Working With Families Institute

In today’s world, families are under increasing stress, from financial and time constraints, to family breakdown, substance abuse, and threats of violence. Family physicians are seeing an increase in psychosocial issues such as anxiety and stress-related disorders, often co-existing with and complicating medical problems such as diabetes or pneumonia. The psychosocial issues are often more difficult to diagnose and manage than are the medical problems—and all take place in the family context. Very often, the family is the key to dealing effectively with the whole spectrum of complaints, requiring a psychosocial assessment. In the crowded family medicine curriculum, this vital area of knowledge and skill is often ignored in favour of more clear-cut procedural skills.

To educate family physicians about dealing with families, a group of family medicine educators, practitioners and mental health professionals affiliated with the Department of Family and Community Medicine at the University Of Toronto founded the Working with Families Institute (WWFI) in 1985. The WWFI has developed various training experiences for trainees and practising physicians.

Goals

The goal of these modules is to provide a learning resource for physicians dealing with common medical and psychosocial issues that have an impact on families. The modules seek to bridge the gap between current and best practice, and provide opportunities for physicians to enhance or change their approach to a particular clinical problem.

The modules have been written by a multidisciplinary team from the Faculty of Medicine, University of Toronto. Each module has been peer-reviewed by external reviewers from academic family medicine centres across Canada. The approach is systemic, emphasizing the interconnectedness of family and personal issues and how these factors may help or hinder the medical problems. The topics range from postpartum adjustment to the dying patient, using a problem-based style and real case scenarios that pose questions to the reader. The cases are followed by an information section based on the latest evidence, case commentaries, references and resources.

How to Use the Modules

The modules are designed for either individual learning or small group discussion. We recommend that readers attempt to answer the questions in the case scenarios before reviewing the case commentaries or reading the information section.

The editors welcome feedback on these modules and suggestions for other modules. Feedback can be directed to Dr. Watson at .

Acknowledgements

The WWFI is grateful to the Counselling Foundation of Canada for its generous educational grant in support of this project. The editors also thank Iveta Lewis (Librarian-DFCM) Brian Da Silva (IT consultant-DFCM), and Danielle Wintrip (Communications Coordinator-DFCM) for their valuable contributions to this project.

In addition, we thank our editorial advisory group including Ian Waters, MSW, Peter Selby MD, Margaret McCaffery, and William Watson, MD.

We also acknowledge the work of the Practice-based Small Group Learning Program of the Foundation for Medical Practice Education, on which these modules are modelled.

Bill Watson

Margaret McCaffery

Toronto, 2014

Working With Families Institute

Individual and Family Life Cycles:

Predicting Important Transition Points

Authors:

Vincent Poon, MD, PsyD, DMin, CCFP, FCFP, FABMP, Assistant

Professor, Department of Family & Community Medicine, University of

Toronto; Professor, Counseling Department, Tyndale University College and Seminary, Toronto

Ed Bader, MA, Associate Professor (retired), Department of Family & Community Medicine, University of Toronto; Project Coordinator, Focus on Fathers Project, York Region, Ontario

Reviewers:

Ian A. Waters, MSW, RSW, social worker and professional practice leader, Department of Family & Community Medicine, Toronto Western Hospital at The University Health Network; Assistant Professor, Department of Family & Community Medicine, University of Toronto

Ruth Brooks, MD, CCFP, staff physician and residency program director, Sunnybrook and Women’s Health Science Centre; assistant professor, Department of Family and Community Medicine, University of Toronto

Editors:

William J. Watson, MD, CCFP, FCFP, Associate Professor, Department of Family & Community Medicine and the Dalla Lana School of Public Health

Margaret McCaffery, Canterbury Communications

Working With Families Institute, 2014

Chair: William J. Watson, MD, CCFP, FCFP

Associate Professor, Department of Family & Community Medicine and the
Dalla Lana School of Public Health

University of Toronto

CONTENTS

SUMMARY...... 5

OBJECTIVES...... 5

Key Features...... 5

Core Competencies...... 5

CASE STUDIES...... 6

INFORMATION POINTS...... 8

Life cycle...... 8

Individual life-cycle/stage models...... 8

Family life-cycle models...... 9

Integrating individual and family life cycle...... 14

Variations of the traditional family life cycle...... 14

CASE COMMENTARIES...... 18

REFERENCES...... 20

SUMMARY

Each individual goes through a sequence of stages in life. At each stage, the person must complete some developmental tasks in order to grow and develop. The family life cycle describes developmental trends within a family over time. There are social and cultural variables within each family life cycle. Family members may carry within themselves and in their relationships unresolved tasks from earlier periods of their lives.Because individuals and families interact, individual and family life cycles often juxtapose and intertwine with each other. When patients understand their pasts, they can plan strategies and activities to grow and live more fully in the present, and envision future possibilities more clearly.

Through awareness of individual and family life cycles, family physicians (FPs) are better able to understand patients and their families. This is important both during their normal and expected life-stage developments as they become healthy, strong adults and when they encounter difficulties in one or more of the life stages. The FP can play a pivotal role in helping these families.

OBJECTIVES

After completing this module, you will be able to:

  1. understand individual and family life cycles in your patients.
  2. use the life cycle theory to assess your patients and their families, particularly in the various life phases.
  3. better help individuals and family members deal with expected and unexpected difficulties in life transitions.

Key Features

  1. An awareness of individual and family life cycles will help the physician assess families in relation to their current and future needs.
  2. The presence of illness at key points in the individual’s and family’s life cycles may delay or prevent individuals and families from completing the tasks of their life cycle stages.

Core Competencies

  1. Understand the developmental tasks of each life cycle stage.
  2. Assist individuals and families to complete the developmental tasks of each stage.
  3. Develop an approach that incorporates understanding of life cycle theory into continuing, comprehensive medical care.

CASE STUDIES

Case 1: Joy, age 20

Joy, a second-year university student, was just discharged from the hospital after attempting to hang herself. A few months ago, she took an overdose of acetylsalicylic acid. Her attempt this time was discovered by her roommate. Joy was initially treated at the intensive care unit of a university hospital. Fortunately, she recovered from this ordeal and did not suffer much brain damage.

Upon her discharge from hospital, her psychiatrist prescribes an antidepressant, venlafaxine(Effexor XR) 150 mg o.d. The psychiatrist also suggests that Joy follow up with more counselling from her family physician (FP), who has an interest in counselling families.

  • What further information would you want to obtain from Joy if you were to approach this situation from a systems approach?

Joy is an only child. Her father, age 52, is a former professor. Her mother, who was four years younger than Joy’s father, was a housewife. She died of colon cancer when Joy was 12. When Joy was 17, her father remarried and took early retirement from university teaching. He and his new wife went to do missionary work in another country. He left Joy with his younger sister’s family. Joy completed high school the next year, and then entered university.

  • What life stage is Joy going through currently?
  • What life stage is Joy’s father going through?
  • What possible difficulties might Joy have experienced since her mother’s untimely death? How would these difficulties relate to her life stage?
  • What kind of support system did Joy have during her different life stages?

Case 2: Mrs. S., age 26

Mrs. S. brings her newborn daughter to see you. Her 18-month-old son is with her in-laws in the waiting room. He is screaming loudly and throwing toys at the wall. Mrs. S. mentions that her son is not yet talking and then begins to cry. She says she is exhausted and even though her husband has always been supportive in parenting their son, they are overwhelmed by the change in the boy, who has always been an easy child.

  • How would you respond to Mrs. S.’s concerns?
  • What additional information would you seek from Mrs. S.?
  • How would you manage this situation?

Mr. S. walks in about five minutes into the interview (he was parking the car) and mentions he just returned from a business trip to his home country. He says his family thinks he and his wife are not raising their child correctly because they are going against the way they were raised in the home country.

  • What health concerns would you have about this family?
  • How would you interact with this couple?
  • What questions will you ask in exploring this life stage of the family?
  • What are the differences between parenting the first child and parenting two pre-school children?

INFORMATION POINTS

Life Cycle

  1. The life cycle or life stages arise from lifespan development theory, which states that each individual will go through a sequence of stages in life. These stages are orderly and have distinct periods. At each stage, a person has to master some developmental tasks. Each task is a growth responsibility that appears at a certain stage of an individual or family’s life, and has emerged from biological needs, cultural imperatives, and family goals. These tasks must be successfully completed in order to secure present satisfaction, social approval, and future success. Failure to do so will result in dissatisfaction, social disapproval and difficulties with later tasks and life. Life cycles have been formulated for both individuals and families. Because individuals and families interact, individual and family life cycles often juxtapose and intertwine with each other.

Individual Life-Cycle/Stage Models

  1. Sigmund Freud was the first to describe a psychosexual development model for the individual.1 In his theory, each stage expresses a manifestation of the sexual instinct in relation to the person’s motor and cognitive development and socialization demands. His five phases cover the period from birth to puberty and onward: oral stage (zero to 12 months), anal stage (one to three years), phallic stage (three to six years), latency stage (seven years to puberty), and genital stage (puberty onward).

Erik Erikson described a psychosocial theory of human growth and development. 2,3,4 He describes human life in terms of “stages” or sequential developmental occurrences (see Table 1).5

Other individual life stage theories include those of Piaget (cognitive development theory),6 Kohlberg (moral development theory),7 Levinson (men’s development theory),8 and Sheehy (women’s development theory).9

Table 1. Erikson’s psychosocial stages 5

Erikson Stage(Freud Stage) / Age / Successful
Resolution
Leads to: / Unsuccessful Resolution
Leads to:
1. Trust vs. mistrust (oral) / Infancy
birth to one year / Hope / Fear
2. Autonomy vs. shame and doubt (anal) / Early childhood one to three years / Willpower / Self-doubt
3. Initiative vs. guilt (phallic) / Play age
four to five years / Purpose / Unworthiness
4. Industry vs. inferiority (latency) / School age
six to 11 years / Competency / Incompetence
5. Ego identity vs. role confusion / Adolescence
12-20 years / Fidelity / Uncertainty
6. Intimacy vs. isolation / Young adulthood 20-24 years / Love / Promiscuity
7. Generativity vs. stagnation / Adulthood
25-65 years / Care / Selfishness
8. Ego integrity vs. despair / Old age
65 years to death / Wisdom / Meaninglessness, despair

Family Life-Cycle Models

  1. The family life cycle describes developmental trends within the family over time. This model includes all dimensions of the individual life course, but emphasizes the family as a whole. Inherent in this model is a tension between the person as an individual and the family as a system. There are social and cultural variables within each person’s family life cycle. The model described here is based on a middle-class, nuclear family. Life cycles of single-parent or blended families would be different.

Evelyn Duvall was the first to describe the family life cycle in 1956;10 her eight stages are:

  1. Married couples (without children)
  2. Childbearing families (oldest child, birth to 30 months)
  3. Families with preschool children (oldest child aged two to six)
  4. Families with school-age children (oldest child aged six to 13)
  5. Families with teenagers (oldest child aged 13 to 20)
  6. Families as launching centres (first child gone to last child’s leaving home)
  7. Middle-aged parents (empty nest to retirement)
  8. Aging family members (retirement to death of both spouses)

Carter and McGoldrick11,12 outlined a six-stage cycle of the intact middle-class, nuclear family, which begins with the unattached adult and continues through retirement. Bader enlarged the six stages into eight stages by adding a stage of Learning to Live Together between marriage and the first child, and subdividing Carter and McGoldrick’s sixth stage of Family in Later Life into two stages of Retirement and Old Age (see Table 2).13

Table 2. Bader’s family life-cycle stages

Stage / Developmental Issues
1. Leaving home /
  1. Establishing personal independence
  2. Beginning the emotional separation from parents

2. Commitment to the couple relationship /
  1. Establishing an intimate relationship with partner
  2. Further development of emotional separation from parents

3. Learning to live together /
  1. Dividing the various couple roles in an equitable way
  2. Establishing a new, more independent relationship with family and friends

4. Parenting the first child /
  1. Opening the family to include a new member
  2. Dividing the parenting roles

5. Living with the adolescent /
  1. Increasing the flexibility of the boundaries to allow the adolescent(s) to move in and out of the family system
  2. Refocusing on midlife marital and career issues

6. Launching children: the empty nest phase /
  1. Accepting the multitude of exits from and entries into the family system
  2. Adjusting to the ending of parenting roles

7. Retirement /
  1. Adjusting to the end of the wage-earning roles
  2. Developing new relationships with children, grandchildren, and each other

8. Old age /
  1. Dealing with lessening abilities and greater dependence on others
  2. Dealing with losses of friends, family members, and eventually each other

Poon further modified the family life stage by Becvar and Becvar and added an additional prime timer stage before old age. 14,15

Table 3. Poon’s family life cycle stages

Stage / Key principles of transition / Developmental Tasks
1. Unattached adult / Accepting parent-offspring separation / a. Differentiation from family of origin
b. Development of peer relations
c. Initiation of career
2. Newly married / Commitment to the marriage
and learning to live together / a. Formation of marital system
b. Making room for spouse with family and friends
c. Adjusting career demands
3. Parenting the first child / Accepting new members into the system / a. Adjusting marriage to make room for child
b. Taking on parenting roles
c. Making room for grandparents
4. Preschool-age child, and other children / Accepting the new personality / a. Adjusting family to the needs of specific child(ren)
b. Coping with energy drain and lack of privacy
c. Taking time out to be a couple
5. School-age child / Allowing child to establish relationships outside the family / a. Extending family/society interactions
b. Encouraging the child’s educational progress
c. Dealing with increased activities and time demands
6. Teenage child / Increasing flexibility of family boundaries to allow independence / a. Shifting the balance in the parent-child relationship
b. Refocusing on mid-life career and marital issues
c. Dealing with increasing concerns for older generation
7. Launching center (early middle age adult) / Accepting exits from and entries into the family / a. Releasing adult children into work, college, marriage
b. Maintaining supportive home base
c. Accepting occasional returns of adult children
8. Post-empty nest (later middle- age adult) / Letting go of children and facing each other / a. Rebuilding the marriage
b. Welcoming children’s spouses, grandchildren into family
c. Dealing with aging of one’s own parents
9. Early retirees (prime- timers) / Early retirement – traditional, forced or intentional / a. Adjustment to retirement life, alone and as a couple
b. Re-considering legacy & meaning of life, and involve in such activities
c. Coping with death of parents
10. Old age (preparing the d awn of life) / Settling towards old age and life destiny / a. Supporting middle generation
b. Closing or adapting family home
c. Coping with deteriorating health and death of spouse, and preparing to leave this world

Poon provides a list of questions that FPs can use in working with families going through these various stages (see Table 4).