Counselling Families with Mentally Ill K. ANURADHA Mental illness, in...
Counselling Families with Mentally Ill
Mental illness, in general, and chronic mental health problems, in particular,
cause a lot of distress to the affected individuals as well as their families. Families
of the mentally ill experience emotional strain and a series of changes in their
family functioning. A family counsellor needs to understand the family dynam-
ics, the emotional climate and level of organisation of the family. In this article,
the author has outlined the purpose and goals for counselling families with men-
tally ill members. The skills required by a family counsellor for such purpose are
also given. The author has recommended a four phased appraoch to to counsell
and empower families with mentally ill individuals.
Dr. K. Anuradha is Faculty, Department of Social Work, S. P. Manila University,
Research provides compelling evidence that the family plays an im-
portant role at every stage of a person's illness or disability, either by
enhancing or retarding the healing process. The capacity of the family
to make adaptive changes required by the mentally ill individual's
condition is an important determinant for the outcome of the mentally
ill individual, as well as the family unit. Any illness or disability is al-
ways of significance, since it influences the relationships of people
with each other.
Mental illness, in general, and chronic mental health problems, in
particular, cause a lot of distress to the affected individuals as well as
their families. The nature and intensity of the problems depend on
various factors like the type of illness, course, prognosis, treatment
availability, utilisation of services, family and community support,
levels of personal and social functioning of the mentally ill, deviance,
tolerance, and so on (Gopinath and Chaturvedi, 1992; Ranganathan,
Nirmala and Pandankatti, 1991).
Sheperd (1984) and Wing and Morris (1981) describe three levels
of disability in the chronically mentally ill:

160 K. Anuradha
• Primary disability, which includes dysfunctions arising out of
the illness;
• Secondary disability, which arises from the experience of the
illness (adverse personal reaction); and
• Social disability which includes stigma, unemployment, poverty
and lack of sense of belonging.
Due to these disabilities, mentally ill individuals become a burden
to the family and as well as the society.
The most common variables associated with the family burden are
the mentally ill individual's aversive behaviour, adverse effects of the
mentally ill and the poor role performance of the mentally ill individ-
ual. Significant mediators include strengthening social support and
coping skills (Macurin and Boyd, 1990).
Families of the mentally ill experience emotional strain and a se-
ries of changes in their family functioning. This is in relation to the
structural changes in the family, normative conflicts underlying fam-
ily care, changes in normal care in relation to the preferred locus of
control and their conception of mental illness (Carr, 1990). The other
problems that are expressed by the families of the mentally ill are eco-
nomic strain, feelings of anxiety, guilt, helplessness and delayed grief
reaction (Franks, 1990; Hanson, 1995; Miller, Dworkin, Ward and
Barone, 1990).
Some of the needs expressed by families with mentally ill are ac-
cess to accurate information about the illness, advice on every day
problems, the need on part of the counsellor to have an insight into the
family's attitude towards the illness, and recognise the stigma of men-
tal illness that the families feel (Main, Gerace and Camilleri, 1993).
Many families of the mentally ill express that their experiences of
grief and loss are impaired by the characteristics of mental illness and the
mixed messages from the mental health system (Riebschleger, 1991). A
family counsellor needs to understand the family dynamics, the emo-
tional climate and level of organisation of the family. A counsellor
should have effective communication and conflict management skills to
make the family more cohesive, to manage conflict, to obtain a greater
locus of control, and to feel more autonomous and empowered (Mills
and Hansen, 1991).
Hence, services for preservation of the families with mentally ill
should include education, treatment and empowerment. The focus
should be on treating vs. teaching of the families, promoting retention
of information, the provider family relationship, meeting the family

Counselling Families with Mentally Ill 161
needs, encouraging formation of supportive family groups, struggle
with concerns of stigma of mental illness, daily management of prob-
lem behaviours, responses to repeated crisis, and access to available
community resources (Mc Peak, 1989; Pfeiffer and Mostek, 1991).
FIGURE 1: The Family Health and Illness Cycle
Figure 1 illustrates the family health and illness cycle (Doherty and
Campbell, 1988) and gives a family's longitudinal experience with
health and illness. The category family health promotion and risk re-
refers to family beliefs and behaviour patterns that either help
family members stay healthy or put them at long-term risk for devel-
oping disease(s).
The next category, family vulnerability and disease onset/relapse
refers to life events and experiences of the family that render family
members more immediately susceptible to becoming ill or relapsing
from a chronic illness. The principal body of research on this topic ex-
amines how family stress, stemming from either internal or external
events renders family members susceptible to illness.
Family illness appraisal refers to the family beliefs about a family
member's illness and to the family decisions about how to deal with
the illness episode.

162 K. Anuradha
Family acute response refers to the immediate aftermath of illness
for the family. This family experience is likely to be tied closely to
family illness appraisal, since the early response to an illness episode
is influenced by the family's assessment of its seriousness. An exam-
ple of acute response is the adjustment a family must make in the pe-
riod following an acute attack of schizophrenia. The family
experiences a crisis situation and normal coping patterns are inade-
Family adaptation to illness and recovery refers to how a family
reorganises itself around a chronic illness or disability of a family
member, and to the ways in which a family adapts to the recovery of
an ill member. This is a phase where the family has to promote the
continued recovery or stabilisation of the family member's health,
while simultaneously maintaining its ability to nurture other family
members and maintain its place in the community.
To summarise, it can be seen in the figure that the temporal flow of
the family health and illness cycle begins with the general functioning
of the families in areas such as stress management and mutual sup-
port, followed by a brief phase — vulnerability and disease onset/re-
lapse — where there may be a pile up of psychosocial stressors that
may precipitate an illness episode. The family then evaluates the
symptom of the illness, the need for medical attention and seeks the
advice of health care professionals. While continuing the appraisal
process the family moves into the acute response phase, during which
reactions to the illness are likely to involve fear and shock, followed
by mobilisation of family resources. Finally, the patient stabilises af-
ter the acute episode and returns home to continue recovery and reha-
bilitation. In this context, the family faces the challenge of adapting to
revised roles and responsibilities, either temporarily or permanently.
The cycle can then be seen as beginning anew as the family confronts
the challenges of reducing the risk of a repeated illness and promoting
the health of the family member.
Purpose and Goals
The purpose and goals for counselling families with a mentally ill
member are to:
• develop a supportive climate for the family;

Counselling Families with Mentally Ill 163
• provide necessary information for the family to understand the
mentally ill person's condition, its demands, and its
consequences for individual and family living;
• alleviate feelings of anxiety, guilt, low self-esteem, and so on;
• enhance appropriate participation of the family members in the
care of the mentally ill individual;
• develop new rules and skills of communication among the
family members;
• assist the family to establish and enhance relationships with
each other and with significant others in the social network;
• develop flexibility in making necessary shifts or role
responsibilities and develop role competence;
• build family social supportiveness;
• improve the family's problem-solving capacities; and
• develop awareness of the family's own resources and provide
access to essential external resources.
Some of the psychosocial problems encountered by the families
with mentally ill may be related to lack of knowledge about a specific
illness; cultural attitudes, and relatives who create barriers in the
utilisation of medical care; dysfunctional interpersonal relationships;
cognitive and emotional difficulties of the mentally ill individual and
significant others; ineffective functioning of the family system;
inadequate social supports; and lack of adequate resources.
A basic ingredient to effective helping is the degree of rapport and
trust established between the counsellor and the families. The coun-
sellor has to initiate, develop and sustain a positive relationship with
the family and each of its members. Such a relationship makes mem-
bers free to disclose their feelings, thoughts and reactions and experi-
ence a sense of respect. The ideal client family- worker relationship is
characterised by non-possessive warmth or acceptance, accurate em-
pathy, genuineness and respect. The intensity of the relationship be-
tween the counsellor and the family varies with the purpose of
service, the form, duration of treatment and the particular characteris-
tics and needs of the family members.

164 K. Anuradha
Cluster of Techniques
The techniques required for working with families with chronically
mentally ill are providing support and sustainment, facilitating venti-
lation or expression of feeling, education, exploration, direction,
structuring, clarification, confrontation, use of conditioning tech-
niques, and facilitation of a process.
Activity oriented interventions
These are also an essential part of working with families. They in-
clude making peace with the past and the present, psycho education,
developing family social supportiveness and promoting family rela-
tion skills. Other activities include exercises in communication, role
play, brain storming, preparation of genograms, modelling, construc-
tive coping, performing tasks related to role performance, demonstra-
tion and rehearsal and participation in mutually enjoyable activities.
The basic idea is that skills in problem-solving and social competence
can be developed through such purposefully designed activities along
with facilitation of discussion.
Underlying the successful use of any procedure or technique is the
professional use of self. Counsellors should be very clear about their
values, and their attitudes towards mental illness and towards particu-
lar individual and families. They should clarify their role and should
be clear about the rationale for selection of a particular model or pro-
cedure. They should examine their feelings, and attitudes, assump-
tions, evaluate their work and use feedback from the individual,
families and colleagues.
Counselling Process
The following four-phased approach may be adopted to empower
families with mentally ill individuals.
Phase One: Building Commitment to the Helping Process
The major tasks that have to accomplished here are:

Counselling Families with Mentally Ill 165
• Clarification of the purpose of family sessions and importance
of family's participation.
• Clarification of the family to the new helping situation.
• Orientation to family to the new helping situation.
• Engaging the family in determining a purpose and more specific
• Initiating a working relationship.
• Enhancing motivation and getting the family ready for work.
• Contracting with the family.
Phase Two: Framing and Reframing the Problem
• Acquiring and using knowledge and skills to the defined
• Using one's capacities and as well as resources both within the
individual and external.
• Using one's capacities and as well as resources both within the
individual and external.
• Restructuring and distribution of role responsibilities.
• Decision-making with regard to family members participation
in the care of the mentally ill individual.
• Identifying and problem solving related to family relationships,
communication and structure.
Phase Three: Developing a Healing Theory
Developing a set of propositions about a particular situation, which
will be useful in explaining a current predicament and the need for as-
sistance and predicting future outcomes. It can be developed through
a continuous discussion with the family members. It provides a se-
mantic antidote for treating and 'curing' the trauma infecting a family
Phase Four: Closure and Preparedness
• Involves bringing the intervention process to a successful
• Family members may express a combination of positive and
negative feelings. Hence this phase is either the hardest or the
• Review and evaluate the process made. Get the families to
appreciate their accomplishments of successfully coping with
the care of a mentally ill individual and to acknowledge how

166 K. Anuradha
successfully they are equipped with the resources necessary for
coping with future stress.
• Complete any unfinished business.
• Continuity of care.
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THE INDIAN JOURNAL OF SOCIAL WORK, Volume 64, issue 2, April 2003