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Families and Family Therapy

Gail Notes


It includes the type of family (nuclear or extended) and the value systems that dictate the roles, communication pattern, and power distribution within the family.

Low-income families tend to have a present time orientation view themselves a subject to the environment and the supernatural. In economic crisis, a spouse leaving or children leaving home disrupt the family relationship. To compensate they take in extended families children or the grandparents give them money or help support them in other ways. Power is usually authoritarian.

Middle-class families tend to have the protestant work ethic. Financial stability and success are viewed as rewards for hard work. Family relationships center around the nuclear family. Socialization is centered on the workplace or the neighborhood. Power is egalitarian but becomes male dominated as the economic level of the family rises. They see themselves as being in control of the environment and able to master it.


In nurturing families, communication is congruent, direct, clear, specific and honest. Rules are flexible, appropriate, subject to change, and human.

Observing interactions among family members assesses communication, self worth, and links to society. Communication is the focus of intervention in the family.

Family systems theory:

A system is a whole that is equal to the sum of its parts. Subsystems are not representative pieces of the whole.

Boundaries exist between people, between subsystems, and between the family system and the environment. The family’s values, style and self worth determine the permeability of the boundaries to outside influences. Boundaries can be clearly defined yet open to change and input, poorly defined that confusion and chaos exist, or so rigid that little input can permeate.

Negentropy- tendency towards openness to the environment both inside and outside the family

Entropy- tendency of a system to be closed to the environment.

Optimal families have an open system orientation, permeable boundaries, contextual clarity (congruency in verbal and nonverbal communication), power is shared and flows from the parents, roles are not shared but compliment each other, and autonomy is encouraged. The affective tone is caring, warm, empathetic and hopeful members ask about and attend to feelings. Conflict is confronted and resolved. Negotiation and task performance are accomplished with input from all members and attention to the developmental capabilities for children. They have a belief system that tolerates and transcends the pain of loss and change.



Change from marriage to divorce decreases the self- esteem of the spouses and the children may blame themselves for the breakup. Most families cannot adequately recover from divorce without counseling.

Other families may experience change through the loss of a family member by death or desertion. Economic conditions vary according to the economic class of the family, whether the lost member was the sole source of income or if he/she brought an income into the family, and whether the death was due to illness.

Single parent families- have limited financial resources and limited parental time and energy. The absent parents’ role modeling is not available to the children. 24% of all households in the U.S are single parent families. Women head 88%. They are more likely to experience economic strain than the two-parent family.

Blended families: Putting two families together. Takes time and patience.

Teenage parents: is increasing in numbers. The parent is not emotionally or financially equipped to take care of a baby and can experience psychological risk.

Environmental influences on the family:

POVERTY- obtaining food, clothing, and shelter occupy the family’s time and energy and depletes its dignity. There is a high level of frustration and desertion and violence are common. Relying on public assistance may be seen as demeaning and limiting individual initiative. A low socioeconomic status is the most significant risk factor for children demonstrating behavior problems.

Television and other media- are blamed for contributing to materialism, violence, irresponsible sexual behavior, etc.

Values- changing values in society have an impact on schools and therefore families.

Family violence- Suspected child abuse and neglect have increased more than 10% per year. One in ten American women are abused by intimate partners. Changes and stressors that affect the family contribute to family violence, such as substance abuse and chronically ill family members.

Parents’ self-esteem is a critical variable in determining whether the family survives and produces capable people.

The six tasks that children of divorced parents must master:

  1. Acknowledge the reality of the marital rupture- usually completed within 1 year of the divorce. Young children have difficulty with this task because of their inability to conceptualize time, space and the nature of the relationship.
  2. Disengage from parental conflict and distress and resume customary pursuits. It is usually completed within 1-2 years of the divorce. The first year following separation or divorce the child has difficulty learning and other school problems. Some children may become involved in sexual activity or stealing. The child must distance themselves from the upset parents and overcome their own depression and anxiety.
  3. Resolution of loss. Takes many years to resolve. In addition to the losses that the divorce precipitates, the child tries to recover from an overwhelming sense of rejection. The feeling of rejection decreases when frequent, reliable visitation occurs and the child bonds and builds a relationship with the noncustodial parent.
  4. Resolving anger and blame. Takes years to complete. Usually in late adolescence, the child begins to understand the parents and the reason for the divorce. The child typically forgives the parents and him/herself.
  5. Accepting the permanence of the divorce. The child wishes for and fantasizes about the parents getting back together.
  6. Achieving realistic hope regarding relationships. This is complicated by fears of rejection and failure based on earlier experiences.


Optimal families: has little physical illness and practices high level health care. Total or near total abstinence from substances with potential for abuse. Regular exercise and recreation, concern for the environment and avoidance of dangerous activities are characteristics of the optimal family. Optimal family equals the "ideal family"

Adequate families: Produce people who do not have mental health problems. Characteristics include the following:

Maintains open systems orientation, flexibility, does not believe that causation of events is linear, boundaries are clearly defined but open, members respect each others privacy, face to face interaction and touch. Societal links are numerous (friends, extended family, church, school, etc). Contextual clarity is present and developmental issues are explored with the children at appropriate ages. The parents provide strong leadership and maintain their relationship as a couple. Communication is clear, direct, congruent, honest and specific. Responsibilities are delegated to the children that are appropriate for their age and stage of development. Roles are clear. Family rules are understood and respected. Power and authority are recognized by the family members ability and individual characteristics. They promote autonomy. Affective tone is warm and caring. Members are empathetic and consider others feelings. Self-esteem is high, but the mother may experience more stress, loneliness or depression than other family members. Decisions are often reached at family meetings but the final answer is up to the parents.


Produce people with mental problems (behaviorally or demonstrate a personality disorder). These families have the following characteristics:

  1. Reasonably, effective but restricted.
  2. There is no open system orientation (members need others under certain circumstances)
  3. Believe they are causes for events. They continuously strive to find answers and do well.
  4. Boundaries are fairly clear but under stress, they tend to solidify their boundaries (keep everything inside) or lose their boundaries.
  5. Interaction between family members is restricted.
  6. Links to society are present but are disrupted when the family is under pressure.
  7. They tend to externalize trouble (push it into the environment) and have contact with law enforcement.
  8. Have difficulty with contextual clarity.
  9. Parental coalition is present but weak and is often undermined by other coalitions
  10. Communication is clear, but is generally expressed with fear, guilt, or anger.
  11. Power is the central difficulty in midrange families. Power and love are confused.
  12. They often believe that caring means controlling the life of another through covert and overt coercion (oughts and shoulds). Children become powerful by manipulating the children.
  13. No encouragement of autonomy. Power struggles and repression of feelings and ideas drain creativity.
  14. Children tend to stay home well into adulthood or leave early in a kind of psuedoautonomy.
  15. Affective issues include depression, anxiety, and anger. There is little empathy, conflict over family norms and rules, frustration, and caring that is controlling. Self –esteem is low.
  16. Transcendent values of hope and altruism are lacking. They deal with loss and change with a great deal of frustration, pain, and anger. They look to the future and say what is going to happen next. Martyrdom is not an unusual stance.
  17. Excessive use of alcohol, prescription tranquilizers and other drugs to relieve the pain of daily living. H/A, ulcers, and obesity. They do meet their basic health needs. They attempt recreation and exercise. They are too preoccupied with daily events to explore health promotion and wellness.


  1. Produce people who exhibit disorders of conduct, personality, or addiction.
  2. They have qualities that are opposite of optimal families.
  3. They are rigid and disordered
  4. Boundaries are rigid with minimal links to society. Links are tentative and mistrustful. Input from larger society is limited. Diffuse boundaries with family business spilling into the environment and interpersonal boundaries are diffusing as well that results to global response to input. Distancing is prevalent.
  5. Contextual clarity is blurred due to a weak parental coalition, cross- generational clinging, and developmental issues remain unresolved. Parents deal with their pain of disappointment in each other by reaching across generational lines for comfort or control of the situation. The clinging takes the form of a triangle. For example, the mother and the son form a coalition against the father. The child is the symptom bearer and often responds with mental disorder, physical illness, or delinquent behavior.
  6. Communication is unclear, dishonest, not congruent nor specific. The family has a low self-esteem and fears rejection and embarrassment from others. To cover up their fear of rejection they use the following communication patterns:
    1. Placating- doing anything to prevent others from getting angry.
    2. Blaming or attempting to look strong and reject first.
    3. Computing or treating others as if they were insignificant by using big words.
    4. Distracting or eliminating the possibility of rejection by changing the subject or talking in a "crazy way".

    Double blind communication- occurs when an incongruent message is sent that includes a direction to do something with a nonverbal message to do the opposite. The receiver of the message is not allowed to comment on it. A child who continuously deals with this does not learn to identify and name normal feelings. Nor can he determine the true meaning of statements.

    Disqualifying- occurs when an individual fails to attend to another’s message by silence, ignoring or changing the subject.

  7. Power is diffuse and does not flow from the parents. Autonomy is discouraged and the family does not tolerate differences. The family tends to view one of the members as different and as the cause of trouble (scapegoat).
  8. Affected tone is depressed, restricted and despairing.
  9. Self-esteem is low. Hate, inability to respond empathetically to others, loneliness, and hopelessness predominates.
  10. Negotiation is not accomplished and the performance of tasks varies widely.
  11. They have a cynical and hopeless outlook on life.


  1. Altered family processes
  2. Ineffective family coping: compromised
  3. Ineffective family coping: disabling
  4. Family coping: potential for growth.


Midrange families are likely to use mental health facilities and interact with nurses in the community health setting.

Troubled families often receive family therapy through therapists in private practice, community mental health centers, or psychiatric inpatient units.


The nurse must posses self-awareness, empathy, therapeutic communication skills, and knowledge of family therapy.

Psycho education for families.

Family therapy to include a family history and communication techniques used in the family.


Family therapy is terminated when everyone in the family can use the first person singular followed by an active verb and ending in a direct object. At this point, the members are free to express feelings and thoughts without the fear of losing self-esteem

Role and dynamics of the Alcoholic family:

Dependent- motivating feeling is shame, identifying symptom is alcohol use for the relief of pain. The possible price is addiction.

Enabler- motivating feeling is anger. Identifying symptom is powerlessness: individual is importance; self-righteousness: family responsibility: possible price illness; martyrdom

Hero – motivating feeling is inadequacy; guilty: identifying symptoms overachievement: individual attention positive: family self-worth: possible price compulsion drive.

Scapegoat- motivating feeling hurt: identifying symptoms delinquency: individual attention negative: family focus away from dependent: possible price self-destruction; addiction.

Lost child - motivating feeling loneliness: identifying symptoms solitariness; shyness: individual escape: family relief: possible price social isolation.

Mascot- motivating feeling fear: identifying symptoms clowning; hyperactivity: individual attention (amused): family fun: possible price immaturity; emotional illness