Psychiatric Mental Health Nursing, 5th Edition

Chapter 11
Intervention with Families

Psychiatric Mental Health Nursing, 5th Edition

Introduction
The family defined:

A family is who they say they are. (Wright &

Leahy, 2000)

Psychiatric Mental Health Nursing, 5th Edition

Introduction (cont.)
Types of Families

Biological family of procreation

Nuclear family (incorporates one or
more members of the extended family)

Sole-parent family

Stepfamily

Communal family

Homosexual couple
or family

Psychiatric Mental Health Nursing, 5th Edition

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

Psychiatric Mental Health Nursing, 5th Edition

Introduction (cont.)
Nurse specialists may perform family therapy.
Family therapy a form of intervention in which
members of a family are assisted to identify and
change problematic, maladaptive, selfdefeating, repetitive
relationship patterns.

Psychiatric Mental Health Nursing, 5th Edition

Stages of Family Development
Stage 1. The Single Young Adult

Goal: Accepting separation from

parents and responsibility for self
Tasks

Forming an identity separate

from that of parents
Establishing intimate peer relationships
Advancing toward financial independence

Problems arise when either the young adult or the

parents have difficulty separating from the previous
interdependent relationship.

Psychiatric Mental Health Nursing, 5th Edition

Stages of Family Development (cont.)
Stage 2. The Newly Married Couple

Goal: Commitment to the new system

Tasks

Establishing a new identity

as a couple
Realigning relationships with members of the
extended family
Making decisions about having children

Problems arise when either partner has difficulty

separating from family of origin or when the couple cut
themselves off completely from extended family.

Psychiatric Mental Health Nursing, 5th Edition

Stages of Family Development (cont.)
Stage 3. The Family with Young Children

Goal: Accepting a new generation

of members into the system
Tasks
Adjusting the marital relationship
to accommodate parental
responsibilities while preserving
the integrity of the couple relationship
Sharing equally in the tasks of child-rearing
Integrating the roles of extended family members
into the family
Problems arise when the parents lack of knowledge about
normal childhood development interferes with satisfactory
child-rearing.

Psychiatric Mental Health Nursing, 5th Edition

Stages of Family Development (cont.)
Stage 4. The Family with Adolescents

Goal: Increasing the flexibility of

family boundaries to include
childrens independence and
grandparents increasing
dependence
Tasks

Shifting of parent-child relationships to permit adolescents

to move in and out of the system

Refocusing on midlife marital and career issues

Beginning a shift toward concern for the older generation

Problems arise when parents are unable to relinquish control and
allow the adolescent increasing autonomy or when the parents
cannot agree and support each other in this effort.

Psychiatric Mental Health Nursing, 5th Edition

Stages of Family Development (cont.)
Stage 5. The Family Launching Grown Children

Goal: Accepting a multitude

of exits from and entries into the
family system
Tasks

Renegotiation of marital system as a dyad

Development of adult-to-adult relationships between
grown children and parents
Realignment of relationships to include in-laws and
grandchildren
Dealing with disabilities and death of parents
(grandparents)

Psychiatric Mental Health Nursing, 5th Edition

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

Psychiatric Mental Health Nursing, 5th Edition

Stages of Family Development (cont.)
Stage 6. The Family in Later Life

Goal: Accepting the shifting of

generational roles
Tasks

Maintaining own and/or couple functioning and

interests in face of physiological decline
Exploration of new familial and social role options
Support for a more central role
for the middle generation
Dealing with loss of spouse,
siblings, and other peers, and preparation for own
death; life review and integration

Psychiatric Mental Health Nursing, 5th Edition

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

Psychiatric Mental Health Nursing, 5th Edition

Major Variations
Divorce
Currently in the United States,
about half of all first marriages
end in divorce.
There is some indication that this trend may be declining.
Stages in the family life cycle of divorce

Deciding to divorce
Planning the breakup of the system
Separation
Divorce

Psychiatric Mental Health Nursing, 5th Edition

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

Psychiatric Mental Health Nursing, 5th Edition

Major Variations (cont.)
Remarriage
About three-fourths of those
who divorce eventually remarry.
The rate of redivorce for
remarried couples is even higher
than the divorce rate after first marriages.
Stages in the remarried family life cycle
Entering the new relationship

Planning the new marriage and family

Remarriage and reestablishment of family

Psychiatric Mental Health Nursing, 5th Edition

Major Variations (cont.)
Remarriage (cont.)

Tasks

Making a firm commitment

to confront the complexities
of combining two families
Maintaining open communication
Facing fears
Realigning relationships with extended family to include
new spouse and children
Encouraging healthy relationships with biological
(noncustodial) parents and grandparents

Psychiatric Mental Health Nursing, 5th Edition

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

Psychiatric Mental Health Nursing, 5th Edition

Major Variations (cont.)
Cultural Variations

Caution must be taken in generalizing

about variations in family life cycle
development according to culture.

Psychiatric Mental Health Nursing, 5th Edition

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

Psychiatric Mental Health Nursing, 5th Edition

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

Psychiatric Mental Health Nursing, 5th Edition

Major Variations (cont.)
Cultural Variations (cont.)
Extended family

Older family members are

valued for their wisdom in
Asian, Latino, Italian, and Iranian subcultures.
Several generations within these subcultures
may live together and share tasks of childrearing.

Psychiatric Mental Health Nursing, 5th Edition

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

Psychiatric Mental Health Nursing, 5th Edition

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

Psychiatric Mental Health Nursing, 5th Edition

Family Functioning (cont.)
1. Communication

Family members are encouraged to express honest

feelings and opinions, and all members participate in
decisions that affect the family system.
Behaviors that interfere with functional communication
include

Making assumptions
Belittling feelings
Failing to listen
Communicating indirectly
Presenting doublebind messages

Psychiatric Mental Health Nursing, 5th Edition

Family Functioning (cont.)
2. Self-concept Reinforcement
Functional families strive to reinforce and strengthen
each members self-concept, with the positive result
being that family members feel loved and valued.
Behaviors that interfere with self-concept reinforcement
include

Expressing denigrating
remarks
Withholding supportive
messages
Taking over

Psychiatric Mental Health Nursing, 5th Edition

Family Functioning (cont.)
3. Family Members Expectations
In functional families, expectations are realistic, flexible,
and individualized.
Behaviors that interfere with adaptive functioning in
terms of member expectations include

Ignoring individuality
Demanding proof of love

Psychiatric Mental Health Nursing, 5th Edition

Family Functioning (cont.)
4. Handling Differences
Functional families understand that it is acceptable to
disagree and deal with differences in an open,
nonattacking manner.
Behaviors that interfere with successful family
negotiations include
Attacking

Avoiding
Surrendering

Psychiatric Mental Health Nursing, 5th Edition

Family Functioning (cont.)
5. Family

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

Psychiatric Mental Health Nursing, 5th Edition

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

Psychiatric Mental Health Nursing, 5th Edition

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

Psychiatric Mental Health Nursing, 5th Edition

Therapeutic Modalities with Families (cont.)
A major contributor to this theory is Bowen. He
has identified the following major concepts:

Differentiation of self

Triangles
Nuclear family emotional process
Family projection process
Multigenerational
transmission process
Sibling position profiles
Emotional cutoff
Societal regression

Psychiatric Mental Health Nursing, 5th Edition

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

Psychiatric Mental Health Nursing, 5th Edition

Therapeutic Modalities with Families (cont.)
Structural Model
The family is viewed as a social system within which the
individual lives and to which the individual must adapt.
Major concepts
Systems

Transactional patterns
Subsystems
Boundaries

Psychiatric Mental Health Nursing, 5th Edition

Therapeutic Modalities with Families (cont.)
Structural Model (cont.)
Goal: to facilitate change in the family structure
Techniques
Joining the family
Evaluating the family structure
Restructuring the family

Psychiatric Mental Health Nursing, 5th Edition

Therapeutic Modalities with Families (cont.)
Strategic Model (cont.)

This model uses the interactional

or communication approach.
Communication theory is
viewed as the foundation for
this model.
Functional families are open systems
with clear, precise messages that are
congruent with the situation.
Dysfunctional families are viewed as closed or partially closed:
communication is vague, and messages are often inconsistent and
incongruent with the situation.

Psychiatric Mental Health Nursing, 5th Edition

Therapeutic Modalities with Families (cont.)
Strategic Model (cont.)
Major concepts of strategic model

Double-bind communication
Pseudomutuality
Pseudohostility
Marital schism
Marital skew

Psychiatric Mental Health Nursing, 5th Edition

Therapeutic Modalities with Families (cont.)
Strategic Model (cont.)
Goal: to create change in destructive behavior
and communication patterns among family
members. The identified problem is the focus
of therapy.
Techniques

Paradoxical intervention
Reframing

Psychiatric Mental Health Nursing, 5th Edition

Evolution of Family Therapy

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

Psychiatric Mental Health Nursing, 5th Edition

Evolution of Family Therapy (cont.)

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

Psychiatric Mental Health Nursing, 5th Edition

Evolution of Family Therapy (cont.)

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

Psychiatric Mental Health Nursing, 5th Edition

Evolution of Family Therapy (cont.)

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

Psychiatric Mental Health Nursing, 5th Edition

Evolution of Family Therapy (cont.)

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

Psychiatric Mental Health Nursing, 5th Edition

The Nursing Process

Calgary Family Assessment Model