Learning Objectives
By the end of this section, you will be able to:
- Explain the role of family dynamics in nursing practice
- Discuss how the family systems model builds collaborative relationships with clients and their families
- Describe collaborative relationships in mental health nursing
With approximately 14.1 million adults and 49.5 percent of adolescents with serious mental illness in the United States needing the help of family caregivers, it is no wonder that family dynamics have a large effect on the outcomes for these clients (National Institute of Mental Health, 2023). The push in more recent years for providing care to individuals with serious mental illness in the least restrictive environments, along with the focus on client-centered care, has increased the need for family members to become caregivers. How does this affect family dynamics and the need for collaborative relationships?
Mental illness does not only affect the individual. It affects the entire family. Nurses can assist family members by educating them about mental illness and disease processes, allowing them to share their feelings, and encouraging open communication between them.
Family Dynamics
The way that the family members interact, communicate, and problem-solve is called family dynamics. Functional families work together toward common goals. They support one another and have good communication. Dysfunctional relationships can cause distress and broken ties within the family, leading to poorer mental health outcomes. Even with effective family dynamics, mental illness can cause changes and challenges to the living environment, as well as the family hierarchy (Sanders et al., 2014). Stigma affects families just as it does the person living with the mental health diagnosis. Families can adopt stigmatizing beliefs and feelings about mental illness and this can influence how they perceive and support the person with the mental health diagnosis.
Families today include a variety of combinations that form the family unit (Table 6.1). These combinations include nuclear family, single-parent family, extended family, childless family, grandparent family, and step family. Because mental illness can affect anyone, family members in any combination or type of familial group will have to adapt.
| Family Structure | Description |
|---|---|
| Nuclear family | Two parents with one or more children |
| Single-parent family | One parent raising one or more children |
| Extended family | Multiple family members raising one or more children |
| Childless family | Two partners, married or unmarried, with no children |
| Grandparent family | Grandparents raising one or more children without the parents |
| Stepfamily or blended family | Two parents with children forming a combined family unit |
Nuclear Families
The traditional family, or nuclear, family was mother, father, and children. The current version of this family model includes two parents, regardless of gender or marital status, and one or more children (Meleen, 2021). This family structure can provide stability from having more than one parent to share the care of the child/children. Nuclear families may also have more than one income, providing financial stability for the family unit. Consistency provided by two parents can increase positive behavior patterns in the children. In a functional nuclear family, children learn how to take responsibility and form positive relationships from watching their parents work together to problem-solve and support one another. The opposite is also true. If the parents in a nuclear family have a dysfunctional relationship, for example one that includes arguing or not supporting one another, then children will learn that type of behavior.
Some cons associated with the nuclear family include burnout, especially in mothers, as they often attend to the needs of the entire family while also working outside of the home. Nuclear families are frequently very tightly bonded and may not seek the assistance of extended family members. Without the assistance of extended family, it may be difficult for parents to juggle work, sick children, household chores, and after-school activities, making them more prone to depression and anxiety (Meleen, 2021). Parental stress observed by the children can also impact the children’s stress levels and cause anxiety.
Single-Parent Families
The single-parent family is formed by one parent with one or more children. Nearly one in four children is born to a single parent (Blessing, 2023). Family members in single-parent households have a higher risk for developing mental illnesses, such as depression (Behere et al., 2017). The mothers in a single-parent household are also at three times the risk for developing depression and substance use as compared with their married counterparts (Behere et al., 2017). Further, having a parent, particularly the mother, with a mental health problem can increase the chances of the children in that household developing depression (Behere et al., 2017).
One contributing factor is that these households tend to fall at a lower socioeconomic level. It is estimated that poverty levels in single-parent households are as high as 50 percent, whereas in households with two parents, it averages about 5 percent (Behere et al., 2017). Poverty can contribute to dysfunction in parent-child relationships and, like divorce, can cause behavioral problems in the children of those families.
Extended Family
An extended family is multiple family members living together with the common goal of raising the children. This family unit usually has positive family dynamics. According to Mind Help (2023), the advantages of this family unit include sharing duties and finances. Having good communication, being supportive of one another, and working together toward the goals of the family creates a positive influence on the overall mental health of the family (Mind Help, 2023). Some disadvantages are a lack of privacy and interference with other people’s relationships within the household. Negative impacts of this family structure include being overinvolved in each other’s personal affairs, thus decreasing individual autonomy and increasing feelings of stress (Mind Help, 2023).
Childless Family
The childless family has no children, by choice or circumstance. This family consists of two partners, married or unmarried. These two adults may have a pet instead of a child with no plans to have children. These couples include working couples, couples who feel that children do not fit into their lifestyle (e.g., they enjoy a lot of traveling), and couples who choose to wait to have children (BetterHelp, 2023). The advantages to this type of family are time to enjoy things like travel and quiet time, financial stability, and not having the stress related to taking care of children (BetterHelp, 2023). The disadvantages are that they may experience loneliness and a feeling that they may be missing out by not having children.
Grandparent Family
This type of family unit is formed when grandparents step in to care for the grandchild/children when their parents are unable to do so. Pebley and Rudkin’s (n.d.) research has illustrated that split-family households, in which the grandparent is the primary caregiver, form when a parent has financial, mental health, or substance use problems and needs the intervention of grandparents to care for the children. There are about 4.5 million grandparents taking care of their grandchildren (Pebley & Rudkin, n.d.), and a higher percentage of grandparents who have grandchildren living with them occurs in Black families. This can create stressors unique to this family unit, such as physical and medical limitations and complications as an aging grandparent is responsible for children, transportation, and financial issues as well as generational conflict.
Stepfamily
Stepfamilies or blended families occur when two adults with children form a combined family unit. The adults may or may not have biological children together. While this type of family is becoming more common, it is not without its own set of problems (Mayntz, 2019). Conflicting family values, roles, and juggling the care of biological and stepchildren are just a few of the difficulties that may occur. In fact, introduction of a stepparent into a family increases the likelihood of abuse by 30 to 40 percent (Behere et al., 2017).
Families with a Parent with Mental Illness
In families where a parent has mental illness, children have a higher risk for developing a mental illness than those without mental illness in their family because of genetic and environmental risk factors (Sanders et al., 2014). Sanders et al. (2014) describe two types of burden that fall on families with mentally ill members: objective burden and subjective burden. The greater likelihood that a family member will neglect finances and routines, overlook other family members, and endure friction between family members, as a direct result of the ill family member, is called objective burden. Feelings related to the family member’s illness, including worries and anxiety, resentments, feeling trapped, and fears associated with stigma and with potential interactions and disturbing behaviors, is called subjective burden (Sanders et al., 2014). These burdens can make siblings and children become secondary victims as they help with caregiving, support their family member, and struggle with the need to grow up faster.
When considering children whose parents have mental illness, it is important for the nurse to examine the best way to support, educate, and promote resilience in these individuals (Tapias et al., 2021). Nurses should take into consideration the age of the child so that supportive measures meet the child’s developmental needs and level of understanding.
Cultural Context
Family Dynamics in Latinx Youth
Family has a high value in the Latinx culture. The strong family bonds should have a protective factor against mental illness. Lazarevic et al. (2021) performed a study testing whether strong family bonds do have a protective factor against mental illness in the context of discrimination faced by Latinx youth. The researchers found that even if the Latinx family had positive family dynamics, it did not protect against the negative effects discrimination had on depression and satisfaction with life in youth. Positive family dynamics only had a positive impact if discrimination levels were low. If the Latinx family had negative family dynamics, it increased the negative effects of discrimination on both depression and life satisfaction. The authors of this study suggested that practitioners working with Latinx families should assess for family conflict and the degree to which discrimination is affecting mental health within the family unit (Lazarevic et al., 2021).
Family Systems Model
In the 1950s, Murray Bowen developed his family systems theory, which is still the central orientation in family therapy practice (Brown, 1999). The purpose of implementing this theory in practice is to enhance the growth of each family member as well as that of the family as a whole. The main concept in this theory is how much the closeness or distance in the relationship between family members affects anxiety. The major focus in the theory is on differentiation of self (Brown, 1999). This is when an individual can feel autonomous and make decisions that help them function independently even within the family group (discussed in greater detail in 5.4 Family Support Systems).
When the nurse or therapist determines that there is fusion among family members, it is their job to teach the family members better ways of coping with stress and anxiety. When a person reacts immediately, without hesitation, to another family member’s demands, this is called fusion. Fusion of the family members increases the chances of taking things personally and being inflexible to dealing with stress (Brown, 1999). In more recent years, this model has also been used in a wider context to include a look at familial changes related to multigenerational stress, age, gender, and life cycle.
Collaborative Relationships
Interprofessional, collaborative relationships are those that evolve between the interprofessional team and the family. This relationship is a partnership in which all parties listen to one another and respect the perspectives of each person (Ness et al., 2014). Collaboration involves individuals, departments, and hospital systems working together to develop solutions for improving the care they provide to their clients, through sharing information (Howard et al., 2022). The collaborative care model has been developed over the past thirty years to connect behavioral health and health-care professionals and increase client engagement through providing evidence-based care that is based on a shared treatment plan (American Psychiatric Association, 2023).
The relationship between the nurse and the client/family can be a pivotal part of increasing positive outcomes when caring for those with mental illness. The education and support that nurses bring to the interaction help both the individual and the family to have a better understanding about how family dynamics affect each other’s mental health. The nurse acts in partnership with the family through learning about the family members, their hopes, their dreams, and how they see their lives unfolding in front of them (Ness et al., 2014). Through this process, they mutually agree on how to collaborate while the nurse teaches the family that working together strengthens the relationships within the family.
Clinical Judgment Measurement Model
Generate Solutions: Involve the Client as a Member of the Decision-Making Process
Psychiatric nursing is not about making decisions for the client, but with the client. Collaborating with the client and the client’s family in the decision-making process will help engage the client in the development of goals, outcomes, and interventions (Ness et al., 2014). Through the previous steps in the CJMM, the nurse will have gathered client history, gained information about what is important to the client in the trajectory of their care, and learned about their expectations for recovery. In generating solutions, the nurse’s interventions are based on the client’s needs and what makes sense to them. The client should have autonomy, the ability to be involved in the decision-making process. Without the client’s buy-in, the interventions suggested by the team could be fruitless.