Good Therapy/what Are Specific Challenges When Counseling Families?

Indian J Psychiatry. 2020 January; 62(Suppl ii): S192–S200.

Family Interventions: Basic Principles and Techniques

Mathew Varghese

Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore, Karnataka, India

Vivek Kirpekar

ⁱNorthward.K.P. Relieve Establish of Medical Sciences, Nagpur, Maharashtra, India

Santosh Loganathan

Department of Psychiatry, National Institute of Mental Wellness and Neuro Sciences (NIMHANS), Bangalore, Karnataka, Bharat

Received 2019 Dec 12; Accepted 2019 Dec 16.

INTRODUCTION

Mental health professionals in India have always involved families in therapy. Withal, formal involvement of families occurred about one to two decades after this therapeutic modality was started in the Westward by Ackerman.[1] In India, families course an of import part of the social fabric and support organization, and as a result, they are integral in being part of the treatment and therapeutic process involving an individual with mental affliction. Mental illnesses afflict individuals and their families too. When an individual is affected, the stigma of being mentally ill is not restricted to the individual alone, but to family members/caregivers also. This type of stigma is known as "Courtesy Stigma" (Goffman). Families are mostly unaware and lack information most mental illnesses and how to deal with them and in turn, may end up maintaining or perpetuating the affliction too. Vidyasagar is credited to be the father of Family Therapy in India though he wrote sparingly of his work involving families at the Amritsar Mental Infirmary.[2] This chapter provides salient features of broad principles for providing family interventions for the treating psychiatrist.

TYPES AND GRADES FOR Family unit INTERVENTIONS

Working with families involves pedagogy, counseling, and coping skills with families of dissimilar psychiatric disorders. Diverse interventions exist for different disorders such as depression, psychoses, child, and boyish related problems and alcohol employ disorders. Such families require psychoeducation most the illness in question, and in addition, will require information about how to deal with the index person with the psychiatric illness. Psychoeducation involves giving bones data about the illness, its form, causes, treatment, and prognosis. These basic informative sessions tin can last from two to 6 sessions depending on the time available with clients and their families. Simple interventions may include dealing with parent-adolescent disharmonize at home, where brief counseling to both parties about the expectations of each other and facilitating direct and open advice is required.

Boosted family unit interventions may cover specific aspects such as future plans, task prospects, medication supervision, spousal relationship and pregnancy (in women), behavioral management, improving advice, so on. These family unit interventions offer specific information may besides terminal anywhere between two and half-dozen sessions depending on the client's time. For instance, explaining the family nearly the spousal relationship prospects of an private with a psychiatric illness can be considered a part of psychoeducation too, only specific information nigh matrimony and related concerns require separate handling. At whatever given time, families may require specific focus and feedback about issues such problems.

Family therapy is a structured grade of psychotherapy that seeks to reduce distress and conflict by improving the systems of interactions betwixt family members. It is an platonic counseling method for helping family members adjust to an immediate family member struggling with an habit, medical issue, or mental health diagnosis. Specifically, family therapists are relational therapists: They are generally more than interested in what goes on between the individuals rather than inside i or more individuals. Depending on the conflicts at issue and the progress of therapy to appointment, a therapist may focus on analyzing specific previous instances of conflict, as past reviewing a past incident and suggesting alternative ways family unit members might have responded to ane another during it, or instead go along straight to addressing the sources of conflict at a more abstract level, equally by pointing out patterns of interaction that the family might not accept noticed.

Family therapists tend to exist more interested in the maintenance and/or solving of issues rather than in trying to identify a single cause. Some families may perceive cause-effect analyses every bit attempts to classify blame to i or more than individuals, with the effect that for many families, a focus on causation is of little or no clinical utility. It is important to note that a circular way of problem evaluation is used, particularly in systemic therapies, equally opposed to a linear route. Using this method, families can exist helped past finding patterns of behavior, what the causes are, and what can be washed to better their state of affairs. Family therapy offers families a way to develop or maintain a healthy and functional family. Patients and families with more difficult and intractable problems such as poor prognosis schizophrenia, conduct and personality disorder, chronic neurotic conditions crave family interventions and therapy. The systemic framework approach offers advanced family therapy for such families. This type of avant-garde therapy requires training that very few centers, such as the Family Psychiatry Center at the National Establish of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India offer to trainees and residents. These sessions may last anywhere from viii sessions upwardly to 20 or more on occasions [Tabular array 1].

Table ane

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	Task-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
Whatever other illness	Behavioral management (e.g., contracting)
	Improving communication

Goals of family therapy

Usual goals of family therapy are improving the communication, solving family issues, understanding and handling special family situations, and creating a better functioning home environment. In addition, it also involves:

Exploring the interactional dynamics of the family and its human relationship to psychopathology
Mobilizing the family's internal forcefulness and functional resources
Restructuring the maladaptive interactional family styles (including improving communication)
Strengthening the family'southward trouble-solving behavior.

Reasons for family interventions

The usual reasons for referral are mentioned below. Nevertheless, it may be possible that sometimes the reasons identified initially may exist just a pointer to many other lurking problems inside the family that may get discovered eventually during after assessments.

Marital issues
Parent–child conflict
Issues betwixt siblings
The furnishings of affliction on the family
Aligning problems among family members
Inconsistency parenting skills
Psychoeducation for family members about an index patient'south disease
Handling expresses emotions.

CHALLENGES FACED BY THE NOVICE THERAPIST

Whether one is a young student, or a seasoned private therapist, dealing with families tin be intimidating at times just also very rewarding if 1 knows how to deal with them. Nosotros have outlined certain challenges that one faces while dealing with families, particularly when i is beginning.

Being overeager to aid

This can happen with beginner therapists as they are overeager and keen to aid and offer suggestions straight abroad. If the therapist starts dominating the interaction by talking, advising, suggesting, commenting, questioning, and interpreting at the outset itself, the family falls silent. Information technology is advisable to probe with open-ended questions initially to understand the family.

Poor leadership

It is appropriate for the therapist to have control over the sessions. Sometimes, there may exist other individuals/family members who maybe administrative and take command. Especially in crisis situations, when the family unit fails to function as a unit, the therapist should take control of the session and set sure conditions which in his professional judgment, maximize the chances for success.

Not immersing or engaging/fear or involving

A mutual trouble for the commencement therapist is to become overly involved with the family. However, he may realize this and try to panic and withdraw when he tin become distant and cold. Rather, i should gently endeavor to bring together in with the family unit earning their true respect and trust before heading to build rapport.

Focusing only on index patient

Many families believe that their problem is because of the alphabetize patient, whereas information technology may seem a tactical fault to focus on this person initially. In doing so, it may essentially agree to the family unit'south hypothesis that their problem is arising out of this person. It is preferable, at the commencement to inform the family unit that the trouble may lie with the family (specially when referrals are made for family therapies involving multiple members), and not necessarily with any 1 individual.

Not including all members for sessions

Many therapeutic efforts fail considering of import family members are not included in the sessions. It is advisable to find out initially who are the central members involved and who should exist attention the sessions. Sometimes, involving all members initially and so advising them to return to therapy as and when the need arises is recommended.

Non involving members during sessions

Even though 1 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 agree back a member of the family in the sessions. Rather, it is recommended that the therapist makes it clear that he/she is open to their presence and interactions, either verbally or nonverbally.

Taking sides with any member of the family

It may be easy to fall into the trap of taking one fellow member's side during sessions leaving the other party doubting the fairness and judgment of the therapist. For example, after meeting one marital partner for a few sessions, the therapist, when entering the couple, discussions may be heavily biased in his views due to his/her prior interaction. Therapists should be aware of this upshot and try to be neutral as possible yet take into confidence each member attention the sessions. Therapist's countertransference can easily influence him/her to take sides, specially in families that are overtly blaming from the start, or with 1 member who may be aggressive in the sessions, or very submissive during the sessions tin can influence the therapist'south sides; and 1 needs to be aware of this early in the sessions.

Guarded families

Some families put on a guarded façade and turn down to challenge each other in the session. By being neutral and nonjudgmental, sometimes, the therapist tin perpetuate this guarded façade put along by families. Hence, therapists must be able to read this and endeavor to challenge them, heed to microchallenges inside the family, must be ready to move in and out from one family member to another, without fixing to one member.

Communicating with the therapist outside sessions

Many families endeavour to reduce tension by communicating with therapist outside the session, and beginning therapist are particularly susceptible for such ploys. The family or a member/s may desire to see the therapist exterior the sessions by trying to influence the therapist to their views and opinions. Therapists must refrain from such encounters and suggest discussing these issues openly during the sessions. Of course, rarely, in that location may be sensitive or very personal data that 1 may want to discuss in person that may be permissible.

Ignoring previous work done past other therapists

Information technology is like shooting fish in a barrel for family therapists to ignore previous therapists. The family therapist's ignorance of the effects of previous therapy tin can serious hamper the piece of work. By discussing the previous therapist helps the new therapist to empathize the problem easily and could relieve time also.

Getting sucked to the family'southward affective state/mood

If transference involves the therapist in family structure, the therapist'south dependency tin can overinvolved him in the family unit'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 mode. The most serious problem tin occur when a family is in a state of anxiety, induces the therapist to become anxious and make his/her comments to seem accusatory and blaming. It is very difficult for the starting time therapist to "feel" where the family is affectively, to be empathic, all the same to be able to relate at times on a unlike melancholia level-to reply co-ordinate to situations. It is important to exist aware of the melancholia land/mood of the family unit simply slips in and out of that land [Table 2].

Table 2

Guidelines for conducting interventions with families

Timings for appointments to be followed for smooth deport of sessions

Arriving late may reduce bodily session time by the same margin

Any cancellation or postponement of sessions to be informed in advance past both parties

Session location would be intimated in advance

An approximate total number of expected family sessions to be informed in the start; including frequency of the sessions

Inform clients about the reason why the family is being seen together

Advise clients that changes may occur gradually after assessments and immediate solutions may not be provided as far as possible

The duration of the sessions would be informed in the beginning itself (45 min to an hour)

Whatever other matters arising, in the end, tin can brought upwards during subsequent sessions

During sessions, clients to refrain from interrupting when someone else is talking

Family members to wait for turns to talk as everyone would be given the opportunity

Clients to avoid exact arguments or fights during the sessions

Inform clients almost the confidentiality of the contents of the sessions and record-keeping practices

Clients to avoid whatsoever discussions outside of therapy sessions with the therapist

Clients to discuss relevant matters every bit far as possible in the sessions fifty-fifty though some matters may exist conflicting in nature

Brand a formal contract with the family near roles of therapist and the family members

In families with violence, a no-violence contract is preferable during the entire process of family unit therapy

FUNCTIONS OF A FAMILY THERAPIST

The family therapist establishes a useful rapport: Empathy and advice amidst 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 than accurate understanding of what is wrong
- This he achieves through a series of partial interventions, which include.
  - Counteracting inappropriate denials, conflicts
  - Lifting hidden intrapersonal conflict to the level of interpersonal interaction.
The therapist fulfills in part the role of true parent figure, a controller of danger, and a source of emotional back up 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 estimation
The therapist serves every bit a personal instrument of reality testing for the family unit.

In conveying out these functions, the family therapist plays a wide range of roles, as:

An activator
Challenger
Supporter
Interpreter
Re-integrator
Educator.

Basic STEPS FOR Family unit INTERVENTIONS

The initial phase of therapy

The referral intake
Family unit cess
Family unit formulation and treatment plan
Formal contract.

The referral intake

Patients and their families are usually referred to as some family unit problem has been identified. The therapist may be accepted to the usual one-on-1 therapeutic situation involving a patient but may be puzzled in his approach by the presence of many family unit members and with a lot of information. A few guidelines are like to the approaches followed while conducting individual therapy. The guidelines for conducting family interventions are given in Table ii. 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 xx–30 min and is held with all the available family members. The aim of the intake session is to briefly understand the family'southward 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 do's and don'ts of the family interventions are laid downwardly to the family unit at the offset of the procedure of the interventions.

The family unit assessment and hypothesis

The assessment of different aspects of family performance and interactions must typically accept about iii–5 sessions with the whole family unit, each session must final approximately 45 min to an hour. Dissimilar therapists may want to take assessments in unlike ways depending on their fashion. Mentioned below are a few tasks which are recommended for the therapist to perform. Usually, information technology is recommended that the naïve therapist starts with a iii-generation genogram and then follows-up with the different life wheel stages and family functions equally outlined beneath.

The three-generation genogram is constructed diagrammatically listing out the alphabetize patient'southward generation and two more related generations, for example, patients and grandparents in an boyish client or parents and children in a eye-anile client. The ages and limerick of the members are recorded, and the transgenerational family patterns and interactions are looked at to empathize 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 unit is dealing with now
The life wheel of the alphabetize family is explored next. The functions of the family and specific roles of dissimilar members are delineated in each of the stages of the family life cycle.[three] The alphabetize family is seen from a developmental perspective, and the therapist gets a longitudinal and temporal perspective of the family unit. Care is taken to see how the family has coped with problems and the process of transition from one stage to some other. If children are likewise function of the family unit, their discipline and parenting styles are explored (east.m., whether there is inconsistent parenting)
Problem Solving: Many therapists look at this aspect of the family unit to see how cohesive or adjustable the family has been. Ordinarily, the family unit members are asked to describe some stress that the family has faced, i.e., some life events, environmental stressors, or illness in a family member. The therapist then gain to go a description of how the family coped with this problem. Here, "circular questions" are employed and therapist focuses on antecedent events. The crunch and the consequent events are examined closely to expect 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. Thus, the therapist gets an "as if I was in that location" view of the family. The same research 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 dissimilar triadic relationships. This tin also be done on a timeline to show changes in relationships in different life bicycle stages and influences from different life events
The Circular Hypothesis: A systemic family hypothesis is at present postulated by looking at the function of symptoms for both the customer and his family. Answers to the following questions provide the circular hypothesis:
1. What the client is trying to convey through his/her symptoms?
2. What is the role of the family in maintaining these symptoms?
3. Why has the family come now?
This circular hypothesis tin be confirmed on further enquiry with the family to come across how the "dysfunctional equilibrium" is maintained. At this stage, nosotros propose that a family formulation is generated, hypothesized and analyzed. This leads to a comprehensive systemic conception involving three generations. This formulation volition determine which family members we need to run into in a therapy, what interventional techniques we should use and what changes in relationships we should effect. The team will also talk over the minimum, most effective treatment plan which emerges considering the most feasible changes the family tin make
Formal Contract: A brief understanding of the family homeostasis is presented to the family unit. Sometimes, the full hypothesis may be fed to the family in a noncritical and positive way ("Positive Connotation"), appreciating the way in which the arrangement is functioning the therapist presents the treatment plat to the family and negotiates with the members the plan and action they would like to take upwardly at the present time. The time frame and modality of therapy is contracted with the family unit, and the therapy is put into force. The frequency and intensity of sessions are determined by the degree of distress felt by the family unit and the geographical distance from the therapy center, i.e., families may be seen every bit inpatients at the center if they are in crisis or if they live far away.

The Family unit Psychiatry Center at The NIMHANS, Bengaluru, Karnataka, India, is 1 of the centers where formal training in therapy is regularly conducted. An outline of the Family Assessment Proforma[5] used at this heart is given in Figure i. Several other structured family assessment instruments are available [Figure one].

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Family assessment proforma (Obtained with permission from the Family unit Psychiatry Center, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India)

Middle phase of therapy

This phase of therapy forms the major piece of 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 agreement of the family during the assessment every bit much as the family – therapist fit. For example, the caste of psychological sophistication of the clients will make up one's mind the use of psychodynamic and behavioral techniques. Similarly, a therapist who is comfortable with structural/strategic methods would put these therapies to maximum use. The nature of the disorder and the degree of pathology may also determine the choice of therapy, i.east., behavioral techniques may be used more in chronic psychotic conditions while the more hard or resistant families may get brief strategic therapies. We will now describe some of the of import techniques used with different kinds of problems.

Psychodynamic therapy

This school was one of the showtime to be described by people like Ackerman and Bowen.[1,six] This method has been made more than contextual and briefer by therapists like Boszormenyi-Nasgy and Framo.[seven,8] Essentially, the therapist understands the dynamics employed past unlike members of the family and the interrelationships of these members. These family ego defenses are interpreted to the members and the goal of therapy is to effects emotional insight and working through of new defence patterns. Family transferences may become evident and may demand interpretation. Therapy ordinarily 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-form backgrounds. Time required is a major constraint.

Behavioral methods

Behavioral techniques notice use in many types of therapies and conditions. It has been extensively used in chronic psychotic illnesses past workers such as Fallon et al., (1986) and Anderson et al.[9,x] Psychoeducation and skills training in advice and problem-solving are institute very useful amid families which exercise not have very serious dysfunction. Techniques such as modeling or part-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. Behavioral techniques used in sexual dysfunction are also possible when adapted according to clients' needs.

Structural family therapy

Described by Minuchin; Fishman and Unbarger[4,eleven,12] has become quite popular over the by few years among therapists in India. This is possibly because of many reasons. Our families are bachelor with their manifold subsystems of parents, children, grandparents and structure is easily discerned and changed. In add-on, in recent years almost 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 betwixt parents. These techniques are useful for many of our clients.

Strategic technique

We have found that these brief techniques can be very powerfully used with families which are difficult and highly resistant to alter. Nosotros normally employ them when other methods have failed, and nosotros need to accept a U-turn in therapy. Techniques employed by the Milan school[13,14] reframing, positive connotation, paradoxical (symptom) prescription have been used finer. Then also have techniques similar prescription in brief methods advocated past Erikson, Watzlawick et al.,[15,16] been useful. Familiarity and competence with these techniques is a must and therapy is usually brief and quickly terminated with prescriptions [Tabular array three].

Table 3

Summaries of the different schools of therapies

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

Family INTERVENTIONS IN SPECIFIC DISORDERS

Techniques to promote family accommodation to disease

Heighten sensation of shifting family unit roles – pragmatic and emotional
Facilitate major family lifestyle changes
Increase advice within and outside the family regarding the illness
Aid family unit to have what they cannot command, focus energies on what they can
Discover meaning in the illness. Help families move beyond "Why us?"
Facilitate them grieving inevitable losses–of function, of dreams, of life
Increase productive collaboration amidst patients, families, and the health-care team
Trace prior family experience with the illness through amalgam a genogram
Set up individual and family goals related to affliction and to nonillness developmental events.

Schizophrenia

Family EE and communication deviance (or lack of clarity and structure in communication) are well-established adventure factors for the onset of schizophrenia.

Psychoeducational interventions aim to increase family members' understanding of the disorder and their ability to manage the positive and negative symptoms of psychosis.

Simple strategies would include reduction of adverse family atmosphere by reducing stress and burden on relatives, reduction of expressions of acrimony and guilt past the family, helping relatives to anticipate and solve issues, maintenance of reasonable expectations for patient functioning, to prepare appropriate limits whilst maintaining some degree of separation when needed; and irresolute relatives' behavior and conventionalities systems.

Programs emphasize family resilience. Address families' need for education, crisis intervention, skills training, and emotional back up.

Bipolar mood disorder

To recognize the early signs and symptoms of bipolar disorder.

Develop strategies for intervening early on with new episodes and assure consistency with medication regimens.

Manage moodiness and swings of the patient, anger management, feelings of frustration.

Depression

Family conflict and rejection, depression family support, ineffective communication, poor expression of touch, abuse, and insecure attachment bonds are chief focus of family unit therapy associated with depression cerebral-behavioral and interpersonal interventions for low.

Anxiety

Family-based treatment for anxiety combines family therapy with cognitive-behavioral interventions.

Targets the characteristics of the family environs that back up anxiogenic beliefs and avoidant behaviors.

The goal is to disrupt the interactional patterns that reinforce the disorder.

To assist family members in using exposure, advantage, relaxation, and response prevention techniques to reduce the patients' anxieties.

Eating disorders

Target the dysfunctional family unit processes, namely, enmeshment and overprotectiveness.

To assist parents build constructive and developmentally appropriate strategies for promoting and monitoring their kid's eating behaviors.

Babyhood disorders

The primary focus is the evolution of effective parenting and contingency management strategies that will disrupt the problematic family unit interactions associated with ADHD and ODD.

Family-based interventions for autism spectrum disorder

Parents taught to utilise communication and social preparation tools that are adapted to the needs of their children and apply these techniques to their family interactions at dwelling.

Substance misuse

Enhance the coping ability of family members and reduce the negative consequences of booze and drug corruption on concerned relatives; eliminate the family factors that constitute barriers to treatment; use family unit support to appoint and retain the drug and/or alcohol user in therapy; change the characteristics of the family surround that contribute to relapse Al-Anon, AL-teen.

Termination phase

This last phase of therapy is finished in a couple of sessions. The initial goals of therapy are reviewed with the family unit. The family and the therapist review together the goals which were achieved, and the therapist reminds the family the new patterns/changes which take emerged. The need to continue these new patterns is emphasized. At the same time, the family unit 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 like shooting fish in a barrel to autumn 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 unit that they volition carry out for the next few months in the follow up menses. The family is told that they need to review these new patterns later a couple of months and so every bit to determine how things take gone and how conflicts have been addressed by the family. This way the family has a meliorate chance of sustaining the change created. Sometimes booster sessions are as well advised after 6–12 months particularly for outstation families who cannot come regularly for follow-ups. These booster sessions will review the progress and negotiate farther changes with the family over a couple of sessions. This follow-up period, after therapy is terminated is crucial for working through procedure and ensures that the client-therapist bond is not severed too quickly. It is easy to bargain with the clients' and therapist' anxieties if this transition phase is smooth.

SPECIAL SOCIOCULTURAL ISSUES IN THERAPY SPECIFIC TO India

Most Indian families are functionally joint families though they may have a nuclear family construction. Furthermore, unlike the Western globe more than than two generations readily come up for therapy. Hence, information technology becomes necessary to bargain with 2 to three generations in therapy and likewise with transgenerational issues. Our families also foster dependency and interdependency rather than autonomy. This issue must also be kept in listen when dealing with parent–child problems. Indians have a varied cultural and religious multifariousness depending on the region from which the family comes. The therapist has to exist familiar with the regional customs, practices, beliefs, and rituals. The Indian family therapist has to too be wary of being too directive in therapy every bit our families may requite the mantle of omnipotence to the therapist and it may be more than difficult for usa to prefer at one-down or nondirective arroyo. Hence, while systemic family therapy is eminently possible in Republic of india one must keep in listen these sociocultural factors then as to get a expert "family-therapist fit."

Constraint factors in therapy

The economic backwardness of most out families makes therapy viable and affordable, in terms of time and money spent, simply to the middle and upper classes of our guild. The poorer families usually drop out of therapy equally they take other more than pressing priorities. The lack of tertiary social back up and welfare or social security makes information technology 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. We work with these constraint factors and so the "family unit-therapy" fit is an important gene for families that are seeking and staying in family therapy.17

CONCLUSIONS

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.

Appendix: Glossary of terms

Construction

The repetitive patterns of interaction that organize the way in which family members relate and interact with each other.

Boundaries

Boundaries are the rules defining who participates in the system and how, i.e., the degree of access outsiders have to the organisation.

Subsystem

It may incorporate of a single person, or several persons joined together by common membership criteria, for example, historic period, gender, or shared purpose.

Coalition

When alignments stand in opposition to another part of the system (i.e., when several family members are confronting another fellow member/southward.

Alliance

The joining together of ii or more members. It popularly designates appositive affinity betwixt two units of a system.

Channels of advice are a mechanism that defines "who speaks to whom." When channels of communication are blocked, needs cannot be fulfilled, problems cannot be solved, and goals cannot be achieved.

Enmeshed families

In which, there is extreme sensitivity among the individual members to each other and their primary subsystem.

Financial support and sponsorship

Cipher.

Conflicts of involvement

In that location are no conflicts of involvement.

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7001353/