Tools for assessing families in primary care

Family Systems Concepts: Tools forAssessing Families in Primary Care

NUNANONG RODCHEUY

13 JUN 2016

Introduction

– Each person lives among an exciting cast of characters who inspire them, support them, and also criticize and fight with them

– To know a person is to know the people in their lives

Family Systems

Anatomy

Development

Function

Family Process

Family Life Cycle

Genogram

The Genogram (Family Anatomy)

– Essential tool to recall information about family member’s names, relationships, and overall structure

– Can be updated at subsequent visits

– Biomedical focus : family medical and genetic information

– Biopsychosocial focus


Information– Names

– Ages

– Marital status

– Former marriages

– Children

– Households

– Significant illnesses

– Dates of such traumatic events as deaths

– Occupations

– Emotional closeness

– Distance, or conflict between members


Information– Transgenerational family patterns of loss

– Dysfunctional emotional patterns

– Common medical problems




The Family Life Cycle

– Developed by family sociologists Hill and Duvall (8 stages)

– A template to quickly assess a patient and family’s developmental concerns

– No single “normal” family life cycle

Married

CouplesChildbearin

g Family

Families with Preschool Children

Families with School-aged

Children

Families with Adolescence

Families Launching Young

Adults

Middle-aged Parents

Families In Later Years

Duvall’s Developmental Stages

Married Couples– Establish couple identity and a mutually

satisfying marriage

– Realign relationships with extended family to include spouse

– Make decisions about parenthood


Childbearing family– Integrate infant into family

– Find mutually satisfying ways to deal with child care responsibilities

– Expand relationships with extended family by adding parenting and grand parenting role


Families with Preschool Children– Socialize the children

– Integrate new children while still meeting needs of the other children

– Maintain healthy relationships within the family and extended family


Families with School-aged Children– Promote the school achievement and foster

the healthy peer relations of children

– Maintain a satisfying marital relationships

– Meet the physical health needs of family members


Families with Adolescence– Balance freedom with responsibility as

teenagers mature and become more autonomous

– Refocus on marital and career issues

Duvall’s Developmental StagesFamilies Launching Young Adults– Develop adult-adult relationships with grown

children

– Expand family circle to include new members acquired by the marriage of grown children

– Assist aging and ill parents of husband and wife

– Renew and renegotiate marital relationship


Middle-aged Parents– Strengthen marital relationship

– Provide health-promoting lifestyle

– Sustain satisfying relationships with aging parents and children


Families In Later Years– Maintain satisfying living arrangement

– Adjust to reduced income

– Maintain marital relationship

– Continue to make sense of one’s existence

– Maintain intergenerational family ties

– Adjust to loss of spouse

Reference

Duvall, E. M. & Miller, B. (1985). Marriage and family development. New York: Harper & Row.



– The individual life cycles of each family member intertwines with the life cycles of other family members, represented by the Family Life Spiral

– Shifting periods

– Centripetal : indicating forces that pull the family together

– Centrifugal : reflecting the forces that pull family members more apart from one another

Family Life Spiral

Family Assessment

– Family assessment is a continuous activity based on theoretical concepts and tools that easily can be integrated into daily practice

Family Assessment

–Brief assessment tools – The Family APGAR

– The Family Circle

– PRACTICE

Family AssessmentFamily APGAR

– Adaptation

– Partnership

– Growth

– Affection

– Resolve



http://www.meddean.luc.edu/lumen/MedEd/family/apgar1.pdf

Family AssessmentFamily Circle

Family AssessmentFamily PRACTICE– Presenting problem

– Roles

– Affect

– Communication patterns

– Time in family life cycle

– Illness history

– Coping with stress

– Ecology and culture

Family Systems Concepts in Primary Care

Family StructureFamily ProcessFamily Across Time

Family Characteristic

Family Characteristics

–The Family as a System–Family Stability–Family Transition–Family World View–Relational Context of the Symptom

Family CharacteristicsThe Family as a System

– The family system is more than just the sum of its individual members

– Family groups have unique characteristics

– Organized by interpersonal structures and processes

– Enable to be both stable and adaptable over time

Family Characteristics Family Stability

– Interpersonal process by which the family strives to maintain emotional balance in the system

Family Characteristics Family Transition

– Interpersonal process by which the family adapts to developmental growth in members, and varying expectations and roles in the community

Family Characteristics Family World View

– Families have general views of themselves as either competent or ineffective, cohesive or fragmented

– Based on culture, previous history, and individual perspectives

Family CharacteristicsRelational Context of the

Symptom

– The presenting symptom is part of a large family and psychosocial context that can influence and be influenced by that symptom

The Purcell Family

Bob Mrs. Purcell Mr. Purcell Mary

The Purcell Family Characteristics

Relational context of the symptom

Mr. Purcell’s more frequent chest pains

Family stabilityFamily transition

Mrs. Purcell’s new jobBob’s upcoming graduation Mary’s engagement

Family world viewFamily as a system

How the family’s functioning as a whole might play a part in Mr. Purcell’s symptoms and their alleviation


Family StructureFamily ProcessFamily Across Time


Family Structure

–Hierarchy–Boundaries–Family Role Selection–Alliance–Coalition

Family StructureHierarchy

– How power or authority is distributed within the family

– General cultural consensus places parents above children in the family hierarchy

– A parentified child, often the oldest, performs parental functions when one or both parents have abdicated the role

Family StructureBoundaries

– Different functional subgroups in the family

– In respectful interactions, families recognize the boundaries around subgroups

Family StructureFamily Role Selection

– The conscious or unconscious assignment of complementary roles to members of a family

– During health crises, family members seem to adopt identifiable roles– Caretaker

– The one who “can’t handle bad news”

Family StructureFamily Role Selection

– The scapegoat or noble symptom bearer, who is

– Identified by the family as the source of problems

– Accepts the family’s blame

– Distracts from other individual or family problems

– Reflects the dysfunction of the family as a whole

Family StructureAlliance

– A positive relationship between any two members of a system

Family StructureCoalition

– A relationship between at least three people in which two collude against a third

The Purcell Family


The Purcell Family Structure

hierarchy Parentified childMary

coalition Mary & Mr. Purcell >> Mrs. PurcellBob & Mrs. Purcell >> Mary

AllianceGenerational boundaries

Mary & Mr. Purcell Bob & Mrs. Purcell

Family role selection Mr. Purcell : Sick member, Scape goatMrs. Purcell : Uncaring spouseMary : Family health expertBob : Mrs. Purcell’s defender


Family Structur

e

Family Process


Family Process

–Enmeshment–Disengagement–Triangulation–Family Patterns

Family ProcessEnmeshment

– A system in which members have– Few interpersonal boundaries

– Limited individual autonomy

– High degree of emotional reactivity

– At later stages of the life cycle, enmeshment can inhibit individual development and growth

Family ProcessDisengagement

– Characterizes a family system in which members are – Emotionally distant

– Unresponsive to each other

Family ProcessTriangulation

– Occurs when a third person is drawn into a two-person system in order to diffuse anxiety or intimacy conflicts in the two-person system

– This process differs from family coalitions

Family ProcessFamily Patterns

– The ordered sequences of interaction that typify how a family functions, particularly when under stress

The Purcell Family


The Purcell Family Process

Enmeshment Mary & Mr. Purcell

Disengagement Mrs. Purcell – MaryMrs. Purcell – Mr. Purcell

Triangulation Mr. Purcell – Mary – Mrs. Purcell

Family pattern The focus of attention shifted to health issues or a third family member when family members became upset with each other


Family Structur

e

Family Process


The Family Across Time

–Family Developmental Stage–Family Projection Process– Intergenerational Coalition

The Family Across TimeFamily Developmental Stage

– Based on the family life cycle, family processes and interactions are varies

– Identifying the life cycle stage helps clinicians to tailor their family-oriented questions

The Family Across TimeFamily Projection Process

– The transmission of unresolved conflicts, issues, roles, and tasks from one generation to another

The Family Across TimeIntergenerational Coalition

– Two members from different generations against a third member of the family

The Purcell Family


The Purcell The family across time

Family Developmental Stage Launching children

Family Projection Process Mr. Purcell’s unresolved grief over his mother’s death

Intergenerational Coalition Mrs. Purcell’s lack of attachment to her mother-in-law

THANK YOU

Education

Tools for assessing families in primary care