Family Interventions: Basic Principles and Techniques

INTRODUCTION Mental health professionals in India have always involved families in therapy. However, formal involvement of families occurred about one to two decades after this therapeutic modality was started in the West by Ackerman.1 In India, families form an important part of the social fabric and support system, and as a result, they are integral in being part of the treatment and therapeutic process involving an individual with mental illness. Mental illnesses afflict individuals and their families too. When an individual is affected, the stigma of being mentally ill is not restricted to the individual alone, but to family members/caregivers also. This type of stigma is known as “Courtesy Stigma” (Goffman). Families are generally unaware and lack information about mental illnesses and how to deal with them and in turn, may end up maintaining or perpetuating the illness too. Vidyasagar is credited to be the father of Family Therapy in India though he wrote sparingly of his work involving families at the Amritsar Mental Hospital.2 This chapter provides salient features of broad principles for providing family interventions for the treating psychiatrist. TYPES AND GRADES FOR FAMILY INTERVENTIONS Working with families involves education, counseling, and coping skills with families of different psychiatric disorders. Various interventions exist for different disorders such as depression, psychoses, child, and adolescent related problems and alcohol use disorders. Such families require psychoeducation about the illness in question, and in addition, will require information about how to deal with the index person with the psychiatric illness. Psychoeducation involves giving basic information about the illness, its course, causes, treatment, and prognosis. These basic informative sessions can last from two to six sessions depending on the time available with clients and their families. Simple interventions may include dealing with parent-adolescent conflict at home, where brief counseling to both parties about the expectations of each other and facilitating direct and open communication is required. Additional family interventions may cover specific aspects such as future plans, job prospects, medication supervision, marriage and pregnancy (in women), behavioral management, improving communication, and so on. These family interventions offering specific information may also last anywhere between 2 and 6 sessions depending on the client's time. For example, explaining the family about the marriage prospects of an individual with a psychiatric illness can be considered a part of psychoeducation too, but specific information about marriage and related concerns require separate handling. At any given time, families may require specific focus and feedback about issues such issues. Family therapy is a structured form of psychotherapy that seeks to reduce distress and conflict by improving the systems of interactions between family members. It is an ideal counseling method for helping family members adjust to an immediate family member struggling with an addiction, medical issue, or mental health diagnosis. Specifically, family therapists are relational therapists: They are generally more interested in what goes on between the individuals rather than within one or more individuals. Depending on the conflicts at issue and the progress of therapy to date, a therapist may focus on analyzing specific previous instances of conflict, as by reviewing a past incident and suggesting alternative ways family members might have responded to one another during it, or instead proceed directly to addressing the sources of conflict at a more abstract level, as by pointing out patterns of interaction that the family might not have noticed. Family therapists tend to be more interested in the maintenance and/or solving of problems rather than in trying to identify a single cause. Some families may perceive cause-effect analyses as attempts to allocate blame to one or more individuals, with the effect that for many families, a focus on causation is of little or no clinical utility. It is important to note that a circular way of problem evaluation is used, especially in systemic therapies, as opposed to a linear route. Using this method, families can be helped by finding patterns of behavior, what the causes are, and what can be done to better their situation. Family therapy offers families a way to develop or maintain a healthy and functional family. Patients and families with more difficult and intractable problems such as poor prognosis schizophrenia, conduct and personality disorder, chronic neurotic conditions require family interventions and therapy. The systemic framework approach offers advanced family therapy for such families. This type of advanced therapy requires training that very few centers, such as the Family Psychiatry Center at the National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India offer to trainees and residents. These sessions may last anywhere from eight sessions up to 20 or more on occasions Table 1.Table 1: Types and grades of family interventionsGoals of family therapy Usual goals of family therapy are improving the communication, solving family problems, understanding and handling special family situations, and creating a better functioning home environment. In addition, it also involves: Exploring the interactional dynamics of the family and its relationship to psychopathology Mobilizing the family's internal strength and functional resources Restructuring the maladaptive interactional family styles (including improving communication) Strengthening the family's problem-solving behavior. Reasons for family interventions The usual reasons for referral are mentioned below. However, it may be possible that sometimes the reasons identified initially may be just a pointer to many other lurking problems within the family that may get discovered eventually during later assessments. Marital problems Parent–child conflict Problems between siblings The effects of illness on the family Adjustment problems among family members Inconsistency parenting skills Psychoeducation for family members about an index patient's illness Handling expresses emotions. CHALLENGES FACED BY THE NOVICE THERAPIST Whether one is a young student, or a seasoned individual therapist, dealing with families can be intimidating at times but also very rewarding if one knows how to deal with them. We have outlined certain challenges that one faces while dealing with families, especially when one is beginning. Being overeager to help This can happen with beginner therapists as they are overeager and keen to help and offer suggestions straight away. If the therapist starts dominating the interaction by talking, advising, suggesting, commenting, questioning, and interpreting at the beginning itself, the family falls silent. It is advisable to probe with open-ended questions initially to understand the family. Poor leadership It is advisable for the therapist to have control over the sessions. Sometimes, there may be other individuals/family members who maybe authoritative and take control. Especially in crisis situations, when the family fails to function as a unit, the therapist should take control of the session and set certain conditions which in his professional judgment, maximize the chances for success. Not immersing or engaging/fear or involving A common problem for the beginning therapist is to become overly involved with the family. However, he may realize this and try to panic and withdraw when he can become distant and cold. Rather, one should gently try to join in with the family earning their true respect and trust before heading to build rapport. Focusing only on index patient Many families believe that their problem is because of the index patient, whereas it may seem a tactical error to focus on this person initially. In doing so, it may essentially agree to the family's hypothesis that their problem is arising out of this person. It is preferable, at the outset to inform the family that the problem may lie with the family (especially when referrals are made for family therapies involving multiple members), and not necessarily with any one individual. Not including all members for sessions Many therapeutic efforts fail because important family members are not included in the sessions. It is advisable to find out initially who are the key members involved and who should be attending the sessions. Sometimes, involving all members initially and then advising them to return to therapy as and when the need arises is recommended. Not involving members during sessions Even though one has involved all members of the family in the sessions, not all of them may be engaged during the sessions. Sometimes, the therapist's own transference may hold back a member of the family in the sessions. Rather, it is recommended that the therapist makes it clear that he/she is open to their presence and interactions, either verbally or nonverbally. Taking sides with any member of the family It may be easy to fall into the trap of taking one member's side during sessions leaving the other party doubting the fairness and judgment of the therapist. For example, after meeting one marital partner for a few sessions, the therapist, when entering the couple, discussions may be heavily biased in his views due to his/her prior interaction. Therapists should be aware of this effect and try to be neutral as possible yet take into confidence each member attending the sessions. Therapist's countertransference can easily influence him/her to take sides, especially in families that are overtly blaming from the start, or with one member who may be aggressive in the sessions, or very submissive during the sessions can influence the therapist's sides; and one needs to be aware of this early in the sessions. Guarded families Some families put on a guarded façade and refuse to challenge each other in the session. By being neutral and nonjudgmental, sometimes, the therapist can perpetuate this guarded façade put forth by families. Hence, therapists must be able to read this and try to challenge them, listen to microchallenges within the family, must be ready to move in and out from one family member to another, without fixing to one member. Communicating with the therapist outside sessions Many families attempt to reduce tension by communicating with therapist outside the session, and beginning therapist are particularly susceptible for such ploys. The family or a member/s may want to meet the therapist outside the sessions by trying to influence the therapist to their views and opinions. Therapists must refrain from such encounters and suggest discussing these issues openly during the sessions. Of course, rarely, there may be sensitive or very personal information that one may want to discuss in person that may be permissible. Ignoring previous work done by other therapists It is easy for family therapists to ignore previous therapists. The family therapist's ignorance of the effects of previous therapy can serious hamper the work. By discussing the previous therapist helps the new therapist to understand the problem easily and could save time also. Getting sucked to the family's affective state/mood If transference involves the therapist in family structure, the therapist's dependency can overinvolved him in the family's style and tone of interaction. A depressed family causes both: Therapist to relate seriously and sadly. A hostile family may cause the therapist to relate in an attacking manner. The most serious problem can occur when a family is in a state of anxiety, induces the therapist to become anxious and make his/her comments to seem accusatory and blaming. It is very difficult for the beginning therapist to “feel” where the family is affectively, to be empathic, yet to be able to relate at times on a different affective level-to respond according to situations. It is important to be aware of the affective state/mood of the family but slips in and out of that state Table 2.Table 2: Guidelines for conducting interventions with familiesFUNCTIONS OF A FAMILY THERAPIST The family therapist establishes a useful rapport: Empathy and communication among the family members and between them and himself The therapist uses the rapport to evoke the expression of major conflicts and ways of coping. The therapist clarifies conflict by dissolving barriers, confusions, and misunderstandings Gradually, the therapist attempts to bring to the family to a mutual and more accurate understanding of what is wrong This he a of which conflicts conflict to the of interaction. The therapist in part the of true a of and a of support and that the family needs but more and of family than the family has The therapist and and the of of conflict, and these and The therapist as a personal of for the family. In out these the family therapist a of FOR FAMILY INTERVENTIONS The of therapy The referral Family Family and treatment The referral Patients and their families are to as family problem has The therapist may be to the usual therapeutic involving a patient but may be in his approach by the presence of many family members and with a of A few are to the while conducting individual therapy. The for conducting family interventions are given in At the time of the the therapist all the available information in the family from the and the This session for and is with all the available family members. The of the session is to understand the family's of their their and need to family and the therapist of for family therapy. this is the and modality of the therapy is to the family and an is made about and of therapist and the family members. The and of the family interventions are to the family at the outset of the process of the The family and hypothesis The of different aspects of family functioning and interactions must take about sessions with the family, each session must last to an therapists may want to take in different ways depending on their are a few which are recommended for the therapist to it is recommended that the therapist starts with a and then with the different and family as outlined below. The is out the index patient's and two more related for example, and in an adolescent or and in a The and of the members are and the family patterns and interactions are at to understand the family from a and The therapist also himself with any family dynamics prior to This a broad to understand the the family is dealing with The of the index family is The of the family and specific of different members are in each of the of the family The index family is from a and the therapist a and of the family. is to how the family has with problems and the process of from one to If are also part of the family, their and parenting styles are there is Many therapists at this of the family to how or the family has the family members are to that the family has or illness in a family member. 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