82 Lodha and De Sousa: Family Therapy – Ethical Issues from an Indian Standpoint

Ethical Viewpoint

Family Therapy – Ethical Issues from an Indian

Standpoint

Pragya Lodha1, Avinash De Sousa2

Research Assistant, Desousa Foundation, Mumbai.

1

Founder Trustee, Desousa Foundation and National Trainer, 3T Bioethics Programme.

2

Corresponding Author: Avinash De Sousa

Email: [email protected]

ABSTRACT

Family therapy has not yet gained acceptance or popularity in the Indian context. The unique
nature of the Indian family presents a number of challenges for the conduction and process of
family therapy with Indian families. There are a number of ethical issues that arise out of these
challenges and the present articles aims to highlight the common ethical dilemmas posed before
therapists that conduct family therapy in India. Issues related to informed consent, confidentiality,
online psychotherapy with family members that are abroad, unconditional positive regard and
therapeutic neutrality are discussed. Issues faced when certain family members may need
individual psychotherapy in addition to family therapy are also addressed.

Key words: ethics, family therapy, Indian setting

Family therapy, also referred to as couple and family therapy or family systems therapy, is a branch
of psychotherapy that works with families and couples in intimate relationships to nurture change
and development. It tends to view change in terms of the systems of interaction between family
members [1]. It emphasizes family relationships as an important factor in psychological health of
an individual and eventually of a family as well. What the different schools of family therapy have
in common is a belief that, regardless of the origin of the problem, and regardless of whether the
clients consider it an "individual" or "family" issue, involving families in solutions is often
beneficial. The involvement of families is commonly accomplished by their direct participation in
the therapy session. The concept of the family is more commonly defined in terms of strongly
supportive, long-term roles and relationships between people who may or may not be related by
blood [2].

Family therapy in India has not yet caught the fancy of patients coming in for psychiatric
treatments. One the most commonly cited reasons for the same is the fact that family members
may rarely have the time to be all together for a therapy session. Many a times, patients that come
in for therapy have interpersonal problems and this may very often lead to the family therapy
sessions being turned into sparring sessions which makes it difficult for the single therapist to
handle. There are many ethical dilemmas when it comes to family therapy in general and therefore
equally so in India as well [3].

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83 Lodha and De Sousa: Family Therapy – Ethical Issues from an Indian Standpoint

There is a need for set of guidelines in order to follow and to maintain the effectiveness of this
psychotherapeutic practice. Some therapists move from individual to family therapy and vice
versa, whereas others conduct all therapy sessions with the entire family or a consistent family
subunit. The ethical issues vary in importance depending on which therapeutic format is used. The
following section discusses some of the challenges like responsibility, confidentiality, patient
privilege, informed consent and the right to refuse treatment and therapist values [4].

Responsibility
One of the defining roles of any therapist is to advocate for the patient’s welfare and protect their
rights and so does a family therapist. It becomes a challenge when the protection of rights and
welfare becomes a conflicting issue with more than one patient being handled at the same and that
too within a similar family system. An Indian family regards the priority of welfare on the basis of
several criteria- either the one who is senior most in the family or is the breadwinner in the family-
it is rare to find and equitable status quo for the same. The challenge doubles in such a situation
[5].

Additionally, individuals seek therapy when there are conflicting interests and goals within
themselves or in the family. More often, the therapist is expected to be a relationship advocate and
maintain a neutral stance in a family therapy session. Though this stance of the therapist is
accepted by the family, there are instances where the therapist is expected to serve as a personal
ally to an individual. It is also a challenge to determine as to which family member gets better
served since the equal benefit of service to all family members is difficult to achieve. An added
challenge to maintain responsibility as a family therapist is that when there are more than two
people involved in a family system, it is difficult to say if the interests of one individual will not
interfere with those of the others and the vice versa. Functioning as a relationship advocate
sometimes has the paradoxical effect of actually creating variance between the aims of family
members and those of the therapist as well. The challenge only adds on when there are clearly
outlined conflicts on interest in the beginning but they divulge into various ‘secret’ conflicts
(pertinent to certain individual members of the family). This happens when the seniors f the house
feel that the younger members need not know ‘everything’ about the particular concern. Indian
families often face this conflict in a parent-child conflict as well where the parent feels they can
determine certain aspects of their child’s life without their consultation whereas the child disagrees.
The similar challenge is also seen between a senior and younger member of the house where the
senior member assumes unsaid authority over the major decision making for the house.

Confidentiality and Informed Consent

The second challenging ethical dilemma is that of confidentiality. In the general practice of family
therapy, the ethical challenge of maintaining confidentiality surfaces with questions in
consideration- ‘Who is the patient / client?’, ‘how is confidential information of more than one
patient / client in the same family handled?’ ‘What should be the degree of disclosure and to
whom?’ and several such questions cross paths with the practice of family therapy. Confidentiality
is a greater challenge in a country like India, where peoples’ lives are inevitably blend with familial,
societal and cultural influence closely [6]. In India, families often believe that there should be no
secrets between family members and often want to know what the other family members are
saying. The hurdle of what to disclose to whom, how much to disclose, when and how to disclose
is also a part of the challenge of confidentiality in the family therapy setting. This leads to a
dilemma for the therapist who tries to maintain utmost confidentiality but there are times when
elder family members or the breadwinning member of the family demand to know details of
sessions held with other family members especially the younger family members and children (for
reasons they justify, as a matter of fact) and may thus impinge on boundaries that the therapist
wishes to maintain [7]. When the therapist may try to maintain confidentiality, these family
members may not like the same and express the same in non-attendance and non-cooperativeness
during sessions.

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84 Lodha and De Sousa: Family Therapy – Ethical Issues from an Indian Standpoint

Informed consent and right to refuse treatment are ethical nuances of any therapeutic practice.
Thus, similarly so, they are also an essential element for family therapy. The procedure of informed
consent and right to refuse treatment communicates an important therapeutic messages: No one
family member is the "sick" or "crazy" person. No one person will be "treated" while others simply
observe. No one will be excluded from knowledge about what is to transpire. Such an assurance
is a promise to the individuals that family therapy addresses them as a system, there is shared
responsibility for the problem and the solution- this in itself is a therapeutic step [8].

Psychotherapy for Individual Family Members

The third ethical dilemma is when some members of the family may need individual therapy
sessions along with the regular family therapy sessions. The individual sessions need to be held
separately and in within psychotherapeutic boundaries. This is even more important as patients in
a family therapy setting when visiting the therapist for individual therapy may try to earn more
favour from the therapist and may try and direct how the family therapy sessions move or even
infuse the therapist with facts in individual sessions that may malign him or her thoughts or align
them towards specific family members [9]. Therapeutic neutrality must be maintained by the
therapist in such a condition, under all circumstances; and this is important as it may otherwise
cause a therapeutic bias towards one family member and the skew the direction of family therapy
as a whole.

The fourth ethical dilemma, attached to the third one, is whether the family therapist must take up
patients for individual therapy or must assign another therapist for the same. The therapist must
be mindful not take the court of an individual member (whom they may also be seeing for
individual therapy) whilst during the family therapy setting. On the other hand, this is possible the
therapist conducting family sessions shall lose the advantage of using the information garnered in
individual therapy sessions for the advantage of the family in therapy. Thus, it is better that the
same therapist conducts the sessions while maintain all professional boundaries and confidentiality
and neutrality with an unconditional positive regard for all family members [10].

Duration of Therapy
The fifth ethical dilemma pertains to the duration of therapy and fee payment. Since there are
multiple family members in family therapy and Indian families are big, how long should the
duration of sessions be as 45 minutes to an hour may not be enough and whether should one
charge more based on duration and number of people coming in for therapy sessions. While this
may be done in consideration, it is also prudent to understand that charging more may lead to
withdrawal from family therapy sessions due to cost and affordability issues. A therapist may
gauge the priority of therapeutic work and take a decisional stance about the financial aspect of
the same. As far as the duration of therapy is required, the therapist must adhere to certain time
limits and keep an allowance for flexibilities in order to ensure the effectiveness of family therapy.
Sometimes, it’s okay to have the extension in session (depending on the gravity and urgency of
situation) however, at times, it may just be futile and fatiguing for the family as well as the therapist
[11].

Issues in Online Psychotherapy with Family Members

Unique ethical dilemmas also come in when one family member is abroad and may seek online
therapy individually while being involved in family therapy sessions via online means. The
internet-based medium may not be the best of the media for family therapy sessions considering
the number of people involved, triangulated conflicts and the multi-fold addressing required to be
done for the same. Apart from that, all the ethical issues that concern online psychotherapy are
enveloped to play out in the situation where family therapy is involved. The ethical dilemmas of
online psychotherapy as beyond the scope of this chapter, however, one can read more about the
same, referring to the recommended reading section of this article [12].

Lack of Proper Training

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85 Lodha and De Sousa: Family Therapy – Ethical Issues from an Indian Standpoint

It is also important to understand that there are ethical issues in training in family therapy in India.
There are barely any training programs in family therapy in India and therapists who are trained
abroad work with families abroad where the dynamics are different and it is very difficult to apply
the same to Indian settings. In India, family therapy training is redundant in psychotherapy syllabi
and training is restricted to teaching the theory alone. There is a scarcity of sound supervision in
individual therapy and family therapy supervision is conspicuous by its absence. There is also a
lack of trained teachers and supervisors to impart knowledge in the subject. Therefore, lack of
training and supervision are added shortcomings with a lack of infrastructure and resources for the
same in a developing country like ours [12].

Legal Aspects of Family Therapy in India

The legality and documentation of family therapy in India is another burning issue. The reason
for the same is lack of legal regulations governing therapists and family therapy in India. Lack of
documentation and case record guidelines in the Indian context can sometimes lead to poor,
incomplete and shabby documentation that affects proper case records when there is a legal matter
involved. There is a lack of computerized therapy session documentation in India and this leads
to poor handwritten notes as very few therapists in India maintain painstaking handwritten records
for session by session documentation of both individual and family therapy [13].
Another aspect related to legality is when the therapist may have to enter in as the relationship
advocate when there is a legal matter involved during the period of family therapy- where two
people may be waiving property matters or a divorce is due in course.

Challenges of the Indian Family

Last but not the least, is the ethical issues when incorporating schools of therapy built in the
western context to suit the Indian context. Mother-in-law and daughter-in-law issues, fights
between elder and younger daughters-in-law, fights within joint families and issues between newly
married couples and their in-laws are all unique to the Indian context and the psychodynamics
and family dynamics of the same needs to be understood in the Indian context through experience
and are not documented in a book anywhere. Cultural and religious values need to be respected
and treated with care in therapy settings and family therapists need to be cognizant of the issues at
hand when handling families from orthodox religions or families with mixed marriages and
religious or cultural diversity. Training for the same is never given and comes over time with the
experience of being a therapist [14].

Conclusion
Thus, multiple ethical dilemmas plague the family therapist in India and it is important that
therapists propagating family therapy are ready to meet these ethical challenges head on and take
on the problems that may be faced in family therapy sessions. If thought upon, the scope of
effectiveness of family therapy in a partly collectivist and partly individualistic country like India
is immense. We, as a country, have the potential to benefit each other as a family system along
with the values that we proud upon.

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Acknowledgements – Nil
Source of Funding – Nil
Conflict of Interest – Nil

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