Family therapy in Romania and lessons for the West

The Kónyas, trained by Irish family therapists, identify additional challenges of introducing family therapy into a culture unfamiliar with the concept. "The fit between systemic therapy and Romanian culture has been a concern of ours since the beginning of our training," they wrote in 2003. "There had been no tradition of people seeing psychotherapists in times of distress. Also, the vast majority of health care professionals had not even heard about family therapy. Would families come to therapy?"

They found that not only did clients come to therapy, but they also were ready to work hard when they did.

"We admire our clients’ courage in facing a series of challenges involved in the therapy process: consulting an outsider for a family problem, participating in sessions as a family, being asked unusual questions, being videotaped and, sometimes, being observed by a team and/or supervisors from abroad," they said.

In their work with patients, the Kónyas write, they have encountered difficulties tied to the use of words and phrases used in systemic therapy.

"For example, the Batesonian phrase 'a difference that makes a difference' is very difficult, if not impossible to properly translate into Romanian – of course, this may only be a problem in a training context, not in therapy. In response to the Romanian or Hungarian translation of the question: ‘And how has this been a problem for you?’ clients almost invariably demonstrate a lack of comprehension: ‘Would you please say that again? I didn’t understand.’ The difficulty here is not that the question makes no sense, but that it is culturally unusual – and therefore potentially therapeutic," they write (Context 2007)

"Also, certain words that might sound neutral in the West sometimes trigger strong emotions in our country. For example, monitoring progress on a 1-10 scale might recall painful experiences connected with school, because in Romania, marks are from 1 to 10. Also, talking about ‘systems’ may trigger discomfort, as this is the word people used during communism to describe the oppressive dictatorial regime. People who challenged the dominant ideas used to be called ‘the enemies of the system.’ "

The communist ideal of "systemization" broke families. Women were encouraged to give birth in a pronatal policy that resulted in orphans and unwanted children. After the 1989 revolution, more than 300,000 Romanians were living in psychiatric institutions. Communist factories were closed, and displaced workers had no place. Raising a voice against the regime risked imprisonment as an enemy of the system. The word "system" is associated with oppression in Romania.

Are there lessons for us in the West? I think the answer is yes and that the Romanian experience highlights several imperatives that are useful for Western mental health professionals. Among those imperatives:

• Family psychiatry needs to agree on a definition of family therapy. Is it any approach that includes families? Do we need to be systemic to be considered family therapists? Does family support qualify as family therapy? Does family psychoeducation qualify as family therapy? Can we embrace these two levels, as well as a third, more-skilled level, a systemic family therapy? Can we accept a three-level definition of family treatment?

• Can we incorporate all the family therapy models into one approach that people will recognize as a generic approach to families? Can we use the common factors approach described by Douglas H. Sprenkle, Ph.D., Sean D. Davis, Ph.D., and Jay L. Lebow, Ph.D., in "Common Factors in Couple and Family Therapy" (New York: The Guilford Press, 2009)? For couples and family therapists, common factors over and above the well-recognized individual psychotherapy factors are conceptualizing the problems in relational terms, using therapy that aims to disrupt dysfunctional relational patterns, expanding treatment to include family members of the index patient, and fostering an expanded therapeutic alliance, according to Dr. Sprenkle, Dr. Davis, and Dr. Lebow.

• Can we develop a protocol that beginners can follow? Aaron Beck’s cognitive-behavioral therapy (CBT) provides a basic template that is easy for the novice therapist and the patient to use, yet brings a unique perspective to psychotherapy. CBT has gone on to develop in several diverse directions, but all CBT models have the same basic set of beliefs. Can a family approach or protocol be both simple AND allow for more sophisticated elaboration? Can we develop a set of basic steps that define family treatment?

• Should there be an approach to families that all disciplines can follow? Family therapy is practiced by physicians, nurses, social workers, and marriage and family therapists. Each discipline tends to work with different populations. Physicians tend to see families in which one person is the identified patient. Social workers tend to see families that have been referred for social services, families who are frequently struggling with such problems as housing, financial, and legal difficulties. Marriage and family therapists are often employed by community and hospital agencies as health care extenders and might work alongside other health care professionals. Would a single approach to families be useful?