T he Family as a

Unit of Care

Mek Villafuerte-Solana,
MD, DPAFP
Aug. 11, 2009
DEFINITION OF
THE FAMILY
p Sociologic Viewpoint
n Enduring social form
in which a person is
incorporated
p Biologic Viewpoint
n Genetic transmission
unit
p Psychologic Viewpoint
n Matrix of personality
development and
the most intimate
emotional unit of
 FAMILIES
COMPRISE
OF PEOPLE
WHO HAVE A
SHARED HISTORY
AND A
SHARED FUTURE
Characteristics of the
Filipino Family
 CHARACTERISTICS OF THE
FILIPINO FAMILY
p Closely knit
p Bilaterally extended
p Strong family
orientation
p Authority based on
age/seniority
p Externally patriarchal,
internally matriarchal
p High value on education
of members
CHARACTERISTICS OF THE
FILIPINO FAMILY
p Predominantly
Catholic(80%
population)
p Child centered
p Average members is 5
p Environmental stresses:
economic, political,
urbanization &
industrialization,
health problems
p
THE FAMILY AS A VERY
SPECIAL UNIT
p Lifelong involvement
p Shared attributes
n Genetics – physical/psychological
n Developmental – shared home, lifestyle &
social activities
p Sense of belonging
n Security/defense against potentially hostile
environment
n Companionship
THE FAMILY AS A VERY
SPECIAL UNIT
p Societal expectations
n Sense of responsibility toward members and others
n Basis of affection/care
p Built-in problems
n Generation gap
n Dependence on members
n Emotional attachment/involvement
p The family endures in-spite of problems
n Resource utilization
n Authority
n Individual sense of responsibility
 FAMILY STRENGTHS
p Ability to provide family’s
needs
n Physical – space
management, balanced
meals, general health
status
n Emotional – helping
members develop their
capacity for sensitivity
to each other’s needs
n Spiritual/Cultural –
sharing beliefs &
FAMILY STRENGTHS
p Child – rearing practices
and discipline
n Capacity of parents to
respect views on
child rearing
practices
n If a Single Parent, the
capacity of a single
parent to be
consistent and
effective in raising
children
FAMILY STRENGTHS
p Communication
n Ability to communicate and express
emotions verbally/non-verbally
p Support, Security & encouragement
n Capacity to provide with feelings of security
& encouragement
n Balance in pattern of family activities
FAMILY STRENGTHS
p Responsible Community Relationships
n Capacity to assume responsibility through
participation in social, cultural or
community activities
p Self-Help & accepting Help
n Ability to seek & accept help when they
need it
FAMILY STRENGTHS
p Flexibility of Family Functions & Roles
n Ability to “fill in” for one another during
times of illness/when needed
p Crisis as a means of Growth
n Ability to unite & become supportive during
crisis/traumatic experience
FAMILY AS A UNIT OF
CARE
p THE FAMILY AS THE SOCIAL CONTEXT
FOR HEALTH CARE
n Transmission of infectious/communicable
diseases
n Health behavior requirements in the unit
n Resource utilization/source of support
n Health and illness definitions
n Health decisions/approaches and strategies
FAMILY AS A UNIT OF
CARE
p THE PATIENT’S PROBLEM IS THE FAMILY’S
PROBLEM
n Doherty and McCubin, 1985: Important
ways in which the family plays a role in
the health of its members:
p health promotion/maintenance and

illness/injury prevention
p coping with stressful life events

p family based health and illness

appraisal
FAMILY STRUCTURE
p Nuclear
n Members: parents & dependent
children
n Occupying separate dwelling not
shared with members of the
family of origin of either
spouse.
n The household is economically
dependent, subsisting from the
occupational earnings of
husband/father
FAMILY STRUCTURE
p Extended Family
n Unilaterally extended
n Bilaterally extended
n Includes 3 generations; family centered;
lives together as a group & through its
kinship network provides support
functions to all members
FAMILY STRUCTURE
p Single-Parent Family
n Children < 17 yrs. old living in a family unit
with a single parent, another relative, or
non-relative
n May result from loss of spouse by death,
divorce, separation, desertion
n Out-of-wedlock birth of a child
n From an adoption
n One parent is working outside the
Philippines (ocw, dhws etc.)
FAMILY STRUCTURE
p Communal/Corporate Family
n Grouping of individuals formed for specific
ideological or societal purposes
n Considered as alternative lifestyle for people
who feel alienated from the
predominantly economically oriented
society
BASIC AREAS OF FAMILY
FUNCTION
p Biologic
n Reproduction
n Child rearing/caring
n Nutrition
n Health maintenance
n Recreation
p Economic
n Provision of financial resources
n Resources allocation
n Ensure financial security of member
BASIC AREAS OF FAMILY
FUNCTION
p Educational
n Teach skills, attitudes and skills relating to
other functions
p Psychologic/ Affection
n Promotes natural development of
personality
n Offer optimum psychological protection
n Promotes ability to form relationship with
people in family circle
p Socio-Cultural
n Socialization of children
n Promotion of status and legitimacy
 ORDINAL POSITION
(DIFFERENCES IN BEHAVIOURS)
p First Born – generally persevering
n Serious
n More responsive to adults
n Achievement oriented
p Middle Child - optimistic
n Sociable
n Aggressive
n Competitive
n Occasionally manipulative
p Youngest - demanding
n Outgoing
n Occasionally narcissistic
n By nature are affectionate
FAMILY SOCIAL CLASS
PATTERNS
p Upper Class
n much more closely knit
n greater concern for maintaining for family
name & prestige
p Middle Class
n believes in hard-work, initiative,
independence, responsibility, economic
security & self improvement through
education
p Lower Class
n sees life as continual struggle for survival
n resigned to a life of frustration and defeat
FAMILY SET-UP
p Democratic
n Parents respect child’s decision/idea
n Understanding & permissiveness prevail
p Authoritarian
n Unquestioned obedience conformity to
Parental guidance
n Pattern of punishment than praise
n Patients with Low self-reliance
n Suspicious adults
n Stand poorly in stressful situation
n Become hostile with pain/discomfort
QUESTIONS?
 Tools of Family
Assessment

Marikka Villafuerte-Solana, MD
San Beda College of Medicine
Objectives of the Session
p Learn to incorporate a family systems
approach to clinical practice
p Understand the different tools of family
assessment
p Apply/ use the tools of family assessment
in clinical practice
Family Systems Approach to
Patient Care
p Better health care results if family
relationships, social and cultural systems
are all considered
p Can facilitate a new level of
understanding of a patient’s problem
p Requires understanding the structure and
function of the family
Incorporating a
Family Systems
Approach into
Clinical Practice
STEP 1- Know the
Individuals/
Members of the Family
p Know the individuals in the family
p Obtain the following information
n Names of members
n Place of residence
n Specific roles in the family
n Stage of the family life cycle
n Significant dates in the family
(marriage, birth, death, etc)
STEP 1- Know the
Individuals/
Members of the Family

p THE FAMILY GENOGRAM

Ø A graphic representation of the genetic
pedigree, psychosocial, and interactions
within the family
Ø Three features:
vThe family tree
vFunctional Chart
vFamily illnesses/ history
STEP 2- Understand Normal
Family Functions
p Provide support to each other
p Establishing independence to enhance
personal growth of each member
p Create rules that govern the conduct of
each member
p Adaptation to change
p Communication with each other
 Smilkstein’s Cycle of Family Function
Family in functional equilibrium
(Functional or nurturing)
Adaptati
on
(coping) Stressful
Resources Life event
adequate
Family in
disequilibrium
Resource
s
inadequa
te Extra-
Crisis familial
resource
s
Maladaptati
on
Pathologic
defense
mechanism Stressf
Terminal
disequilibri Pathologic disequilibrium ul life
STEP 3- Assess Family
Structure and Function

p Tools of Family Assessment

Ø Family Genogram
Ø Family Map
Ø Family Circle
Ø Family APGAR
Ø SCREEM
Ø DRAFT (Draw a Family test)
Ø Life Line (Clinical biographies and life
events)
Ø
 THE FAMILY
GENOGRAM
p Uses of the family genogram
n Records names and roles of each
member of the family
n Separates extended family into several
household
n Documents medical problems of each
member of the family
n Documents significant dates in the family
history
 THE FAMILY
GENOGRAM
p The Family Tree
Ø Consists of three generations
Ø The first-born of each generation is farthest
to the left
Ø The family name is placed above each
major family unit
Ø Given names and ages are placed below
each symbol
Ø Index patient is identified with an arrow
Ø Date is indicated when the chart was
developed
 ESPINOSA- REFULGENTE FAMILY
C H
T A
I Ernesto JOLENE Efron
Rizza Jun
54 48
30 57

II
Lucil Hazel Salva
Joy Ayn Ivy
22 21 17
25 20 18
III

C C- cancer

MAE BRAYN T- tb
25
23 H- hepatitis
- HPN
Reid
1
May 19, 2003 A- asthma
 SOLANA-VILLAFUERTE FAMILY

I
Graciano Remedios David Tess
82 65 58 55

II
Manding
Amy George Lydia Imelda Elizabeth Grace
Reggie Jhay Bhen
31 22 20
Victoria Nene Hearty Mandy
Julie Mien
28 28

III 4 4 6 Lester
Michael

Heart disease Chai

Diabetes P P 3

Asthma Justin Mek

Nanay
39 33 Puring
HPN
58
Stroke Junilyn
Thea
P Provider 28
2 mos

C Caregiver Nov. 25, 2007

 THE FAMILY
MAP
p DEVELOPED BY Salvador Minuchin, a
Psychiatrist-Family Therapist
p Facilitates the communication of
information about a family system to
colleagues so that they can be
understood
THE FAMILY
MAP
p Functional/close relationship
p Indicates dysfunction
p Over-involved relationship
p Rigid boundary where the rules
are clear but not negotiable
p Boundary that is clear but
negotiable
p Boundary that is diffuse or
unclear
p Coalition or alliance
p Escape from the system
THE FAMILY
MAP
p Conflictual relationship
p Distant relationship
p Dominant relationship
p Marital discord
p Divorce, mother has custody of
two girls
p Solid or dashed line indicating
individuals living together
p
 ESPINOSA- REFULGENTE FAMILY
C H
T A
I Ernesto
JOLENE Efron
48 Rizza Jun
54
30 57

II
Lucil Hazel Salva
Joy Ayn Ivy
22 21 17
25 20 18
III

C- cancer

MAE BRAYN T- tb
25
23 H- hepatitis
- HPN
Reid
1 A- asthma
May 19, 2003
THE FAMILY
MAP JOLENE Jun

MAE

Efron Rizza

Joy Lucil

Salva
Ayn
 
  Hazel
Ivy

BRAYN
 THE FAMILY
CIRCLE
p
p The Family Physician draws a large circle
on a piece of paper and instructs the
patient to draw small circles
representing himself and each
member of his family
THE FAMILY
CIRCLE
Reggie
Papa
Daday

Jhay
Bhen

Nanay
a m a
a rty Purs
M He Mek
Chai Thea Justin

Juni
 THE FAMILY
APGAR
p Consists of five questions that assess
family function
p Rapid screening instrument for family
dysfunction
p Measures the individual’s level of
satisfaction about family relationship

 THE FAMILY
APGAR
p Part I helps define degree of patient’s
satisfaction w/ family
p Part II delineates relationship w/ other
members, and identifies people who can
give assistance to the patient
p Scores of 8-10 points= highly functional
family

4-7= moderately dysfunctional

0-3= severely dysfunctional

 THE FAMILY
APGAR
p Situations where the APGAR is needed
n When the family will be directly
involved in caring for the patient
n When treating a new patient, in order
to assess family function
n When treating a patient whose family is
in crisis
n When a patient’s behavior makes you
suspect a psychosocial problem due
to family dysfunction
THE FAMILY
APGAR
 SCREE
M
p Shows the capacity of the family to
participate in the provision of health care
or to cope with crisis
p Each factor can be considered as a
resource or a pathology
 DRAW A FAMILY
TEST
p Provides clues on the individual members
of the family w/ regards their
personalities
p Members of the family find the opportunity
for self-expression, thus revealing and
relieving innate difficulties w/in the
family systems
 LIFE LINE/LIFE
CHART
p The individual’s experiences with health
and sickness are connected with his
personal life
p If life events and clinical events are put
side by side accdg to dates of
occurrence, the correlation between the
two can be shown
 LIFE LINE/LIFE
CHART Mae was born to Jolene and
May,1980
Ernesto

Childhood
days
 
Happy days
College
Years

Feb, 1998 Mae met Brayn

 LIFE LINE/LIFE
Oct,CHART
2000 Espinosa-Refulgente wedding

Disillusionment about the wedding

  Return to mother for comfort

Aug, 2002 Birth of Reid

Feb, 2003 Medical illness

Feb, 2004 Death

Questions?
ASSIGNMENT
p Makeyour own family genogram in
three generations, APGAR,
SCREEM, and family circle