GURUGRAM

ASSIGNMENT

ON

FAMILY THERAPY

SUBJECT: PSYCHIATRIC NURSING

SUBMITTED TO: Pro. POONAM SHARMA

ACON

SUBMITTED BY: Rakesh Kumar

M.sc (N) 1st year

SUBMITTED ON: 09/09/2019

 FAMILY THERAPY
INTRODUCTION:

The term family therapy coined by the American psychiatrist Nathan Ackerman in the 1950’s. Family
therapy is method drawn from one or more of a range of, schools which seeks to help the individual
patient who is the locus of psychopathology-it is at one extreme and at other is a way of thinking about
psychotherapy; the intervention may involve “the individual alone, the nuclear family or extended family
network; however the focus is not so much on the individual but rather than relationship between people.

DEFINITION:

A psychotherapeutic approach that focuses n altering interactions between a couple within nuclear family
or it’s members n extended family or between the family or other interpersonal systems with the goal of
alleviating problems initially presented by individual family members, family subsystems, the family as a
whole or other referral sources.

Wyne, 1988

HISTORICAL DEVELOPMENT:

Ackerman and Murray Bowen were leaders in the family therapy. The family has been recognized as the
fundamental unit of social organization in the human life. Regardless of the specific pattern of family lie,
the fundamental narratives, myths, legends and folklore of all cultures emphasize the power of family
relations to mould the character of individual and serves as an example of the moral and political order of
society.

THE FUNCTIONS OF FAMILY:

 MANAGEMENT: use of decision making power for all family activities rule making, provision
of financial and other support, successful negotiation with extra family system with present and
future planning
 BOUNDARY FUNCTION: boundaries will maintain a distinction between individuals within the
family. Clear boundaries define the roles of the members within the family and allow for
differences among members.
 COMMUNICATION FUNCTION: healthy communication among within the family encourages
its members to express their feelings or emotions appropriately. Open expression of feelings like
joy, angry, sorrow…healthy communication will help the family member to solve the problems.
  SUPPORTIVE FUNCTION: healthy families are concerned with each other’s needs they feel
support from those around and are free to grow and explore new roles and facets of their
personality.
 SOCIALIZATION FUNCTION: Socialization skills are learnt by each individual within the
family. They learn how to interact, adopt coping sills. First learns how to function within the
family then applies these skills in the society.
 BIOLOGICAL FUNCTION: replacement of species through the propagation of progeny family
is a medium where the sex relation are controlled and regulated.
 PSYCHOLOGICAL FUNCTON: love belongingness, affection, sympathy, security, attention, is
of off springs, sexual relation; intimacy e.t.c… will be learned by the family.
 EDUCATONAL FUNCTON: mother is the first teacher and primary caregiver who will take care
of the children. Child’s character formation will be attained through family.
 PROTECTIVE FUNCTON: protects the child’s interest, provides security to cultivate healthy
behavior.
 RELIGIOUS FUNCTON: family develops religious thoughts kind heartedness and fellow
belonging. The child learns oral values, ethic, odes, honesty, traditions and religious pattern
through family.
 CULTURAL FUNCTON: family moulds its members according to the culture. Family serves as
the instrument for transmission and continuity.

THE EFFECTIVE FAMILY:

The effective family is able to facilitate the growth and development of its members while still
maintains cohesion and identity as a unit. The characteristics of this family are:
 The family concerns the emotional, physical, social needs of its members over other concerns
such as acquisition of possessions or status.
 The family recognizes values and accommodates to differences among its members
 The family is sufficiently flexible so that changes stemming from within the and outside the
system can be accommodated without loss of family stability.
 The family seeks and uses information from relevant outside sources, simultaneously maintaining
its autonomy.
 The family makes and carries out decisions, taking it in to account its goal and age. And
experience of its members.
An effective family is not necessarily a family without problems, conflicts or stress. Rather, an
effective family has developed a structure and pattern of functioning that enables it to deal with
its problems as they arise and learn to grow together from the problem solving process.

THE INEFFECTIVE FAMILY

Families that are unable to establish and maintain a structure and patterns of behavior conducive effective
functioning often show signs of continuous, irresolvable stress. Such stress may be manifested by the
entire system, as when overt tension and hostility occur among members who is covertly designated to
assume and act out the family problems. This family member may often, although not always be a child.
Since children are more vulnerable and less powerful as they are highly dependent on the family. Bed
wetting, learning difficulty, antisocial behavior, chronic depression. in a child may all be symptoms of an
ineffective family. The abuse and violence is one of increasing and common and very serious form of
ineffective family functioning.

CLIENT SELECTION: Families may be referred to treatment by:

 Private physicians
 Welfare agencies, e.g. school, parole officers, judges.
  Family physicians.
 Emergency room psychiatric O.P.D., e.g. after crisis within the family, drug abuse.
 After discharging from psychiatric hospital for follow up services.
 Marital or sibling conflicts.
 Situational crisis and maturational crisis, e.g. birth of a child, sudden death of family members.

APPROACHES TO FAMILY THERAPY:

 DOUBLE BLIND THEORY: It describes a situation in which two conflicting messages are given
simultaneously on two levels verbal or non verbal. As the messages are conflict people find
themselves in a double blind, in which no acceptable response exists.
 STRATEGIC MODEL therapy of Jay Haley, Mitton Erickson: by changing any single element in the
family system, change can be brought about in the entire system. This model aims to change the
patterns, the rules and the meaning of family interaction.EG. Children to be present at the time of
decision making. it is built upon the premises that a therapist is responsible for planning a strategy
that solves successfully the family’s presenting problem. The therapists set clear goals that intervene
by changing relational and communicational process in family. These therapies are designed as a
counter point to psychodynamic psychotherapy by emphasizing how people can behave as they do.
The central aim of therapist is to motivate family members to try novel solutions, rather than,
repeating what has been tried in the past. Psycho education, direct behavioral directives such as-
refraining the symptoms, prescribing the symptoms, restraining the system, positions.
 STRUCTURAL MODEL: it is based on normative concept of a healthy family, emphasizing the
boundaries between family subsystem and the establishment, maintenance of a clear hierarchy based
on parental competence. The therapists would emphasize the importance of flexibility in the family
system that would allow for change inherent to normal growth and development. of the family rules
and roles that shapes its member’s action it considers problem involving a particular family members
linked to the organization context of the entire family. It solves problem by changing the family’s
organization context. It emphasizes an understanding of family in terms
In this therapist observes closely the flow of family structure as family members talk about and
interact together around the presenting problem of the therapy. He observes how boundaries,
hierarchy as well as representative behavioral sequences that involves symptomatic behavior.
 FAMILY SOCIAL/SYSTEMS APPROACH: Therapy emphasis the natural healing powers of the
family. It involves bringing several people together as a social network. It decreases emotional
reactivity and to encourage differentiation among individual family members.
 INSIGHT ORIENTED FAMILY THEORY: It improves insight in to problematic relationship;
family is an emotional system and is responsible for its own solutions the therapists uses nurturing
and identifies dysfunctional communication pattern.
 BEHAVIORAL FAMILY THEORY: It focuses on organizational pattern, boundary system and
subsystem it clarifies boundaries, changes repetitive and maladaptive interaction pattern prescribes
rituals it change cognition behavior and helps in skill training.
 PSYCHODYNAMIC FAMILY THERAPY: it helps family members to solve relational problems by
understanding better how emotional process influence the perception, feelings and actions of those
involved. This therapy concentrates on motivation, conflicts, defenses and the relationships from the
past that are currently influence the present.
Psychodynamic family therapists i.e. opening emotional expression clarifying communication,
encouraging family members to speak from the “I” position and interpretation of unconscious
conflicts.
 POST MODERN FAMILY THERAPY: these are group of therapies which involve narrative,
solution focused, collaborative language systems and feminist family therapies. Innovation introduced
by post modem therapies have opened new ways of families to solve problems by valuing and
 learning from their own experiences, histories, traditions, value and identities instead of seeking
answers from mental health experts. The Post modern family therapies have sought to empower
families by helping them to develop reflective processes for exercising choice to build supportive
communities with other families and to clarify undesirable ways in which cultural influences have
limited appreciation and utilization of family’s own practical wisdom.

 FAMILY PSYCHO-EDUCATION THERAPY: this approach emerged that sought to ”put the illness
in its place” by helping families to acquire knowledge, skills and resources needed to minimize the
loss of time, money and energy from chronic medical and psychiatric disorder. This approach made
maximal use of psychotropic medication to control disruptive symptoms and openly embraced
interventions drawn from other individuals, family, or social network therapies.psychoeducation
mainly consists discussion about diagnosis, etiology, use of antipsychotic medication, needs of
patient and family members, creation of social contacts and support, problem solving with others
bearing the burden of the same disorder, counteracting stigma, cross parenting of adolescents
normalizing family communication and intervening effectively during crisis.

STAGES OF FAMILY THERAPY

Initial interview phase

Intervention phase

Termination phase

INITIAL INTERVIEW PHASE:

During the initial interview the therapist facilitates the process of determining which problems the family
has identified as needing attention. This process occurs in stages and includes:

 Engagement stage: the family meets and is put at ease by the therapist

 Assessment stage: problems that concern the family are identified.

 Exploration stage: the therapist and family explore additional problems that may have a bearing
on present family concerns.

 Good setting stage: the therapist synthesis all the information, and the family members state what
they would like to see changed.

 Termination stage: the initial interview ends an appointment is set for the next session and it is
determined which family members need to attend.

During the initial interview the therapist asses and synthesis all the information the family has
provided and formulates ideas or intervention for bringing about positive changes to resolve the
identified problems.

INTERVENTION PHASE:
The goal of the intervention phase is to help family accept and adjust to change. During this phase the
therapists identifies the strengths and problems of the family. The therapist determines which of these
strengths are present in the family seeking help because strengths are useful in helping the family
remain stable when other relationship seems threatened by change. Twelve family strength identified
by Otto are the ability to:

1. Provide for the physical, emotional and spiritual and emotional needs of each family member.

2. Be sensitive to the needs of the family members.

3. Communicate feelings emotions beliefs and values effectively.

4. Provide support, security and encouragement to enhance creativity and independence.

5. Initiate and maintain growth- producing relationship within and without the family system.

6. Maintain and create constructive and responsible community relationship in the neighbor school,
town, and local and state governments.

7. Grow with and through children.

8. Help oneself and accept help when appropriate.

9. Perform family roles flexibility.

10. Show mutual respect for the individuation and independence of each family member

11. Use a crisis as a means of growth.

12. Have a concern for the family unity and loyalty for cooperation among family members.

During the intervention phase, families do a lot of work, and the therapist participates in the
therapeutic process. Usually, family session occur once a week for approximately 1 hour. Some
family members may be motivated to participate to help the identified client other members may be
reluctant to participate because of fears of having family secrets revealed. It is unusual for all family
members to be willing and eager to participate in family therapy sessions. The therapists can ask all
members their view of the problems what they would like to see changed and their thought and
feelings about others members of the family. Through this technique the therapists can a great deal
about the problems and conflicts that are occurring in the family system.

The therapist does not assume the role of a parent, child or arbitrator. The therapists facilitates open
honest communication among family members learning appropriate methods of expressing
themselves may cause some stress in the family members .as therapy continues family members begin
to realize that relationship can change . They recognize that the roles do not have to be fixed and rigid
they may change as personal growth occurs in the family. Family members become more autonomous
as positive change such as open communication and alteration in behavior (independent roles) occur.
They also recognize that change is equal in all family members are satisfied with their new level of
functioning before terminating therapy.
 TERMINATION PHASE:

If the family has achieved the goals and the identified specific problems have been resolved the it is
time to initiate the termination phase. However the therapists should remember that no family
terminates therapy without experiencing some problems. Also some family members may be
somewhat reluctant to terminate the session because they fear that dysfunctional behaviors may recur
or because they have become dependent on the therapist. By the time of termination, typically the
family has learned how to solve its own problems in a healthy manner , has developed its own
internal support system and has learned to communicate openly, honestly and directly. Power has
been appropriately assigned and redistributed and family members are able to workout and resolve
problems at home without therapists help or intervention. The original problem or symptom has been
alleviated and it is time for termination of family therapy session

There are times when it is appropriate for nurses to seek input of additional resources, for e.g. referral
may be made to family support group such as parent anonymous. Nurse need to have an extensive
knowledge of professional resources within the community to refer families for additional support.

TYPES OF FAMILY THERAPY:

1. INDIVIDUAL FAMILY THERPY: ach family member will have single family therapists: they
will work out on specific issues that have been defined by individual members; occasionally the
family members will meet along with their therapists to observe how each member will be
relating to one another in solving the issues.
2. SINGLE FAMILY THERAPY: family interaction is the focus of therapy. family therapists
observes the family interaction pattern and the family interaction pattern and helps the family
members to clearly define the problem which are pointed out by the family members and suggests
the ways or solutions to attack the problem and problem and help the family member to
implement the activities evaluates its effect and if needed modified strategies will be taken..
Nuclear family will be considered in single family therapy.
3. COUPLES THERAPY/ MARITAL THERAPY: Whenever there are relational problems among
the couples or marital unit, family therapy will be considered, couples together visit the family
therapist: therapists will observe the family pattern, interaction communication styles, each
partner’s goals hopes, expectation and suggest certain methods or ways to solve the problem
Or to find a common ground to resolve the conflicts .partners have to recognize and respect each
others similarities and differences. Certain time will be needed to resolve the issues: if the
problem was not solved alternative strategy will be adopted: repeated counseling sittings may be
required wit both partners together to implement alternate strategies in order to solve family
problems.
4. MULTIPLE FAMILY GROUP THERAPY: This therapy encourages the family members to
formulate new relationship outside the group, it provides support for all families. It improves the
interaction pattern, social skills individual responsibilities among the group methods of
 confronting and dealing with common problems issues, ability to function well in the home and
within the community. In this therapy 4-5 families meet weekly to discuss about their problems
and dealing the issues which are common to them. For e.g. Meetings within the apartments
families who have hospitalized a member in an inpatient settings.
5. MULTIPLE IMPACT THERAPY: it is more intense and time limited focus on developing social
skills and working together as a family with other families with the community. several families
will live together and deal with pertinent issues related to each family member in context of the
group. Several therapists come together with the families in a community setting.
6. NETWORK THERAPY: it includes 40-6- members like family members, friends, neighbor, well
wisher, professional groups, who invested in the outcome of the current crisis. Thus, therapy may
be conducted within the family or in community itself a person or a group of individual invested
efforts and resources, no they are experiencing certain crisis. The groups know each other and
interact on a regular basis. in this people will mobilize their energy with efforts definitely reward
will be more and effective. The therapist will guide the group members by clarifying the issues
reinforces the importance emphasizes on collective effort assist in development and effective
management in problem solving.

GOALS OF FAMILY THERAPY FOR THE INITIAL SESSION:

The first family consultation occurs soon after the patient’s illness is identified and treatment has
begun.
1. Establishing empathetic / supportive connection: typically, relatives will enter the treatment
system after the crisis. They can be expected to be demoralized, fearful and exhausted.
At, the beginning it is important to help the relatives to ventilate, communicating to them that
their feeling are both expectable and acceptable.
Allow relatives to tell their story in their own way. Demonstrate empathy and support and
trustworthiness.
Role of nurse would include taking a history, giving certain information, promoting a certain kind
of behavioral change.
2. Evaluating the family’s current needs: for family whose ill relative has just suffered an acute
Traumatic, first psychotic episode crisis intervention, respite and basic information about the
initial phase of treatment may be all that is needed. At, this point extended educational
intervention would likely be inappropriate. Skill building interventions are most useful prior to
discharge from inpatient services.
Explore the expectations of relatives.
Experiences by all members of the family.
3. Orienting relatives to the current situation: confusion is a major bock to the road to mastery.
Inadequate orientation is common; it undermines relative’s sense of efficacy and gets the family
professional relationship off to a rocky start. Orientation should be geared to the particular needs
of specific families.
4. Developing an initial plan for family service/involvement: the initial phase of family consultation
moves towards conclusion when relatives have established rapport with and trust in the
professional. When they understand the current situation, and where the professional understand
their feelings, strengths, wishes, and needs. The end product is a plan that specifies how and for
what purpose relatives will continue to be involved with both the patient and mental health
system.
What clinical or non clinical services to be provided to the family, when and how the plans will
be reviewed? The plan should consider the needs of the family members.
In addition person with the illness should be included in planning for family involvement.
 GUIDELINES FOR THERAPISTS:
1. Address the families concern to work together with family therapists.
2. Orient family to the therapy process through role induction.
3. Do not assume familiarity with client in the first session.
4. Join with his family before gathering sensitive information.
5. Maintain a broad definition of family when assessing family structure and roles.
6. Assess and intervene multisystemmaticially.
7. Report to family members who are unable or unwilling to attend.
8. Do home visit.
9. Use a problem solving focus in treatment.
10.Use scriptural reference/ metaphors.
11. Be creative and flexible when involving male family member in therapy.
12. Acknowledge strength resources and success.
13. Help family to function better while respecting difference in family structure.

FUNCTION OF FAMILY THERAPISTS:

 Establish a rapport, empathy and communication among family members.
 Evolves the major conflicts and ways of coping clarifies by dissolving barriers, confusions and
misunderstandings. Helps to bring more mutual and accurate understanding.
 Extends emotional support. Plays a role of a true parent- figure-a controller of danger.
 Serves as a personal instrument of reality testing for the family
 Serves as educator and a personifier of useful models of family health.

APPLICATION OF NURSING PROCESS IN FAMILY THERAPY:

ASSESSMENT: Assessment of family system, subsystems and individual within the family is
required. A careful analysis of sound assessment will help the health team members to identify
the appropriate family intervention for salvation of family problems. Essential information should
be gathered related to:
 Socio-cultural issues
 Past medical and mental illness
 Family interaction communication
 Areas of stress within the family
 Pattern of family life cycle
 Multi generational issues
 Developmental crisis
 The skills related to:
-parenting
-problem solving
-conflict management
-limit setting
 NURSING DIGNOSIS:
The problem related to relational problems, abuse or neglect or bereavement has to be identified.
For example:
 Impaired adjustment
 Impaired parenting
 Sexual dysfunction
 Interrupted or dysfunctional family process
 Strain of caregiver
 Spiritual distress
 Defect in utilization of defense/ coping mechanisms
 Impaired communication pattern.

PLANNING:
Nurse clinician has to determine the immediate and long term needs of family and formulate its
goals interventions. Nurse clinician has to be non-judgmental in presenting the information as
well in tone of voice and responses given.
Nurse clinician helps the e family members to learn about illness, medication, situational support
and availability of resources, measures for improving quality of life
.
NURSING INTERVENTION:
 Nurse clinician will provide counseling by the use of problem solving approach to meet
immediate difficulty of individual within the family.
 Advanced sessions motivate the families to develop and practice good listening skills
positive attitude, non judgmental type of practices.
 Sometimes informal conversation also will have greatest effect(therapeutic encounter)
 A few general guidelines will help the nurse clinician to be non judgmental in the
information presented, as well as tone of voice and questions asked.
 Nurse considers the family’s culture, ethnicity, socio-economic status, family cycle, and
attitude towards illness which will affect individual’s health and its progress and response
to case management while planning and implementing nursing intervention.

INTERVENTIONS ARE:
 Case management
 Psycho-education
 Appropriate referrals
 Provision of emotional support and guidance and counseling
 Utilization of community resources
 Utilizes various theoretical approaches in provision of family interventions.

Evaluation:
Nurse clinicians will observe whether the family is able to cooperate in provision of care to meet the
client’s need within the family and in the society where they are living I they are cooperating and
fulfilling their needs the frequency of family therapists’ visits will be reduced otherwise for implementing
modified strategies the counseling sessions frequency will be increased.
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