Stress management in family environment

INTRODUCTION

Stress and family are important factors that determine the course and prognosis of various psychiatric disorders. Even in the absence of obvious psychiatric disorders, stress and its association with family, in other words, “stress in the family,” might have to be considered a therapeutic target. This is because acute or chronic stress is known to predispose individuals to negative mental (such as anxiety, depression, and insomnia) and physical (such as worsening of hypertension and diabetes) consequences. In these clinical practice guidelines, we intend to provide guiding principles to mental health professionals for managing “family stress” in general and in the context of various psychiatric disorders.

STRESS AND FAMILY STRESS—MODERN THEORIES AND BASIC CONCEPTS

Before we describe the guidelines for stress management in a family environment, we briefly explain the concepts we need to have a basic understanding of.

Stress, family stress, and family resilience

The term “stress” was introduced to medical terminology by Hans Selye, who described it as a “nonspecific response of the body to any demand” in 1936.[1] Selye's “stress theory” describes a “triphasic pattern of nonspecific physiological responses” to “nocuous agents” that he termed “general adaptation syndrome.” This response represents “a generalized effort of the organism to adapt itself to new conditions,” and Selye draws parallels between this response and the human immune response to infections. Essentially, an interplay between the feedback and feedforward mechanisms explains the complex phenomenon of stress response in human beings. While reactive and compensatory responses represent the feedback mechanism, predictive and anticipatory responses are the feedforward mechanisms.[2] Stress does not necessarily mean that it will always lead to negative consequences. Within many tissues, stress is an important factor for morphogenesis, that is, tissue growth and remodeling.[3] Broadly, the stress framework includes inadequate stress (sustress), good stress (eustress), and bad stress (distress).[4] While predicting what levels of stress lead to positive and negative consequences has been a challenge, some newer models include calculating stress based on a thermodynamic construct—entropy. The measurement of the stress entropic load (SEL) has been proposed to differentiate health and disease in an individual.[5]

Understanding that family crisis can also be nocuous, Reuben Hill (1949)[6] proposed the “family stress theory” according to which three factors influence the causation of family crisis (X)—the event (A); the family resource that meets the event (B); and the family make (C). It has also been called the ABCX model. Furthermore, emphasizing the role of family resilience in the family stress response, Patterson (1988)[7] proposed the family adjustment and adaptation response (FAAR) model, similar to Selye's “general adaptation.” This theory marked the start of the use of “family ‘resiliency’” approach in practice settings. Understanding resilience to stress from a systemic perspective is also essential. According to the systemic model, resilience occurs across various systems—biological, psychological, social, cultural, economic, legal, communication, and ecological. Across systems, resilience has been identified as an open, dynamic, complex, and diverse process that occurs in the context of stress or adversity and promotes learning and connectivity.[8] Similarly, at an individual level, even at a family level, stress can be good. Across various stages of the life cycle, there are useful stresses that promote family growth, such as the birth of a newborn, children's schooling or graduating, employment, marriage, and retirement. The concept of entropy to predict positive outcomes from stress has also been validated at a family level. Family entropy is determined by the level of organization and structure within the family.[9]

Various other theories in this respect highlight the role of family resilience in tackling family stress. It has been postulated that both internal relational processes and risks or opportunities in the social systems influence family resilience, in the wake of a single significant stressor or piling up of multiple stressors.[10]

Family types, family environment, structure, or system

As the terms “family make” and “internal relational processes” are important in understanding family stress, it is very important to understand the constructs of “family structure and types” and “family environment.”

A redefined classification of family structure and types in India was proposed in 2013 [Table 1].[11]

Table 1.

Family structure and types[11]

Types	Name	Description
I	Proton	A single individual living alone or managing food or cooking for self even when staying with others
II	Electron	Two or more unmarried or widowed individuals staying together
III	Nuclear	A married couple staying with married or unmarried children
IV	Atom	A nuclear family with any other unmarried family member, such as widowed mother and divorced sister
V	Molecular	Two married couples of any two vertical generations with or without unmarried people of any other generation
VI	Joint	Two or more married couples of a single generation (horizontal level) or three or more couples of multiple generations (vertical levels)
VII	Quasi	To be added to any of the types—type III onwards for a couple who are sharing kitchen and financial resources as a married couple but not legally married

Some special types of families are also described. They are 1) single-parent family and 2) reconstituted family, where the family unit consists of a married couple with one or both of them having children from a previous marriage. Stepfamilies are considered reconstituted families.[12]

The family genogram, routinely drawn in clinical settings, also can be used to understand family type and family structure broadly.

The recently concluded National Family Health Survey (NFHS-5), 2019–21, reports that, in both rural and urban areas, nuclear family is the predominant form of family type in India.[13] Studies suggest that while the type of family may not differentiate the family stress responses, other factors, such as the family environment and socioeconomic status, mediate it.[14,15]

The domains of family environment can be understood by the 10 dimensions of the family environment scale[16] [Table 2]. Indian adaptation of this tool[17] suggests an additional dimension of “acceptance and caring” in Indians' family environment.

Table 2.

Dimensions of family environment[16]

Dimension	Subdomains	Description
Relationships	Cohesion	“Degree of commitment, help and support family members provide for each other”
	Expressiveness	“Extent to which family members are encouraged to act openly and to express their feelings”
	Conflict	“Amount of openly expressed anger, aggression and conflict in the family”
Personal growth	Independence	“Extent to which family members are assertive and self-sufficient, and make their own decisions”
	Achievement orientation	“Extent to which activities (e.g. school or work) are seen in an achievement-oriented or competitive manner”
	Intellectual cultural orientation	“Interest in political, social, intellectual and cultural activities”
	Active recreational orientation	“Participation in social/recreational activities”
	Moral religious emphasis	“Emphasis on ethical/religious issues and values”
System maintenance	Organization	“Degree of clear organization and structure in planning family activities and responsibilities”
	Control	“Set rules and procedures used to run family life”

While the assessment of the family environment can be performed using tools, such as the family environment scale, a more useful tool that assesses family structure and depicts it in the form of a pictorial representation is the “eco-maps.”[18] A representative explanation of the eco-maps is given in Figure 1. As you can see from the figure, internal stressors, such as strained relationships among family members, can also be depicted and identified using eco-maps.

Figure 1.

Representation of eco-map

It is important to understand that the kind of family relationship, that is, whether they are supportive (i.e., loving and caring) or strained (i.e., argumentative, demanding, and critical), has a definite and contrasting impact on well-being and therefore on stress coping skills.[19]

Related to these constructs of family structure and family environment is the concept of family systems. According to family system theory, a family is conceptualized as a “complex, dynamic, and changing collection of parts, subsystems and family members.” The Circumplex model of marital and family systems, proposed by Olson (2000),[20] proposes that there are three central dimensions of a family system—cohesion, flexibility, and communication. Figure 2 shows a representation of this model. According to the model, a balance across these three dimensions in a family tends to make it more functional in the wake of family stress.

Figure 2.

Representation of Olson's multiplex model

The Family Adaptability and Cohesion Scale (FACES) is based on Olson's Circumplex model. FACES, which has 129 items, can be used to comprehensively assess family adaptability.[21] An alternate short version is also available for quick administration.[22]

Family functioning is another important part of the family structure or system. An important aspect of the family functioning in the family systems theory is the “hierarchy.” Hierarchy within a family is considered an “essential building block that builds the foundation of a family.”[23] Hierarchy refers to varying levels of power and authority among family members. For example, the father has a bigger say in purchasing a family vehicle than the eldest daughter, and the eldest daughter has a bigger say than her youngest brother. Clear boundaries between various hierarchical levels, which imply a strong hierarchical family system, have been suggested to have greater levels of resilience in the wake of stress.

In particular, to understand the interaction patterns within a family, the Family Interaction Patterns Scale, developed in India itself,[24] can be used. In particular, to understand the relationship between a marital couple, Spanier's Dyadic Adjustment Scale (DAS)[25] can be used. An Indian version of the same is available too.[26] Similarly, the Marital Quality Scale,[27] developed in India, can also be used.

“Expressed emotions” in the family have been understood as an important construct, especially from the point of view of precipitation and relapse of severe mental illnesses, such as schizophrenia. Negatively expressed emotions, such as critical comments, have been found to be detrimental in these aspects. There are various scales: the Camberwell Family Interview (CFI), which is very comprehensive and takes 4 to 5 hours for administration, and the Family Emotional Involvement and Criticism Scale (FEICS), which has been widely used in Indian settings.[28,29]

A special note on the Indian family system

Classical Indian family system

The Indian family serves as the core of society, which is “collectivistic” in that it encourages family togetherness, collaboration, solidarity, and conformity. The term “collectivism” is a philosophical, economic, or social outlook that places a strong emphasis on how interdependent humans are. It is the fundamental cultural component of social group cohesion, emphasizing the importance of group goals above individual goals in contrast to “individualism,” which highlights what makes each person unique and encourages participation in competitive activities. Collectivism is thought to predominate in Asia, where social norms are important and jobs are interdependent.[30]

In collectivistic civilizations, such as ours, the self is defined in relation to others, with a concentration on tiny, select in-groups at the expense of out-groups. It is also concerned with belongingness, dependency, empathy, and reciprocity. Relationships with people are prioritized, whereas individual freedom, privacy, and space are viewed as supporting roles.

Indian families take far more time to care for their members and deal with more stress than their Western counterparts. Indian families are more familiar with the sufferer's problems and are more willing to participate in therapy than Western families are. Due to the existing joint family structure, which reportedly offers additional support, fewer people with mental illness from rural families have been found to be hospitalized when compared to metropolitan households. Children from large families have been reported to exhibit much fewer behavioral issues than those from nuclear families, such as eating disorders, aggression, dissocial behavior, and criminality. Even the World Health Organization (WHO)'s large-scale international studies on schizophrenia—the International Pilot Study on Schizophrenia and the Determinants of Outcome of Severe Mental Disorders—found that people with schizophrenia fared better in India and other developing nations than in the West, largely because of the greater family support and social integration they received there.[31]

The changing Indian family

India's sociocultural environment is changing at a breakneck pace, fundamentally altering family structure in the process. The previous few years have seen not only frantic and disorganized changes in the social, economic, political, religious, and professional arenas but also shifts in power dynamics, marital customs, and the position of women inside families. Nuclear families are increasingly taking over as the most common type of Indian family institution.[32] In fact, the nuclear family is the majority form of household structure in India.[13] Household fragmentation was initially suggested by the 1991 census, and the pattern continued till recent censuses. This scenario is especially so in urban areas, and a gradual decline in the size of households. Rapid urbanization is suspected to be a major factor responsible for the “crumbling” of the “institution of family.”[32] Other significant developments include a decline in the average age of the family head, which reflects a shift in the balance of power, and an increase in homes headed by women, which indicates a shift in traditional gender roles. Although urban “new order” nuclear families have largely displaced traditional joint families, it would be incorrect to see current Indian families as such straightforward bimodal units. Joint families are widespread and consist of people who live under one roof but have separate living quarters, a separate budget, and a great deal of independence. Others may live in different homes, yet they congregate in the same neighborhood. Although structurally nuclear, such transitional families may nonetheless carry on as joint families.[30]

Along with urbanization issues, changes in roles, status, and power brought on by women's increased employment (both partners working), migration among the younger generation, and the loss of the experience advantage of the elderly family members, these changes—which include a switch from the joint or extended to the nuclear family—have increased the stress and pressure on such families, making them more susceptible to emotional problems and disorders.[30]

Increased digitalization and allied virtual isolation have resulted in changes in family dynamics and coping skills. Real-time emotional exchange and expression have been replaced by virtual exchange. Increased screen time in children has resulted in imploding emotional issues confounded by cryptic issues, such as cyberbullying. Traditional Indian family subsystems have seemed to be on the road to change due to digitalization. Not all shall be seen with pessimism, and long-distance relationships do seem to benefit from the growing technologies.

Another important issue that is on the rise among Indian families is that of the “one-person households (OPH).” While it shows a large variation across countries for the share of OPH (38% in Switzerland to 2.6% in Cambodia), there has been a steady worldwide rise in OPH. Interestingly, however, contrary to one's belief, India did not show such a rise.[33] Nevertheless, OPH shows an array of negative consequences of stress-poor eating and exercise behaviors, substance use, etc.[34]

Another shadow pandemic affecting the changing Indian family system brought about by nuclearism and digitalization is increasing rates of domestic violence (around 20%).[35] Higher rates were observed post-coronavirus disease 2019 (COVID-19) era, and a few reasons cited were financial constraints (60.0%), inability to socialize or too much time spent at home (23.8%), sharing responsibility of children (17.8%), and sharing responsibilities of the elderly (14.8%). Basically, stress rises with changing family roles. One of the commonly prevalent reasons among couples, which propagates domestic violence, is substance use. Exposure to intimate partner violence would in turn negatively affect mental and physical health outcomes.

In summary, the “importance of fostering the institution of family”[32] has to be realized and integrated for promoting mental health in India.

Forms of family stress

Now that we have described the construct of family environment and family system, we also need to understand what the various forms of family stress are.

Table 3 shows various forms of family stress classified based on source or locus, intensity, duration, and impact of stress.[36]

Table 3.

Various forms of family stress[36]

Classification	Stress	Description
Source or locus	External	Stress that comes from outside the family For example, job stress and stress due to ill health of an extended family member
	Internal	Stress that originates within the family For example, marital conflict and sibling rivalry
Intensity	Macro	Critical life events, such as severe illness, unemployment, death of a family member, and childbirth
	Minor	Everyday stressors, such as missing a flight, child’s sickness, and both parents working
Duration	Acute	Stressors that occur for a single instance, such as a road traffic accident and theft
	Chronic	Stressors that last a long time—illness, unemployment, etc.
Impact	One person	Sleep problem of a parent
	A few members	A temporary argument between parents
	Entire family	Most stressors, unless proved otherwise, affect the entire family in some or the other way

Management of family stress by mental health professionals therefore needs to understand which of these subsystems needs to be addressed, along with the understanding of the nature of family stress, and which of the family environment dimension is in crisis. Broadly, two parts of the stress management strategy will be 1) improving family coping while attempting to address the nature of stress and 2) improving family resilience.

PRACTICAL STRATEGIES FOR THE MANAGEMENT OF FAMILY STRESS

Step 1: Identification of family stress and the family stressor

In most instances, the primary role of the mental health professional is to help the family or family member identify the event or an incident that is causing stress in the family. In fact, many families do not even endorse that the family is under stress. Many families might have difficulty realizing the source of stress, due to their educational and cultural background. The mental health professional has to make a thorough assessment of the locus or source of stress and ascertain it. Single or multiple stressors may be present. The fact that the family is under stress is reflected in the mental health professional in the reason for consultation or referral to him or her. The family has to be communicated regarding this. There needs to be open communication between the professional delivering stress management and the family or family member. All the members of the family members should ideally be communicated regarding this by the mental health professional. In case that is not feasible, the responsibility of communicating with all family members should be given to a specific family member. Acceptance of the same also has to be noted, and if not acceptable to others, subsequent sessions may have to be required in step 1.

Step 2: Assessment of severity of family stress

In step 1, the locus or source of family stress is identified. In this step, that is, step 2, the other forms of family stress—that is, intensity, duration, and number of family members it has impacted—are assessed. Several tools may be used to assess the stressors' intensity and their impact on the family. The Social Readjustment Rating Scale (SRRS) by Holmes and Rahe (1967)[37] can be administered with ease, and it has good psychometric properties. Some important items of the SRRS are given in Table 4. For use in India, Singh et al. (1984)[38] developed the Presumptive Stressful Life Events Scale (PSLES). Furthermore, PSLES classifies the stressors as desirable (pregnancy of wife, marriage of daughter, purchase of house, etc.) and undesirable (death of spouse, divorce, lack of child, etc.). In fact, the use of such rating tools allows families or family members to have defined feedback on family stress. However, it is important to remember that the impact score must be considered in association with other factors, such as the duration of the stressor. It is also important to endorse that a differential impact of the stressor is expected in different family members.

Table 4.

Items of the social readjustment rating scale and impact score of each of the stressful event[37]

Death of spouse, 100

Divorce, 76

Death of close family member, 63

Marriage, 50

Fired at work, 47

Retirement, 45

Pregnancy, 40

Sex difficulties, 39

Death of a close friend, 37

Change in responsibilities at work, 29

Son or daughter leaving home, 29

Trouble with in-laws, 29

Trouble with boss, 23

Change in school of the child, 20

Change in number of family get-togethers, 15

Festivals approaching, 12

Step 3: Assessment of the family environment or system and family adaptability

Various tools or scales that can be used to assess family environment, family system, family relationships, and family adaptation are shown in Table 5. These tools have been explained earlier in Section 2.2.

Table 5.

Scales to assess family environment, structure, system, or adaptability

Domain assessed	Scale	Indian version
Family environment	Family Environment Scale (FES)[16]	Yes[17]
Family structure	Eco-maps[18]	Not applicable
Family systems	Family Interaction Patterns Scale (FIPS)[24]	It is Indian
	Spanier’s Dyadic Adjustment Scale (DAS)[25]	Yes[26]
	Marital Quality Scale[26]	It is Indian
Family adaptability and cohesion	Family Adaptability and Cohesion Scale (FACES)[21]	No
	FACES Short Form[22]	No
Expressed emotions	Camberwell Family Interview (CFI)[28-29]	NA
	Family Emotional Involvement and Criticism Scale (FEICS)[28-29]	Yes[28-29]

Step 4: Identify ways to reduce the stressor

For all practical purposes, that is, in clinical settings for a mental health professional, this refers to the treatment of the mental illness or condition one or more members of the family are diagnosed to have. Confusion regarding the diagnosis, course and prognosis, and proper adequate treatment can cause high levels of family stress. It is important to provide detailed psychoeducation regarding the illness, its course, and prognosis to alleviate the stress related to the diagnosis itself. Family psychoeducation, for example, in families with a member diagnosed with paranoid schizophrenia,[39] has been shown to reduce family stress levels significantly. Similarly, the provision of specific management strategies for the alleviation of adolescent mental health issues reduced family stress levels significantly.[40] The management of illness and condition may either be using pharmacological intervention or psychotherapeutic intervention or both, in most cases. There are some psychotherapeutic interventions that have family stress management already embedded as one of their components, such as family-focused family therapy for bipolar affective disorder. Various types and grades of family interventions for different mental health conditions are also intended to reduce family stress.[41] Figure 3 shows the list of family interventions for various mental health conditions. Grief counseling may also involve the entire bereaved family and not just the person experiencing significant grief, which also tends to reduce family stress. Similarly, improving work relationships to alleviate job stress has been noted to reduce family stress.[42] Caregiver burden on family members is another form of stress that is associated with the care of persons with mental illnesses in the family. All key caregivers feel negative consequences and have a poor quality of life because they experience multiple negative health and mental health consequences due to multiple “concurrent stressful events and extended, unrelenting stress.”[43] There are several approaches for families to reduce caregiver burden.[44]

Figure 3.

Types and grades of family interventions (adapted from Varghese et al., 2020)[41]

Alternately, managing stressors, such as poverty and unemployment, is managed at a more broader community level.

Step 5: Improve stress coping

Coping with family stress involves both individual and family coping. Various problem-solving methods must be emphasized in the family to enhance coping among family members.

In general, relocating existing resources to reduce the stressor must be the primary problem-solving mechanism. These resources include time, finances, skills, and support from members outside the family. For example, finances may be relocated from money saved from shifting from the use of own vehicle to the use of public transport to the treatment of illness. If the relocation of existing resources was also not sufficient, attempts at looking for new resources must be planned, for example, a bank loan for financial aid.

By and large, the resources can be classified as internal and external. A bank loan, as mentioned here, is an example of an external resource. Other external resources include support from members of the extended family and outside the family, spiritual practices, and support from health care policies. Treatment with medications and even the psychoeducation regarding the mental illness of a family member received from a mental health professional fall into the category of external resources. Internal resources include communication, care, and respect among family members and coping abilities of individuals in the family.

The internal resources focus on the emotional aspects of problem-solving. Both individual and family coping mechanisms must be targeted. Support and unity among family members, reorganization of individual roles, decision sharing, etc., with respect to dealing with particular stress, form family coping mechanisms. Recognition, acceptance, preparation, and planning at the individual level are important domains of individual coping mechanisms. For coping with stress at an individual and family level, the following may be advised[45,46] [Table 6].

Table 6.

Advice for coping with stress at an individual and family level

Individual level		Family level
1	Being realistic. Not going overboard but rather relocate or try and find realistic alternate resources	1	Having open communication and creating a healthy family environment
2	Journal writing. This helps ventilate emotional stress	2	Enhancing family cohesion
3	Involving in hobbies and regular physical activity. Physical exercises have been shown to have a significant effect on stress levels	3	Flexibility in roles and responsibilities
4	Practice relaxation exercises. Activities, such as deep breathing, yoga, and mindfulness, to be practiced	4	Planning about and gaining access to resources in a collaborative manner
5	Talking to others. Take time to talk to friends, neighbors, extended family members, and others about issues that may or may not be related to the ongoing stress	5	Enhancing faith in the family members and performing spiritual activities together as a family
6	Maintaining good sleep. This is an important point for preventing further consequences of stress
7	Focus on one thing at a time or change one habit at a time. Preparing a list of tasks according to priority, allocating a particular timeline, and then focusing on each, one after the other. Avoid multitasking
8	Coping by humor. While laughter is a good stress buster, the use of humor and laughter together is important for coping effectively

The World Health Organization's illustrated guide on “Doing what matters in time of stress”[47] can be used as a useful guide for various coping strategies to overcome individual-level and family-level stress.

For improving communication, especially in the context of expressed emotions and schizophrenia, a specific family intervention has been designed in India very recently. It includes a total of 10 sessions—six on psychoeducation, two on communication training, and one on stress management exclusively.[48]

For improving family cohesion, the components of the “Strengthening Families Program (10–14)”[49] can be incorporated. Table 7 shows various steps to enhance family cohesiveness (modified from the “Strengthening Families Program (10–14)”).

Table 7.

Steps to enhance family cohesiveness

Sessions	Session details
Session 1	Appraise regarding qualities expected from themselves and each of the other family members
	Appraise on how to support each other in their goals, both emotionally and through resources
Session 2	Understand each other’s physical and emotional needs, according to their age and gender
	Understand each other’s expected emotional reactions, according to their age and gender
	Appraise about each other’s strengths and weaknesses
Session 3	How to notice good behavior in each other and reward or appreciate it
	Understanding the value of and conducting family meetings and fun activities
	Identify and predict stressful situations
	Learn about healthy ways of coping
Session 4	Staying calm and respectful to each other
	Understanding rules and appraising the advantages of following them
	Using small penalties by members higher in the family hierarchy when younger ones commit mistakes
	Importance of saving large consequences for major problems
Session 5–6	Understand the meaning of listening and understanding the basis for mistakes
	Younger members to learn about skills to resist “bad” behaviors
	Elders to monitor for “bad” behaviors
	Appraising the need to interact with other member’s friends, colleagues, or teachers
	Understanding the need for a good friend’s or colleague’s company
Session 7	Review of sessions and expression of appreciation
	Appraise regarding any special needs of the family

Step 6: Enhance family resilience

It is necessary to understand that enhancing family resilience is from the point of view of the coping with future stress. As the index family faced with family stress, it is assumed that the family has a vulnerability of facing significant stress in future events too. Therefore, strategies to assess and enhance family resilience have to be incorporated into every family stress management protocol. Mainly, three important domains are important to determine family resilience—communication or connectedness, positive outlook, and perceived availability of external resources [see Table 8]. Walsh (2016)[50] has also enumerated key processes in family resilience. Family resilience can be assessed in clinical settings using the Family Resilience Scale Short Form (FRS16),[51] which assesses all three domains mentioned here.

Table 8.

Factors determining family resilience

Domains	Description
Communication or connectedness (shared decision-making)	Ability to compromise on roles
	Ability to communicate with all family members
	Mutual decision-making
	Defining stress positively
	Discussing until decisions are reached
	Respect and importance to every family member
	Clarity in decision-making
Positive outlook	Confidence in solving major problems together as a family
	Accepting stress as a part of life
	Accept the unexpected nature of stressful events
	Making meaning of adversity
Perceived availability of resources	Perceived support from members of the family during the crisis
	Perceived religious or spiritual support

Each of these aspects is targeted, and enhancement in each of the domains found deficient is sought using skill-building approaches. This aspect is also called the horizontal component of family resilience. Aspects of family coping strategies, considered part of the family resilience training, are called vertical components.

The horizontal component of family resilience enhancement can be guided using the practice descriptions of the Families OverComing Under Stress (FOCUS) family resilience program, proposed by Saltzman (2016)[52] [Table 9].

Table 9.

Practice components of the family resilience enhancement schedule[52]

Components	Description
Eliciting family systemic goals	During the initial sessions, family members are provided a clear systemic formulation about the issues and how all the members have a role in the generation and management of current stress
Providing family psychoeducation and developmental guidance	Family members are educated about the developmental trajectory and age-appropriate emotional and behavioral reactions of children in the family. In all cases, information and guidance are woven into conversation with family members, specific to their presentation and needs, thereby facilitating action
Developing shared family narratives using the timeline technique	A structured opportunity is given to each family member to describe their perception of upsetting events in a timeline technique (parents → children → whole family). This whole process helps in rebuilding the communication, cohesion, and support of the family members
Supporting open and effective communication	Ensuring direct, clear, consistent, and honest communication between members and the capacity to tolerate open expression of emotion is the hallmark of a resilient family. The sessions are carried out to help them find appropriate ways of sharing a wide range of feelings and respecting differences.
Enhancing selected family resilience skills	Specific parent skill sets and family-level coping strategies can help families anticipate and mitigate the impact of stressful events and situational triggers and improve child adjustment. Within the sessions and at home family members build skills to collectively manage stress by identifying and anticipating stressful situations, monitoring idiosyncratic expressions of distress among different family members, and providing support in a timely and developmentally appropriate manner

CHALLENGES

The risk of continued family stress, despite the application of stress management strategies, is dependent on various factors:

• Attitudes toward stress management sessions—that include their acceptance, their regularity with the sessions, and support of other family members toward stress management strategies. In fact, the mental health professional delivering the stress management session(s) should also take into account the resistance (or even denial of stress) of the family toward stress management strategies and use principles of motivation enhancement therapy or motivational interview to bring about a change in attitudes.

• The family or family members might already be using some coping strategies that may not be good or even maybe “ugly.”[53] Explaining the nature of “wrong” in the coping strategies already being employed might meet resistance.

• Demands of the family—the capability and capacity of the family members to deal with the tasks suggested may be varied and some might show early fatigue.

Summary

A summary of the recommendations we suggest is shown in Table 10.

Table 10.

Summary of recommendations

Sl. no.	Recommendations
1	A thorough knowledge of family stress and family structure, environment, and systems is necessary
2	We suggest a 6-step family stress management strategy: Identification of family stress and the stressor Assessment of severity of family stress Assessment of the family environment or system and family adaptability Identify ways to reduce the stressor Improve stress coping Enhance family resilience
3	We suggest the use of specific methods for assessment of the family environment, family adaptability, and family stress, such as “eco-maps” and Social Readjustment Rating Scale
4	We suggest different grades of family interventions for reducing the stress of mental health-related conditions
5	We suggest various strategies to cope with stress at an individual and family level
6	We then suggest practical components for enhancing family resilience

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.