7 steps How to prevent Thalassemia : Dr Sharda Jain & Vandana Gupta
Evaluating the family the family models
1. EVALUATING THE FAMILY – THE FAMILY
MODELS
DR OGECHUKWU MBANU
DEPARTMENT OF FAMILY MEDICINE
AKTH KANO NIGERIA
11 / 4 / 18
2. Pre test
The stage of the family life cycles are defined by
Duvall in terms of
A. The age and school placement of the oldest
child
B. The ages of the parents
C. The age of the middle child
D. Years of marriage
3. 2 ) Regarding family development
A.Friedman family model
B.Calgary model
C.Duval developemental model
D.Systems model
E.Stevensons model
4. •3) satir’s model of healthy family consists of
the following except
A.Self-worth
B.Confidence
C.Communication
D.Roles
E.Links to the society
5. •4) Friedman structural – functional model
A.Family structure
B.Family function
C.Environmental data
D.Developmental stage
E.All of the above
6. •5) family functions are
A.Affective
B.Socialization
C.Reproduction
D.Economic
E.All of the above
8. INTRODUCTION
•Family evaluation is the process of gaining insight
into the family’s world,their goals ,needs ,concerns
,their strengths and support net works
•The aim is to improve the health and wellbeing of
the family
•Process of collecting data systematically using
predetermined guidelines and then classifying and
analyzing the data so as to make diagnoses with
goals and interventions for care created in
collaboration with the patient and family members
9. THE FAMILY
• That group of individuals who are related to a patient biologically,
legally or by choice , from whom the patient can reasonably expect a
measure of support in the form of food, shelter, finance and emotional
nurturing and that share a past, present and a future.
• A group of people who are closely related by birth, marriage or
adoption.
• An organization or social institution with continuity, having a past,
present and future, in which there are certain behaviors in common that
affect each other
• Types of family include :nuclear ,single parent ,blended or reconstituted
,cohabiting , gay / lesbian family, patriarchal /patrilocal /patrilineal
/Patricentric ( consider the opposite) ,neolocal
10. THE FAMILY CONT’D – FUNCTIONS OF THE FAMILY
• Physical maintenance – shelter, clothing, food, and health care.
• Division of labour - family members decide who will assume what
responsibilities, such as providing income
• Reproduction
• Placement of members in the larger society-.
• Provide protection from hostile forces
• Families pass on culture ,including faith
• Maintenance Of order - order is maintained by the communication of
acceptable behavior.
• DYSFUNCTIONAL FAMILY :-defined as a family with chronic inability to
respond to the needs or to cope with changes and stresses within the family
and its environment
11. FAMILY MODEL
•These are set standards of families which serve as basis or
guidelines for evaluating different aspects of the family
institution
•No model can capture fully all the dimensions of a family’s
experience
•Family model is seen as a family evaluation tool but some
models also make use of the other tools in to properly
evaluate the family
•Family evaluation - used by family physicians , psychologists
psychiatrists , family therapists ,nurses ,social workers
12. IMPORTANCE OF FAMILY EVALUATION
•It helps the doctor understand the family's perspective of
things
•The family is a unit of care and each member has
responsibility for others
•Helps the doctor to promote development and
maintenance of health for all
•Dysfunction in a family member affects others, increases
stress and decreases resources
•Collaborating with families to develop useful interventions
13. FAMILY EVALUATION TOOLS
ANATOMY
• Genogram
DEVELOPMENT
• Family life cycle
• Family spiral
FUNCTION
• APGAR
• Family Map
• Lifeline
• Ecomap ,etc
RESOURCES
• FACES
• SCREEM
14. TYPES OF FAMILY MODEL
Developmental
model
• Duval’s
family life
cycle
• Stevenson's
• Carter and
McGoldricks
Structural -
functional
• Friedman
Interactional
•Satir
•Calgary
Systems
model
• BOWENS
15. STEVENSON’S FAMILY DEVELOPMENT MODEL
•Joanne Stevenson(1977)
• Applies more to nuclear families
•family structure is not evaluated
•Does not address health promotion and health –
related concerns
•There are Four stages
•Stages are delineated by the number of years the
couple are married and their approximate age
16. STEVENSON’S FAMILY DEVELOPMENT MODEL
•basic tasks and responsibilities of families into four
stages:
• maintaining a common household,
• rearing children,
• and finding satisfying work and leisure
•Tasks also extended to include
•sustaining appropriate health patterns
•providing mutual support
•acculturation of family members.
18. SATIR’S INTERACTIONAL FAMILY MODEL
• Healthy families help their members know themselves through communication
of everyday events
• This communication promotes each individual’s self-esteem and self-worth
• Satir’s model of the healthy family consists of four concepts
• self-worth
• Communication
• roles
• links to society – the ecomap can be used
• Desired communication stance is the congruent stance
• Other communication stances eg blamer ,placator ,supper-reasonable ,
irrelevant are maladaptive
• Roles e.g. the martyr ,the victim ,the rescuer ,the good child / parent ,the bad
child / parent should be explored
19. FAMILY SYSTEMS THEORY
• Developed from THE GENERAL SYSTEMS THEORY proposed by Ludwig Von
Bertalanffy(1968) which describes the principle that govern all living
systems
• A system is viewed as being
- self regulatory
- having self correcting feedbacks
- functions in same way
- parts have functional and structural relationships with each other
• The interrelationship in a family system are closely tied
• Change in one part results in change in the other
• The main components of family systems theory are BOUNDARIES,RULES
,ROLES , HIERARCHY ,CLIMATE , EQUILIBRIUM (adaptability) .
20. BOWENS FAMILY SYSTEMS THEORY
•Also known as Bowen Natural Systems Theory,
describes the natural emotional processes which
shape how families and other social groups
function.
•Built from study of the human family as a living,
natural system.
• Whole is greater than sum of its parts
•A change in one part part of the system can impact
change in the entire system
21. BOWENS FAILY SYSTEMS THEORY
•Four background concepts and assumptions:
• CHRONIC ANXIETY
• BASIC LIFE FORCES
•EMOTIONAL PROCESS
• THE FAMILY AS AN EMOTIONAL UNIT.
22. FOUR BACKGROUND CONCEPTS AND ASSUMPTIONS
•CHRONIC ANXIETY - Anxiety is an organism's response to
a real or imagined threat.
•All living things experience anxiety in some form
• Chronic anxiety differs from acute anxiety.
• Acute anxiety is usually a response to a real threat and is
of short duration.
• Chronic anxiety is ordinarily a response to an imagined
threat and has a more enduring quality
• family members may react more to the disturbance in
the relationship system than to the events themselves
23. four background concepts and assumptions cont’d
•BASIC LIFE FORCES - Bowen defined two life forces at work in
human relationship systems ie :
• TOGETHERNESS AND
• INDIVIDUALITY
• Togetherness :- pressure and desire to be like others, to agree on
beliefs, principles, values, and feelings
• Individuality or differentiating force :- impetus to define a separate
self from others
• Differentiating force is responsible for self without making demands
on others
• the togetherness force assumes responsibility for the happiness,
comfort, and well-being of others
24. four background concepts and assumptions cont’d
The Family as an Emotional Unit
•Family is seen as one organism.
• Pathology in a member of the family is a symptom
of imbalance in the family emotional system
•Symptoms can fall into : physical, emotional, and
social dysfunction.
•Eg , developing cancer, getting depressed, or
committing a crime, would each be conceptualized
as symptoms of emotional process in the family.
25. four background concepts and assumptions cont’d
EMOTIONAL SYSTEM - Bowen distinguished between
emotions and feelings
•Feelings can be felt while emotions operate outside of
awareness
•Feelings like joy, despair, anger, or guilt, may be a
surface awareness of emotions
•There is thinking influenced by the feeling and
emotional system and
•thinking which is independent of feeling and
emotions(objective thinking)
26. EIGHT INTERLOCKING CONCEPTS OF BOWEN THEORY
•Differentiation of self
•Triangles
•Nuclear family emotional process
•Family projection process
•Cutoff
•Multigenerational transmission process
•Sibling position
•Societal emotional Process
27. DIFFERENTIATION OF SELF
•solid self, the part of self that is not negotiable in
relationships.
•Ability to think and act for self
•At higher levels of differentiation, people maintain separate,
solid selves under considerable stress and anxiety
• At lower levels of differentiation, people depend on others
to function, and they develop significant symptoms under
stress
• The opposite of differentiation is fusion – mercy of
emotional reactions & become anxious at low levels of stress
(fusion differentiation scale)
28. TRIANGLES
• A two-person system (dyad) becomes unstable once
anxiety increases
• third person may be pulled in to relieve some of the
pressure
•In a three-person system, anxiety has more release
therefore more relief
•If anxiety is not contained, more people are involved and
forms a series of interlocking triangles.
• if one member of the triangle remains calm the system
automatically calms down or members lock into a
triangular position, and develop symptoms
29.
30. NUCLEAR FAMILY EMOTIONAL PROCESS
•People choose mates with similar levels of differentiation
•Poorly differentiated marital dyad will become highly
fused
•When highly fused, three possible resulting symptomatic
patterns will develop
• physical emotional dysfunction in a parent
• marital conflict (cycles of emotional distance vs. over
closeness)
• psychological impairment in child (parents overly focused on
child)
31. FAMILY PROJECTION PROCESS
•Some parents may focus anxiety or their
relationship issue on a child and the child
develops problems.
• Parents then usually attempt to get the child to
change or they ask an expert to "fix" the child
32. EMOTIONAL CUTOFF
•There is extreme distancing posture
•family members discontinue emotional contact with
each other
•People look for other relationships to substitute for
the cut off relationship (as a way to cope with
unresolved fusion and anxiety)
•Bowen contended that adults must resolve their
emotional attachments to their families of origin
33. MULTIGENERATIONAL TRANSMISSION PROCESS
•Degrees of differentiation transmitted over several
generations
•If the least well differentiated members of two families
marry, then the offspring may have even lower
differentiation levels
•These people are vulnerable to anxiety & fusion
34. SIBLING POSITION
•Oldest, youngest, and middle children tend toward
certain functional roles in families
SOCIETAL EMOTIONAL PROCESS
•It refers to the tendency of people within a society to be
more anxious and unstable at certain times than others
35. FRIEDMAN STRUCTURAL – FUNCTIONAL MODEL
•Introduced by TALCOTT PARSONS (1951) and later applied
to family nursing by FRIEDMAN etal (1986)
•The family is viewed a basic unit of the wider society ie a
subsystem within the society
•The main focus is family structure and functions and the
family’s relationship with supra- systems in the
community e.g. Religious organizations education and
health
36. FRIEDMAN STRUCTURAL – FUNCTIONAL MODEL CONT’D
•The model has six broad categories for
evaluation namely ;-
•Family structure
•Family function
•Environmental data
•Developmental stage
•Identification data
•Family coping patterns
37. FRIEDMAN EVALUATION CATEGORIES
FAMILY IDENTIFYING DATA
• Family last name
• Family composition – a genogram is used
• Racial / Ethnic background
• Religious identification
• Social class status
ENVIRONMENTAL DATA
•Evaluated with the following elements
•Characteristics of home
•Neighborhood and larger community
•Family’s social support system
38. FRIEDMAN EVALUATION CATEGORIES
FAMILY STRUCTURE - The way the family is arranged , the units are
organized and how all these units link to each order
• how well it fulfills its functions and the goals important to its members
and the society
• should serve to facilitate the achievement of the functions of the family
• Family structure is evaluated based on the following elements
• Communication
• Roles
• Power structure
• Values
• The doctor must identify the individuals that make up the family , the
relationships between the family and other social system
40. FRIEDMAN EVALUATION CATEGORIES cont’d
FAMILY FUNCTION
•five main elements of family function evaluated are
•Affective
•Socialization and social placement
•Reproduction
•Economic
•Healthcare / physical necessity
DEVELOPMENTAL STAGE AND HISTORY OF THE FAMILY
•Duval’s developmental staging is applied
41. FRIEDMAN EVALUATION CATEGORIES cont’d
FAMILY COPING PATTERNS
•Factors to be considered are
•Current stressors
•Coping strategies used
•Dysfunctional adaptive strategies used
•Problem areas in which family has achieved
mastery
•Some tools that can be used to help us get the facts
includes- family mapping ,genogram ,ecomap
42. DUVALLS FAMILY LIFE CYCLE
•Family life cycle is a dynamic process of change that
occurs in a family involving stages of development which
reflect the biological functions of raising children
•The family life cycle describes family life overtime as
comprising series of stages and transitions
•A family stage is an interval of time in which the
structure and interaction of role relationships in the
family are qualitatively and quantitatively distinct from
other periods
44. Stages I -- The Beginning Families
•This is the stage of marriage.
•marks the beginning of a new family with the movement
from the former family of origin to the new intimate
relationship.
•Developmental Task
• Establishing a mutually satisfying marriage.
•Relating harmoniously to the kin network.
•Planning a family – Decisions about parenthood.
45. STAGES I -- THE BEGINNING FAMILIES CONT’D
HEALTH CARE CONCERNS
•Family planning education and counseling.
•Pre-natal education and counseling.
• Sexual and marital role adjustment.
•Lack of information often results in sexual and
emotional problems, fear, guilt feelings, unplanned
pregnancies and veneral disease either before or
after marriage
46. STAGE II -- CHILD BEARING FAMILY
•Stage II begins with the birth of the first child and continues
through the infants 30th month
47. STAGE II -- CHILD BEARING FAMILY
DEVELOPMENTAL TASKS
•Setting up the young family as a stable unit. This
involves integrating of the new baby into the family.
•Reconciling conflicting developmental tasks and needs of
various family members.
•Maintaining a satisfying marital relationship.
•Expanding relationships with extended family by adding
parenting and grand parenting roles.
48. STAGE II -- CHILD BEARING FAMILY CONT’D
HEALTH CARE CONCERNS
•Issues related with pregnancy
e.g. Morning sickness, PIH
• Preparation for birth
experiences.
• Infant care.
• Prompt recognition and
appropriate handling of
physical health problems with
the child
• Immunizations.
•Normal growth and
development.
• Safety measures
• Family planning
• Good health practices
(sleep, nutrition, exercise
49. STAGE III – FAMILIES WITH PRESCHOOL CHILDREN
•Commences when the first born child is about 2½ years old
and terminates when he or she is 5 years
of age.
•Consist of three to five persons with
paired positions of husband-father,
wife-mother, son-brother,
daughter-sister
50. FAMILY DEVELOPMENTAL TASKS
•Socializing the children
•Integrating new child members while still meeting
needs of other children
•Maintaining healthy relationship within the family
(marital and parent-child)and outside the family
(extended family and community)
•Meeting family members needs for adequate
housing , space, privacy and safety
51. HEALTH CARE CONCERNS
• Accident prevention and home safety (e.G falls, burns, poisoning)
• Sibling relationships
• Family planning
• Communicable diseases of children
• Growth and development needs
• Parenting issues
• Child abuse and neglect
• Good health practices (e.G sleep, nutrition, exercise,)
• Home safety
• Family communication problems
52. STAGE IV
FAMILIES WITH SCHOOL- AGED CHILDREN
•When the first born child enters school fulltime
usually at the age of 5 years to
when he or she reaches puberty
( around 13 years of age)
•Peer relationships and outside
activities play larger roles in
the school aged child
53. DEVELOPMENTAL TASK
•Socializing the children, including promoting school
achievement and fostering of healthy peer relations
of children.
• Maintaining a satisfying mental relationship
•Meeting the physical health needs of family
members.
•Learning to deal with the child's separation or more
simply letting the child go
54. HEALTH CARE CONCERN
•Health challenges to children (e.G. Vision, hearing ,
speech.)
• Dental health
•Child abuse and neglect
• Substance abuse
•Communicable diseases
• Chronic conditions
•Behavior problems
• Good health practices
55. STAGE V -- FAMILIES WITH TEENAGERS
•Starts when the firstborn turns 13years of age and usually last
about six to seven years,
•Challenges in working with a family at this stage revolves
around the mental and
hormonal changes adolescents
go through
•Cognitive changes , identity
formation and biological
growth
56. DEVELOPMENTAL TASKS
•Balancing of freedom with
responsibility
• Refocusing the marital
relationship
•Communicating openly
between parents and
children
•Maintaining the families
ethical and moral standard.
HEALTH CARE CONCERNS
• Accidents
•Sports injuries
•Drug and alcohol misuse
• Sex education
•Unexpected pregnancies
•Marital relationship
•Adolescent parent
relationship
•Good health practices.
57. STAGE VI - FAMILIES LAUNCHING YOUNG ADULTS
• begins when the first child leaves home and ends when the last child has
left home
• Usual length is six to seven years
• More older children living at home after schooling and starting working
usually due to economic reason thus prolonging the stage
• Grandparent roles starts , which creates changes in roles and self image
the
• “caught” period of life
• Caught between the demands of youth / expectations of the elderly and
between the world of work /demands of the family
• Stage of menopause and andropause / middlescence
58. DEVEVELOPMENTAL TASK
• Expanding the family circle to
include new family members
acquired by marriage
• Continuing to renew and readjust
in the marital relationships
• Assisting aging and ill parents of
the husband and wife
HEALTHCARE
CONCERNS
• Role transitional problems for
husband and wife
• Emergence of chronic health
problems
• Family planning for young adults
• Menopausal /andropause
• Effects of prolonged drinking,
smoking and poor dietary
practices
• Wellness lifestyles
• Preventive medical screening for
some diseases
59. STAGE VII - MIDDLE AGED PARENTS
•when the last child leaves home -- “empty nest” and ends with
retirement or death of one of the spouses
•The “plateau phenomenon”
• Salaries and promotions may no longer be available , leading to
feelings of discontentment, boredom and stagnation
•Feelings of vulnerability to illness generated when friend
/family members of same age group has health challenges eg
heart attack, stroke or cancer
•“generational squeeze” – many women find themselves in a
generational squeeze as they attempts to balance the needs of
their aging, frail or ill parents, their children and grand children
60. DEVELOPMENTAL TASK
• Providing a health-promoting environment
• Sustaining satisfying and meaningful relationships
with aging parents and children
• Strengthening the marital
relationship
•Accepting and welcoming
grandchildren into the
family
61. HEALTH CARE CONCERNS
• Promoting good health
practices such as adequate rest
, leisure activities, good
nutrition, regular exercise,
cessation of smoking,
reduction/ cessation of alcohol
• Maintaining good marital
relationships
• Communicating with and
relating to children , in-laws,
grand children and aging
parents.
• Care giving issues and
concerns
• social isolation and financial
difficulties
• Adjustment to physiological
changes of aging
• Coping with emergence of
chronic illness eg. Arthritis,
HTN, obesity
• Preventive health screening –
prostrate CA, colorectal CA,
breast CA
62. STAGE VIII - FAMILIES IN RETIREMENT AND OLD AGE
• Cycle begins with the retirement of one or both spouses, continues
through the loss of one spouse and ends with the death of the other
spouse
• Perception of this stage has a lot to do with financial resources and
health status
• Loss of independence due to ill health lead to low morale, behavioral
and psychological problems
• Loses common to aging
people include economic
status, housing ,
family members
and friends ,health
63. DEVELOPMENTAL TASKS
• Maintaining a satisfying living
arrangement
• Adjusting to a reduced income
• Maintaining marital
relationship
• Adjusting to loss of spouse
• Maintaining intergenerational
family ties
• Continuing to make sense out
one’s existence (life review and
integration
HEALTH CARE CONCERN
• Increasing functional
disabilities
• Mobility impairment
• Chronic illness
• Diminished physical vigor and
function
• Long term care services
• Social isolation
• Grief / depression
• Cognitive impairment
64. DUVALLS FAMILY LIFE CYCLE CONT’D
•In this developmental model evaluation the doctor
should
•Name the developmental stage of the family
•Document the extent to which the family is fulfilling
the developmental tasks
•Nuclear family history
•History of family of origin
•Health care concerns not met
•A genogram is drawn and has to include the parents
families of origin
65. CALGARY FAMILY MODEL
•Calgary family model evaluates the
•Structural
•Developmental
•Functional aspects of the family
•The genogram and the ecomap are used in this
evaluation model
•The developmental model used is the CARTER AND
McGoldricks developemental model
•Usually used alongside the Calgary family intervention
model(CFIM)
66. CALGARY FAMILY MODEL cont’d
•Internal structure
•External structure
•context
Structural
•Carter and McGoldrick
developmental model
Developmental
•Instrumental
•Expressive
Functional
67. STRUCTURAL
• Family composition
• GenderInternal structure
(6 categories)
•Extended family -- a genogram is used
•The larger system – ecomap is applied
here
External structure
(2 sub-categories)
Context (5 sub-
categories)
Family composition Rank order
Gender Subsystems
Sexual orientation Boundaries
Ethnicity Spirituality
Race Environment
Social class
68. FUNCTIONAL ASPECT
• refers to routine activities of daily living
such as eating, sleeping, preparing
meals, giving medications
• Crucial interactions amongst family
members
Instrumental
functioning
Expressive
functioning
(9 sub-
categories)
Emotional
communication
Circular
communication
Inluences and
power
Verbal
communication
Problem solving beliefs
Nonverbal
communication
roles Alliances and
coalitions
69. DEVELOPMENTAL ASPECT
•Carter and McGoldrick dev. Model is used
•Developed in 1985 is one of the modifications of Duvall's
developmental model
•Unlike the Duvall's it recognizes single adults , divorced families
,remarriage and domestic partners
•The model has six stages of family cycle namely:-
1. Leaving home - single adult
2. Joining of families - usually through marriage – the new couple
3. Families with young children
4. Families with adolescents
5. Launching children and moving on
6. Families in later life
70. CALGARY FAMILY EVALUATION MODEL CONT’D
•After obtaining the above data then the doctor
goes further to analyze all the information
•Assessment summary
•Family strengths and weaknesses
•Family diagnosis
•Family comparisons
•Family care plan – To include GOALS and
INTERVENTION or plan for achieving the goals
71. SIGNS INDICATING THE NEED FOR FAMILY EVALUATION
•Nonspecific symptoms in a patient who visits
frequently: - particularly in the absence of organic
disease.
•Over utilization of medical care services or frequent
visits by different family members
• Difficulty in the management of chronic illness
•The “Ripple Effect” : - when one member of the family
presents with the same symptoms of a serious illness or
crisis as another member, or a series of illnesses occur
in close sequence within the family
72. INDICATIONS FOR FAMILY EVALUATION CONT’D
• Emotional and behavioral problems, such as “acting out” in the
adolescent, depression, or anxiety in the adult
• suicidal tendency
• Marital and sexual problems
• Diseases causally related to lifestyles and environmental factors
(liver disease and alcoholism, lung disease and smoking, peptic
ulcer and emotional stress) .
• Loss of a family member, loss of home or employment,
disfigurement or amputation by accident, family violence , child
abuse or neglect, separation
73. CONCLUSION
•The overall purpose of family evaluation for the family
physician is to help improve the health of the family
•Family health can be affected by biological ,
psychological , sociological ,cultural and spiritual factors
•The use of family models helps the doctor look into
these factors with the aims of
•Health promotion
•Health maintenance
•Disease prevention
•Illness management
74.
75. REFERENCE
• Barrier, D. & Christie-seeley, J. (1984). Working With The Family In Primary Care. Praeger Publishers New York, NY. 02/11
• Doherty, W. J. & Baird M (1983). Family Therapy And Family Medicine. Guilford Press: New York. 02/11
• Mohammed Muala Almutairi, Mansour Awad M, Rami M. Almutairi, Al Johani Abdulrahman. Working With Families In Illness
And Health. International Journal Of Chinese Medicine. Vol. 1, No. 2, 2017, Pp. 45-48. Doi: 10.11648/J.Ijcm.20170102.12
• Child Health Nursing Theme; Family Assessment .Community And Home Health Nursing : School Nursing accessed 22 MAR
2018
http://Intra.tdmu.edu.ua/data/kafedra/I_nurse
• Veridiano J I ,Ofelia S Tools in Family Assessment
• Session 5 family assessment tools 2013
http://akademikciamik2010.files
• Brown J:Bowen Family Systems Theory and Practice: Illustration and Critique
http://www.thefsi.com.au
• Macon ,Georgia , Savanah ,understanding and Assessing Families in primary care Medicine Mercer University School of
Medicine 2011
• Adetola O. Family structure and family functions
• Scoh J . Family Systems Theory . 3. The eight interlocking concepts
http://Courses.aiu.edu/
76. • Doreenwestera .Family Assessment in Community Health Nursing
m.youtube.com accessed March 21 2018
• Gail Grammatica .Family Assessment video lecture NSG 3032 Population Health in
Community Apr 14 2016
m.tube.com Accessed Mar 22 2018
• Stephanie Valiente .N480 : Freidman Assessment Model jul 21 ,2016 accessed 21 2018
m.Youtube.com
• Diane Gehart .Satir Family Therapy Mar 13 ,2015
Accessed Mar 24 2018 m.youtube.com
• Cheers S .Family Assessment : Utilizing the Calgary Family Assessment Model
https://rn2bsn.weebly.com
• Mohammed Muala AlMutairi, Mansour Awad M, Rami M. AlMutairi, Al Johani
Abdulrahman. Working With Families in Illness and Health. International Journal of
Chinese Medicine. Vol. 1, No. 2, 2017, pp. 45-48. doi: 10.11648/j.ijcm.20170102.12
• Family life cycle and Family structure CCS
• Family Developmental theory Family 5-10
Editor's Notes
WHY IS THE FAMILY IMPORTANT TO THE FAMILY PHYSICIAN
Family is the basic unit of the society
Health decisions are made in the family
Families are increasingly responsible for health of ill family members
Families are getting complicated
Placement of members in the larger society-Family members establish roots in society through relationships in the church, school, political and economic system, and other organizations
PLACATER - PEACE AT ANY PRICE, TRY TO PLEASE OTHERS OR APOLOGIZE
BLAMER – FAULTFINDERS, COMPENSATE FOR LONELY FEELINGS BY BOSSING OTHERS AROUND
DISTRACTER - MAKE IRRELEVANT STATEMENTS, EVADE ISSUES, WITHDRAW FROM SITUATIONS
LEVELER - COMMUNICATE IN A STRAIGHTFORWARD WAY, HONEST THOUGHTS, VERBAL AND NONVERBAL COMMUNICATION IS CONGRUENT
BOUNDARIES HAVE TO DO WITH WHO AND WHO ARE CONSIDERED MEMBERS OF THE FAMILY AND WHO IS NOT
BOUNDARIES CAN BE
PERMEAVBLE
LOOSE OR OPEN
RIGID OR CLOSED EG VERY CLEAR SEPERATION BETWEEN FATHER AND CHILDREN
POOR BOUNDARIES LEAD TO ENMESHMENT
RULES
RULES CAN BE SPOKEN OR UNSPOKEN
RULES CHILDREN DISAGREE WITH
1.. RULES THEY DON’T UNDERSTAND
2.. RULES THE DISAGREE WITH
3..RULES THAT ARE DIFFERENT AT HOME AND AT SCHOOL
4… RULES BASED ON CULTURE THAT ARE MISUNDERSTOOD AT SCHOOL
5…UNSPOKEN RULES
INDIVIDUALS CANNOT BE UNDERSTOOD IN ISOLATION FROM ONE ANOTHER , BUT RATHER AS A PART OF THEIR FAMILY , AS THE FAMILY IS AN EMOTIONAL UNIT
INDIVIDUALS CANNOT BE UNDERSTOOD IN ISOLATION FROM ONE ANOTHER , BUT RATHER AS A PART OF THEIR FAMILY , AS THE FAMILY IS AN EMOTIONAL UNIT
DEPRESSION IN AN OBESSED CHILD ,SIBBLINGS ARE ALL OF NORMAL SIZES
A MAN WHOSE FATHER DIED OF COMPLICATIONS OF DIBETRES
AN ALCOHOLIC MAY HAVE BACKGROUND FINANCIAL OR FAMILY ISSUES
A MAN LOOSES JOB ,THE WIFE TAKES OVER FINANCIAL ISSUES IN FAMILY ,SHE IS NO LONGER AVAILABLE TO THE HUSBAND AS BEFORE ,THE MAN TARTS FEELING THAT THE WOMAN IS DISRESPECTING HIM ,STARTS ABUSING THE WIFE ,THE CHILDREN BEGIN TO BEHAVE IN AN OUT OF CONTROL MANNER
THE TOGETHERNESS FORCE ASSUMES RESPONSIBILITY FOR THE HAPPINESS, COMFORT, AND WELL-BEING OF OTHERS
WHILE A PERSON DIFFERENTIATING A SELF ASSUMES RESPONSIBILITY FOR ONE'S OWN HAPPINESS AND COMFORT AND WELL-BEING
CONNECTION BETWEEN FAMILY MEMBERS THAT INFLUENCES THEIR BEHAVIORS OUTSIDE OF THEIR CONSCIOUS AWARENESS
BOWEN MADE A DISTINCTION BETWEEN THINKING THAT IS INFLUENCED BY THE FEELING AND EMOTIONAL SYSTEM, AND THINKING THAT IS INDEPENDENT OF IT( OBJECTIVE THINKING
EG A CHILD THAT IS OVER AGGRESSIVE AT SCOOL , FIGHTS ALL THE TIME
THE LAST CHILD IN THE FAMILY
Eg – northern families and immunization
SELF DIFFERENTIATION ALSO HAS TO DO WITH THE ABILITY TO MAINTAIN ONES AUTONOMY WHILE ALLOWING OTHER COMPONENTS OF A SYSTEM TO DO THE THE SAME
INDIVIDUALS RETAIN THEIR OWN IDENTITY WHILE RETAINING ALSO THE SYSTEMS IDENTITY AS WELL
IF PARENTS CAN INSTEAD MANAGE THEIR OWN ANXIETY AND RESOLVE THEIR OWN RELATIONSHIP ISSUES, THE FUNCTIONING OF THE CHILD AUTOMATICALLY IMPROVES
JOYCE MEYER WAS SEXUALLY ABUSED BY FATHER AS A CHILD FOR SEVERAL YEARS ,THE MOTHER KNEW BUT SHE DID NOTHING ,AT APOINT THE FETHER BEGAN TO PHYSICALLY ABUSE HER MOTHER ,THE FAMILY BECAME TOTALLY DYSFUNCTIONAL ,HIS BROTHER COMMITTED SUICIDE ,JOYCE RAN AWAY FROM HOME AS A TEENAGER
FRIEDMAN MODEL ASSUMES THAT INDIVIDUALS BEHAVE ACCORDING TO A SET OF INTERNALIZED VALUES AND NORMS THAT ARE LEARNED PRINCIPALLY IN THE FAMILLY THROUGH THE PROCESS OF SOCIALIZATION .
IF ONE ELEMENT IS INFLUENCED OR IMPACTED , THE REST OF THE ELEMENTS WILL SURELY BE AFFECTED
THE STRUCTURE OF THE FAMILY REFERS TO HOW IT IS ORGANIZED— I.E., THE MANNER IN WHICH MEMBERS RELATE TO ONE ANOTHER, AND THE FORM IT TAKES, SUCH AS NUCLEAR OR
BLENDED.
TODAY, SOCIETY IS COMPOSED OF A GREATER MULTIPLICITY OF VALUES, LIFESTYLES, AND FAMILY FORMS THAN EVER BEFORE.
THE TWO-PARENT NUCLEAR FAMILY CONSISTING OF A MOTHER AND FATHER BONDED BY MARRIAGE WITH ONE OR MORE CHILDREN NO LONGER REFLECTS CONTEMPORARY LIFESTYLES
KNOWLEDGE OF A CHILD'S FAMILY STRUCTURE HELPS THE DOCTOR TO DETERMINE THE COMMUNICATION PATTERNS AND DECISION-MAKING AUTHORITY WITHIN THE FAMILY UNIT (GROSSMAN, 1996).
SUCH INFORMATION IS VITAL WHEN THE DOCTOR IS DECIDING WHO WILL BE INVOLVED IN MAKING DECISIONS RELATED TO HEATH CARE.
THE WHEEL –
THERE IS ONE PERSON WHO IS THE DOMINANT PERSON AND COMMUNICATION GOES THROUGH THAT PERSON
THE ISOLATE –
THER IS COMMUNICATION GOING ON IN THE FAMILY BUT ISOLATING ONE PERSON
THE CHAIN –
COMMUNICATION HAS TO GO THROUGH ONE PERSON BEFORE IT CAN GET TO THE NEXT
SWITCHBOARD –
EVERYONE BASICALLY COMMUNICATES WITH EVERYONE ELSE
THE AFFECTIVE FUNCTION IS ONE OF THE MOST VITAL FUNCTIONS FOR THE FORMATION AND CONTINUATION OF THE FAMILY UNIT.
THIS FUNCTION REFERS TO THE FAMILY MEETING THE NEEDS FOR LOVE AND BELONGING OF EACH MEMBER.
THE FAMILY IS A HOME BASE WHERE THE INDIVIDUALS CAN EXPRESS THEIR TRUE FEELINGS AND THOUGHTS WITHOUT FEAR OF REJECTION.
THE FAMILY IS THE SOCIAL MILIEU FOR THE GENERATION AND MAINTENANCE OF AFFECTION, WHERE ONE IS FIRST LOVED AND GIVEN TO, AND LEARNS TO LOVE AND GIVE IN RETURN.
ALTHOUGH THE AFFECTIVE FUNCTION IS IMPORTANT FOR ALL FAMILIES, THOSE THAT MUST FOCUS ON PROVIDING THE BASIC PHYSICAL NECESSITIES OF LIFE HAVE MINIMAL ENERGY
REMAINING TO MEET THE AFFECTIVE NEEDS.
SOCIALIZATION AND SOCIAL PLACEMENT FUNCTION REFERS TO TEACHING CHILDREN HOW TO FUNCTION AND ASSUME ADULT SOCIAL ROLES.
THIS FUNCTION INVOLVES THE ACQUISITION OF INTERNAL CONTROLS NEEDED FOR SELF-DISCIPLINE AND VALUES SUCH AS WHAT IS RIGHT AND WRONG ACCORDING TO SOCIETY.
SOCIALIZATION OCCURS PREDOMINATELY IN THE FAMILY, AND CAREGIVERS ARE THE PRIMARY AGENT (GELLES, 1995).
THE CONTINUITY OF BOTH THE FAMILY AND SOCIETY CONTINUES TO BE ENSURED THROUGH THE REPRODUCTIVE FUNCTION
. IN THE PAST, MARRIAGE AND THE FAMILY WERE DESIGNED TO CONTROL SEXUAL BEHAVIOR AS WELL AS
REPRODUCTION.
INDIVIDUALS CONSIDERED IT THEIR RESPONSIBILITY TO MARRY, HAVE MANY CHILDREN, AND REAR THOSE CHILDREN WITHIN THE BOUNDS OF MARRIAGE.
THE REPRODUCTIVE FUNCTION IS CARRIED OUT VERY DIFFERENTLY TODAY
MANY SINGLE PEOPLE ARE HAVING CHILDREN, INCLUDING ADOLESCENTS, AND MANY MARRIED COUPLES ARE REMAINING CHILDLESS.
REPRODUCTION HAS ALSO BEEN INFLUENCED BY TECHNOLOGICAL ADVANCES SUCH AS ARTIFICIAL INSEMINATION, IN VITRO FERTILIZATION, AND SURROGATE MOTHERS.
THE ECONOMIC FUNCTION INVOLVES THE FAMILY'S PROVISION OF SUFFICIENT RESOURCES AND THEIR EFFECTIVE ALLOCATION.
AN ASSESSMENT OF THE FAMILY'S ECONOMIC RESOURCES PROVIDES THE DOCTOR WITH INFORMATION ABOUT THEIR ABILITY TO APPROPRIATELY ALLOCATE THESE RESOURCES TO MEET NEEDS SUCH AS FOOD, SHELTER, CLOTHING, AND HEALTH CARE.
BY GAINING AN UNDERSTANDING OF HOW A FAMILY DISTRIBUTES ITS RESOURCES, THE DOCTOR CAN ALSO OBTAIN A PERSPECTIVE ABOUT THEIR VALUE SYSTEM.
ONE RESPONSIBILITY OF THE DOCTOR IS TO ASSIST FAMILIES IN OBTAINING APPROPRIATE COMMUNITY RESOURCES TO MEET THEIR NEEDS.
THE HEALTH CARE FUNCTION INCLUDES PROVISION OF PHYSICAL NECESSITIES TO KEEP THE FAMILY HEALTHY, SUCH AS FOOD, CLOTHING, AND SHELTER AS WELL AS HEALTH CARE(FRIEDMAN, 1998).
THE FAMILY KEEPS ITS MEMBERS WELL BY PASSING ON ATTITUDES, VALUES, AND BEHAVIORS THAT PROMOTE HEALTH AND BY CARING FOR THEM IN TIMES OF ILLNESS.
CURRENT STRESSORS eg LIKE DISABILITY IN A CHILD
TEENAGE PREGNANCY
SICK GRAND PARENT LIVING WITH THE FAMILY
PARENTING STYLES
AUTHORITARIAN
PERMISIVE – HIGH LOVE LOW LIMITS
UNINVOLVED / NEGLECTING PARENTS – LOW LOVE ,LOW LIMITS
AUTHORITATIVE OR DEMOCRATIC
THIS PERIOD MAY BE ASSOCIATED WITH MENOPAUSE, IT IS A STAGE ALSO WHEN MEN IN THEIR MIDDLESCENCE FACE CRISIS SUCH AS
THE DRIVE TO GET “AHEAD” IN THEIR CAREERS WITH THE REALIZATION STAGETHAT THEY HAVE NOT SUCCEEDED OR HAVE NOT REACHED THEIR ASPIRATIONS.
FINANCIAL WORRIES
SIGNS OF DIMINISHING MASCULINITY SUCH AS LOWER ENERGY LEVELS AND LESSENED POTENCY AND SEXUAL EXCITATION AS WELL AS FIGURE , HAIR AND SKIN AGING SIGNS
CRITICS OF FAMILY DEVELOPEMENTAL MODEL
ITS ASSUMPTION OF HOMOGENEITY I.E. IT’S LACK OF ADEQUATE ATTENTION TO FAMILY DIVERSITIES.
IT HAS A MIDDLE – CLASS BIAS
IT ASSUME STABILITY AT EACH STAGE
IT DOES NOT EXPLAIN THE PROCESS THAT OCCUR BETWEEN STAGES THAT ALLOW FAMILIES TO CHANGE.
FAMILIES DON'T ALWAYS EXPERIENCE STAGES IN SEQUENTIAL ORDER.
MAJOR LIFE EVENTS CAN DISRUPT STAGES E.G. NATURAL DISASTERS.
ALL FAMILIES ARE NOT NUCLEAR FAMILIES.
FAMILY COMPOSITION – WHO AND WHO MMAKE UP THE FAMILY . THE FAMILY ARE THE ONLY DETERMINANT OF WHO IS THE MEMBER OF THE FAMILY , A PET CAN BE SEEN AS PART OF A FAMILY ,A FRIEND ETC
Rank Order -- Refers to the position of the children in the family with respect to age and gender. Sibling position is an organizing influence of the personality, but it is not a fixed influence. it is important to identify the facts that the individual may be influenced by.
Subsystems -- a family carries out its functions through it subsystems. They can be defined by generation, sex, interest, function or history. You are a member of many different subsystems within the same family, which all have different levels of
power.
Boundaries -- refers to rules defining who participates and how; the function is to define or protect the differentiation of the system or subsystem. They can be diffuse, rigid, or permeable. When rigid boundaries are preset the subsystems tends to become disengaged; permeable boundaries allow appropriate flexibility. In diffuse there is often a blurring of lines between parents and children.
FUNTIONAL EVALUATION – the functional evaluation describes the family’s current interactions with each other and how they behave in relation to one another.ther are two basic aspects
Instrumental
Expressive
INSTRUMENTAL FUNCTIONING
this evaluates crucial interactios amongst the family members .
Routine activities of daily living ,e.g eating ,sleeping ,preparing meals ,house work, caring for children
EXPRESSIVE FUNCTIONING
This is divided into
Emotional
Verbal
Nonverbal
Circular
Problem solving roles
Influence and power
Beliefs
Alliances
Coalitions
The main focus in structural evaluation is patterns of interaction
EMOTIONAL COMMUNICATION – Are the ope with each other concerning their feelins , how do the children communicate emotionally. Refers to the range and types of emotions or feelings that families express or the practitioner observes
VERBAL – COMMUNICATION – what is then nature of verbal communication between the couples ,between the parents and the children and between the children
NONVERBAL COMMUNICATION -Focuses on the various nonverbal and paraverbal messages that family members communicate. They include body posture, eye contact, gestures, facial movements. Personal space, the proximity or distance between family members is also an important part of nonverbal communication. Note that it is closely linked to emotional communication. what are the non verbal expressions exhibited by family members eg children rubbing eyes when tired , crossing of arms when angry , the use of eye contact. Paraverbal communication includes tonality ,guttural sounds ,stammering , crying ,etc
CIRCULAR COMMUNICATION –
This has to do with an issue that is always raised but has never been resolved eg the husband not helping with house chores.
Circular communications usually leaves one party angry or frustrated .
Reciprocal communication between people where each influences the behavior of the other. Inferences can refer to cognition(ideas, beliefs, concepts) or affect(emotional states
PROBLEM SOLVING –
Refers to the family's ability to solve its own problems effectively. It is strongly influenced by the family's beliefs about it abilities and past successes. It is important to note who identifies the problem. Is the problem instrumental (routine day to day logistics) or emotional? What are the cost of the solutions being used to solve problems
how do the solve problems , do they rely on extended family , are they able to financially solve their problems
Roles
Refers to the established patterns of behaviors for the family members. It is a consistent behavior in a particular situation which are not static but instead developed through an individuals interactions with others. They are influenced by culture, race and other norms.
INFLUENCE AND POWER -refers to behavior used by one person
to affect another's behavior-
How is decision making shared , who has the final say.
We should discuss members
areas of power and influence on decision making about illness management, work, life goals and activities, homework, finances, and sex
Types of influence --
Instrumental Influence -- power or control that refers to the use of
objects or privileges such as money, car, cell phone, candy, etc as reinforcers.
Psychological Influence -- power that refers to the use of communication and feelings to influence behavior. Examples are praise, criticism, threats, and guilt.
Corporal Control -- refers to actual body contact, such as
hugging, spanking and so forth
BELIEFS –
refers to fundamental attitudes, premises, values and assumptions held by individuals and families . Beliefs are the blueprint from which people construct their lives and intermingle them with the lives of others. Beliefs are challenges, threatened and affirmed when illness arises. Any healing transaction involves three sets of beliefs : those of the ill patient, those of other family members, and those of the nurse what are the beliefs that resonate in the family , describe their spirituality , what are the moral issues , how is their affecting healthissues in the family
ALLIANCES AND COALITIONS ,- what is the pattern of closeness between the couples ,between the couple and their children ,between the sibblings
NONSPECIFIC SYMPTOMS IN A PATIENT WHO VISITS FREQUENTLY: HEADACHE, BACKACHE, AND ABDOMINAL PAINS, PARTICULARLY IN THE ABSENCE OF ORGANIC DISEASE.
DIFFICULTY IN THE MANAGEMENT OF CHRONIC ILLNESS. (INVOLVEMENT OF THE FAMILY IS ALWAYS A USEFUL PART OF CHRONIC DISEASE MANAGEMENT, BUT PROBLEMS IN MANAGEMENT MAKE FAMILY ASSESSMENT MANDATORY.) EXAMPLES INCLUDE DIFFICULTIES IN OBTAINING DRUG AND DIET COMPLIANCE IN SUCH DISEASES AS EPILEPSY AND HYPERTENSION; AND RECURRING PROBLEMS SUCH AS DIABETIC COMA OR INSULIN REACTIONS AND SEVERE ASTHMATIC ATTACKS
