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| REVIEW ARTICLE |
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| Year : 2018 | Volume
: 2
| Issue : 2 | Page : 88-92 |
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Family therapy in India
Anuradha Vishwas Sovani
Department of Psychology, SNDT Women's University, Mumbai, Maharashtra, India
| Date of Web Publication | 30-Nov-2018 |
Correspondence Address:
Anuradha Vishwas Sovani
“OM”, 31, Shreesh Society, LIC Cross Road, Off Eastern Express Highway, Thane (West) - 400 604, Maharahstra
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/aip.aip_22_18
Origins of family therapy are traced, acknowledging that this is in fact a group of therapeutic approaches. An overview of work done at major mental health centers in India is followed by an attempt at outlining key differences in Indian vis-a-vis Western approaches to family therapy, addressing some of the unique problems that are encountered in our country. Traditional systems of arranged marriage and a joint family, in vitro fertilization interventions and the family pressures to have a baby, the impact of work on family life and the onslaught of social media and family migrations across the globe are some of the issues outlined. Major approaches to family therapy are selected, and their key features are highlighted. Specifically, Minuchin's structural family therapy and Virginia Satir's conjoint family therapy are described. Touching very briefly on Milton Erickson's strategic family therapy, the article moves on to White and Epston's narrative family therapy; and each approach is described vis-a-vis its strengths when applied to an Indian family setup. The article ends on preventive, promotive, and rehabilitative approaches espoused by the author as also by many therapists in India. Behavioral family interventions by Sanders are outlined as is the positive parenting program and its Indian avatar in Palakshaala. Preventive approaches such as functional family therapy by Sexton and Alexander are described. Rehabilitative work with patients and caregivers is outlined, citing examples. The article ends by highlighting some recent changes in the social fabric that seem to be deeply affecting family structures.
Keywords: Applications in urban settings, family therapy, Indian research
How to cite this article:
Sovani AV. Family therapy in India. Ann Indian Psychiatry 2018;2:88-92 |
| Introduction | |  |
Perhaps the simplest definition of family therapy which is in fact an extremely convoluted process is as follows: “A form of psychotherapy that seeks to reduce distress and conflict by improving the systems of interactions between family members.” In reality, even if one has a couple and their child in one's consulting room, you are in fact dealing with a number of different and intricate processes. The cognitive and emotional processes of all four people in the room come into play including the processes within the therapist, who also harks back to a particular set of familial experiences and needs to set those aside while dealing with the case as a professional. One cannot deny the fact that we learn our vocabulary, our habits, our customs, and rituals in the family we are born into and that is a factor that shapes how we view the world around us.
Formal training in family therapy approaches in India needs to be augmented. The need for these strategies in therapy is high, and several good options are available but mental health professionals need to be formally trained for the same. Anisha Shah, Ahalya Raghuram, Mathew Varghese, and Srilatha Juvva among others have attempted to evaluate the brief family therapy training at NIMHANS in Bangalore, India and have highlighted these processes of ensuring empathy and yet remaining detached. They attempted to evaluate perceptual and interview skills and reported that analysis of the pre- and post-scores of thirty one students showed that the trainees report an improvement on many of the basic family therapy skills (P < 0.001) and show enhancement of conceptual skills.[1]
However, empirical evaluations such as these are nevertheless fraught with difficulty because the processes described above include many combinations of interactions, as described above. That with all four people in the room, and besides that the interaction between the couple, among the couple and their child as a triad, as well as between dyads of therapist and each of the individual people in the room.
Historical background
Most articles on family therapy and family counseling in international publications begin with the long tradition of the clergy counseling family members, and occasionally, doctors and lawyers also assaying this role. Formal community centers for family counseling began in the West around the 1940s, and even then, boundaries were not really clear between marital therapy exclusively and family therapy addressing the unit of the family as a whole. Some approaches still separated the problems pertaining to the children in the family and partitioned them away to child guidance clinics. The overall approach to marital and family conflicts and emotional discord was largely of a brief and problem-solving nature.
Mittal and Hardy[2] go so far as to pronounce, “the formalized discipline of marital and family counseling/therapy has its theoretical foundation in the West.” There could be multiple views about this since Indian psychology as a discipline takes a collectivistic world view as opposed to the individualistic view of the West, which in effect also translates into many family dynamics as they exist in India. Everything is seen in context, depending on the time, place, and situation when events occurred. Further, the Indian worldview focuses on the environment and relationships, as against the Western anthropocentric world view.[3] Conjoint therapy dealing with the various members in the family came much later, post the half century mark, and this article will attempt to trace these early beginnings. However, more importantly, one must acknowledge that if family therapy in the West was dominated by clergy and that in India was almost exclusively handled by the “elders” in the large joint and extended family and the community. To quote Thomas, a social worker, India is most known for “ancient traditions, rituals, religious orientation, spiritual outlook and folk beliefs, warmth, strong bonds, hierarchy, extended support, cultural orientation, shared values and time, tolerance, respect for the aged and inculcation of religious teachings and traditions in families.”[4]
Interventions that are subsumed within family therapy
Thomas goes on in his paper to explore the roles of various interventions under the broad umbrella of family therapy. These may include therapy for sexual difficulties. One of the new emerging stress areas is the stress associated with in vitro fertilization (IVF). The family exerts great pressure on the young couple to have a baby, and the IVF treatment process places unprecedented physical and emotional stress which is often hard to deal with. IVF counselors in every such medical setting are now made mandatory. However, stigma associated with being childless is unique to oriental cultures in general and India in particular. Tulsian and Sovani[5] have explored these processes and found that Indian couples are very reluctant to undergo group interventions of a psychotherapeutic nature although these are liberally cited in western literature.
Thomas[4] also writes of psychoeducative approaches and covers the span from parent management training to geriatric group services, and from grief counseling to psychosocial rehabilitation, discussed later in this paper. Preventive and promotive services such as premarital training programs and parent training programs, family intervention workshops, and relationship training programs are discussed.
Carson and Chowdhury[6] have titled their paper “Family therapy in India: A new profession in an ancient land?” They emphasize the urban rural divide and the role of religion, caste, and other social institutions, as well as poverty, overcrowding, and other ills that affect Indian society deeply.
Other problems
Shalini Bharat from TISS has highlighted the presence of a plethora of problems other than emotional problems that may plague Indian families. These include lack of social resources and supports and isolation from the mainstream for rural families. For both urban and rural families, there is poverty and disease, overcrowding, pollution, migration, natural disasters, and political instability, to list just a few of their problems.[7]
Marriage and related issues
Older family members, both first-degree and second-degree relatives, have a large part to play in the approval of marriage partners. A large number of case referrals for couple therapy, which invariably segues into family therapy, generally circles around this issue. Many couples speak of communication problems with parents of their spouse. “In-laws” is a term perhaps unique to India in its use, but this is an important area in therapeutic resolutions. Unique to Indian culture are several other pain points which lead to stress in family relationships. These include dowry-related issues, intercaste marriage and related matters as well as religious and cultural nuances. Many of the family therapy sessions in these cases are devoted to problem-solving vis-a-vis sharing domestic chores and child care, as well as dual career families, perhaps another term coined in our country. The family therapist needs to maintain a multicultural and inclusive, democratic viewpoint as clients arrive at solutions to problems. Impact on an adolescent child in a disturbed family can be great. Shalini and Raguram[8] have discussed the impact of marital conflict on adolescents, highlighting how several disorders such as conduct disorder may have roots in such discord.
It is important to examine which among the various commonly used models of family therapy would work well in the Indian cultural setting and help the therapist to address some of the issues described above and the emotional consequences of the same.
Models of family therapy
There are number of different models of family therapy that a professional can choose from and each is discussed along with its implications for use in India.
Salvador Minuchin: Structural family therapy
This approach asserts that pathology does not rest in the individual; it rests within the family system. Hence, it is essential to understand and discover the invisible rules which govern the functioning of every family. Relationships and transactional patterns between family members need to be mapped, and dysfunctional relationships need to be disrupted and restructured. In this model, thus, a system approach is espoused. On discovering the existing structures, the therapist strives to understand underlying dynamics and to provide new alternative ways of problem-solving.
In general, this approach lends itself rather well to resolving intergenerational issues and perhaps may not be the therapeutic approach of choice for resolving marital conflict of violence and abuse issues. For instance, Minuchin's approach would observe that in healthy families, boundaries between the parents and the child are clear, and yet, there is room for negotiation since they are semidiffuse, as against coalitions and power hierarchies that may exist in less healthy families, where a child may have to play surrogate roles in the physical or emotional absence of a parent for instance.[9]
Virginia Satir: Conjoint family therapy
Even as a child, Satir has written that “I realized a lot went on in families that didn't meet the eye.” Trained as a social worker, Satir observes in her writings that families often present with a “surface problem” that is not really the “real problem” and the therapist needs to pick up what lies underneath. Satir emphasizes human validation and leans toward a humanistic and a positive approach emphasizing growth and connectedness. She often utilized material such as meditations and poetic writing into her public workshops and her oft-quoted line from her writings is a poem written by an angry teenage girl that begins “I am me…………. In all the world, there is no one else exactly like me.”[10]
Milton Erickson: Strategic family therapy
This approach is harder to use in a multicultural and diverse setup like that in our country. Erickson's approach is typified by his belief in “using” anything and everything about a patient to help them change. This could be their habits, their beliefs, their favorite words, as well as their cultural background and personal history.
He conceptualized the unconscious as highly separate from the conscious mind, with its own awareness, interests, responses, and learnings. He believed that the unconscious mind was creative, solution generating, and often positive. He espoused techniques such as hypnotherapy with an unusual conceptualization of conversational hypnosis where the client is allowed a lot of control and is permitted to move at their own pace, and neuro-linguistic programming which may not have a large empirical base, and thus, this approach may not get wide usage in our country. However, in a few highly intelligent and insightful clients, applications of this approach often prove useful.[11]
White and Epston: Narrative family therapy
Within a narrative frame, human problems are viewed as arising from and being maintained by oppressive stories which dominate the person's life. Therapeutic intervention then would constitute efforts at opening space for the authoring of alternative stories. White draws on the works of French philosophers Derrida and Foucault and the therapist and client collaboratively coauthor the story as the therapist very respectfully accepts changing client stances. The final goal is to help clients internalize personal agency. They would finally develop a self-narrative in which they view themselves as powerful, and in this journey, they would be helped along by the therapist.[12] This approach is slowly gaining strength in India with recent conferences such as “A Roomful of Stories” held collaboratively by Ummeed, Narrative Practices Adelaide and Re-Authoring Teaching, Vermont in October 2016.[13]
The author would now share some corrective, preventive, and rehabilitative approaches that may prove useful in Indian settings.
Corrective approaches
In India, with the pressing need to effect change quickly and at low expense to the client, behavioral family interventions[14] prove very effective. The approach is based on a social information processing model. The therapist interacts with family members and attempts to build on existing strengths inherent to the family. It is important to address known risk variables and connect to available social support networks. It goes without saying that all this is done with a gender sensitive and culturally appropriate stance, designed to facilitate success.
Citing an example for each of the above, one may encounter a very rational relative in the family, for instance an older sibling, or an aunt or uncle, who seems to exert influence on the problem individual, who could be an adult or a child.
The next approach outlined (the Triple P) is targeted at children and adolescents, but behavioral family interventions may also be addressed to adults in the family who may have long-standing behavioral issues including addictions or personality disorders. Empowering a cotherapist from within the family can facilitate and hasten change. Connecting this key individual to other supporting networks in the extended family or community creates more therapeutic opportunities and strengthens the hands of the cotherapist. Risk variables such as emotional instability in the patient and potential for self-harm can also be highlighted through the therapeutic process, thus minimizing crises.
Another powerful and very widely used approach is the positive parenting program popularly known as the Triple P.[15] The aim of this program is to augment resilience and create a better understanding and knowledge about high risk behaviors of children and adolescents through psychoeducation of parents. Parents are addressed after grouping them as per the age of their offspring so as to better address typical developmental problems at that life stage. The interventions augment their resourcefulness and skills. Parents are taught to render their children more emotionally healthy by fostering self-determination of goals and also promoting self-regulation, self-monitoring, and self-evaluation. At the core of this program is an effort to promote personal agency in the parent as well as the child or adolescent.
The Institute for Psychological Health (IPH), Thane, Maharashtra, has conducted Paalakshaala (literally translated as parenting school) modules designed around this model for the last two decades with success. The modules also incorporate basic Rational Emotive Behavior Therapy principles and philosophy and train parents and even grandparents to work with the youngsters in their family with a minimum of strife.[16]
Preventive approaches
Functional family therapy[17] focuses on multiple domains of client experience and attempts to strengthen mental health resources and abort crises where possible. The various domains covered are biological, behavioral, affective, cognitive, cultural, and relational. This approach too, like Triple P, begins with dissemination, in the form of training modules for those who wish to work on family mental health. Training and development follows, and there is regular supervision to ensure adherence. The strength of this model lies in imparting healthy modes of family communication to anticipate problems that may occur and direct the family members to means of quick and amicable resolution and maximization of emotional well-being for all.
Rehabilitative approaches
Family therapy can prove to be a mainstay in interventions for chronic mental illness.
In the rehabilitation of persons with psychosis, for example, it is crucial to also address their caregivers. Training those recovering from chronic mental illness can ensure low relapse rates and better mainstreaming into society. WHO and NIMHANS have worked together to create intervention modules for families whose members are dealing with mental illness.[18] Murthy[19] too has done a lot of work with caregivers of persons with mental illness.
Three crucial group approaches from a family therapy perspective in this context are:
- Patient support groups
- Family support groups
- Caregiver groups.
At a number of social enterprises all over the country, all these activities are regularly conducted to ensure that persons with mental illness who have improved with pharmacotherapy and psychotherapy stay well and continue to be contributory and healthy members of society. Efforts are on at a number of institutions in Guwahati (Ashadeep), Kolkata (Iswar Sankalp), Pune (SAA), and Chennai (Aasha and The Banyan), among many others. In the suburbs of Mumbai, Thane (IPH) and Karjat (Shraddha Rehabilitation center) are doing a great deal of work with persons with mental illness and their families. Psychiatry departments of most teaching hospitals too generally conduct regular groups for patients and caregivers, thereby addressing family issues.
At IPH, the sheltered workshop and activity center for persons recovering from schizophrenia spectrum disorders, Tridal, has been active for two decades. These Shubharthis, as they are called to take away the pejorative diagnostic label of schizophrenia, meet daily at Tridal and work. This activity gives their life a social context, generates some income which they proudly take home at the end of the month, and most importantly, provides a vehicle for cognitive rehabilitation.
Their caregivers continue to get support from the monthly workshops which are conducted for them. There are various modules that are incorporated into these workshops. They generally begin with sharing emotions experienced by the caregivers once their loved one is diagnosed. Then, a psychoeducational module helps them understand what really happens in the brain of the person with schizophrenia and why there are such startling behavioral and emotional changes, disturbed perceptions, and thoughts.
Further, some major theoretical understanding about various etiological factors is shared, such as the research on expressed emotion by Vaughn and Leff,[20] Amaresha, and Venkatasubramanian.[21] Caregivers are also explained in simple language how symptoms manifest and why medication as well as psychosocial interventions are beneficial, and compliance is required to both.
Volunteers working with Tridal include those who are family members of persons with mental illness, as well as those who are not.
Media influences
New threats to the Indian family fabric hover on the horizon in the form of overuse of social media, gaming, and selfie and internet addictions. Cellphone overuse seems to be pan generation and has created distances between once closely-knit family members.
Films are an interesting medium which throw a lot of light on family structures in any culture and community. Deakin and Bhugra[22] have written an interesting paper on Indian films and family dynamics, in a special issue of the International Review of Psychiatry devoted exclusively to family and family therapy across cultures. They write “film is one of the most potent media in understanding how a culture responds to various issues, from mental illness to social attitudes and behavior. Films reflect the society within which they are made but also influence society as a result.” Specifically about India, they say “the conventional cinema industry in India produces 600 films per year, ranking above Hollywood in terms of number of total films produced and the size of audiences it attracts.” The paper goes on to deconstruct and unpack changing family structures, changing sexual mores, and ends on understanding issues such as depression and alcohol use and how it affects families.
Using footage selected from popular Hindi films and using audio material from popular film songs and regional music, IPH has created a set of modules under the title Prakashdoot. This project was completed in collaboration with Sangath and PHFI, New Delhi and was funded by the Tata Trust. Audio as well as audio visual clippings of Prakashdoot are now played by trained volunteers in remote areas of Maharashtra (the modules on alcohol use disorders and depression, delivered by Anand Nadkarni and Anuradha Sovani, are in Marathi and Hindi, the regional and national languages) and accompanied by a manual with Frequently Asked Questions which helps them address questions raised in the community.[23],[24]
| Conclusions | | |
This article has attempted to trace the progress of family therapy in India, highlighting the need for more formal training on the one hand and the emergence of many innovative family-based and community-based interventions on the other. Government initiatives in this area of mental health propagation have been slow, and only very recently, some partnerships are emerging between government hospital setups and nongovernment social enterprises which target community well-being at low cost to the patient.
However, it is clear that there is a high need for family interventions in a country like India where the family and its support is what most individuals fall back on in times of stress. A source for support as well as strife at the same time the Indian family would do well with planned and structured interventions to improve its wellness quotient.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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