Transcript Chapter 11 Intervention with Families Psychiatric Mental Health Nursing, 5th Edition

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
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

Goal: Increasing the flexibility of
family boundaries to include
children’s 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 one’s 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 double–bind messages
Psychiatric Mental Health Nursing, 5th Edition
Family Functioning (cont.)
2. Self-concept Reinforcement
 Functional families strive to reinforce and strengthen
each member’s 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
 Bowen’s 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