Chapter 11

1. Chapter 11 Intervention with Families

2. Introduction The family defined: “A family is who they say they are.”(Wright & Leahy, 2000)

3. 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

4. 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.

5. 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.

6. 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.

7. 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.

8. Stages of Family Development (cont.) Stage 3. The Family with YoungChildren • 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.

9. Stages of Family Development (cont.) Stage 4. The Family with Adolescents • Goal: Increasing the flexibility of family boundaries to include children’s 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.

10. 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)

11. 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.

12. 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

13. 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.

14. 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

15. Major Variations (cont.) Divorce (cont.) • Tasks • Accepting one’s 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

16. 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

17. 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

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

19. Major Variations (cont.) Cultural Variations • Caution must be taken in generalizing about variations in family life cycle development according to culture.

20. 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.

21. 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.

22. 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.

23. 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.

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

25. 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 double–bind messages

26. Family Functioning (cont.) 2. Self-concept Reinforcement • Functional families strive to reinforce and strengthen each member’s 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

27. 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

28. 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

29. 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

30. 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.

31. 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.

32. 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

33. 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

34. 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

35. 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

36. 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.

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

38. 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

39. Evolution of Family Therapy Basic Models of Family Therapy • Bowen’s Family Theory • Structural Model • Strategic Model

40. Evolution of Family Therapy (cont.) Newer Models of Family Therapy • Narrative Therapy • Emphasizes the role of the stories people construct about their experience.

41. 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

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

43. 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.

44. The Nursing Process Calgary Family Assessment Model