2022 1.

5 THE FAMILY AS UNIT OF CARE

DR. ALVENDIA| 03/02/2021
PHFCM 3

OUTLINE "A group of persons united by ties of marriage, blood

I. THE FAMILY AS UNIT V. Impact of illness on the family
OF CARE VI. Incorporating family system
II. WHAT is family approach into clinical practice
III. Family structure VII. Family ASSESSMENT
IV. Family life cycle TOOL
VIII. FAMILY APGAR,
MAPPING, GENOGRAM
or adoption; consisting of a single household; interacting and
communicating with each other in their respective social roles and
maintaining a common culture"
- Burgess and Locke, 1960
"The family is a social group characterized by common residence,
economic cooperation and reproduction"
- Murdock, 1965

LEGEND "Families comprise people who have a shared history and a shared
Remember Lecturer Book Previous Presentation future"
Trans - Carter and McGoldrick, 1999
Hello
Essential Functions of Families
Important sentence. 1. Physical maintenance and care of family members
2. Addition of new members thru procreation or adoption and their
• What the lecturer said
relinquishment when the have matured
• A paragraph from the book.
3. Socialization of children for adult roles
• Info from previous trans 4. Maintenance of family morale and motivation
5. To ensure task performance both within the family in other
THE FAMILY AS UNIT OF CARE groups 6. Production and consumption of goods and services
- Zimmerman (cited in Schlesinger, 1988)
2 Principles in Understanding a Family as a Unit of Care
1. Whatever illness may beset the patient, will affect the entire The Family is a...
family in varying degrees • BIOLOGIC UNIT
• Roles and rules → Reproduction, child rearing
→ Head of the family • SOCIO-CULTURAL UNIT
→ Authority figures → Socialization, values
→ Financiers ▪ Interdependence
→ Coordinators ▪ Maintenance of boundaries
• "Role Reorganization" ▪ Exchange of energy with the environment
▪ Adaptive
2. Therapeutic Triad • PSYCHOLOGIC UNIT
• Involving the Doctor, Patient and his Family → Emotional support, protection
• All providing inputs and interaction that can be used in • ECONOMIC
managing and addressing the issues related to the case/ → Financial resources, security
patient • EDUCATIONAL
• Therapeutic allies → Skills, attitudes

Family -Centered Care The Filipino Family

• Identify primary “Care Partners" 1. Closely knit
• Awareness of family involvement assist patients in strained 2. Bilaterally extended
relationships re-engage with family members in a positive and 3. Authority based seniority/age
meaningful matter 4. Externally patriarchal, internally matriarchal
• Particularly useful when the patient is a child 5. High value on education
6. Predominantly Catholic
Core Concepts of Patient and Family Centered Care:
1. DIGNITY AND RESPECT • Emerging Structures
2. INFORMATION SHARING → Changing commitments
3. INVOLVEMENT → Global and Urban Migration
4. COLLABORATION → Changing role of women

What is a family? The Family as a Very Special Unit

According to Textbook:
• Lifelong involvement
• Group of 2 or more persons related by birth, marriage, • Shared attributes
adoption or emotional ties residing together in a single → Genetics: physical and psychological
household. → Developmental: shared home, lifestyle and social
• Social unit consisting of parents and children activities
• Biological and marital kinship rules and patterns of reciprocal • Sense of belongingness
obligations → Security/defense against a potentially hostile environment
→ Companionship

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→ Grouping of individuals which are formed for specific

A. Societal expectations ideological or societal purposes
- Sense of responsibility towards members → Considered as an alternative lifestyle for people who feel
- Sense of responsibility towards others alienated from the economically privileged society
- Basis of affection/care
FOSTER FAMILY
B. Built-in problems
→ One or more of the children are not the natural children of
- Generation gap
the parents.
- Dependence of members
→ The child may stay with the family for an extended period
- Emotional attachment/involvement
through special government agencies
C. The family endures in spite of problems
Community Family
- Resource utilization
- Authority → Grouping individuals which are formed for specific ideological
- Individual sense of responsibility or societal purposes.
→ Considered as an alternative lifestyle for people who feel
Family Strengths alienated from the economically privileged society.
Foster Family
1. The ability to provide for the family's needs
2. Child rearing practices and discipline → One or more of the children are not the natural children of the
3. Communication parents.
4. Support, security and encouragement → The child may stay with the family for an extended period
5. Growth through special government agencies.
6. Responsible community relationships
7. Self-help and accepting help THE FAMILY AS A SYSTEM
8. Flexibility of family functions and roles What is a system?
9. Crisis as a means of growth
10. Family unity, loyalty and intra-familial cooperation → An entity composed of discrete parts which are connected in
such a way that a change in one part results in changes in all
Family Structure other parts.

NUCLEAR FAMILY Understanding Families: Elements of the family system

• Parents, dependent children → Structures
• Married couple without children → Rules
• Separate dwelling not shared with members of the family of ▪ Overt
origin/orientation of either spouse ▪ Covert
• Economically independent → Boundaries
→ Subsystems
EXTENDED FAMILY → Roles coalitions
→ Power structures
• Includes 3 generations
• Number of nuclear families linked together by virtue of the
kinship bond between parents and children or between siblings Structures
• Unilaterally extended → Behavioral patterns repeated over and over again.
• Bilaterally extended → Behaviors skeleton around which the family is built.

SINGLE PARENT FAMILY Exploring Structures: Series questions

→ When situation A happens, what happens to member 1?
• Children < 17 years of age, living in a family unit with a single
→ When this happens to member 1, what happens to member 2?
parent, another relative or non-relative
When member 2 behaves in that way happens to member 3?
• May result from:
Rules
→ Loss of spouse by death, divorce, separation, desertion
→ Out of wedlock birth of a child → Commonly agreed upon ways of dealing with other, dealing
→ From adoption with situations, and dealing with the external environment.
→ Migration (OFWs) → Overt rules
→ Covert rules
BLENDED FAMILY → Specific function assigned to a family member.
▪ Bread winner
→ One or both of the parents have had a previous marriage, ▪ Caregiver
and possibly children from that marriage ▪ Symptoms carries
→ Includes step-parents and step-children ▪ Family doctor
→ Caused by divorce, annulment with remarriage and ▪ Medical specialist
separation
Exploring Roles: “Who-does-what-and-when” Questions
COMMUNAL FAMILY → When someone gets sick in the family, who do you usually go
to first?

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→ When that person does not know what to do, who does he Roles are clear and reasonable
consult. → Change as children mature.
→ When the patient has to be admitted to the hospital, whose → Punishment of wrongdoing is humane and on a scale
permission must be obtained? commensurate with the crime.
→ Rigid and unchallengeable: rebel or passive or dependent.
Subsystems
→ Subgroups within a family separated from each other by a Good communication is essential
significant period of time. → Speak for themselves
→ Grandparental, parental, sibling subsystems. → Children are listened to and input respected.

Boundaries Authority or power is clearly vested in individuals

→ With tacit agreement of all family members.
→ Special rules that govern the interactions between subsystems
→ As family moves through different stages of the family life cycle,
in the family.
there are shifts in the family’s power base.
→ May be clear, rigid or diffuse.
→ Ideally, should be clear enough to prevent interferences but A full range of emotions is acceptable, appropriate, and
flexible enough to allow contact across subsystems. encouraged.
→ Clear – with clarify and negotiable: allows flexibility when family → With tacit agreement of all family members.
goes through periods of change.
→ As family moves through different stages of the family life cycle,
→ Rigid – not open to negotiations. there are shifts in the family’s power base.
→ Diffuse – lack of clarify; intrusions by one subsystem to another.
A full range of emotions is acceptable, appropriate, and
Coalitions encouraged.
→ Alliances between members. → Imposing taboos on expression: incongruity between emotions
→ Informal groupings within the family of people who usually side and behavior.
each other.
Individual differences in energy levels, perception of time, and
Eligible Conditions: “Who agrees with whom” Questions space requirements are respected.
→ Who is the person that the patient usually disagrees with in the → Adopted temporary challenges.
family?
→ In case of a disagreement with that person, who in the family High esteem, both for the individual and the family, develops
agrees with the patient? naturally
→ Who in the family usually agrees with the other persons? → Well functioning family: Not necessarily quiet, well-oriented,
and rational all the time.
Power structures → Negotiation, setting rules, and challenging rules also lead to
→ Decision-makes lively exchanges.
→ Usually parental generation

Family processes
→ Enmeshment
→ Disengagement
→ Triangulation

Exploring Emotional Closeness and Distance: “Closer-farther”

Questions
→ Who is closest to this patient? After that person who is next
closest? And the next closest after that?
→ Who is the person who feels farthest away emotional from the
patient? Then who is the next farthest?

Well Functioning Family: Cocivera

→ Role distinctions are clear and with distinct boundary between
the integral family members and those in the extended family.
▪ Husband and wife play dual roles.
▪ Spouse: provide companionship, affection, sharing
and sex.
▪ Parents: nurture, control and guidance of children. THE FAMILY LIFE CYCLE
→ Individual and a high degree of differentiation are encouraged FAMILY LIFE CYCLE
▪ Children and adults develop their own interests. • Important concept essential in thoroughly understanding
▪ Continual tug and pull between separateness and the health and illness responses of patients and their
mutuality. families
▪ Conflict: Individual expression as threat.

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• It delineates various developmental stages in the status of Terms to Remember:

families and describes the manner in which a family is
functioning
• In each stage, a family projects various identities and roles,
the fulfillment of which would ensure advancement to the
next or higher level, which may involve transitions,
extensions and overlaps.
• ADAPTATION- key element in studying families, occurs
as one member moves through the different stages over
a period of time
• Family Life Cycle- a set of predictable steps or patterns
and developmental tasks families undergo within a given
time frame which include the emotional, psychosocial and
physical changes attendant on each step
• Family stage- a time period in the life of a family that has
a unique structure
• Transition- the shift from one family stage to another
Six- Stage Cycle
• STAGE 1- The Unattached Young Adult
• STAGE 2- The Newly Married Couple
• STAGE 3- The Family With Young Children
• STAGE 4- The Family at Midlife: with Adolescents and
Aging Parents
• STAGE 5- The Stage of Launching Children and Moving
On
• STAGE 6- The Family in Later Life

FAMILY LIFE CYCLE Emotional Process of Changes in Family status Required to proceed Developmentally
STAGE Transition
I.unattached young Accepting financial and • Differentation of the self in relation to the family of origin
adult emotional responsibility for • Development of intimate perr relationships
oneself • Establishment of oneself in relation to work and financial
dependence
II.The newly married Commitment to the new • Formation of the marital system
couple (the joining of system • Realignment of relationships with extended families and
families through friends to include the spouse
marriage)
III.Becoming parents Accepting new members • Adjusting the marital system to make space for children
and families with within the system • Joining in child rearing and financial and household task
young children • realignment of relationships with the extended family to
include parenting and grandparenting role
IV.The family with Increasing flexibility of • shifting of parent-child relationships to permit adolescents to
adolescents family boundaries to include move in and out of system
children’s independence • focus on midlife and marital issues
and granparents’ traitalies
V.Launching Family Accepting a multitude of • Beginning shifting toward joint caring for the older generation
exits from and entries the • Renegotiation of marital system as dyad
system • Developmental of adult to adult relationships between grown
up offspring and their parents
• Realignment of relationships to include in-laws and
grandchildren
• Dealing with the disabilities and death of grandparents
VI.The family in later Accepting the shifting of • Maintaining own and or couple functioning and interests in the
years generationa face of physiological decline;exploration of new familial and
roles social role options
• Support foe more central role of middle generation
• Making room in the system for the wisdom and experience of
the elderly and supporting the older generation
• Dealing with loss of spouse,siblings,and peers,preparation for
ones own death
• Life review and integration
transition to the next phase of life, otherwise the family
• While the life cycle is normative and the developmental may move on to the next stage without acquiring the skills
tasks are predictable, it is evident that disruption can take that are needed to succeed
place in the daily functioning of the family
• The family has to cope up with the crisis brought about by
an illness situations, particularly a serious or complex one
or the stress of everyday living which can delay the

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IMPACT OF ILLNESS ON THE FAMILY
What is the difference between disease and illness?
Disease:
• Refers to the physiological abnormalities taking place in a
patient's body
• Physician focuses on the clinical and laboratory evidence
of biologic dysfunction in order to arrive at a diagnosis and
treatment plan
Illness:
• Encompasses the patient's perceptions, emotions and
experiences of disease, as well as the suffering and
changes the family have to undergo in the presence of that
disease
• For the physician to understand the illness of the patient,
he has to listen to the patient and his family's explanatory
models and be able to see them in the context of their
social and cultural realities
Impact of Illness
• Very much felt among Filipinos because of their strong
family ties
• Thus, assessment of such impact can help physicians
craft plans of interventions that can mobilize the family to
support the patient and lessen the burden brought about
the illness
• The psychoemotional impact of illness is readily apparent
among family members who see the suffering of their
loved ones
o Depression
o Anxiety
o Sleep problems
What factors influence how families cope with Illness?
► The ability to cope with the onslaught of illness depends both on
the
► Internal integrity and resources of the family
► External burden of the disease
Factors Components
Intrafamilial Factors • Family resources
• Family life cycle p
• Degree of family
functionality
How to assess the family’s ability to copenwith illness?
• Main tools a physician needs
o Active listening and learning concerning the
patient and the family’s experience of the illness
o Tools in assessment
• If family’s coping strategies are in place-supportive role
• If coping mechanisms are poor-offer family meetings and
counseling
Family Illness Trajectory
Stage 1: Onset of Symptoms/ Illness
Stage 2: Impact Phase- Reaction to Diagnosis
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PHFCM 3
Stage 3: Major Therapeutic Efforts
Stage 4: Recovery phase- Adjustment to Outcome
Stage 1: Onset of Symptoms/ Illness
• Period from the time the patient demonstrates physical
symptoms or feels that there is something wrong to the
period of consultation
• Health beliefs and previous experience help shape what
patients and their families do at this stage and how soon
they seek consult
Stage 2: Impact Phase- Reaction to Diagnosis
• Initial contact with physician is established
• Diagnosis of curable diseases or chronic non debilitating
diseases== acceptance and immediate movement to the
next stage
• Diagnosis to a debilitating or terminal illness==reaction
might range from D-A-B-D-A and result to a protracted
second stage
Stage 2: Impact Phase- Reaction to Diagnosis
• During this time, the physician must explore on what the
patient and his family already know and ask what they still
want to know regarding the disease
Stage 3: Major Therapeutic Efforts
• This is the period of great mobilization when the family
pursues avenues for treatment or palliation
o A good support system and a wealth of
resources
o Offer the family options that are cost effective
and acceptable to the patient and family's belief
systems
o View the family as a therapeutic ally and not
merely as a recipient of care
Stage 4: Recovery phase- Adjustment to Outcome
• Acute self limiting illness== marked by the disappearance
of symptoms
• Chronic ilnesses== returning to the home environment
and some degree of functionality
• When fully recovery without incapacity is expected== no
problems are anticipated
• When partial recovery, permanent disability or even death
is expected==the family experiences some form of crisis.
Stage 4: Recovery phase- Adjustment to Outcome
• Acute self limiting illness- marked by the disappearance of
symptoms
• Chronic illnesses- returning to the home environment and
some degree of functionality
• When fully recovery without incapacity is expected- no
problems are anticipated
• When partial recovery, permanent disability or even death
is expected- the family experiences some form of crisis.
• A Physician must be able to prepare the family for the
potential outcomes of a disease so that they may learn to
deal with fhem and prepare a realistic plan
• For Chronically ill patients, the physician should also be
able to continually provide support and guidance to the
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family, educate the caregiver, and arrange for home care Two Types of Changes:
when necessary 1. First order change
2. Second order change
INTRODUCTION TO FAMILY ASSESSMENT 3. Families communicate with each other
TOOLS • mostly verbal, non-verbal and implied messages
Family Medicine • Other functions become impossible without
• Patient: a member of the family communication
• Pineda (1999): reactions of patients to an illness depends • Communicafion is very important in coping with changes
a lot on his family and stresses
o Family relationships
o Family social system Functional Family
o Family cultural system A family with established balance between basic functions thus
adequately responding to the needs of the members
INCORPORATINGA FAMILY SYSTEMS APPROACH INTO
CLINICAL PRACTICE Dysfunctional family
Pineda (1999)
Step 1: Recognize Family Structure A family with chronic inability to respond to the needs of the
Step 2: Understanding Normal Family Function members or to cope with changes and stresses in the environment.
Step 3: Learn to Assess Family Structure and
• Function in Clinical Practice STEP 3: LEARN TO ASSESS FAMILY STRUCTURE AND
FUNCTION IN CLINICAL PRACTICE
STEP 1: RECOGNIZE FAMILY STRUCTURE • Meeting the family as a unit has become the standard
• To know the individuals in the family medical practice in the context of patient with:
1. Life-threatening ailment
• The following information should be obtained:
1. Names of the individual family members 2. Chronic illness
2. Place of residence 3. Ensuing death
3. Specific roles in the family • Family assessment tools help the family physician in
4. Stage of the family in the family life cycle convening families
5. Significanf dates in the famly (marriage, birth, death, etc.
FAMILY GENOGRAM FAMILY ASSESSMENT TOOLS
1. SCREEM (Social, Cultural, Religious, Economic, Educational
and Medical)
STEP 2: UNDERSTANDING NORMAL FAMILY FUNCTION 2. Clinical Biography and Life Events
• The five basic functions performed by all families are: 3. Family APGAR
o Families provide support to each other. 4. Family Mapping
o Families establish autonomy and independence 5. Family Genogram
for each person in the system, which enhance
personal growth of individuals within the family. SCREEM-RES
o Families create rules that govern the conduct of
the family and of the individuals within the family. • Assesses the family as to the capacity to parficipate in the
o Families adapt to change in the environment. provision of health care or to cope with crisis
o Families communicate with each other. • Each part of the acronym is considered in terms of
• The five basic functions performed by all families are: resources and pathology
o Families provide support to each other.
o Support can be physical, financial, social, and Social
emotional sense of belonging to one another Cultural
2. Families establish autonomy and independence for each Religious
person in the system, which enhance personal growth of Economic
individuals within the family. Educational
Medical
• each member has defined roles to play within and outside
the limits of the family
• families do a lot of things together but they also do other
things separately
• autonomy function: the ability to maintain the integrity of
each individual member.
3. Families create rules that govern the conduct of the family and
of the individuals within the family.
• these rules often deal with inferaction pafferns, privacy,
authority, and decision making
• these are rules of behaviours that are mostly unwritfen
and become apparent when an outsider visits the family.
4. Families adapt to change in the environment.
it is essential that the family adapts changes and grows in order to
progress from one stage to another in the family's life cycle.

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• The physician assesses from the responses obtained

whether a particular factor can be considered a strength
or a weakness in the family

CLINICAL BIOGRAPHIES AND LIFE CHART

• Valuable tools which can facilitate analysis of Connecfion
between a person's experiences of health and illnesS fo
his personal life.

FAMILY APGAR
• An assessment tool originally described by Smilkstein
which is applied in basic situations like
1. In direct involvement in patient care
2. In providing information while patient is being treated
3. In a family crisis
4. In psychosocial problems
• A rapid screening instrument for family function • Delineates relationship with other members
• Measures the individual's level of satisfaction about family • Identifies persons who can give assistance to the patient
relationship • Indicates conflict not identified in Part 1
Part I
A- Adaptation: capability of the family to utilize and share resources FAMILY MAPPING
which are either intra-familial or extra-familial • Developed by Salvador Minuchin, a Psychiatrist-Family
P- Partnership: sharing of decision making measures satisfaction Therapist
attained in solving problems • Facilitates the communication of information about a family
G- Growth: physical and emotional growth measures satisfaction of system to colleagues so that they can be understood
the available freedom to change
A - Affection: how emotions like love, anger and hatred are shared
measures the members' safisfaction with the intimacy and
emotional interaction that exist
R- Resolve: how time, space and money are shared measures
satisfaction with the commitment made by other members

FAMILY APGAR
APGAR QUESTIONNAIRE ALMOST SOME OF HARDLY
ALWAYS THE TIME EVER
I am satisfied that I can turn to
my family for help when FAMILY GENOGRAM
something is troubling me (A) • Is a scheme or graphic chart representation of both the
I am satisfied with the way my generic pedigree of family and key psychosocial and
family talks over things w/ me interactional data using standardized symbols.
and shares problems w/ me • It is a graphic representation of the structural composition,
(P) functional status and medical history of a family
I am satisfied that my family • A family assessment tool used by family physicians and other
accepts and supports my health care professionals, summarized in one page, from which
wishes to take on new a large amount of information relating to a family is obtained.
activities and directions (G) • Synonyms:
I am satisfied with the way my → family tree
family expresses affection and → family pedigree
responds to my emotions (A) → genealogic chart
I am satisfied with the way my • Average time to finish is 16 minutes
family and I share time → (Range : 9-30mins).
together (R) • Advantages, uses and information derived:
1. Records names and roles of each member
Then add up the points and interpret as to the following: 2. Separates extended family into several households
8-10 points Highly functional family 4- 7 points Moderately 3. Documents medical problems of each member of the
dysfunctional family 0-3 points Severely dysfunctional family family
4. Documents significant dates in the family history
FAMILY APGAR-PART II 5. Reveals more subtle information about the family
• Disadvantages:
1. Limited role in assessing family functions
2. Time consuming to prepare and complete

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FAMILY GENOGRAM
A. Family Tree
B. Functional Chart
C. Family Illness/ History

BASIC GENOGRAM COMPONENTS

A. Family Tree
1. It must consist of 3 or more generations and each generation B. Functional Chart
is identified by Roman Numerals.
2. The first born of each generation is farthest to the left, with • Gives a more dynamic image of the family, specially
siblings following to the right in order of birth. relationship of members
3. The family name is placed above each major family • It allows one to judge the totality of the family units, its
unit. strengths and weaknesses and its ability to withstand future
situations
• Includes dates of marriage

• MARRIAGE DETAILS

• FUNCTIONAL RELATIONSHIPS

4. Given names and ages are placed below each symbol.

5. One member of the family is of greater medical significance
because of an illness and is identified with an arrow. (Index
patient)
6. Date is indicated when the chart was developed so that
ages would be adjusted over time.

C. Family Illness/ History

• denotes the presence of inherited diseases or familial
tendencies indicating potential problems in the family.
• its presence in the medical record allows a physician to
correctly interpret the genogram data even if he has not seen
the family
• Includes any death indicating age and year of death and cause

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