Families, functioning and therapies

All happy families are alike, each unhappy family is unhappy in its own way.

Leo Tolstoy (Anna Karenina, 1873)

When Tolstoy wrote these words over 125 years ago, the role of the family was somewhat different from what it is now and these changes have occurred due to a number of political, social and economic challenges. From agrarian communities where families lived either in the same household or lived close by with ease of access to filial support; with the industrial revolution and the introduction of fast modes of transport a degree of fragmentation started. With further changes in ways of communication and the impact of urbanization and globalization, it is inevitable that there will be an increase in individualism and a change in the family structure. The traditional model of family has varied across cultures for a number of centuries. However, the usual stereotypical model of husband and wife or partners with two children has given way to same-sex couples having children through surrogacy or adoption. Similarly, partner A divorces partner B, who marries C, who has already divorced D and E, and has children from each of them, thus creating a complex notion and structure of families.

Families are the building blocks of society and as such are meant to provide security, nurturing and support as needed. Material and emotional support is critical under the circumstances. Families in the context of the culture are crucial in child-rearing and the development of cognitive schema and managing distress and stress. Furthermore, patterns of attachments are significant factors in the development of the individual's strategies in coping with loss and managing life's stresses. Individual identities are also strongly influenced by the family and child rearing, especially in the context of the culture. Cultures have been broadly divided into collectivist and individualist by Hofstede (2001), who also describes other dimensions of cultures. However, it is not that every individual born in a collectivist (or socio-centric) culture will also be socio-centric. There are other factors, including developmental and biological, which influence personality traits and responses. Families no doubt also influence the social identity of the individual, as well as their social and individual functioning. When assessing a patient, it is critical that they be assessed in the context of their proximal functioning, which is in relation to family, kinship and employment, and distal functioning, which is in relation to society and culture at large.

Family therapy has a key role to play in a number of psychiatric conditions. In addition, there are a large range of therapies available, from psycho- education to systems approaches. Not all therapies are accessible across all cultures or even uniformly across the same culture. In various clinical settings, modifications have taken place in family therapy. These changes obviously depend upon not only the type of family in that particular culture but also on what health resources are available and how people seek help. It is critical that therapists are aware of local structures, strictures and needs and are able to deliver what will be acceptable to the population. Family therapy can focus on any number of aspects of functioning of the family to lead to optimal levels of functioning within which patients are able to manage not only their illness but also function effectively in society. Assessing the understanding of the condition and its implications by patients and their carers and families is an important step. Understanding one's own prejudices and explanatory models helps enable the clinician to engage the family. Models of explanation and pathways into care are crucial in help-seeking as well as encouraging therapeutic adherence. It is important that clinicians are able to elicit these. Working with families also means that different members of the family may hold varying explanatory models and may also have differing expectations both of the patient and of the therapy itself. This adds another dimension to engagement and possibly to outcome.

Family therapy may have developed in the west, but it has been used universally – sometimes with modification and sometimes without modification. There are several models and several approaches to family therapy. It is important that clinicians are aware of changing family structures and expectations and use suitable and appropriate techniques. The broader impact of changing political and economic factors must be taken into account when developing and delivering therapies. It is helpful to know what the context is within which treatment is sought. It is critical that therapists take the distal and proximal contexts into account.

In this issue we have deliberately focused not on therapy where the therapists and families come from different cultures, but instead focused on differences across cultures in family structures and therapies. This special issue is not meant to be a therapeutic manual but more a reflection of the current state of play of families, their structures and family therapy in a number of countries around the world. Although there may be superficial similarities in models and delivery the acceptance, the role and delivery itself will depend very much upon resources and pathways into care.

We would like to take this opportunity to thank our contributors who, in spite of their busy schedules, managed to deliver excellent papers on time.