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Psychiatric-Mental Health Nursing

5.4 Family Support Systems

Psychiatric-Mental Health Nursing5.4 Family Support Systems

Learning Objectives

By the end of this section, you will be able to:

  • Describe the importance of family support in psychiatric-mental health illness recovery
  • Define family systems therapy concepts and their benefits related to psychiatric-mental health nursing

Even though the individual client is the focus of therapy, it is vital to remember the importance that family support systems play in the client’s treatment and recovery. A thorough client history, including questions about who the client considers their support person(s), must be part of the initial assessment process.

Family Support in PMH Recovery

Recovery is a lifelong process for a person with psychiatric-mental health issues. Piat et al. (2011) state that there are two main parts to recovery: clinical recovery and personal recovery. Clinical recovery involves all the ways the clinicians rate a person’s recovery over time, including “diagnosis, objective measures of symptom management and remission, and psychosocial functioning” (p. 3). Personal recovery starts with the person’s life experiences and how those experiences shape a person’s identity. As a person delves into those aspects of their life, they can begin to reshape their identity in a healthy way. “Key concepts in the recovery process include hope; personal responsibility, self-advocacy and wellness; empowerment and self-determination; and acceptance” (p. 3).

Families can help by expressing a belief that the person can get better. This helps to instill a sense of hope. Family members also protect the person by being advocates for their health care and provide support by trying to keep the client’s self-image intact even if they have had negative treatment experiences. Families help the individual see their strengths and ability beyond their mental health diagnosis. Families offer the individual acceptance, trust, a sense of belonging, encouragement, and a place in a community. Remember, however, that “families” may look very different from one another and are defined by the client.

Key Concepts of Family Systems Therapy

Family therapy is a special form of group therapy, consisting of one or more families. Although there are many theoretical orientations in family therapy, one of the most predominant is the systems approach. In this approach, the family is viewed as an organized system, and each individual within the family is a contributing member who creates and maintains processes within the system that shape behavior (Minuchin, 1985). Each member of the family influences and is influenced by the others. The degree to which individuals express or react to life’s stressors is based on the way the family of origin reacted to the same. The goal of family systems therapy is to enhance the growth of each family member as well as that of the family as a whole. The Bowen family systems theory (BFST) was developed in the 1950s and is one of the main approaches used in marriage and family therapy (Calatrava et al., 2022). The theory is formed around eight main concepts, some of which are detailed more thoroughly here:

  • Nuclear family emotional process: Relationship patterns that guide where conflict occurs in the family unit
  • Differentiation of self: The difference between the individual and groups to which they belong
  • Triangles: The idea of a relationship system of three people
  • Emotional cutoff: Ending emotional contact with another in the family
  • Family projection process: The way that parents can transfer their emotional issues to their children
  • Multigenerational transmission process: The idea that differences between parents and their children grow throughout the generations
  • Sibling position: The position in which siblings are born affects behavior and development
  • Emotional processes of society: This same system applies to groups within societies beyond families

Emotional Triangles

Emotional triangles, one of the components of Bowen’s theory, result when parents have a lower level of differentiation of self and project their anxiety onto their children by being overreactive and overprotective. This causes triangulation because it makes the child unable to become differentiated from their parents, reducing their feeling of autonomy and increasing their levels of reactivity and anxiety (Cepukiene, 2021).

Differentiation of Self

Individuals vary in the degree of “self” they develop and this degree does depend, in part, on family dynamics. This trait begins to form in young adulthood when the individual can be emotionally objective in the midst of high anxiety related to other people within their group of belonging. The person begins to be able to have different opinions and values from the rest of the group members, while still being emotionally connected to them. This group could be their family, friends, children, or intimate relationships (Calatrava et al., 2022). The higher the level of differentiation of self, the better the ability of that individual to think for themselves by using intellectual reasoning. Being able to distinguish oneself from the rest of the group can ultimately affect the family’s patterns of functioning and their level of interaction.

Family Projection Process

The family projection process was also developed by Bowen to explain the way that stressful life events that happen in childhood shape the attachment that a child has to other members of the family (Palombi, 2016). Depending upon that level of attachment, the child is at risk of needing to have those family members in order to function. The way that the family unit adapted its response during stress shapes each individual within that family.

Multigenerational Transmission Process

The multigenerational transmission process explains “how anxiety is transmitted from generation to generation” (Calatrava et al., 2022, p. 2). Lower levels of anxiety experienced as a child can lead to lower levels of anxiety experienced as an adult based on the person’s learned reaction to stressful situations.

Emotional Cutoff

When people have lower levels of differentiation of self, they continue to be connected to their families in a way that creates unclear boundaries within their relationships (Messina et al., 2018). They do not develop their own opinions and values. They seek approval from one another instead of dealing with any tension within their relationships and may be unable to define their own personal values (Messina et al., 2018). People who are emotionally cut off lack the ability to find true autonomy even though they may project the look of independence.

With family therapy, the nuclear family (i.e., parents and children) or the nuclear family plus (whoever lives in the household, e.g., grandparent) come into treatment. Family therapists work with the whole family unit to heal the family. The main benefit of family systems therapy is that the therapist helps family members resolve issues and learn to communicate more effectively.


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