Families, like individuals, experience stages in growth.  Each new stage of development presents challenges to the family system which requires adaptation to a new reality.  Challenges include the birth of the first child, births of succeeding children, a grown child leaving home, retirement, aging, and death of first one parent and then the other.  Each change, whether an expected one, like the arrival of a new child, or an unexpected one, such as a job loss, divorce, or serious illness, requires some difficult adjustments in family roles and functions.

If the death of a family member occurs in the midst of a new stage in the family's growth, the stress of adjusting to the death combined with the stresses of adjusting to a new phase of growth can create tremendous challenges for the family system.

The Nature of Family Systems

When we are trying to understand the nature of family systems a map or framework can help us make sense of what we observe.  Several experts have developed models of family interaction to help us "make sense" of the families undergoing hospice care.

Enmeshed/Disengaged
Salvador Minuchin described family systems as either enmeshed or disengaged.  When a family is enmeshed, the identity of each of its members is con connected to the family as a whole, and to each of its other members, that the death of one member presents difficult identity and self-esteem problems for he survivors.  A mother may feel she has no separate existence from her child.  A husband may feel he is nothing without his wife.

The bonds between members of an enmeshed family system are so tightly interwoven they present an almost impenetrable barrier between the family and the outside world.  An enmeshed family may have difficulty accepting the help of a home care nurse or volunteer because the family has an unspoken rule against "letting strangers know our business."

A disengaged family represents the other extreme.  members of disengaged family are so separate from one another there may be almost no mutual dependence.  Instead of too much closeness and involvement, family bonds are so weak they seem almost nonexistent.  There is so little structure and cohesion that hospice staff may have difficulty determining who is a member of the family and who is a friend or visitor.  However, disengaged families may also set up strong barriers between the family and the outside world.

Most families are on a continuum somewhere between enmeshed and disengaged.  The terms enmeshed and disengaged does not always imply dysfunction.  When a child is born, en enmeshed relationship is appropriate between the infant and caretaker.  When a family member is dying, a certain amount of enmeshment is appropriate as the family's energy is directed toward the care of the dying person.  The "functional enmeshment" is appropriate and includes more sharing of functions, more dependence, and increased support of one another.

Closed/Open
Virginia Satir's framework for describing families focuses on the nature of th family's communication patterns, rules, and relationship with the outside world.  Se describes systems as being open or closed.

Characteristics of a closed family system:

• extremely resistant to change

• restricts contact or transactions with the outside world

• uses indirect, unclear, and nonspecific communication

• uses covert, out-of-date rules to govern family behavior

• prohibits any comments about family rules and beliefs

Satir says closed family systems evolve from certain set of beliefs among them:

• People are basically evil and must be controlled to be good

• Relationships have to be regulated by force or dread of punishment

• There is one right way, and the person with the most power knows it

• There is always someone who knows what is best for you

Satir also points out that in closed family systems:

• self-worth is secondary to power and performance

• actions are subject to the whims of the "boss"

• change is resisted

Closed family systems establish rigid boundaries between family members and outsiders.  many of the characteristics of closed family system can be used to describes other dysfunctional groups, whether they are social or religious groups or hospice interdisciplinary teams.

Characteristics of an open family system

• Change is viewed as inevitable and normal

• Supportive relationships with the outside world are encouraged

• Direct, clear, and specific communication iw welcomed

• Flexible rules that meet the needs of individual family members govern the entire family's behavior

• The family permits communication and comment about the family's rules and beliefs.

According to Satir's framework, in open system:

• self-worth is primary; power and performance are secondary

• actions represent one's beliefs

• change is welcome and seen as normal and desirable

• communication about family rules is allowed

Most families are somewhere on a continuum between closed and open. The important point for hospice caregivers to remember is a family's framework, or pattern of behavior, influences many things including: how the family responds to death of one of its members; whether or not help will be accepted; whether or not the illness and/or death can be discussed; whether or not family members will be available to help care for the dying person; how much difficulty the family will experience adjusting to the loss.

An open family system's permeable boundaries and encouragement of supportive relationships outside the family usually allow the hospice team greater access to the family.  Learning to work within the rules and prohibitions of a closed family presents a challenge for the hospice team that needs to be met with respect for the family's needs.

The purpose of identifying the type of family systems is not to change or judge, but to help us understand the effects of the family system on their ability to cope with terminal illness and death.

Family Subsytems

Within a family system, smaller groups called subsystems interact with one another.  Subsystems may be grouped according to age, such as the two subsystems of adults and children; by sex, such as mothers and daughters; by areas of interest, such as a hobby shared by a father and his children; or by function, such as the three subgroups of grandparents, parents, and siblings.  In an open system, family members may join different subsystems from time to time.  For example, a father may form a "fishing" subgroup with anyone who is interested in fishing.

Virginia Satir and William White describe other types of subgroups that exist within each family.

Pairs - Each pair within a family has a role name, such as husband-wife, mother-son, husband-son, mother-daughter, etc.  Families can experience difficulties if they have very rigid beliefs, or rules, about the appropriate role for each member of the pair.  For instance, a rule that says "only wives cook" will result in adjustment difficulties if the wife becomes too ill to cook.

Triangles - Any family with more than two members also contains subsystems of triangles.  Satir notes a two-person system remains stable as long as no stress challenges the subsystem.  However, when anxiety levels increase and another person becomes involved pairs become triangles.  For example:  if two children begin fighting, one of the parents commonly intervenes, forming  a triangle.  If two parents experience difficulties in their relationships, it is common for one of them to turn to a child for support...or to an outside affair.

According to Satir, triangles are important because the way families operate depends a great deal on how they manage their triangles.  Triangles can become difficult and entangled because so many of them exist in each family.  A family of five has thirty triangles: the father/mother/first son - father/mother/daughter - father/first son/daughter - mother/father/second daughter and so on!

Coalitions - Subgroups of family members who band together for a special purpose are called coalitions.  A family subgroup that joins together to go fishing is an example of a coalition.  Family members frequently form coalitions during a terminal illness.  For example, some members of the family may join together to insist the patient be cared for at home, while others join together to insist the patient be moved to a nursing home.