DELHI PSYCHIATRY JOURNAL Vol. 11 No.
2 OCTOBER 2008
Review Article
Family and Psychopathology: An Overview
Series-1: Children and Adults
Pradeep Kumar, S.C .Tiwari
Department of Geriatric Mental Health, CSM Medical University, Lucknow - 226 003.
Family
None of us live utterly alone. Family is the
primary unit where individuals find their self
identity and desire to live. A rigid defininition of
family involves persons united by ties of marriage,
blood, or adoption. The members of a family have
a common habitat, share same roof and constitute a
single house hold. They interact and communicate
with each other in the performance of roles, as
spouse, mother and father, son, daughter, etc. This
unit has certain common characteristics in all
societies although the relationship between the
individuals, family, society, culture and civilization
are variable and complex1. The family maintains a
common culture, but may operationalize it
differently. A rather loose definition of family
connotes a group of individuals who live together
during important phase of their lifetime and are
bound to each other by biological or social or
psychological relationship.
Psychopathology
Psychopathology refers to an abnormality,
dysfunction, mental illness, or family psycho-
pathology manifested in terms of behavioral,
interpersonal, emotional, cognitive and psycho-
physiological functioning. Mental illness is a term
that is largely synonymous with psychopathology,
although it carries the implication that the unusual
or aberrant patterns of functioning seen in these
conditions reflect some form of disease or illness.
Family psychopathology implies various risk
situations (e.g. dysfunctional family structure,
dysfunctional family functioning, faulty family
relationship and communication patterns, etc)
140 Delhi Psychiatry Journal 2008; 11:(2) Delhi Psychiatric Society
which have impact on mental health. In another
words, it can be said that when the pathological
life of the family creates problems in the equilibrium
(balance) of the family environment, it is called as
family pathology. Family psychopathology
represents a particular risk in the immediate
postpartum period, especially if family members
suffer from bipolar affective disorder compared to
other diagnostic groups2.
Emergent Role of Families in Mental Disorder
Available evidence suggests that the prevalence
of psychopathology among children in the family
or foster care is higher than would be expected from
normative data 3. Family is the main socializing
agent for the child and is important in all aspects of
a human development. From family, an individual
gets emotional, financial, mental support and is able
to cope with his/her problems with the help of the
members of the family. Scientific observations on
mental disorders and mental patients have indicated
that family contributes significantly to the
development of mental disorders. The importance
of the role of the family as a causative factor in the
development of mental disorders is getting more
and more established, particularly over the past
decade. Clinical work and research on families,
theories of family structure and dynamics had their
beginning since 1940s with the work by Social
scientist (Meyer and Sullivan). It is indicated that
family has a crucial role in the development of
mental disorders. Mental disorders develop as a
result of family pathology or faulty communication
or interper sonal r elationship. Although the
individual is affected, yet the whole family is sick
OCTOBER 2008
because of inter or intrapsychic problems4. The role
of family in mental disorder/psychopathology has
been classified into three broad categories such as:-
1. Causative role of the family
2. Maintenance role of the family and
3. Therapeutic role of the family.
1. Causative Role of The Family
Mental disorders do not occur in a vacuum, they
develop in a family setup with family dynamics
playing causative role5. In following areas family
plays crucial role in the development of psycho-
pathology:
(I) Faulty Parent Child Relationship :
Several types of specific parent child patterns
appear with great regularity in children who show
emotional disturbances. Some of these patterns are:
(a) Rejection: Rejection is manifested through
physical neglect, denial of love and
affection, lack of interest in the childs
activities and achievements, failure to
spend time with the child and lack of
respect for the childs right and feeling as
a person. In few cases, it also involves cruel
and abusive treatment. It shows that
parental rejection tends to foster low self
esteem, feeling of insecurity and
inadequacy, retarded conscience and
general intellectual development, increased
aggression, lovelessness and inability to
give and receive love. Cold and rejecting
mothers report persistent bed-wetting,
aggressiveness, slow conscience develop-
ment in their children6. Parental rejection
is associated with diminished intelligence
during the early school years, discourage-
ment and general inhibiting and suppress-
ing effect on childs intellectual develop-
ment and functioning7. Parental rejection
is a key factor amongst children suffering
from excessive fear 8.
(b) Overprotection and Restrictiveness- -
Maternal overprotection or MOMISM
involves the smothering of the childs
growth. Overprotective mother may keep
watch on the children constantly, protect
them from the slightest risk, overly cloth
and medicate them more than necessary and
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DELHI PSYCHIATRY JOURNAL Vol. 11 No.2
take decision on their behalf on slightest
opportunity and make up their mind for
them of the slightest opportunity. Such
maternal reactions appear to represent a
compensatory type of behaviour in which
the mother attempts to gain satisfaction
through her contact with the child. Such
children are denied the much needed oppor-
tunity for reality testing and development
of essential competencies. They became
overanxious or have excessive fears. Rigid
enforcement of roles and standards give the
child little autonomy or freedom for
growing his/her own way. It may foster well
controlled, socialized behaviour, but it also
tends to nurture fear, dependency, sub-
mission, repressed hostility and some
dulling of intellectual striving. Over
anxious youngsters are reported to have an
over familiarizing overprotective mother.9
(c) Over Permissiveness and Over Indul-
gence - Sometimes one or both parents
cater to the childs slightest whims and in
doing so fail to teach and reward desirable
standards of behaviour. Children of overly
indulgent parents are characteristically
spoiled, selfish, inconsiderate and demand-
ing. High permissiveness and low punish-
ment at home correlates positively with
antisocial and aggressive behaviour. These
children readily enter into relationship but
exploit people for their own purpose .Such
children are often rebellious.
(d) Unrealistic Demands- Some parents place
excessive pressures on their children to live
up to unrealistically high standards. Under
such sustained pressure, there is little room
left for spontaneity or development as an
independent person. No matter how hard
the child tries, he seems to fail in the eyes
of his/her parents and ultimately in his/her
own eyes. It leads to pain, frustration and
self-devaluation. Often parents dont take
into consideration the capabilities and
temperament of their children. In some
instances, parental demands are unrealis-
tically low and parents dont care what the
child does as long he/she stays out of
trouble. The children of such parents are
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significantly lower in both achievements
and self esteem10. Thus, it is evident that
unrealistic demands, too high, too low or
distorted and rigid can be important cause
of faulty development and maladjustment.
(e) Faulty Discipline Parents are some times
confused about appropriate forms of
discipline. Inconsistent discipline makes it
difficult for the child to establish stable
values for guiding their behaviour. They
often become more resistant to punishment
and to extinction of their aggressive
behaviour. There is high correlation
between inconsistent discipline and later
delinquent and criminal behavior. At
present discipline is thought of more
positively as providing needed structure
and guidance for promoting healthy growth
on the part of the child.
(f) Undesirable Parental Models Since
children tend to observe and imitate the
behavior of their parents, it is apparent that
parental behavior can have a highly
beneficial or detrimental effect on the way
a youngster learns to perceive, think, feel
or act. Parents become undesirable models
if they have faulty reality and value
assumption. A parent who is emotionally
disturbed or addicted to drugs or otherwise
maladjusted may also serves as an
undesirable model. Neurotic behaviour in
the mother might lead to over anxious
neurotic child .Undesirable parental model
is an important reason why mental disorder,
delinquency, crime and other forms of
maladaptive behavior tend to run in
families.
(II) Maladaptive Family Structure:
Current research on families has revealed that
the general family environment as well as the child
relationships may foster maladaptive behaviour on
the part of the child with one or both parents. There
is no model of the ideal family. However a few types
of families that clearly have a detrimental influence
on the child developments are:
(a) The Inadequate Family This type of the
family is characterized by inability to cope
with the ordinary problems of the daily
142 Delhi Psychiatry Journal 2008; 11:(2) Delhi Psychiatric Society
OCTOBER 2008
living. It lacks the resources, physical and
psychological for meeting demands.
Incompetence of such families cant give
its children the feeling of safety and
security or adequately guide them in the
development of essential competencies.
(b) The Disturbed Family or Home:
Disturbed family may have cer tain
characteristics like (1) the presence of
parents who are fighting to maintain their
own equilibrium and who are unable to give
the child the needed love and guidance (2)
Exposure of the child to emotional and
faulty parental models and (3) almost
inevitably, the inclusion of the child in the
emotional conflicts of the parents.
Disturbed homes have been associated with
high incidence of psychological distur-
bances among children. It represents a
threat to his/her base of operation and
the only security he knows.
(c) The Antisocial Family: Here the family
espouses values not accepted by the wider
community. The parents are overtly or
covertly engaged in behavior that violates
the standards and interests of the society at
large. They provide undesirable models to
the child. Children in such families may
be encouraged in dishonesty, deceit and
other undesirable behaviour patterns and
imitate the behaviour and attitudes of their
parents. Their social interactions are
shallow and manipulative. It has found that
poor mental health in a congested urban
area, with a higher mental risk for children
who disapproved of their parents charac-
ter11.
(d) The Disrupted Family- Disrupted families
are incomplete, whether as a result of death,
divor ce, separation or some other
condition. A number of studies have shown
traumatic effects of divorce on a child.
Feelings of insecurity and rejection may be
aggravated by conflicting loyalties. Delin-
quency and other maladaptive behaviours
are much higher among children and
adolescents coming from disrupted homes.
(e) The Discordant Family: Here one or both
the parents are not getting satisfaction and
OCTOBER 2008
may express feelings of frustration and
disillusionment in hostile ways such as
nagging, belting and doing things purposely
to annoy the other person. Ser ious
discordant relationships are likely to be
frustrating, hurtful and generally patho-
genic in their effects on both the adult and
the children.
(III) Family Factors In The Etiology of
Schizophrenia
(a) Double bind (Bateson, Haley and Weak-
land) It emphasises on giving the child
incomplete messages (e.g. strictly
avoiding a physical embrace, while saying
why dont you show me more affection?).
This theory hypothesized that repeated
exposure to such as dilemma generates or
aggravates the schizophrenic state.12
(b) Schism and skew (Ruth Lide and
Weakland)- They systematically studied
the character-istics of schizophrenic
families using a psychoanalytic oriented
psychodynamic perspective. Their main
emphasis was on the triadic and dyadic
relationship in the families. In one type
of family, there is a prominent power
struggle between the parents and one
parent gets overly close to a child of the
oppositive sex. In other types of family,
skewed relationship with one parent
involves a power struggle between the
parents and the resulting dominance of
one parent.13
(c) Pseudo-mutuality and pseudo-hostility
(Lyman Wynne and Margaret Singer) -
They described families in which
emotional expression is suppressed by the
consistent use of pseudo mutual or pseudo
hostile verbal communications. This
suppression results in the development of
verbal communication that is unique to
that family and not necessarily compre-
hensible to anyone outside the family.
Problems arise when the child leaves
home and has to relate to other people.
(d) Family interaction pattern - Environ-
mental studies on the etiology of schizo-
phrenia have stated that pattern of
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DELHI PSYCHIATRY JOURNAL Vol. 11 No.2
communication relating to family systems
are thought to contribute to a member
becoming schizophrenic. It has been seen
that schizophrenic families communicate
with less clarity and accuracy than do
normal families14. Deviances in family
interactions may get manifested in a
variety of ways like:
Communication deviance It is a measure
that reflects the inability of the parent to
establish and maintains a shared focus of
attention during transaction with the child.
It has found that Communication deviance
to be characteristics of parents of schizo-
phrenics.15
Affective climate In schizophrenic
families, the climate and emotional
interchange at the surface represents a
shar p contrast with what goes on
emotionally in depth in the families with
bipolar disorder.16
Schizophrenic Schizophrenic mothers
have been characterized as rejecting,
dominating, cold, over protective and
impervious to the feelings and needs of
others. The child is deprived of a clear
cut sense of his own identity, distorting
his views of himself and his world and
causing him to suffer from pervasive
feelings of inadequacy and helplessness.
The schizophrenic father has been
described as a somewhat inadequate,
indifferent, or passive father who appears
detached and humorless; a man who rivals
the spouse in his insensitivity to others
feelings and needs. Often he appears to
be rejecting towards his son and seductive
towards his daughter. The daughter often
develops severe inner conflict as she feels
an incestuous attachment to her father.
(IV) Family Factors Contributing To The
Etiology of Various Psychiatric Disorders/
Pathogenic Behaviors
Psychoanalysis has suggested that childhood
deprivation of maternal affection through
separation or loss predisposes to depressive
disorders in adult life. Increased affective
morbidity in adult life whereas children
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separated from their parents as a result of
marital problems or divorces do subsequently
have increased rates of depression17. Patients
with severe depressive disorders and mild
depressive disorders remember their parents
have been less caring18. Loss of parents early
in life are associated not with overt mood
disorders but with immatur ity, hostile
dependency, manipulativeness, impulsiveness
and low threshold for alcohol and drug abuse
in adulthood without directly affecting the life
time risk of depression. These characteristics
may precipitate life events which may trigger
depression earlier in life and result in more
frequent episodes of depression. Similarly,
40% of depressed patients who have
personality disorder experience more stress,
an earlier onset of depression and poorer
recovery than those without such disorders.
Family dysfunction is one among many causal
factors on the generation of drugs misused and
related social and behavior disorder among
adolescent and young adults. Parental
substance use tends to put children and
adolescent in such families of a heightened
risk of a variety of stressful life event,
behavioral and emotional difficulties, and
weakened ties drug used in adolescence.
Violence, sexual abuse and victimization
appear to be a strong risk factor for life time
mental health problem in the family. A set of
six variables reflecting chronic familial
adversities that cumulatively proved to be
significantly associated with psychiatric
disorder in the offering. (1) Severe mental
disorder. (2) Low social status. (3) Over-
crowding and large family size. (4) Paternal
criminality (5) Maternal psychiatric disorder
and (6) Placement of the child in foster care.
Presence of even two risk factors increased
the probabilities of disorder four folds 19.
2. Maintenance Role of The Family In Mental
Disorders:
In the last few decades there has been an
increasing trend towards treating psychiatric
patients in the family setting rather than in mental
hospital. Most people with schizophrenia who live
their life with their families remain significantly
144 Delhi Psychiatry Journal 2008; 11:(2) Delhi Psychiatric Society
OCTOBER 2008
disordered by their illness, while their careers suffer
ongoing distress.20 Only a quarter of patients make
a good recover from the first episode of
schizophrenia despite the availability of effective
treatments. 21 Most sufferers now live outside
hospital, about half with their family 22. Some are
well but for others family care continues at the cost
of hardship and distress to careers 22,23. Majority of
relatives of patients with bipolar disorder
experience subjective distress in relation to the
patients symptoms, role dysfunction and the
adverse effect of the patients illness on the relatives
own work and leisure time. The degree of burden
experienced will be greatest in relatives who believe
that the patient is able to control over the patient
illness- related behavior and in those relatives who
are fully aware of the seriousness and prognosis of
the illness. Caring for family member with a chronic
illness could be both rewarding and challenging
experience for the care givers. In an overview of
family burden of psychiatric patients, it was noted
that, the Indian family often tolerates considerable
burden without complain24 . However, due to the
rapid industrialization and urbanization and
subsequent changes in the family structure and role,
care for psychiatric patients impose a significant
burden in the families in developing countries like
India.25 It has found that perceiving the patients
illness symptoms under his or her control has been
associated with higher level of expressed emotion
critical comments, perceiving as helplessness or
rage, contributing to the experience of the burden.
It has also been seen that people with poor quality
of marital relationship are heavier drinker. Husband
undermining behaviours negatively affected the
mental health and functioning of their wives.26 Work
place support enhances well being of the family.
Supportive supervisors were linked to decrease in
health problems in married men. Studies show that
both mothers and fathers are assigned to the low
care and high protection quadrant by patient with
depressive neurosis, social phobias, anxiety
neurosis and agrophobia.18
Social status has always been associated with
social attitude and there is no difference for attitude
toward mental illness. Research finding indicated
that people of lower social class almost never
actively sought psychiatric help for themselves or
for their relatives. Relatives of many mentally ill
OCTOBER 2008
people in high socioeconomic class express feeling
of shame and guilt, whereas relative5 of low social
status showed fear and resentment.27
It is estimated that one in four families have at
least one member currently suffering from a mental
or behavioral disorder. Families in which one
member is suffering from mental disorder make a
number of adjustments and compromises that
prevalent other members of the family from
achieving their full potential in work, social
relationships and in leisures.28 Family often has to
set aside a major part of their time to look after the
mentally ill relatives and suffer economic & social
depr ivation because he or she is not fully
productive. There is also a constant fear that the
recurrence of illness may cause sudden and
unexpected disruption in the lives of the family
members.29
3. Therapeutic Role of The Family
It is universally recognized that family plays a
crucial role in the raising of children to become
reasonably well adjusted member of the society. The
positive role of the familys mental health care
programmes has been recognized relatively
recently.29 Substantial evidence demonstrates the
benefit of involving families in the treatment and
management of schizophrenia, mental retardation,
alcohol dependence and childhood behaviour
disorder. These are indications that the outcomes
for patients living with their families are better than
for those in institutions. It has been seen that by
changing the emotional atmosphere in the home,
the relapse can be reduced.30 In contact to epilepsy
related factors, family factors especially those
related to quality of the parent child relationship
appeared to be strong predictors of psycho-
pathology. In treating children with epilepsy, clini-
cian should be aware of the importance of the
parent-child relationship quality. Strengthening the
relationship quality may prevent or reduce psycho-
pathology.31
The family commonly provides useful informa-
tion about the patients and other illness. This
facilitates a treatment plan, in which the family can
play a prominent role in helping to supervise
medication, encouraging participation in rehabili-
tation programmes generally providing an environ-
ment conductive to promoting recovery or reducing
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disability. The family support provides an
opportunity to patient to ventilate their anxiety
freely, to arise at a shared understanding of the
disease and to explore various alternative coping
strategies.32
Family can offer an important reinforcement
in the psychiatric therapeutic management. There
are some basic steps in the family treatment to
include family to participate in the management.
These are
Improving problem solving ability of the
families
Educating the family regarding the illness.
Modification of the family communication
patterns
Family guidance.
Lowering the expressed emotion of the
family members towards the patients.
Manipulation of the power alliance within
the family.
Expanding social network.
Enhancing social support.
Crisis intervention.
The therapy for marital discord is the core
approach to family change. 16 Several family
intervention approaches for schizophrenia have
been developed based on the general assumption
that maladaptive interaction pattern within the
family produce high level of stress for the patient
and tend to relapse. 33 These intervention have
attempted to reduce the risk of relapse either by
altering communication and problem solving in the
home or by the modifying family attitudes about
the patient through education about the illness.
Home visit and focused communication training has
been shown to be effective in studies.33 Reduction
of expressed emotion is associated with good
treatment outcome, especially in the families with
high level of face to face contact with the patient.
Superior patient outcome with two variations of
behavioral approach compare to family education
and routine treatment. 34 Intensive behavioral
intervention may not be cost effective and that
change in the family communication pattern may
only be important for a subset of families.35 On the
wake of de-institutionalization campaigning and
placing the ill with the honor at the family network
principle, role of the family has to be qualitatively
positive. Present trend is to show the role of the
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family not in the causation of mental disorder, but
the amelioration or deterioration of patients illness
is largely dependent on the families notion of the
attitude towards the illness. In this context, it is
noteworthy to mention that to reduce the grievance
of faulty care and attitudinal problems originated
from family members out look towards the patient
family centered therapeutics services has now
become an indispensable process of management
of the patients with mental disorder.
Assessment of family and psychopathology
there are four principle areas to be investigated in
carrying out a family assessment.
(a) The problem- A clear understanding of the
nature of the problems is essential in
deciding how to deal with it.
(b) The family is a social system The family
generally perceived by society as the unit
responsible for children with environment
that serves their physical and emotional
needs. It is accepted practice today to view
the family as a system organized around
the support, regularity, nurturance and
socialization of its members.37
(c) The family and its environment It is
important to have clear understandings of
the overall scope of the families environ-
ment and recognize that it consist not only
of create realities such as food, cloth,
shelter, medical care, employment.
Physical safety, education, recreation etc.
but also includes social realities in terms
of interpersonal relationship.38
(d) The family life cycle Discussed the
importance of family life cycle into six
stages of family development which are (1)
the unattached young adult (ii) the new
couple (iii) the family with younger
children (iv) the family with adolescents
(v) the family which is launching
children.(vi )the family in later life. In each
of the stages, there are specific tasks that
create stresses in the individual as well the
family and sometimes help is required to
deal with the problems that result.39
Assessment Models of The Families
Mc Master Model of the family functioning is
a useful way of looking families and is based on
146 Delhi Psychiatry Journal 2008; 11:(2) Delhi Psychiatric Society
OCTOBER 2008
system approach. It considers six aspects of family
functioning viz. problem solving, communication,
roles, affective r esponsiveness, affective
involvement and behaviour control.40 This model
deals with the current functioning of the family
rather than its past development or present
development stage. The process model of family
functioning derives from the family categories
schema. It considers family functioning along six
dimensions-problem solving, role performance,
communication, affective involvement, control,
value and norms.41
The Structural Model for Assessing Families
The model outlines six aspects of family
functioning: family structure flexibility, resonance,
life context, development stage and the relationship
of the identified patient symptom to the family
transactional patterns.37
The Circumflex Model
It identified two aspects of family behavior:
cohesion and adaptability. Cohesion measures the
emotional bonding that family members have
toward one another. Family adaptability is the
measure of how far the family permit changes
(Morphogenesis) and how for it is characterized by
stability (Morphostasis).42
The Beavers Model
It has two axes one is concerned with the stylistic
quality of family interaction, which is classified as
either centripetal, mixed or centrifugal.43 The other
is concerned with structure, available information
and adaptive flexibility of the system. Triaxial
classification identified three classes of family with
problem:- Family Development dysfunction,
Family system dysfunction, and Family group
dysfunction.44
The Global Assessment of Relational
Functioning
It is a simple rating scale on which any
relational unit (i.e. family, couple or other grouping)
can be rated for its functionality on a 100 points
scale. 45 The family system test as an innovative
technique that utilizes the generation of figure by
family member to represent emotional bonds and
hierarchical structure. 46 The family environment
scale contains ninety true/false questions assessing
OCTOBER 2008
three domains: relationship, personal growth and
system maintenance.47 Family Interaction Pattern
Scale measure the quality of family functioning,
the scale has one hundred six items under six
domains:- reinforcement, social support system,
role, communication, cohesions and leadership on
a 4 points Likert scale.48 There are some scales to
administer family interaction factors like expressed
emotion, burden in the family life, attitude question-
naire by Sethi et al, social support questionnaire by
Nehra and Kulahra, family burden Inventory
schedule by Pai and Kapoor etc.
In the last few decades, a global need is being
felt for a staff in mental health care from psychiatric
institution to community based services. Family has
an important role in the planning as well as
implementation of deinstitutionalization and
community mental health programme, which is
needed and recommended by WHO in World Health
Report 2001.28 Family should not only be involved
in the treatment process but also in the decision
making of policies, programs and services.49
Conclusion
The family unit is the single most important
variable in the onset, progression, treatment and
outcome of psychiatric illness or mental disorders.
Various researcher s as well as theoretical
formulations have been explored to understand the
role of family pathology in the causation (genesis)
and maintenance of mental disorders. However,
most of the families studied have been carried out
in relation with schizophrenia and some with
affective disorders, particularly depression. Some
of the clinical studies clearly mentioned, especially
in early childhood experiences, familial stress
factors such as parental death, parental separation,
parental rejection, marital discord, violence at
home, faulty family communication, etc. which
have life long effects on mental health. However,
the etiological aspects of various mental disorders
require more exploration in the context of family
life and its dynamics. Falling sick is a family event.
It affects the well being of not only the patient but
also that of the whole family by disrupting the
normal day to day routine. The family is required
to mobilize its internal and external resources to
cope with the impending crisis. For any meaningful
intervention, it is important to identify families,
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which are more vulnerable and need support. The
family as a unit is still the best bet for health care
intervention. Situation can improve by helping the
patient and family members to develop realistic
expectation about the problem and its ramification.
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