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The Family as a Unit of Care

Aileen B. Pascual, MD, FPAFP


What is a family?
A group of persons united by ties of
marriage, blood 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
Families comprise people who have
a shared history and a shared future
Carter and McGoldrick, 1999
Family Structure
NUCLEAR FAMILY
Parents, dependent children

Separate dwelling not


shared with members of the
family of origin/orientation
of either spouse

Economically independent
Source: http://en.wikipedia.org/wiki/File:Simpsons_FamilyPicture.png
Types of Nuclear Family

Father Spouse
Mother Son
Siblings Daughter

ORIENTATION/ PROCREATION
ORIGIN
EXTENDED FAMILY

Includes 3 generations
Live together as a group
Kinship network provides
function to all members
Unilaterally extended
Bilaterally extended
SINGLE PARENT FAMILY
Children < 17 years of age, living in a family unit with a
single parent, another relative or non-relative

May result from:


Loss of spouse by death, divorce,
separation, desertion
Out of wedlock birth of a child
From adoption
Migration (OFWs)
BLENDED FAMILY
Includes step-parents
and step-children

Caused by divorce,
annulment with
remarriage and
separation
COMMUNAL FAMILY

Grouping of individuals which


are formed for specific
ideological or societal purposes

Considered as an alternative
lifestyle for people who feel
alienated from the economically
privileged society
The Family is a

BIOLOGIC UNIT
Reproduction, child rearing

PSYCHOLOGIC UNIT
Emotional support, protection

SOCIO-CULTURAL UNIT
Socialization, values
Basic Areas of Function

ECONOMIC
Financial resources, security

EDUCATIONAL
Skills, attitudes
The family is the social
context in which illness
occurs and where
recovery takes place.
The Filipino Family

Closely knit
Bilaterally extended
Authority based seniority/age
Externally patriarchal, internally matriarchal
High value on education
Predominantly Catholic
The Filipino Family
Emerging Structures
Changing commitments
Global and Urban Migration
Changing role of women
New Parental Configurations
Single mothers
Single fathers
Step parents
Absconding fathers or mothers
Absent fathers or mothers
Surrogate parents
Bicultural parents
Two daddies, two mommies
The Family as a System
What is a 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
The Family as a System

- exhibits circular changes

- has a tendency to resist change and maintain a


state of homeostasis

- reaches a state of equilibrium even if change


happens within the system
Structural Approach to Family Systems

Pioneered by Dr. Salvador Minuchin

Focus on familys STRUCTURE

It has to have clear hierarchy, roles,


subsystems & boundaries

Familys ability to adapt to stressors


depends on the clarity and
appropriateness of its STRUCTURE
Understanding Families:
Elements of the Family System

Structures Subsystems

Rules Roles
Overt
Covert Coalitions

Boundaries Power Structures


Structures

Behavioral patterns repeated over and


over again

Behavioral skeleton around which the


family is built
Exploring Structures: Series Questions

When situation A happens, what happens to


member 1?

When this happens to member 1, what happens


to member 2? When member 2 behaves in that
way what happens to member 3?
Rules

Commonly agreed upon ways of dealing


with each other, dealing with situations,
and dealing with the external environment

Overt Rules
Covert Rules
Roles
Specific function assigned to a family
member

Breadwinner
Caregiver
Symptom carrier
Family Doctor
Medical Specialist
Exploring Roles:
Who-does-what-and-when Questions
When someone gets sick in the family, who do
you usually go to first?

When that person does not know what to do,


who does he consult?

When the patient has to be admitted to the


hospital, whose permission must be obtained?
Subsystems

Subgroups within a family separated from


each other by a significant period of time

Grandparental, parental, sibling


subsystems
Boundaries

Special rules that govern the interactions


between subsystems in the family

May be clear, rigid or diffuse

Ideally, should be clear enough to prevent


interferences but flexible enough to allow
contact across subsystems
Boundaries

Clear with clarity and negotiable: allows


flexibility when family goes through periods of
change

Rigid not open to negotiations

Diffuse lack of clarity; intrusions by one


subsystem to another
Coalitions
Alliances between members

Informal groupings within the family of


people who usually side with each other
Eliciting Coalitions:
Who agrees with whom Questions
Who is the person that the patient usually
disagrees with in the family?

In case of a disagreement with that person, who


in the family agrees with the patient?

Who in the family usually agrees with the other


person?
Power Structures
Decision-makers
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


emotionally from the patient? Then who is the
next farthest?
Circular Questions

Series Questions
Explores repetitive behavior

Who-does-what-and-when Questions
Explores different roles
Circular Questions

Closer-farther Questions
Explores emotional closeness and distance

Who agrees with whom Questions


Elicits information about coalitions
Family Map
Application of Family Systems Concepts

Characteristics : members
Structure: boundaries, alliances, coalitions
Process: enmeshment, disengagement
Across time: intergenerational coalition
Family Map Symbols

Functional relationship

Enmeshed or over-
involved relationship

Dysfunctional relationship
Family Map Symbols
Clear

Rigid

Diffused
Family Map Symbols

Coalition or Alliance

Escape from the system/


Disengagement

Triangulation
Family Assessment Tools
Family Assessment Tools
Structure
Genogram
Development
Family Life Cycle
Function
Family APGAR
Family Lifeline
Resources
SCREEM
Ecomap
Family Genogram
Inheritance patterns
Family illnesses
Family members
Family relationships
Significant dates
A complete genogram should include:
Names, ages of all family members
Exact dates of birth, marriage, separation, divorce, death
and other significant life events
Information covering 3 or more generations
Illness (hereditary and significant illnesses)
Firstborn of each family to the left and other siblings
sequentially to the right
Indication of which members live together in the same
household
Names of 2 families with the address of the index family
The informant/s
Date the genogram was generated
Genogram Symbols
Male Female

Unknown sex Pregnancy/


Child in utero

Spontaneous abortion

Induced abortion
Genogram Symbols

Bert, 5 Jane, 12

Roy, 50 May,29

Index patient
Name, Age
Genogram Symbols

Dizygotic Twins Monozygotic Twins

Unknown sex of child Adopted


Genogram Symbols

Death
And Cause RHD Stroke
Pneumonia MI
Genogram Symbols

2008 2008

Marriage and Year Not married and


Year started living together

2008
2008

Separation and Year Divorce and Year


Genogram Symbols
Genogram Symbols

Joseph, 72 Margaret,
69

Emily, 48 Marco, 49 Jane, 47 William Martha

Daniel, 26 Johanna, 22 Tomas, 26

March 2012
Legend: Nathan, 25 Katerina, 20

Hypertension
Dyslipidemia Montenegro-Alcantara
Diabetes mellitus March, 2012
Informant: Katerina
Manila
Family Assessment Tools
Structure
Genogram
Development
Family Life Cycle
Function
Family APGAR
Family Lifeline
Resources
SCREEM
Ecomap
The Family Life Cycle
Conceptual tool for understanding family
development
Transitions from one stage to another are rarely
clear cut
Stages tend to merge
Several different models
3 general phases: coupling, expansion,
contraction
6 stages
Unattached
Young
Adult

Newly
Family in
Married
Later Years
Couple

Family with
Launching
Young
Family
Children

Family with
Adolescents
Family Assessment Tools
Structure
Genogram
Development
Family Life Cycle
Function
Family APGAR
Family Lifeline
Resources
SCREEM
Ecomap
Family APGAR
Developed by Dr. Gabriel Smilkstein

5-item questionnaire to assess family function

Measures individual satisfaction about family


relationships
Component Definition

Capability of the family to utilize and share inherent


Adaptation
resources

Sharing of decision making


Partnership Measures the satisfaction attained in solving problems by
communicating
Emotional and physical growth
Growth
Measures satisfaction of the available freedom to change
How emotions are shared between members
Affection
Measures satisfaction with emotional interaction

How time, space, money are shared,


Resolve Measures the satisfaction with the commitment made by
other members of the family
Almost Some of Hardly
FAMILY APGAR Part I
Always the Time Ever
I am satisfied that I can turn my
A family for help when something is
troubling me
I am satisfied with the way my family
P talks on things with me and shares
problems with me
I am satisfied that my family accepts
G and supports my wishes to take on
new activities or directions

I am satisfied with the way my family


expresses affection and responds to
A emotion such as anger, sorrow and
love
I am satisfied with the way my family
R and I share time together
Paminsan Halos
FAMILY APGAR Part I Palagi
-Minsan hindi
Akoy nasisiyahan dahil nakakaasa ako
A ng tulong sa aking pamilya sa oras ng
problema
Akoy nasisiyahan sa paraang
P nakikipagtalakayan sa akin ang aking
pamilya tungkol sa aking problema
Akos nasisiyahan at ang aking pamilya
ay tinatanggap at sinusuportahan ang
G aking mga nais na gawin patungo sa
mga bagong landas para sa aking pag
unlad
Akos nasisiyahan sa paraang
ipinadadama ng aking pamilya ang
A kanilang pagmamahal at nauunawaan
ang aking damdamin katulad ng galit,
lungkot at pag-ibig
Akoy naisisiyahan na ang aking pamilya
R at ako ay nagkakaroon ng panahon sa
isat isa.
Who lives in your house? How do you get along?
Sinu-sino ang nakatira sa inyong tahanan? Paano ang inyong relasyon?
Name and Relationship Age Sex Well Fairly Poor

Pangalan at Relasyon Edad Kasarian Mabuti Hindi Hindi mabuti


gaanong
mabuti

If you dont live with your family, list the


persons whom you can turn to for help.
How do you get along?
Kung hindi ka nakakahingi ng tulong sa
Paano ang inyong relasyon?
iyong sariling pamilya, kani-kanino ka
humihingi ng tulong?
Pangalan at Relasyon Edad Kasarian Mabuti Hindi Hindi mabuti
gaanong
mabuti
Family APGAR
Scoring:
Almost always 2
Some of the time 1
Hardly ever 0

Total :
8-10 highly functional
4-7 moderately dysfunctional
0-3 severely dysfunctional
The Family APGAR is valuable in the
following:

Psychosomatic disorders
Difficult patients
Marital difficulties
Multiple presentations by single/multiple family
members
Drug or alcohol abuse
Evidence of sexual and physical abuse
Family Assessment Tools
Structure
Genogram
Development
Family Life Cycle
Function
Family APGAR
Family Lifeline
Resources
SCREEM
Ecomap
Family Lifeline
Significant events among family members over a
period of time in a chronological sequence

Allows exploration of certain family issues


Family Assessment Tools
Structure
Genogram
Development
Family Life Cycle
Function
Family APGAR
Family Lifeline
Resources
SCREEM
Ecomap
SCREEM
Assess ability of family to participate in
provision of health care and cope with crisis

Sources of help

Barriers to patient care

Relationships of health behavior, practices and


utilization of health services
SCREEM Family Resource Survey
SCREEM-RES

12-item family resource questionnaire

Assesses the familys capacity to participate in


the provision of health care or to cope with crisis
Lubos Sumasa Hindi Lubos
na ng-ayon sumasa na hindi
Questions sumasa ng-ayon sumasa
ng-ayon ng-ayon

Ang bawat isa ay nagtutulungan sa aming


pamilya
S
Natutulungan kami ng aming mga kaibigan at
kasamahan sa komunidad.
Ang aming kultura ay nagpapanatag ng loob ng
aming pamilya

C Ang kultura ng pagtutulungan at


pagmamalasakit sa aming komunidad ay
nakakatulong sa aming pamilya.
Ang aming pananampalataya at relihyon ay
nakakatulong sa aming pamilya.
R
Natutulungan kami ng aming mga kasamahan
sa simbahan o mga grupong relihyoso.
Lubos Sumasa Hindi Lubos
na ng-ayon sumasa na hindi
Questions sumasa ng-ayon sumasa
ng-ayon ng-ayon

Sapat ang naipong pera ng aming pamilya para


sa aming mga pangangailangan
E
Sapat ang kinikita ng aming pamilya para sa
aming mga pangangailangan
Sapat ang aming edukasyon/kaalaman upang
maintindihan ang mga impormasyon tungkol sa
sakit.
E
Sapat ang aming edukasyon/kaalaman upang
maalagaan ang sakit.
Madaling makakuha ng tulong medikal sa aming
komunidad.
M
Natutulungan kami ng mga duktor, nars at
health workers
SCREEM-RES
Scoring:
Lubos na sumasang-ayon 3
Sumasang-ayon 2
Hindi sumasang-ayon 1
Lubos na hindi sumasang-ayon 0

Total :
13 18 = adequate family resources
7 12 = moderately inadequate family resources
0 6 = severely inadequate family resources
ECOMAP
A snapshot of the patient within his/her family
and social environment at a particular point in
time

A graphical representation that shows all of the


systems at play in an individual's life.
College
Prayer Group Barkada
Church
Tennis Club

Sister

School
Org
Px +++++++++++
Parents

Brothers
School
Family
Family Assessment Tools
Structure
Genogram
Development
Family Life Cycle
Function
Family APGAR
Family Lifeline
Resources
SCREEM
Ecomap
Other Family Assessment Tools
DRAFT Draw a Family Test

The Family Circle


DOMAIN ASSESSMENT TOOLS
Areas
Structure for Assessment:
Family GenogramSt. FRED
Rules, Roles, Coalitions, Family Map
Transactional Patterns Circular questions
Flexibility Family Lifeline
Resonance Circular questions
Ecological Context SCREEM
Ecomap
Development Family Life Cycle Stage/Genogram
Illness Typology and Trajectory
Levels of Family Intervention
LEVELS OF FAMILY INTERVENTION
Doherty & Baird, 1987

Level 1: Minimal Involvement

Level 2: Ongoing medical information & advice

Level 3: Provision of emotional support

Level 4: Systematic assessment & planned intervention

Level 5: Family Therapy


Level 1: Minimal Involvement

Doctor hardly sees the family


Focus of treatment is mostly individual patient
Family is involved only in medico-legal issues

Example: Consent
Level 2: Ongoing Medical Information
and Advice

Doctor involves the family by providing them


with information about patients illness
Focus: Health education both patient & family
Primarily cognitive in nature

Example: Disclosure
Level 3: Provision of emotional support

In addition to health education, the doctor :


probes deeper into the emotional impact of
illness
offers emotional support to the family
members

Example: Family CEA


Level 4: Systematic assessment &
Planned Intervention

Doctor makes systematic assessment of the


dynamics of the family and how it is interacting
with the illness

Plans and carries out intervention to change


structures in the family so that health problem of
the patient can be better dealt with
Level 5: Family Therapy

Optional for physicians

Requires additional training

Average family physicians will likely REFER to


professionals when confronted with family
dysfunctions that require this intervention
References
Counseling Skills for Caring Physicians Book 1: Individual
Interventions. Manila: Primary Health Care Foundation for the
Empowerment of Families and Communities, 2005.
McDaniel, S., Campbell, T., Hepworth, J., & Lorenz, A. Family
Oriented Primary Care, 2nd ed. New York: Springer. 2005
Proceedings of the Orientation Course in Family Medicine,
Philippine Academy of Family Physicians
Textbook of Family Medicine Volume 1. Philippine Academy of
Family Physicians
Dr. Richa Opina Tan
Dr. Tricia Mercado
Dr. Cherry Bernardo-Lazaro