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The Family as
a Unit of Care
Aileen B. Pascual, MD, FPAFP
08 July 2013
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
“The State recognizes the Filipino
family as the foundation of the nation.
Accordingly, it shall strengthen its
solidarity and actively promote its
total development.”
Article 15, Section 1
1987 Philippine Constitution
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
Mother
Siblings
Spouse
Son
Daughter
ORIENTATION/
ORIGIN
PROCREATION
EXTENDED FAMILY
 Unilaterally extended
 Bilaterally extended
 Includes 3 generations
 Live together as a group
 Kinship network provides
function to all members
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
Defines health
and illness
Makes health
decisions
Transmission of
infectious disease
Health behavior is
acquired from the
family
Psychosocial stress
can occur within the
family
Source of social
support
Cause of
illness or
problem
Resource for
prevention or
cure; solution
of the problem
The Filipino Family
Closely knit
Bilaterally extended
Authority based seniority/age
Externally patriarchal, internally
matriarchal
High value on education
Predominantly Catholic
Poverty incidence: 22.3% (2012)
The Filipino Family
Tatay
Nanay
Mga Anak
Kuya
Ate
Bunso
The Filipino Family
Emerging Structures
 Changing commitments
 Global and Urban Migration
 Changing role of women
The Family as
a System
Characteristics
Circularity
Equilibrium
Homeostasis
Elements of the Family System
Structures
Rules
 Overt
 Covert
Boundaries
Structures
Behavioral patterns repeated over
and over again
Behavioral skeleton around which
the family is built
Rules
Commonly agreed upon ways of
dealing with each other, dealing
with situations, and dealing with the
external environment
Overt Rules
Covert Rules
Boundaries
Special rules that govern the
interactions between subsystems in
the family
Clear
Rigid
Diffuse
Elements of the Family System
Roles
Coalitions
Power Structures
Roles
Specific function assigned to a
family member
 Breadwinner
 Caregiver
 Symptom carrier
 “Family Doctor”
 “Medical Specialist”
Coalitions
Alliances between members
Informal groupings within the family
of people who usually side with
each other
Power Structures
Decision-makers
Usually parental generation
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 May
 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
Triangulation
Jun 50 May
50
Ringo
18
Chary
16
Family
Assessment
Tools
Family Assessment Tools
• Genogram
Structure
• Family Life Cycle
Development
• Family APGAR
• Family Lifeline
Function
• SCREEM
• Ecomap
Resources
Genogram
Inheritance patterns
Family illnesses
Family members
Family relationships
Significant dates
Genogram Symbols
Male Female
Unknown sex
Spontaneous abortion
Pregnancy
Induced abortion
Genogram Symbols
Index patient,
Name, Age
Bert, 5 Jane, 12
May,29Roy, 50
Genogram Symbols
Unknown sex of child
A
Dizygotic Twins Monozygotic Twins
Adopted
Genogram Symbols
Death
And Cause
Pneumonia MI
RHD Stroke
Genogram Symbols
2008
Marriage and Year
Separation and Year Divorce and Year
2008
2008
2008
Not married and
Year started living together
Genogram Symbols
Genogram Symbols
Jane, 47 Martha



William
Tomas, 26
Katerina, 20Nathan, 25
Johanna, 22
Marco, 49
Daniel, 26
Emily, 48
Joseph, 72 Margaret,
69
Montenegro-Alcantara
March, 2012
March 2012
Legend:
 – Hypertension
 – Dyslipidemia
 – Diabetes mellitus
Family Assessment Tools
• Genogram
Structure
• Family Life Cycle
Development
• Family APGAR
• Family Lifeline
Function
• SCREEM
• Ecomap
Resources
The Family Life Cycle
The Family System undergoes important
psychosocial changes
Changes are predictable and observable
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
The Family Life Cycle
First Order Changes
 Involves increments of mastery and
adaptation
 “need to do”
 No change in the main structure of the
family
 No change in individual’s identity and self-
image
 TASKS that must be accomplished within
a stage of the FLC
The Family Life Cycle
Second Order Changes
 Involves transformation of an individual’s
status and meaning
 “need to be” something new
 Change in the basic attributes of the
family system
 Change in the role and identity of family
members
 Occur between stages of the FLC
Unattached
Young
Adult
Newly
Married
Couple
Family with
Young
Children
Family with
Adolescents
Launching
Family
Family in
Later Years
Anticipatory Care through the
Family Life Cycle (July 11, 2013)
10 to 15-minute creative
presentation about the family life
cycle stage assigned to your group
Highlights:
Biomedical Issues
Psychosocial Issues
Family Assessment Tools
• Genogram
Structure
• Family Life Cycle
Development
• Family APGAR
• Family Lifeline
Function
• SCREEM
• Ecomap
Resources
Family
Function
Family APGAR
Developed by Dr. Gabriel Smilkstein
5-item questionnaire to assess
family function
Measures individual satisfaction
about family relationships
Component Definition
Adaptation
Capability of the family to utilize and share inherent
resources
Partnership
Sharing of decision making
Measures the satisfaction attained in solving problems by
communicating
Growth
Emotional and physical growth
Measures satisfaction of the available freedom to change
Affection
How emotions are shared between members
Measures satisfaction with emotional interaction
Resolve
How time, space, money are shared,
Measures the satisfaction with the commitment made by
other members of the family
Almost
Always
Some of
the Time
Hardly
Ever
A
I am satisfied that I can turn my
family for help when something is
troubling me
P
I am satisfied with the way my family
talks on things with me and shares
problems with me
G
I am satisfied that my family accepts
and supports my wishes to take on
new activities or directions
A
I am satisfied with the way my family
expresses affection and responds to
emotion such as anger, sorrow and
love
R
I am satisfied with the way my family
and I share time together
Palagi
Paminsan
-Minsan
Halos
hindi
A
Ako’y nasisiyahan dahil nakakaasa ako
ng tulong sa aking pamilya sa oras ng
problema
P
Ako’y nasisiyahan sa paraang
nakikipagtalakayan sa akin ang aking
pamilya tungkol sa aking problema
G
Ako’s nasisiyahan at ang aking pamilya
ay tinatanggap at sinusuportahan ang
aking mga nais na gawin patungo sa
mga bagong landas para sa aking pag
unlad
A
Ako’s nasisiyahan sa paraang
ipinadadama ng aking pamilya ang
kanilang pagmamahal at nauunawaan
ang aking damdamin katulad ng galit,
lungkot at pag-ibig
R
Ako’y naisisiyahan na ang aking pamilya
at ako ay nagkakaroon ng panahon sa
isa’t isa.
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
Family
Resources
SCREEM
Assess ability of family to participate in
provision of health care and cope with
crisis
Sources of help
Barriers to patient care
Family Lifeline
Significant events among family
members over a period of time in a
chronological sequence
Allows exploration of certain family
issues
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.
Px
School
Church
Tennis Club
School
Org
Prayer Group
College
Barkada
Parents
Brothers
Family
Sister
+++++++++++
Family Assessment Tools
• Genogram
Structure
• Family Life Cycle
Development
• Family APGAR
• Family Lifeline
Function
• SCREEM
• Ecomap
Resources
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
 Dr. Richa Opina Tan
 Dr. Tricia Mercado
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