INTRODUCTION:“Family faces are magic mirrors. Looking at people who belong to us, we see the past, present and future.” Gail Lumet Buckley Family is the first social unit for developing the qualities of an individual. A true family grows and moves through life together. The word "family" implies warmth, a place where the core feelings of the members are nurtured. Family values represent the core values and guidelines that parents and family members hold in high regard for the well-being of the family. Family provides necessary security and support, and acts as a buffer against external problems. A family made up of secure people generates a magnetic power that can get things done. They are the hope for real security in a stressful world. THEORIES OF FAMILY DYNAMICS: A variety of theoretical frameworks provides the nurse with a holistic overview of health promotion for the individual and families across the life span. Major theoretical frameworks that nurses use in promoting the health of the individual are need theories , developmental stage theories , and system theories. Major theoretical frameworks that nurses use in promoting the health of the family are developmental stage theories , and general system theories, Bowen’s family theory and structural – functional theories. Family Development Task( Theory of Family):Family development refers to the process of progressive structural diffentiation and transformation over time. A family development is defined as a “growth responsibility that arises at a certain stage in the life of a family, the successful achievement of which leads to present satisfaction . approval and success with later”. Failure in completing the task can lead to family unhappiness , societal disapproval and difficulty with latter development. The healthy family performs all roles appropriately according to family member’s age , competencies and needs during family life cycle. Family life cycle dimensions provide the basis for the study of families over time, emphasis family members and families developmental task at every stage of development ,identities, family, stresses on critical developmental periods and recognizes the need for services and programme for families through out the life cycles. 1. Beginning family/ married couple • Establishing mutually satisfying marriage • Relating with kin network • Family planning 2. Early child – bearing family • Integrating new baby in to the family • Reconciling conflicting developmental task and needs of individual family members • Maintaining satisfying marital relationship • Expanding relationship with extended family 3. Family with preschool children • Nurturing and socializing children • Integrating new member (newborn) into the family while still meeting needs of older children • Maintaining healthy relationship with marital partner , children , extended family and community members 4. Family with school age child • Socializing children • Promoting school achieving • Maintaining satisfactory marital relationship • Meeting health needs of the family members 5. Family with teenagers • Balancing teenage freedom and responsibilities • Maintaining open parent child communication • Focusing more attention on the marital relationship

• Building a foundation for future family stages 6. Launching family • Releasing children as young adults • Continuing to renew and readjust in the marital relationship • Assisting aging and ill parents of the husband and wife 7. Middle age family • Strengthening the marital relationship • Sustaining relationship with parents and children • Providing a healthy environment • Cultivating leisure time activities • Adjusting to retirement • Maintaining satisfactory living arrangement • Adjusting to reduced income • Adjusting to health problem • Adjusting to death of spouses • Maintaining intergenerational family ties • Continuing to make sense of one’s life Bowen’s family theory:This theory views each family as being within a multigenerational context and suggest that pattern of family interactions end to repeat themselves over generations. Eight interwoven concepts capture the familial and emotional interaction pattern they are; differentiation, triangulation, family projection process, multigenerational transmission process, nuclear family emotional system , sibling position, emotional cutoff and social regression. Due to centrality of differentiation concept , key element related to differentiation are described. Differentiation Is the process of unfolding ,growth and maturation, leading to a balance between emotional and intellectual components. A summary of key elements of the concept notes that Bowen view person’s as having both an emotional and an intellectual level of functioning. The emotional level is associated with lower brain centers and relates to feelings. The intellectual level is associated with the cerebral cortex or higher brain centers and relates to cognition. The degree of connectedness between emotional and intellectual system of a person dramatically affects the person’s functioning, especially in social circumstances such as family. Low level of differentiation:When there is low level of differentiation the person is governed by emotions , acts impulsively , has difficulty in gratification ,cannot cannot step back and analyze a situation therefore reacting and cannot maintain intimate interpersonnel relationships. Moderate level of differentiation:A person at this stage of development is less dominated by the emotional system. However emotions dominate much of the persons relationships. Intellectually the person tend to engage dualities thinking. The person views the world in terms of black and white things are either good or bad, people are smart or stupid , loved or rejected. High level of differentiation:People at a higher level of differentiation have a balance between emotions and intellect. These people express emotions and understand at the same time. They are able to feel anger and step back from anger to understand what caused it. The people are able to temper anger by using intellectual functioning. Family dynamics and level of differentiation:Family takes on a character that reflect the level of differentiation of the adult family members. Families whose adult members operates at a low level of differentiation exhibit impulsive patterns of interactions. They make decision without thinking through the effects and consequences. They relate on an emotional level. They often exhibit spousal abuse and other forms of violence, as they are unable to use intellectual powers to

check an emotion as strong as anger . A family whose adult members are developed to a moderate level of differentiation exhibits rigid patterns of interactions . the family is bound by rules and orders. Each members were expected to have defined roles, and the family does not tolerate any variation in the expected behavior or roles. In contrast a family whose adult members have developed to a higher level of differentiation is flexible in its interactions. The family actively seeks to support all of its members. Because the adult are able to see the world from another person’s perspective , the family understands each member to develop differently from one another the family roles are assigned on the basis of knowledge , skill and interest. Triangulation:Triangulation is most commonly used to express a situation in which one family member will not communicate directly with another family member, but will communicate with a third family member, forcing the third family member to then be part of the triangle. The concept originated in the study of dysfunctional family systems, but can describe behaviors in other systems as well, including work. In the family triangulation system the third person can either be used as a substitute for the direct communication, or can be used as a messenger to carry the communication to the main party. Usually this communication is an expressed dissatisfaction with the main party. For example, in a dysfunctional family in which there is alcoholism present, the non-drinking parent will go to a child and express dissatisfaction with the drinking parent. This includes the child in the discussion of how to solve the problem of the afflicted parent. Sometimes the child can engage in the relationship with the parent, filling the role of the third party, and thereby being "triangulated" into the relationship. Or, the child may then go to the alcoholic parent, relaying what they were told. In instances when this occurs, the child may be forced into a role of a "surrogate spouse" The reason that this occurs is that both parties are dysfunctional. Rather than communicating directly with each other, they utilize a third party. Sometimes, this is because it is unsafe to go directly to the person and discuss the concerns, particularly if they are alcoholic and/or abusive. Family projection process:The process describes the situation where adult family members deal with theirown anxiety inrelationship by projecting the anxiety on to a child. Multigenerational transmission process:When this family projection process goes through successive generation it is called multigenerational transmission process. When the Family projection process target one child , that child is believed to have limited chances of reaching higher level of differentiation. Therefore this child is likely to choose a partner with a similar low level of differentiation & the family pattern will continue across generation. Nuclear family emotional system:It describes how a family manages anxiety . Besides projecting the anxiety into a child the family manages the anxiety through marital conflict. Sibling position:It plays a role in the analysis of expected behavioral characteristics based on the birth order. Bowen observed that there is a tendency for sibling in certain position to assume certain roles and behaviors such as older children being and responsible & taking in the role of care taker of the other children & sometimes taking on the role of adult family member. Emotional cutoff:This term used for a family members effort to distance self from family to reduce anxiety. Societal regression:Is used to describe the process of how intense anxiety leads to emotional based decision. Family interactional theory:The family interactional approach stems from symbolic interaction as applied to the family by Fill and Hensen , Turner, Rose and others. In the family interactional approach the general focus is one the way in which family members relate to one another. Thus the family is viewed as a set of interacting personalities , and internal family dynamics and the relation between the individual and the family group is addressed in detail.

Schraneveldt explains that within the family each member occupies position where a number of roles are assigned . The individual perceives norms or role expectation held individually or collectively by other family members for his behaviors or attributes.… It is this tendency to shape the phenomenal world into roles which is the key to role taking as a crone process in interaction. An individual defines his role expectations in a given situation in terms of a reference group and by his own self conception. Individual family members family role play. The family And its individual family members are studied through the analysis of overt interactions each family is not only supported but limited by family life pattern which has involved in its interaction in society . through this limitation or support , each family in interaction process achieves its own temper or rhythms of family living. A unique, differentiating characteristics of the international approach is that it is based on the action of the family resulting from communication process. It views family behavior as an adjustive process , cues are given , individual members respond to these stimuli. In other words the interactional approach strives to interpret family phenomena in terms of internal dynamics. These processes or dynamics consist of role playing, status relation , communication pattern , decision making , coping patterns, and socialization , with the assessment of roles and communication processes forming the care of framework. Both personality and socialization are also viewed as central concerns of the interactional network. Family communication patterns:The effectiveness of family communication determines the family’s ability to function as a cooperative , growth producing unit , messages are constantly being communicated among family members , both verbally and nonverbally. The information transmitted influences how members work together, fulfill their assigned roles in the family incorporate family values , and develop skills to function in society. Intra family communication plays a significant role in the development of self esteem, which is necessary for the growth of personality. Family that communicate effectively transmits message clearly . members are free to express their feeling without fear of jeoparding their standing in the family . family members support are another and have the ability to listen , emphasis , and reach out to one another in times of crisis when the needs of the family members are met they are more able to reach out to meet the needs of others in the society. When patterns of communication among family members are dysfunctional, message are often communicated unclearly verbal communication may be incongruent with nonverbal messages. Power struggles may be evidenced by hostility, anger and silence. Research evidence 1. Shigeto, Aya., Mangelsdorf, Sarah., Brown, Geoffrey., Schoppe-Sullivan, Sarah. and Szewczyk Sokolowski, Margaret. "Parental and child influences on family interaction patterns"(2006) Paper presented at the annual meeting of the XVth Biennial International Conference on Infant Studies, Westin Miyako, Kyoto, Japan, Jun 19 Background and Aims: Family systems theory suggests that the family operates as a whole and that family members and relationships influence one another in a continuous, reciprocal fashion (e.g., Cox & Paley, 1997; Minuchin, 1988). Due to lack of research examining beyond individuals and dyads of the family, the goal of the current investigation was to explore how parental and marital characteristics prebirth as well as child characteristics were related to 13-months family interaction patterns. Methods: 55 expectant parents completed questionnaires about depression (BDI; Beck et al., 1961), traditional beliefs about paternal roles (a modified version of the Role of the Father Questionnaire; Palkovitz, 1984), and marital adjustment (DAS; Spanier, 1976). Child temperament (ICQ; Bates et al., 1979) and marital adjustment were assessed at 3.5 months postpartum, and family interaction was videotaped in the laboratory at 13 months. Based on the scales used to code family interaction (Lindahl & Malik, 2000; Paley, Cox, & Kanoy, 2000), we used two family interaction variables, sensitive engagement and family intrusiveness. Key Results and Conclusion: Fathers’ traditional beliefs about paternal roles were associated with less sensitive engagement, r = -.28, p < .05, and greater family intrusiveness, r = .35, p < .05. Difficult temperament was negatively associated with family intrusiveness, r = -.36, p < .05. Regression analyses indicated that when the child was temperamentally easy, families with more depressed fathers prebirth showed more intrusive behaviors

than families with less depressed fathers (beta = -.24, p < .05). When the child was easy, parents who viewed being a disciplinarian and a breadwinner as important roles for the father were more intrusive (for mothers, beta = -.28, p < .05; for fathers, beta = -.28, p < .05). Families whose marital adjustment decreased over the transition to parenthood were more detached when the child was easy (the effects were most specific to one of components of sensitive engagement, family detachment), whereas families whose marital adjustment did not change or increased were more detached when the child was difficult (beta = -1.09, p < .05). Taken together, these results suggest that prebirth and postbirth parental and child characteristics play important roles in shaping family interaction patterns. 2. Brook JS, Brook DW, Gordon AS, Whiteman M, Cohen P. The psychosocial etiology of adolescent drug use: a family interactional approach.Genet Soc Gen Psychol Monogr. 1990 May;116(2):111-267. The purpose of this monograph was to propose a framework, family interactional theory, for explaining the psychosocial aspects of adolescent drug use. Three themes are stressed: (a) the extension of developmental perspectives on drug use, (b) the elucidation of family (especially parental) influences leading to drug use, and (c) the exploration of factors that increase or mitigate adolescents' vulnerability to drug use. We present a developmental model with two components; the first deals with adolescent pathways to drug use, and the second incorporates childhood factors. The model was tested in two studies: one cross-sectional study of 649 college students and their fathers, and one longitudinal study of 429 children and their mothers. The subjects were given self-administered questionnaires containing scales measuring the personality, family, and peer variables outlined in the model. The results of each study supported the hypothesized model, with some differences between parental influences. We also found that individual protective factors (e.g., adolescent conventionality, parentchild attachment) could offset risk factors (e.g., peer drug use) and enhance other protective factors, resulting in less adolescent marijuana use. General Systems Theory: Provides social workers with a conceptual framework that shifts attention from a cause/effect relationship of paired behaviors, to a broader environmental etiology of behavior  Observes the following: o A person is only a piece of their entire life situation o Dynamic interactions between person, systems and environments o Functionality as an individual and a system  It is not enough for the social worker to simply assess the client and then the environment, but the dynamic processes must be integrated into a biopsychosocial hypothesis that reflects the presenting behavior within the context of ecological systems One of the Best Ways to view General Systems Theory is in the context of family life: a subsystem of the larger community system  The whole is greater than the sum of its parts  Changing one part of the system, results in changes to other parts of the system  Families become organized and developed over time. Families are always changing and, over the life span, family members assume different roles  Families are generally open systems in that they receive information and exchange it with each other with people outside the family. Families vary in their degree of openness and closedness, which can vary over time according to circumstance  Individual dysfunction is often reflective of an active emotional system. A symptom in one family member is often a way of deflecting tension way from another part of the system and hence represents a relationship problem (I.E. the identified patient) Four key Domains of Environmental Interactions  Situation: The part of the environment that is accessible to an individual’s perception at any given moment of time  Micro: The part of the physical and social environment that the individual has direct contact with and can interact with in daily life

 Mezzo: The part of the environment that in some way or other influences and determines the character and functioning of the micro environment  Macro: Common to most members of groups living in it and involves physical, social, cultural, economic, and political structures of the larger society Rules & Roles in General Systems Theory o Rules can be conscious and unconscious  Often times the unconscious rules have more impact on social exchange  Boundaries: Both physical and unconscious o Roles: Adopted within the family systems in order to maintain equilibrium  Role Contiguity: Whether Peter’s expectations of Peter’s behavior is the same as Susan’s expectations of Peter’s Behavior  Role Competency:Does one have the skill or knowledge to meet prescribed role expectations and does the person understand their role  Role Conflict: Demands of two roles conflict with each other…example: being a mother and a full-time student Structural Family Theory (Minuchin): Basic Goal: By changing the structure of the family, both the behavior and intrapsychic processes of the family will be changed.  This theory is very concrete, based upon the here and now, and a very involved social worker  It Consists of Seven Basic Premises o Focuses on Concrete Issues o Located in the Present o Mediated through Client’s Experience o Based on Reorganizing the Structure of Family Relationships o Built upon Client Strengths o Aimed at Palpable Outcomes o Active Involvement of the Social Worker  Focused on Concrete Issues: o The social worker addresses the most urgent issue that has the families attention first  This is considered the most compelling concern.  Success breeds success o The concrete issue can be anything as long as it is of the utmost concern to the family o Look for motivations behind actions and tie these motivations into interventions as they will increase the likelihood of success o Spirituality, Existential Meanings, Key Relationships…whatever works….think practical  Located in the Present  The past is accessible through the present, as current behaviors are related to past interpretations…there is no need for regressional work  The client issue contains the focal point of today’s concern, the dynamics currently generating the distress, and traces the family history that explains the why and how of the problem’s birth.  Be remedying and changing the current structure, past memories, perceptions, and psychological residue are alleviated.  Mediated through the client’s experience  The primary model of intervention is enactment of their issue in session…there is less focus on the verbal recount of a situation as noted in traditional family therapy.  The structural family social worker seeks to understand the unique experience of each individual within the context of the presenting concern and looks for areas of convergence and divergence in experience.  Based upon Reorganizing the Structure of Relationships

 The social worker pays close attention to the structure of the family in context of the presenting concern  Boundaries: What defines who is in or out of a family relationship in the context of the focal issue, as well as what their roles are in this interaction  Alignment: Who is with or against the other in the transactions generating the problem  Power: What the relative influence is of the participants in the interactions that contributes to the presenting problem  Alignments, Coalitions, Disengaged Families, Enmeshed Families  Look for the etiology of problems • Conflicting feelings and needs • Weakly organized relationships • Both  Encourage adaptive structures in family dynamics.  Built Upon Strengths  Identify current and underutilized family strengths/ resources to assist in alleviating the presenting concern.  Integrate these strengths and resources within the family structure or relating  Look to draw the good out of the bad  Characterized by Active Social Work Involvement  Join the family interaction in a carefully planned, goal directed way  The social worker may purposefully draw attention to the area of conflict to increase the emotional dynamics of the family system  The social worker may purposely block pathological interactions within the family systems and force the family members to develop new methods of communication/interaction  Supports adaptive behaviors  Intensive use of “self” in the therapy process  Assignment of homework…practicing a specific skill to change family structure. IMPACT OF ILLNESS ON THE CLIENT AND FAMILY:Impact of illness is not an isolated event. The client and the family deal with changes resulting from illness and treatment. Each patient respond uniquely to illness and therefore nursing interventions must be individualized. The client and family commonly experience behavioral and emotional changes as well as changes in family life, roles , body images and self concept & family dynamics Factors determining the impact of illness on the family: The nature of illness which ranges from minor to life threatening  The duration of illness , which ranges from short term to long term  The residual effects of illness, including none to permanent disability  The financial impact of the illness, which is influenced by factors such as insurance and ability of the ill person to return to work  The effect of illness on future functioning Behavioral and emotional changes:People react differently to illness or threat to illness. Individual behavioral and emotional reactions depend on the nature of illness. Clients attitude towards it, the reaction of others to it & variables of the illness behaviors. Short term non life threatening illness evoke few behavioral changes in functioning of the client/ family. A husband or father who have cold, for example may lack energy and patience to spend time with family activities and may be irritable and may prefer not to interact with family. This is a behavioral change but the change is subtle and does not lost long . some may even consider such a change as normal response to illness. An individual’s emotional state, as well as attitude towards the loss of health and well being tends to vary . STRAIN identified several psychological reactions that a person may experience after the diagnosis of illness. 1. Loss of control or one’s body that threatens self esteem and sense of body wholeness

2. Fear that illness and dependent others will cause significant others to withdraw love & general approval of the person 3. Loss of independence and loss of control over body functions 4. Anxiety because of separation from loved ones and familiar environment due to hospitalization 5. Fear of loss of or injury to body parts 6. Guilt of fear of retaliation from family for having incurred the health problems in the first place 7. Fear of pain 8. Fear of strangers providing intimate care The 5 stages of emotional reactions:1. Denile or disbelief: avoids discussion on illness. “there is nothing wrong with me” is the answer 2. Anger : client blames and complaints “I often directs anger towards god or others” 3. Bargaining :client or family members promises to live better life in exchange for promise of good health 4. Resolution :client or family members begin to express openly realizes that illness has created changes in life 5. Acceptance : client recognizes reality of condition strives for independence. Family behavior: according to BROOKS:BROOKS identified 3 types of family behaviors that sometimes emerges in the family limits of the ill client. 1. A rejecting family:- makes no place for the client. The family members are capable of carryout the family routines without any regard to the persons needs. Other members are united and exclude the ill person. This can lead to divorce or institutional placement. 2. Scarifying family :- in which the client becomes the centre of all family members. They over emphasis his needs and support . They become over protective and anxious and foster the dependent behaviors. Family members may force their opinion without regard for clients interest ,personal plans resulting in client regression , depression, filling of helplessness and anxiety. 3. Natural family :- it is the traditional family setup where they know what is the needs of the patient and they attend the needs of the individual when ever they require. Flexibility and good communication skills are necessary to overcome many physical, psychological and social barriers. Good adjustment can be made after few weeks of diagnosis. The family participations result in better ability to cope with disability and illness. Impact of family life:Those people who closely associated with the ill person may feel relief and depressed. Not all the members of the family work through the stages of grief at the same rate. One griever may be in a state of shock , where as the other may be depressed. As each person goes through an action mental stage, the family system as a whole proceeds through intensive changes. Serious of prolonged illness is a common source of stress , posing major problems of adjustments for both client and family. Severe injury , diagnosis of chronic illness and resultant disabilities also can mean catastrophe for the family as well as the individual family members . Impact on Body image:Severe illness particularly those that are life threatening that are life threatening can lead to more extensive emotional and behavioral changes , such as anxiety, shock, denial, anger, withdrawal . There are common responses to stress of illness. The nurse can develop interventions to assist the client and family coping with and adapting to this stress because the stressor itself have great impact on body image. Body image is the subjective concept of physical appearance and client and families react differently to these changes. Those reactions of client and family to changes in body image depend on following the type of changes, the adaptive capacity , the rate at which the change take place ,support services available when a change in the body and body image occurs such as result from a leg amputation , the client generally adjust in the following phase , shock withdrawal acknowledgement phase. They accept the loss. During rehabilitation the change in the body image through use of prosthesis or changing lifestyle and goals. Impact on self – concept:-

Self concept is a mental self image of strengthened weakness in all aspect of personality. Self concept deepens impact on body image and roles also include other aspects of psychology and spirituality. The impact of illness on self concept of client and family members may be more complex and less readily observed than role changes. Self concept is important in relationship with other family members. A client whose concept changes because of illness may no longer meet the family expectations leading to tension or conflict. As a family members change their interaction with the client. In the course of providing a care a nurse is able to observe changes in the self concept of the family members and develop a care plan to help them adjust to the change resulting from illness. Impact on family roles:. . All family members were subjected to social and psychological stress and may find themselves undergoing a adjustment process as they respond to changing roles and functions within family unit. Role reversal also common . if a parent of an adult child become ill and cannot carryout initial activities the adult after assessing many of parents responsible for and in essence become a parent to parent. Such a reversal of usual situation becomes a stressful event and such a change may be subtle and short term /long term. And individual and family generally adjust more easily to subtle/short term changes. In most cases the role changes in comparing and will not require prolonged adjustment phases. Long changes however require an adjustment process similar to the grief process. The client and family often require specific counselling and guidance to assist them in coping with role changes. • All family members are subjected to social and psychological stress and may find themselves undergoing an adjustment process as they respond to changing roles and functions within family unit • Problems associated with child care and discipline come about us changes in living routines need to be made • Dietary and sleeping pattern are disturbed • Problems associated with the lack of consistent authority , figure arise when siblings are expected to care for the younger brothers and sisters Research evidence Wilcox-G,k, Virginia. "The Impact of Illness on Family Labor Supply and Earnings" (2006 ) Paper presented at the annual meeting of the Economics of Population Health: Inaugural Conference of the American Society of Health Economists, TBA, Madison, WI, USA, Jun 04, As the population of the United States ages, Alzheimer’s disease has become, and will continue to be, a major public health concern. Because of the millions of individuals afflicted by AD, there are many more millions of family members indirectly burdened by the disease. The goal of this research is to estimate the indirect effects of illness on the labor market outcomes of family members. Cost-of-illness studies examining labor market costs have generally focused on the primary caregiver and used small data sets that are not representative of the United States population. In this research, we estimate the labor market effects of illness for all family members using data from the Medical Expenditure Panel Survey (MEPS). MEPS is a large, nationally representative data set that contains information describing labor force outcomes, sociodemographics, and medical diagnoses and measure of severity of illness. By are able to link the records of persons living in the same household, thereby permitting examination of the effects of Alzheimer’s disease on the labor market outcomes of family members. Our measures of labor market outcomes are labor force participation, employment, hours worked, and earnings. First we estimate a wage equation for all employed family members and predict a market wage for individuals who are not employed. We then estimate the effects of illness on labor force participation, employment, hours of work, and earnings using the predicted wage in a model allowing self-selection out of the labor force. This analytical model controls for the endogeneity between the market wage rate and the decision to be a fulltime caregiver. Our preliminary findings indicate that the presence of a family member with Alzheimer’s disease increases the probability that a woman will drop out of the labor force. Further, among women who work, the presence of a family member with Alzheimer’s disease has a negative effect on weekly hours of work and annual earnings. In comparison, while men’s labor force participation is unaffected, we find that the average effect for men is to increase hours of work per week and increase annual earnings. This is the first empirical evidence that male

family members respond to the family member’s illness by increasing hours of work. Our results indicate that average family earnings fall, reflecting the relatively larger magnitude of the effect on women’s earnings. By examining the effects of the disease on all members of the family, rather than solely the primary caregiver, we provide a broader and more accurate picture of the family burden of illness. Our estimates demonstrate that there is substitution among family members to compensate for lost market earnings when one member reduces labor supply to provide caregiving. However, this compensation is insufficient to totally offset the loss in family earnings. Impact on family dynamics:Because of the effect of illness on the client family dynamics often change. Family dynamics is a process by which the family functions , make decision ,give support to the individual members and cope with everyday changes. If the parent in the family becomes ill, family activities and decision making often come to halt. As family members are inactive due to fathers illness to pass or delay action because of the relatedness to assess ill parent role. Because of all these stress and reaction , family dynamics always change. The nurse must view the whole family as a client under stress , planning care and help the family to regain its maximum level of functioning. Social stigmas:Illness and economic stress placed on the family can lead to decreased social mobility. If the breadwinner of the family become sick the older adult member of the family has to take care of the financial status of the family. It will create a great stress and tension to other family members. The impact of illness can be taken it have positive or negative aspect is depends upon the family vulnerability to stress. Their responses and interactions can lead to overprotection , negligence , avoiding giving care of the sick etc. EFFECT OF ABUSE ON FAMILY DYNAMICS Abuse, neglect and trauma always take place in a social context. The impact of abuse is not limited to the person who has been abused. One prominent impact from the perspective of family systems is the limitation on available roles within the family or abusive system. The constraints on family roles which take place in families in which one member is addicted (hero, scapegoat, lost child, mascot etc.) is the same kind of constriction happens in families in which one person has been abused — whether or not the abuser is part of the family. A number of people have suggested that the roles available to members of families where abuse is a factor can be summarized by looking at three primary roles: victim, abuser, hero/messiah and non-protective person. None of these three roles is healthy. They are all best understood as part of the abusive system. One of the more important things to observe about the abusive system is the relative ease with which people within the system can change roles. Because each of these roles is part of the abusive system, they all are painful to experience. And so people often try to switch roles, hoping that one of the other roles will be less painful. Here are short descriptions of all available options–notice the obvious, they are all bad options: Bad Options for a Victim

A Victim can become a Non-Protective Person. Example: someone who was sexually abused by a father who finds themselves later in life unable to protect their children from their grandfather. • A Victim can become an Abuser. Some people talk about this as an attempt to find a more powerful role. “I’m tired of being the victim. I need to be more powerful than that. I can fight back.” Others think of this as a kind of returning to the scene of the crime–returning to an abusive situation but in a more powerful role. This is what Sandra Wilson is getting at in her book “Hurt People Hurt People.”

A Victim can become a Hero/Messiah. Example: someone who prematurely seeks to turn their own painful experiences into ministry to others. The focus on others can truncate the healing process. There’s nothing wrong with helping others but if it is a way to avoid doing my own recovery work, then the results are not pretty. Bad Options for a Hero/Messiah

A Hero/Messiah can become a victim. Example: I have worked myself to death rescuing victims and sometimes they don’t even appreciate all my sacrificial giving. In fact some of them resent me. I’m starting to feel like I’m the victim here. • A Hero/Messiah can become a Non-Protective Person. I call this the ‘trajectory of the burnt out social worker’. Example: “I’ve been giving too much for too long and I’m just not able to care anymore. I’m resentful at people who have not appreciated my work. And I’ve learned my lesson . . . I’m not going to be a hero anymore. I can’t fix this and I’m not going to pretend that I can. I’ll do what I’m required to do but that’s it. I can’t protect everyone anyway. And a lot of them don’t even want to be protected.” • A Hero/Messiah can become an Abuser. Think of a spouse of someone who was sexually abused as a child. When it first becomes apparent that abuse is part of their spouse’s story, they commit themselves to being the perfect spouse. “My spouse needs me now more than ever. I’m going to be really strong and really helpful and really good.” But over time you get tired. Hurtful things are said. You are getting hurt. . . and you need to defend yourself. The once strong, helpful, good person can eventually find themselves doing things which the Victim says are hurtful. Even if they do no actual harm. . . they have made the move from the hero/messiah role to the abuser role.

Bad Options for an Abuser

An Abuser can become a Non-protective Person. When an abuser starts to feel threatened, they may try to find safety by distancing themselves from the whole situation. “This is not my problem. I can’t help you with this. I can’t protect you from whatever you think is going on.” When neither the hero role nor the victim role are available, this may become an attractive transition for someone who feels stuck in the abuser role. • An Abuser can become a Victim. The most common response of abusers when their abuse becomes known is to argue that they are really the victim. People are accusing them falsely. People are hurting them by thinking such evil things. When the abuser role becomes painful it feels safer to compete for the victim role. If an abuser was abused earlier in life this sense of entitlement to the victim role can be particularly strong. • An Abuser can become a Hero/Messiah. The classic example of this is domestic violence. Immediately after a violent episode the abuser will typically be full of remorse, will promise that it will never happen again and will be determined to be the best husband ever. None of this represents a move towards health. It

is just a move from the abuser role to the hero/messiah role. It is a move within the system — not a step outside of the system. Bad Options for a Non-Protective Person.

Person can become a Victim. Think here about a mother who was unable to protect her children from being sexually abused by their grandfather even though she knew they were at risk. The abusive system may seek to reassign this mother to the abuser role (see below) but this effort will be resisted by the non-protective parent who may argue that they are really the one who has been betrayed. They may insist that they are just as much a victim in this situation as the children. This may, of course, have some truth to it. But the move from non-protective person to victim does not represent any progress. Both roles are part of the abusive system. • A Non-Protective Person can become a Hero/Messiah. Earlier I characterized the transition from Hero to Non-protective Person as the ‘trajectory of the burnt out social worker.’ A transition in the opposite direction is what can happen when a burnt out social worker (or pastor, or spouse or whatever) finds a way to recharge their batteries. They take a break, find some more energy and get right back into the battle. The experience of burn-out does not always lead to substantive change. We may just rest, recharge and plunge as soon as possible back into the same role which lead us to burn-out in the first place. • a Non-Protective Person can become an Abuser. A person in the non-protective role is always at risk of being reassigned to the abuser role. “If you didn’t stop it, you are just as responsible. If you didn’t know, you should have known.” Note that a person does not need to act abusively to be assigned to the abuser role. These are roles — the system rarely feels an obligation to be fair when role assignments are made. There are three main reasons for taking the time to focus on roles in abusive systems. First, it is important to emphasize again that all of these roles are grace-less, hurt-full roles. None of them provide people what they really need and long for — to love and be loved. But they are very powerful roles as well. Once in an abusive system it will take significant effort to imagine other ways of being in the world. Second, it is important to say the obvious: changing roles has very little to do with healing. Changing roles is a classic rearranging the deck chairs on the Titanic kind of thing. Moving to a different role may seem to provide some respite from the pain of our current role, but the respite is temporary at best. Any healing will require finding a way to get ‘outside of the box’ of abusive systems. That presents an obvious problem: when you are inside the box, the inside of the box is all you can see. It may be literally unimaginable that things could be different. That is why recovery is not something we can do by ourselves. We just can’t see what we need to see. We need other people to help us. Finally, if you are a pastor or other person in a caring role, you will be invited to participate in systems of this kind — typically the invitation will come as a recruitment for the vacant position of hero-messiah. If this seems like a wonderful invitation to you — like an invitation that is a good match for your gifts and interests — then you will be in significant danger of becoming part of the abusive system. And once part of the system you will find it extremely difficult to be helpful. Even if you are aware of your limitations and conscious of the dangers of becoming part of abusive systems, people inside the system will experience you as if you were part of the system. And, if you are not really, really good at the hero-messiah role you may find that you are at risk of being reassigned to a different role within the system. Finding a way to speak truth and offer hope in the context of abusive systems without becoming enmeshed in the abusive dynamics is not easy. Possible. But never easy.

•A Non-Protective

FAMILY COPING MECHANISMS:“Family coping mechanisms are the behaviors the family uses to deal with the stress or change.” Coping mechanisms can be viewed as “an active method of problem solving developed to meet the life’s challenges. The coping mechanism the individual and the family uses reflect their individual resourcefulness.” Family may use the same coping mechanism rather consistently overtime or may change their coping strategies when new demands are made on the family. Coping is a basic function that helps the family meet the demands imposed from both within and with out. The success of the family depends on how well it copes with the stresses it experiences.

Family Coping • • • • Continual demands force families to adapt in order to survive Without effective family coping processes, affective, social, economic & health care functions cannot be achieved. Nurses can assist families to adapt. Goal: to strengthen & encourage adaptive responses & reduce stressors on family.

• An active process where the family utilizes existing family resources and develops new behaviors and resources to strengthen the family unit and reduce the impact of stressful life events. (McCubbin, 1979). • A family crisis results when current resource and adaptive strategies are not effective in handling the stressors. Family Adaptation • • Involves restructuring of family patterns of functioning. “the process in which families engage in direct responses to the extensive demands of a stressor, and realize that systemic changes are needed within the family unit, to restore functional stability and improve family satisfaction and wellbeing” McCubbin & McCubbin (1993, p.57).

Stressors & Their Impact • • • Most widely used tool to assess life changes in families is Family Inventory of Life Events & Changes (FILE). Families with higher scores have been found to have lower family functioning and poorer health (McCubbin & Patterson, 1991). Five most stressful life events are: (1) a child member dies (2) parent or spouse dies (3) spouse/parent separated or divorced (4) physical or sexual abuse in the home (5) member becomes physically disabled or chronically ill Family Coping Strategies

• • •

Are stressor specific (e.g. cognitive strategy of “accepting the situation” may be helpful to those who have lost a job, but not to couples coping with infertility). Most harmful coping behaviors: suppressing emotions; taking out feelings on others; not sharing extent of stressor with others; denying, avoiding, or running away from problems. Internal Strategies (from within the family) (1) Relationship (2) Cognitive (3) Communication

External Strategies (outside supports & resources) (1) Community links (2) Social Support systems (3) Spiritual

Internal Strategies 1.Relationship Strategies Family Group Reliance (cohesiveness) • • • • Some families cope by becoming more reliant on their own resources “Pulling together to weather the storm” Establishment of greater structure (more rigid routines) to increase control in their lives Closing of family boundaries

Greater Sharing Together • • • • • • Sharing of feelings and thoughts Strengthening of family cohesion Very high cohesion = enmeshed Very low cohesion= disengaged Level of cohesion influenced by culture Family rituals helpful (e.g. shiva)

Role Flexibility • • Ability of mates to change or share roles when needed is important Flexible roles associated with better functioning

2. Cognitive Strategies Normalizing • • • Acknowledging a chronic condition, but defining family life as normal View the social effects of having a member with a chronic condition as `minimal’ Families who coped this way do better than those with focus on sick member

Reframing & Passive Appraisal • Positive outlook & maintaining hope key to resiliency

• • • •

Influenced by family beliefs Beliefs shape how families experience and interpret their environment Religious beliefs play important role Passive acceptance of situation helpful to some families, especially where situation inevitable.

Joint Problem Solving • • Family able to discuss a problem, seek logical solutions, & reach consensus on what to do Collaborative problem-solving approach

Gaining Information & Knowledge • • • Increases sense of control and fear of unknown Provision of information a major nursing intervention Assisting family to use Internet effectively to gain accurate information important nursing role

3. Communication Strategies Being Open & Honest • • Good communication vital during periods of stress or crisis Communication must be direct, clear, open, & honest

Use of Humor • Humor & laughter invaluable in coping & can bolster immune system

External Family Coping Strategies 1. Maintaining Active Links with Community • Continuing long-term associations with clubs, organizations & community groups

2. Social Support Strategies • • In addition to extended family & network of health care professionals, there are neighbors, employers, classmates, teachers, & cultural or recreational groups as potential supports Many people don’t seek needed external supports for variety of reasons

3. Spiritual Strategies • Spiritual or religious beliefs often at core of a family’s ability to cope

Dysfunctional Coping Strategies • Can temporarily reduce stress, but do not solve the problem and have long-term deleterious effects.

(1) Denial of Family Problems (2) Family Dissolution & Addictions (3) Family Violence (1) Denial of Family Problems

• • • • • •

Scapegoating reduces tension in family at expense of one member Scapegoat becomes focus of family’s problems, hiding the real problem but results in state of equilibrium Scapegoat begins to take on the assigned role & internalizes it Triangulation – used to reduce tension in a dyad by focusing on a third member Emotional distancing – creation of a façade of cohesiveness; affective communications very limited Extreme authoritarianism /submissiveness to achieve family equilibrium

(2) Family Dissolution & Addictions (3) Family Violence /abuse Factors influencing the effectiveness of coping: The number , duration , and intensity of the stressors  Past experiences of the individual  Support systems available for the individual  Personal qualities of the person Research evidence Bossert E. Factors influencing the coping of hospitalized school-age children. Journal of Pediatric Nursing. (1994). Oct;9(5):299-306. Factors influencing the coping process in hospitalized children were examined by studying the effect of health status (acutely or chronically ill), gender, and trait anxiety on the coping behaviors used in response to intrusive hospital events and the perceived effectiveness of the overall coping process used during hospitalization. The sample consisted of 82 children, age 8 through 11 years, hospitalized in an acute care pediatric unit in one of six California hospitals. Data were obtained on the second or third day of admission, through interview, word graphic rating scale, and State-Trait Anxiety Inventory for Children (STAIC). Significant results indicated that acutely ill children are more likely to perceive their coping as effective than are chronically ill children, and children with low trait anxiety are more likely to perceive their coping behaviors as effective than do those with high anxiety. Types of coping stratagies:Two types of coping strategies have been described : • • Problem focused coping refers to efforts to improve a situation by making changing or taking some action. Emotion focused coping include thoughts and actions that relieve emotional distress. It will not improve the situation but the person often feels better

Nurses working with the families realize the importance of assessing coping mechanisms as a way of determining how families relate to stress. Also important are the resources available to the family. Internal resources such as knowledge , skill, effective communication pattern, and a sense of mutuality and the purpose with in the family , assist in problem solving process. In addition external support system promote coping and adaptation. These external systems may be extended family, friends , religious affiliation , health care professionals and social services. The development of social support system is particularly valuable today because many Families , due to stress , mobility or poverty, are isolated from resources that would help them to cope.

Another classification: • Long term coping strategies can be constructive or realistic. For example , incertain condition talking with other about the problem and trying to findout more about the condition are long term stratagies. Other long term strategy include those that involve a change in the life style pattern such as eating a balanced diet, exercising regularly etc… • Short term coping strategies can reduce stress to tolerable limit temporarly but are in long run ineffective way to deal with reality. They may even have a destructive or detrimental effect on the person. For example use of alcoholic beverages , or drugs , day dreaming and fantasizing, relying on the belief that every thing will work out, and giving into others to avoid anger. • Coping can be adaptive or mal adaptive. Adaptive helps the person to deal effectively with stressful events and minimizes distresses associated with them. Mal adaptive can result in unnecessary distress for the person and others associated with the person or stressful event. INVOLVEMENT OF NURSE OR NURSE’S ROLE IN THE FAMILY:A nurse plays a great role in the functioning of the unit in the hospital as well as in the community. A comprehensive assessment leads to formulation of nursing diagnosis with two major areas.  That those focus on the family unit ,and  That those emphasis the individuals with in the family The diagnostic statement of altered family process should be used for the normally healthy family unit, that is challenged by the stress of the acute or chronic illness. Some of the family behaviors include , verbal outbursts , interference with necessary treatment , inappropriate communication patterns and verbalization of the fear , anxiety or anger. In nursing diagnostic statement of ineffective family coping should be used when the behavior of the family is considered to be destructive like neglecting or abusing of a family member , depression, agitation ,hostility distortion of reality and aggression. Nurse encourage the patient to take active participation in identifying their health needs and solving their own problems. Nursing rounds are one method of encouraging patient participation. He is urged to identify his external and internal resources and to capitalize on these strength during hospitalization and when he returns to the community. During each contact with the psychiatric patients nurse gives both formal and informal patient education. She can conduct group education program to give community living skills , re –socialization skills and assertiveness training. The therapeutic family communication is one of the ways where a nurse can extend her care . The nurse can adopt a systematic interaction of 4 stages: a. Engagement(orientation) b. Assessment c. Intervention d. Termination Assessing the health of the family:The purpose of family assessment is to determine the level of family functioning, clarify family interaction pattern , identify family strength and weakness , and describe the health status of the family and its individual members. Also important are the family living pattern, including communication,childrearing , coping strategies , and health practices.

Family assessment Guide:• Family structure  Size and type  Age and sex of members • Family roles and functions  Family members working outside the house and the type of work and their satisfaction  Household task and responsibilities and how tasks are distributed  Ways childrearing responsibilities are shared  Major decision maker and method of decision making’  Family members satisfaction with roles • Physical health status • Interaction pattern  Ways of expression of affection , love and sorrow, anger and so on  Most significant family member in person’s life  Openness of communication with all family members • Family values  Cultural and religious practices  Use of leisure time( whether it is used with all the family members)  Families view on education , teachers and school system  Health values( exercise , diet and preventive measures ) • Coping resources  Degree of emotional support offered to one another  Availability of support persons and affiliations outside the family( friends , church membership etc)  Methods of handling stressful situations and conflicting goals of the family members  Financial ability to meet the current and future needs Intervention The health task of the family are the nurse’s primary concern. The health tasks are the following:  Recognizing ,interruption of the health development such as failure to thrive  Making decision about seeking healthcare concerns  Dealing effectively with health and non health crisis  Providing health care services to the sick , disabled or dependent members of the family  Maintaining a home environment conducive to health maintenance and personal development  A nurse must keep the family in focus through out its life cycle  See family members in interactions with one another  Observe the ways in which the family members and the family unit influence each other  Recognizing what a given family experiencing at a particular time  Identify the critical periods of growth and development for both individual family members and family  Recognize the commonalities and variations among the life cycles of families  Respect the way in which culture and family influence each other  Forecast what a family will be experiencing at any period of its life cycle Instructions to improve family dynamics Step1 Reconsider your roles. If you're feeling resentful because you're always the one who cleans the house, makes dinner, disciplines the kids or helps with homework, for example, switch responsibilities from time to time to get out of the rut. Step2

Eliminate labels in your family. If you constantly call your kids dramatic, shy, unreliable or selfish, for example, they may subconsciously live up to those reputations. Allow family members to act and express feelings without worrying that you'll pigeonhole them because of it. Step3 Give your children the opportunity to establish their own identities and make mistakes along the way. If you micromanage their lives and give them the third degree whenever they make a decision or attempt to exert their independence, they may rebel or become secretive, leading to family conflict. Step4 Be open and honest with one another to stimulate interesting and valuable family conversations. Learn to trust, support and really listen to each other. Discuss your differences until you're satisfied with the outcome instead of walking away angry. Forgive each other for prior arguments. Take the time to talk even amidst your hectic daily schedule. Step5 Schedule regular "family nights" and put work, school, friends and cellphones aside and devote your attention to the rest of the family. Cook dinner, watch movies, play games or sing karaoke, for example. Learn to be silly with one another, laugh and make happy memories that will improve the way you interact in the future. Step6 Consider consulting a family therapist if you've been experiencing power struggles, arguments, mistrust or resentment and can't seem to improve the family dynamics on your own. The nurse should identify the key issues invarious family life cycles and play a role of councilor , teacher, coordinator, facilitator, supervisor, supporter, care finder, referrer , and monitor of the health and welfare of the family. CONCLUSION:The family is superior to society in purpose and destiny , and must be recognized as being so. The family is the first source of support and comfort during wellness and illness.The good health of the society has therefore to begin with the good health by one’s family. BIBLIOGRAPHY:1. Bhushan Vidya. An introduction to Sociology. 31st edition .Kitab Mahal Agencies: Allahabad;1998 2. Rao C.N. Shankar.Sociology Primary Principles. 3rd edition.S chand & Company : Newdelhi; 2000 3. Haber. Comprehensive Psychiatric Nursing .4th Edition . Mosby Year book: United State;1992 4. Burgers Ann Wolbert . Psychiatric Simon and Schuster Company: Stamford; 1997 5. Hitch Cock Janice. Community Health Nursing Caring Action. 2nd edition. Thomson learning: USA; 2003 6. Pilli Heri Adele . Maternal And Child Health Nursing. 3rd edition:Philadelphia;1999 7. Park K. Preventive and Social Medicine.18th edition. Banarsidas Bhanot Tabalpur ;2005 8. Barbara Kozier. Fundamentals of Nursing .7th edition. Pearson education: Delhi;2004 9. Dr.C. M. Francis . Building healthy Families for a Healthy Society (May 2005). Health Action. 10. Louise Rebraca Shives, “Basic concepts of psychiatric mental health nursing” 6th edition, chapter-2, Lippincott Williams and Wilkins,page no.13-18. 11. (Surgery on girl born with eight limbs deemed a success) retrieved on 12. 02 2010 12. hl=en&source=hp&q=family+relationships&meta=&aq=4&oq= FAMILY retrieved on 12. 02 2010] 13. Bossert E. Factors influencing the coping of hospitalized school-age children. Journal of Pediatric Nursing. (1994). Oct;9(5):299-306. 14. Wilcox-G,k, Virginia. "The Impact of Illness on Family Labor Supply and Earnings" (2006 ) Paper presented at the annual meeting of the Economics of Population Health: Inaugural Conference of the American Society of Health Economists, TBA, Madison, WI, USA, Jun 04,209-210

15. Brook JS, Brook DW, Gordon AS, Whiteman M, Cohen P. The psychosocial etiology of adolescent drug use: a family interactional approach.Genet Soc Gen Psychol Monogr. 1990 May;116(2):111-267. 16. Shigeto, Aya., Mangelsdorf, Sarah., Brown, Geoffrey., Schoppe-Sullivan, Sarah. and Szewczyk Sokolowski, Margaret. "Parental and child influences on family interaction patterns"(2006) Paper presented at the annual meeting of the XVth Biennial International Conference on Infant Studies, Westin Miyako, Kyoto, Japan, Jun 19 ;112(6): 45-48


SUBMITTED TO: Mrs.Jasveena Mathias Asst. Prof NUINS

SUBMITTED BY: Ms. Shesly P. Jose I MSc (N) NUINS

SUBMITTED ON: 20.02.2010

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