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Family Dynamics

Fakultas Kedokteran Universitas Andalas

With Courtesy to
Leilanie A. Nicodemus, MD, MsCM-FM
Tujuan pembelajaran
Able to explane
• concept of family dynamics
• methods of assessing family
• application of family dynamics
assessment in patient care
What is Family Dynamics??
• Inter-relationships between and among
individual family members
• Term used when describing the forces
which work within a family to produce or
result in certain behaviours
• This also refers to the way in which a
particular family lives and relates with one
Family Systems Theory
• Useful paradigm to understand behaviour
of families

– Family composed of “parts” which are

connected that a change in one part results in
changes in all other parts (parts = family
Components of Assessment of
Family Dynamics
1. Structure (Roles, Rules, Transactional,
Patterns, Coalitions)
2. Flexibility
3. Resonance
4. Ecological Context
5. Developmental Stage
1. Structure
• Behavioural patterns repeated over time
(pola kebiasaan yang berulang)
• The “behavioural skeleton” around which
family life is built.
– Deviation from these structures causes
members of the family to undertake corrective
• Components of Structure:

– Roles
– Rules
– Coalitions
– Transactional Patterns
Structure: Roles
• It is the function that is assigned to a
family member, and that function
maintains the stability and ensuring the
survival of the family system

• Method of Assessment:
– “Who does what and when???”
Structure: Roles: Who does What
and When?
• When someone gets sick in your family, who
does he go to first?
• Who assists that person?
• Who does he go to when he doesn’t know what
to do?
• Who decides when admission is necessary?
• Who will pay for this admission?
• Who will stay with the patient?
Structure: Rules
• Rules of behaviour are commonly agreed
upon ways of dealing with each other.
• Overt Vs. Covert rules
– Overt rules: Rules clearly and verbally stated
– Covert rules: not stated but everyone conform
to them
• Boundaries between subsystems
– Special rules that govern the interaction
between subsystem in the family
Structure: Transactional Patterns
• The particular patterns of interaction between
family members.
• The family “dance”
• For example, a mother tells her child to pick up
his socks and he obeys.
This interaction defines who she is in relation to
him and who he is in relation to her. Repeated
interactions constitute a transactional pattern
• The same sequence questions “ROLES” can
be used to determine this patterns
Structure: Coalitions
• The alliances between members of a
subsystem versus the other members.
• Who agrees with whom?
– Who in your family disagree with each other
the most?
– When they disagree, who agrees with A….?
– …..and who agrees with B..?
2. Flexibility
• The degree to which a family can adapt to changes in its
internal or external environment
• Assessment tool: Lifeline
• Lifeline:
– List of significant events in the family
– Sometimes placed side-by-side with illness history
– Focus for processing for information of flexibility
– Based on family life cycle theory
– Every stage has second order changes involving changes in
ROLE and necessitating changes in BOUNDARIES
– There are NORMATIVE CHANGES. How flexible is the family
in handling them?
– How well is the family handling the NON-NORMATIVE
CHANGES? Financial hardship, war, flood, fire, accident, etc.
Flexibility: Example: The family
in later life
• Making room in the system for the wisdom
and experience for the elderly; supporting
the older generation without over
functioning them
• Dealing with loss of spouse, siblings, and
other peers; preparation for own death; life
review and integration
Sample of Life line
date Psychological Medical Event
1997 Retirement of husband; Depression diagnosed
favourite daughter got in husband
married and leaves.
1998 Diagnosis of lung
cancer in husband

1999 Death of husband

200 Breast cancer

3. Resonance
• The degree of emotional reactivity between
• Ranging from Enmeshed to Disengaged
• Sequence Questions:
– When A does/says this, what happens to B?
– What does B do/say as a result?
– When B does/says this, what happens to C?
– ……and so on…..
– Does this happen all the time??
– Who is closest to A? Who is next closest?
– Who is farthest from A? Who is the next farthest?
– Who was most upset about A’s illness? Who was next
most upset?
– Who was least upset about A’s illness? Who was next
least upset?
4. Ecological Context
• Obstacles and resources
– Socio-Cultural
– Religious
– Economic
– Environmental
– Medical

5. Developmental Stage
• Genogram
• Life Cycle Stage
• Typology of illness
– Onset; acute Vs. chronic
– Course; progressive vs constant vs relapsing
– Outcome; immediately fatal vs eventually fatal
Family Dynamic Assessment
1. Structure (Roles, Rules, Transactional,
Patterns, Coalitions)
2. Flexibility
3. Resonance
4. Ecological Context
5. Developmental Stage
What the doctor can do?
provide information (making the
family aware of their dynamics)
Counsel/emotional support
Identify coping mechanisms (maximize
the use of these mechanisms to achieve
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