children in the current
sample. If a patient feels too depressed to join a session during the
group cycle, the partner and/or the children may come alone. If a
family member cannot attend the session, the patient may come alone.
A total of six out of the thirty-five families did not complete the group
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Gilbert M.D. Lemmens et al.

programme: one family never started, two families dropped out after
the first session, and one each stopped attending after the second,
third and fourth session. All of them had discharged themselves from
the unit or were admitted to another hospital. This could again
indicate how important it is that family discussion groups are embedded in the therapeutic programme of the unit (Lemmens et al.,
2005). Conducting the children sessions is difficult if the childrens
ages vary too much. This, in our opinion, was definitely the case in a
group with two married children, two adolescents and one girl aged 8.
The little girl participated actively in the group, but one can only
wonder if the discussed themes were not too much outside her
current life experience and if the process was not too verbally focused
for her. However, in another group with similar age differences the
younger children benefited, in the opinion of their mother, from
listening to the older, adult children.
Therapeutic team and the unit
The group sessions are always held in the evenings because most
partners are working during the day. Conducting these groups,
therefore, places additional demands on the therapeutic team, but
in our experience this is offset by the fact that conducting these
groups is of great value for improving therapeutic skills. Because of
this, it is important that the groups are seen as a valuable and integral
part of the therapeutic programme of the resulting unit. Otherwise,
the groups may not fully benefit the patient and his or her treatment,
the family members and the clinic team, and may lead to discontinued
running of the groups. It is also important to give consideration to the
choice and style of working of the co-therapists (Saayman et al., 2006).
As with other co-therapies, it is important that both therapists have a
good working relationship (role model) and similar experience in
conducting groups. At the same time it is useful if the co-therapists are
different from one another (gender, age, profession, ethnicity) to
bring in alternative perspectives.
The group
The closed format is important because it contributes to a sense of
safety and cohesion within the group. The latter seems also to be
reinforced by the sharing of similar experiences and by having to deal
with similar problems. Our clinical experience suggests that the
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optimum number of couples in the group is four to seven. The

presence of less than four families in the group may offer too little
opportunity for having a varied and differentiating conversation. On
the other hand, the presence of more than seven families is likely to
make the discussion too superficial or may give each couple too little
opportunity to speak.
For the purpose of the research study, we decided on a fixed
number of six sessions and one follow-up session. This was based on
our experiences of offering similar groups outside the research
context when we run open-ended groups for up to one year and
also briefer group formats of up to five sessions. The relatively brief
format of seven sessions meant that most families wanted to continue
the group after sessions 6 and 7. It is possible that a longer group
programme may have been more beneficial for some of the families,
allowing them to consolidate better the treatment gains. On the other
hand, the families had already received a considerable amount of
treatment during the six months, and outside the therapeutic sessions
they were clearly urged to rely increasingly on their own competences
and resilience.

Conclusion
We have developed a family discussion group for hospitalized depressed patients and their family members in the context of a
specialist inpatient unit. Our clinical experience is that this therapeutic format helps the patients and families to cope better with the
depression and offers the therapeutic team an opportunity to broaden
their interventions in supporting the families. Although patients,
families and the therapeutic team are enthusiastic about this intervention, the results of the ongoing clinical trial will shed more light on
the effectiveness of this family intervention.

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