Family therapy in Brazil: Current status

Abstract

In the last three decades there has been a noticeable trend in the redefinition of the nuclear family in Brazil. A recent increase in the rates of divorces and paradoxically also in the rates of marriages, the legalization of same-sex unions and adoption by these couples, and the phenomenon of teenage pregnancy are some of the aspects that reflect on the current Brazilian family. This review highlights these changes and describes how family therapists in Brazil are facing the challenge of assisting these families, in a continental-sized country with uneven distribution of training courses and healthcare assistance.

Introduction

The composition of the Brazilian family has its roots in the very same origins of the country itself. Historically colonized firstly by the Portuguese, Brazil developed its family structure primarily with inherited characteristics of the rural colonial bourgeoisie. At that time, the family structure was patriarchal, with the male role much more prominent inside and outside the family. Brazilian society changed considerably in the nineteenth century with the proclamation of the republic, the abolition of slavery, the development of the south-east region of the country, the novel arrival of immigrants, and following growth of urban centres (Samara, 2002). These changes affected profoundly the structure of society, and the familial structure also started to change.

Along with economic difficulties during the industrial revolution, women began to be part of the work force alongside men, but earning less and not being fully recognized for their material contribution (Wagner & Fleck, 2003). The shifts of the female role are of strong importance for our understanding of the current status of the Brazilian family, mainly in a treatment setting. The modern Brazilian family is certainly a reflection of the development of the whole society. Nowadays family therapists engage in the understanding of the many different structures of family in the country.

Brazil is a country of continental proportions and also of profound regional particularities, which also adds complexity to the understanding and conceptualization of the typical family (Souza & Botelho, 2001). Traditionally it has been composed of parents and children, but in the last four decades it is more accurate to say that therapists deal with a myriad types of families.

The aim of this review is to describe the characteristics of the current Brazilian family, the current development of family therapy in Brazil, and discuss the difficulties, weaknesses and strengths in the field.

The structure of the Brazilian family

The attempt to describe the profile of the Brazilian family is not an easy task (Wagner & Féres-Carneiro, 1998). Despite this difficulty in the last three decades there has been a noticeable trend in the redefinition of the nuclear family in Brazil (Wagner et al., 1999). Studies in the early 1990s showed a reduction in the size of the families, the number of children, an increase in the number of divorces, second, and third marriages, an increase in the number of families without children, and an increase in participation of women as the primarily financial supporter of the family (Goldani, 1994). Another changing aspect is the role of each parent when raising a child (Wagner et al., 2005).

National surveys conducted by the governmental agency of statistics have shown that from 1981 to 1990, then from 2001 to 2009, the average number of people per family decreased from 4.3 to 3.9 and then kept decreasing from 3.4 to 3.1, respectively (IBGE, 2001, 2002). When considering the lowest income families, the average figure reaches 4.2 people per family in the latest survey, showing that other structures are also linked with socio-economical status. The current average number of children per family is 1.5. In 1970 it was 5.8 children per family on average, and in 1999 it had already decreased to 2.3 children (IBGE, 2001, 2002). Many factors are associated with this decrease, including a shift of values among many sectors of Brazilian society, the massive increase in women in the labour market, and also the decrease in fecundity related to increased higher education access by women. By 1999, women with only four years of regular education were having, on average, 3.1 children, while women with eight years or more were having 1.6 children, on average. Considering that in 2010 the figure for the whole nation was 1.5 children per family, this represents a major change in the configuration of the average Brazilian family.

Another shift is the reduction of the percentage of couples with children from 55% (in 1992) to 47.0% (in 2002). Even though the traditional family pattern with both parents and children is still the most common (around 55%), families composed of the mother with children and without the husband has increased from 15.1% to 17.9% from 1992 to 2002. Along the same trend, but in a different manner, the percentage of families where the woman is in charge of the family, meaning also in charge financially, went from 16.9% in 1981, to 26% in 1999, to 27.3% in 2001, and then to 30.6% in 2005. The proportion of these families where the husband is present was only 3.5% in 1995 and went to 18.5% in 2006, showing a real change in the division of responsibility within the average family (IBGE, 2001, 2006, 2010). These figures characterize how the Brazilian family is in almost constant change closely linked with the economical and social developments of the country.

A major social and familial concern in Brazil and also focus of governmental programmes on female contraception and sexual education is teenage pregnancy. Even though in the whole country the average number of children per woman reduced, this figure among girls from 15 to 17 years old increased from 6.8% in 2004 to 7.1% in 2005 (IBGE, 2010). Teenage pregnancy is a phenomenon which became a major public health issue in many countries and it is also of great importance for the understanding of families (Yazlle et al., 2009). In Brazil, a recent study by Heilborn and Cabral (2011) showed that female pregnancy occurs in all social classes and has a different meaning in different strata of society. Contrary to popular belief, ‘teen pregnancy’ is not the consequence of promiscuous sexual activities, but a way to gain social status amidst the poorer social segments, given the lack of academic or professional perspectives that these communities still face. On the other hand, among the middle class, motherhood is considered an experience to be lived in later stages of life, when one's professional and financial status have been consolidated, therefore teenage pregnancy is viewed as a tragedy many times over by the family (Heilborn & Cabral, 2011). Teenage pregnancy can be an important trigger for a family to seek a family therapist, therefore the understanding of the social, psychological and developmental factors intertwined is vital.

With the increase of life expectancy, as shown by the diminished gap between the richest areas of Brazil (south-east, highest life expectancy) and the poorest (north-east, lowest life expectancy) which was of 10 years in the 1980s and dropped to 5 years in 1999, the average Brazilian is living two years longer (women 72.3 years and men 64.6) (IBGE, 2010). The transformation of Brazil into a society with 30 million elderly by the year 2035 will bring to more attention the issue of the role of the elderly in the family. This change is already in place as people older than 60 years already account for 9.1% of the total population and in 1999, 65% of the elderly were in charge of their families and as much as a third of them were still working daily (IBGE, 2010).

The shape of the Brazilian family has changed profoundly and it is continuing to change in response to a number of social changes. Even though the traditional format family (parents and children) is still the majority, there are many other types of family. Besides the ones mentioned above (without husbands or without children) there are also those that are formed by parents coming from a previous marriage, and also homosexual couples. Recently in Brazil the Supreme Court voted overwhelmingly in favour of allowing same-sex couples the same legal rights as married heterosexuals (STF, 2011). Since Brazil is the world's most populous Roman Catholic nation and has an estimated 60,000 gay couples, this represents a concrete recognition of this type of family (BBC News, 2011). The Supreme Court also ruled in favour of a homosexual couple to stay with two adopted children, an unprecedented legal act in Brazil that also symbolizes this major shift (STJ, 2010). Still within the legal context, another ruling made way for an increase in the number of divorces, since the necessary legal steps to dissolve a marriage became faster and less bureaucratic in 2010. The rates of divorce skyrocketed and reached the highest level since 1984 with 1.8 divorces per 1000 inhabitants in 2010 (Globo, 2011). In the same trend, paradoxically, the wedding rates also increased 4.5% (from 2009 to 2010) and the second or third marriage rates reached 18.3% of all unions, meaning that many families are being formed or being restructured (Globo, 2011). These reconfigurations of families and the many following types of families pose a challenge for the family therapists of Brazil.

The current status of family therapy in Brazil

Early studies of the Brazilian family focused on historical, anthropological, and sociological perspectives, especially in the work of the internationally known Brazilian anthropologist Gilberto Freyre (1969), who first described colonial families and Brazil's changes into today's state. The first institution to deliver a form of family-based mental health assistance was the Catholic Church. Long before the existence of family therapists or couples therapist graduates, several support groups were organized by the Catholic Church for the counselling of couples and newly formed families (Couples with Christ, encounters of engaged couples and newly-weds). After that, the pioneer universities that started teaching, research, and therapy for couples and families in the country were the Catholic University of São Paulo, the University of Brasília, and the Catholic University of Rio de Janeiro (Bucher & Da Costa, 2005). Following their lead, in the late 1980s many other family therapy institutes, societies and outpatient clinics started laying the groundwork for the therapy movement. Still today the field keeps growing with more centres of training and assistance.

The Brazilian Family Therapy Association, the Associação Brasileira de Terapia Familiar (ABRATEF) was created during the first National Meeting of Family Therapy in 1994, although the history of organized meetings of Brazilian family therapists dates back to 1982, when the first National Encounter of Family Therapy took place in São Paulo under the coordination of Mathilde Neder and Clea Pilnik (Neder, 2005). Nowadays it comprises eleven regional associations from eleven different states or regions of the nation. The association covers more than 1400 associated family therapists countrywide (ABRATEF, 2011). These professionals more commonly are psychologists, but physicians, nurses, social workers, and education specialists (psychopedagogues) also practise as family therapists in Brazil.

The family therapy often takes place within psychology departments in the universities and also in private institutions not necessarily related to traditional academia. Usually each institution tends to focus more on a specific model, like the family systems therapy, the psychodynamic model, the structural model, the strategic model, and/or the behavioural and cognitive behavioural models (Costa, 2010). Traditionally in Brazil there was predominance towards the psychodynamic approach and the systemic approach in spite of the others. This was mostly because the first professionals that went to study abroad, in the 1970s, and then returned to Brazil and started their own courses in the country were trained either within a psychodynamic/psychoanalytical or a systemic framework (Féres-Carneiro & Ponciano, 2005). Despite this preponderance, today's therapists are more prone to eclecticism and integration of the contributions of the many models, in order to achieve optimal results in the treatment setting. This tendency is also present in other countries around the world (Prochaska & Norcross, 2009). The whole formation lasts from two to three years after graduation in a previous course (e.g. psychology, medicine).

A Brazilian family can access treatment through two pathways: the public healthcare system or the private sector. With the creation of the national public healthcare system, the Sistema Único de Saúde (SUS) in 1988 and along with the developments of psychiatric reform throughout the 1990s and 2000s there was an increase in the availability of this form of treatment in the public system (MS, 2005). Today, Brazil has a total of 1620 Centros de Atenção Psicossocial (CAPS) (psychosocial aid centres where children, adolescents, adults and the elderly receive psychiatric and psychosocial care, assisted by psychiatrists, social workers, psychologists, nurses and occupational and speech therapists) distributed through the five regions of the country where the public can request family therapy. The implementation of CAPS is still an ongoing process, because many areas of the nation are still underserved, although the overall statistics are moderately positive (0.66 CAPS per 100,000 inhabitants) (MS, 2010). Psychiatric patients are assisted at the CAPS as well as their families, mainly through multi-familiar groups that support families in how to deal with the many types of psychiatric disorder (Benevides et al., 2010; Costa, 2011) as well as with psychological difficulties and issues.

The other pathway of family treatment happens in private institutions and private offices. Usually these institutions are concentrated in major cities, mainly in the capitals, although private offices are much more widely distributed. Training courses are very often held in these institutions and usually trainees learn through clinical assistance and supervision. Treatments in these institutions provide an additional advantage for these families because the treatment fees are reduced when compared with private offices. Families can also be assisted by in-training therapists, without any costs, information courses at public universities, or with reduced costs at private universities.

Family therapy in Brazil has also developed research with national psychological publications such as the journal produced by the Family Therapy Institute of Rio de Janeiro (Nova Perspectiva Sistêmica), the journal of the University of Brasilia (Psicologia: Teoria e Pesquisa), the journal of the Federal University of Rio Grande do Sul (Psicologia: Reflexão e Crítica), and the journal of the Catholic University of Brasilia (Texto Didático – Série Psicologia), just to name a few (Bucher & Da Costa, 2005). Research groups in the universities have also published in international journals, supported by post-graduate courses across the country with master's theses and doctoral dissertations.

Considering that Brazil is a country of continental size and profound regional differences, family therapy also appears to be available at different levels through the country, as some places have lots of centres and others have fewer. This reflects the situation that also happens with medical and psychiatric care in general, which is also concentrated in the major cities and capitals. Unfortunately, the interior of the country is not adequately served by these professionals, or by family therapists, although governmental policy towards the betterment of this situation is already in place (Planalto, 2011).

Conclusion

Clearly, an inclusive twenty-first-century definition of family must go beyond traditional thinking to include people who choose to spend their lives together in a kinship relationship despite the lack of legal sanctions or blood lines (Goldenberg & Goldenberg, 2007). This is exactly how the current Brazilian family is today and these are the families that are reaching for the help of family therapists. The development of the field of family therapy in Brazil has been remarkable in the last 30 years, with the spread of courses beyond the cities where it first started (in São Paulo and Rio de Janeiro) and the growth of research. Nowadays family therapy is a modality of treatment that is accessible to the general population, although sometimes and in some places with a certain difficulty, but the overall situation is more positive than the contrary. The increase in awareness by the general population that they can rely on a professional such as the family therapist is, in itself, a way to develop the field. The more the common citizen is aware of this type of assistance, the more the profession is valued, and therefore governmental policies can be created to foster the improvement of family care in the public healthcare system, and also more professionals will be encouraged to work at their private offices as well.

Considering the scientific and clinical development of family therapy in Brazil and, at the same time, noticing that many areas of the nation still lack assistance, Brazilian family therapists have a great opportunity and challenge ahead of them in the quest to spread assistance to the farthest and still unassisted areas and improve research-based treatments in a culturally appropriate manner. Family therapists also have to be aware of the constant societal movements in values and behaviour in order to fully assist this ever-changing entity: family.

Declaration of interest: The authors report no conflicts of interest. The author alone is responsible for the content and writing of the paper.