Introduction to Family Systems
Community
Medicine
Community Family
Medicine I Systems
Medical
Ethics
All Family Systems course
materials can be found online at
http://medicine.mercer.edu/Departments/Co
mmunity%20Medicine/cm_familysystems
This includes in class materials
(cases, readings, etc) and the
guide to your community visit
and family interviews.
FAMILY SYSTEMS
Three tutorials on campus
Session One
Systems Theory
Use of the Genogram
Session Two
Individual and Family Life Cycle
Family Assessment Instruments
Family APGAR
SCREEM
Session Three
Clinical “Red Flags” in Primary Care
Healthy Family Functioning
PCP Treatment Planning
Two Family Interviews in community
Family Interviews during Community
Visit
Preceptor will assign two families
Student will interview these families based
on knowledge and skill gained during
tutorial sessions
Two written family assessment reports
Why is this important?
Moreover, the books all seem to say pretty much the
same things: families are both necessary and
problematic; people live in more or less intimate groups,
"systems," and "context"; they grow and develop
through stages in a life cycle, and their groups, too,
have cycles; communication within and among these
intimate groups is both nurturing and destructive; people
often make each other sick, teach each other how to be
sick, or drive each other crazy; their sicknesses are
usually disguised as physical symptoms or destructive
behavior and I must learn how to detect and interpret
the "real" causes of these symptoms and behaviors as
family problems; and if I do not deal with them on a
systems level, it is because I am intransigently wed to a
nonbiopsychosocial, reductionistic view of medicine and
technology. It is enough to make a regular, hardworking
family doctor throw up his/her hands in despair!
Substantial evidence demonstrates that
chronic and serious physical illness has
profound effects on family members
and on the family as a whole.
Substantial evidence demonstrates that
families can have beneficial or harmful
effects on a family member’s physical
health.
Families have a powerful influence
on health, equal to traditional
medical risk factors.
The strongest evidence for this statement
comes from the social and family support
literature.
Numerous large epidemiologic studies have
demonstrated that social support,
particularly from the family, is health
promoting.
Women who are isolated and
have few or no family or social
supports after suffering a
myocardial infarction have two
to three times the mortality rate
compared to other women
(Berkman et al.).
Emotional support is the most
important and influential type of
support provided by families.
Instrumental
Informational
Emotional
Sense of belonging
For adults, marriage is the most
influential family relationship on
health.
Marital relationships have been the most
carefully studied family relationship and
demonstrate the strongest influence on
health.
Married individuals are healthier than the
widowed, who are in turn healthier than
either divorced or never married
individuals.
Many large studies have shown that
bereavement or death of a spouse
increases mortality, especially for men.
Marital quality, measured by a
composite of self report and
observation of marital interaction:
Predictive of survival from congestive heart
failure, after controlling for the initial
severity of the heart failure (Coyne et al.,
2001).
As strong a predictor of death as the
severity of heart failure itself and had a
stronger effect for women than men.
Dyadic negativity has been shown to
worsen survival in women who have end
stage renal disease and are on dialysis.
Negative, critical, or hostile family
relationships have a stronger
influence on health than positive or
supportive relationships.
Schizophrenia
Depression THINK STRESS
Smoking cessation RESPONSE…
Weight management CORTISOL
Diabetes ADRENALINE
Breast Cancer BLOOD SUGAR AND
Cardiovascular disease THE EFFECT OF
Asthma CHRONIC
EXPOSURE!
Migraine headaches
How Families Influence Health
Direct Biological Pathway
Airborne and bloodborne through living in the
same household (tuberculosis, influenza, Hep
B).
Perhaps the most important direct family
influence is through shared genes.
How Families Influence Health
Health Behavioral Pathway
The behaviors that influence our health are
strongly influenced by our families.
Life-style behaviors (e.g. smoking, exercise, similar
diets)
Health care behaviors (e.g. adherence to medical
treatment)
Family caregiving
Use of substances (tobacco, alcohol, illicit drugs)
All of these behaviors are usually developed,
maintained, or changed within the family
setting.
How Families Influence Health
Psychophysiological Pathway
Family relationships can influence physical
health by changes in cognitions and
emotions that result in physiological
responses, which in turn can influence
health outcomes.
Much of the research on stress, including
family stress, has focused on
psychophysiological effects, especially
neuroendocrine and psychoimmunological
pathways.
Of the top stressful life events on the Holmes
and Rahe scale, ten are family events.
How Families Influence Health
Psychophysiological Pathway
Divorced or separated individuals have poorer
immune responses than similar married
persons (Kiecolt-Glaser et al., 1987). Among
married women, marital dissatisfaction and
conflict is correlated with both depression and
decreased immunity (Schleifer, Keller, Bond,
Cohen, & Stein, 1989).
Evidence that partners of women with BCA
have compromised immune systems.
The Stress Response
Think cave man being chased by a
lion…fight or flight
A series of biochemical changes that
prepare you to deal with a threat or
danger (perceived or actual)
How does the brain deal with stress?
The Stress Response
Visual or auditory perception of threat
Message to hypothalamus in mid brain
– signals sympathetic division of ANS
“Send adrenaline”
Immediate boost to system while
additional messages being delivered
“Send cortisol”
1. Our heart rate increases
2. Our muscles tense
3. Our blood pressure rises
4. Our breathing speeds up and
switches to the chest
5. Blood is moved to muscles (an
increase of 300%)
6. Blood is moved to important areas
like the brain and away from less
important areas like digestion.
7. Our mouth dries up
8. We get sweaty clammy hands
9. Perspiration increases
10. Pupils dilate
11. Our sense of hearing becomes more
acute
12. Digestion slows
13. Our blood clots more easily
14. Blood sugar levels rise
15. Blood cholesterol levels rise
16. We can think more quickly and
clearly
17. Our spleen discharges extra red
blood cells into the bloodstream.
Acute and Adaptive Stress
Stress
More Stress
Stress Reduction
Return to Prepared
Acute Baseline for further
Stress Stressors
The problem is chronic stress. What happens when
we don’t reset to the baseline? A new and higher
homeostatic level is established.
Allostasis
Maintaining stability (homeostasis)
through change
Capacity to adapt or constantly change
thereby modifying physiological
parameters in order to adjust to ever
shifting environmental conditions
(stressors)
Adapting to life’s changing “weather conditions”
Allostatic Loading
Wear and tear the body experiences
due to repeated cycles of allostasis
Accumulated effects on body of
allostatic stress response, as well as
inefficient turning on and switching off
Anxiety and depression are allostatic
load disorders with dysfunction of fear
conditioning and stress response
systems
Allostatic Load
Cumulative measure of physiological
dysregulations over multiple systems; a
composite score of stress
12 hour overnight urinary excretion of:
Cortisol
Norepinephrine
And Epinephrine
Allostatic Load
As well as:
Average systolic BP
Average diastolic BP
Waist to hip circumference ratio of BMI
Serum HDL
Cholesterol to HDL ratio
Hemoglobin A1C
Allostatic Load Diseases
Hypertension
Truncal obesity
Hypercholestrolemia
Insulin resistant DM
Autoimmune disease
Anxiety
Depression
Chronic pain and headache
Chronic and Maladaptive Stress
Chronic Stress
More Stress
Without Stress
Reduction
Acute
Stress
The Land of Chronic Illness!
Protective factors:
Family closeness or connectedness
Caregiver coping skills
Mutually supportive relationships
Clear family organization
Direct communication about the illness
So welcome to the world of families in
health care. I invite you to open your
mind to possibility that family may be just
as important and influential as traditional
medical variables in assessing and
understanding disease process. Be
curious. Think outside of the box.
Each one of you is a participant observer
of family. Yet often this experience is
confused with the study of family from a
scientific perspective. So let me ask you to
use your family experience to help you
understand but be willing to suspend
some of the strongly held notions that you
have developed throughout your life.
Read all the readings.
Clearly organized by Session Number.
For tomorrow read “Family Assessment
Tutorial: Session One Readings.” Follow
this link:
Family Systems Readings on CM web page
Think about your own experiences as they
will help you illustrate and understand the
material.
Come to class prepared to discuss the
material with your colleagues and faculty.
Next Tuesday afternoon we will spend an
hour reviewing the requirements for your
Family Assessment Reports.