Introduction

Mental health is a dynamic concept which gets greatly influenced by social conditions, social structure, and social arrangements [1]. Sociogenesis has ascribed the reality of mental illness to overwhelming social stressors, including poverty, migration, and social disintegration. The social determinants of employment conditions, discrimination, familial relationships, parenting styles, and community characteristics significantly impact mental health outcomes among youth [2]. The socio-genetical conditions reflect in the mental health outcomes and they act as a catalyst for the onset of mental illness. The theories of the sociogenesis of mental illness emphasize the importance of working with the family to manage the psychosocial stressors related to mental illness [3]. There is a reciprocal relationship between mental illness and family functioning because the components of the family relationship including family connectedness, family satisfaction and social support, generate more remarkable mental health outcomes. Hence, the components of family functioning are potential areas for rehabilitation to reduce disability in the family unit.

Family-Centric Rehabilitation as an intervention is “a process that facilitates families, dysfunctional due to PMI, to reach their optimal level of independent functioning by harnessing resources available within the community” [4]. In India, families influence social regulation, and interdependent familial roles are culturally accepted [5]. In contact with biological vulnerability, toxic family stress promotes illness onset and recurrence [6]. Supporting the families of persons with mental illness creates more significant improvement in all aspects of the patients’ level of functioning, including self-maintenance, social functioning, community living skills, and a substantial reduction in patient rehospitalizations [7]. Family interventions can help reduce the expressed emotions and symptom relapse [8]. Traditionally psychiatric rehabilitation has been considered and practised as an individual-centric treatment modality. Compared to the western condition, Indian families are more involved in the caregiving process of the mentally ill, and contemporary family interventions are restricted to psychoeducation to a greater extent. The vicious cycle of family impact and mental illness creates the subsequent possibility of family-centric treatment. Hence, if rehabilitation is provided to the entire family as a unit, it would help the person with mental illness, and the family members manage their relative with mental illness more effectively and take care of their health and needs. The family interventions like the educational approach, stress management strategies, social skills training, vocational training, specific cognitive behavioural strategies and home-based crisis management create clinically significant outcomes (Falloon, 2003). The current study has added techniques including communication training, enhancing support systems, and reducing expressed emotions as interventions for the family. The focus of the treatment is the family rather than the individual and can effectively mitigate the sociogenesis of mental illness. This paper depicts case examples of how family-centric rehabilitation can be used as an effective intervention to deal with the sociogenesis of mental illness. This scientific paper was approved by the NIMHANS Institute Ethics Committee (IEC) as a retrospective file review—case study.

Case Illustration-1

Mr T is a 32-year-old man from middle socioeconomic status, urban background, and educated up to graduation. His family consisted of his father, mother, younger brother and grandmother. His father, a businessman, and his younger brother, a graduate in engineering, were the family's breadwinners. He was diagnosed with Unspecified Non-organic Psychosis and internet addiction for seven years and had undergone multiple individual treatment modalities. He was referred to Psychiatric Rehabilitation Services (PRS), National Institute of Mental Health and Neurosciences (NIMHANS) in September 2019, and the psychiatric social worker for vocational rehabilitation and to address the expressed emotions among family members.

The analysis of the family situation from the sociogenesis model of illness revealed that the psychological stressors in the family included a high level of expectations and expressed emotion towards Mr T in the form of over-involvement and criticality. The social stressors present were lack of social support and stigma/comparison with peers. The environmental stressors included a lack of opportunities for education and employment due to mental illness. A social analysis showed that the client resorted to internet addiction as a coping mechanism to avoid the high level of expressed emotion in the family environment.

The family was in crisis due to the illness of Mr T, and the family rituals were affected. The family functioning had been disrupted, and the coping strategies adopted by the family members were inadequate in managing the symptoms and bringing back the family to equilibrium.

Family-Centric Rehabilitation Interventions

To deal with the Psychological Stressors in the Family

To reduce his face time with family members, especially the expressed emotions experienced, interventions with Mr T involved helping him schedule his day to include family activities including cooking, washing, and gardening. To further reduce his face time with the family, Mr T was referred to a vocational training institute for a three months training in data entry to gain skills which helped him gain confidence in facing people and moving on in his life and career.

The parents were taught to deal with the residual symptoms of anxiety and suspicion by agreeing to his demands to an extent and keeping track of his medications adherence and activity schedule. The mother was the main person who experienced burnout as she was over-involved with his activities. A separate activity schedule was prepared for the mother where she was asked to take out time for herself in the absence of Mr T. This schedule was drawn in discussion with Mr T as he felt anxious in the absence of his mother. The mother was involved as a participant in a performing arts workshop for caregivers, where she was allowed to ventilate through the medium of dance and drama. The grandmother and father were critical of Mr T and his inability to move on in life. The family (especially the father) was psycho-educated about the medical model of illness and was explained about the sociogenesis of anxiety of Mr T (i.e. their over-involvement and negative expressed emotions). The mother used to involve even in the patient's personal space like choosing food, selecting clothes, accompanying the patient for a walk, and the father used to critically comment on frequently changing jobs and not settling in life. Thus, reflection was used as a technique in sessions with the family to explain the importance of making Mr T independent and avoiding over-involvement in decision-making. The family was helped in understanding that they should not consider him as a child and that his decisions need to be respected in education and vocation based on his current skills and ability. The therapist discussed the reciprocal relationship of treating Mr T as an adult and gaining his confidence and trust. The discussions helped the family reduce their expectations from Mr T and also helped build a healthy relationship with him.

To Deal with the Social Stressors in the Family

The family did not seek any social support, as they had not revealed Mr T's illness to their relatives. They had also started avoiding going to functions due to the possibility of being asked about Mr T’s behaviour. It was discussed with family that by avoiding social functions, they were compounding to the social anxiety symptoms of Mr T. Discussion with the parents on how family time can be brought back with an informal online get-together with relatives was one method of getting the family and Mr T into social circles. This method was acceptable to the family and Mr T as he did not find it intimidating. The family was also advised not to discuss family matters behind his back and involve him in all the important decisions on the family. Mr T felt inadequate when talking to his cousins as he thought they had all moved ahead of him in life. His brother, too, was getting married, which upset Mr T as he felt that he was the elder brother and had not settled in life. As the brother was unavailable for sessions, the parents were told to ask him to discuss this aspect with Mr T and seek his permission to get married. The parents were also asked to reassure Mr T that he would also be encouraged to look for a life partner once he can move on in his career.

To Deal with Environmental Stressors in the Family

The advent of mental illness had caused reduced self-confidence in Mr T in getting back to education and career. Mr T was unable to get back into his higher education (post-graduation) due to a lack of opportunities and lack of reasonable accommodation provided by universities to persons with disabilities to join after a break. Further, he could not secure a job as he had a career break and companies were hesitant to take him despite his excellent communication skills. The Psychiatric social worker liaised with the Skill training institute for Persons with disabilities in Bengaluru and helped Mr T gain certification in Data entry. She also helped him prepare his resume facing job interviews and liaise with companies for reasonable accommodation for his job placement. The process of job matching, job placement is currently ongoing with companies. The family members have been explained about the efforts taken by the patient and need to acknowledge his efforts. The patient's mother has been involved in the process by accompanying the patient in job training and home assignments like resume preparation. The father and brother have been involved in job searching and logistical arrangements for the patient and mother.

Implications of Interventions in the family-1

The family got a better understanding of the socio genesis of Mr T’s mental illness and consciously tried to change the family environment to mitigate family stressors contributing to the illness. They reduced their over-involvement and started giving him independence in activities and decision making. Mr T got a structure for his daily activities, and these activities helped him have a few goals during the pandemic. Mr T resumed his studies for postgraduate education. He started to take on more responsibility in his home rather than blaming the family for considering him as a child. His social anxiety improved with meeting his cousins in online gatherings. The improvement in family level communication helped gain trust among family members, and they started involving him in the decision-making process.

Case Illustration-2

Mrs A was a 52-year-old lady from middle socioeconomic status, urban background, educated up to post-graduation in Hindi. Her family consisted of Mrs. A, her husband, her daughter and her son. The husband was a chemical engineer working in a private firm, but he had resigned to take care of his wife during her illness period. Both the children were engineering postgraduates and were working in the private sector. She was diagnosed with Generalized Anxiety Disorder and Recurrent Depressive Disorder and was referred to PRS, NIMHANS, in May 2019 for vocational rehabilitation and improving the family's social support. The patient reported an illness duration of 22 years, and she had undergone pharmacological treatment from various hospitals.

The analysis of the family situation reveals that factors related to sociogenesis contributed to her illness substantially in the development of mood and anxiety symptoms. The psychological issues in the family include a high level of criticality from the husband. The sociological issues in the family included lack of social support from the secondary and tertiary sources and burden faced by the husband in caregiving due to unavailability of other family members. The husband's awareness about the illness was poor, and he could not provide support to his wife during her symptomatic phase. There were environmental issues in the family, including a lack of accessible mental health facilities to continue holistic care in the hometown and financial difficulties due to the lack of employment of both Mrs. A and her husband. The husband was extremely stressed as he had to depend on his daughter for financial support.

The psychosocial problems faced by the families can be represented in the following diagram (Fig. 1).

Fig. 1
figure 1

Social determinants of illness and impacts in the family

Full size image

Family-Centric Rehabilitation Interventions

To Deal with the Psychological Stressors in the Family

Mrs. A was psycho educated about her illness. She was asked to look at her condition objectively and not from the subjective aspect to not hold herself responsible for her illness. A systematic activity schedule, including activities that she liked doing, such as dancing, was made for Mrs. A with her consent to help her divert her mind from her illness symptoms. The family members had been explained about the nature of the illness that she is having and were asked to manage and supervise the treatment. The husband has been described the connection between his high criticality and the symptoms of Mrs. A in the context of expressed emotions. The husband was provided role-play situations to improve his communication with Mrs. A, which helped enhance their marital relationship [9].

To Deal with the Social Stressors in the Family

For dealing with a lack of family support, the children were encouraged to stay in regular contact with their parents. The psychiatric social worker explained to the daughter that the father was psychologically burnt out due to the caregiving role and that she should help her father take care of the mother during her vacation breaks. The daughter was also explained to voluntarily support her parents financially as the father was reluctant to ask her help for any financial support. Other family members, such as Mrs A’s sister and son, were also contacted to support her in times of need when she returned to her hometown (sister stayed in the same town as Mrs A).

The patient was engaged in Psychiatric Rehabilitation Services, NIMHANS, for three months to help her gain work habits, and she was assessed for her vocational potential. Since she was good in Hindi, it was decided that she could take tuitions for children at home. She started taking classes for children at home after her discharge as advised and managed her work and house activities. The husband was also happy with her getting back to normal life activities.

To Deal with the Environmental Stressors of the Family

Mrs A reported that she wants to go back to the native place to join with her extended family and continue treatment there. The patient reported difficulties in availing of treatment in her hometown and her inability to follow the rehabilitation activities. For this, the psychiatric social worker liaised with a local psychiatric social worker and connected Mrs A to her for continued psychosocial support. The husband was helped to find a job to address the financial stressors. For this, her resume was circulated to many pharma companies, and the therapist personally contacted psychiatrists who knew the pharma company Human Resource manager to get the husband a job. Due to the age factor, it was challenging to place the husband in any position. However, Mrs A was encouraged to take tuitions in her house for children, which helped them earn money for their monthly expenses.

Implications of Intervention in the Family-2

The Family centric rehabilitation interventions helped Mrs A get back to her daily schedule, get into a job of taking tuition, and become more independent and cope with her mental illness. She started taking the household responsibilities, and her anxiety levels when reduced significantly. The family’s understanding of the condition improved, and the husband's burden eased with the daughter's availability and the extended family members to take care of Mrs A. The interaction between her and family members (especially her husband) improved, and she started to share issues with them whenever she felt stressed.

Discussion

The sociogenesis model of mental illness focuses on the factors contributing to mental illness from the person in the environment approach [10]. Further, when looking from the sociogenesis approach, family factors contribute to a large extent in developing and maintaining mental illness. [8] found that family interventions in mental disorders can bring changes in the family environment, helps in addressing the biological vulnerability, improve medication compliance, diminish the use of substances, and reduce expressed emotions. The empirical evidence shows need for rehabilitative interventions in family for overall improvement in functioning of the family and easing the disability in the patient. Family centric rehabilitation is an intervention process that provides treatment to the family system rather than treating the person with mental illness.

The above case illustrations show that there are common sociogenic issues in both the families that contributed to the person's mental illness, such as the burden of caregiving, lack of employment, and lack of support from the relatives. The improvement in one area of functioning leads to improvement in other areas. For example, the awareness creation among the family members significantly reduced the expressed emotion among the family members towards the patient. It helped in improving the attitude of the family members towards the patient. A study by Sharma et al. in 2020 states that adaptive coping such as information, communication, and social involvement are associated with lower expressed emotions among caregivers of persons with bipolar disorder [11]. The current study found that the support provided in employment has significantly helped reduce the burden on the family. Creating a family environment with a role for all the family members, including the patient, improved the relationships in the family and made the client more independent. The enhanced support from the family members helped reduce the relapse and helped in managing the residual symptoms carefully. Laine et al., in 2014 [12], found that there is a positive correlation between favourable psychosocial working conditions and improvement in common mental disorders. The unique feature in both cases is the improvement in family functioning.

The current study tried to address the family's pathology in general and the psychopathology of the mentally ill family member. In both the families, individual interventions had been provided to the family members apart from interventions focused on the patient. In case example 1, the patient had persecutory ideas towards the father, which made him hostile towards the son. Through education and communication training, the hostility had been reduced, by which the primary support from the father has been enhanced. In case example 2, the patient's husband was critical towards the mentally ill wife due to the inability in terms of financial contribution and burden due to caregiving. Here, the children have been incorporated into the caregiving process by employing the daughter for financial support and the son for material support for the patient.

The sociogenic reasons for mental illness, including poor social support, the burden of caregiving, and over expectations, can also be addressed through family-centric rehabilitation. It is well recognized that psychological morbidity impairs an individual's coping and socio-occupational capabilities. The negative correlations between social support and stress and dysfunction suggest that a lack of supportive relationships makes an individual even more vulnerable [13]. In family-centric rehabilitation, enhancing the social support of the family is an essential aspect of intervention for the rehabilitation of the client.

While addressing the sociogenesis of mental illness through a family-centric rehabilitation model, the psychiatric social worker faced some challenges. In family-centric rehabilitation, the participation and cooperation of all the family members are essential. It was a significant challenge during the intervention to bring all the family members together for intervention and make them understand the effectiveness of the intervention.

Conclusion

Sociogenic factors can impact the family's overall functioning and the mental health outcomes of the client. The intervention has helped improve the attitude and response of the family members towards mental illness and helped enhance the overall functioning of the family. Family centric rehabilitation can be a helpful intervention to mitigate the sociogenesis of mental illness in the family.