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Family Interventions: Basic Principles and Techniques

Article  in  Indian Journal of Psychiatry · January 2020

DOI: 10.4103/psychiatry.IndianJPsychiatry_770_19

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CLINICAL PRACTICE GUIDELINES

Family Interventions: Basic Principles and Techniques

Mathew Varghese, Vivek Kirpekar1, Santosh Loganathan
Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore, Karnataka,
1
N.K.P. Salve Institute of Medical Sciences, Nagpur, Maharashtra, India

INTRODUCTION disorders. Various interventions exist for different disorders

such as depression, psychoses, child, and adolescent
Mental health professionals in India have always involved related problems and alcohol use disorders. Such families
families in therapy. However, formal involvement of families require psychoeducation about the illness in question,
occurred about one to two decades after this therapeutic and in addition, will require information about how to
modality was started in the West by Ackerman.[1] In India, deal with the index person with the psychiatric illness.
families form an important part of the social fabric and Psychoeducation involves giving basic information about
support system, and as a result, they are integral in being the illness, its course, causes, treatment, and prognosis.
part of the treatment and therapeutic process involving These basic informative sessions can last from two to six
an individual with mental illness. Mental illnesses afflict sessions depending on the time available with clients and
individuals and their families too. When an individual is their families. Simple interventions may include dealing with
affected, the stigma of being mentally ill is not restricted to parent‑adolescent conflict at home, where brief counseling
the individual alone, but to family members/caregivers also. to both parties about the expectations of each other and
This type of stigma is known as “Courtesy Stigma” (Goffman). facilitating direct and open communication is required.
Families are generally unaware and lack information about
mental illnesses and how to deal with them and in turn, Additional family interventions may cover specific aspects
may end up maintaining or perpetuating the illness too. such as future plans, job prospects, medication supervision,
Vidyasagar is credited to be the father of Family Therapy marriage and pregnancy (in women), behavioral
in India though he wrote sparingly of his work involving management, improving communication, and so on. These
families at the Amritsar Mental Hospital.[2] This chapter family interventions offering specific information may also
provides salient features of broad principles for providing last anywhere between 2 and 6 sessions depending on
family interventions for the treating psychiatrist. the client’s time. For example, explaining the family about
the marriage prospects of an individual with a psychiatric
TYPES AND GRADES FOR FAMILY illness can be considered a part of psychoeducation too, but
INTERVENTIONS specific information about marriage and related concerns
require separate handling. At any given time, families may
Working with families involves education, counseling, require specific focus and feedback about issues such issues.
and coping skills with families of different psychiatric
Family therapy is a structured form of psychotherapy that
Address for correspondence: Dr Mathew Varghese,
seeks to reduce distress and conflict by improving the
Professor of Psychiatry, National Institute of Mental Health & systems of interactions between family members. It is an
Neuro Sciences (NIMHANS), Bangalore, Karnataka, India. ideal counseling method for helping family members adjust
E‑mail: [Link]@[Link] to an immediate family member struggling with an addiction,
Received: 12th December, 2019, Accepted: 16th December, 2019,
Publication: 17th January, 2020 This is an open access journal, and articles are distributed under the terms of
the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License,
Access this article online which allows others to remix, tweak, and build upon the work non‑commercially,
as long as appropriate credit is given and the new creations are licensed under
Quick Response Code
the identical terms.
Website:
[Link] For reprints contact: reprints@[Link]

DOI:
How to cite this article: Varghese M, Kirpekar V, Loganathan S.
Family interventions: Basic principles and techniques. Indian J
10.4103/psychiatry.IndianJPsychiatry_770_19
Psychiatry 2020;62:S192-200.

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Varghese, et al.: Family interventions: Basic principles and techniques

medical issue, or mental health diagnosis. Specifically, family lurking problems within the family that may get discovered
therapists are relational therapists: They are generally more eventually during later assessments.
interested in what goes on between the individuals rather • Marital problems
than within one or more individuals. Depending on the • Parent–child conflict
conflicts at issue and the progress of therapy to date, a • Problems between siblings
therapist may focus on analyzing specific previous instances • The effects of illness on the family
of conflict, as by reviewing a past incident and suggesting • Adjustment problems among family members
alternative ways family members might have responded • Inconsistency parenting skills
to one another during it, or instead proceed directly to • Psychoeducation for family members about an index
addressing the sources of conflict at a more abstract level, patient’s illness
as by pointing out patterns of interaction that the family • Handling expresses emotions.
might not have noticed.
CHALLENGES FACED BY THE NOVICE
Family therapists tend to be more interested in the THERAPIST
maintenance and/or solving of problems rather than in
trying to identify a single cause. Some families may perceive Whether one is a young student, or a seasoned individual
cause‑effect analyses as attempts to allocate blame to one therapist, dealing with families can be intimidating at times
or more individuals, with the effect that for many families, but also very rewarding if one knows how to deal with them.
a focus on causation is of little or no clinical utility. It is We have outlined certain challenges that one faces while
important to note that a circular way of problem evaluation dealing with families, especially when one is beginning.
is used, especially in systemic therapies, as opposed to a
linear route. Using this method, families can be helped Being overeager to help
by finding patterns of behavior, what the causes are, and This can happen with beginner therapists as they are
what can be done to better their situation. Family therapy overeager and keen to help and offer suggestions straight
offers families a way to develop or maintain a healthy away. If the therapist starts dominating the interaction by
and functional family. Patients and families with more talking, advising, suggesting, commenting, questioning,
difficult and intractable problems such as poor prognosis and interpreting at the beginning itself, the family falls
schizophrenia, conduct and personality disorder, chronic silent. It is advisable to probe with open‑ended questions
neurotic conditions require family interventions and initially to understand the family.
therapy. The systemic framework approach offers advanced
family therapy for such families. This type of advanced Poor leadership
therapy requires training that very few centers, such as It is advisable for the therapist to have control over the
the Family Psychiatry Center at the National Institute of sessions. Sometimes, there may be other individuals/
Mental Health and Neurosciences (NIMHANS), Bengaluru, family members who maybe authoritative and take control.
Karnataka, India offer to trainees and residents. These Especially in crisis situations, when the family fails to
sessions may last anywhere from eight sessions up to 20 or function as a unit, the therapist should take control of the
more on occasions [Table 1]. session and set certain conditions which in his professional
judgment, maximize the chances for success.
Goals of family therapy
Usual goals of family therapy are improving the Not immersing or engaging/fear or involving
communication, solving family problems, understanding A common problem for the beginning therapist is to become
and handling special family situations, and creating a overly involved with the family. However, he may realize this
better functioning home environment. In addition, it also and try to panic and withdraw when he can become distant
involves: and cold. Rather, one should gently try to join in with the
1. Exploring the interactional dynamics of the family and family earning their true respect and trust before heading
its relationship to psychopathology to build rapport.
2. Mobilizing the family’s internal strength and functional
resources Focusing only on index patient
3. Restructuring the maladaptive interactional family Many families believe that their problem is because of the
styles (including improving communication) index patient, whereas it may seem a tactical error to focus
4. Strengthening the family’s problem‑solving behavior. on this person initially. In doing so, it may essentially agree
to the family’s hypothesis that their problem is arising out of
Reasons for family interventions this person. It is preferable, at the outset to inform the family
The usual reasons for referral are mentioned below. that the problem may lie with the family (especially when
However, it may be possible that sometimes the reasons referrals are made for family therapies involving multiple
identified initially may be just a pointer to many other members), and not necessarily with any one individual.

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Not including all members for sessions Ignoring previous work done by other therapists
Many therapeutic efforts fail because important family It is easy for family therapists to ignore previous therapists.
members are not included in the sessions. It is advisable The family therapist’s ignorance of the effects of previous
to find out initially who are the key members involved and therapy can serious hamper the work. By discussing the
who should be attending the sessions. Sometimes, involving previous therapist helps the new therapist to understand
all members initially and then advising them to return to the problem easily and could save time also.
therapy as and when the need arises is recommended.
Getting sucked to the family’s affective state/mood
Not involving members during sessions If transference involves the therapist in family structure, the
Even though one has involved all members of the family in therapist’s dependency can overinvolved him in the family’s
the sessions, not all of them may be engaged during the style and tone of interaction. A depressed family causes
sessions. Sometimes, the therapist’s own transference may both: Therapist to relate seriously and sadly. A hostile family
hold back a member of the family in the sessions. Rather, may cause the therapist to relate in an attacking manner.
it is recommended that the therapist makes it clear that The most serious problem can occur when a family is in a
he/she is open to their presence and interactions, either state of anxiety, induces the therapist to become anxious
verbally or nonverbally. and make his/her comments to seem accusatory and
blaming. It is very difficult for the beginning therapist to
Taking sides with any member of the family “feel” where the family is affectively, to be empathic, yet
It may be easy to fall into the trap of taking one member’s to be able to relate at times on a different affective level‑to
side during sessions leaving the other party doubting respond according to situations. It is important to be aware
the fairness and judgment of the therapist. For example, of the affective state/mood of the family but slips in and out
after meeting one marital partner for a few sessions, the of that state [Table 2].
therapist, when entering the couple, discussions may be
FUNCTIONS OF A FAMILY THERAPIST
heavily biased in his views due to his/her prior interaction.
Therapists should be aware of this effect and try to be
1. The family therapist establishes a useful rapport:
neutral as possible yet take into confidence each member
Empathy and communication among the family
attending the sessions. Therapist’s countertransference
members and between them and himself
can easily influence him/her to take sides, especially in
2. The therapist uses the rapport to evoke the expression
families that are overtly blaming from the start, or with
of major conflicts and ways of coping.
one member who may be aggressive in the sessions, or
• The therapist clarifies conflict by dissolving barriers,
very submissive during the sessions can influence the
confusions, and misunderstandings
therapist’s sides; and one needs to be aware of this early
• Gradually, the therapist attempts to bring to the
in the sessions. family to a mutual and more accurate understanding
of what is wrong
Guarded families • This he achieves through a series of partial
Some families put on a guarded façade and refuse to interventions, which include.
challenge each other in the session. By being neutral and • Counteracting inappropriate denials, conflicts
nonjudgmental, sometimes, the therapist can perpetuate • Lifting hidden intrapersonal conflict to the level
this guarded façade put forth by families. Hence, therapists of interpersonal interaction.
must be able to read this and try to challenge them, listen 3. The therapist fulfills in part the role of true parent
to microchallenges within the family, must be ready to move figure, a controller of danger, and a source of emotional
in and out from one family member to another, without support and satisfaction‑supplying elements that the
fixing to one member. family needs but lacks. He introduces more appropriate
attitudes, emotions, and images of family relations than
Communicating with the therapist outside sessions the family has ever had
Many families attempt to reduce tension by communicating 4. The therapist works toward penetrating (entering into)
with therapist outside the session, and beginning therapist and undermining resistances and reducing the intensity
are particularly susceptible for such ploys. The family or of shared currents of conflict, guilt, and fear. He
a member/s may want to meet the therapist outside the accomplishes these aims mainly using confrontation
sessions by trying to influence the therapist to their views and interpretation
and opinions. Therapists must refrain from such encounters 5. The therapist serves as a personal instrument of reality
and suggest discussing these issues openly during the testing for the family.
sessions. Of course, rarely, there may be sensitive or very
personal information that one may want to discuss in In carrying out these functions, the family therapist plays a
person that may be permissible. wide range of roles, as:

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• An activator and interactions are looked at to understand the

• Challenger family from a longitudinal and epigenetic perspective.
• Supporter The therapist also familiarizes himself with any family
• Interpreter dynamics prior to consultation. This gives a broad
• Re‑integrator background to understand the situation the family is
• Educator. dealing with now
ii. The life cycle of the index family is explored next. The
BASIC STEPS FOR FAMILY INTERVENTIONS functions of the family and specific roles of different
members are delineated in each of the stages of the
The initial phase of therapy family life cycle.[3] The index family is seen from a
a. The referral intake developmental perspective, and the therapist gets a
b. Family assessment longitudinal and temporal perspective of the family. Care
c. Family formulation and treatment plan is taken to see how the family has coped with problems
d. Formal contract. and the process of transition from one stage to another.
If children are also part of the family, their discipline
The referral intake and parenting styles are explored (e.g., whether there
Patients and their families are usually referred to as some is inconsistent parenting)
family problem has been identified. The therapist may be iii. Problem Solving: Many therapists look at this aspect
accustomed to the usual one‑on‑one therapeutic situation of the family to see how cohesive or adaptable the
involving a patient but may be puzzled in his approach by family has been. Usually, the family members are asked
the presence of many family members and with a lot of to describe some stress that the family has faced, i.e.,
information. A few guidelines are similar to the approaches some life events, environmental stressors, or illness
followed while conducting individual therapy. The guidelines in a family member. The therapist then proceeds to
for conducting family interventions are given in Table 2. At get a description of how the family coped with this
the time of the intake, the therapist reviews all the available problem. Here, “circular questions” are employed and
information in the family from the case file and the referring therapist focuses on antecedent events. The crisis
clinicians. This intake session lasts for 20–30 min and is held and the consequent events are examined closely to
with all the available family members. The aim of the intake look for patterns that emerge. The family function
session is to briefly understand the family’s perception of (or dysfunction) is heightened when there is a crisis
their problem, their motivation and need to undergo family situation and the therapist look at patterns rather than
intervention and the therapist assessments of suitability the content described. Thus, the therapist gets an “as
for family therapy. Once this is determined the nature and if I was there” view of the family. The same inquiry is
modality of the therapy is explained to the family and an possible using the technique of enactment[4]
informal contract is made about modalities and roles of iv. The Structural Map: Once the inquiry is over, the therapist
therapist and the family members. The do’s and don’ts of draws the structural map, which is a diagrammatic
the family interventions are laid down to the family at the representation of the family system, showing the
outset of the process of the interventions. different subsystems, its boundaries, power structure
and relationships between people. Diagrammatic
The family assessment and hypothesis notions used in structural therapy or Bowenian therapy
The assessment of different aspects of family functioning are used to denote relationships (normal, conflictual, or
and interactions must typically take about 3–5 sessions distant) and subsystem boundaries, in different triadic
with the whole family, each session must last approximately relationships. This can also be done on a timeline to
45 min to an hour. Different therapists may want to take show changes in relationships in different life cycle
assessments in different ways depending on their style. stages and influences from different life events
Mentioned below are a few tasks which are recommended v. The Circular Hypothesis: A systemic family hypothesis is
for the therapist to perform. Usually, it is recommended that now postulated by looking at the function of symptoms
the naïve therapist starts with a three‑generation genogram for both the client and his family. Answers to the
and then follows‑up with the different life cycle stages and following questions provide the circular hypothesis:
family functions as outlined below. 1. What the client is trying to convey through his/her
i. The three‑generation genogram is constructed symptoms?
diagrammatically listing out the index patient’s 2. What is the role of the family in maintaining these
generation and two more related generations, for symptoms?
example, patients and grandparents in an adolescent 3. Why has the family come now?
client or parents and children in a middle‑aged This circular hypothesis can be confirmed on further
client. The ages and composition of the members are inquiry with the family to see how the “dysfunctional
recorded, and the transgenerational family patterns equilibrium” is maintained. At this stage, we suggest

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Table 1: Types and grades of family interventions

Family psychoeducation (basic information) Family interventions (specific information) Family therapy (systemic framework)
Depression and anxiety Medication supervision Schizophrenia with poor prognosis
Schizophrenia and bipolar disorders (psychoses) Marriage and pregnancy counseling Conduct and personality disorders
Alcohol use disorders Job‑related counseling Chronic neurotic conditions
Child and adolescent conditions/issues Future plans‑ education, stress Severe expressed emotions
Organic brain disorders Coping and stigma Family discord and major conflicts
Any other illness Behavioral management (e.g., contracting)
Improving communication

Table 2: Guidelines for conducting interventions with modality of therapy is contracted with the family, and
families the therapy is put into force. The frequency and intensity
Timings for appointments to be followed for smooth conduct of sessions of sessions are determined by the degree of distress felt
Arriving late may reduce actual session time by the same margin by the family and the geographical distance from the
Any cancellation or postponement of sessions to be informed in advance by therapy center, i.e., families may be seen as inpatients
both parties at the center if they are in crisis or if they live far away.
Session location would be intimated in advance
An approximate total number of expected family sessions to be informed in
the beginning; including frequency of the sessions The Family Psychiatry Center at The NIMHANS, Bengaluru,
Inform clients about the reason why the family is being seen together Karnataka, India, is one of the centers where formal
Advise clients that changes may occur gradually after assessments and training in therapy is regularly conducted. An outline of the
immediate solutions may not be provided as far as possible
Family Assessment Proforma[5] used at this center is given
The duration of the sessions would be informed in the beginning itself
(45 min to an hour) in Figure 1. Several other structured family assessment
Any other matters arising, in the end, can brought up during subsequent instruments are available [Figure 1].
sessions
During sessions, clients to refrain from interrupting when someone else is Middle phase of therapy
talking
This phase of therapy forms the major work that is carried
Family members to wait for turns to talk as everyone would be given the
opportunity out with the family. Depending on the school of therapy, that
Clients to avoid verbal arguments or fights during the sessions is used, these sessions may number from a few (strategic) to
Inform clients about the confidentiality of the contents of the sessions and many sessions lasting many months (psychodynamic). The
record‑keeping practices techniques employed depend on the understanding of the
Clients to avoid any discussions outside of therapy sessions with the
family during the assessment as much as the family – therapist
therapist
Clients to discuss relevant matters as far as possible in the sessions even fit. For example, the degree of psychological sophistication
though some matters may be conflicting in nature of the clients will determine the use of psychodynamic
Make a formal contract with the family about roles of therapist and the and behavioral techniques. Similarly, a therapist who is
family members comfortable with structural/strategic methods would put
In families with violence, a no‑violence contract is preferable during the
entire process of family therapy
these therapies to maximum use. The nature of the disorder
and the degree of pathology may also determine the choice
of therapy, i.e., behavioral techniques may be used more
that a family formulation is generated, hypothesized in chronic psychotic conditions while the more difficult or
and analyzed. This leads to a comprehensive systemic resistant families may get brief strategic therapies. We will
formulation involving three generations. This now describe some of the important techniques used with
formulation will determine which family members we different kinds of problems.
need to see in a therapy, what interventional techniques
we should use and what changes in relationships we Psychodynamic therapy
should effect. The team will also discuss the minimum, This school was one of the first to be described by people like
most effective treatment plan which emerges Ackerman and Bowen.[1,6] This method has been made more
considering the most feasible changes the family can contextual and briefer by therapists like Boszormenyi‑Nasgy
make and Framo.[7,8] Essentially, the therapist understands the
vi. Formal Contract: A brief understanding of the family dynamics employed by different members of the family and
homeostasis is presented to the family. Sometimes, the the interrelationships of these members. These family ego
full hypothesis may be fed to the family in a noncritical defenses are interpreted to the members and the goal of
and positive way (“Positive Connotation”), appreciating therapy is to effects emotional insight and working through
the way in which the system is functioning the therapist of new defense patterns. Family transferences may become
presents the treatment plat to the family and negotiates evident and may need interpretation. Therapy usually lasts
with the members the plan and action they would like from 15 to 30 sessions and this method may be employed
to take up at the present time. The time frame and in persons who are psychologically sophisticated, and able

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Table 3: Summaries of the different schools of therapies

School of therapy Key elements Remarks
Psychodynamic Based on psychoanalysis; emphasis on conscious and unconscious processes; Change is steady; requires long‑term
therapy the past issues are still dynamic in the current setting; early life experiences investment (20-40 sessions); psychological
are significant; intrapersonal and interpersonal processes are entangled mindedness of client required
Behavioral methods Maladaptive behaviors, not underlying causes, should be the targets of Parent‑skills training and behavioral
change; not required to treat the entire family; the therapist is the expert, treatment of sexual dysfunctions are
teacher, collaborator, and coach examples; treatment is short term
Structural family Symptoms are understood in terms of family interaction patterns, family Especially useful with juvenile delinquents,
therapy organization must change before symptom reduction; emphasis on the whole alcohol use and anorexia, low SES
family and its subunits; therapist joins, maps out, and helps transform family families, and cross‑cultural populations
Strategic technique Not helpful to tell families what they are doing wrong; behavior change must Short‑term treatment; techniques are very
precede other changes; directives from therapist are instructions given to innovative; useful in eating disorders and
family, necessary to make changes within the first three sessions substance use
SES – Socioeconomic status

Structural family therapy

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.
Figure 1: Family assessment proforma (Obtained with
permission from the Family Psychiatry Center, National Strategic technique
Institute of Mental Health and Neurosciences, Bengaluru, We have found that these brief techniques can be very
Karnataka, India) powerfully used with families which are difficult and
highly resistant to change. We usually employ them when
to understand dynamics and interpretations. Sustained other methods have failed, and we need to take a U‑turn
and high motivation is necessary for such a therapy. This in therapy. Techniques employed by the Milan school[13,14]
method is found useful in couples with marital discord from reframing, positive connotation, paradoxical (symptom)
upper middle‑class backgrounds. Time required is a major prescription have been used effectively. So also have
constraint. techniques like prescription in brief methods advocated by
Erikson, Watzlawick et al.,[15,16] been useful. Familiarity and
Behavioral methods competence with these techniques is a must and therapy
is usually brief and quickly terminated with prescriptions
Behavioral techniques find use in many types of therapies
[Table 3].
and conditions. It has been extensively used in chronic
psychotic illnesses by workers such as Fallon et al., (1986) and FAMILY INTERVENTIONS IN SPECIFIC
Anderson et  al.[9,10] Psychoeducation and skills training in DISORDERS
communication and problem‑solving are found very useful
among families which do not have very serious dysfunction. Techniques to promote family adaptation to illness
Techniques such as modeling or role‑plays are useful in • Heighten awareness of shifting family roles – pragmatic
improving communication styles and to teach parenting and emotional
• Facilitate major family lifestyle changes
skills with disturbed children. Obviously, motivation for
• Increase communication within and outside the family
therapy is a major requisite and hence techniques such as
regarding the illness
contracting, homework assignments are used in couples • Help family to accept what they cannot control, focus
with marital discord. Behavioral techniques used in sexual energies on what they can
dysfunction are also possible when adapted according to • Find meaning in the illness. Help families move beyond
clients’ needs. “Why us?”

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• Facilitate them grieving inevitable losses–of function, The goal is to disrupt the interactional patterns that
of dreams, of life reinforce the disorder.
• Increase productive collaboration among patients,
families, and the health‑care team To assist family members in using exposure, reward,
• Trace prior family experience with the illness through relaxation, and response prevention techniques to reduce
constructing a genogram the patients’ anxieties.
• Set individual and family goals related to illness and to
nonillness developmental events. Eating disorders
Target the dysfunctional family processes, namely,
Schizophrenia enmeshment and overprotectiveness.
Family EE and communication deviance (or lack of clarity
and structure in communication) are well‑established risk To help parents build effective and developmentally
factors for the onset of schizophrenia. appropriate strategies for promoting and monitoring their
child’s eating behaviors.
Psychoeducational interventions aim to increase family
members’ understanding of the disorder and their Childhood disorders
ability to manage the positive and negative symptoms of The primary focus is the development of effective parenting
psychosis. and contingency management strategies that will disrupt
the problematic family interactions associated with ADHD
Simple strategies would include reduction of adverse and ODD.
family atmosphere by reducing stress and burden on
Family‑based interventions for autism spectrum disorder
relatives, reduction of expressions of anger and guilt by the
Parents taught to use communication and social training
family, helping relatives to anticipate and solve problems,
tools that are adapted to the needs of their children and
maintenance of reasonable expectations for patient
apply these techniques to their family interactions at
performance, to set appropriate limits whilst maintaining
home.
some degree of separation when needed; and changing
relatives’ behavior and belief systems.
Substance misuse
Enhance the coping ability of family members and reduce
Programs emphasize family resilience. Address families’
the negative consequences of alcohol and drug abuse
need for education, crisis intervention, skills training, and
on concerned relatives; eliminate the family factors that
emotional support. constitute barriers to treatment; use family support to
engage and retain the drug and/or alcohol user in therapy;
Bipolar mood disorder change the characteristics of the family environment that
To recognize the early signs and symptoms of bipolar contribute to relapse Al‑Anon, AL‑teen.
disorder.
Termination phase
Develop strategies for intervening early with new episodes This last phase of therapy is finished in a couple of
and assure consistency with medication regimens. sessions. The initial goals of therapy are reviewed
with the family. The family and the therapist review
Manage moodiness and swings of the patient, anger together the goals which were achieved, and the therapist
management, feelings of frustration. reminds the family the new patterns/changes which have
emerged. The need to continue these new patterns is
Depression emphasized. At the same time, the family is cautioned that
Family conflict and rejection, low family support, ineffective these new patterns will occur when all members make a
communication, poor expression of affect, abuse, and concerted effort to see this happen. Family members are
insecure attachment bonds are primary focus of family reminded that it is easy to fall back to the old patterns of
therapy associated with depression cognitive‑behavioral functioning which had produced the unstable equilibrium
and interpersonal interventions for depression. necessitating consultation.

Anxiety At termination, the therapist usually negotiates new goals,

Family‑based treatment for anxiety combines family therapy new tasks or new interactions with the family that they will
with cognitive‑behavioral interventions. carry out for the next few months in the follow up period.
The family is told that they need to review these new
Targets the characteristics of the family environment that patterns after a couple of months so as to determine how
support anxiogenic beliefs and avoidant behaviors. things have gone and how conflicts have been addressed

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by the family. This way the family has a better chance of the techniques for therapy are drawn from different
sustaining the change created. Sometimes booster sessions schools namely the structural, strategic, and behavioral
are also advised after 6–12 months especially for outstation psychodynamic therapies.
families who cannot come regularly for follow‑ups. These
booster sessions will review the progress and negotiate APPENDIX: Glossary of terms
further changes with the family over a couple of sessions. Structure
This follow‑up period, after therapy is terminated is The repetitive patterns of interaction that organize the way
crucial for working through process and ensures that the in which family members relate and interact with each other.
client‑therapist bond is not severed too quickly. It is easy
to deal with the clients’ and therapist’ anxieties if this Boundaries
transition phase is smooth. Boundaries are the rules defining who participates in the
system and how, i.e., the degree of access outsiders have
SPECIAL SOCIOCULTURAL ISSUES IN THERAPY to the system.
SPECIFIC TO INDIA
Subsystem
Most Indian families are functionally joint families though It may comprise of a single person, or several persons joined
they may have a nuclear family structure. Furthermore, together by common membership criteria, for example,
unlike the Western world more than two generations age, gender, or shared purpose.
readily come for therapy. Hence, it becomes necessary to
deal with two to three generations in therapy and also Coalition
with transgenerational issues. Our families also foster When alignments stand in opposition to another part of
dependency and interdependency rather than autonomy. the system (i.e., when several family members are against
This issue must also be kept in mind when dealing with another member/s.
parent–child issues. Indians have a varied cultural and
religious diversity depending on the region from which Alliance
the family comes. The therapist has to be familiar with the The joining together of two or more members. It popularly
regional customs, practices, beliefs, and rituals. The Indian designates appositive affinity between two units of a
family therapist has to also be wary of being too directive in system.
therapy as our families may give the mantle of omnipotence
to the therapist and it may be more difficult for us to Channels of communication are a mechanism that defines
adopt at one‑down or nondirective approach. Hence, while “who speaks to whom.” When channels of communication
systemic family therapy is eminently possible in India one are blocked, needs cannot be fulfilled, problems cannot be
must keep in mind these sociocultural factors so as to get a solved, and goals cannot be achieved.
good “family‑therapist fit.”
Enmeshed families
Constraint factors in therapy In which, there is extreme sensitivity among the individual
The economic backwardness of most out families makes members to each other and their primary subsystem.
therapy feasible and affordable, in terms of time and money
spent, only to the middle and upper classes of our society. Financial support and sponsorship
The poorer families usually drop out of therapy as they have Nil.
other more pressing priorities. The lack of tertiary social
support and welfare or social security makes it less possible Conflicts of interest
to network with other systems. We are also woefully There are no conflicts of interest.
inadequate in terms of trained family therapists to cater to
our large population. In our country, distances seem rather REFERENCES
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