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. 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. 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. It is advisable for the therapist to have control over the sessions. 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.
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. 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.
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. 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. 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.
Therapists should be aware of this effect and try to be neutral as possible yet take into confidence each member attending the sessions. 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.
Many families attempt to reduce tension by communicating with therapist outside the session, and beginning therapist are particularly susceptible for such ploys. 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. 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. 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 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.
The therapist fulfills in part the role of true parent figure, a controller of danger, and a source of emotional support and satisfaction-supplying elements that the family needs but lacks. He introduces more appropriate attitudes, emotions, and images of family relations than the family has ever had. The therapist works toward penetrating entering into and undermining resistances and reducing the intensity of shared currents of conflict, guilt, and fear.
He accomplishes these aims mainly using confrontation and interpretation. In carrying out these functions, the family therapist plays a wide range of roles, as:.
Patients and their families are usually referred to as some family problem has been identified. The therapist may be accustomed to the usual one-on-one therapeutic situation involving a patient but may be puzzled in his approach by the presence of many family members and with a lot of information. A few guidelines are similar to the approaches followed while conducting individual therapy. The guidelines for conducting family interventions are given in Table 2.
At the time of the intake, the therapist reviews all the available information in the family from the case file and the referring clinicians. This intake session lasts for 20—30 min and is held with all the available family members. The aim of the intake session is to briefly understand the family's perception of their problem, their motivation and need to undergo family intervention and the therapist assessments of suitability for family therapy.
Once this is determined the nature and modality of the therapy is explained to the family and an informal contract is made about modalities and roles of therapist and the family members. The assessment of different aspects of family functioning and interactions must typically take about 3—5 sessions with the whole family, each session must last approximately 45 min to an hour.
Different therapists may want to take assessments in different ways depending on their style. Mentioned below are a few tasks which are recommended for the therapist to perform. The three-generation genogram is constructed diagrammatically listing out the index patient's generation and two more related generations, for example, patients and grandparents in an adolescent client or parents and children in a middle-aged client.
The ages and composition of the members are recorded, and the transgenerational family patterns and interactions are looked at to understand the family from a longitudinal and epigenetic perspective. The therapist also familiarizes himself with any family dynamics prior to consultation. This gives a broad background to understand the situation the family is dealing with now. The life cycle of the index family is explored next.
The functions of the family and specific roles of different members are delineated in each of the stages of the family life cycle. Care is taken to see how the family has coped with problems and the process of transition from one stage to another. If children are also part of the family, their discipline and parenting styles are explored e. Problem Solving: Many therapists look at this aspect of the family to see how cohesive or adaptable the family has been.
Usually, the family members are asked to describe some stress that the family has faced, i. The therapist then proceeds to get a description of how the family coped with this problem. The crisis and the consequent events are examined closely to look for patterns that emerge. The family function or dysfunction is heightened when there is a crisis situation and the therapist look at patterns rather than the content described.
The same inquiry is possible using the technique of enactment[ 4 ]. The Structural Map: Once the inquiry is over, the therapist draws the structural map, which is a diagrammatic representation of the family system, showing the different subsystems, its boundaries, power structure and relationships between people.
Diagrammatic notions used in structural therapy or Bowenian therapy are used to denote relationships normal, conflictual, or distant and subsystem boundaries, in different triadic relationships. This can also be done on a timeline to show changes in relationships in different life cycle stages and influences from different life events.
The Circular Hypothesis: A systemic family hypothesis is now postulated by looking at the function of symptoms for both the client and his family. Answers to the following questions provide the circular hypothesis:. At this stage, we suggest that a family formulation is generated, hypothesized and analyzed. This leads to a comprehensive systemic formulation involving three generations. This formulation will determine which family members we need to see in a therapy, what interventional techniques we should use and what changes in relationships we should effect.
The team will also discuss the minimum, most effective treatment plan which emerges considering the most feasible changes the family can make.
Formal Contract: A brief understanding of the family homeostasis is presented to the family. The time frame and modality of therapy is contracted with the family, and the therapy is put into force. The frequency and intensity of sessions are determined by the degree of distress felt by the family and the geographical distance from the therapy center, i. An outline of the Family Assessment Proforma[ 5 ] used at this center is given in Figure 1. Several other structured family assessment instruments are available [ Figure 1 ].
This phase of therapy forms the major work that is carried out with the family. Depending on the school of therapy, that is used, these sessions may number from a few strategic to many sessions lasting many months psychodynamic. The techniques employed depend on the understanding of the family during the assessment as much as the family — therapist fit. For example, the degree of psychological sophistication of the clients will determine the use of psychodynamic and behavioral techniques.
The nature of the disorder and the degree of pathology may also determine the choice of therapy, i. We will now describe some of the important techniques used with different kinds of problems. This school was one of the first to be described by people like Ackerman and Bowen.
These family ego defenses are interpreted to the members and the goal of therapy is to effects emotional insight and working through of new defense patterns.
Family transferences may become evident and may need interpretation. Therapy usually lasts from 15 to 30 sessions and this method may be employed in persons who are psychologically sophisticated, and able to understand dynamics and interpretations.
Sustained and high motivation is necessary for such a therapy. This method is found useful in couples with marital discord from upper middle-class backgrounds. Time required is a major constraint. Behavioral techniques find use in many types of therapies and conditions. It has been extensively used in chronic psychotic illnesses by workers such as Fallon et al. Techniques such as modeling or role-plays are useful in improving communication styles and to teach parenting skills with disturbed children.
Obviously, motivation for therapy is a major requisite and hence techniques such as contracting, homework assignments are used in couples with marital discord.
Described by Minuchin; Fishman and Unbarger[ 4 , 11 , 12 ] has become quite popular over the past few years among therapists in India.
This is possibly because of many reasons. Our families are available with their manifold subsystems of parents, children, grandparents and structure is easily discerned and changed. In addition, in recent years most clients present with conduct and personality disorders in adolescence and early adulthood.
Hence, techniques like unbalancing, boundary-making are quite useful as the common problems involve adolescents who are wielding power with poor marital adjustments between parents.
These techniques are useful for many of our clients. We have found that these brief techniques can be very powerfully used with families which are difficult and highly resistant to change. We usually employ them when other methods have failed, and we need to take a U-turn in therapy.
Techniques employed by the Milan school[ 13 , 14 ] reframing, positive connotation, paradoxical symptom prescription have been used effectively. So also have techniques like prescription in brief methods advocated by Erikson, Watzlawick et al. Familiarity and competence with these techniques is a must and therapy is usually brief and quickly terminated with prescriptions [ Table 3 ]. Set individual and family goals related to illness and to nonillness developmental events.
Family EE and communication deviance or lack of clarity and structure in communication are well-established risk factors for the onset of schizophrenia. Programs emphasize family resilience. Develop strategies for intervening early with new episodes and assure consistency with medication regimens. Manage moodiness and swings of the patient, anger management, feelings of frustration. Family conflict and rejection, low family support, ineffective communication, poor expression of affect, abuse, and insecure attachment bonds are primary focus of family therapy associated with depression cognitive-behavioral and interpersonal interventions for depression.
Family-based treatment for anxiety combines family therapy with cognitive-behavioral interventions. Targets the characteristics of the family environment that support anxiogenic beliefs and avoidant behaviors. Target the dysfunctional family processes, namely, enmeshment and overprotectiveness. To help parents build effective and developmentally appropriate strategies for promoting and monitoring their child's eating behaviors.
The primary focus is the development of effective parenting and contingency management strategies that will disrupt the problematic family interactions associated with ADHD and ODD. Parents taught to use communication and social training tools that are adapted to the needs of their children and apply these techniques to their family interactions at home. This last phase of therapy is finished in a couple of sessions.
The initial goals of therapy are reviewed with the family. The need to continue these new patterns is emphasized. At the same time, the family is cautioned that these new patterns will occur when all members make a concerted effort to see this happen. Family members are reminded that it is easy to fall back to the old patterns of functioning which had produced the unstable equilibrium necessitating consultation.
At termination, the therapist usually negotiates new goals, new tasks or new interactions with the family that they will carry out for the next few months in the follow up period.
The family is told that they need to review these new patterns after a couple of months so as to determine how things have gone and how conflicts have been addressed by the family. This way the family has a better chance of sustaining the change created. Sometimes booster sessions are also advised after 6—12 months especially for outstation families who cannot come regularly for follow-ups.
These booster sessions will review the progress and negotiate further changes with the family over a couple of sessions. This follow-up period, after therapy is terminated is crucial for working through process and ensures that the client-therapist bond is not severed too quickly.
Most Indian families are functionally joint families though they may have a nuclear family structure. Furthermore, unlike the Western world more than two generations readily come for therapy. Hence, it becomes necessary to deal with two to three generations in therapy and also with transgenerational issues. Our families also foster dependency and interdependency rather than autonomy. This issue must also be kept in mind when dealing with parent—child issues. Indians have a varied cultural and religious diversity depending on the region from which the family comes.
The therapist has to be familiar with the regional customs, practices, beliefs, and rituals. The Indian family therapist has to also be wary of being too directive in therapy as our families may give the mantle of omnipotence to the therapist and it may be more difficult for us to adopt at one-down or nondirective approach.
The economic backwardness of most out families makes therapy feasible and affordable, in terms of time and money spent, only to the middle and upper classes of our society. The poorer families usually drop out of therapy as they have other more pressing priorities. The lack of tertiary social support and welfare or social security makes it less possible to network with other systems.
We are also woefully inadequate in terms of trained family therapists to cater to our large population. In our country, distances seem rather daunting and modes of transport and communication are poor for families to readily seek out a therapist. Over the last few years, a systemic model has evolved for service and for training.
The model uses a predominantly systematic framework for understanding families and the techniques for therapy are drawn from different schools namely the structural, strategic, and behavioral psychodynamic therapies. The repetitive patterns of interaction that organize the way in which family members relate and interact with each other. Boundaries are the rules defining who participates in the system and how, i. It may comprise of a single person, or several persons joined together by common membership criteria, for example, age, gender, or shared purpose.
When alignments stand in opposition to another part of the system i. The joining together of two or more members. It popularly designates appositive affinity between two units of a system. In which, there is extreme sensitivity among the individual members to each other and their primary subsystem. National Center for Biotechnology Information , U.
Journal List Indian J Psychiatry v. Indian J Psychiatry. Published online Jan Vivek Kirpekar 1 N. Author information Article notes Copyright and License information Disclaimer. Offers advice on counseling couples with marital problems, describes the ingredients of a happy marriage, and examines severe and chronic marital conflicts and techniques for their resolution. Get A Copy. Hardcover , pages. Published September 11th by W. More Details Original Title.
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