Objectives

 To define family
 To know the types of family structure
 To describe a Filipino family
 To identify and understand family systems
theory
 To identify the different family assessment tools
and their applications to family practice
 To identify the 5 levels of family intervention
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

 NUCLEAR FAMILY

 Parents, dependent children

 Separate dwelling not shared with members of the

family of origin/orientation of either spouse

 Economically independent
g
Types of Nuclear Family

Father Spouse
Mother Son
Siblings Daughter

ORIENTATION/ PROCREATION
ORIGIN
 EXTENDED FAMILY
 Includes 3 generations
 Live together as a group
 Kinship network provides
function to all members
 Unilaterally extended
 Bilaterally extended
 Families of orientation are
merged with families of
procreation
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, nutrition

PSYCHOLOGIC UNIT
 Emotional support, protection

SOCIO-CULTURAL UNIT
 Socialization, values
Basic Areas of Function

ECONOMIC
 Financial resources allocation and security

EDUCATIONAL
 Skills, attitudes
 Family Relationships

 ORDINAL POSITION
First born: generally persevering
serious
more responsive to adults
achievement oriented
Middle Child: optimistic
sociable
aggressive
competitive
occasionally manipulative
Youngest: demanding
outgoing
affectionate by nature
 Family Set-up
 DEMOCRATIC
parents respect their child’s decisions and ideas
understanding and permissiveness prevail

 AUTHORITARIAN
unquestioned obedience
pattern of punishment than praise
suspicious of adults
stand poorly in stressful situation
become hostile with pain and discomfort
The family is the social
context in which illness
occurs and where
recovery takes place.
The Filipino Family

 Closely knit
 Bilaterally extended
 Authority based seniority/age
 Externally patriarchal, internally matriarchal
 High value on education
 Predominantly Catholic
The Filipino Family
Emerging Structures
 Changing commitments
 Global and Urban Migration
 Changing role of women
New Parental Configurations
 Single mothers
 Single fathers
 Step parents
 Absconding fathers or mothers
 Absent fathers or mothers
 Surrogate parents
 Bicultural parents
 Two daddies, two mommies
•introduced by Dr. Murray Bowen in the
1950's.

This theory suggests that a person cannot

be understood in detachment from others
, but rather as a part of the family they
are connected to, because the family is
the affecting factor to the person's life.
What does it mean to say a family
is a system?

A family is greater than the sum

of its parts

Every member is interconnected

Movement of one affects the
others.
The Family as a System…
- exhibits circular changes

- has a tendency to resist

change and maintain a state
of homeostasis

- reaches a state of
equilibrium even if change
happens within the system
Structural Approach to Family
Systems
 Pioneered by Dr. Salvador Minuchin

• Focus on family’s “STRUCTURE”

• It has to have clear hierarchy, roles,

subsystems & boundaries

• Family’s ability to adapt to stressors depends

on the clarity and appropriateness of its
STRUCTURE
Understanding Families:
Elements of the Family System
 Structures  Subsystems

 Rules  Roles
 Overt
 Covert  Coalitions

 Boundaries  Power Structures

Exploring Structures: Series
Questions
• “When situation A happens, what happens to
member 1?”

• “When this happens to member 1,

• what happens to member 2?”
• When member 2 behaves in that way what
happens to member 3?
Rules
 Commonly agreed upon ways of dealing with
each other, dealing with situations, and
dealing with the external environment

 Overt Rules: openly communicated and

highly visible
 Covert Rules: unspoken and tends to be
rigid.not open for negotiation
Roles
 Specific function assigned to a family
member

 Breadwinner
 Caregiver
 Symptom carrier
 “Family Doctor”
 “Medical Specialist”
Exploring Roles:
“Who-does-what-and-when”
Questions
• “When someone gets sick in the family, who
do you usually go to first?

• “When that person does not know what to

do, who does he consult?

• “When the patient has to be admitted to the

hospital, whose permission must be
obtained?”
Subsystems

 Subgroups within a family separated from

each other by a significant period of time

 Grandparental, parental, sibling

subsystems
Boundaries
 Special rules that govern the interactions
between subsystems in the family

 May be clear, rigid or diffuse

 Ideally, should be clear enough to prevent

interferences but flexible enough to allow
contact across subsystems
Boundaries

• Clear – with clarity and negotiable: allows

flexibility when family goes through periods of
change

• Rigid – not open to negotiations

• Diffuse – lack of clarity; intrusions by one

subsystem to another
Coalitions
 Alliances between members

 Informal groupings within the family of

people who usually side with each other
Eliciting Coalitions:
“Who agrees with whom” Questions

• “Who is the person that the patient usually

disagrees with in the family?

• “In case of a disagreement with that person, who

in the family agrees with the patient?”

• “Who in the family usually agrees with the other

person?
Power Structures
 Decision-makers
 Usually parental generation
Family Processes

 Enmeshment

 Disengagement

 Triangulation
Exploring Emotional Closeness
and Distance: “Closer-farther”
Questions
 “Who is closest to this patient? After that
person who is next closest? And the next
closest after that?”

 “Who is the person who feels farthest away

emotionally from the patient? Then who is
the next farthest?
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 Map
 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/

Disengagement

Triangulation
Family Assessment Tools

Structure
• Genogram
Development
• Family Life Cycle
Function
• Family APGAR
• Family Lifeline
Resources
• SCREEM
• Ecomap
Family Genogram
 Inheritance patterns
 Family illnesses
 Family members
 Family relationships
 Significant dates
A complete genogram should
include:
 Names, ages of all family members
 Exact dates of birth, marriage, separation, divorce, death and other
significant life events
 Information covering 3 or more generations
 Illness (hereditary and significant illnesses)
 Firstborn of each family to the left and other siblings sequentially
to the right
 Indication of which members live together in the same household
 Names of 2 families with the address of the index family
 The informant/s
 Date the genogram was generated
Genogram Symbols
Male Female

Unknown sex Pregnancy/

Child in utero

Spontaneous abortion

Induced abortion Single Parent

Genogram Symbols

Bert, 5 Jane, 12

Roy, 50 May,29

Index patient
Name, Age
Genogram Symbols

Dizygotic Twins Monozygotic Twins

Unknown sex of child Adopted

Genogram Symbols

Death
And Cause RHD Stroke
Pneumonia MI
Genogram Symbols

2008 2008

Marriage and Year Not married and

Year started living together

2008
2008

Separation and Year Divorce and Year

Genogram Symbols
Genogram Symbols
Family Assessment Tools

Structure
• Genogram
Development
• Family Life Cycle
Function
• Family APGAR
• Family Lifeline
Resources
• SCREEM
• Ecomap
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
 Unattached
Young Adult

Newly
Family in
Married
Later Years
Couple

Family with
Launching
Young
Family
Children

Family with
Adolescents
Unattached young adult
 “Between families”
 Young adult separates from the family of
origin without fleeing to a substitute of
emotional refuge
 He formulates personal goals.
Newly Married Couple
 “joining of families through marriage”
 Transition stage of the couple from their
family of origin and their lives as individual
to the life of couple
FAMILY WITH YOUNG
CHILDREN
 Starts at pregnancy with the first child and
continues up to the emergence of adolescents
 The coming of children defines a new family
status as the wife becomes the mother and the
husband becomes the father
 Children start going to school which is their
first contact with people
 conflict with practices in the home and school
regulations may occur in this stage
FAMILY WITH ADOLESCENTS

 3 HALLMARKS
changes in the balance of responsibility
along with overfunctioning and under
functioning
shifts in intensity of relationships
surge of exchange with the community
Parents approaching middle life stage and
grandparents in later stage
Not only teens are undergoing crisis (identity) but
their parents as well
LAUNCHING FAMILY
 Begins when the first child leaves home and
ends when the last child leaves home.
 Usually prolonged
FAMILY IN LATER YEARS
 Begins with departure of last child and
continuous through retirement of one or
both couple and ends when both are dead.
Family Assessment Tools

Structure
• Genogram
Development
• Family Life Cycle
Function
• Family APGAR
• Family Lifeline
Resources
• SCREEM
• Ecomap
Family APGAR
 Developed by Dr. Gabriel Smilkstein

 5-item questionnaire to assess family

function

 Measures individual satisfaction about

family relationships
Component Definition

Capability of the family to utilize and share inherent

Adaptation
resources

Sharing of decision making

Partnership Measures the satisfaction attained in solving problems by
communicating
Emotional and physical growth
Growth
Measures satisfaction of the available freedom to change
How emotions are shared between members
Affection
Measures satisfaction with emotional interaction

How time, space, money are shared,

Resolve Measures the satisfaction with the commitment made by
other members of the family
 Almost Some of Hardly
FAMILY APGAR Part I
Always the Time Ever
I am satisfied that I can turn my
A family for help when something is
troubling me
I am satisfied with the way my family
P talks on things with me and shares
problems with me
I am satisfied that my family accepts
G and supports my wishes to take on
new activities or directions

I am satisfied with the way my family

expresses affection and responds to
A emotion such as anger, sorrow and
love
I am satisfied with the way my family
R and I share time together
 Paminsan Halos
FAMILY APGAR Part I Palagi
-Minsan hindi
Ako’y nasisiyahan dahil nakakaasa ako
A ng tulong sa aking pamilya sa oras ng
problema
Ako’y nasisiyahan sa paraang
P nakikipagtalakayan sa akin ang aking
pamilya tungkol sa aking problema
Ako’s nasisiyahan at ang aking pamilya
ay tinatanggap at sinusuportahan ang
G aking mga nais na gawin patungo sa
mga bagong landas para sa aking pag
unlad
Ako’s nasisiyahan sa paraang
ipinadadama ng aking pamilya ang
A kanilang pagmamahal at nauunawaan
ang aking damdamin katulad ng galit,
lungkot at pag-ibig
Ako’y naisisiyahan na ang aking pamilya
R at ako ay nagkakaroon ng panahon sa
isa’t isa.
 Who lives in your house? How do you get along?
Sinu-sino ang nakatira sa inyong tahanan? Paano ang inyong relasyon?
Name and Relationship Age Sex Well Fairly Poor

Pangalan at Relasyon Edad Kasarian Mabuti Hindi Hindi mabuti

gaanong
mabuti

If you don’t live with your family, list the

persons whom you can turn to for help.
How do you get along?
Kung hindi ka nakakahingi ng tulong sa
Paano ang inyong relasyon?
iyong sariling pamilya, kani-kanino ka
humihingi ng tulong?
Pangalan at Relasyon Edad Kasarian Mabuti Hindi Hindi mabuti
gaanong
mabuti
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
The Family APGAR is valuable in the
following:

 Psychosomatic disorders
 Difficult patients
 Marital difficulties
 Multiple presentations by single/multiple
family members
 Drug or alcohol abuse
 Evidence of sexual and physical abuse
Family Assessment Tools

Structure
• Genogram
Development
• Family Life Cycle
Function
• Family APGAR
• Family Lifeline
Resources
• SCREEM
• Ecomap
Family Lifeline
 Significant events among family members
over a period of time in a chronological
sequence

 Allows exploration of certain family issues

Family Assessment Tools

Structure
• Genogram
Development
• Family Life Cycle
Function
• Family APGAR
• Family Lifeline
Resources
• SCREEM
• Ecomap
SCREEM
 Assess ability of family to participate in
provision of health care and cope with crisis

 Sources of help

 Barriers to patient care

 Relationships of health behavior, practices and

utilization of health services
SCREEM Family Resource
Survey
SCREEM-RES

 12-item family resource questionnaire

 Assesses the family’s capacity to participate

in the provision of health care or to cope
with crisis
 Lubos Sumasa Hindi Lubos
na ng-ayon sumasa na hindi
Questions sumasa ng-ayon sumasa
ng-ayon ng-ayon

• Ang bawat isa ay nagtutulungan sa aming

pamilya
S
• Natutulungan kami ng aming mga kaibigan at
kasamahan sa komunidad.
• Ang aming kultura ay nagpapanatag ng loob ng
aming pamilya

C • Ang kultura ng pagtutulungan at

pagmamalasakit sa aming komunidad ay
nakakatulong sa aming pamilya.
• Ang aming pananampalataya at relihyon ay
nakakatulong sa aming pamilya.
R
• Natutulungan kami ng aming mga kasamahan
sa simbahan o mga grupong relihyoso.
 Lubos Sumasa Hindi Lubos
na ng-ayon sumasa na hindi
Questions sumasa ng-ayon sumasa
ng-ayon ng-ayon

• Sapat ang naipong pera ng aming pamilya para

sa aming mga pangangailangan
E
• Sapat ang kinikita ng aming pamilya para sa
aming mga pangangailangan
• Sapat ang aming edukasyon/kaalaman upang
maintindihan ang mga impormasyon tungkol sa
sakit.
E
• Sapat ang aming edukasyon/kaalaman upang
maalagaan ang sakit.
• Madaling makakuha ng tulong medikal sa aming
komunidad.
M
• Natutulungan kami ng mga duktor, nars at
health workers
SCREEM-RES
 Scoring:
Lubos na sumasang-ayon – 3
Sumasang-ayon – 2
Hindi sumasang-ayon – 1
Lubos na hindi sumasang-ayon – 0

 Total :
13 – 18 = adequate family resources
7 – 12 = moderately inadequate family resources
0 – 6 = severely inadequate family resources
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.
 Prayer Group Barkada

Church
Tennis Club

Sister

School
Org
Px +++++++++++ Parents

Brothers
School
Family
Family Assessment Tools

Structure
• Genogram
Development
• Family Life Cycle
Function
• Family APGAR
• Family Lifeline
Resources
• SCREEM
• Ecomap
Other Family Assessment Tools
 DRAFT – Draw a Family Test

 The Family Circle

 Areas for Assessment: “St.
FRED”
DOMAIN ASSESSMENT TOOLS
Structure Family Genogram
Rules, Roles, Coalitions, Family Map
Transactional Patterns Circular questions
Flexibility Family Lifeline
Resonance Circular questions
Ecological Context SCREEM
Ecomap
Development Family Life Cycle Stage/Genogram
Illness Typology and Trajectory
 LEVELS OF FAMILY
INTERVENTION
Doherty & Baird, 1987

Level 1: Minimal Involvement

Level 2: Ongoing medical information & advice

Level 3: Provision of emotional support

Level 4: Systematic assessment & planned intervention

Level 5: Family Therapy

Level 1: Minimal Involvement

 Doctor hardly sees the family

 Focus of treatment is mostly individual patient
 Family is involved only in medico-legal issues

 Example: Consent
Level 2: Ongoing Medical Information
and Advice

• Doctor involves the family by providing them with

information about patient’s illness
 Focus: Health education both patient & family
 Primarily cognitive in nature

• Example: Disclosure
Level 3: Provision of emotional
support

• In addition to health education, the doctor :

 probes deeper into the emotional impact of illness
 offers emotional support to the family members

 Example: Family CEA

Level 4:Systematic assessment &
Planned Intervention

• Doctor makes systematic assessment of the

dynamics of the family and how it is interacting
with the illness

• Plans and carries out intervention to change

structures in the family so that health problem of
the patient can be better dealt with
Level 5: Family Therapy
• Optional for physicians

• Requires additional training

• Average family physicians will likely

REFER to professionals when confronted
with family dysfunctions that require this
intervention
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
 Textbook of Family Medicine Volume 1. Philippine Academy of
Family Physicians
 Dr. Richa Opina Tan
 Dr. Tricia Mercado
 Dr. Cherry Bernardo-Lazaro