COMMENTARY
Psychiatric social work services in family psychiatry unit: a NIMHANS experience
Renjith R Pillai, R Parthasarathy1
Assistant Professor, Department of Social Work, Central University of Rajasthan, Bandarsindri, Rajasthan,
1Professor, Department of Psychiatric Social Work, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India
Abstract
Involvement of the family members in the therapeutic interventions for the benefit of the client has been traditionally part of various social work interventions. Psychiatric social workers (PSWs) in the family psychiatry centre, National Institute of Mental Health and Neurosciences (NIMHANS) conceptualise the case/problem referred to the unit as the resultant of the maladaptive family relationships and interactions. Interventions are carried out on the basis of standard procedures such as a comprehensive family assessment, framing a circular hypothesis, and a series of problem-solving initiatives directed at bringing about changes in the maladaptive family functioning. Apart from the therapeutic clinical services, preventive and promotive services are also done by PSWs at the centre. PSWs do teaching, trainings and research activities.
Pillai RR, Parthasarathy R. Psychiatric social work services in family psychiatry unit: a NIMHANS experience. Dysphrenia. 2014;5:71-4.
Keywords: Marital/Couple Therapy. Premarital Counselling. Psychoeducation. Sex Therapy. Parental Management Training. Life Skills Education. Mental Health Professionals.
Correspondence: renjithpsw@gmail.com
Received on 27 April 2013. Accepted on 8 May 2013.
Introduction
Historically, in India, families were part of the treatment process at a time when family involvement was considered as ‘toxic’ in many other parts of the world.[1] Dr Vidya Sagar initiated the trend at Amritsar Mental Hospital,[2] who is acclaimed to be the father of family therapy in India. Formal family work started first in Mental Health Centre at Vellore,[3] followed by the establishment of a family psychiatry centre at the National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru.
Family psychiatry unit at NIMHANS
Family psychiatry unit of NIMHANS was formally opened in 1977, though family work had been going on in the institute since 1960’s.[4] It is basically a referral unit, wherein cases with pathological family dynamics, identified by the six adult psychiatry units, child and adolescent centre, de-addiction centre, neurology and neurosurgery units, are seen and treated. Couples and families also avail direct services at the centre. Various research works[5-8] carried out in the centre have proved that involving families in the management of a variety of psychiatric and medical disorders is beneficial. Currently, the family psychiatry unit of NIMHANS is the only centre in the entire country, which practices formal systemic family therapy and provides training in the same.[3]
Family interventions such as family counselling services, family therapy, marital/couples therapy, premarital counselling services, family life education (FLE), family psychoeducation, sex therapy, etc. are provided in the centre, right from its inception. Psychiatric social workers (PSWs), functioning in the family psychiatry unit both as trainees and consultants, have been actively involved in providing all the above mentioned services. This paper is based on the work experience of the authors at the family psychiatry centre in NIMHANS and the various available literatures. The role of a PSW in the family psychiatry unit could be broadly categorised into four, namely (1) clinical supervisor/teacher, (2) clinician/therapist, (3) trainer, and (4) researcher.
Clinical supervision and teaching
NIMHANS is a teaching institute cum hospital and the major specialities are psychiatry, neurology and neurosurgery. Students of psychiatry, psychiatric social work, clinical psychology and psychiatric nursing are periodically posted in the family psychiatry centre for training. Psychiatric social work consultants supervise these students in their clinical work. Discussion with the supervisor is mandatory after a trainee completes two sessions with a family that is receiving any kind of services from the unit. Along with the clinical work, trainees are also taught to document the process of the family interventions systematically. Academic programmes in the unit, such as topic discussions, case presentations, video presentations, etc. are facilitated by the psychiatric social work consultants. Apart from the unit level teaching, PSWs deliver guest lectures at various college/universities which run courses related to the mental health field, such as Masters in Social Work (MSW), MA Psychology, MSc Psychiatric Rehabilitation, MA Counselling Psychology, etc.
Clinician or therapist
The mental health services provided by PSWs in the family psychiatry centre are mentioned below:
Family counselling: This is one of the primary services offered at the unit. It is generally indicated when the issue bothering the family is not too severe and had not created any maladaptive family functioning. Ex: Selection of a course of study for the child. It is also indicated when family is in a crisis situation, but does not requiring in-depth assessment or intervention. Ex: Couple decided to divorce but need to make some arrangement for the children, coping with a newborn baby, coping with the chronic illness or death, etc. Family counselling helps to promote better relationships and understanding within a family. The intervention would be completed in three to four sessions and the results would be evident within that time.
Family therapy: Worldwide, social workers and psychotherapists do offer family therapy services. Here, the attention is shifted away from the individual’s problems to the family, viewed as an interdependent system (systemic perspective). Treatment involves assessing, hypothesising, and working on the identified unhealthy familial dynamics.
Steps of the family therapy process involves: (1) Intake, wherein a glimpse of the problem of the family is elicited, ensuring equal opportunity and participation of all the available family members. After the intake, which generally lasts for 20-30 minutes, the actual significant members to be present for the therapy is decided, who will only participate in the subsequent sessions. (2) Construction of three generation genogram. (3) Assessment across the life cycle stages, which may take two to three sessions, through which the core problematic areas are identified. (4) Pathological structural map is drawn, which is the diagrammatic representation of the index family system. (5) Circular hypothesis is worked out which would answer two questions: (a) what is that the client trying to communicate through his/her symptoms, and (b) what is the role of the family in maintaining these symptoms? (5) Feedback and contact: wherein the brief understanding about the family is presented to them and plan of action is discussed, following which a formal contact is made.[4]
Subsequently the family is guided through the problem-solving process through discussions employing various techniques drawn from psychodynamic therapy, behavioural methods, structural family therapy and strategic therapy. In the termination phase, the therapist reminds the new pattern/changes that have emerged and emphasise the need for the same to be continued for the better functioning of the family.
Marital/couple therapy: Strains in couple relationship is being increasingly reported in these days. The probable reasons could be the disintegration of joint family system and emergence of nuclear family culture, problems in differentiating from the families of origin, urban culture where both the partners are working and therefore rarely finding time to spend for each other, sexual problems, etc. PSWs assess couple relationships through interview, identify functions of interpersonal conflict, work with the issues bothering the couple pertaining to culture, ethnicity, gender and religion, sexual orientation, disabilities or socioeconomic status, and create conflict resolution interventions.
Premarital counselling: It helps people prepare for marriage and give themselves a greater chance of success. NIMHANS, in collaboration with the Central Social Welfare Board, has prepared a Premarital Counselling Programme for young men and women. The topics included under this programme were: (1) adolescence as a life cycle stage, (2) common sources of stress, (3) reproductive health education, (4) sexually transmitted diseases, (5) marriage as an institution, (6) types and functions of families, (7) gender and power structure, (8) communication skills, (9) coping skills, (10) interpersonal skills, (11) decision making skills, (12) parenting, (13) time management, (14) financial management, (15) sleep and food hygiene, and (16) positive health.[9]
Family life education: The definition given by the National Council of Family Relations (NCFR) tells, “Family Life Education is the educational effort to strengthen individual and family life through a family perspective”. Through FLE, individuals and families are prepared regarding the roles and responsibilities of family living, which ultimately enrich and improve the quality of individual and family life.[10] Major objectives of FLE include: (1) gaining insight into one’s self and others, (2) acquiring knowledge about human development and behaviour in the family setting over the life course, (3) understanding marital and family patterns and processes, (4) acquiring interpersonal skills for present and future family roles, and (5) building strengths in individuals and families.[10] PSWs with their expertise in working with families provide FLE to the needy beneficiaries.
Family psychoeducation: Family psychoeducation involves: (1) joining (developing an alliance), (2) on-going education about the illness, (3) problem-solving, (4) creating social supports, and (5) developing coping skills. People most benefitted from family psychoeducation are those diagnosed with schizophrenia or schizoaffective disorder and their families. Psychoeducation as a family intervention ensures a better quality of life for patients in the context of their homes.[11,12]
Sex therapy: Sex therapy is a short-term form of counselling, where the clients are instructed about the gentle art of love making. Sex therapy can involve a number of different components, including the following: (1) learning more about basic anatomy, (2) learning what one’s true feelings are about the body, (3) learning what one’s basic attitude toward sex and sexuality are, (4) learning to relax with a partner and to get in a sexually responsive mood, (5) learning to sense one’s own body and how the setting affects the body’s responses, (6) learning sexual techniques, (7) exploring one’s own and one’s partner’s body, (8) developing new sexual attitudes and techniques, and maintaining them over time.[13]
Training activities
Parenting management training: It is a behavioural family intervention approach, wherein parents are educated and trained to change their child’s problem behaviours, using principles of learning theory and behaviour modification. In the sessions, parents are taught: (1) to increase positive interactions with children, (2) to reduce coercive parenting practices, (3) to reduce inconsistent parenting practices, (4) to increase consensus in parenting practices, and (5) age appropriate parenting practices.[9]
Workshops
Life skills education programme: World Health Organization strongly recommends life skills education programme for children and adolescents, so as to help them to deal with the day-to-day problems and challenges effectively. The ten essential skills that would equip a child to grow as an ideal healthy personality is the following: decision making, problem-solving, critical thinking, creative thinking, interpersonal relationship, effective communication, self-awareness, empathy, coping with stress, and coping with emotions.[14] PSWs do undertake training programme on the same for children, adolescents, parents and teachers in the unit as well as in schools, non-government organisations (NGOs), government organisations related to family and children.
Marital and family intervention: This kind of workshop is organised for other professionals like school teachers, lay counsellors, volunteers, students, etc. They are trained in doing basic family assessment and counselling, so that it facilitates early identification and referral of couples/families with issues.
Multifarious training programmes which are preventive and promotive, treatment and intervention in nature, catering to the needs of family members, mental health professionals, paraprofessionals, etc. are undertaken by PSWs.
Research activities
The trainee and the consultant PSWs have conducted numerous research works related to working with family. Publications from the unit dates back from 1980’s. Few examples of research publication by PSWs in the fields of family and marriage are: Social support and family burden,[15] Family dimensions in Indian families,[16] Model for enhancing marital and family relationships,[7] Family life education,[17] Parenting.[18]
Conclusion
Our society is passing through an era where the family bonds are loose unlike the old good days. This loose bonding is reflected in the society in terms of increasing mental health issues among children, adolescents and adults. The role of a PSW is apparent in this scenario. They are trained to work with the individuals and families to bring about positive changes. However, at this juncture, having a family psychiatry centre at NIMHANS alone would not be sufficient to address the mental health needs of the citizens of the entire nation. There is a dire need for such centres all over the country with trained mental health professionals. The existing mental health centres in the country should work towards establishing and strengthening family units within the same. And PSWs have a pivotal role in such family psychiatry centres.
Source of support: Nil. Declaration of interest: None.
References
1. Murthy RS. Mental health initiatives in India (1947-2010). Natl Med J India. 2011;24:98-107.
2. Vidya Sagar. Innovations in psychiatric treatment at Amritsar hospital. Report in a Seminar on the Organization and Future Needs of Mental Health Services. New Delhi: World Health House; 1971.
3. Varghese M, Bhatti RS, Ahalya R, Prabha SC, Udaya Kumar GS, Shah A. Training in family therapy at NIMHANS. In: Bhatti RS, Varghese M, Raguram A, editors. Changing marital family systems: challenges to conventional models in mental health. Bangalore: NIMHANS; 2003.
4. Varghese M, Udaya Kumar GS. An integrative systemic model of family therapy at NIMHANS. In: Bhatti RS, Varghese M, Raguram A, editors. Changing marital family systems: challenges to conventional models in mental health. Bangalore: NIMHANS; 2003.
5. Bhatti RS, Janakiramaiah N, Channabasavanna SM. Family psychiatric ward treatment in India. Fam Process. 1980;19:193-200.
6. Bhatti RS, Janakiramaiah N, Channabasavanna SM. Group interaction as a method of family therapy. Int J Group Psychother. 1982;32:103-14.
7. Bhatti R, Sobhana H. A model for enhancing marital and family relationships. Indian J Soc Psychiatry. 2000;16:47-52.
8. Shah A, Varghese M, Udaya Kumar GS, Bhatti RS, Raguram A, Sobhana H,et al. Brief family therapy training in India: a preliminary evaluation. J Fam Psychother. 2000;11:41-53.
9. Udaya Kumar GS, Jane H, Bino T. Psychosocial care for marital and family life. In: Sekar K, Parthasarathy R, Muralidhar D, Chandrasekar Rao M, editors. Handbook of psychiatric social work. Bangalore: NIMHANS; 2007.
10. Family Life Education - An Overview of Family Life Education [Online]. 2009 [Cited 2009 Dec 3]. Available from:http://family.jrank.org/pages/540/Family-Life-Education-An-Overview-Family-Life-Education.html
11. Pitschel-Walz G, Leucht S, Bäuml J, Kissling W, Engel RR. The effect of family interventions on relapse and rehospitalization in schizophrenia--a meta-analysis. Schizophr Bull. 2001;27:73-92.
12. McFarlane WR, Dixon L, Lukens E, Lucksted A. Family psychoeducation and schizophrenia: a review of the literature. J Marital Fam Ther. 2003;29:223-45.
13. Parthasarathy R, Renjith RP, Shobotha R, Pooja M, editors. Reading material for the workshop on family mental health – intervention, training and research, 2009 Jul 22-24, Department of Psychiatric Social Work: Bangalore.
14. Bonin YS, Pillai RR. Impact of spiritual practices on social work: students’ perception of life skills. Dysphrenia. 2013;4:49-58.
15. Ali RM, Bhatti RS. Social support system and family burden due to chronic schizophrenia in rural and urban background. Indian J Psychiatry. 1988;30:349-53.
16. Bhatti RS, Shah A, Udaykumar GS. Study of family dimensions in Indian families. Indian J Soc Psychiatry. 1998;14:22-9.
17. Jane H, Parthasarathy R. Family life education. Unpublished thesis submitted to NIMHANS, Bangalore; 2009.
18. Bino T, Parthsarathy R. Parenting. Unpublished thesis submitted to NIMHANS, Bangalore; 2009.
This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.