Cultural Competence

Cultural competence is essential in family interventions. The culture of the family can facilitate recovery from mental illness and can also present barriers, such as stigma. Respecting the roles of family members and community structures, hierarchies, values, and beliefs within the patient’s culture is critical.

Specific multicultural contexts include immigration status, economics, education, ethnicity, religion, gender, age, role, minority-majority status, and geography. Nurses need to examine their own sociocultural contexts, recognize similarities and differences with those of patients and families, assess the sociocultural context of the patient and family, and include sociocultural considerations in the assessment and planning of care for the family (Chapter 7).

The Office of Minority Health National Standards for Culturally and Linguistically Appropriate Standards of Care case-based nursing curriculum modules and guidelines developed for youth with emotional, behavioral, and mental disorders and their families also can be used as guides to ensure cultural competence in the delivery of mental health services to families (U.S. Department of Health and Human Services, 2007a,b).

Professional Training

Clinical training programs in family psychotherapy are open to psychiatric nurses and other health care professionals across the United States. They vary in duration, theoretical framework, and the level of knowledge and credentials required for participation. They usually are limited to clinicians with graduate degrees in mental health.

Although the nurse generalist needs knowledge of family systems and psychoeducation in the daily clinical work with patients, the nurse family therapist should have a graduate degree and didactic content and clinical seminars focused on family theory and intervention science and individual or group counseling related to awareness of the family of origin.

The nurse also should be supervised on an individual or group basis when doing family psychotherapy to facilitate the refinement of clinical skills and the theoretical understanding of family systems and interventions. Students can be trained in family psychotherapy by acting as co-therapists with experienced therapists or being supervised by means of recorded sessions or live observation.

The professional association for the field of marriage and family therapists is the American Association for Marriage and Family Therapy (AAMFT). The organization has defined what should constitute the education, training, and certification for family therapists, supervisors, and teachers. Licensing is also available through AAMFT. Nurses are well represented in the more than 50,000 therapists in this field.

Framework for Family Work

Much of the original family therapy work was defined by specific schools, approaches, or models of family therapy. No unified system of family functioning has been established. However, recognized family theories, such as developmental, gender, organizational, functional, conflict, and symbolic interaction systems; family life course development; ecology; social exchange and choice; and risk and protective factors do exist.

Theoretical approaches to intervention include cognitive behavioral, experiential, integrative, brief, systemic, narrative, psychodynamic, psychoanalytical, solution-focused, strategic, structural, and transgenerational approaches (Sadock and Sadock, 2007). Many of these family theories and interventional approaches overlap, and some have clinical evidence of effectiveness but not research evidence. During past decades, there has been a shift toward integrative family therapy.

The risk and protective factors framework has been widely used in the family movement and in mental health prevention. These factors can include individual aspects of biology, behavior, personality, psychiatric, family, and environmental studies (O’Connell et al, 2009). Box 32-3 lists family risk and protective factors impacting children and adolescents.

There is an overlap in family and environmental risk factors and an interaction effect of all risk factors with each other. Many of these family factors have been recognized by the Institute of Medicine as being associated with poorer outcome in the management of chronic medical illnesses.

Examples of family risk factors include a sibling’s drug use or a lack of consistent discipline by parents. Family protective factors can include parental supervision, family cohesion, and attachment and bonding between parents and children. The risk and protective factors model is consistent with predisposing factors, precipitating stressors, and appraisal of stressors in the Stuart Stress Adaptation Model (see Chapter 3).

Family theories provide a way to examine family processes, such as hierarchy (who is in charge), boundaries (closeness without too much closeness or enmeshment and distance or estrangement), and organization (how tasks are structured). It is important for the family therapist and psychiatric nurse to differentiate between adaptive and maladaptive family functioning in order to appropriately identify target symptoms for interventions. Characteristics of functional families are described in Chapter 10.

At the opposite end of the continuum are dysfunctional families. Some of the more common dysfunctional family patterns (conceptualized as symptoms within a pathology paradigm and maladaptive coping within the empowerment model) include the following: