NURS 318

Communication and
Health Professionals

10. Communication With

Families
 Objectives
By the end of the lecture the student will be able to :
Identify family dynamics
Discuss different forms of family unit
Perform assessment of family relationships within the
larger social system
Perform family interventions to strengthen family
functioning
Dr. Lourdes P. Cuevas
 Outline
I. Family Dynamics II. Family Assessment
 Family Structures  Demographic Information
 Stages of Family Development  Medical and Mental Health History
 Family Characteristics and Dynamics  Family Interactional Data
 Family Roles  Family Burden
 Family Boundaries  Family System Data
 Power Structure  Needs, Goals, Values and Aspirations
 Relationship Strains and Conflicts  Family Genogram
 Relationship and Communication  Family Ecomap
Dysfunctions in Families

III.Family Interventions
Dr. Lourdes P. Cuevas
 Functions of family communication

 Help children learn about the environment

 Communicates rules about how family members should think and act

 Nurtures and develops self- esteem

 Transmits cultural values and traditions

 Express emotions within the family unit

 Resolves family conflict Dr. Lourdes P. Cuevas

 Functions Matters
 It’s important to have a healthy family life with your partner and
children to have work-life balance in your life.

 Having good family communication is a key ingredient in having a

healthy family life.

Dr. Lourdes P. Cuevas

 Release the Pressure!

 Families with long-lasting, poor

communication become like a ‘pressure
cooker’ that will eventually blow

Dr. Lourdes P. Cuevas

 Family communication
• It refers to the way verbal and non-verbal information is
exchanged between family members.
• Communication involves the ability to pay attention to
what others are thinking and feeling. In other words, an
important part of communication is not just talking, but
listening to what others have to say.

Dr. Lourdes P. Cuevas

 Family dynamics
• Family Structures
• Stages of Family Development
• Family Characteristics and Dynamics
Family Roles
Family Boundaries
Power Structure
Relationship Strains and Conflicts
• Relationship and Communication Dysfunctions in Families
Dr. Lourdes P. Cuevas
 Family structures
• The family is the primary system to which a person
belongs and in most cases, it is the most powerful system
of which a person will ever be a member.
• Birth, puberty, marriage and death can all be considered
family experiences.
• The family can be the source of love or hate, pride or
shame, security or insecurity.
• Family provides the primary context of human
development
Dr. Lourdes P. Cuevas
 Family structures
• What is a Family?
• Family is defined as reciprocal relationships in which
people are committed to one another.
• The traditional nuclear family is a two parent, two
generation family consisting of a married couple and
their children by birth or adoption.

Dr. Lourdes P. Cuevas

 Family structures
Families may look like one of the following:
─ Traditional Nuclear Family: A mother, a father with one or more
children living together as a single family unit.
─ Extended family :nuclear family unit`s combination of second-and
third generation members related by blood or marriage but not living
together
─ Dyad family: husband and wife or other couple living alone without
children.
─ Blended Family: A couple with 8 children:3 of hers, 3 of his and 2 of
theirs.
─ Single Mother Family: A divorced woman and her 2 teenagers.

Dr. Lourdes P. Cuevas

Continuation..
Family structures
─ A widowed man, his child and his parents.
─ A grandmother raising her three grandchildren.
─ A 33 year old single engineer and his three foster
children.
─ Three single women friends sharing an apartment,
none could afford alone.
─ Two lesbian women – Western culture.
─ Two gay men – Western culture
Dr. Lourdes P. Cuevas
Continuation..
Family structures
Nuclear family
2 Generations

1st generation Parent 1 Parent 2

(mother) (Father)
2nd generation Child (ren)

Dr. Lourdes P. Cuevas

 Vertically Extended Family
3 Generations

1st generation Grand parents

2nd generation Parent

3rd generation Child (ren)

Dr. Lourdes P. Cuevas

 Horizontally Extended Family
2 Generations
Brothers / Sisters Parents 1st generation

Dr. Lourdes P. Cuevas

 Single-Parent Family
2 Generations
1st generation

Broken Nuclear family

Parent 1-------- Parent 2 Divorce
Death
Desertion
Dr. Lourdes P. Cuevas
 Stages of Family Development /
Family Life Cycle
 One of the most important theory describing the family
development, was formulated by Duvall 1967 and
expanded upon by Duval and Miller in 1985.
 Family development theory is based on the assumption
that families, like individuals, change over a period of
time.
 The families progress through a series of similar
developmental stages and face similar transition points and
developmental tasks.
Duvall’s Stages of Family
Development
 Family Characteristics and
Dynamics
– Family Roles.
– Theoretical framework
– Family Boundaries.
– Power Structure.
– Relationship Strains and Conflicts
– Whether they are functional or dysfunctional, families
have certain characteristics and dynamics.
– In each family, each person’s behavior is contingent on
and affects the behavior of the others.
 Family Roles

– Members of the a family must determine how to

accomplish family developmental tasks.
– They do so by establishing family roles, pattern of
behavior sanctioned by the culture.
– Families set roles by operating as a rule – governed
system, an ordered format designed so that
members may be aware of their positions in
relation to one another.
 Family Roles
– When members are unable or unwilling to perform
assigned roles, the family experiences stress.
– For the health of the family system which includes not
only family members but also their relationships, their
communication with one another, and their interaction
with the environment – roles often must be negotiated
in other than stereotyped ways.
– When the roles are not negotiated satisfactorily, family
disequilibrium results.
 Theoretical Framework

– Family system theory helps explain how

family/families strive for harmony and balance
– how family is able to maintain its continuity
despite of challenges
– How family is to change and grow overtime in
response to challenges
 Family Boundaries

Boundaries
– Barriers that separates a system or subsystem from
its broader context.
– A healthy family must be flexible ( have some
boundaries & at the same time must be strong
enough to allow the family remain intact.
– Family with no boundaries or too weak is at risk
for disintegrating into the environment.
 Family Boundaries
Boundaries defined as:
 Boundaries are guidelines between people about suitable
behavior and responsibilities.
 Who participates in the family.
 The amount or intensity of emotional investment in the
family.
 The amount and kind of experiences available outside the
family.
Boundaries
 Family Boundaries - Clear

• Clear Boundaries
 Boundaries are very important part of creating a sense of belonging and an assurance that everyone
cares.
 Highly functioning families have clearly defined boundaries in them. Clear boundaries define the
authority of the parents while allowing the children to develop as appropriate for their age.
 Clear, stable and healthy boundaries allow for personal and meaningful relationships with others.
 Boundaries should be clear and reasonable. They need to be consistent.
 A person with healthy boundaries has a solid sense of self.
 There are feelings of belongings to family as well as to others outside the family.
 “I – ness” and “We – ness”.
 Family Boundaries – Rigid

• Rigid / Disengaged Boundaries

─ Those in which rules and roles are maintained under all conditions.
─ Keep members from having meaningful relationship with and understanding
one another.
─ People with rigid boundaries can become isolated or withdrawn.
─ The isolation extends to the outside community as whole and the family is cut
off from others.
 Family Boundaries – Rigid

• Rigid boundaries are found in families where the members are

isolated from one another and communication has broken down. In
these families, there is little respect for the individuality of the
people in them.

Examples of rigid boundary

The son is going to bed at 7:00 p.m. until he’s 18 years old. In this
scenario, there’s no room for the son’s voice or an allowance for his
individual growth.
A young teenage boy and girl engaged and want to hold hands but, if
they do, they will face hostility from their family and community.
 Family Boundaries - Diffuse

Diffuse / Enmeshed Boundaries

 Is the opposite of rigid boundaries.
 A person with diffuse boundaries has no clear definable boundaries with others.
 Characterized by family over involvement in the lives of its members leading to
loss of independence by one or all family members.
 Parents and children become increasingly dependent on one another.
 Increased dependency allows the destructive behavior to continue.
 Example: In the bedtime example, the son would be allowed to go to bed whenever
his parents went to bed and perhaps even sleep in the same bed with them.
 Power Structure

 Power / hierarchy.
 Some times referred to as management of the family.
 Most families have a hierarchal power structure in which adults wield the
power.
 The power structure is often developed in this way because it creates a safe
environment in which young children can grow and develop.
 Stress develops when disagreements exists about who holds the power.
 Power Structure
They will already
allow,Once they already
grow mature to have the
children responsibilities for
 When children mature and become capable of assuming greater their own self

responsibilities for their own functioning, power is often diffused among all
members of a family system in more democratic fashion.
 Certain families do not allow power to be redistributed, thus hindering the
individual development of the members.
 In some dysfunctional families, there is chronic discord about power.
 Relationship Strains or Conflicts

 Strains or conflicts can occur in the family or among various parts of the
family or outside of it.
 A strain can exist between two siblings.
 Conflict or strain can also occur between a member of a family and the rest
of the family.
 Or between a minority of family members and the other members.
 Strain can also exist between a family and the community.
 Healthy Communication among Families
Healthy Communication among families are characterized by:
 Clear and comprehensive messages.
 Encouraging members to ask for what they want and express their
feelings appropriately.
 Feelings of affection and conflict are both openly expressed.
 Members get the attention they need without manipulation.
Good Communication helps create:
 A sense of belonging in a family
 Increases understanding
 Empathy between family members
 Relationships and Communication
Dysfunctions in Families
 Triangulation
 Scapegoating
 Double bind
 Manipulating
 Distracting
 Generalizing
 Blaming
 Relationships and Communication
Dysfunctions in Families
Triangulation

 A tendency, when two person relationships are stressful and

unstable, to draw in a third person to stabilize the system.
 A triad or a triangle consists of a dyad plus one.

For example:
 Adult partners may unite to discipline the child.
 Mother and child may unite to argue for a family vacation.
Relationships and Communication
Dysfunctions in Families
 Relationships and Communication
Dysfunctions in Families
You are threat family
Scapegoating
 A form of displacement in which a family member (usually the
least powerful) is blamed for another’s or another family
member’s distress.
 The purpose is to keep the focus off the painful issues and the
problems of the blamers.
 In a family the blamers are often the parents and the scapegoat is
the child
 Double bind

 A situation in which a positive command (often verbal)

is followed by a negative command (often nonverbal),
which leaves the recipient confused, trapped and
immobilized because there is no appropriate way to act.
 A double bind is a no win situation in which one is
darned if s/he does, darned if s/he does not.
 Manipulating
You try to manipulate other people because you are
strong and more powerful, you know how to play with
them, you know how to get what you want

 Instead of asking directly for what is wanted, family

members manipulate others to get what they want.
For example:
 a child starts a fight with a sibling to get attention
 a family member blackmailing another member “
If your do this for me, I won’t tell Dad you are
getting poor grades in school”.
For example, if you don’t go with For example, if you will give me a
us, we will not help you with your new bag, I will not tell baba that u
assignment. failed on one of the subjects
 Distracting & Generalizing
Distracting You go away of the main point

 To avoid functional problem solving and resolve conflicts

within family, family members introduce irrelevant details
For example, when you are late for home and
into problematic issues. your mother got angry then you say “ oh you
look a beautiful today “
Generalizing . ( ‫ انا بس مره عصبت فقالو عني عيلتي كل مره ) انتِ دايم معصبه‬،‫مثال‬
‫ ) انتِ دايم تنامني متاخر ( وانا بس نمت بس كم مره متاخر‬، ‫او مثال‬
‫وهكذا‬

 When dealing with problematic family issues, members use

global statements like always and never instead of dealing
with specific problems and areas of conflict
 Family members may say “ Fahd is always angry” instead of
“ Fahd, what is upsetting you?” never come early to clinical For
For example, marym you are
example, you are
always lazy or angery duty
 Blaming
• Family members blame others for failures, errors and negative
consequences of an action to keep the focus away from
themselves. ‫الوم غييري على اخطائي‬

• This is a response to fear of being blamed by others.

For example, the reason why I For example, the reason why why I
• Trust, safe ,secure to come late , because my sister fail because my sister always
wake up late. disturbed me when I study

Scapegoat = Is the person

Blam= blamed others to errors
 Family Assessment
Family assessment involves gathering data in several different areas.
1. Demographic information
• How actively does the family pursue religious / spiritual activities?
• Who in the family is employed? What are their attitudes about employment?

2. Medical and Mental Health History

• Past and present medical and mental health problems, illnesses.
• Gather information about the developmental stage of the family.
 Family Assessment
3. Family interactional Data / Dynamics and relationships
 What family rules foster stability in the family?
 What are the formal roles of family members?
 What are the informal roles (scapegoating, aggressor, decision maker)?
 Family communication ( Who speaks to whom? Are the messages clear?
 Do members hear one another?
 Family cohesion by noting who accompanies the patient? and who visits the patient?
 Do members spend time interacting and sharing activities, do they sit quietly together
or do they maintain physical and emotional distance from one another?
 Family Assessment
4. Burden
 Family burden refers to the difficulties and responsibilities or
family members with psychiatric disability.
 Family burden involves
─ Financial strain.
─ Violence in the household.
─ Reduction in the physical and mental health of family caregivers.
─Disruption of family routines.
─ Worry about the future.
─ Impact of stigma.
─ Inability to cope.
 Family Assessment

5. Family System Data

• Determine how the family interacts with the outside world?
• Assess the boundaries for being rigid or diffuse?
• To what degree the family is deviant from the larger culture?
• Determine alliances / closeness within the family
• Who supports whom?
• Which members are in conflict with one another or with the family as a
whole?
• Are there extended family supports?
• What other social supports are available to the family?
 Family Assessment

6. Needs, Goals, Values and Aspirations

• Determine whether essential needs are met or not?
• Are physical needs met?
• Are emotional needs met an to what level?
• Is the family willing or able to meet the individual needs of its
members?
• Are the goals and values shared by all?
• Do some members compromise?
• Do other members simply give up?
 Family Assessment - Genogram
7. Family Genogram - Is the family diagram that records information
about the family member and their relationship for at least three
generations.
• Three parts:
 mapping family structure,
 recording family information,
 describing nature of family relationship
• It provides information about the structure of intergenerational
relationship, psychological data on education, martial status, and
occupation, and heath status.
 Family Assessment - Genogram
Family Genogram - Is the family diagram that records information
about the family member and their relationship for at least three
generations.
• Three parts:
 mapping family structure,
 recording family information,
 describing nature of family relationship
• It provides information about the structure of intergenerational
relationship, psychological data on education, martial status, and
occupation, and heath status.
Family Assessment - Genogram
Family Assessment - Genogram
Family Assessment - Genogram
 Family Assessment - Ecomap
• Offers a means of
diagramming the
relationships with other
people that the family has
contact with outside the
immediate family.
• It represents the relationship
between family members
and the community based
system such as school,
work, health care system,
and neighborhood
 Family Intervention – Critical points
• Developing and practicing active
listening skills.
• Viewing family members in a positive
nonjudgmental way.
• Critical observations of cues of family
stress so that appropriate interventions
may be made in a timely manner.
 Family Intervention – Family Therapy

• According to the family therapy, the emotional symptoms or

problems of an individual are an expression of emotional
symptoms of problems in a family.
• Therefore, the family is viewed as the unit of treatment.
• The therapy is focused on relationships between the family
members
 Family Therapy -Phases

• The unit of treatment.

• Contract or goal negotiation.
• Intervention.
• Terminating family therapy.
 Family Therapy

The unit of treatment

- It’s recommended that all the people in the family
participate in the assessment phase of family therapy to see how the
family as a whole operates.
 Family Therapy

Contract or Goal Negotiation

- The negotiation phase is begun by identifying what each
member would like changed in the family.
- When each family member and the therapist identified
important goals, they begin negotiating a set of attainable
goals that everyone is willing to work on them.
- Compromise is needed at that time.
 Family Therapy

Interventions done by therapist

• Create safe setting for family members can look at themselves and their actions.
• Teaching family members how to share their observations with one another.
• Asking for and giving information in a matter of fact nonjudgmental way.
• Responding as a role model.
• Setting rules for interactions to ensure that all family members participate
(Interruptions and acting out are not tolerated) – No one speaks for anyone else.
 Family Therapy
Interventions done by therapist
• Clarifying the content and relationship aspects of messages.
• Pointing out significant discrepancies and incogruneuities and
double messages.
• Helping everyone to speak out clearly and be heard by others.
• Not taking sides and viewing the family as a system
• Teaching about role responses and choices.
 Family Therapy
Terminating Family Therapy
 Family therapy is terminated when family members can:
-See how they appear to others.
-Give feedback to others, telling them how they appear.
-Sharing their hopes, fears and expectations with one another.
-Openly discuss problems and disagree with each other.
-Give clear messages & seek validation.
-Ask for clarification.
-Support one another.
-Achieve the family’s goals.
 References

 Arnold, E., Boggs ,k. (2003): Interpersonal relationships-

professional communication skills for nurses.5th ed.
Elsevier, Saunders. Pg. No: 289-315