The Framework of Family Therapy in Clinical Practice and Research in Serbia

Abstract

In the last two decades, Serbia has had to deal with multiple social and economic problems reflecting on society's demographics and seemed to weaken its core cell – the family. The paper describes the framework of family therapy in clinical practice and research, within the recent transition of the Serbian family. Family therapy treatment in Serbia uses the systemic family therapy (SFT) approach, applied according to the standards of the European Association for Psychotherapy. A large number of professionals who practise in Serbia hold European qualifications, setting high standards in education, clinical practice, and research. Although SFT is also available in the private sector, the majority of patients are still treated in state institutions. Family therapy is often used for adults and adolescents with psychosis and addictions in psychiatric hospital settings. However, in counselling centres it is used for marital and relationship problems. Interestingly, family therapy has recently started to emerge as a more frequent tool in consultation-liaison, particularly psycho-oncology but also in correctional institutions. The clinical practice and research interests are interlinked with changes in social settings.

Introduction

Similar to the majority of the countries in eastern Europe, in the past two decades, Serbia also has faced multiple social and economic turbulences. These have affected society's demographics and its core cell – the family. The breakdown of the country, the war on the territory of the former Yugoslavia, and the air strikes on Serbia in 1999, together with the migrations and persistent feeling of economic insecurity, have caused transitional changes in family structures and values. These transitional changes have brought modern trends and expectations, which substantially altered the family structure and organization. The last population census in Serbia revealed similarities with other countries of central and eastern Europe in the post-socialistic transformation and European integrations (Bobic, 2008; Kocic et al., 2008). However, it is inevitable that the complexity of recent sociopolitical changes has led to multiple psychological, psychopathological, sociodeviant, moral, and economic problems, which have also contributed to a weakening of the family core. On the other hand, high rates of psychiatric morbidity and the stress affecting the Serbian population require interventions on both the individual as well as the family level (Priebe et al., 2010a, 2010b). Thus, the importance of family therapy for the prevention and management of psychiatric disorders cannot be underestimated. This paper describes the family structure in the country, the difficulties the family has faced during past decades, and the current status of clinical and research practice in family therapy, in Serbia.

The structure and specific needs of the Serbian family

Serbia has always had cultural patterns of strong family ties and social networks, characterized by emotionally closer and more supportive relations across generations. The intrafamilial ties are based on a strong sense of reciprocity and remain strong throughout an individual's life-course (Jovanović et al., 1993). In reality, the family in Serbia consists of more generations (Stevanovic, 2008), although the law defines it solely as the union of parents and their children. This kind of solidarity and intergenerational connections are considered important in southern, and particularly in central and eastern European countries (Brannen et al., 2002; Wallace & Kovatcheva, 1998). This also reflects kinship relationships and close links across members of the wider group.

Strong family interconnections were encouraged and nourished by the socialist political system, which favoured the sociocentric family model, orientating the most rights and privileges towards the family rather than the individual (Tomanovic, 2008). The family was predominantly extended, but gradually changed to nuclear at the time of the peak of the country's economic prosperity before the civil war in the former Yugoslavia (Halpern et al., 1996). In the Balkan countries patriarchal ideology additionally shaped kinship and family patterns within households. It has long preserved the traditional economic family model with its clear-cut gender-based division of the roles and tasks. Even today, close to 80% of families follow the same pattern, and a vast majority of testators and legal owners are still men (Jovanovic et al., 2008; Mihic & Petrovic, 2009). However, it has been shown that such a type of family organization often risks the development of triangular relationships and reversion of family roles, which could negatively reflect on the quality and functionality of some family relations, and the family as a whole (Mihic & Petrovic, 2009).

The sociopolitical reforms and economic problems which Serbia has faced since the beginning of the 1990s, have led to important changes within the population. Severe voluntary and forcible migrations caused mainly by political factors (the civil war in the former Yugoslavia, the air strikes on Serbia, the civil war in Kosovo) and social factors (brain drain), changed the demographic composition and the future of family structures. As opposed to other countries where refugees are mainly accommodated in refugee camps and collective centres, more than a half of the total number of refugees were accommodated in the homes of close relatives and family friends, additionally shaping the family model (Raduski, 2007).

After the war, in the transition from state socialism to market economy, the security provided by the socialist system vanished, and the family became even more essential in providing both material and non-material resources. As in the case of some other post-socialist countries, such as Bulgaria, the family has taken on the important role of compensating for institutional deficiency (Kovacheva, 2004). The increasing importance of primary relations and networks for the survival of individuals and the family, together with the modernization of family members’ roles, represent the current status of the family in Serbia (Tomanovic, 2008). Turning back to premodern coping strategies, the increase in the share of extended family households, up to one third, and a tighter kinship association within the family, was caused by the economic crisis and prolonged transformation (Milić, 2005; Tomanovic, 2008). In spite of the fact that the formation of the newly extended families created a protective environment for the individual, at the same time it also emerged as a risk factor for more domestic violence and other disturbances of family relations (Miletic Stepanovic, 2005). However, the 2002 census also confirmed the slight but consistent rise of single-parent households and modern forms of family unions seen typically in the societies of western Europe (Bobic, 2008).

Recent studies which look into marital relations in Serbia confirm that the country, along with the majority of countries in transition, comes closer to the European model of marriage (Kuhar & Reiter, 2010). Marriage is becoming less universal, getting married occurs at a later age, alternative forms of unions are all more common, divorce happens more often, and marriages are short lived (Rašević & Penev, 2001). The detailed study by Kocic et al. (2008) on marital and divorce rates in Serbia in the period 1950–2005 showed that the rate of marriage decreased by a half, reaching its lowest point of under six marriages per 1000 population, in 2005. At the same time, the divorce rate continues to rise, apart from the two short drops, during the beginning of the 1990s and in 2000 (Bobić, 2000; Kocic et al., 2008). The average age at the time of marriage has also substantially increased, for both men and women – above 31 and 27 years respectively.

The situation in other regional countries followed the same pattern as in Serbia (Kocic et al., 2008). In countries of the former Yugoslavia (Slovenia, Croatia, Bosnia and Herzegovina) higher divorce rates and an increase of the average age at entering marriage were also observed (Council of Europe, 1999). It seems that the recent socio-economic crisis affected previously low divorce rates, and divorce has become a more frequent phenomenon, especially in economically stable and fairly educated groups (Polovina & Zegarac, 2005). In addition to the modernization of marriage and interpersonal relationships, some important steps towards the legalization of same-sex unions have been taken. At the same time, the country also has low fertility rates in line with other countries of southern Europe and the Far East though, as in Serbia, a strong traditional family structure was expressed there as well (Dalla-Zuanna, 2007; Fukuda, 2009). Contemporary theories of declining fertility associate this with overinvestment of parental social capital in children, and the absence of egalitarian marital relations (Palomba, 1995). This change may reflect economic changes in Serbia too.

Recent trends of changes in family life and family structure in Serbia indicate that past patterns of traditional family structures are beginning to change in line with the models experienced in western societies which focus on the individual and promote a more egocentric family model. However, in Serbia this is still accompanied by preserving extended family unions. The modernization of Serbian society seems to strongly compete with traditional family values and patterns. However, family structure still remains more defined than in contemporary western society. Despite its weakening, or even the disappearance of several traditional social and economic functions, the Serbian family has succeeded in activating its strengths, resources, and resilience to adapt to stressful events occurring over the last decades (Gacic et al., 2004).

Training in family therapy

Training in family therapy in Serbia largely focuses on systemic family therapy (SFT). This occurs through two separate certified educational centres, one pertaining to the state and the other the private sector. The training aims to provide trainees with basic knowledge and skills in SFT necessary for a systemic understanding of the family systems approach. The programmes are concordant, and organized and implemented in accordance with the standards of the European Association for Psychotherapy (EAP). The training and education take place over a 4-year academic period with a total of 1550 hours (550 hours of theoretical lessons, 600 hours of clinical practice and 400 hours of supervision – individual, group and ‘live’ over the one-way mirror). After completing the first two years of the programme, the participants are considered trained in counselling work with families, but obtaining the family therapist degree and the European Certificate for Psychotherapy (ECP) requires a further two years of training. Eligible candidates for training as future family therapists are selected from psychiatrists, trainee psychiatrists, physicians in residency, psychologists and social workers following an interview aimed to assess their motivation, interpersonal sensitivity and ability to comprehend individual and social diversities (Calovska Hercog et al., 2011a). The courses are often attended not only by professionals from Serbia, but also by those from other former-Yugoslav republics (Bosnia and Herzegovina, Macedonia and Montenegro). Keeping the educational process flexible towards different needs of candidates and its application in various cultural surroundings are considered imperatives of education (Calovska Hercog et al., 2011b).

The basic method of teaching is an interactive group-work type of workshop, with introductory theoretical lectures, preparation and participation in seminars, clinical case analysis, and the use of a one-way mirror in the supervision, with trained and experienced systemic family therapists as supervisors (Calovska Hercog et al., 2011a). A recent study on personal characteristics and professional competencies of both supervisors and candidates in psychotherapy in Serbia confirmed their ability to skilfully engage in educational activities and subsequent clinical practice (Šakotić-Kurbalija, 2007, 2011a, 2011b)

According to the data of the Serbian Union of Associations for Psychotherapy (SUAP), there are two registered associations to which family therapists in Serbia can belong. The European Family Therapy Association (EFTA) coordinates 40 registered family therapists from the country (10% general practitioners, 55% psychiatrists and psychologists, 20% social workers, 15% others). Furthermore, a great number of all the SUAP members are family therapists, speaking in favour of the prominence and pervasive use of family therapy in Serbia. The high number of those having the European Certificate for Psychotherapy (ECP) confirms the high standards set in both the education and practice of family therapy in Serbia since its introduction.

Family therapy in clinical and research practice

In spite of the use of dynamic psychotherapy and its overwhelming presence in the number of published textbooks and registered schools, family therapy remains probably the most frequently used psychotherapy in public sector healthcare facilities. Although also available in the private sector, the majority of patients are still treated in state institutions. This is generally due to lack of economic resources for most patients. The patients are thus, in a way, pushed to be supported through social security, which covers all the expenses for treatment by state employed family therapists, predominantly board certified psychiatrists and psychologists.

The most frequent application of family therapy is for adults and adolescents, treated within psychiatric hospitals for addictive disorders and psychosis, and within counselling centres for marital and relationship problems (Calovska Hercog et al., 2011a; Nastasić, 1996; Stanković et al., 1992). In addition to this, family therapy recently began to emerge as a more acceptable treatment tool in consultation- liaison services, especially in psycho-oncology and even within prisons and juvenile offender institutions (Gojkovic, 2008; Klikovac et al., 2011). Overall, the therapeutic approach is based on the principles and concepts of systemic therapy, including strategic (directives and tasks, joining, re-labelling, positive connotation, paradoxical intervention, etc.), structural, functional, problem-focused, and integrative techniques (Mićović et al., 1992).

This clinical reality reflects well on the research within the field. Research papers published on family therapy in Serbia in the last 30 years indicate that family therapy in Serbia is most frequently applied within the clinical setting. The commonest clinical condition is where members are suffering from one of the addiction disorders, mainly alcoholism. The studies deal with the use of family therapy in families of patients with alcohol problems in outpatient clinics. Various authors question the adjustment of family therapy to inpatient conditions and the need for individualization of family therapy programmes (Nastasić, 1996; Stanković et al., 1992). Research on the efficacy of family therapy was initiated in the mid 1970s in order to judge the remission rates after one year of family therapy (Dragisic Labas & Djokic, 2010; Gačić, 1978). The studies which followed were more sophisticated regarding methodology, and dealt with particular factors influencing the quality of remission and the therapeutic response. Various facets of interest included the family value system (Dragišić Labaš et al., 2011), transgenerational transmission of alcohol abuse (Nastasić, 1997), cohesion and adaptability as aspects of the family's functionality (Trbić, 2000), and the influence of psycho-education and motivation on treatment outcome (Dragisic Labas & Djokic, 2010). Overall, research has shown that family therapy in Serbia can be used successfully, with remission rates of up to 83% (Dragisic Labas, 2008; Gačić, 1978). These rates are particularly impressive considering that Serbia is a ‘wet’ culture, with alcohol consumption as the patrimonial heritage and socially desirable in men (Dragišić Labaš et al., 2011).

In addition to the high interest in the application of family therapy on patient populations, recent research interest has shifted towards societal settings. Various studies have followed the contemporary transition and development of the Serbian family in the cultural context and clinical practice. The focus is primarily on female individualization and the conflict created between the professional and familial roles of women (Basta et al., 2011; Mihic & Petrovic, 2009) as well as on strategies for overcoming stress in the new forms of households (Marinković, 2011). In spite of the popularity and broad application of family therapy in clinical practice, the research and publications regarding some fields of application (psychoses, marital relations, etc.) need to explore individual aspects of intervention in some detail.

Conclusion

The impact of the socio-economic crisis on family relations and its contribution to the modern family transition in Serbia is evident. In recent years, families have proved to have their fragilities, but it is crucial to continue to perceive them as a possible resource for managing patients with addictions as well as mental illness We need a promotional approach, created within cultures and society so that clinicians are able to assist families and prevent future problems and fragilities by empowering families to deal with potential problems and difficulties. In order to reach this change in perspective, we need families to get a clear confirmation of their rights as well as their social responsibilities. Although the most commonly used family therapy model in Serbia has been evaluated, more work is needed to measure not only overall standards but also quality of the received therapy in the private and state sectors. Furthermore, apart from the success of family therapy for addiction, its application for other conditions also needs to be examined carefully. To this end, further training in psychotherapy research may be needed. Further application, development and success of family therapy in Serbia will obviously depend on a number of factors – social, political and economic. Changes in demographic structures of the country, and other factors such as the changing role of kinship, attitudes of the family to mental illness, and family and cultural dynamics will also need to be ascertained in this context.

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