Chapter Ten. The family
A psychological perspective
Neil Frude
Introduction
The individual person was traditionally the principal unit of examination, diagnosis and treatment in medicine. Indeed, in many cases attention was focused on a narrower ‘subsystem’ such as the respiratory system or the cardiovascular system. In recent decades it has been recognized as appropriate to adopt a more holistic approach in which biological, psychological and social factors are all acknowledged to be important contributors to physical and emotional health. This focus now extends beyond the ‘whole person’ to include wider systems such as the family and the community. Thus ‘family medicine’, ‘family nursing’, ‘family therapy’, ‘community medicine’ and ‘community nursing’ have all become well-established disciplines.
This chapter will examine some of the ways in which psychologists think about families. Of course, there are other ways of looking at family issues, including those offered by the political, ethical, legal and sociological perspectives (see Chapter 9 for examples). The various perspectives can often be seen as complementary although they tend to focus on different issues and employ different concepts and methods of analysis. Thus while a sociologist is likely to be concerned with the family as an institution within society, and might therefore emphasize the relationship between the family unit and wider systems such as the health service or the taxation system, psychologists are typically more concerned with the interactions and relationships within particular families and how these change as a result of the impact of events such as illness, death or the birth of a child.
The aim of this chapter is to provide a basic framework for thinking, psychologically, about families rather than to summarize knowledge about the effects of particular illnesses or treatments on families. Extensive reviews of the impact of illness, handicap, divorce, bereavement, etc. on family life are available elsewhere (Frude 1991, Power, Dell Orto, 2004 and Power, Dell Orto, 2004). The first part of this chapter examines the family as the background or context for understanding the individual and demonstrates that family relationships have a substantial impact on individuals’ physical health and psychological well-being. The second half of the chapter focuses on the family group, discusses the nature of ‘healthy’ and ‘dysfunctional’ families and considers how different families respond when an individual member becomes ill.
The family as the context for the individual
The value of family relationships
Being part of a family brings a number of costs and benefits to an individual. If a person decides that the costs of family membership outweigh the benefits (so that family membership has a negative value), then he or she may decide to withdraw from the family. According to one influential psychological theory (‘social exchange theory’), the decisions that people make about their lives, including their family life, reflect their own cost–benefit analyses (Nye 1982, Ruben 1998). This kind of analysis has been used, for example, to explain why people choose to have (or not to have) children, why they may choose to separate, and why older children choose to leave home or to continue living with their parents (Rigazio-DiGilio and Cramer 2000, Veevers and Mitchell 1998). A good deal of research has been aimed at discovering what people want (i.e. the benefits they hope for) from relationships, and what they wish to avoid (i.e. the costs). Some adults who have ended an unsatisfactory marital relationship feel that the risks associated with any close relationship are too high, and avoid such relationships. On the other hand, the majority of people who have experienced a divorce hope for a better relationship in the future and exert considerable effort to find ‘the right person’. When interviewed, such people are often able to identify what they are looking for in a relationship – they are able to provide a list of hoped-for benefits.
It is clear that many marriages and long-term cohabiting relationships eventually end (according to some estimates, around 50% of all those who are currently entering into a marriage will eventually divorce). There is also a good deal of conflict and violence within families. Few families, indeed, could be described as completely harmonious. In view of these facts, it might be tempting to conclude that the family is a disaster area and that people would be better off without family ties. However, such a conclusion would be unjustified. We have to consider the benefits as well as the costs, and the love and support as well as the conflict and violence. On average, people value their relationships positively and there is strong evidence that, on the whole, close relationships benefit individuals.
When people are asked what makes them happy, what provides them with satisfaction, and what gives meaning to their lives, they emphasize their close relationships much more than any other aspect of their life, including their occupation, hobbies, health or money (Carr 2003). This is not to deny that many people blame a key relationship for their unhappiness, or that intimate relationships often provoke the most intense anger, anxiety and sadness, but, on the whole, people do assess the impact of their closest relationships in positive rather than in negative terms. Furthermore, in support of such subjective assessments, there is objective evidence suggesting that, overall, the effects of close relationships are more often favourable than unfavourable.
Relationships and life events
It is now well established that psychological and physical health is profoundly affected by life events such as divorce, the birth of a child, bereavement or moving house. Several lists (or ‘inventories’) of commonly experienced life events have been compiled, with each item being assigned a weighting to reflect the likely impact of an event of that nature. These inventories can be used to assess how much ‘life change’ an individual has experienced in the past 6 months, or the past year. Individuals’ total life change scores have been found to predict many health outcomes, including susceptibility to infection, the risk of being involved in a serious accident and the risk of cardiovascular disease (Richter and Guthke 1993). Generally speaking, those who have experienced several recent major changes are more vulnerable to physical and psychological illness than those who have not experienced such changes.
A high proportion of the events listed in inventories compiled to assess major life changes (e.g. Gray et al 2004, Holmes and Rahe 1967) are directly related to family life. Such events include the illness of a family member, a bereavement, a child leaving home, marital separation and sexual problems. Lists of major positive events in people’s lives also show a preponderance of family-related items (Argyle and Henderson 1985), and the same is true of minor positive and negative events (sometimes referred to as ‘uplifts’ and ‘hassles’ respectively). Compared with those who live in isolation, people who live in a family setting have lives which are relatively full of incident. They experience more ‘entrances’ (such as the birth of a child) and more ‘exits’ (the death of a family member, marital separation or a young adult leaving home). They experience more ‘uplifts’ (such as birthdays, anniversaries and school successes), but they also experience more ‘hassles’ (such as minor illnesses of family members, or family rows) (Harper et al 2000, Maybery and Graham 2001). Many of those who live in isolation are lonely and feel that their life lacks interest, excitement or involvement. Whereas many early studies stressed the potential danger of exposure to ‘excess life change’, it is now appreciated that a modest degree of incident and transition promotes healthiness and well-being.
Intimacy, well-being and health
Studies that have asked people to report how happy they are, how lonely they feel and how stressed they feel, have revealed a number of interesting findings. For example, Wood et al (1989) conducted a ‘meta-analysis’ whereby they re-analysed the findings from 93 previously published studies that had addressed the issue of happiness and positive well-being. They showed that, overall, women reported greater happiness and life satisfaction than men (despite the fact that women are twice as likely to be clinically depressed as men). They also showed that marriage was associated with higher levels of well-being both for women and for men, a finding that has been demonstrated repeatedly in other research (Wilson and Oswald 2005). Similarly, studies comparing the reported happiness, loneliness and stress experienced by married people, single people, the widowed and the divorced also indicate that those who are currently married have fewer problems and have a greater sense of positive well-being than those in any of the other groups (Cohen 2004).
Objective indicators point in the same direction. Overall, married people have better physical health than those who have never married or are divorced or widowed. They are less likely, for example, to suffer from asthma, diabetes, ulcers, tuberculosis, cancer of the mouth and throat, hypertension, strokes and heart attacks (Cohen 2004). The association between health and being married is even apparent in mortality data. Married people are at significantly less risk of dying at a young age, compared to those who are single, widowed or divorced (Wilson and Oswald 2005).
A broadly similar pattern emerges when the statistics for mental health are considered. When groups of people matched for age, sex and social class are compared in terms of their psychiatric history, morbidity rates are lowest for the married population (Bebbington et al 2000). General community surveys also reveal that married people experience the fewest psychological symptoms, with an intermediate rate among widowed and never-married adults, and the highest rates among those who are divorced or separated.
Before we conclude that ‘marriage is good for you’, however, it does need to be stressed that the statistics merely show an average advantage for those who are married. It must be remembered that for many people the marital relationship is oppressive or violent, and that conflict and aggression can jeopardize both physical and psychological health. There can be little doubt that many people would be much healthier if they were to opt out of an unhealthy relationship. Although divorce is often a major stressor, many divorced people adjust to a new lifestyle and end up healthier and better adjusted than many of those who opt to remain in a conflictual or violent marital relationship (Kim and McKenry 2002).
Why do good relationships promote health?
How can we explain the association between a stable, intimate relationship and relatively good health? One explanation is that people who are in a secure relationship are likely to have a greater sense of well-being than those who lack a partner, and that as a result they may be less vulnerable to stress. Another suggestion is that it might be especially useful to have access to a partner and confidant(e) during critical periods, for example when the individual faces a major life change. One way in which a partner may help is by listening to the person’s worries and providing informal therapy. In their classic study of the social origins of depression among women, Brown and Harris (1978) found that the presence of an intimate partner and confidant was associated with a relatively low impact of stressful events.
People often ‘consult’ their partners when they are under emotional strain, and many report that they derive great comfort from their partner’s counsel and that it helps them to survive a crisis. Health and counselling professionals are often a ‘last resort’ for those who seek help for psychological problems. Relatives, friends, work colleagues, neighbours, volunteer helpers (e.g. the Samaritans) and other professionals (e.g. religious leaders) are frequently used as counsellors, advisers and ‘sounding boards’. However, when people are asked whom they ‘really depend on’ when personal problems arise, they are more likely to cite their partner than anyone else (Griffith 1985). Informal psychotherapy is a feature of the majority of marriages and it has been found that those who are satisfied with their partner’s ‘therapeutic’ efforts are likely to be satisfied with the marriage as a whole (Nye and McLaughlin 1982).
The presence of a partner may also contribute to health because one partner acts as a ‘guardian’ of the other, monitoring behaviours and providing encouragement and guidance. Thus partners, relatives and close friends often encourage a person to comply with certain ‘rules’ and help them to refrain from dangerous activities (Tucker and Mueller 2000). A partner will often keep a watchful eye on an individual’s smoking and drinking, encouraging them to eat well, to exercise regularly, to attend for medical check-ups and to comply with medical advice. People who are socially isolated do not receive the mixture of encouragement and censure that helps others to check any excessive or dangerous behaviour. Although it may not be experienced as pleasant or useful to be on the receiving end of such frequent ‘nagging’ about the need to maintain a healthy lifestyle, it is undoubtedly beneficial for many people. Those who do not have a partner to support them in this way are more likely to lead disordered lives and to expose themselves to danger. Thus many of those who are newly divorced eat and sleep irregularly, smoke and drink to excess.
The family unit
So far, family relationships (especially marital relationships) have been considered in terms of their costs and benefits to the individual. We have focused exclusively on adults and the costs and benefits they derive from their relationship with their partner, but we could also examine the costs and benefits that an adult or a child may derive from the relationship with any other family member. But we might also consider what any individual gains (or loses) overall by being a member of the family and we can go beyond this and focus on the whole family as a unit. Families are not merely ‘backdrops for individuals’ or simply collections of individual people. A family is a unit in which ‘the whole is greater than the sum of the parts’. A family unit, indeed, can be viewed as if it were an organism in which the individual family members are constituent elements. The organism metaphor can be a fruitful one, for it leads to a number of interesting questions. What are the anatomical features of this type of organism? What is known of its physiology? What is known of the life cycle? What variations are there between different organisms (families)? And what forms of pathology are found?
Like organisms, families pass through a developmental sequence or ‘career’. They are ‘formed’, they undergo changes, and in the end they ‘die’. Some analysts divide the ‘family life cycle’ into a number of stages. In one classic formulation, for example, Duvall (1977) distinguished eight stages, starting with a ‘newly formed’ couple who have no children and ending with the ageing family – a stage that lasts from retirement until death. Such models are clearly oversimplified, but they can be useful in mapping broad patterns of change and identifying common problems at particular stages of development. Thus the pressures typically experienced by ‘young families’ are somewhat different from those faced by families with adolescent children.
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