Family Medicine & Community Health 2

Family System: Family Oriented Primary Care

Zorayda E. Leopando, MD, MPH, FPAFP | 04 August 2018 | Topic 1
Outline o A living arrangement in which an unmarried couple lives
I. Family Vs. Household together in a long term relationship that resembles a
A. Understanding the Family marriage.
II. Basic Premises of Family – oriented Primary Care
A. Types of Family Foster Parent Families
III. Family Oriented Practitioners o Families who take in children temporarily
IV. Tools for Family Assessment
V. Family Structure
Empty Shell Family
o A family in name only, where a couple continues to live
under the same roof but as separate individuals
o Separation is difficult for legal, religious or financial reasons
I. FAMILY VS. HOUSEHOLD o Couple decides to stay together for the sake of the children.
• Family Communal or Corporate Family
o Any group of people related either biologically, o Groups of families joined together, share properties, and
emotionally or legally look after each other’s children as if they were their own.
o The group of people that the patient defines as o Established with ideological purposes, based on sharing of
significant for his or her well being political, economic and religious beliefs.
o Family remains the most basic relational unit in II. BASIC PREMISES OF FAMILY – ORIENTED PRIMARY CARE
society
• Household 1.TRIPLE BURDEN DISEASE
• structure where people stays
• Non household family member can be important to patient 1. Communicable diseases
healthcare
• The household is more often than not the primary focus of
the family –oriented clinician’s care o Morbidity
o *yaya/ maid-not a member of the family but stays
in the household
2.Non-communicable diseases
• Joint family-2 families and only 1 cook for the family

Understanding the Family o Mortality

– First bullet
• What are your objectives in taking care of the family?
3. Diseases of industrialization and urbanization
• Is the family:
§ Healthy
§ At risk 1. Family- oriented healthcare is conceptualized within a
§ With Problem
Types of Family biopsychosocial framework
Nuclear family
• Husband, wife and biological or adopted children
2. The primary focus of healthcare is the patient in the context of the
Types of nuclear family family:
• Family of orientation
o The nuclear family into which the person is
• The family is the primary source of many health benefits
born or adopted
and behaviors
• The stress family developmental transitions may become
Family of procreation
•
manifest in physical symptoms-*emotional transitions
o the family one creates through, and following,
one’s marriage ex. Newly married couple because of adjustment
Extended Family
• Composed of two or more generations Adolescents with middle-age parents
of a kin that functions as an independent social and
economical unit. • Somatic symptoms can serve an adaptive function within
Blended/ Step Families the family and be maintained by family patterns
• A family in which one or both spouses have children from
*practices family usually do
previous relationships.
Single Parent family
• Includes only one parent, the mother or the father, who lives • Families are a valuable resource and source of support for
with the children. o Single parents may be divorced, the management of illness
windowed, unwed, or abandoned *family is always there to support us. Rotation of roles
o Widow: Husband died
o Widower: Wife died in taking care of the sick member
Cohabitation
3. The patient, family and clinician are partners in medical care

Transcribed by: Marmar, Tabjan, Velasco Page 1 of 6

 FMC201 FAMILY SYSTEM T1

4. The clinician is part of the treatment system

III. FAMILY ORIENTED PRACTICIONER

FAMILY ORIENTED CARE APPROACH

For practitioner
• Gathers information about family relationship, patterns of
health and illness across generations, emotional connections
with deceased and geographically removed members, and
life-cycle transitions
• Mobilizes the patient’s natural support system to enhance
health and well being. In daily practice, the family oriented
clinician is most often interested in family who live within
the same house or apartment

For approach
• Involves thinking about a symptoms or problem in the
context of the whole person and the person’s significant
others
• Planned and purposeful family participation in healthcare
can be useful to the patient, the family, and the clinician. Not
including family members or family information -> risk of
incurring roadblocks or, at least, detours on the road-to
effective and efficient primary case
• Including family members means the clinician has enlisted
his or her most potent allies in the treatment of his or her
patients

System
• An entity composed of discrete parts which are connected in
such a way that a change in one part results in changes in all
other parts
General system perceptive: what is
• Examines the way components of a system interact with one
another to form a whole rather than just focusing on each of
the separate parts, a system perspective focuses on the
connectedness and the interrelation and interdependence of
all the parts
• Permits one to see how a change in one component of the
system affects the other components of the system, which in
turns affects the initial component
• It application has particular relevance to the study of the
family s families are compromised of individual members
who share a history, have some degree of emotional
bonding, and develop strategies for meeting the needs of
individual members and the family s a group

Transcribed by: Marmar, Tabjan, Velasco Page 2 of 6

FMC201 FAMILY SYSTEM T1

• Families create
rules that governs
conduct within the
family
• Families adapt to
changes in the
environment
• Families
communicate with
each other
Learn to assess family • Meet the family as
structure and function in a unit
clinical practice • Transfer clinical
information from
doctor to family
members
• Should be able to
listen more and talk
less

IV. TOOLS FOR FAMILY ASSESSMENT

FAMILY SYSTEM THEORY
Basic concept/ proportions FAMILY GENOGRAM
• One of the central premises of family systems theory is that Ø Recognize the family structure
family system organize themselves to carry out the daily Family tree Family names; three or more
challenges and task of life as well as adjusting to the generations; names and age
developmental needs of its members. of all members sequentially
• Critical to this premises is the concept of holism. a family from left to right; significant
systems approach argues that in order to understand a family ideas
system we must look t the family as a whole
Family background on health
Social and interactional influences
Challenges and future directions
• Family systems theory has had a significant impact in the
study of families and on approaches working with families. I. Family tree
• It has guided research into such areas as understanding Ø Must consist of 3 or more generations, each generation
traumatic events of chronic health issues and their impact on identified by roman numerals
individuals and family substance abuse intervention and Ø Left to right
treatment modalities and kinship networks Ø Eldest to the youngest
Index patient: greatest medical significance family member, serious
FAMILY SYSTEM
medical problem member.
• Family system theory allows one to understand the
organizational complexity of families, as well as the
interactive patterns that guide family reactions. II. Functional chart
Ø Gives more dynamic image of the image of the family
especially of the relationship of members
Incorporating a family system approach into clinical practice
III. Family illness/history
Steps Ø Denotes the presence of inherited disease or familial
Recognize family structures • Names of the tendencies indicating potential problems in the family.
individual family
members
• Place of residence
• Specific roles in the
family
• Storage family life
cycle
• Significant dates in
the family
Understanding normal • Families provide
family function support to each
other
• Families establish
autonomy and
independence for uses of GENOGRAM
each person in the • quick overview on the family members and relationship
system • a way to visually overlay biomedical and psychosocial
information

Transcribed by: Marmar, Tabjan, Velasco Page 3 of 6

FMC201 FAMILY SYSTEM T1
• a study tool for gaining a comprehensive understanding

FAMILY APGAR PART 1

Adaptation
o how resources are utilized and shared
o the degree to which a member is satisfied with the assistance
received when family resources are needed
Partnership
o how decisions are shared
o this measures the satisfaction attained in solving problems by
communicating
Growth
• how nurturing is shared
• the member’s satisfaction FAMILY CIRCLE
Affection • a big circle is drawn
• how emotional experienced are shared • the patient is asked to draw smaller circles within the big
Resolve circle or outside
• how time and space and money are shared • each circle represents significant people in his/her life
• the member’s satisfaction • distance and size vary according to degree of closeness and
significance to the patient
score of APGAR: • assessment is through interpretation by the one draws
• there are no right or wrong answers
• almost always: 2
• aide physician when a support is necessary
• some of the time: 1
• Hardly ever: 0

Interpretation of total score:

• 8-10 – highly functional family
• 4-7 moderately functional family
• 0-3 severely dysfunctional
DRAW A FAMILY TEST: (DRAFT) COMMUNITY BASED FAMILY
FAMILY APGAR PART 2 ASSESSMENT TOOLS
• delineates relationship with other family members • DRAFT is a projective technique that can be administered
• also it identifies person who can give assistance to the patient individually or in-group test
• indicated problem no revealed in part 1 • Usefulness: patient who exhibit evasiveness and
guardedness seems more likely reveal
Indications of APGAR
• the family will be directly involved in caring for the patient ECOMAP
• treating new patients • Solid line: strong relationship
• treating a patient whose family is in crisis • Broken lines: tenuous relationship
• a patient behavior makes you suspect a psychosocial • Draw arrow lines to indicate flow of resources and energy
problem due to family dysfunction from or into household

Transcribed by: Marmar, Tabjan, Velasco Page 4 of 6

FMC201 FAMILY SYSTEM T1
1. FAMILY SYSTEM CONCEPTS: TOOLS FOR ASSESSING FAMILIES
PRIMARY CARE
• Family characteristics
• Family as a system
• Family stability
• Family transition
• Family world view
• Relational context of system

FAMILY MAPPING
Uses:
• Reflects relationship and interaction
• Provides schematic description whom to ask for assistance in
making decision for patient
• Identify possible source of somatic complaints
SCREEM (SOCIAL CULTURAL RELIGIOUS ECONOMIC
EDUCATIONAL MEDICAL)
• Help family assess their resources to meet a crisis
V. FAMILY STRUCTURE
- Hierarchy
o (It depends on the power distributed in the family.
The moment you said you’re going to be a medical
student. Tumaas yung ranko mo sa family. As you
go higher in your medical education,
nadadagdagan yung influence mo over the other
members of the family kasi you could teach them
about health and kung may degree ka na, nasa
major decision maker ka na. You are a very
important child in your family. Like, yung baon mo
and baon ng kapatid mo na nasa college pa ay
magkaiba. Mas mataas yung baon mo.)
- Boundaries
o (have defined different subgroups within the
family. Meron magkakapatid na magkakampi or
meron din naman tatay and son na magkakampi
and ganun din yung daughter and mother.)
- Family Role Selection
o (is the conscious and unconscious assignment of
complementary roles to the members.)
- Alliance
- Coalition
FAMILY PROCESSES
- Enmeshment
o (masyadong close tong family parang hindi sila
mapasok ng iba. Yung tipong pag dating nila sa
bahay ay direcho na sa kwarto at di na sila lalabas
dahil nasanay na sila. Forgetting na andun yung
nanay na gusto rin ng kausap.)

- Disengagement
o (characterized a family system which members are
emotionally distant and unresponsive with each
other. The husband does not tell his wife and
children about his health problems kasi ayaw niya
sila mag-worry.)

FAMILY LIFELINE
• Summarizes the history of the family, significant experiences
chronologically sequenced and how family coped with the
stress
• Assessment: to detect any relationship between the clinical
and life events
FACES (FAMILY ADAPTABILITY AND COHESION EVALUATION
SCALES)
FES (FAMILY ENVIRONMENT SCALE)
• 90 item questionnaire developed by MOOS
• separate scales of family parameters
- Triangulation
o (occurs when the third person is drawn in the two-
person system in order to diffuse anxiety and
intimacy conflicts in the two-person system. So,
may papasok or mag-iintervene.)
- Family Patterns
o (are ordered sequences of interactions that identify
how family functions particularly when under
stress. Like for example, what is the family pattern
during enrolment time? Ano ginagawa ng parents
niyo during enrolment?)
- Family Projection Process
o (is in terms of transmission of unresolved conflicts
from one generation to another. Like for example,
kung ayaw mong mahatian ng asawa na hindi mo
naman alam ugali, ibigay mo as gift to your child
yung other properties. In San Mateo mayroong
home for the aged but this is special, “home of

Transcribed by: Marmar, Tabjan, Velasco Page 5 of 6

FMC201 FAMILY SYSTEM T1
abandoned elderlies” who were previously rich na Ø Emotional cutoff: The act of reducing or cutting off
ipinamana nalang nila lahat ng kanilang emotional contact with family as a way managing
kayamanan sa mga anak kahit sarili nilang bahay unresolved issues.
o pinaalis sila. o Meron parents na sumama ang loob sa anak dahil
nag golden anniversary at hindi pumunta yung
- Intergeneration Coalition anak and the family. Ngayon, kinasal yung apo and
o (tatay at anak vs nanay at anak) nung tinawag yung family of the groom, hindi
pumunta yung lolo. Kaya napahiya yung parents
FAMILY SYSTEM THEORY BY BOWEN ng groom dun sa bride kasi parang hindi nila
tinanggap yung kanilang anak kasi hindi
• A theory of human behavior that views the family as an
emotional unit and uses systems thinking to describe the nagpapicture.
complex interactions in the unit. Ø Sibling position: The impact of sibling position on
development and behavior
•
Ø Societal emotional process: The emotional system governs
• It is the nature of a family that its members are intensely
behavior on a societal level, promoting both progressive and
connected emotionally. Often people feel distant for
regressive periods in a society.
disconnected from their families, but this is more feeling than
fact.
•
• Families so profoundly affect their members’ thoughts,
feelings, and actions that it often seems as if people are living
under the same “emotional skin”. People solicit each other’s
attention, approval, and support and react to each other’s
needs, expectations, and upsets.
• Their emotional interdependence presumably evolved to
promote the cohesiveness and cooperation families require
to protect shelter and feed their members
• Heightened tension, however, can intensify these processes
that promote unity and teamwork, and this can lead to
problems.
• When family members get anxious, the anxiety can escalate
by spreading infectiously among them. As anxiety goes up,
the emotional connectedness of family members becomes
more stressful than comforting. Eventually, one or more
members feel overwhelmed, isolated, or out of control.
These are the people who accommodate the most to reduce
tension in others. It is a reciprocal interaction.

EIGHT INTERLOCKING CONCEPTS IN FAMILY THEORY

Ø Triangles: The smallest stable relationship system. Triangles
usually have one side in conflict and two sides in harmony,
contributing to the development of clinical problems.
Eto yung may kampi kampihan na nangyayari
Ø Differentiation of self: The variance in individuals in their
susceptibility to depend on others for acceptance and
approval.
Ø Nuclear family emotional system: The four relationship
patterns that define where problems may develop in a family.
o Marital conflict
o Dysfunction in one spouse
o Impairment of one or more children
o Emotional distance
My niece resigned for her work because her son was
diagnosed na may autism. Ang sabi ko “you don’t have to
resign, you just have to try and believe” pero gusto niya mag-
focus kaya yun nag-focus.

Ø Family protection process: The transmission of emotional

problems from a parent to a child.
You’re protecting your children sa mga away. ‘Pag may mga
mag-cousins na hindi magkakasundo, wag niyo ipaparinig sa
anak dahil ang mangyayari dyan ay magkakalayo ang
magcousins. They will grow up na hindi sila magkakalapit.
Ø Multigenerational transmission process: The transmission of REFERENCES
small differences in the levels of differentiation between 1. Dr. Leopando’s PPT and Discussion
parents and their children. 2. Recordings

Transcribed by: Marmar, Tabjan, Velasco Page 6 of 6