Pharmacy 440: Pharmaceutical Care Systems I Spring 2002
Development Across the Life Span
Learning Objectives:
§ List Erikson’s stages of development
§ Describe Rolland’s Stages of Chronic Illness
§ Discuss the family as a system
§ Discuss how illness can affect the family and how the family can affect an individual’s illness
§ State what is meant by first and second order change
Introduction: One of the important roles of pharmaceutical care is disease state management. In order to provide optimal pharmaceutical care, pharmacists need to understand the role of psychosocial influences of illnesses. Being ill or healthy is not simply a matter of the individual patient’s responses to a disease state. Family, society, and culture are important factors in an individual’s health and responses to drug therapy.
This lecture overviews expected “normal” individual development (e.g., Erikson’s Stages of Development), the family as a system, and family influences on the individual. Rolland’s Stages of Chronic Illness serve as an example of how stages of development and family systems theories converge during illness.
Suggested Reading: For detailed information on these topics, see Stoudemire, A. (1994). Human behavior: An introduction for medical students. Philadelphia: JB Lippincott. This handout is generally an outline of elements from chapter of 9.
I. The Family System – Elements in Common with Systems
A. Families are more than the sum of its parts (individuals)
B. Stress one member of a system or family, all components/members are affected
C. Repeated interactional patterns regulate each other’s behavior. These are based on implicit and explicit rules that govern such functions as conflict management, decision making, and celebrating (e.g. holidays, birthdays). These patterns maintain the family structure and system homeostasis.
D. Like systems, families need to have a certain amount of flexibility to adapt to changes. Too much flexibility can lead to chaos, while too much rigidity can also lead to disintegration of the system.
When confronted with change perceived as overwhelming or when the system is too rigid, each member may exert more pressure to maintain the status quo. This can be dysfunctional. For example consider the alcoholic, who attempts to change, but whose alcoholism is actually encouraged by the family. Family members are comfortable in their present roles and learning new roles to accommodate a recovering alcoholic seems too overwhelming/threatening.
E. Minuchin developed the notion of families as systems noting that families are composed of subsystems (=any group of 2 or more who are organized around a common function, e.g. Husband and wife form the marital subsystem, which interacts with the sibling subsystem, etc.)
Boundaries are essential in maintaining the autonomy of each subsystem and prevent enmeshment (overinvolvement).
F. Quality of relations can be defined by a continuum from disengaged to enmeshed. Neither extreme allows for personal growth and development; therefore, somewhere in between is desirable for a healthy family.
II. Family Life Cycle
A. Normal families go through a series of “relatively stable plateaus and more stressful transitions” (see class handout for stages of family development)
B. More stable times involve first order change (e.g., increase or decrease in mastery/adaptation. The illustration in class was of the positive mastery type: a child, who knows how to ride his/her bike around the block, then learns to ride the bike to school or some new place. A negative or decreasing mastery is when a person suffers a stroke or head trauma and losses some proficiency in speech.)
C. Second order changes are not so much transitions as transformations involving status or meaning (e.g., a person gains a new identity: becomes a husband/father or wife/mother). Other transformations occur – a person who becomes a paraplegic will gain a new identity; and the health care provider works to help that person gain a positive, healthy identity). Divorce is a 2nd order change often involving overwhelming feelings of loss, guilt, betrayal, grief, and the need to heal a ruptured life. Family stress is highest during 2nd order change.
D. Physical and/or psychological symptoms are most likely to occur when normal patterns of family life are disrupted. Expected feelings during transitions include feeling strange, sad, confused, anxious, betrayed and a clear sense of discontinuity. People can also have positive feelings: excitement, happiness. However, it is the negative feelings which often cause people to seek help.
III. The Function of Symptoms in the Family System
A. Family members may become ill in response to stresses on the family
Example 1: A child whose parents are distanced from one another develops asthma symptoms in an effort to restore a more desired relationship between the parents.
B. Rolland (1987) notes Developmental Stages of Illness. Knowing these phases can help clarify understanding about family functioning during chronic illnesses.
§ Crisis Phase
People know something is wrong and the family pulls together to deal with it (e.g., when a member has a heart attack, the family rallies around the patient and begin to discuss such things as what the illness means, the uncertainty of the outcome on both the patient and family members, and come to a way of accepting the illness
§ Chronic Phase
During this time the family learns to accept the permanence of the change, grieve for the pre-illness identity, and negotiate roles for chronic care (e.g., post MI, if patient cannot resume normal activities, who will take over some of the patient’s responsibilities)
§ Terminal Phase
Some conditions do not resolve but lead to death. Death and dying will be discussed later in the quarter.
C. When treating chronic illnesses that do not respond to appropriate therapy, the pharmacist as a disease state manager must look beyond simply the drug therapy to potential issues of family dysfunction. Questions to ask include:
§ When did the event (e.g., asthma attack) occur
§ Who was present and who wasn’t
§ Who did what
§ What happened as a consequence
According to Stoudemire, these questions reveal individual patterns that will differ depending on what role/function the illness serves in the family
D. The following are listed by Stoudemire as Red Flags (p. 283-284) and should help the pharmacist understand when to refer for psychological evaluation. As a pharmacist, you may want to alert the patient’s physician to your concerns and work referrals through that provider.
§ An illness that is not responding in a typical way to the typical treatment
§ An illness such as asthma or diabetes that was previously under good control but that has suddenly become more difficult to manage or increased in frequency
§ Atypical headaches of long-standing duration and other unexplained pain complaints
§ Chronic anxiety and many office visits over several years for multiple diffuse complaints without significant evidence of organic disease
§ A primary complaint of chronic fatigue which, of course, may be indicative of depression
§ Insomnia-also a possible reflection of anxiety or depression
§ Multiple physical complaints of a nonspecific nature
§ Complaints of nonspecific allergies
§ In children: enuresis or encopresis, poor appetite, poor sleep patterns, hyperactivity, poor school performance or behavior problems
§ Family history of serious chronic psychosocial problems, such as chemical dependency, chronic depression and anxiety, child or spousal abuse, or eating disorders.
IV. Personal Development
A. Just as families go through life phases individuals also have developmental life phases
§ Takes a lifetime to develop a complete human being
§ Unique path through “milestones” called lifecycle - Erikson’s Stages
§ Consider as you read how these concepts of developmental stages relate to pharmacy
B. Terminology
Transition / Bridge between successive stages / Late adolescence
Limbo state / Sticking point / Prolonged adolescence
Rite of passage / Social ritual facilitating transition / Graduation, Marriage
Normative crisis / Rapid change challenging adaptive capacity / Childbirth, Marital crisis
Normal illness / Features both illness and normative crisis / Pregnancy, Bereavement
Stage / Period of consolidation of skills / Early adulthood
Plateau / Period of developmental stability / Adulthood to midlife
Developmental Lines / Independent courses of development of particular skill, capacity / Love
Work
Play
Delay vs
Precocity / Variations in timing / “Late bloomer” vs prodigy
Regression / Temporary retrograde vector / Revival of adolescent or childhood behaviors
Repetition / Reworking and reliving past stages / Second separation-individuation crisis of young adulthood/
late adolescence
C. Erikson’s Stages of Development (see Stoudemire, p. 290)
Stage / Usual Age /Fundamental Issues
/ Strengths Based on Favorable Outcomes1 / 0 -18 mo / Trust/Mistrust / Drive/hope
2 / 18 mo -
3.5 yrs / Autonomy / Self-control
3 / 3.5 - 5 yrs / Initiative / Purpose
4 / 5 - 12 yrs / Industry / Competence
5 / 12-20 yrs / Identity / Devotion
6 / 20-35 yrs / Intimacy / Affiliation
7 / 35-65 yrs / Generativity / Production
8 / 65 yrs + / Ego integrity / Reconciliation
D. Summary
§ Just as families go through various stages of normal development, each individual in the family also progresses through various stages of personal development.
§ Illness is a psychosocial crisis that can affect both the individual and the family.
§ There are various potential outcomes to an illness, which are influenced by member, subsystem, and family system functioning. In addition,
§ The health care provider, including the pharmacist, who is concerned with quality of life, has a responsibility to help direct outcomes through understanding and responding appropriately to individual and family developmental issues.
§ While the pharmacist’s primary responsibility is outcome of drug therapy, the pharmacist must recognize when to refer individuals and families for psychosocial help to achieve optimal pharmaceutical care.
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ã 1999, University of Washington, Seattle, Washington, USA
Author: Karan Dawson, R.Ph., M.S.