Ethnographic observations and interviews with psychiatrists at two general hospital psychiatric units in northern India reveal the extent of family involvement in the localized adaptation of biomedical psychiatry that occurs in these settings. By assuming many of the roles filled by auxiliary personnel in the USA, families maintain considerable control over many aspects of the psychiatric process: defining disorder, outpatient consultation, record keeping, admissions, inpatient care, discharge, and continuing care. The implications of these observations are considered in relation to theoretical concerns about biomedical hegemony, advantages and disadvantages of family involvement from an applied perspective, and the methodological adequacy of cross-cultural psychiatric epidemiology with respect to studies of "expressed emotion."