Whether in rich or poor countries, ‘developed’ or ‘developing’, the health of individuals is influenced by family life, and families are affected by the illnesses and misfortunes of their members. Ian McWhinney (1926–2012)
Working with families is the basis of family practice. Families living in relative harmony provide the basis for the good mental health of their members and also for social stability.
However, the traditional concept of the nuclear family, where the wife stays at home to care for the children, occurs in only about 15% of Australian families. Approximately 46% of Australian marriages end in separation. Families take many shapes and forms, among them single-parent households, de facto partnerships, same-sex couples and families formed by a partnership between two separated parents and their children. Psychosocial problems may occur in almost any family arrangement and family doctors need to know how to address such problems.
Family therapy is ideally undertaken by GPs, who are in a unique position as providers of continuing care and family care. It is important for them to work together with families in the counselling process and to avoid the common pitfalls of working in isolation and assuming personal responsibility for changing the family. We should understand that definitions of family vary greatly across cultures.
Bader1 summarises working with families succinctly:
From the perspective of family therapy, working with families means avoiding the trap of being too directive, too responsible for the family's welfare, with the result that the family becomes overly dependent on the general practitioner for its health and development. From the perspective of family education, working with families means developing the skills of anticipating guidance, helping families to prepare, not only for the normal changes occurring as the family develops, but also for the impact of illness on the family system.
Characteristics of healthy families
Successful families have certain characteristics, an understanding of which can give the family doctor a basis for assessing the health of the family and a goal to help set targets for change in disrupted families. Such characteristics are:
Healthy communication. In this situation family members have freedom of expression for their feelings and emotions.
Personal autonomy. This includes appropriate use of power sharing between spouses/partners.
Flexibility. This leads to appropriate ‘give and take’ with adaptation to individual needs and changing circumstances.
Appreciation. This involves encouragement and praise so that members develop a healthy sense of self-esteem.
Support networks. Adequate support from within and without the family engenders security, resistance to stress and a healthy environment in general (see FIG. 2.1). The family doctor is part of this network.
Three generations of a supportive family network