Intervention with Families

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Chapter 11

• Intervention with Families

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Introduction

• The family defined
• A family is who they say they are. (Wright
  Leahy, 2000)

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Introduction (cont.)

• Types of Families
• Biological family of procreation
• Nuclear family (incorporates one or
• more members of the extended family)
• Sole-parent family
• Stepfamily
• Communal family
• Homosexual couple
• or family

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Introduction (cont.)

• Families may more
• appropriately be determined
• based on attributes of
• affection, strong emotional
• ties, a sense of belonging,
• and durability of membership.
• Nurse generalists provide support and referrals
  to families of ill clients. They should be
  familiar with the tasks of adaptive family
  functioning.

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Introduction (cont.)

• Nurse specialists may perform family therapy.
• Family therapy a form of intervention in which
  members of a family are assisted to identify and
  change problematic, maladaptive, self-defeating,
  repetitive
  relationship patterns.

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Stages of Family Development

• Stage 1. The Single Young Adult
• Goal Accepting separation from
• parents and responsibility for self
• Tasks
• Forming an identity separate
• from that of parents
• Establishing intimate peer relationships
• Advancing toward financial independence
• Problems arise when either the young adult or the
  
• parents have difficulty separating from the
  previous
• interdependent relationship.

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Stages of Family Development (cont.)

• Stage 2. The Newly Married Couple
• Goal Commitment to the new system
• Tasks
• Establishing a new identity
• as a couple
• Realigning relationships with members of the
  extended family
• Making decisions about having children
• Problems arise when either partner has difficulty
  separating from family of origin or when the
  couple cut themselves off completely from
  extended family.

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Stages of Family Development (cont.)

• Stage 3. The Family with Young Children
• Goal Accepting a new generation
• of members into the system
• Tasks
• Adjusting the marital relationship
• to accommodate parental
• responsibilities while preserving
• the integrity of the couple relationship
• Sharing equally in the tasks of child-rearing
• Integrating the roles of extended family members
  into the family
• Problems arise when the parents lack of
  knowledge about normal childhood development
  interferes with satisfactory child-rearing.

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Stages of Family Development (cont.)

• Stage 4. The Family with Adolescents
• Goal Increasing the flexibility of
• family boundaries to include
• childrens independence and
• grandparents increasing
• dependence
• Tasks
• Shifting of parent-child relationships to permit
  adolescents to move in and out of the system
• Refocusing on midlife marital and career issues
• Beginning a shift toward concern for the older
  generation
• Problems arise when parents are unable to
  relinquish control and allow the adolescent
  increasing autonomy or when the parents cannot
  agree and support each other in this effort.

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Stages of Family Development (cont.)

• Stage 5. The Family Launching Grown Children
• Goal Accepting a multitude
• of exits from and entries into the
• family system
• Tasks
• Renegotiation of marital system as a dyad
• Development of adult-to-adult relationships
  between grown children and parents
• Realignment of relationships to include in-laws
  and grandchildren
• Dealing with disabilities and death of parents
  (grandparents)

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Stages of Family Development (cont.)

• Stage 5. The Family Launching Grown Children
  (cont.)
• Problems arise when parents are unable to accept
  the departure of their children from the home and
  their status as adults, or
• the death of their own parents,
• or when the marital bond has
• deteriorated.

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Stages of Family Development (cont.)

• Stage 6. The Family in Later Life
• Goal Accepting the shifting of
• generational roles
• Tasks
• Maintaining own and/or couple functioning and
  interests in face of physiological decline
• Exploration of new familial and social role
  options
• Support for a more central role
• for the middle generation
• Dealing with loss of spouse,
• siblings, and other peers, and preparation
  for own death life review and integration

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Stages of Family Development (cont.)

• Stage 6. The Family in Later Life (cont.)
• Problems arise when older adults have failed to
  fulfill the tasks of earlier stages and are
  dissatisfied with the way their lives have gone.

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Major Variations

• Divorce
• Currently in the United States,
• about half of all first marriages
• end in divorce.
• There is some indication that this trend may be
  declining.
• Stages in the family life cycle of divorce
• Deciding to divorce
• Planning the breakup of the system
• Separation
• Divorce

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Major Variations (cont.)

• Divorce (cont.)
• Tasks
• Accepting ones own part in
• the failure of the marriage
• Working cooperatively on
• problems related to custody
• and visitation of children and finances
• Realigning relationships with extended family
• Mourning the loss of the marriage relationship
  and the intact family

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Major Variations (cont.)

• Remarriage
• About three-fourths of those
• who divorce eventually remarry.
• The rate of redivorce for
• remarried couples is even higher
• than the divorce rate after first marriages.
• Stages in the remarried family life cycle
• Entering the new relationship
• Planning the new marriage and family
• Remarriage and reestablishment of family

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Major Variations (cont.)

• Remarriage (cont.)
• Tasks
• Making a firm commitment
• to confront the complexities
• of combining two families
• Maintaining open communication
• Facing fears
• Realigning relationships with extended family to
  include new spouse and children
• Encouraging healthy relationships with biological
  (noncustodial) parents and grandparents

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Major Variations (cont.)

• Remarriage (cont.)
• Problems arise when there is a blurring of
  boundaries between custodial and noncustodial
  families.

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Major Variations (cont.)

• Cultural Variations
• Caution must be taken in generalizing about
  variations in family life cycle development
  according to culture.

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Major Variations (cont.)

• Cultural Variations (cont.)
• Marriage
• Attitudes toward marriage are
• strongly influenced by Roman
• Catholicism in many Italian
• American and Latino American families.
• In Asian American families, although marriages
  are no longer arranged, strong family influence
  on mate selection still exists.
• Jewish American families are as diverse as the
  mainstream culture.
• In many ethnic subcultures, the father is
  considered the authority figure and head of the
  household, and the mother assumes the role of
  homemaker and caretaker.

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Major Variations (cont.)

• Cultural Variations (cont.)
• Children
• Roman Catholicism promotes
• marital relations for procreation,
• and large numbers of children are encouraged.
• In the traditional Jewish community, having
  children is seen as a scriptural and social
  obligation.
• In traditional Asian American cultures, sons are
  more highly valued than daughters, and the most
  important child is the oldest son.

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Major Variations (cont.)

• Cultural Variations (cont.)
• Extended family
• Older family members are
• valued for their wisdom in
• Asian, Latino, Italian, and Iranian
  subcultures.
• Several generations within these subcultures may
  live together and share tasks of child-rearing.

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Major Variations (cont.)

• Cultural Variations (cont.)
• Divorce
• In the Jewish community, divorce is often seen
  as a violation of family togetherness.
• Because of the opposition to
• divorce by Roman Catholicism,
• a low rate of divorce has existed
• among those cultures that are
• largely Catholic.

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Family Functioning

• Boyer and Jeffrey describe six elements on which
  families are assessed to be either functional or
  dysfunctional.

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Family Functioning (cont.)

• 1. Communication
• Family members are encouraged to express honest
  feelings and opinions, and all members
  participate in decisions that affect the family
  system.
• Behaviors that interfere with functional
  communication include
• Making assumptions
• Belittling feelings
• Failing to listen
• Communicating indirectly
• Presenting doublebind messages

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Family Functioning (cont.)

• 2. Self-concept Reinforcement
• Functional families strive to reinforce and
  strengthen each members self-concept, with the
  positive result being that family members feel
  loved and valued.
• Behaviors that interfere with self-concept
  reinforcement include
• Expressing denigrating
• remarks
• Withholding supportive
• messages
• Taking over

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Family Functioning (cont.)

• 3. Family Members Expectations
• In functional families, expectations are
  realistic, flexible, and individualized.
• Behaviors that interfere with adaptive
  functioning in terms of member expectations
  include
• Ignoring individuality
• Demanding proof of love

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Family Functioning (cont.)

• 4. Handling Differences
• Functional families understand that it is
  acceptable to disagree and deal with differences
  in an open, nonattacking manner.
• Behaviors that interfere with successful family
  negotiations include
• Attacking
• Avoiding
• Surrendering

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Family Functioning (cont.)

• 5. Family Interactional Patterns
• Family interactional patterns are functional when
  they are workable and constructive and promote
  the needs of all family members.
• They are dysfunctional when they become
  contradictory, self-defeating, and destructive.
  Examples are patterns that
• Cause emotional discomfort
• Perpetuate or intensify
• problems rather than
• solve them
• Are in conflict with each
• other

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Family Functioning (cont.)

• 6. Family Climate
• A positive family climate is
• founded on trust and is reflected
• in openness, appropriate humor and laughter,
  expressions of caring, mutual respect, a valuing
  of the quality of each individual, and a general
  feeling of well-being.
• A dysfunctional family climate is
• evidenced by tension, pain, physical
• disabilities, frustration, guilt, persistent
• anger, and feelings of hopelessness.

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Therapeutic Modalities with Families

• The Family as a System
• The family can be viewed as a system
  composed of various subsystems, such as the
  marital subsystem, parent-child subsystems,
  and sibling subsystem.

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Therapeutic Modalities with Families (cont.)

• A major contributor to this theory is Bowen. He
  has identified the following major concepts
• Differentiation of self
• Triangles
• Nuclear family emotional process
• Family projection process
• Multigenerational
• transmission process
• Sibling position profiles
• Emotional cutoff
• Societal regression

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Therapeutic Modalities with Families (cont.)

• Systems Approach to Family Therapy
• Goal to increase the level of differentiation of
  self while remaining in touch with the family
  system
• Techniques
• Defining and clarifying the relationship among
  the family members
• Helping family members develop one-to-one
  relationships with each other and minimizing
  triangles in the system
• Teaching family members about the functioning
  of emotional systems
• Promoting differentiation by encouraging I
  position stands during course of therapy

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Therapeutic Modalities with Families (cont.)

• Structural Model
• The family is viewed as a social system within
  which the individual lives and to which the
  individual must adapt.
• Major concepts
• Systems
• Transactional patterns
• Subsystems
• Boundaries

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Therapeutic Modalities with Families (cont.)

• Structural Model (cont.)
• Goal to facilitate change in the family
  structure
• Techniques
• Joining the family
• Evaluating the family structure
• Restructuring the family

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Therapeutic Modalities with Families (cont.)

• Strategic Model (cont.)
• This model uses the interactional
• or communication approach.
• Communication theory is
• viewed as the foundation for
• this model.
• Functional families are open systems
• with clear, precise messages that are
• congruent with the situation.
• Dysfunctional families are viewed as closed or
  partially closed communication is vague, and
  messages are often inconsistent and incongruent
  with the situation.

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Therapeutic Modalities with Families (cont.)

• Strategic Model (cont.)
• Major concepts of strategic model
• Double-bind communication
• Pseudomutuality
• Pseudohostility
• Marital schism
• Marital skew

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Therapeutic Modalities with Families (cont.)

• Strategic Model (cont.)
• Goal to create change in destructive behavior
  and communication patterns among family members.
  The identified problem is the focus of therapy.
• Techniques
• Paradoxical intervention
• Reframing

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Evolution of Family Therapy

• Basic Models of Family Therapy
• Bowens Family Theory
• Structural Model
• Strategic Model

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Evolution of Family Therapy (cont.)

• Newer Models of Family Therapy
• Narrative Therapy
• Emphasizes the role of the stories people
  construct about their experience.

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Evolution of Family Therapy (cont.)

• Newer Models of Family Therapy (cont.)
• Feminist Family Therapy
• Applicable to both men women
• Addresses family gender roles, patriarchal
  attitudes, and social and economic inequalities
  in male-female relationships

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Evolution of Family Therapy (cont.)

• Newer Models of Family Therapy (cont.)
• Social Constructionist Therapy
• Concerned with all family members views about
  the problem

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Evolution of Family Therapy (cont.)

• Newer Models of Family Therapy (cont.)
• Psychoeducational family therapy
• Emphasizes education of family members to help
  them understand and cope with a seriously
  disturbed family member.

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The Nursing Process

• Calgary Family Assessment Model