Family & Couple Unit, First Department of Psychiatry, National and Capodistrian University of Athens

This work was presented by V. Pomini at the HESTAFTA – SIRTS Symposium titled “Families, therapists and services facing the economic crisis: Enhancing resilience”  at the 9th EFTA Conference,  Athens,  September 28th – October 1st 2016.


The long- lasting socio-economic crisis which affects Greece, influences the quality of life and relationships of families and individuals in various ways, producing changes at different levels.  It is essential for therapeutic practices to adapt to new needs and new modalities of expressing them. Mental health services need to face on one hand the increased demand for aid and support, as well as the severity of  psychological difficulties and psychiatric disorders presented by families and individuals, and on the other hand, the increasingly limited resources available for treatment facilities. This paper describes changes observed in the frame of a Family Therapy Unit functioning in Athens, within a public university psychiatric hospital. The unstable balance between hopelessness and hope, overwhelming difficulties and resilience, passivity and motivation to change, regards not only families and couples – asking for help and presenting a wide range of psychological problems, but also the therapeutic team and the therapeutic relationship. In this context, therapists’ competencies need to include a higher level of social responsibility, empathic participation and effective management of available resources.

In memory of Anastasia Armeniakou


The economic crisis in Greece, since 2009, has now completed its eighth year, without any credible signs of improvement and a way out of the on- going emergency state.

On the contrary, references to additional austerity measures and the lack of sustainability of the National Debt continue to be part of the daily routine. The economic and social situation that the country has been facing has been labeled using various terms: humanitarian crisis, socio-economic impasse and the list goes on. In addition, the turnout of hundreds of thousands of refugees, mainly since the beginning of 2015, has posed unexpected challenges to a country that had already reached a state of exhaustion.

The prolonged situation of economic downturn (25% reduction of Greek GDP since 2008), the rise in unemployment (according to estimations, 25.8% unemployment  among the general population and 60% among young people), the reduction in the annual income and the concomitant increase in taxes, the increase of households in debt and the prevailing sense of uncertainty about the future, form elements that continue to shape stressful- living conditions, with psychological consequences for the entire age range. Families are finding it increasingly difficult to ensure their members a decent standard of living, since it is estimated that 25% of the population belongs in the below the poverty line group (third place for Greece among European Countries). The difficulties are multiplied for families with a member who presents a chronic physical or mental illness, while there is an increase in the number of families with more than one member with mental health problems (Kentikelenis et al., 2011; Economou et al., 2011; Bonovas & Nikolopoulos, 2012;  Ifanti et al., 2013; Economou et al., 2013; Anagnostopoulos & Soumaki, 2013; Pomini et al., 2016).

The consequences of the crisis in public health have been the target of investigation in several studies. More specifically, it becomes clear from the literature that the economic crisis is associated with an increase in symptoms of depression, particularly among men, and an increase in cardiovascular problems. It is worth noting that the householders facing financial difficulties seem to present up to 2.6 times a higher risk of developing depressive symptoms (Economou et al., 2011; Economou et al., 2013). Moreover, the increase in alcohol consumption and high-risk behaviors that are associated with the use of illegal psychoactive substances are facts which can also be identified as effects of the crisis (Pomini et al., 2014; Tsiboukli, 2015). A sudden and rapid increase of HIV infection cases among users of illicit substances was observed in 2011 (Paraskevis et al., 2011), a rise which is estimated to be directly linked with factors related to the economic crisis (Hatzakis et al., 2015). Finally, a significant increase in suicides and suicide attempts was assessed in 2011 and 2012, in comparison with the findings of 2010 (Michas, 2013), although further research in the following years did not manage to procure adequate confirmation regarding the above-mentioned trend. (Rachiotis et al., 2015; Hellenic Center for the Prevention of Suicide).

The functioning of the National Health System has been directly affected by the crisis, as public health expenditure has been slashed since 2009, with consequences both in the ability to respond to requests for assistance and the quality of the service provided, while, at the same time, more people are turning to public services since they can no longer afford the private sector. More specifically, with regard to mental health, it has been estimated that the reduction in state funding for mental health services and psychosocial services has exceeded by 40% the expenditure of previous years (Polyzos, 2012; Kondilis et al., 2013; Triliva et al., 2015). Moreover, many professionals employed by the psychosocial services, especially those who were recruited through Government and European Programmes, have been laid off or forced to work under contract, in part-time or timeshare positions; hiring in the public sector has frozen, as the personnel who retired has not been replaced with new employees (Polyzos, 2012; Kondilis et al., 2013; Triliva et al., 2015). It is estimated that over 120,000 young scientists left Greece to seek work abroad, including several mental health professionals (Ioannou, 2015).

As a result, the situation faced by treatment facilities became even more difficult and complex: an increase in requests for assistance aimed at public mental health services was noticed, and, consequently, an extension of waiting lists, while the burnout syndrome in health and mental health professionals rose to even higher levels.  Last, but not least, the quality of service also took a turn for the worse. As K. Politou (2013) describes, the function of a psychiatric emergency in recent years appears as follows:

In the emergency department, we see an ever-increasing number of people with mental health issues who are homeless or whose families can no longer care for them as they struggle for their own survival. In addition, in outpatient clinics, the number of patients with no health insurance has increased, while some of them report having to discontinue their medication due to financial difficulties. At the same time there is an increase of patients with substance and alcohol problems, even among the elderly. In the same social context, first- and second-generation immigrants arrive in clinics with various psychological and psychiatric issues relating to racial discrimination and bullying in the workplace or at school. Also, people who are unemployed or have recently been made redundant come to the hospital with acute stress reaction or severe adjustment disorders. (p. 2).

The Family and Couple Therapy Clinic as ‘observatory’ of the crisis[1]

The Family and Couple Therapy Clinic, serves as Department of Systemic Psychotherapy in the context of the Centre of Psychotherapy, First Department of Psychiatry at the National and Capodistrian University of Athens, Eginition Hospital.

Within this frame, the main objectives of its functioning  can be described as follows: To provide counseling and psychotherapy to families and couples with an adult and/or juvenile member suffering from a mental disorder, as well as families and couples who face  relational problems (such as high conflict, chronic problems in communication, intra-family violence, confrontational divorce, etc.); to provide training in Systemic Family and Couple Psychotherapy, a program aimed at mental health professionals and to runresearch studies pertaining families and couples who present a variety of mental health disorders and/or relational problems. The therapeutic team consists of senior therapists, supervisors and trainee mental health professionals [2] , performing the role of observers and/or co-therapists.

In a historical period of rapid change made evident in lifestyle, habits and values, the family is the primary social system that “absorbs” the shocks of the crisis (Gournas, 2013), and acts as an intermediary between the individual and the community, while at the same time is required to adapt to change and support its members. The challenges in family relationships are intensified by the effects of the crisis, a fact that is made evident in the way the reactions of the each member can be directly associated with the overall ability of the family to function. The ways in which each family faces the challenges brought on by the crisis is unique and related to a variety of factors, including the stage of family life cycle (McGoldrick & Gerson, 1985). Family members’ capacity to face challenges is related to their acquired mechanisms which are activated as a learned method of responding to adversity and   stressful life events (Pomini et al, 2014), to the quality of relationships that has been established  among its members, their material and spiritual resources, and resilience of single individuals and the family as a unit (Walsh, 2006).

Since the early years of the crisis, the difficulties associated with the Country’s overall economic and social situation started to be gradually but clearly evident in the families who addressed the Family and Couple Therapy Clinic. The word “crisis” became much more frequent in the therapeutic dialogue, as well as the narration of changes and difficulties reported by family members, such as their intense anxiety, the methods they would have to adopt in order to be able to adapt, and their plans, now combined with alternative perspectives as a way to carve out their future. In this context, feelings of insecurity and uncertainty were beginning to form a therapeutic context of resonance which could be characterized as rather intense if compared to previous years, since the anxiety about the unknown course of the crisis became an experience shared by everybody in the therapeutic system.

A few years ago, in 2013, the Clinic team decided to focus on and record the main issues that arose in family sessions, those associated with the economic and social crisis. The benchmark was the literature review and especially the studies conducted in Argentina after the collapse of its economy (Falconier & Epstein, 2011; 2012), and in Finland after the crisis in the beginning of the ’90s (Solantaus et al., 2004).

Results of  Falconier & Epstein studies (2010, 2011) in Argentina revealed that the economic crisis has an effect in family relations and particularly in couple relation. The authors mentioned the  state of anxiety  family members find themselves in due to economic difficulties, a factor that  tends to increase family tension, conflict and negative emotions. Couples may experience increased alienation and hostility in their relationship, feelings which in turn can cause criticism towards one another, irritability, and aggression leading up to the development of psychological or physical violence, in other words, behaviors that cause severe consequences on the physical and psychological health of family members. On the other hand, it was estimated that the accumulation of stress results in a reduction of the coping capacities and affects the ability to offer mutual support, when emergencies call for it. Therefore, within the couple relationship, the stressful state enhanced by economic difficulties, tends to result in the reduction of positive interactions within the couple and the increase of dysfunctional interactions, thereby reducing the feeling of satisfaction in the relationship. In the sample of families studied in Argentina during that period, it seemed that, compared to men, women were more expressive when it came to their demands on satisfaction in their relationship, and more receptive and flexible towards the necessary changes required in order to adapt to the crisis (Falconier & Epstein, 2010, 2011).

Solantaus et al. (2004) studied the effects of the economic crisis that afflicted Finland in the early ’90s, reaching similar observations and connecting the satisfaction experienced by members of the couple with the quality of their parenting and its impact on their children’s mental health. Despite the influence of protective factors, on an individual and relational level – which have not been studied thoroughly yet -, it seemed that the mental health of children was directly related to the parenting skills of their parents, a fact which, in turn, was affected by the quality of the couple relationship and the stress associated with the financial difficulties faced by the family. The impact of poverty on children has been assessed as a risk factor for physical and mental development, equally relevant as other traumatic situations (Rocchietta Tofani, 2016).



The main reflection process of the therapeutic team focused on the data collecting methodology regarding the consequences of the economic crisis reported by families, and the changes observed at multiple levels during recent years. After reviewing the referred literature, the administration of questionnaires to family members was rejected as a method to be adopted, due to cost and time restrictions, although it is argued that such a solution would function as a more solid methodology. The alternative method of therapists registering the main issues related to the economic crisis that emerged in the therapeutic dialogue was preferred by the team.

The first phase of the assessment was conducted in 2013. In a process that included three brain-storming meetings attended by the Clinic members, the main issues raised were assessed to be representative of the crisis, taking into account that the same issues had been often mentioned by families that had contacted the clinic and/ or had been observed by therapists along the therapeutic process.

Finally, a questionnaire of 15 issues/conditions was created and filled out regarding 79 families/couples met during the time period 2011-2013[3].  One of the items (pathological gambling viewed by family members as a way to grow their income) was removed from the first version of the questionnaire, since it was not found to be relevant.   Subsequently, the final form of the questionnaire included 14 issues (Table 1). The questionnaire was completed for each family or couple included in the sample by the main therapist, a member of the Clinic, in collaboration with the supervisor, after having reached accordance. Each item referred to an issue/situation directly associated with the crisis. Therapists had to assess the relevance of the specific issue/situation as expressed by each family or couple that had addressed for help to the Clinic during the time period 2011 – 2015, according with what was referred during the sessions with the specific family/couple.  The choice of the time interval of observation was also subject to debate. More specifically, while the official dates that marked the beginning of the crisis can be traced back to 2009, the sense of being afflicted by a crisis, and the references to serious consequences in the family realm became evident much later. Such a delay in the emotional realization of the crisis, could be the result of the gradual formation of measures evaluated as indispensable for the sustainability of the Greek economy, meaning, practically, that the contraction in incomes, the tax burden, the rise in the unemployment rates, the reduced spending on public health and all other relevant measures were, in fact, gradually implemented over the years. Therefore, it was decided that the evaluation of the period 2011-2015 was preferable, since it was within that exact time frame during which the effects of the crisis became more apparent.A dual rating (yes/no), which referred to the presence or absence of the specific issue, was employed as a more convenient method of evaluating results. Therapists agreed that the answer “yes” would mean frequent occurrence of the issue, as a persistent condition, rather than a sporadic condition of the single family. The questionnaires were completed separately regarding each family who had been in therapy at the Family Therapy Clinic during the specific time period for at least three sessions, regardless of the continuity of therapy. The comparison of the results concerning the time period 2011-2015 with the results concerning the first phase of the study (2011-2013), was deemed as a second objective of the study, as a way to explore temporal development in the course of the issues/situations reported.



During the five year period 2011–2015, 163 new families, 55 of which (33.7%) were couples, were referred for treatment to the Family and Couple Therapy Clinic. The average number of sessions held by each family/couple was 7.6 (SD 7.3). In cases where a family member was diagnosed with a psychiatric disorder, almost half of them were female (52.1%). The overall average age was 29.5 years (SD 15.2). Additionally, as far as regarding their position in the family, the subjects diagnosed were predominantly children (68.1%), mother or spouse (17.4%) and less frequently father or spouse (13.7%). More than half (55.8%) of the families/couples  were referred from the inpatient or outpatient departments of Eginition Hospital, whereas the rest of them were referred from other mental health services, public as well as private, 26.4% and 17.8%, respectively. Psychiatric disorders was the most frequent reason of referral (55.8%) followed by difficulties/conflicts in family relations (27.6%), and the combination of both (mental disorder plus conflictual relations) (16.6%). A wide spectrum of psychiatric disorders was presented by members of the families, such as depression (18.9%), behavioral disorders (12.9%), psychosis (12.1%), obsessive-compulsive disorder (12.1%), eating disorders (10.6%), bipolar disorder (7.6%), anxiety disorders (5.3%), and other disorders (12.9%). Given the fact that there were two observed time intervals (2011-2013 and 2011-2015) in this study, the opportunity of a longitudinal comparison of the results (Table 2) was given.

Specifically, more than one quarter of the families/couples, an  increased rate compared to the 2013 rate (28.2%), reported having a member who was unemployed, while another member (i.e., the wife) was required to find a job (26.3%). Consequently, alterations in family dynamics and in family roles were assessed in one third of the families/couples, a significantly higher percentage in comparison with the findings of 2013. In many families, stress linked to the uncertainty of their employment situation and the fear of losing their job (36.8%) proved to be factors that increased the percentage estimated in 2013. Half of the families/couples reported a drastic reduction in their income and also having contracted debts, in a higher level compared to 2013. Among the families of the sample, 9.8% felt forced to shut down their family business, a slightly smaller percentage than the proportion observed in 2013, and 7.4% of the families included a member forced to enter premature retirement. It is worthwhile to note that, in 8.6% of the families, there was a member that had already relocated abroad in order to find a job, a rate three times higher than the one estimated in 2013. Furthermore, 12.3% of the families reported that they had to change houses and, in some cases, region as well, due to financial difficulties, also at an increased rate compared to 2013. In addition, a quarter of the families (24%), a figure more than 50% higher than the percentage calculated in 2013, reported significant changes in the everyday lives of their children, such as changing schools (students previously attending private schools had to move to public ones), reduction of extra-curricular activities and the necessity to include their children to the work dynamic of the family, by having them enter the employment field during their summer holidays.

Finally, unemployment linked to the crisis delayed the process of young adults gaining their autonomy and achieving their independence from the paternal family in a percentage of 27% of the families, which is an increased rate compared to 2013, while at a percentage of 18.4% (a rate three times higher than that of 2013) couples that indented to separate or divorce saw no other option but to live together, thus being forced to cohabitation. Serious conflicts associated with economic difficulties were reported or observed in more than half of the families/couples (52.4%), again at an increased rate compared to 2013, and almost half of them presented great difficulties in adapting to new living conditions and other changes, a percentage that was much smaller in 2013.



1.     The consequences of the crisis on family life

A comparison of the results with the observations of 2013, showed a high increase of repercussions on almost all parameters, much more than expected, despite the “feeling” the group of therapists had, that the consequences of the crisis on Greek families have “stabilized”. Financial issues are now at the heart of the therapeutic dialogue, much more than in the past. Families discuss about their financial difficulties more often and more openly, and, furthermore, they don’t conceal the fact that their financial difficulties are often the cause and the core of their family problems and conflicts. The consequences on children’s lives are all the more evident as children find themselves exposed to the increasing anxiety of their parents, and are asked to adapt to significant changes in their lives. More specifically, these changes concern their education, the reduction or interruption of their extra-curricular activities, or the change of house and environment, as in the case of forced cohabitation with members of the family of origin, or forced cohabitation of parents living together despite their decision to separate, the increased absence of parents from home during the day, as well as the early assumption of responsibilities, etc. (Rocchietta Tofani, 2016).

Another important observation concerns the delay in the autonomy of young adults from their parental family. The “leaving home” process seems to have been delayed and postponed to a significant extent, with consequences in the quality of life of young adults as well as that of their parents. The result is a growing number of adults-only families. On the one hand, the unemployment rate, which is extremely high among young people, delays their autonomy, and on the other hand, the choice to go abroad in order to find more professional opportunities – which concerns a large number of young Greeks – generate a generational gap in the population, with still unknown consequences for the future of the country (Ioannou, 2015).

Changes in relations with families of origin have been observed in several cases: often the pension of an older member represents the only family income, and this is threatened by repeated reductions. Also, it is not uncommon, as it turns out, to find cases of moving to the grandparents’ home in order to reduce expenses, or hosting the elderly in the home of their adult children, with inevitable changes in cross-generational boundaries.

Significant changes were also observed in the couple’s subsystem, as financial difficulties seem to play a decisive role in the decision to resolve conflicts. Many couples which express a joint decision to separate are unable to financially support this decision. Even the divorce process represents an expense which they cannot cope with, and therefore they remain in a state of forced cohabitation. For already separated couples, parents’ difficulties in meeting their parental responsibilities are often intense, with divorce being one of the factors that force more adults and children to live in poverty. Also, abrupt changes in the sharing of roles in the couple were often observed, with confusions and conflicts in their relationship, related to balance changes in their economic power. For instance, when the wife financially supports the family, while the unemployed husband has not learned or refuses to contribute to the organization and maintenance of the household (Pomini, 2008).

Regarding the mental disorders manifested by families during this specific time period, an increase in anxiety and mood disorders, which seem to be related to the family’s financial difficulties, has been observed. As reported by Solantaus et al. (2004), the stress of the threat of losing a job may be more intense than the anxiety experienced by people who are already unemployed. The sense of permanent insecurity and threat may eventually be harder to cope with than the real situation of unemployment. Undoubtedly, both situations represent stressful conditions which prevent planning for the future, at an individual and family level, making it difficult to adapt to change and to greater emergencies.

Another significant observation concerns intra-family violence. Indeed, an increase was observed in the number of families experiencing intra-family violent relationships, verbally and physically abusive behaviors, both within the couple and from parents to children, but also from adolescent or adult children towards the parents. According to the model described by Falconier and Epstein (2011, 2012), as was mentioned above, hostility and aggression in the couple relationship are directly related to economic difficulties.

One of the emotions that accompany severe financial difficulties, and has been often reported by the families with whom we have worked in recent years, is the feeling of shame. Shame regarding the situation of unemployment they find themselves into, regarding the changes in the quality of life that their children have suffered, regarding the inability to find another job, regarding the fact that they live with the pension of an older parent, etc. Consequently, poverty brings feelings of shame and inferiority, which can lead to a tendency to isolation and feelings of guilt, even though the overall social environment suffers and financial difficulties affect the majority of the population.

But also…

Despite the given unfavorable social and economic context, positive aspects of family life emerged, such as greater family cohesion, solidarity within the extended family as well as the community, the redefinition of values, the simplification of family life style and daily habits, the enhancement of the female role in the family system and her subsequent empowerment, the activation of adjustment strategies, and reinforced resilience both on an individual as well as a familial level. It is worthwhile to note that the social stigma concerning mental health problems in some cases decreased, in front of the general social condition of poverty.


2.     The impact of the crisis on therapists

The members of the therapeutic team reflected on and shared experiences regarding the effects the new social and working conditions on every therapist individually, and as a group. In 2013, the team faced the untimely passing of a beloved colleague, and the mourning process was particularly challenging. More specifically, the sudden passing  of the colleague not only  left a great void, but also a shared sentiment of unfairness, as the loss was associated with  the deceased’s increasing state of anxiety regarding the future.

In parallel with the uncertainty resulting from   a sense of fluidity on a personal and social level, the therapists of the Family and Couple Clinic, same as every other mental health professional in our country, were called upon to manage a growing number of therapeutic requests regarding, primarily, severely dysfunctional families and states of emergency. Therapists found themselves under increased pressure to respond more quickly and effectively to the growing needs of their patients, and in addition, to handle issues such as the lack of resources at a multi-level scale, the difficulty to refer cases evaluated as unsuitable for the Family Clinic to other mental health services, an increase in the cost of sessions for the patient, etc. Mostly, the members of the therapeutic team shared the feeling that a greater degree of effectiveness was required in a restricted time frame and a smaller number of sessions, in order to meet the added and pressing demands.

But also…

As in most conditions associated with a socio-economic crisis, where changes and adaptations are required, along with the negative consequences, positive effects were also observed, such as an increased need to evaluate treatment services and the effectiveness of therapeutic interventions within mental health services. This growing need led the therapeutic team to the incorporation of new psychometric tools, serving in the evaluation process.  Also, the therapists working in the Family and Couple Therapy Clinic gradually became more concerned regarding their higher responsibility as providers of support, not only to socially vulnerable families, but also to people who until recently had not considered contacting mental health public services, thus allowing therapists to take active part in the social emergency.

Among the positive aspects, an increased attention to the role psychotherapy plays as a main treatment tool dealing with mental health problems was noted to develop. Indeed, the use of expensive psychiatric medicines, according to the international guidelines for severe mental disorders, and the limitations to drug prescriptions imposed by the National Health Service could open up new potentials for psychotherapeutic interventions. A proposal for less medication, shorter duration of hospitalization, and an emphasis placed upon the role of psychotherapy became part of the dialogue among mental health professionals, in search for a considerable reduction in the total mental health costs.

Finally, the reduction of resources, led the members of the therapeutic team, now more than ever, towards searching for new partnerships at a national and  an international level, as alternative sources of support and opportunities (i.e., the participation to the Continuous Education Program in Systemic Family Therapy addressed to mental health professionals of remote Greek regions, organized by the Hellenic Systemic Thinking and Family Therapy Association with the financial support of the “Stavros Niarchos” Foundation – Pomini et al., 2016).


3.     The impact of the crisis on the treatment system and the therapist-patient relationship.

As we can clearly deduce from the above mentioned data, the therapeutic system (family, therapists and their relationship) could not have remained unaffected by the consequences of the crisis and the changes occurring on a micro and macro-level system. Each therapeutic relationship is a unique interaction between therapist and client (in our case families and couples) which takes place within specific time and place frames. Αbasic component of this relationship is the ability to  guarantee to all participants a safe emotional environment, where an interpersonal dialogue takes place, aiming at reducing the emotional  pain and enhancing mental resilience (Pomini, 2015)

In the post-modern era, psychotherapy can be defined as an ethical practice, while the responsibility of the therapist cannot be defined by objective criteria, since the nature of the therapeutic process is not only professional, but is also a human encounter, which is unique and occurs in a specific time (Bianciardi & Bertrando, 2009). Feelings of uncertainty experienced both by patients and therapists regarding the continuity of their relationship and of the provided treatment are directly related to the general sense of uncertainty manifested, either directly or indirectly, in various fields. In certain cases, clients expressed a hidden hostility against therapists employed by the public sector (making claims such as ”at least you have a secured and steady employment”). Αs already described, patients’ demands of help are often of an urgent and pressing nature, while, at the same time, they are expressed in an unclear manner. The therapeutic system often faces the challenge of intervening in situations where family relations are ruled by growing negativity, manifested as aggression, hostility and violence, both verbal and physical.

But also….

Our focus, however turns also on positive aspects, such as the fact that social issues were much more present within the therapeutic dialogue, and solidarity was increased and facilitated by the process of sharing feelings of uncertainty. More specifically, the feelings of uncertainty families shared with therapists had a direct resonance to their own personal experiences, since therapists, too, had to face the reduction of income, the anxiety related to the reduction of costs in the public health sector and the surrounding rumors. Therapists expressed greater empathy regarding the difficulties faced by many families, while, at the same time, they focused more strongly than in the past on the positive potential of individuals and family systems, on their resources and mental resilience.  As systemic therapists, we feel greater responsibility to be more focused on our work, since there is evidence that family-based treatment interventions are effective in a wide range of mental health problems (Carr, 2009a, 2009b; von Sydow et al., 2010, 2013).

The cooperation with the family as a whole, offers more opportunities to support families presenting multiple problems and to prevent chronicity. Family therapy increases resilience not only in individuals but also in families (Rutter, 1999; Walsh, 2003), and strengthens their connection with the community, which is essential during periods of social crisis, such as the present one.


Brief provisional conclusions

Our era is characterized by a state of social fluidity which is experienced both on a community, national and global level, affecting each individual personally and professionally. Subsequently, any drawn conclusion can only be of a temporary nature, and fairly easily overthrown by future developments. Living conditions and quality of life constantly change, therefore family relationships and dynamics are bound to be affected in various ways. Therapeutic practices, especially those aimed at families as a whole, need to adapt and respond to the rising needs and requests of patients and families, even those that are not expressed overtly.

On the one hand, mental health services are plagued by the reduction of staff members and the related diminished therapeutic effectiveness, while, on the other hand, demands for treatment have not only grown in numbers, but have also become more challenging, since they are directly linked with an increased number of problems of a psychosocial nature and mental disorders.

The fragile  balance between hope and despair, optimism and pessimism, resolution not to give up and exhaustion, need to action and resignation to a passive state of existence, affect more drastically families and couples  addressing for help for a wide range of psychological and psychosocial problems. Undoubtedly, the effects are deeply felt by therapists as well, as individuals, but also as members of the therapeutic team, leaving a mark on the therapist-patient relationship. Therefore, it comes as no surprise that the therapists’ competence must include their ability to feel and exhibit social responsibility by becoming  more aware of current conditions and challenges, their stance to offer more support and participate more actively, armed with  an increased capacity of empathy, but also effective management of the restricted available resources.


Annex 1. Questionnaire “The impact of crisis on the family”

1.     Unemployment

2.     Great fear of losing job

3.     Wife or other family member had to find a job

4.     Severe reduction of family income/debts

5.     Individual/family enterprise closed down for financial reason

6.     Forced retirement

7.     Migrationfor  financial reason

8.     Change of house for financial reason

9.     Consequences on children: change of school/cut of extra-curricular activities/going to work

10.  Family conflicts linked to financial difficulties

11.  Change in family plans (leaving home)

12.  Forced co-housing in case of separation

13.  Change in couple dynamics

14.  Difficulties in coping with changes



Table 1.Questionnaire “The impact of crisis on the family”: Comparison between the two time periods 2011-2013 and 2011-2015





Unemployment 22.8 28.2
Fear of losing job 22.8 36.8
Other family member (wife) had to find a job 20.2 26.3
Severe reduction of family income/debts 49.3 54.6
Individual/family enterprise closed down 13.9   9.8
Forced retirement   7.6   7.4
Migration   2.5   8.6
House change   7.6 12.3
Consequences on children: change of school/cut of extra-curricular activities/going to work 10.1 24.0
Family conflicts linked to financial difficulties







Change in family plans (leaving home)


20.2 27.0
Forced co-housing in case of separation


 6.3 18.4
Change in couple dynamics


 8.8 30.0
Difficulties in coping with changes


13.9 42.9



[1] The Family and Couple Therapy Clinic founded by V. Tomaras and V. Pomini, is functioning since 1988 at the First Department of Psychiatry, the National University of Athens, Eginition Hospital (Chair Prof. Ch. Papageorgiou), and since 2007 belongs to the Centre of Psychotherapies (Chair Prof. G. Vaslamatzis) as Department of Systemic Psychotherapy.

[2] The Four-year Postgraduate Program in Family and Couple Systemic Psychotherapy (Co-Chairs: V.Tomaras, V.Pomini) belongs to the University Mental Health Research Institute (UMHRI) (Chair Prof. E. Patsouris), in collaboration with the First Dept. of Psychiatry, National and Capodistrian University of Athens, and it is addressed to Psychologists, Psychiatrists and Child-Psychiatrists, the Three-year Postgraduate Program in Systemic Family and Couple Counseling (Co-Chairs: R. Gournelis, V.Pomini, V.Tomaras) of UMHRI  in collaboration with the First and Second Dept. of Psychiatry and Child Psychiatry, National and Capodistrian University of Athens, is aimed at Social Workers, Sociologists, Health Visitors and Psychiatric Nurses.

[3] The first results of the work were presented by V. Pomini at the International Conference of the Societa’  Italiana di Psicologia e Psicoterapia Relazionale, Prato, March 7th-9th 2013.




Anagnostopoulos, D. C., & Soumaki, E. (2013). The state of child and adolescent psychiatry in Greece during the international financial crisis: a brief  report. European Child and Adolescent Psychiatry22, 131–134.

Bianciardi, Μ., & Bertrando, P. (2009). Ethical Therapy: A Proposal for the Postmodern Era. Human Systems: The Journal of Therapy, Consultation & Training20 (2):87-101.

Batsialias, K. (2013). Solidarity clinic at Heraklion: An interactive solidarity process. Systemic Thinking & Psychotherapy, vol. 2.

Bonovas, S., & Nikolopoulos, G. (2012). High-burden epidemics in Greece in the era of economic crisis: early signs of a public health tragedy. Journal of Preventive Medicine and Hygiene53, 169–171.

Carr, A. (2009a). The effectiveness of family therapy and systemic interventions for child-focused problems.  Journal of Family Therapy31, 3-45.

Carr, A. (2009b). The effectiveness of family therapy and systemic interventions for adult-focused problems.  Journal of  Family Therapy31, 46-74.

Cecchin, G., Lane G. & Ray, W.A. (1995). Irreverence: a strategy for therapists’ survival. Karnac, London.

Conger, R.D., Elder, G.H.,  Lorenz, F.K., Conger, K.J., Simons, R.L., Whitbeck ,L.B., S. Huck, S. &  Melb, J.N.   Linking economic hardship to marital quality and instability. Journal of Marriage and the Family52: 643-656

Economou , M., Madianos, M., Theleritis, C., Peppou,  L. E. & Stefanis, C. N. (2011). Increased suicidality amid economic crisis in Greece. Lancet, 378, 9801, 1459.

Economou, M., Madianos, M., Peppou, L. E., Patelakis, A. & Stefanis, C. N. (2013). Major depression in the Era of economic crisis: a replication of a cross-sectional study across Greece. Journal of Affective Disorders145, 308–314.

Falconier, M.K. & Epstein, N.B. (2011). Female-demand/male-with draw communication in Argentinian couples: A mediating factor between economic strain and relationship distress Personal Relationships18 (2011), 586–603.

Falconier, M.K. & Epstein, N.B. (2012). Relationship satisfaction in Argentinean couples under economic strain: gender differences in a dyadic stress model. Journal of Social and Personal Relationships27: 781-799.

Fargues, P. (2015). 2015: The year we mistook refugees for invaders (Policy Brief 2015/12), retrieved from

Gorell  Barnes, G. (2006). Family therapy in changing times (2nd ed.). Palgrave Macmillan, New York.

Gournas, G. (2013). Dealing with the Crisis: Actualizing the Power of the Group. Systemic Thinking & Psychotherapy, vol. 2.

Hatzakis, A., Sypsa, V., Paraskevis, D., Nikolopoulos, G., Tsiara, C., Micha, K., Panopoulos, A., Malliori, M., Psichogiou ,M., Pharris, A., Wiessing, L., van de Laar, M., Donoghoe, M., Heckathorn, D.D., Friedman, S.R. & Des Jarlais D.C. (2015). Design and baseline findings of a large-scale rapid response to an HIV outbreak in people who inject drugs in Athens, Greece: the ARISTOTLE programme. Addiction, 110:1453-1467.

Ifanti, A. A., Argyriou, A. A., Kalofonou, F. H.  & Kalofonos, H. (2013). Financial crisis and austerity measures in Greece: their impact on health promotion policies and public health care,. Health Policy113 (1-2), 8-12.

Ioannou, L. (2015). Imagine a country losing all of its college grads, retrieved February 20, 2016, from

Kentikelenis, A., Karanikolos, M., Papanicolas, I., Basu, S., McKee, M. & Stuckler, D. (2011). Health effects of financial crisis: omens of a Greek tragedy. Lancet, 378, 9801, 1457–1458

Kondilis, E., Giannakopoulos, S., Gavana, M., Ieorodiakonou, I., Waitzkin, H. & Benos, A. (2013). Economic crisis, restrictive policies, and the populations health and health care: the Greek case. American Journal of Public Health, Published online, e1–e8.

Mc Goldrick M. & Gerson R. (1985). Genograms in family  assessment.  New York: Norton

Michas, G. (2013).Suicides in Greece: a light at the end of the tunnel. British Medical Journal , 347:f6249.

Paparrigopoulos, T. & Liappas, I. (2011). Greek academic psychiatry and neurology before the firing squad? The Lancet, 378:313.

Paraskevis, D., Nikolopoulos ,G., Tsiara, C., et al. (2011). HIV-1 outbreak among injecting drug users in Greece, 2011: a preliminary report. Eurosurveillance16: 19962.

Polytou, K. (2013). Experiences of a psychiatric trainee in the time of crisis: The role of training in psychotherapy in the public sector. Systemic Thinking & Psychotherapy, vol.2.

Polyzos, N. (2012). Health and the financial crisis in Greece. Lancet379: 9820- 1000.

Pomini, V., Mellos, L., Paparrigopoulos,T.  & Liappas, J. (2014). Alcohol misuse in Greece: a 15-year experience from a specialized outpatient service. Psychiatriki, 25(3), 208–216.

Pomini, V., Akalestou, M.I., Tomaras, V. & Charalabaki, K. (2016). Systemic Training for “Frontier” Mental Health Professionals: An experience from Greece, in the face of the financial crisis. Human Systems27:23-35.

Rocchietta Tofani, L. (2016). Η κοινωνικοοικονομική περιθωριοποίηση και η σχέση της με την ψυχική λειτουργία: πώς μπορεί να βοηθήσει η θεραπεία οικογένειας. Συστημική Σκέψη και Ψυχοθεραπεία,  Τεύχος 10.

Rutter, M. (1999). Resilience concepts and findings: implications for family therapy. Journal of Family Therapy21, 119-144.

Solantaus T.,  Leinonen J.  &Punamaki R.L. (2004). Children’s mental health in times of economic recession: replication and extension of the family economic stress model in Finland. Developmental Psychology40, 3: 412-429.

Tomaras,V. &Pomini,V. (2002). The interlocking of therapy and supervision: the Athenian experience from the viewpoint of supervisors and supervisees. In: Campbell D., Mason B. (eds). Perspectives on supervision. Karnac, London, pp.81-90.

Τomaras, V. & Pomini ,V. (2004). Systemic family therapy in Greek health work. Context73, 9 – 10.

Triliva, S., Fragkiadaki, E. & Balamoutsou, S. (2013). Forging  partnerships for mental health: the case of a prefecture in crisis ravaged Greece. European Journal of Psychotherapy & Counselling15, 375-390.

Tsiboukli,  A. (2015). Greek crisis: impact on drug treatment services, research and population. Nordic Studies on Alcohol and Drugs ,32, 3:1-5.

Von Schlippe, A. & Schweitzer, J. (2003). Lehrbuch  der systemischen  Therapie und Beratung [Textbook of systemic therapy and  counselling], Vandenhoeck und Ruprecht, Göttingen (Greek translation: University Studio Press, Thessaloniki).

Von Sydow, K., Retzlaff , R., Beher, S., Haun, M. & Schweitzer, J. (2013). The efficacy of systemic therapy for childhood and adolescent externalizing disorders: a  systematic review of 47 RCT.  Family Process52, 576-618.

Von Sydow, K., Beher, S., Schweitzer, J. &  Retzlaff, R. (2010) The efficacy of systemic therapy with adult patients: a meta-content analysis of 38 randomised controlled trials. Family Process49, 457–485.

Walsh, F. (2003). Family Resilience: a Framework for Clinical Practice. FamilyProcess42, 1-18.

Πομίνι, Β. (2008) Συγχύσεις και συγκρούσεις ρόλων στο σύγχρονο ζευγάρι. Στο: Τομαράς Β., Καραμανωλάκη Χ., Ζέρβας Ι. (επιμ. εκδ.) Θεραπεία Ζεύγους. Καστανιώτη, Αθήνα. Σελ. 211-240. [Pomini, V. (2008). Confusion and conflicts of roles in the couple. In: Tomaras, V., Karamanolaki, Ch. & Zerbas, I. (Eds). Couple Therapy. Athens: Kastanioti. Pp. 211-240]

Πομίνι, Β. & Τομαράς, Β. (2015) Η θεραπευτική σχέση στη συστημική προσέγγιση: Πολλαπλοί δεσμοί. Στο: Καραμανωλάκη Χ., Χαραλαμπάκη Κ., Μιχόπουλος Γ. (Επιμ. Εκδ.). Η θεραπευτική σχέση. Ψυχοθεραπευτικές προσεγγίσεις από την ψυχαναλυτική, τη γνωσιακή και τη συστημική οπτική. Αθήνα: Καστανιώτη. Σελ. 85-123. [Pomini, V. & Tomaras, V. (2015). Therapeutic relationship in systemic approach: Multiple bonds. In: Karamanolaki, Ch., Charalabaki, K. & Michopoulos I. (Eds). Therapeutic relationship. Psychotherapeutic approaches from  psychodynamic, cognitive and systemic perspectives. Athens: Kastanioti. Pp. 85-123]

Τομαράς, Β. & Πομίνι, Β. (2000) Η θεραπεία με την οικογένεια σε εξέλιξη – Θεραπευτικό και εκπαιδευτικό σύστημα σε εξέλιξη. Στο: Καφταντζή Χάστα Β. (επιμ.). Οικογενειακή θεραπεία – Συστημική θεραπεία στην Ελλάδα σήμερα. Συστημική προσέγγιση και πρόληψη στην ψυχική υγεία. Τόμος Β’. Έκδοση ΨΝΘ, Θεσσαλονίκη. [Tomaras, V. & Pomini, V. (2000). Family therapy: Therapeutic and training system  co-developing. In: Kaftantzi Chasta, V. (Ed). Systemic Family Therapy in Greece Today. Vol. 2o.  Thessalonica.]