Families as Resources, Caregivers, and Collaborators

Families as Resources, Caregivers, and Collaborators

Gail W. Stuart

Families are the largest group of caregivers for the mentally ill. Most patients live with or are cared for by their families. Psychiatric nurses must partner with families as resources, caregivers, and collaborators in their clinical practice. Past and present family relationships affect a patient’s self-concept, behavior, expectations, values, and beliefs. Thus understanding principles of family dynamics and interventions is critically important. Competence in this area will enhance the nurse’s ability to:

Family Assessment

The concept of “family” has evolved from the “two married heterosexual parents with several children of their own” to a variety of extended and creative nontraditional “family systems.” Nurses encounter many different types of families in their clinical work. This can challenge the nurse’s evaluation skills and perhaps the nurse’s own value system. Figure 10-1 presents four dimensions of parent status that can describe families in society: biological ties, marital status, sexual orientation, and gender roles. Although the definitions of family have become more fluid in recent decades, a family is usually defined in terms of kinship: individuals joined by marriage or its equivalent or by parenthood.

A broader definition describes family members as those who by birth, adoption, marriage, or declared commitment share deep, personal connections and are mutually entitled to receive, and obligated to provide, support, especially in times of need.

Over time in the United States, the number of households with married families has declined, whereas the number of nonfamily households has increased (Figure 10-2).

Characteristics of the Functional Family

A well-functioning family can shift roles, levels of responsibility, and patterns of interaction as it experiences stressful life changes. A well-functioning family may, under acute or prolonged stress or increased vulnerability, express maladaptive responses but should be able to rebalance as a system over time. Ultimately, family members remain focused on healthy patterns and established values, and family relationships remain intact. Characteristics of such a family include the following:

• It completes important life cycle tasks.

• It has the capacity to tolerate conflict and to adapt to adverse circumstances without long-term dysfunction or disintegration of family cohesion.

• Emotional contact is maintained across generations and between family members without blurring necessary levels of authority.

• Overcloseness or fusion is avoided, and distance is not used to solve problems.

• Each twosome is expected to resolve the problems between them. Asking a third person to settle disputes or to take sides is discouraged.

• Differences between family members are encouraged to promote personal growth and creativity.

• Children are expected to assume age-appropriate responsibilities and to enjoy age-appropriate privileges negotiated with their parents.

• The preservation of a positive emotional climate is more highly valued than doing what “should” be done or what is “right.”

• Within each adult there is a balance of affective expression, careful rational thought, relationship focus, and caregiving; each adult can selectively function in the respective modes.

• There is open communication and interactions among family members.

These functional characteristics represent an ideal family that may be more fictional than real. Most families have some but not all of these elements and still operate with integrity and respect.


Nurses have a professional responsibility to be aware of and be sensitive to aspects of family structures that are due to social, cultural, and ethnic differences (Box 10-1). Specifically, culture within a family determines the following:

Family History

Family history information usually includes all family members across three generations (McGuinness et al, 2005). It is helpful to use a family genogram as the organizing structure for collecting this information. A three-generation family genogram is a structured method of gathering information and graphically showing the factual and emotional relationship data (McGoldrick et al, 2008). A sample genogram is presented in Figure 10-3. Drawing a family genogram in full view of the family on large easel paper or a blackboard broadens the family’s focus and facilitates an understanding of the family constellation.

The genogram is usually designed around the patient, and all relatives are included. First-degree relatives include parents, siblings, and children of the patient. Second-degree relatives include grandparents, uncles, aunts, nephews, nieces, and grandchildren. All family members by marriage, partnership, or adoption also are included. The health status of each is noted, as are the relationships between members. The genogram provides an invaluable family map both for discovering individual and family insights and for generating discussions. It can continue to be updated by the family over time.

Family APGAR

Once the family structure is clear, the nurse can explore roles, relationships, and family dynamics. An evidence-based tool commonly used to assess the patient’s satisfaction with relationships in the immediate family is the Family APGAR (Smilkstein, 1978). It measures how the following are shared within the family:

Working with Families

Partnering with patients’ families is an essential part of nursing care. Nurses have always made intuitive observations about family dynamics. Although many nurses have gained additional knowledge and received training in formal family therapy, all nurses must learn how to work with families in everyday nursing practice.

Competence Model

The competence model of care focuses on family strengths, resources, competencies, values, and empowerment instead of dependency. It stresses the importance of treating people as collaborators who are the masters of their own fate and capable of making healthy changes (Marsh, 2000) (Table 10-1).

Using an empowerment model increases the nurse’s understanding of familial traits that can help in coping with mental illness. It assesses the positive attributes among family members, offers a blueprint for designing effective interventions for patients and families, and assists in evaluating the outcome of family-oriented services.

Unlike pathology models that may stigmatize and alienate families, the competence model fosters positive alliances between families and health care providers and enhances the delivery of services. The competence model emphasizes the following points:

It is expected that families will play a major role in deciding what is important to them, what options they will choose to achieve their goals, and whether they will accept help that is offered to them.

Psychoeducational Programs

Psychoeducational programs for families are designed primarily for education and support. They are the result of the emergence of the family self-help movement in psychiatry and the efforts of such family groups as the National Alliance on Mental Illness (NAMI). These programs are educational and practical in approach. Their aim is to improve the course of the family member’s illness, reduce relapse rates, and improve patient and family functioning.

These goals are achieved through educating the family about the illness, teaching families techniques that will help them cope with symptomatic behavior, and reinforcing family strengths. In general, a comprehensive program for working with families should include the following:

The educational program outlined in Box 10-2 is designed to meet the cognitive and behavioral needs of families. Psychoeducational programs for families should meet a range of needs and provide families with an opportunity to ask questions, express feelings, and socialize with each other and with mental health professionals.

Feb 25, 2017 | Posted by in NURSING | Comments Off on Families as Resources, Caregivers, and Collaborators
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