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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 36  |  Issue : 4  |  Page : 296-302

Taking therapy beyond clinics – An evaluation of family therapy training program with lay counselors


Department of Psychiatric Social Work, NIMHANS, Bengaluru, Karnataka, India

Date of Submission07-Feb-2020
Date of Decision13-Mar-2020
Date of Acceptance10-May-2020
Date of Web Publication31-Dec-2020

Correspondence Address:
Dr. Janardhana Navaneetham
Department of Psychiatric Social Work, NIMHANS, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijsp.ijsp_22_20

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  Abstract 


Background: Families have been accommodating the changes to suit the present situation. Indian families even though structurally moving toward nuclear families, still carry on the values of the joint families of connectedness, interfamily influences, extended family influences on decision-making, etc., Subjects and Methods: The study aims at understanding the effectiveness of family training with lay counselors. An interview schedule was prepared to collect sociodemographic profile, knowledge about family therapy (FT), and confidence of practicing FT. The participants were enrolled for training based on ‘first come first serve’; those who completed postgraduation and PG diploma were included for the training program, and most of them were involved in the helping profession either as part of the training or service. This study was of a quasi-experimental design with assessments at two timelines – pre-post training sessions. Results: Most of them expressed that they had previously worked with families with child abuse, academic difficulties in children, marital issues, domestic violence, etc. A test of Wilcoxon's signed-rank test showed the change in the knowledge and confidence level of the trainees. Nearly 48.1% and 46.3% of the participants felt they have high and moderate skills in identifying cases that require family interventions, respectively, 70.4% said that the sessions were high in clarity, while 25.9% reported moderate clarity. Almost 68.5% expressed no difficulty in understanding sessions. This article attempts to share their experience of conducting the dissemination of systemic family intervention for the people in the service sector. It was found that the participants appreciated the training programs and were able to see the benefit of including systemic approach in their family intervention. Conclusion: This article attempts to share the experience of conducting the dissemination of systemic family intervention for the people in the service sector. It was found that the participants appreciated the training programs and were able to see the benefit of including systemic approach in their family intervention.

Keywords: Family therapy, lay counselors, training


How to cite this article:
Navaneetham J, Roy T. Taking therapy beyond clinics – An evaluation of family therapy training program with lay counselors. Indian J Soc Psychiatry 2020;36:296-302

How to cite this URL:
Navaneetham J, Roy T. Taking therapy beyond clinics – An evaluation of family therapy training program with lay counselors. Indian J Soc Psychiatry [serial online] 2020 [cited 2021 Jan 20];36:296-302. Available from: https://www.indjsp.org/text.asp?2020/36/4/296/305941




  Introduction Top


Families have been changing constantly with the influence of modernization, industrialization, and globalization. Families have been accommodating the changes to suit the present situation. Indian families even through structurally moving toward nuclear families, still carry on the values of the joint families of connectedness, interfamily influences, extended family influences on decision-making, traditional conceptualizations of marital functions of procreation, parental role, demarcation in husband and wife's role, and cordial relationship with other family members, which may be still existing but through a largely modified form with increased need for flexibility and equalitarian system. Family dimensions pertaining to reinforcements, social support, communication, roles, cohesion, and leadership have changed significantly over the past decade.[1]

The field of family therapy (FT) is rapidly expanding over the last two decades. Many helping professionals are showing interest in learning about family interventions, and applying the same as part of their helping process. Training opportunities have increased dramatically over the past decade as the field has become an international phenomenon. The increase in European and other worldwide training sites has been surpassed only by the proliferation of independent family institutes in the United States.[2] Universities have also become involved in the business of training on family interventions. In the past 5 years, especially departments of psychology, psychiatry, social work, family studies, and pastoral counseling have included FT as an acceptable curricular component.[3] A comparative review of over 100 references in FT training and supervision[4] led to the identification of some basic content areas relevant for all teachers of FT.

Pathway of care for people with mental illness is through various sources – family physicians, private psychiatric/nonpsychiatric professionals, para professionals, lay counselors, traditional faith healers, alternative healers, etc.[5] Families devoid of mental illness but having discord might seek help through other appropriate sources such as a family physician, nongovernmental organizations providing counseling services, school counselors/school social workers, family courts, women crisis centers, advocates, and mediation centers.

Mental health care includes curative, preventive, and promotive interventions. In the busy hospital schedule, often, the treating team would give more importance to curative services, and provide less priority to preventive and promotive interventions. Mental health professionals need to devote 2/3rd of their work on preventive and promotive services so that dissemination of services in the community can be ensured and stigma attached toward mental illness also can be reduced. This article is an attempt to disseminate family intervention techniques to the counselor/those, who are involved in helping profession, so that they can utilize the same while providing family interventions. Research evidence from India and abroad[6] shows the effectiveness of delivering various mental health services such as those for alcohol use, depression, and perinatal depression[7] through lay counselors as very impactful and cost-effective,[8],[9] and effective in school interventions.[10]

The knowledge of dealing with family discord is very essential in these helping professions. Sometimes, it is difficult to work with all members maintaining “neutrality.”[11] While working with families, the therapists often find it difficult to maintain neutrality, which determines the therapeutic relationship. Most often, therapists notice resistances in families due to their past unsuccessful interactions with family counselors where one person felt “blamed” or “labeled.”[12] People in the helping profession often lacks knowledge of assessing “family as a system” and not able to use basic skills of addressing various issues of family discord from systems point of view, often would search for solutions to the presenting problems rather than resolving the systemic issues.[13] Hence, it becomes necessary for the helping professionals to upgrade their knowledge to understand the family problems from systemic perspectives so that they can bring second-order change rather than aiming at first-order change.[14]

In order to fill the training gap, the researchers organized the training program to impart basic knowledge and skills to interested mental health professionals through:

  • Two-day workshop in systemic family intervention and
  • A follow-up meeting with one organization (Samadhana) to consolidate the skills learned and provide hand holding.



  Subjects and Methods Top


The aim of this study was to develop a 3-day training module on family interventions for the counselors/professionals providing services for people with adjustment problems. The authors also have made an attempt to capture the significant learning and also tested the feasibility of the capacity building training program.

The objectives were to understand their current levels of knowledge about systemic family intervention and the confidence level of the therapist in practicing family interventions. Researchers followed a quasi-experimental design with assessments at two timelines – pre-post training sessions.

Researchers used knowledge about family interventions and confidence level of practicing family interventions as an outcome variable in order to test its feasibility. Knowledge with regard to family intervention was based on their awareness on the techniques of FT: circular questioning, genogram, hypothesis, sex therapy, etc. The respondents were also asked about their confidence level in using these techniques while practicing the family interventions.

Materials

The authors developed an interview schedule in order to collect sociodemographic profile, knowledge about FT techniques, and confidence of practicing FT. The interview schedule was rated on 4-point Likert type assessing the knowledge of systematic FT and confidence level. The interview schedule had questions about familiarity of various family techniques such as circular questioning, hypothesis, genogram, influences of family orientation etc., and confidence level in practicing these techniques.

Data collection

The participants were enrolled for training based on 'first come first serve'; those who completed postgraduation and PG diploma were included for the training program, and most of them were involved in the helping profession either as part of the training or service. Data were collected at baseline and immediately after the training program.

Statistical analysis has been done in IBM Corp. (Released 2013. IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp). Descriptive statistics of percentages, median, modes, etc., and test of significance was done through Wilcoxon's signed-rank test based on the total scores arrived from the interview schedule.

The training program covered the following topics: understanding Indian families, systems approach, principles of FT, family developmental stages, family dynamics, assessment, hypotheization, techniques, and basic interventions and approaches.

A 2-day workshop in systemic family intervention was conducted in September 2017. The workshop was open to any counseling service provider or trainees in mental health who are termed here as lay counselors. The information about the workshop was available online on NIMHANS website for anyone to access. The needs of training programme was evolved through brainstorming for ideas, looking for feasibility, and final shape of the workshop was arrived by the authors. During registrations, care was taken to ensure the inclusion criteria were met and were monitored by the current authors too.

The topics and schedule of sessions were finalized after a pilot testing of 1-day session with Masters of Social Work trainees who were present in the Department of Psychiatric Social Work, NIMHANS, for block placement in the same year. There were approximately forty trainees for the same. Final list was in consultation with two other practicing family therapists who were also the organizing committee members and resource persons.

The topics of the 2-day program included: introduction and understanding Indian Families, FT in India, introduction to systems theory and concepts, couple therapy, family assessment, genograms and family dynamics, family interventions, family intervention with children, family intervention for substance dependence, one-panel discussion, sex therapy, and therapy challenges.

Each session was approximately 1½ h in duration with appropriate breaks. The sessions maintained a chronology of introduction of the context of therapy and theories and skills of assessment and interventions and moved to specific areas of interventions with different family issues and lastly challenges. The sessions were conducted in English with Kannada where sought.

The sessions used various modes of delivery such as PowerPoint presentations, role plays, case discussions, group discussions, group activities and presentations from groups, and brainstorming sessions. To keep the sessions grounded to knowledge and skill impartment with hands-on experience, the participants were grouped and given one case study per group. Assessments, genograms, family dynamics, and interventions were addressed through discussions of these cases to make the concepts easier to grasp. In addition, role plays and examples from in-clinic cases generated more discussions. Confidentiality for any client information shared was prioritized by not divulging name, residence, domicile, family details, or other information that can divulge a person's identity.

The resource persons for the training program had a unique blend of eminent family therapists (department of psychiatric social work, clinical psychology, and psychiatry) with at least 15–20 years of experience, senior faculties from the Department of Psychiatric Social Work from NIMHANS, and current practicing young therapists from NIMHANS (PhD in Psychiatric Social Work, PhD in Clinical Psychology, and MPhil in psychiatric Social Work) with minimum 4 to maximum 8 years of experience in mental health field.


  Results Top


Participants

The participants were lay counselors from various parts of India. The sociodemographic details are shown in [Table 1].
Table 1: Sociodemographic details

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There were 23 members who have been trained and are associated with “Samadhana”– a nonprofit organization in Bengaluru.

Other details about their past orientation to family interventions are shown in [Table 2].
Table 2: Prior exposure to family interventions

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Of the members who expressed they had prior exposure or training to family interventions, all were lay counselors trained from the nonprofit organization “Samadhana” except one member (who expressed high level of exposure) was an advocate in family court. Most of them expressed that they had previously worked with families with child abuse, academic difficulties in children, marital issues, domestic violence, etc. Most of the lay counselors who are currently undergoing Masters of Social Work and Psychology surprisingly reported “no” exposure to family interventions as a part of their training or curricula yet.

Effectiveness of training program

Two items were assessed at presession and postsession – knowledge of FT and confidence in practicing FT. The results are show in [Figure 1].
Figure 1: Knowledge and confidence in practicing family therapy

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A test of Wilcoxon's signed-rank test showed the change in both domains seemed statistically significant at P < 0.005.

Other aspects of the workshop that were noted at post session were 48.1% and 46.3% felt that they have high and moderate skills in identifying cases that require family interventions, respectively, 70.4% said the sessions were high in clarity, while 25.9% reported moderate clarity. Nearly 68.5% expressed no difficulty in understanding sessions. However, 9.3% expressed moderate levels of difficulty, which needs to be examined. Overall, 81.5% felt that sessions were highly effective, while 16.7% felt it was moderately effective.

Other important details

Most useful sessions ranked in the order of hierarchy were: couple therapy, family assessment and dynamics including genograms, family interventions, intro to systems, concepts understanding Indian families, FT with children, FT for substance dependence, panel discussion, sex therapy, FT practice in India, and therapy challenges.

The topics that were not covered came as suggestions were: families with geriatric population, parenting and adolescent issues, premarital counseling, divorces and domestic violence, and handling child abuse issues in families.

Handholding sessions

It was planned to continue to provide therapeutic inputs for the members of “Samadhana.” The said members met up with the organizing team once every month for the next few months. Learning would take place through case presentations and brainstorming. The nonstructured feedback was taken after meetings. The response for such meetings has been positive so far.

Analysis

Descriptive statistics was used to arrive at the frequencies for socio demographic data, bar charts were drawn to understand the knowledge, and confidence level. Wilcoxon's signed rank test was carried out in order to test the efficacy of the training programme.


  Discussion Top


The training program catered to lay counselors from various qualifications and backgrounds – people who are actively involved/or will be involved as being the initial contact for families in need. As FT is currently practiced mostly in hospitals and private clinics, it is accessible only to a few. However, as mentioned earlier, a large number of families might require these services from other service delivery systems such as their offices, schools, and organizations. In addition, some might view the therapy provided in hospital as stigmatizing. Therefore, lay counselors' intervention becomes very important to bridge that gap. The most important concern in the field of global mental health is addressing this massive treatment gap which routinely exceeds 75% in most parts of the world.[15] Coming to developing countries like India, availability of skilled personnel and openness for receiving such interventions are seen as the most important barriers.[16] There have been attempts to understand the content and processes involved in training lay counselors.[7] It has been found that with brief training and supervision, lay counselors from middle- to low-income countries could detect, diagnose, treat, and monitor mental health issues and family caregiver burden.[17] Lay counselors after training are also documented to have intervened in mother–child dyads (where mothers have postpartum depression), social networks, and interpersonal issues such as conflict with husbands and in-laws.[7] Lay counselors and clergy were found to be as effective as university staff for short-term premarital interventions.[18] An interesting aspect of using lay counselors mentioned in a previous study was the ability to connect to the community through usage of local language, terminologies, and idioms. In this workshop also, there were many lay counselors who have been dealing with psychosocial issues and are dedicated to provide their services to the community. One aspect which stood out in the workshop group is the sense of altruism in lay counselors and their belief of ethical obligation to “give back” to the society. The passion to “help the distressed” was very evident and therefore their connections to grassroots service provision were very noteworthy.

The practice of FT has grown steadily since its inception.[19],[20],[21] This evolution as a clinical framework and orientation in practice offers unique contributions to care professionals, especially family therapists.[22],[23],[24] Family therapy provides therapists with skills to treat a wide variety of interpersonal problems associated with people with chronic illness and their families. Professionals need to pay conscious attention to both the aspects of medical illness and the role this plays in the interpersonal lives of the family.[22],[24] The framework bridges physical, psychological, and relational health by examining the reciprocal influences between persons, families, and broader social contexts.[25] In the study conducted by Puffer, it has been concluded that the intervention increased protective aspects of family well-being for migrant children and caregivers in a middle-income country. The strongest effects were on parent–child relationship quality and family functioning, while results were mixed on changes in discipline practices. Results suggest that a behavioral family-based approach implemented by lay providers in community settings is a promising intervention approach for strengthening families in highly stressed contexts.[26]

It is seen that most of the participants were not exposed to FT and therefore were having little or no knowledge about the same. While skill building takes close and continued supervision of each counselor,[6] this workshop aimed to provide the basic knowledge and exposure to practice-oriented family intervention. Past research suggests that the training for such interventions should be active, experiential, and should be through various learning techniques.[27] Also, kept in mind was the adult learning model where trainer stance moved from supervisory to collaborative exploratory through group activities and brainstorming.

The fact that the group were exposed to other forms of counseling but not systemic family interventions might point to the fact that family intervention training has been limited to skilled professionals with adequate degrees. It was also difficult to balance the importance of imparting theoretical background versus practical skills. As both go hand in hand, absence of either can affect service provision. This might be the reason for the sessions being perceived as difficult by some and suggestions to include more examples. Despite introducing concepts through case studies and role plays, the minute nuances of systemic intervention required more illustrations to grasp.

The sessions found most important were interestingly again practice related, therefore it seems sessions covering very generic topics on family intervention or very theory laden topics need to be revised. Suggestions for future change points to sessions oriented around various family issues – couples issues, alcohol dependence, parent–child, premarital, etc., rather than techniques or skill based (communication, negotiation, boundary creation, etc.). However, sessions on assessments and intervention being valued by everyone as important show the need to teach as per the basic teaching structure followed in NIMHANS Family Psychiatry Centre for the institute trainees.[28]

Implications

This article provides information about developing a capacity building training program on family interventions so that clinical skills can be practiced in nonclinical settings, thereby identifying early signs of mental illness and strengthening the coping abilities of people so that they would be able cope with the daily hazards, adjustment problems, and interpersonal relationships within the family, which are essentials for every marriage. Similar capacity-building exercises need to be developed and tested so that the services can reach masses in the community. In this article, researchers are sharing their experiences of conducting family intervention training program for the counselors and social work trainees so that they can use family intervention techniques, such as circular questioning, genogram, influences of family of orientation, neutrality, nonjudgmental attitudes, and self-reflection while providing support to the couples with adjustment problems. These techniques would strengthen their helping skills and make their therapeutic interventions more effective. The article highlighted the need, description, and effectiveness of family intervention workshop with lay counselors. The implication of such dissemination is to:

  • Recognize the “gap” in service providers and users in the field of family problems
  • Recognize the potential and possibilities to enroll the participation of lay counselors and para professionals in providing systemic family interventions
  • To create a structure to such training programs. When the authors were pondering the feasibility of such program, it was realized there were no empirical evidence of components of such training from the Indian context. This article might help in future planning of such workshops by others
  • This also shows the effectiveness of a 2-day workshop on the knowledge of lay counselors. It also points out to the need of continued handholding through supervisory sessions
  • Tertiary mental health training pioneers such as NIMHANS can consider such workshops as a part of their training activities as the effects of continued workshops will be impactful in the community
  • Practicing family therapists need to embrace skills and proficiency to translate clinical and theoretical aspects to simpler language, create novel and interesting activities to deliver systemic intervention skills to grassroots, and not limit it to the walls of clinics only
  • Family interventions can be made available to the community at a preventive, promotive, or curative level at primary care centers. Help can be received before it turns chronic or severe enough to seek clinical services
  • Such workshops to lay counselors in turn increases the attitude and knowledge of healthy families, and to identify family issues at its initiation. These information are passed on to their social groups, therefore impacting the quality of family life in a positive direction.


Limitation

The article has some limitations which should be pointed out:

  • The authors involved in conducting the workshop considered disseminating the impact through academic endeavor as secondary to training objective. Therefore, a robust data collection was not attempted in terms of sociodemographic details or other pre-post session components. The article lacks the depth of such data
  • The findings cannot be generalized as this was the first attempt to document a family intervention workshop. Systematic data need to be gathered from more such workshops to derive an empirically sound structure to the workshop
  • The article bases the understanding of effectiveness as reported by the participants. Therefore, it is subjective and it open to biases.



  Conclusion Top


This article attempted to disseminate a 2-day workshop in systemic family intervention for lay counselors. It has thrown light on to the important components of systemic family interventions to be imparted and the effectiveness of the same. Future endeavors to continue such workshop will allow the benefits of such workshop to be far reaching.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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