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Family as a unit of care
- 1. The Family as a Unit of Care Aileen B. Pascual, MD, FPAFP
- 2. What is a family?
- 3. âA group of persons united by ties of marriage, blood or adoption; consisting of a single household; interacting and communicating with each other in their respective social roles and maintaining a common cultureâ Burgess and Locke, 1960
- 4. âThe family is a social group characterized by common residence, economic cooperation and reproductionâ Murdock, 1965
- 5. âFamilies comprise people who have a shared history and a shared futureâ Carter and McGoldrick, 1999
- 7. NUCLEAR FAMILY ⢠Parents, dependent children ⢠Separate dwelling not shared with members of the family of origin/orientation of either spouse ⢠Economically independent Source: http://en.wikipedia.org/wiki/File:Simpsons_FamilyPicture.png
- 8. Father Mother Siblings Spouse Son Daughter Types of Nuclear Family EGO ORIENTATION/ ORIGIN PROCREATION
- 9. EXTENDED FAMILY ⢠Includes 3 generations ⢠Live together as a group ⢠Kinship network provides function to all members ⢠Unilaterally extended ⢠Bilaterally extended
- 10. SINGLE PARENT FAMILY ⢠Children < 17 years of age, living in a family unit with a single parent, another relative or non-relative ⢠May result from: ď§ Loss of spouse by death, divorce, separation, desertion ď§ Out of wedlock birth of a child ď§ From adoption ď§ Migration (OFWs)
- 11. BLENDED FAMILY ⢠Includes step-parents and step-children ⢠Caused by divorce, annulment with remarriage and separation
- 12. COMMUNAL FAMILY ⢠Grouping of individuals which are formed for specific ideological or societal purposes ⢠Considered as an alternative lifestyle for people who feel alienated from the economically privileged society
- 13. The Family is a⌠BIOLOGIC UNIT ⍠Reproduction, child rearing PSYCHOLOGIC UNIT ⍠Emotional support, protection SOCIO-CULTURAL UNIT ⍠Socialization, values
- 14. Basic Areas of Function ECONOMIC ⍠Financial resources, security EDUCATIONAL ⍠Skills, attitudes
- 15. The family is the social context in which illness occurs and where recovery takes place.
- 16. The Filipino Family ⢠Closely knit ⢠Bilaterally extended ⢠Authority based seniority/age ⢠Externally patriarchal, internally matriarchal ⢠High value on education ⢠Predominantly Catholic
- 17. The Filipino Family Emerging Structures ď§ Changing commitments ď§ Global and Urban Migration ď§ Changing role of women
- 18. New Parental Configurations ⢠Single mothers ⢠Single fathers ⢠Step parents ⢠Absconding fathers or mothers ⢠Absent fathers or mothers ⢠Surrogate parents ⢠Bicultural parents ⢠Two daddies, two mommies
- 19. The Family as a System
- 20. What is a system? An entity composed of discrete parts which are connected in such a way that a change in one part results in changes in all other parts
- 21. The Family as a System⌠- exhibits circular changes - has a tendency to resist change and maintain a state of homeostasis - reaches a state of equilibrium even if change happens within the system
- 22. Structural Approach to Family Systems ⢠Pioneered by Dr. Salvador Minuchin ⢠Focus on familyâs âSTRUCTUREâ ⢠It has to have clear hierarchy, roles, subsystems & boundaries ⢠Familyâs ability to adapt to stressors depends on the clarity and appropriateness of its STRUCTURE
- 23. Understanding Families: Elements of the Family System ⢠Structures ⢠Rules ď§ Overt ď§ Covert ⢠Boundaries ⢠Subsystems ⢠Roles ⢠Coalitions ⢠Power Structures
- 24. Structures ⢠Behavioral patterns repeated over and over again ⢠Behavioral skeleton around which the family is built
- 25. Exploring Structures: Series Questions ⢠âWhen situation A happens, what happens to member 1?â ⢠âWhen this happens to member 1, what happens to member 2?â When member 2 behaves in that way what happens to member 3?
- 26. Rules ⢠Commonly agreed upon ways of dealing with each other, dealing with situations, and dealing with the external environment ⢠Overt Rules ⢠Covert Rules
- 27. Roles ⢠Specific function assigned to a family member ď§ Breadwinner ď§ Caregiver ď§ Symptom carrier ď§ âFamily Doctorâ ď§ âMedical Specialistâ
- 28. Exploring Roles: âWho-does-what-and-whenâ Questions ⢠âWhen someone gets sick in the family, who do you usually go to first? ⢠âWhen that person does not know what to do, who does he consult? ⢠âWhen the patient has to be admitted to the hospital, whose permission must be obtained?â
- 29. Subsystems ⢠Subgroups within a family separated from each other by a significant period of time ⢠Grandparental, parental, sibling subsystems
- 30. Boundaries ⢠Special rules that govern the interactions between subsystems in the family ⢠May be clear, rigid or diffuse ⢠Ideally, should be clear enough to prevent interferences but flexible enough to allow contact across subsystems
- 31. Boundaries ⢠Clear â with clarity and negotiable: allows flexibility when family goes through periods of change ⢠Rigid â not open to negotiations ⢠Diffuse â lack of clarity; intrusions by one subsystem to another
- 32. Coalitions ⢠Alliances between members ⢠Informal groupings within the family of people who usually side with each other
- 33. Eliciting Coalitions: âWho agrees with whomâ Questions ⢠âWho is the person that the patient usually disagrees with in the family? ⢠âIn case of a disagreement with that person, who in the family agrees with the patient?â ⢠âWho in the family usually agrees with the other person?
- 34. Power Structures ⢠Decision-makers ⢠Usually parental generation
- 35. Family Processes ⢠Enmeshment ⢠Disengagement ⢠Triangulation
- 36. Exploring Emotional Closeness and Distance: âCloser-fartherâ Questions ⢠âWho is closest to this patient? After that person who is next closest? And the next closest after that?â ⢠âWho is the person who feels farthest away emotionally from the patient? Then who is the next farthest?
- 37. Circular Questions ⢠Series Questions ⍠Explores repetitive behavior ⢠âWho-does-what-and-whenâ Questions ⍠Explores different roles
- 38. Circular Questions ⢠âCloser-fartherâ Questions ⍠Explores emotional closeness and distance ⢠âWho agrees with whomâ Questions ⍠Elicits information about coalitions
- 39. Family Map ⢠Application of Family Systems Concepts ⢠Characteristics : members ⢠Structure: boundaries, alliances, coalitions ⢠Process: enmeshment, disengagement ⢠Across time: intergenerational coalition
- 40. Family Map Symbols Functional relationship Enmeshed or over- involved relationship Dysfunctional relationship
- 41. Family Map Symbols â ⢠Clear ⢠Rigid ⢠Diffused
- 42. Family Map Symbols Coalition or Alliance Escape from the system/ Disengagement Triangulation
- 45. ⢠Genogram Structure ⢠Family Life Cycle Development ⢠Family APGAR ⢠Family Lifeline Function ⢠SCREEM ⢠Ecomap Resources Family Assessment Tools
- 46. Family Genogram ⢠Inheritance patterns ⢠Family illnesses ⢠Family members ⢠Family relationships ⢠Significant dates
- 47. A complete genogram should include: ⢠Names, ages of all family members ⢠Exact dates of birth, marriage, separation, divorce, death and other significant life events ⢠Information covering 3 or more generations ⢠Illness (hereditary and significant illnesses) ⢠Firstborn of each family to the left and other siblings sequentially to the right ⢠Indication of which members live together in the same household ⢠Names of 2 families with the address of the index family ⢠The informant/s ⢠Date the genogram was generated
- 48. Genogram Symbols Male Female Unknown sex Spontaneous abortion Pregnancy/ Child in utero Induced abortion
- 49. Genogram Symbols Index patient Name, Age Bert, 5 Jane, 12 May,29Roy, 50
- 50. Genogram Symbols Unknown sex of child A Dizygotic Twins Monozygotic Twins Adopted
- 51. Genogram Symbols Death And Cause Pneumonia MI RHD Stroke
- 52. Genogram Symbols 2008 Marriage and Year Separation and Year Divorce and Year 2008 2008 2008 Not married and Year started living together
- 53. Genogram Symbols
- 54. Genogram Symbols
- 55. Jane, 47 Martha ďľ ďŹ ďŽ William Tomas, 26 Katerina, 20Nathan, 25 Johanna, 22 Marco, 49 Daniel, 26 Emily, 48 Joseph, 72 Margaret, 69 Montenegro-Alcantara March, 2012 March 2012 Legend: ďŹ â Hypertension ďŽ â Dyslipidemia ďľ â Diabetes mellitus Informant: Katerina Manila
- 56. ⢠Genogram Structure ⢠Family Life Cycle Development ⢠Family APGAR ⢠Family Lifeline Function ⢠SCREEM ⢠Ecomap Resources Family Assessment Tools
- 57. The Family Life Cycle ⢠Conceptual tool for understanding family development ⢠Transitions from one stage to another are rarely clear cut ⢠Stages tend to merge ⢠Several different models ⢠3 general phases: coupling, expansion, contraction ⢠6 stages
- 58. Unattached Young Adult Newly Married Couple Family with Young Children Family with Adolescents Launching Family Family in Later Years Family Life Cycle
- 59. ⢠Genogram Structure ⢠Family Life Cycle Development ⢠Family APGAR ⢠Family Lifeline Function ⢠SCREEM ⢠Ecomap Resources Family Assessment Tools
- 60. Family APGAR ⢠Developed by Dr. Gabriel Smilkstein ⢠5-item questionnaire to assess family function ⢠Measures individual satisfaction about family relationships
- 61. Component Definition Adaptation Capability of the family to utilize and share inherent resources Partnership Sharing of decision making Measures the satisfaction attained in solving problems by communicating Growth Emotional and physical growth Measures satisfaction of the available freedom to change Affection How emotions are shared between members Measures satisfaction with emotional interaction Resolve How time, space, money are shared, Measures the satisfaction with the commitment made by other members of the family
- 62. FAMILY APGAR Part I Almost Always Some of the Time Hardly Ever A I am satisfied that I can turn my family for help when something is troubling me P I am satisfied with the way my family talks on things with me and shares problems with me G I am satisfied that my family accepts and supports my wishes to take on new activities or directions A I am satisfied with the way my family expresses affection and responds to emotion such as anger, sorrow and love R I am satisfied with the way my family and I share time together
- 63. FAMILY APGAR Part I Palagi Paminsan -Minsan Halos hindi A Akoây nasisiyahan dahil nakakaasa ako ng tulong sa aking pamilya sa oras ng problema P Akoây nasisiyahan sa paraang nakikipagtalakayan sa akin ang aking pamilya tungkol sa aking problema G Akoâs nasisiyahan at ang aking pamilya ay tinatanggap at sinusuportahan ang aking mga nais na gawin patungo sa mga bagong landas para sa aking pag unlad A Akoâs nasisiyahan sa paraang ipinadadama ng aking pamilya ang kanilang pagmamahal at nauunawaan ang aking damdamin katulad ng galit, lungkot at pag-ibig R Akoây naisisiyahan na ang aking pamilya at ako ay nagkakaroon ng panahon sa isaât isa.
- 64. Who lives in your house? Sinu-sino ang nakatira sa inyong tahanan? How do you get along? Paano ang inyong relasyon? Name and Relationship Age Sex Well Fairly Poor Pangalan at Relasyon Edad Kasarian Mabuti Hindi gaanong mabuti Hindi mabuti If you donât live with your family, list the persons whom you can turn to for help. Kung hindi ka nakakahingi ng tulong sa iyong sariling pamilya, kani-kanino ka humihingi ng tulong? How do you get along? Paano ang inyong relasyon? Pangalan at Relasyon Edad Kasarian Mabuti Hindi gaanong mabuti Hindi mabuti
- 65. Family APGAR ⢠Scoring: Almost always â 2 Some of the time â 1 Hardly ever â 0 ⢠Total : 8-10 â highly functional 4-7 â moderately dysfunctional 0-3 â severely dysfunctional
- 66. The Family APGAR is valuable in the following: ⢠Psychosomatic disorders ⢠Difficult patients ⢠Marital difficulties ⢠Multiple presentations by single/multiple family members ⢠Drug or alcohol abuse ⢠Evidence of sexual and physical abuse
- 67. ⢠Genogram Structure ⢠Family Life Cycle Development ⢠Family APGAR ⢠Family Lifeline Function ⢠SCREEM ⢠Ecomap Resources Family Assessment Tools
- 68. Family Lifeline ⢠Significant events among family members over a period of time in a chronological sequence ⢠Allows exploration of certain family issues
- 70. ⢠Genogram Structure ⢠Family Life Cycle Development ⢠Family APGAR ⢠Family Lifeline Function ⢠SCREEM ⢠Ecomap Resources Family Assessment Tools
- 71. SCREEM ⢠Assess ability of family to participate in provision of health care and cope with crisis ⢠Sources of help ⢠Barriers to patient care ⢠Relationships of health behavior, practices and utilization of health services
- 73. SCREEM Family Resource Survey SCREEM-RES ⢠12-item family resource questionnaire ⢠Assesses the familyâs capacity to participate in the provision of health care or to cope with crisis
- 74. Questions Lubos na sumasa ng-ayon Sumasa ng-ayon Hindi sumasa ng-ayon Lubos na hindi sumasa ng-ayon S ⢠Ang bawat isa ay nagtutulungan sa aming pamilya ⢠Natutulungan kami ng aming mga kaibigan at kasamahan sa komunidad. C ⢠Ang aming kultura ay nagpapanatag ng loob ng aming pamilya ⢠Ang kultura ng pagtutulungan at pagmamalasakit sa aming komunidad ay nakakatulong sa aming pamilya. R ⢠Ang aming pananampalataya at relihyon ay nakakatulong sa aming pamilya. ⢠Natutulungan kami ng aming mga kasamahan sa simbahan o mga grupong relihyoso.
- 75. Questions Lubos na sumasa ng-ayon Sumasa ng-ayon Hindi sumasa ng-ayon Lubos na hindi sumasa ng-ayon E ⢠Sapat ang naipong pera ng aming pamilya para sa aming mga pangangailangan ⢠Sapat ang kinikita ng aming pamilya para sa aming mga pangangailangan E ⢠Sapat ang aming edukasyon/kaalaman upang maintindihan ang mga impormasyon tungkol sa sakit. ⢠Sapat ang aming edukasyon/kaalaman upang maalagaan ang sakit. M ⢠Madaling makakuha ng tulong medikal sa aming komunidad. ⢠Natutulungan kami ng mga duktor, nars at health workers
- 76. SCREEM-RES ⢠Scoring: â Lubos na sumasang-ayon â 3 â Sumasang-ayon â 2 â Hindi sumasang-ayon â 1 â Lubos na hindi sumasang-ayon â 0 ⢠Total : â 13 â 18 = adequate family resources â 7 â 12 = moderately inadequate family resources â 0 â 6 = severely inadequate family resources
- 77. ECOMAP ⢠A âsnapshotâ of the patient within his/her family and social environment at a particular point in time ⢠A graphical representation that shows all of the systems at play in an individual's life.
- 80. ⢠Genogram Structure ⢠Family Life Cycle Development ⢠Family APGAR ⢠Family Lifeline Function ⢠SCREEM ⢠Ecomap Resources Family Assessment Tools
- 81. Other Family Assessment Tools ⢠DRAFT â Draw a Family Test ⢠The Family Circle
- 82. Areas for Assessment: âSt. FREDâ DOMAIN ASSESSMENT TOOLS Structure Rules, Roles, Coalitions, Transactional Patterns Family Genogram Family Map Circular questions Flexibility Family Lifeline Resonance Circular questions Ecological Context SCREEM Ecomap Development Family Life Cycle Stage/Genogram Illness Typology and Trajectory
- 83. Levels of Family Intervention
- 84. LEVELS OF FAMILY INTERVENTION Doherty & Baird, 1987 Level 1: Minimal Involvement Level 2: Ongoing medical information & advice Level 3: Provision of emotional support Level 4: Systematic assessment & planned intervention Level 5: Family Therapy
- 85. Level 1: Minimal Involvement ⢠Doctor hardly sees the family ⢠Focus of treatment is mostly individual patient ⢠Family is involved only in medico-legal issues ⢠Example: Consent
- 86. Level 2: Ongoing Medical Information and Advice ⢠Doctor involves the family by providing them with information about patientâs illness ⢠Focus: Health education both patient & family ⢠Primarily cognitive in nature ⢠Example: Disclosure
- 87. Level 3: Provision of emotional support ⢠In addition to health education, the doctor : ⍠probes deeper into the emotional impact of illness ⍠offers emotional support to the family members ⢠Example: Family CEA
- 88. Level 4: Systematic assessment & Planned Intervention ⢠Doctor makes systematic assessment of the dynamics of the family and how it is interacting with the illness ⢠Plans and carries out intervention to change structures in the family so that health problem of the patient can be better dealt with
- 89. Level 5: Family Therapy ⢠Optional for physicians ⢠Requires additional training ⢠Average family physicians will likely REFER to professionals when confronted with family dysfunctions that require this intervention
- 90. References ⢠Counseling Skills for Caring Physicians Book 1: Individual Interventions. Manila: Primary Health Care Foundation for the Empowerment of Families and Communities, 2005. ⢠McDaniel, S., Campbell, T., Hepworth, J., & Lorenz, A. Family Oriented Primary Care, 2nd ed. New York: Springer. 2005 ⢠Proceedings of the Orientation Course in Family Medicine, Philippine Academy of Family Physicians ⢠Textbook of Family Medicine Volume 1. Philippine Academy of Family Physicians ⢠Dr. Richa Opina Tan ⢠Dr. Tricia Mercado ⢠Dr. Cherry Bernardo-Lazaro
Editor's Notes
- Connectivity, not completeness &lt;number&gt;
- Connectivity &lt;number&gt;
- Family defines health and illness; Family makes health decisions Transmission of diseases happens within families Health behavior is acquired from the family Families can cause stress, may be a source of social support &lt;number&gt;
- slightly more female OFWs (50.5%) than male (49.5%) OFWs &lt;number&gt;
- Connectivity, not completeness &lt;number&gt;
- Families are SYSTEMS of interconnected and interdependent individuals. To understand the individual, we must understand the family system of that individual. People cannot be understood in isolation from one another. &lt;number&gt;
- Enmeshment is a concept introduced by Salvador Minuchin to describe families where personal boundaries are diffuse, sub-systems undifferentiated, and over-concern for others leads to a loss of autonomous development Triangulation can occur in a variety of ways, but always involves a pair of family members incorporating or rejecting a third family member &lt;number&gt;
- Emotional closeness = Resonance &lt;number&gt;
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- The genogram provides a quick overview of the family members and relationships Gives both biomedical and psychosocial information Tool for understanding multigenerational family systems &lt;number&gt;
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- Limitations: data obtained is restricted to what the patient is willing to disclose Measures the patientâs satisfaction with his familyâs functioning &lt;number&gt;
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- Resonance=closer-farther questions &lt;number&gt;