Family is a social system composed of two or more persons who coexist within the

context of some expectation s of reciprocal affection, mutual responsibility, and

temporal duration. The family is characterized by commitment, mutual decision
making, and shared goals. (Department of Family Nursing, Oregon Health Sciences
Center, 1985, quoted in Hanson & Boyd, 1996, p. 6)
Other Definition of Families
Legal- A family is a group of two or more persons residing in the same household
who are related by blood, marriage, or adoption (U.S. Census Bureau, 2002).
Family Science- A family is two or more persons who are committed to each other
and share intimacy, resources, decisions, and values (Olson & DeFrains, 1994).
Sociology- Family is an intimate association of persons who are related to one
another by blood, a marriage, formal or informal adoption, or appropriation; often
sharing a common residence (Billingsley, 1992)
Family Therapy- Family is a natural social system with rules, ascribed roles,
power structures, intricate communication, and a reciprocal emotional attachment
that varies across the family life course (Goldberg & Goldberg, 1996)
Family Nursing- A family is two or more persons who are joined together by bonds
or sharing and emotional closeness and who identify themselves as being a part of
the family (Friedman, Bowden, & Jones, 2003).
Family Systems Nursing- Family is a group of individuals who are bound by
emotional ties, a sense of belonging, and a passion for being involved in one
anothers lives (Wright, Watson, & Bell, 1996, p. 45).
Family Health Center Nursing- Family refers to two or more individuals who
depend on one another for emotional, physical, and economical support. The
members are self-defined (Hanson, 2001, p. 6).

Family as System
In the family-as-system approach the family is viewed as more than the sum
of its individual parts. If a significant event affects one family member, there is an
impact on others. The nurse assesses both the individual members and the family
group simultaneously. System theory suggests that the individuals within a family
are emotionally connected such that any important event that affects one family
member will have an effect to others as well. According to system theory, when
people are connected to each other in some meaningful way, events will necessitate
a change or adjustment in all other parts of the system. It is helpful to think of the
family as in balance. A family works achieve a state of equilibrium. Then, if

something happens to one member, the equilibrium is upset and the relationships,
supports, and tasks of everyday living need to be readjusted (Frisch & Kelley, 1996).
This family systems approach is used in mental health nursing, and the nurse
focuses on the significant event, its impact on the individual, and its impact on the
family unit. This family systems approach is also frequently used in family therapy.
The Family as a System
General systems theory is a way of organizing thought according to the holistic
perspective. A system is considered dynamic and ever changing. A change in one
part of the system causes a change in the others parts of the system as a whole.
When studying families, it is helpful to conceptualize a hierarchy of systems.
The family can be viewed as a system composed of various subsystems, such as the
marital subsystem, parent-child subsystems and sibling subsystems. Each of these
subsystems is further divided into subsystems of individuals. The family system is
also a subsystem of larger suprasystem, such as the neighborhood or community
Bowen (1978) Eight Major Concept:
1.
2.
3.
4.
5.
6.
7.
8.

Differentiation of Self
Triangles
Nuclear Family Emotional Process
Family Projection Process
Multigenerational Transmission Process
Sibling Position Profiles
Emotional Cutoff
Societal Regression

1. Differentiation of Self- is the ability to define oneself as a separate being. The

Bowen Theory suggests that a person with a well-differentiated self recognizes
his or her realistic dependence on others, but can stay calm and clear headed
enough in the face of conflict, criticism, and rejection to distinguish thinking
rooted in a careful assessment of the facts from thinking clouded by
emotionally (Georgetown Family Center, 2004a).
The degree of differentiation of self can be viewed on a continuum from high
levels, in which an individual manifests a clearly defined sense of self, to low
levels, or undifferentiated, in which emotional fusion exists and the individual is
unable to function separately from a relationship system. Healthy families
encourage differentiation, and the process of separation from the family ego
mass is most pronounced during the ages of 2 to 5 and again between the ages
of 13 and 15. Families that do not understand the childs need to be different
during these times may perceive his or her behavior as objectionable.

Bowen (1971) used the term stuck-togetherness to describe family with the
fused ego mass. When family fusion occurs, none of the members has a true
sense of self as an independent individual. Boundaries between members are
blurred, and the family becomes enmeshed without individual distinguishing
characteristics. In this situation, family members can neither gain true intimacy
nor separate and become individuals.
Differentiation of self involves two processes: intrapsychic and interpersonal.
Intrapsychic differentiation means separating thinking from feeling: a
differentiated individual can distinguish between thoughts and feelings and can
consequently think through behavior. For example, a person who has
experienced intrapsychic differentiation, even though angry, will think it through
the underlying issue before acting. However, the feeling of the moment will drive
the behavior of an undifferentiated individual. Interpersonal differentiation is the
process of freeing oneself from the familys emotional chaos. That is, the
individual can recognize the family turmoil but avoid re-entering arguments and
issues. For Bowen, the individual must resolve attachment to this chaos before
he or she can differentiate into a mature, healthy personality. Nursing research is
currently investigating the use of assessment tools measure differentiation.
2. Triangles- refers to three person emotional configuration that is considered the
basic building block of the family system. Bowen (1978) offers the following
description of triangles:
The basic building block of any emotional system in the triangle. When
emotional tension in two-person system exceeds a certain level, it triangles in
a third person, permitting the tension to shift about within the triangle. Any
two in the original triangle can add a new triangle. An emotional system is
composed of a series of interlocking triangles. (p. 306)
Triangles dysfunctional in that they offer relief from anxiety through diversion
rather than through resolution of the issue. For example, when stress develops in
a marital relationship, the couple may direct their attention to a child, whose
misbehavior gives them something on which to focus other than the tension in
their relationship. When the dynamics within a triangle stabilize, fourth person
may be brought in to form additional triangles, in an effort to reduce tension.
This triangulation can continue almost indefinitely as extended family and
people outside the family, including the family therapist, can become entangled
in the process. The therapist working with families must strive to remain detriangled from the emotional system.
3. Nuclear Family Emotional Process- describes the patterns of emotional
functioning in a single generation. The nuclear family begins with a relationship
between two people who form a couple. The most open relationship usually
occurs during courtship, when most individuals chose partners with similar levels

of differentiation. The lower the level of differentiation, the greater the possibility
of problems in the future. A degree of fusion occurs with permanent
commitment. This fusion results in anxiety and must be dealt with by each
partner in an effort to maintain a healthy degree of differentiation.
4. Family Projection Process- spouses who are unable to work through the
undifferentiation or fusion that occurs with permanent commitment may, when
they become parents, project the resulting anxiety onto the children. This
occurrence is manifested in most families with children.
The child who becomes the target of the projection may be selected for various
reasons.
1. A particular child reminds one of the parents of unresolved childhood
issue.
2. The child is of a particular gender or position in the family.
3. The child is born with a deformity.
4. The parent has a negative attitude about the pregnancy.
This behavior is called scapegoating. It is harmful to both the childs
emotional stability and ability to function outside the family (Goldenberg &
Goldenberg, 2005).
Scapegoated family members assume the role assigned them, but they may
become so entrenched in that role that they are unable to act otherwise.
Particularly in dysfunctional families, individuals may be repeatedly labeled as
the bad child-incorrigible, destructive, unmanageable, troublesome- and they
proceed to act accordingly. Scapegoated children are inducted into specific
family roles, which over time becomes fixed and serve as the basis for chronic
behavioral disturbance. (p. 386)
5. Multigenerational Transmission Process- Bowen (1978) describes this as
the manner in which interactional patterns are transferred from one generation
to another. Attitudes, values, beliefs, behaviors, and patterns of interaction are
passed along from parents to children over many lifetimes, so that it becomes
possible to show in a family assessment that a certain behavior has existed
within a family through multiple generation.
Genograms is a convenient way to plot a multigenerational assessment.
Genograms offer the convenience of a great deal of information in a small
amount of space. They can also be used teaching tools with the family itself. An
overall picture of the life of the family over several generations can be conveyed,
including roles that various family members play as well as emotional distance
between specific individuals. Areas for change can be easily identified. A sample
genogram is presented.

6. Sibling Position Profiles- the regarding this matter is that the position one
holds in a family influences the development of predictable personality
characteristics. For example, firstborn children are thought to be perfectionistic,
reliable, and conscientious; middle children are described as independent, loyal,
and intolerant of conflict; and younger children tend to be charming, precocious,
and gregarious (Leman & Leman, 1998). Bowen uses this to help determine level
of differentiation within a family and the possible direction of the family
projection process. For example, if an oldest child exhibits characteristics more
representative of youngest child, there is evidence that this child may be product
of triangulation. Sibling position profiles are also used when studying
multigenerational transmission processe and verifiable data are missing for
certain family members.
7. Emotional Cutoff- describes differentiation of self from the perception of the
child. All individuals have some degree of unresolved emotional attachment to
their parents and the lower the level of differentiation, the greater the degree of
unresolved emotional attachment.
Emotional cutoff has very little to do with how far away one lives from the
family of origin. Individuals who live great distances from their parents can still
be undifferentiated, while some individuals are emotionally cutoff from their
parents who live in the same town or even the same neighborhood.
Bowen (1976) suggest that emotional cutoff is the result of dysfunction within
the family of origin in which fusion has occurred and that emotional cutoff
promotes the same type of dysfunction in the new nuclear family. He contends
that maintaining some emotional contact with family of origin promotes healthy
differentiation.
8. Societal Regression- Bowen Theory views society as an emotional system. The
concept of societal regression compares societys response to stress to the same
type of response seen in individuals and families in response to emotional crisis:
stress creates uncomfortable levels of anxiety, that leads to hasty solutions,
which add to the problems, and the cycle continues. This concept of Bowen
Theory is explained as follows (Georgetown Family Center, 2004b).
Human societies undergo periods of regression and progression in their
history. The current regression seems related to factors such as the population
explosion, a sense of diminishing frontiers, and the depletion of natural
resources. The symptoms of societal regression include a growth of crime and
violence, an increasing divorce rate, a more litigious attitude, a greater
polarization between racial groups, less principled decision-making by leaders,
the drug abuse epidemic, an increase in bankruptcy, and a focus on rights over
responsibilities.
Goal and Techniques of Therapy

The goal of Bowens systems approach to family therapy is to increase the level of
differentiation of self, while remaining in touch with the family system. The premise
is that intense emotional problems within the nuclear family can be resolved only by
resolving undifferentiated relationships with the family of origin. Emphasis is given
to the understanding of past relationships.
The therapeutic role is that of the coach or supervisor, and emotional
involvement with the family is minimized.
Therapist techniques include (Moriarty & Shepard, 2001)
1. Defining and clarifying the relationship between the family members.
2. Helping family members develop one-one relationships with each other and
minimizing triangles within the system.
3. Teaching family members about functioning of emotional systems.
4. Promoting differentiation by encouraging I position stands during the
course of therapy.
Family life cycle refers to stages that evolve based on significant event related to
the arrival and departure of family members, such as birth or adoption, child
rearing, departure of children from home, occupational retirement, and death. The
family life cycle is a process of expansion, contraction, and realignment of
relationship systems to support the entry, exit, and development of family
members in a functional way (Carter & McGoldrick, 2005). A familys life cycle is
conceptualized in terms of stages throughout the years. To move from one stage to
the next, the family system undergoes changes. Structural and potential structural
changes within stages can usually be handled by rearranging the family system
(first-order changes), whereas transition from one stage to the next requires
changes in the systems itself (second-order changes). An example in school and the
stay-at-home parent returns to work. The system is rearranged, but the structure
remains the same. In second-order changes, the family structure does change, such
as when a member moves away from family home to live independently.
Transition times are the addition, subtraction, or change in status of family
members. During transitions, family stresses are more likely to cause symptoms or
dysfunction. Significant family events, such as the death of a family member or the
introduction of a new member, also affect the familys ability to function. During
transitions, families may seek help from the mental health systems.
Cultural Variations
In caring for the families from diverse cultures, the nurse should examine whether
the underlying assumptions and frameworks of the dominant life-cycle models
apply. Even the concept of family varies among cultures. For example, the
dominant Caucasian middle-class cultures definition of family refers to the intact
nuclear family. For Italian Americans, the entire extended network of aunts, uncles,

cousins, and grandparents may be involved in family decision making and share
holidays and life cycle transitions. For African Americans, the family may include a
broad network of kin and community that included long-time friends who are
considered family members (Hines & Boyd-Franklin, 2005)
American families may emphasize the wake, viewing death as an important lifecycle transition. African American families may emphasize funerals, going to
considerable expense and delaying services until all family members arrive. Italian
American and polish American families may place great emphasis on weddings
(McGoldrick, Giordano, & Garcia-Preto, 2005)
Families in Poverty
The family life cycle of those living in poverty may vary from those adequate
financial means. People living in poverty struggle to make ends meet, members
may face difficulties in meeting their own or other members basic developmental
needs. To be poor does not mean that a family is automatically dysfunctional. But
poverty is an important factor that can force even the healthiest families to
crumble. In studying African American families living in poverty, Hines (1999)
observed four distinguishing characteristics: condensed life cycle, female headed
households of the extended-family type, chronic stress and untimely losses, and
reliance on institutional supports.
When the life cycle is condensed, family members leave home, mate, have
children, and become grandparents at much earlier age than their working-class
and middle-class counterparts. Consequently, many individuals in such families
assume new roles and responsibilities before they developmentally capable.
The condensed life cycle can be loosely divided into three overlapping
stages: adolescence and unattached adulthood, family with young children, and
family in later life. In the American African family living in poverty, members may
either push male adolescents out of the home or cling to them desperately as a
source of assistance. Education subsequently becomes a low priority, and these
teens often drop-out of school. Peer relationships are powerful and can conflict with
expectations at home. Male adolescents cannot differentiate themselves from either
family or peers. They often cannot find employment, except for menial work. They
may assert their masculinity in transient heterosexual relationships. Both family
burdens and peer pressure leave them ill-equipped handle later stages. They
quickly move into the next stages. They quickly more into the next stage of family
with young children but often cannot assume parental roles.
The second characteristic that Hines observed is female-headed households
of the extended-family type, in which a woman, her children and her daughters
children often live together without clear delineation of their respective roles. This
scenario can create economic and emotional burdens for the older women and
difficulty for the younger women in assuming parental responsibilities.

Often, the role of women living in poverty is conscripted to child rearing as

pregnancies interrupt their education and they eventually become dependent on
public support. Then, older family members (usually the babys grandmother)
become the primary sources of assistance. Subsequent pregnancies may increase
the burden of care giving. The next stage, the family in later life, does not signal a
decrease in daily responsibilities or a shift into concerns about retirement. Instead,
despite possible poor health, elderly family members continue to work to support
their children and grandchildren (Hines, 1999).
The third characteristic is chronic stress and untimely losses. Families living in
poverty are subject to family disruption via abrupt loss of members, loss of
unemployment compensation, illness, death, imprisonment, or alcohol or drug
addiction. Men may die relatively young compared with their middle-class
counterparts. Ordinary problems, such as transportation or a sick-child, can become
major crisis because of a lack of resources to solve them.
Reliance on institutional supports is the final distinguishing characteristic.
Poor families are often forced to seek public assistance, which ultimately can result
in additional stress in having a deal with a governmental agency.
Family Life Cycle and Tasks for Three Types of Family Life Cycles
Middle-Class North American Family Life Cycle
1. Launching the single young adult
a. Differentiating self in relation to family of origin
b. Developing intimate peer relationship
c. Establishing self in relation to work and financial independence
2. Marriage the joining families
a. Establishing couple identity
b. Realigning relationships with extended families to include spouse
c. Making decision about parenthood
3. Families with young children
a. Adjusting marital system make space for child
b. Joining in child rearing, financial, and household task
c. Realigning relationships with extended family to include parenting and
grand parenting roles
4. Families with adolescents
a. Shifting parent-child relationships to permit adolescents to move into or
out of system
b. Refocusing on midlife marital and career issues
c. Beginning shift toward joint caring for older generation
5. Launching children and moving on
a. Renegotiating marital system as a dyad
b. Developing adult-to-adult relationships between grown children and their
parents
c. Realigning relationships to include in-laws and grown children
d. Dealing with disabilities and death of grand parents

6. Families in later life

a. Maintaining own and/or couple functioning and interest in the face of
physiological decline exploration of new familial and social role options
b. Making room in the system for the wisdom and experience of the seniors
c. Deal with loss of spouse, siblings, and other peers and preparation for
death
Divorce and Post Divorce Family Life Cycle
1. Deciding to divorce
a. Accepting ones own part in the failure of the marriage
2. Planning the breakup of the system
a. Working cooperatively on problems of custody, visitation, and finances
b. Dealing with extended family about the divorce
3. Separation
a. Mouring loss of nuclear family
b. Restructuring marital and parent-child relationships and finances;
adapting to living apart
c. Realigning relationships with extended family; staying connected with
spouses extended family
4. Divorce
a. Retrieving hopes, dreams, and expectations from the marriage
Post-divorce: single-parent (custodial)
a. Making flexible visitation agreements with ex-spouse and his or her family
b. Rebuilding own financial resources
c. Rebuilding own social network
Post-divorce: single-parent (noncustodial)
a. Finding ways to continue effective parenting relationship with children
b. Maintaining financial responsibilities to ex-spouse and children
c. Rebuilding own social network
Remarried Family Life Cycle
1. Entering the new relationship; conceptualizing and planning the new
marriage and family
a. Recommitting to marriage and to forming a family
b. Developing openness and avoiding pseudomutuality in the new
relationship
c. Planning financial and coparental relationships with ex-spouse
d. Planning to help children deal with fears, loyalty conflicts, and
membership in two systems
e. Realigning relationships with extended family to include new spouse and
children
f. Planning maintenance of connections for children with extended family
and ex-spouse(s)
2. Remarriage and reconstitution of family

a. Restructuring family boundaries to allow for inclusion of new spouse-step

parent
b. Realigning relationships and financial arrangements throughout
subsystems to permit interweaving of several systems
c. Making room for relationships of all children with custodial and
noncustodial parents and grand parents
d. Sharing memories and histories to enhance step family integration
From Nurses and Families: A Guide in Family Assessment and Intervention (2nd ed.).
by L. Wright and m. Leahey. 1994. Philadelphia: F. A. Davis.