Families and Health Care

Psychosocial Practice

Kathleen Ell

• Publisher: Routledge
• Year: 2018
• Print ISBN: 9780202360607
• eBook ISBN: 9781351327541
• Topic: Política y relaciones internacionales
• Subtopic: Política social

This book offers an antidote to the medicalization of health care and observes the special needs of socioeconomically disadvantaged persons with respect to health. It is useful for practitioners in the fields of mental health, family and child welfare, gerontology, and industrial practice.

1
Relevant Theoretical Frameworks

The theoretical base that underpins a discussion of family-focused health promotion and family-focused medical care is a product of synthesizing scientific and epistemological movements within and across disciplines. Indeed, a chronicle of relatively recent theoretical developments in the fields of public health and medicine dramatically illustrates this knowledge synthesis in an evolutionary response to new information. Kuhn (1970) proposed that when faced with unanswered questions or a need for new explanations of observed phenomena, long-held assumptions or paradigms undergo a shift or, in the most extreme case, are replaced with a new paradigm. Consistent with this proposition, the emergence of the general systems paradigm (a paradigm that was originally formulated in the face of similar empirical observations within many different scientific fields) and parallel developments in the field of ecology spurred a dramatic shift in thinking about the human organism and its relationship to its environment. These developments, in turn, provided the impetus for shifting and refining underlying assumptions about interactions between people and their environments as they affect health and illness. At the same time, the influence of the systems and ecological paradigms can be traced in social work theory and family theory.

In this chapter, we examine this theoretical progression as it converges to support our basic contention, namely, that health promotion and health care should include a primary focus on the family. In an overview of paradigm shifts and theoretical convergence, we trace the influence of the general systems paradigm and the ecological perspective as overarching conceptual frameworks within public health, medicine, health psychology, social work, and family therapy. Social stress, social integration, and transactional stress models are presented in some detail as they are related to the family-health/illness connection. The ecosystemic and biopsychosocial models are described as synthesizing meta-theoretical frameworks. Finally, we review emerging perspectives on the family, including the family systems model and family stress and coping models. Overall, the progression of knowledge within each of the cited disciplines and health professions parallels the trend toward synthesis that characterizes the scientific community as a whole (Schwartz, 1982). It is this integration and progression of knowledge that provides the rationale for including a family perspective in health care practice.

The General Systems Paradigm

The general systems paradigm was first formulated in the 1950s, and its influence has been widespread (Bertalanffy, 1974; Boulding, 1956; Buckley, 1968). Analyzing recent paradigm shifts in such diverse fields as physics, chemistry, ecology, mathematics, biology, psychology, and others, Schwartz and Ogilvy (1979) have identified radical shifts in a view of the world that can be traced to the influence of the systems paradigm, including: (1) a shift from a simple and probabilistic world toward a view of its complexity and diversity; (2) a shift from a view of a hierarchically ordered world to a world ordered by heterarchy that emphasizes interactive influence, mutual constraints, and simultaneous interests; (3) a shift from the image of a mechanistic and machine-like universe toward one that is holographic, recognizing that everything is interconnected with each part containing information about the whole; (4) a shift from an assumption of direct causality to assumptions of mutual causality; and (5) a shift from the notion that complex systems are merely the sum of more simple units toward the metaphor of morphogenesis which describes the creation of new forms.

The process of explicating the general systems paradigm within specific disciplines was begun in the 1950s and continues today. For example, numerous applications to social work practice have been elaborated and the paradigm’s underlying assumptions have been recognized as consistent with the profession’s long-held focus on the person and environment (Coulton, 1981; Germain, 1977; 1987; Hearn, 1969; Hollis, 1981; Meyer, 1983a; Northen, 1969, 1988). Although frequently referred to as general systems theory, the paradigm is more accurately viewed as an overarching framework, an abstract meta-theory or a model about relationships among objects (Buckley, 1968). The paradigm is best characterized as a way of thinking and a means of organizing our perceptions of relatedness and dynamic processes. Therefore, it has been termed “the skeleton of science” (Boulding, 1956). The paradigm is not specific to a single discipline but, rather, proposes a common language to be used among many disciplines. For this reason, it is a particularly useful paradigm for integrating knowledge across disciplines. In fact, the emergence of new interdisciplinary fields such as psychoneuroimmunology and social psychophysiology has been attributed to the systems perspective (Schwartz, 1982).

Several basic assumptions are intrinsic to the general systems paradigm (Buckley, 1968). Living and nonliving forms can be regarded as a system, having discrete properties that can be observed and studied. Systems are organized wholes, not just the sum of their separate parts, and consist of elements that are related in varying mutual or unidirectional, nonlinear, and intermittent causal networks. Of prime importance, living systems are assumed to be capable of primary as well as reactive change and evolution. Finally, living systems maintain their differentiation through continuous inputs from and outputs to their environment. In the subsequent discussion of family systems theory, we will illustrate the application of these assumptions at a lower level of abstraction.

The emergence of the general systems paradigm can be characterized as a scientific revolution in Kuhnian terms (1970) because it challenged existing paradigms that were held within various disciplines. Pertinent to our discussion, the paradigm provides a framework from which to reframe questions about mind-body relationships and person and environment transactions as an object of legitimate scientific inquiry in the matter of health and disease (Viney, Clarke, & Benjamin, 1986).

The Ecological Perspective

Ecology is the study of relations between organisms and their environments (Catalano, 1979). Specifically, ecologists study adjustment or adaptation to environmental change. Originally, the perspective was applied to analyze phenomena among animal and plant life. Early ecologists tried to explain changes in the size, mix, spatial distribution, and behavior of subhuman populations in a given geographic area. An ecosystem referred to habitats and the relationships among organisms living there (Catalano, 1979).

Major assumptions of the ecological perspective include: (1) that individual behavior is best explained within the total environmental context in which individuals are embedded; (2) that human environments are extremely complex and include physical dimensions as well as elaborate social, economic, and political structures; and (3) that individuals must maintain an adaptive mutuality with their environments as persons and environments are reciprocally influenced (Catalano, 1979; Germain, 1977; Germain & Gitterman, 1980; Holahan, Wilcox, Spearly, & Campbell, 1979). Application of the ecological perspective by social and behavioral scientists challenges theorists to describe and conceptualize the complex social environment. In this vein, Bronfenbrenner (1979) has proposed envisioning the environment as a nested arrangement of circumjacent contexts, including the microsystem or person, the mesosystem or interpersonal relations within family, school, and work contexts, the exosystem or social structures and institutions, and the macrosystem or overarching cultural patterns, values, and ideologies. Each of these environmental contexts is recognized to have potential effects on health and illness (Winett, 1985).

As early as the 1920s, sociologists began applying the ecological perspective to the human community in attempts to understand the nature, location, and growth of cities (Catalano, 1979). In recent years, this conceptual framework has been borrowed by social and behavioral scientists to better understand human adaptation in relation to changing environments (Barker, 1978; Micklin & Choldin, 1984; Moos & Insel, 1974). An underlying assumption of the early sociologists persists among social ecologists of today, namely, that major sources of physical illness and abnormal behavior or psychopathology are adaptation-related disorders that occur in interaction with community, social, and economic change (Catalano, 1979) and with characteristics of the environment (Moos & Insel, 1974).

A Social-Ecological Perspective in Public Health

Paradigm shifts are most evident in recent population-based studies of health and illness. Epidemiology, the study of the origin and spread of disease in human populations, has always been a central line of inquiry in the field of public health. Early in its history, the discipline focused on infectious disease and operated primarily from the germ paradigm (Catalano, 1979). In the face of new information, however, the field expanded its focus to include more emphasis on chronic disease and on illnesses associated with individual lifestyles (Moos, 1979). In recent years, a distinct subfield, social or psychosocial epidemiology, has emerged (Polinkas, 1985). Two major research thrusts have characterized much of this line of epidemiological research: the relationship between stress and physical and mental illness; and the direct or indirect effects of social integration, social network membership, and social support on health and on the stress-illness relationship. Knowledge gained from this social epidemiological research has spurred the development of theoretical models that can be applied in conceptualizing relationships between families and health.

Social Stress and Illness

The common sense and intuitive observation made by practitioners that illness often, although not always, followed stressful periods in the lives of individuals, was probably the earliest recognition of the potential health effects of life stress. It was not until the 1940s, however, that accumulating evidence began to suggest that the central nervous system was a plausible mechanism to explain the observed associations. Historical antecedents of the proposition that stressful life events have an etiological role in illness are found in the work of Cannon, who illustrated that stressful life events can be harmful, and by Adolf Meyer, who proposed that such events were etiological factors in illness (Dohrenwend & Dohrenwend, 1981).

In the progression of knowledge concerning social stress, the work of Selye marks a critical landmark. His research provided a physiological basis for future conceptualizations regarding social stress and the biological organism (Selye, 1956). Consistent with a biological paradigm, Selye envisioned stress as a bodily state, rather than as an external component of the environment. He posited that all stressors, regardless of type, produced the same pattern of physiological response, a pattern that he termed the general adaptation syndrome (GAS). In early laboratory studies, he identified the natural state of the organism to be one of equilibrium with its environment. Change in one part of the organism was seen to result in disequilibrium among all parts. The struggle to reestablish homeostasis was proposed to involve several processes including an alarm phase, in which the organism is mobilized for fight or flight, and a resistance phase, during which the organism copes with the change. If the organism fails to overcome the threat over time, a state of exhaustion is said to occur, eventually resulting in diseases of adaptation. The contribution of Selye’s seminal research is reflected in the voluminous literature that has followed his work. Criticisms of his contribution have not detracted from its importance. Rather, knowledge about the physiological processes underlying stress responses has undergone major advances in recent years (McCarthy, Horwatt, & Konarska, 1988; Stein & Schlieifer, 1985; Williams, 1985).

Life Event Research

The influence of Selye’s stress model is clearly reflected in the epidemiological research on stressful life events. In this body of research, stress is conceptualized as the readjustment or change in usual behavior required by the individual in response to specific life events. These studies test the hypothesis that the intensity or magnitude of threat, disruption, or readjustment evoked by life events is associated with emotional arousal and neuroendocrine changes, which, if prolonged, may result in impaired functioning or illness (Gunderson & Rahe, 1974). Individuals are inventoried regarding their stressful life experiences within a specified time period (Dohrenwend & Dohrenwend, 1981). In general, numerous studies have identified associations (albeit in most cases small) between stress scores and illness onset. Criticisms of this seminal work have centered on: (1) methodological weaknesses; (2) its failure to distinguish positive versus negative stressors and the extent to which the individual had control over the event; (3) inadequate consideration of daily strains and chronic stress; and (4) perhaps most important from a clinical standpoint, the failure to take into account mediating processes. Recognizing that stress is a fact of life, theoretical refinements and improved research methods are currently being applied to further explicate the relationship between social stress and health (Fleming, Baum, & Singer, 1984; Kaplan, 1983; Kasl & Cooper, 1987; Vingerhoets & Marcelissen, 1988; Weinberger, Hiner, & Tierney, 1985; Zales, 1985). As will be observed in Chapter 2, most stress inventories include a significant proportion of family-related events, thereby highlighting the family as a source of stress with potential effects on health.

Social-Structural Stress

Social epidemiologists have also examined the influence of social-structural phenomena on health. Guided by an ecological perspective, these studies hypothesize that macroenvironmental events generate individual stress and thereby influence individual health. For example, total mortality, infant mortality, child abuse, and psychiatric admissions have been traced to unemployment policies and economic fluctuations (Brenner, 1984). Other studies have demonstrated the negative effects of unemployment on adult physical and mental health (Kessler, House, & Turner, 1987). Studies have demonstrated increases in the incidence of stressful life events (Catalano & Dooley, 1977) and suicide rates (Brenner, 1985) associated with economic decline. Community-wide stressors, such as widespread unemployment and the Three Mile Island nuclear accident, also have negatively affected health (Dew, Bromet, & Schulberg, 1987). Haan, Kaplan, and Camacho (1987) conclude that the consistent finding of poorer health status among the poor is attributable to the health hazards that are ubiquitous in the environment of the poor. As the primary social unit, the family is crucial in buffering the health-related impact of social change and social environments on individual family members. We will return to this issue in Chapter 3 as we discuss the social context and specific social policies that influence the family-health/illness connection.

Stressful Physical Environments

In still other research guided by a social-ecological perspective, physical aspects of the environment have been demonstrated to have health effects (see Moos, 1979, for a review). For example, physical and mental illness and mortality rates are higher in urban than rural areas and highest in crowded cities (Maddocks, 1980; Moos, 1979). Of particular import is evidence that the physical environment, as manifested in household crowding, is related to problems in family functioning in areas of parental discipline and the marital relationship (Moos, 1979).

Other research has drawn attention to the influence of treatment environments on individual health behavior (Greenley & Davidson, 1988; Moos, 1985; Whitehead, Fusillo, & Kaplan, 1988). These studies have enhanced our understanding about the differential effects of the physical setting, as well as organizational structures on patient outcomes and on family behavior. For example, physical and structural aspects of rehabilitation hospitals have been shown to deter or promote independent behaviors of patients with spinal cord injuries (Willems & Halstead, 1978). In other work, the social structure of emergency and intensive care units has been shown to negatively affect family members of patients with a heart attack (Speedling, 1982).

Social Integration, Social Networks, Social Support, and Health

One of the earliest social epidemiological studies was Durkheim’s (1951) study of suicide in which he found that suicide rates were related to community divorce rates and religious participation. He concluded that these findings were attributable to the negative effects of social isolation and its resultant normlessness or anomie. For this seminal work, Durkheim is considered a forerunner of contemporary research on social integration and social network participation. In later studies, Leighton (1974) proposed that communities could be plotted on a continuum of community integration-disintegration. He suggested that individual mental health is, to some extent, a product of community integration and mutual obligation. In contrast, poorly integrated communities are perceived to be stressful, especially insofar as they fail to provide access to needed resources. In more recent studies, Warren (1981) has identified differences in the “social health” of communities by assessing patterns of helping networks.

Evidence of the physical health effects of primary social network membership began accumulating from epidemiological studies conducted during the 1960s. Bruhn and colleagues (Bruhn, Chandler, Miller, Wolf, & Lynn, 1966; Bruhn, Phillips, & Wolf, 1982) found that rates of coronary heart disease differed between neighboring communities in Pennsylvania. Closer examination indicated that the community life of the population with lower rates of illness was characterized by close-knit family and neighborhood relationships. Other studies have implicated sociocultural mobility (resulting in severed social ties) in the etiology of illness (Syme, 1984).

It was in the mid-1970s that the emergence of social support theory appeared, linking concepts of social integration, social networks, and social support to physical health. In two seminal articles, Cassel (1976) and Cobb (1976) reviewed more than 30 human and animal studies that found social relationships to be protective of health. They concluded that future research and theory-building take into account the potential direct and buffering roles of the social support that is exchanged within social relationships as it might influence health directly by enhancing individual well-being and indirectly by mediating the stress-illness relationship. House, Landis, and Umberson (1988) conclude that although the studies that these investigators reviewed were methodologically flawed, large-scale prospective studies conducted within the past 10 years have established a theoretical basis and strong empirical evidence for a causal impact of social relationships on health.

Theory concerning social relationships and social support and health is still in a formative stage. Although the research in this area has been characterized by little definitional consensus and the absence of standardized measures, findings are remarkably consistent in identifying influences on health. Future theoretical refinement a...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Contents
• Foreword
• Preface
• 1. Relevant Theoretical Frameworks
• 2. Research on Health, Illness, and Families
• 3. The Social Environment and Family-Focused Health Care
• 4. Evaluation of Family Interventions
• 5. Assessment Frameworks and Assessment Tools
• 6. Social Work Intervention with Families in Health Care
• 7. Family Therapy
• 8. Crisis Intervention
• 9. Discharge Planning, Placement, and Follow-up
• 10. Group Work with Families
• References
• Index