Ch.15: Family Assessment and Interventions

Family Social Domain

-An assessment of the family's social domain provides important data about the operation of the family as a system and its interaction within its environment -Areas of concern include the system itself, social and financial status, and formal and informal support networks

Definition of Differentiation of Self

-An individual's resolution of attachment to his or her family's emotional chaos -It involves an intrapsychic separation of thinking from feelings and an interpersonal freeing of oneself from the chaos

Comprehensive Family Assessment

-A comprehensive family assessment is the collection of all relevant data related to family health, psychological well-being, and social functioning to identify problems for which the nurse can generate nursing diagnoses -The assessment consists of a face-to-face interview with family members and can be conducted during several sessions -Nurses conduct a comprehensive family assessment when they care for patients and their families for an extended period -They also use them when a patient's mental health problems are so complex that family support is important for optimal care

Family Dysfunction

-A family becomes dysfunctional when interactions, decisions, or behaviors interfere with the positive development of the family and its individual members -Most families have periods of dysfunction such as during a crisis or stressful situation when the coping skills are not available -Families usually adapt and regain their mentally healthy balance -A family can be mentally healthy and at the same time have a member who has a mental illness -Conversely, a family can be dysfunctional and have no member with a diagnosable mental illness

Nurses and the Family Life Cycles

-Apply family life cycle phases to a specific family with a member who has a psychiatric disorder -Identify the emotional transitions and the required family changes

Creating Genograms

-A genogram includes the age, dates of marriage and death, and geographic location of each member -Symbols are used in the genogram and are defined in a legend -Squares represent men, and circles represent women; ages are listed inside the squares and circles -Horizontal lines represent marriages with dates; vertical lines connect parents and children -Genograms can be particularly useful in understanding family history, composition, relationships, and illnesses -Genograms vary from simple to elaborate -The patient's and family's assessment needs guide the level of detail -In a small family with limited problems, the genogram can be rather general -In a large family with multiple problems, the genogram should reflect these complexities -Thus, depending on the level of detail, nurses collect various data -They can study important events such as marriages, divorces, deaths, and geographic movements -They can include cultural or religious affiliations, education and economic levels, and the nature of the work of each family member -Psychiatric nurses should always include mental disorders and other significant health problems in the genogram

Family

-A group of people, connected by emotions, blood, or both, that has developed patterns of interaction and relationships -Family members have a shared history and a shared future -Includes the entire emotional system of three, four, or even five generations held by blood, and legal, emotional, and/or historical ties -Relationships with parents, siblings, and other family members go through transitions as they move through life -Are unique in that, unlike all other groups, they incorporate new members only by birth, adoption, or marriage, and members can leave only by divorce or death

Resilience

-Ability to recover readily from illness, depression, adversity, or the like -The ability to recover or adjust to challenges over time -Attaining good mental health despite the presence of risk factors and genetic predisposition

Launching Children and Moving on at Midlife

-Accepting a multitude of exits from and entries into the system a. Renegotiation of couple system as a dyad b. Development of adult-to-adult relationships between parents and grown children c. Realignment of relationships to include in-laws and grandchildren d. Realignment of relationships with community and larger social system to include new structure and constellation of family relationships e. Exploration of new interests or career given the freedom from child care responsibilities f. Dealing with care needs, disabilities, and death of parents (grandparents)

Emerging Young Adults

-Accepting emotional and financial responsibility for self a. Differentiation of self in relation to family of origin b. Development of intimate peer relationships c. Establishment of self in respect to work and financial independence d. Establishment of self in community and larger society e. Establishment of one's worldview, spirituality, religion, and relationship to nature f. Parents shifting to consultative role in young adult's relationships

Families with Young Children

-Accepting new members into the system a. Adjustment of couple system to make space for children b. Collaboration in child-rearing, financial, and housekeeping tasks c. Realignment of relationships with extended family to include parenting and grandparenting roles d. Realignment of relationships with community and larger social system to include new family structure and relationships

Families Nearing the End of Life

-Accepting the realities of limitations and death and the completion of one cycle of life a. Dealing with loss of spouse, siblings, and other peer b. Making preparations for death and legacy c. Managing reversed roles in caretaking between middle and older generations d. Realignment of relationships with larger community and social system to acknowledge changing life cycle relationships

Families in Late Middle Age

-Accepting the shifting generational role a. Maintaining or modifying own and/or couple and social functioning and interests in face of physiologic decline: exploration of new familial and social role options b. Supporting more central role of middle generations c. Making room in the system for the wisdom and experience of elders d. Supporting the older generation without overfunctioning for them

Triangles

-According to Bowen, the triangle is a three-person system and the smallest stable unit in human relations -Cycles of closeness and distance characterize a two-person relationship -When anxiety is high during periods of distance, one party "triangulates" a third person or thing into the relationship -For example, two partners may have a stable relationship when anxiety is low -When anxiety and tension rise, one partner may be so uncomfortable they confide in a friend instead of the other partner -In these cases, triangulating reduces the tension but freezes the conflict in place -In families, triangulating occurs when a husband and wife diffuse tension by focusing on the children -To maintain the status quo and avoid the conflict, which tends to produce symptoms in the child (e.g., bed wetting, fear of school), one of the parents develops an overly intense relationship with one of the children

Changing Family Structure

-Although families may be defined differently within various cultures, they all play an important role in our lives and influence who and what we are -Traditionally, families are considered a source of guidance, security, love, and understanding -This is also true for people experiencing mental illnesses and emotional problems -Often the family assumes primary care for the person with mental illness and supports that individual through recovery -For patients, the family unit may provide their only constant support throughout their lives -Family structure and size influence the strength of a family system -Family structure and size have changed drastically in recent times and so have the functions and roles of family members

Lesbian, Gay, Bisexual, Transsexual, and Queer or Questioning Families

-Among the most stigmatized people are those who are lesbian, gay, bisexual, transsexual, and queer or questioning (LGBTQ) -It is estimated that most LGBTQ populations have encountered some form of verbal harassment or violence in their lives -Higher rates of depression, stress, and low self-esteem have been seen in this population than in similar heterosexual groups -However, these mental health problems may improve as public acceptance increases -Although, historically, some believed that being LGBTQ was a result of faulty parenting or personal choice, evidence shows that sexual orientation and identity are determined early in life by a combination of factors, including genetic predisposition, biologic development, and environmental events -In the past, it was also believed that sexual orientation could be changed through counseling by making a concerted effort to establish new relationships -However, no evidence supports the hypothesis that changes in sexual orientation are possible

Family's Psychological Domain

-Assessment of the family's psychological domain focuses on the family's development and life cycle, communication patterns, stress and coping abilities, and problem-solving skills -One aim of the assessment is to understand the relationships within the family -Although family roles and structures are important, the true value of the family is in its relationships, which are irreplaceable -For example, if a parent leaves or dies, another person (e.g., stepparent, grandparent) can assume some parental functions but can never really replace the emotional relationship with the missing parent

Formal and Informal Support Networks

-Both formal and informal networks are important in providing support to individuals and families and should be identified in the assessment -These networks are the link among the individual, families, and the community -Assessing the extent of formal support (e.g., hospitals, agencies) and informal support (e.g., extended family, friends, and neighbors) gives a clearer picture of the availability of support -In assessing formal support, the nurse should ask about the family's involvement with government institutions and self-help groups such as Alcoholics Anonymous -Assessing the informal network is particularly important in cultural groups with extended family networks or close friends because these individuals can be major sources of support to patients -If the nurse does not ask about the informal network, these important people may be missed -Nurses can inquire whether family members volunteer at schools, local hospitals, or nursing homes -They can also ask whether the family attends religious services or activities

Multigenerational Transmission Process

-Bowen believed that one generation transfers its emotional processes to the next generation -Certain basic patterns among parents and children are replicas of those of past generations, and generations to follow will repeat them -The child who is the most involved with the family is least able to differentiate from their family of origin and passes on conflicts from one generation to another -For example, a spouse may stay emotionally distant from his partner just as his father was with his mother

Sibling Position

-Children develop fixed personality characteristics based on their sibling position in their families -For example, a first-born child may have more confidence and be more outgoing than the second-born child, who has grown up in the older child's shadow -Conversely, the second-born child may be more inclined to identify with the oppressed and be more open to other experiences than the first-born child -These attitudinal and behavioral patterns become fixed parts of both children's personalities -Knowledge of these general personality characteristics is helpful in predicting the family's emotional processes and patterns -These theoretical ideas of Bowen have not been supported by research, but the more general principle that a child's position in the family origin affects the child has significant empirical support

Couple Formation: the Joining of Families

-Commitment to new system a. Formation of couple systems b. Expansion of family boundaries to include new partner and extended family c. Realignment of relationships with extended family, friends, and larger community to include new partners

Childless Families

-Couples can be involuntarily childless because of infertility or voluntarily childless by choice -Approximately 10% to 15% of all couples in the reproductive age are involuntarily childless -As the opportunities for women have increased, many people have chosen not to have children -Research on childlessness is sparse, but it appears lifetime childlessness is associated with long-term illness, poorer midlife physical function for men, and poorer cognition -The studies on depression are mixes in later life

Mental Health Status

-Detecting mental disorders in families may be difficult because these disorders often are hidden or the "family secret" -Very calmly, the nurse should ask family members to identify anyone who has experienced mental illness -The nurse should record the information on the genogram as well as in the narrative -If family members do not know if anyone in the family had or has a mental illness, the nurse should ask if anyone was treated for "nerves" or had a "nervous breakdown" -A good family history of mental illness across multiple generations helps the nurse understand the significance of mental illness in the current generation -If one family member has a serious mental illness, the whole family will be affected -Usually, siblings of the mentally ill member receive less parental attention than the affected member

Subsystems

-Develop when family members join together for various activities or functions -Minuchin et al. (1996) view each member, as well as dyads and other larger groups that form, as a subsystem -Obvious groups are parents and children -Sometimes, there are "boy" and "girl" systems -Such systems become obvious in an assessment when family members talk about "the boys going fishing with dad" and "the girls going shopping with mother" -Family members belong to several different subgroups -A mother may also be a wife, sister, and daughter -Sometimes, these roles can conflict -It may be acceptable for a woman to be very firm as a disciplinarian in her role as mother -However, in her sister, wife, or daughter role, similar behavior would provoke anger and resentment

Phases of the Family Life Cycles

-Emerging young adults -Couple formation: the joining of families -Families with young children -Families with adolescents -Launching children and moving on at midlife -Families in late middle age -Families nearing the end of life

Mobility and Relocation

-Families are more mobile and may change residences frequently -Leaving familiar environments and readjusting to new surroundings and lifestyles stress the family system -These moves impose separation from the extended family, which traditionally has been a stabilizing force and a much needed support system

Family Mental Health

-Families can be viewed as a system often consisting of several generations with multiple health care needs -In a mentally healthy family, members live in harmony among themselves and within society -These families support and nurture their members throughout their lives -However, stress and illnesses can negatively affect a family's overall mental health -Ideally, families can access health care services in an integrated system where primary health services and mental health care are linked

Promoting Self-Care Activities

-Families often need support in changing behaviors that promote self-care activities -For example, families may inadvertently reinforce a family member's dependency out of fear of the patient being taken advantage of in work or social situations -A nurse can help the family explore how to meet the patient's need for work and social activity and at the same time help alleviate the family's fears -Caregiver distress or role strain can occur in families that are responsible for the care of members with long-term illness -Family interventions can help families deal with the burden of caring for members with psychiatric disorders -Family intervention may decrease the frequency of relapse (in persons with schizophrenia) and encourage compliance with medication

Genograms

-Families possess various structural configurations (e.g., single-parent, multigenerational, same-gender relationships) -The nurse can facilitate taking the family history by completing a genogram, which is a multigenerational schematic depiction of biologic, legal, and emotional relationships from generation to generation -The nurse can use a genogram as a framework for exploring relationships and patterns of health and illness

Communication Patterns

-Family communication patterns develop over a lifetime and are important information during an assessment -Some family members communicate more openly and honestly than others -In addition, family subgroups develop from communication patterns -Just as in any assessment interview, the nurse should observe the verbal and nonverbal communication of the family members -Who sits next to each other? -Who talks to whom? -Who answers most questions? -Who volunteers information? -Who changes the subject? -Which subjects seem acceptable to discuss? -Which topics are not discussed? -Can spouses be intimate with each other? -Are any family secrets revealed? -Does the nonverbal communication match the verbal communication? -Nurses can use all of this information to help identify family problems and communication issues -Nurses should also assess the family for its daily communication patterns -Identifying which family members confide in one another is a place to start examining ongoing communication -Other areas include how often children talk with parents, which child talks to the parents most, and who is most likely to discipline the children -Another question considers whether family members can express positive and negative feelings -In determining how open or closed the family is, the nurse explores the type of information the family shares with nonfamily members -For example, whereas one family may tell others about a member's mental illness, another family may not discuss any illnesses with those outside the family

Family Development

-Family development is a broad term that refers to all the processes connected with the growth of a family, including changes associated with work, geographic location, migration, acculturation, and serious illness -In optimal family development, family members are relatively differentiated (capable of autonomous functioning) from one another, anxiety is low, and the parents have good emotional relationships with their own families of origin

Effects of Mental Illness on Family Functioning

-Family members with mental disorders have special needs -Many adults with mental disorders live with their parents well into their 30s and beyond -For these adults with persistent mental illness, the family serves several functions that those without mental illness do not need (providing support, providing information, monitoring services, advocating for services) -The stigma associated with having a family member with a psychiatric disorder underlies much of the burden and stress the caregivers experience -Families can become socially isolated and financially stressed and lose employment opportunities as they struggle to care for their loved one (frustration, anxiety, and low self-esteem may result) -Conflicts can occur between parents and mental health workers who place a high value on independence -Members of the mental health care system may criticize families for being overly protective when, in reality, the patient with mental illness may face real barriers to independent living -Housing may be unavailable; when available, quality and conditions may be inadequate -The patient may fear leaving home, may be at risk for relapse if they do leave, or may be too comfortable at home to want to leave -When long-term caregivers, usually the parents, die, their adult children with mental illness experience housing disruptions and potentially traumatic transitions -Siblings who have other responsibilities expect to be less involved than their parents in the care and oversight of the mentally ill brother or sister (few families actually plan for this difficult eventuality)

Family Size

-Family size in the United States has decreased -In 1790, about one third of all households, including servants, those individuals enslaved, and other people not related to the head, consisted of seven people or more -By 1960, only 1 household in 20 consisted of 7 people or more -The average family household in 2018 was 2.6 people -Married couples make up 47.8% of the households in the United States; almost half of adults today do not live with a spouse

Family Interventions

-Focus on supporting the integrity and functioning of the family as defined by its members -Although family therapy is reserved for mental health specialists, the generalist psychiatric mental health nurse can implement several interventions, such as counseling, promotion of self-care activities, supportive therapy, education and health teaching, and the use of genograms -In implementing any family intervention, flexibility is essential, particularly when working with culturally diverse groups -The nurse creates the context for change by making sure the interventions are possible for the family -For example, weekly appointments may be ideal but impossible for a busy family -To implement successful, culturally competent family interventions, nurses need to be open to modifying the structure and format of the sessions -Longer sessions are often useful, especially when a translator or interpreter is used -Nurses also need to respect and work with the changing family composition of family and nonfamily participants (e.g., extended family members, intimate partners, friends and neighbors, community helpers) in sessions -Because of the stigma that some cultural groups associate with seeking help, nurses may need to hold intervention sessions in community settings (e.g., churches and schools) or at the family's home -If adequate progress is made, it is time to decrease the frequency of sessions and move toward termination -Families may move toward termination if they recognize that improvement has been made

Analyzing and Using Genograms

-For a genogram to be useful in assessment, the nurse needs to analyze the data for family composition, relationship problems, and mental health patterns -Nurses can begin with composition -How large is the family? -Where do family members live? -A large family whose members live in the same city is more likely to have support than a family in which distance separates members (of course, this is not always the case) -Sometimes even when family members live geographically close, they are emotionally distant from one another -The nurse should also study the genogram for relationship and illness patterns -For relationship patterns, the nurse may find a history of divorces or family members who do not keep in touch with the rest of the family -The nurse can then explore the significance of these and other relationships -For illness patterns, alcoholism, often seen across several generations, may be prevalent in men on one side of a family -The nurse can then hypothesize that alcoholism is one of the mental health risks for the family and design interventions to reduce the risk -Or the nurse may find via a genogram that members of a family's previous generation were in "state hospitals" or had "nerve problems"

Using Genograms

-Genograms not only are useful in assessment but also can be used as intervention strategies -Nurses can use genograms to help family members understand current feelings and emotions as well as the family's evolution over several generations -Genograms allow the family to examine relationships from a factual, objective perspective -Often, family members gain new insights and can begin to understand their problems within the context of their family system -For example, families may begin to view depression in an adolescent daughter with new seriousness when they see it as part of a pattern of several generations of women who have struggled with depression -A husband, raised as an only child in a small Midwestern town, may better understand his feelings of being overwhelmed after comparing his family structure with that of his wife, who comes from a large family of several generations living together in the urban Northeast

Emotional Cutoff

-If a member cannot differentiate from their family, that member may just flee from the family, either by moving away or avoiding personal subjects of conversation -Yet a brief visit from parents can render these individuals helpless -In using the family systems therapy model, the nurse can observe family interactions to determine how differentiated family members are from one another -Are members autonomous in thinking and feeling? -Do triangulated relationships develop during periods of stress and tension? -Are family members interacting in the same manner as their parents or grandparents? -How do the personalities of older siblings compare with those of younger siblings? -Who lives close to one another? -Does any family member live in another city? -The Bowen model can provide a way of assessing the system of family relationships

Cultural Variations

-In caring for families from diverse cultures, the nurse should examine whether the underlying assumptions and frameworks of the dominant life cycle models apply -Even the concept of "family" varies among cultures -For example, the dominant White middle-class culture's definition of family refers to the intact nuclear family -Many children grow up with parents from separate cultures where they experience differences in daily living -For Italian Americans, the entire extended network of aunts, uncles, cousins, and grandparents may be involved in family decision-making and share holidays and life cycle transitions -For African Americans, the family may include a broad network of kin and community that includes long-time friends who are considered family members -Cultural groups also differ in the importance they give to certain life cycle transitions -For example, Irish American families may emphasize the wake, viewing death as an important life cycle transition -African American families may emphasize funerals, going to considerable expense and delaying services until all family members arrive -Italian American and Polish American families may place great emphasis on weddings -The life cycle of Mexican immigrant families can be examined in the context of familismo, parental authority, and extended family -The impact of living in a different country, learning a different language, and lack of extended family may create family conflict as they adjust to a different cultural environment -Their children are faced with academic expectations that need parental involvement and support -Family emotional climate increases as both parents share parenting responsibilities

Relationship Building

-In preparing for a family assessment, nurses must concentrate on developing a relationship with the family -Although necessary when working with any family, relationship development is particularly important for families from ethnic minority cultures; because of the discrimination that they have experienced, they may be less likely to trust those from outside their family or community -Developing a relationship takes time, so the nurse may need to complete the assessment during several meetings rather than just one -To develop a positive relationship with a family, nurses must establish credibility with the family and address its immediate intervention needs -To establish credibility, the family must see the nurse as knowledgeable and skillful -Possessing culturally competent nursing skills and projecting a professional image are crucial to establishing credibility -With regard to immediate intervention needs, a family that needs shelter or food is not ready to discuss a member's medication regimen until the first needs are met -The nurse will make considerable progress in establishing a relationship with a family when they help members meet their immediate needs

Families with Adolescents

-Increasing flexibility of family boundaries to permit children's independence and grandparents' frailties a. Shift of parent-child relationships to permit adolescent to have more independent activities and relationships and to move more flexibility into and out of system b. Refocus on midlife couple and career issues c. Begin shift toward caring for older generation

Problem-Solving Skills

-Nurses assess family's problem-solving skills by focusing on the more recent problems the family has experienced and determining the process that members used to solve them -For example, a child is sick at school and needs to go home -Does the mother, father, grandparent, or babysitter receive the call from the school? -Who then cares for the child? -Underlying the ability to solve problems is the decision-making process -Who makes and implements decisions? -How does the family handle conflict? -All of these data provide information regarding the family's problem-solving abilities -After these abilities are identified, the nurse can build on these strengths in helping families deal with additional problems

Boundaries

-Invisible barriers with varying permeabilities that surround each subsystem -They regulate the amount of contact a person has with others and protect the autonomy of the family and its subsystems -If family members do not take telephone calls at dinner, they are protecting themselves from outside intrusion -When parents do not allow children to interrupt them, they are establishing a boundary between themselves and their children -According to Minuchin et al. (1996), the spouse subsystem must have a boundary that separates it from parents, children, and the outside world -A clear boundary between parent and child enables children to interact with their parents but excludes them from the spouse subsystem -Vary from rigid to diffuse -If boundaries are too rigid and permit little contact from outside subsystems, disengagement results, and disengaged individuals are relatively isolated -On the other hand, rigid boundaries permit independence, growth, and mastery within the subsystem, particularly if parents do not hover over their children, telling them what to do or fighting their battles for themselves -Enmeshed subsystems result when boundaries are diffuse -That is, when boundaries are too relaxed, parents may become too involved with their children, and the children learn to rely on the parents to make decisions, resulting in decreased independence -According to Minuchin et al. (1996), if children see their parents as friends and treat them as they would treat their peers, then enmeshment exists -Autonomy and interdependence are key concepts, important both to individual growth and family system maintenance -Relationship patterns are maintained by universal rules governing family organization (especially power hierarchy) and mutual behavioral expectations -In the well-functioning family, boundaries are clear, and a hierarchy exists with a strong parental subsystem -Problems result when there is a malfunctioning of the hierarchical arrangement or boundaries or a maladaptive reaction to changing developmental or environmental requirements -Minuchin et al. (1996) believe in clear, flexible boundaries by which all family members can live comfortably

Differentiation of Self

-Involves two processes: intrapsychic and interpersonal -Intrapsychic differentiation means separating thinking from feeling: a differentiated individual can distinguish between thoughts and feelings and can consequently think through behavior -For example, a person who has experienced intrapsychic differentiation, even though angry, will think through the underlying issue before acting -However, the feeling of the moment will drive the behavior of an undifferentiated individual -Interpersonal differentiation is the process of freeing oneself from the family's emotional chaos -That is, the individual can recognize the family turmoil but avoid reentering arguments and issues -For Bowen, the individual must resolve attachment to this chaos before they can differentiate into a mature, healthy personality

Single-Parent Families

-It is estimated that 50% to 60% of American children will reside at some point in a single-parent home -Almost a quarter of U.S. children live with a singlesolo parent, more than any other nation -Singlesolo parents are overwhelmingly female -Among singlesolo parents, 42% are White and 28% are Black -Single mothers are more than twice as likely to be Black as cohabiting mothers (30% vs. 12%) and approximately four times as likely as married mothers (7% are Black)

Family Systems

-Just as any group can be viewed as a system, a family can be understood as a system with interdependent members -Family system theories view the family as an open system whose members interact with their environment as well as among themselves -One family member's change in thoughts or behavior can cause a ripple effect and change in everyone else's -For example, a mother who decides not to pick up her children's clothing from their bedroom floors anymore forces the children to deal with the cluttered rooms and dirty clothes in a different way than before -One common scenario in the mental health field is the effect of a patient's improvement on the family -With new medications and treatment, patients are more likely to be able to live independently, and this subsequently changes the responsibilities and activities of family caregivers -Although on the surface members may seem relieved that their caregiving burden is lifted, in reality, they must adjust their time and energies to fill the remaining void -This transition may not be easy because it is often less stressful to maintain familiar activities than to venture into uncharted territory -Families may seem as though they want to keep an ill member dependent, but in reality, they are struggling with the change in their family system -Several system models are used in caring for families: the Wright Leahey Calgary model; Bowen family system (1975, 1976); and Minuchin, Lee, and Simon's (1996) structural family system

Calgary Family Model

-Lorraine M. Wright and Maureen Leahey developed the Calgary Family Assessment Model and the Calgary Family Intervention Model -These nursing models are based on systems, cybernetics, and communication and change theories -Families seek help when they have family health and illness problems, difficulties, and suffering -These two models are multidimensional frameworks that conceptualize the family into structural, developmental, and functional categories -Each assessment category contains several subcategories -Structure is further categorized into internal (e.g., family, gender, sexual orientation), external (i.e., extended family and larger systems), and context (i.e., ethnicity, race, social class, religion, spirituality, environment) -Family developmental assessment is organized according to stages, tasks, and attachments -Functional assessment areas include instrumental (e.g., activities of daily living) and expressive (i.e., communication, problem-solving roles, beliefs) -The Calgary Family Assessment Model and Calgary Family Intervention Model are built around four stages: engagement, assessment, intervention, and termination

Contemporary Roles

-Men and women's family roles have changed drastically in the past years -Many women work outside the home and many men are involved in parenting -Today, most women, including those who are mothers, work—both in dual-income families and in single-parent families -Women make up 46.9% of the American civilian work force -More than half of the female work force is married, and only 27% of married mothers and 7% of married fathers with children are stay-at-home parents

Unmarried Cuples

-More unmarried couples are cohabitating before or instead of marrying -In the United States, 53% of adults age 18 and older are married, down from 58% in 1995 -During that time, the cohabitation rate increased from 3% to 7% -More than half of cohabiters are raising children, including about a third who are living with a child they share with their partner -There is variation in marriage rates by race and ethnicity -Fifty-seven percent White adults and 63% of Asian adults are married; fewer than half of the Hispanic (48%) and Black adults (33%) are married -The majority of cohabiters have only lived with one partner -Most Americans view cohabitation as acceptable even without marriage plans

Family Systems Therapy Model

-Murray Bowen (1913-1990) recognized the power of a system and believed that there is a balance between the family system and the individual -Bowen developed several concepts that professionals often use today when working with families -Includes the differentiation of self, triangles, family projection process, nuclear family emotional process, multigenerational transmission process, sibling position, and emotional cutoff

Work and Family Conflict

-While work can provide the economic security of a family, it can also cause stress -Parents are often torn between responsibilities of work and home -Conflict between two expectations can lead to additional family stress and poorer mental health

Nurses and the Effects of Mental Illness on Family Functioning

-Nurses must use an objective and rational approach when discussing independence and dependence of those with mental illness who live with aging parents -Family emotions often obscure the underlying issues, but nurses can diffuse such emotions, so that everyone can explore the alternatives comfortably -Although separation must eventually occur, the timing and process vary according to each family's particular situation -Parents may be highly anxious when their adult children first leave home and need reassurance and support

Counseling

-Nurses often use counseling when working with families because it is a short-term problem-solving approach that addresses current issues -The nurse should avoid taking sides by forming an alliance with one family member or subgroup -If the assessment reveals complex, long-standing relationship problems, the nurse needs to refer the family to a family therapist -If the family is struggling with psychiatric problems of one or more family members or the family system is in a life cycle transition, the nurse should use short-term counseling -Instead of giving advice, the counseling sessions should focus on specific issues or problems using sound group process theory -Usually, a problem-solving approach works well after an issue has been identified

Stress and Coping Abilities

-One of the most important assessment tasks is to determine how family members deal with major and minor stressful events and their available coping skills -Some families seem able to cope with overwhelming stresses, such as the death of a member, major illness, or severe conflict, but other families seem to fall apart over relatively minor events -Some family caregivers of persons with mental illness have resilience -For some families, they not only survive the day-to-day stresses of caring for a family member with a serious mental health problem but also seem to grow stronger and healthier -It is important for the nurse to listen to which situation a family appraises as stressful and help the family identify usual coping responses -The nurse can then evaluate these responses -On the other hand, if the family's responses are maladaptive (e.g., substance abuse, physical abuse), the nurse will discuss the need to develop coping skills that lead to family well-being -Identifying stressful events and coping mechanisms should be a priority in a family assessment

Providing Education and Health Teaching

-One of the most important family interventions is education and health teaching, particularly in families with mental illness -Families have a central role in the treatment of mental illnesses -Members need to learn about mental disorders, medications, actions, side effects, and overall treatment approaches and outcomes -For example, families are often reluctant to have members take psychiatric medications because they believe the medications will "drug" the patient or become addictive -The family's beliefs about mental illnesses and treatment can affect whether patients will be able to manage their illness

Families in Poverty

-Prior to the coronavirus disease 2019 pandemic, 10.5% of the U.S. population lived below the poverty rate -During the pandemic, the poverty rate in the United States reached 17.5% -As the impact of the pandemic is beginning to subside, the poverty rate is expected to decrease -A disproportionate number of children from minority groups live in poverty -LGBTQ people have a poverty rate of 21.6%, much higher than others -The family life cycle of those living in poverty may vary from those with adequate financial means -People living in poverty struggle to make ends meet, and family members may face difficulties in meeting their own or other members' basic developmental needs -To experience poverty does not mean that a family is automatically dysfunctional -But poverty is an important factor that can force even the healthiest families to crumble

Assessment stage

-Problems are identified and relationships among family members and health providers develop -During this stage, the nurse opens space for the family members to tell their story

Stepfamilies

-Remarried families or stepfamilies have a unique set of challenges that are not completely understood -More than 50% of U.S. families are remarried or recoupled -Many parents find that stepparenting is much more difficult than parenting a biologic child -The bonding that occurs with biologic children rarely occurs with the stepchildren, whose natural bond is with a parent not living with them -However, the stepparent often assumes a measure of financial and parental responsibility -The care and management of children often become the primary stressor to the marital partners -In addition, the children are faced with multiple sets of parents whose expectations may differ -They may also compete for the children's attention -It is not unusual for second marriages to fail because of the stressors inherent in a remarried family

Family Structure Model

-Salvador Minuchin (1921-2017) emphasizes the importance of family structure -In their model, the family consists of three essential components: structure, subsystems, and boundaries -In the family structural theory, what distinguishes normal families is not the absence of problems but a functional family structure to handle them -Husbands and wives must learn to adjust to each other, rear their children, deal with their own parents, cope with their jobs, and fit into their communities -The types of struggles change with developmental stages and situational crises -The psychiatric nurse assesses the family structure and the presence of subsystems or boundaries -The nurse uses these data to determine how the subsystems and boundaries affect the family's functioning -Helping family members change a subsystem, such as including younger and older children together in family activities, may improve family functioning

Social and Financial Status

-Social status is often linked directly to financial status -The nurse should assess the occupations of the family members -Who works? -Who is primarily responsible for the family's financial support? -Families of low social status are more likely to have limited financial resources, which can place additional stresses on the family -Cultural expectations and beliefs about acceptable behaviors may cause additional stress when in conflict with beliefs of caregivers -Nurses can use information regarding the family's financial status to determine whether to refer the family to social services

Supporting Family Functioning and Resilience

-Supporting family functioning involves various nursing approaches -In meeting with the family, the nurse should identify and acknowledge its values -In developing a trusting relationship with the family, the nurse should confirm that all members have a sense of self and self-worth -Encouraging positive thinking and participating in support groups will contribute to the family's well-being -Supporting family subsystems (e.g., encouraging the children to play while meeting with the spouses) reinforces family boundaries -Based on assessment of the family system's operation and communication patterns, the nurse can reinforce open, honest communication -In communicating with the family, the nurse needs to observe boundaries constantly and avoid becoming triangulated into family issues -An objective, empathic leadership style can set the tone for the family sessions

Family Life Cycles

-The concept of family life cycle refers to a system evolving through phases based on significant events related to the arrival and departure of members, such as birth or adoption, child-rearing, departure of children from home, occupational retirement, and death -Identifying the family life cycle is helpful in assessing family relationships, roles, and stresses -The family life cycle is a process of expansion, contraction, and realignment of relationship systems to support the entry, exit, and development of family members -A family's life cycle is conceptualized in terms of phases throughout the years -To move from one phase to the next, the family system undergoes changes -Structural and potential structural changes within phases can usually be handled by rearranging the family system (first-order changes), but transition from one phase to the next requires changes in the system itself (second-order changes) -An example of a first-order change is when all the children are finally in school and the stay-at-home parent returns to work -The system is rearranged, but the structure remains the same -In second-order changes, the family structure does change, such as when a member moves away from the family home to live independently -The nurse should not view a family model as "the normal" life cycle because a family's system is always evolving -As second marriages, career changes in midlife, and other life events occur with increasing frequency, this traditional model is being modified and redesigned to address contemporary structural and role changes (this model also may not fit many cultural groups) -Variations of the family life cycle are presented for the divorced and remarried family -During transitions, family stresses are more likely to cause symptoms or dysfunction -Significant family events, such as the death of a member or the introduction of a new member, also affect the family's ability to function -During transitions, families may seek help from the mental health system

Family Physical and Mental Health

-The family assessment includes a thorough picture of physical and mental health status and how the status affects family functioning -The family with multiple health problems, both physical and mental, must try to manage these problems as well as obtain the many financial and health care resources the family members need -Includes physical health status, mental health status

Physical Health Status

-The family health status includes the physical illnesses and disabilities of all members; the nurse can record such information on the genogram and also include the physical illnesses and disabilities of other generations -Illnesses of family members are an indication not only of their physical status but also of the stress currently being placed on the family and its resources -The nurse should pay particular attention to any physical problems that affect family functioning -For example, if a member requires frequent visits to a provider or hospitalizations, the whole family will feel the effects of focusing excessive time and financial resources on that member -The nurse should explore how such situations specifically affect other members

Family Structures

-The organized pattern in which family members interact -As two adult partners come together to form a family, they develop the quantity of their interactions or how much time they spend interacting -For example, a newly married couple may establish their evening interaction pattern by talking to each other during dinner but not while watching television -The quality of the interactions also becomes patterned -Whereas some topics are appropriate for conversation during their evening walk (e.g., reciting daily events), controversial or emotionally provocative topics are relegated to other times and places -Family rules are important influences on interaction patterns -For example, "family problems stay in the family" is a common rule -Both the number of people in the family and its development also influence the interaction pattern -For instance, the interaction between a single mother and her children changes when she remarries and introduces a stepfather -Over time, families repeat interactions, which develop into enduring patterns -For example, if a mother tells her son to straighten his room and the son refuses until his father yells at him, the family has initiated an interactional pattern -If this pattern continues, the child will come to see the father as the disciplinarian and the mother as incompetent -However, the mother will be more affectionate to her son, and the father will remain the disciplinarian on the "outside"

Psychiatric Nurse and the Family

-The psychiatric nurse interacts with families in various ways -Because of the interpersonal and chronic nature of many mental disorders, psychiatric nurses often have frequent and long-term contact with families -Involvement may range from meeting family members only once or twice to treating the whole family as a patient -Unlike a therapeutic group, the family system has a history and continues to function when the nurse is not there -The family reacts to past, present, and anticipated future relationships within at least a three-generation family system

Nuclear Family Emotional Process

-This concept describes patterns of emotional functioning in a family in a single generation -This emotional distance is a patterned reaction in daily interactions with the spouse

Family Projection Process

-Through this process, the triangulated member becomes the center of the family conflicts; that is, the family projects its conflicts onto the child or other triangulated person -Projection is an anxious, enmeshed concern -For example, a husband and wife are having difficulty deciding how to spend money -One of their children is having difficulty with interpersonal relationships in school -Instead of the parents resolving their differences over money, one parent focuses on the child's needs and becomes intensely involved in the child's issues -The other parent then relates coolly and distantly to the involved parent

Family Composition

-Unmarried couples -Single parent families -Stepfamilies -Childless families -Lesbian, gay, bisexual, transsexual, and queer or questioning families

Nursing Implications for Parenting Stress

Early prevention programs should focus on both children's behavior and parenting stress in the first year and work to reduce family conflict and increase parental supportiveness.

Decision to Divorce

Emotional Process -Acceptance of inability to resolve marital problems sufficiently to continue relationship Developmental Issues -Acceptance of one's own part in the failure of the marriage

Planning the Breakup of the System

Emotional Process -Supporting viable arrangements for all parts of the system -Developmental Issues a. Working cooperatively on problems of custody, visitation, and finances b. Dealing with extended family about the divorce

Divorce

Emotional Process -Working on emotional divorce: overcoming hurt, anger, guilt, and so on Developmental Issues a. Mourning loss of intact family; giving up fantasies of reunion b. Retrieving hopes, dreams, expectations from the marriage c. Staying connected with extended families

Definition of Genogram

A multigenerational schematic diagram that lists family members and their relationships

Familismo

A value of close connection between immediate and extended family members

Separation

Emotional Process a. Willingness to continue cooperative coparental relationship and joint financial support of children b. Working on resolution of attachment to spouse Development Issues a. Mourning loss of intact family b. Restructuring marital and parent-child relationships and finances; adaptation to living apart c. Realignment of relationships with extended family; staying connected with spouse's extended family

Renegotiation of Remarried Family at all Future Life Cycle Transitions

Emotional Process -Accepting evolving relationships of transformed remarried family Developmental Issues a. Changes as each child graduates, marries, dies, or becomes ill b. Changes as each spouse forms new couple relationship, remarries, moves, becomes ill, or dies

Family Life Cycle for the Divorcing and Remarrying Families

Divorce -Decision to divorce -Planning the breakup of the system -Separation -Divorce Postdivorce Family -Single parent (custodial household or primary residence) -Single parent (noncustodial) Remarriage -Entering new relationship -Conceptualizing and planning new marriage and family -Remarriage and reconstruction of family -Renegotiation of remarried family at all future life cycle transitions

Conceptualizing and Planning New Marriage and Family

Emotional Process -Accepting one's own fears and those of new spouse and children about forming a new family -Accepting the need for time and patience for adjustment to complexity and ambiguity of the following: a. Multiple new roles b. Boundaries: space, time, membership, and authority c. Affective issues: guilt, loyalty conflicts, desire for mutuality, unresolvable past hurts Developmental Issues a. Working on openness in the new relationships to avoid pseudomutuality b. Planning for maintenance of cooperative financial and coparental relationships with ex-spouses c. Planning to help children deal with fears, loyalty conflicts, and membership in two systems d. Realignment of relationships with extended family to include new spouse and children e. Plan maintenance of connections for children with extended family of ex-spouses

Entering New Relationship

Emotional Process -Recovery from loss of first marriage (adequate "emotional divorce") Developmental Issues -Recommitment to marriage and to forming a family with readiness to deal with the complexity and ambiguity

Single Parent (Noncustodial)

Emotional Process -Willingness to maintain financial responsibilities and parental contact with ex-spouse and to support custodial parent's relationship with children Developmental Issues a. Finding ways to continue effective parenting b. Maintaining financial responsibilities to ex-spouse and children c. Rebuilding own social network

Single Parent (Custodial Household or Primary Residence)

Emotional Process -Willingness to maintain financial responsibilities, continue parental contact with ex-spouse, and support contact of children with ex-spouse and their family Developmental Issues a. Making flexible visitation arrangements with ex-spouse and family b. Rebuilding own financial resources c. Rebuilding own social network

Remarriage and Reconstruction of Family

Emotional Process a. Resolution of attachment to previous spouse and ideal of "intact" family b. Acceptance of different models of family with permeable boundaries Developmental Issues a. Restructuring family boundaries to allow for inclusion of new spouse—stepparent b. Realignment of relationships and financial arrangements to permit interweaving of several systems c. Making room for relationships of all children with all parents, grandparents, and other extended family d. Sharing memories and histories to enhance stepfamily integration

Monitoring Services

Families observe the progress of their relative and report concerns to those in charge of care

Providing Information

Families often have complete and continuous information about care and treatment over the years

Advocating for Services

Family groups advocate for money for residential care services

Providing Support

People with mental illness have difficulty maintaining nonfamilial support networks and may rely exclusively on their families

Termination Phase

Refers to the process of ending the therapeutic relationship

Intervention stage

The core of the clinical work and involves providing a context in which the family can make changes (see Intervention section in this chapter)

Extended Family

Several nuclear families who may or may not live together and who function as one group

Engagement stage

The initial stage in which the family is greeted and made comfortable

Definition of Sibling Position

The relative social status of the children in the family based on birth order

Dysfunctional

The state of a group, such as a family, whose interactions, decisions, or behaviors interfere with the positive development of the group as a whole and its individual members

Transition Times

Times of addition, subtraction, or change in status of family members