Of course not each of these topics should be discussed in every visit (there simply isn't time in most visits), but a healthcare provider who neglects to discuss at least a few relevant family-centered topics may be missing an opportunity to better assess thier patient's needs and partner with the patient's family members in addressing them.

A whole field of study exists regarding how family systems operate, and although you don't need to be an expert, you should understand at least these 4 basic principles of family systems theory as described below:

1. Triangulation

When conflict or disagreement develops between two people there is a tendency to draw in a third person in order to relieve some of the tension. For example, have you ever had a friend or family member try to get you to take their side during an argument? They are attempting to triangulate you. This certainly happens in medicine, for example:

• Your elderly female patient is struggling with end-stage congestive heart failure. Her daughter thinks she should be in a nursing home, but her son insists that she will be fine at her own house. You're not sure what's best for your patient, but the daughter comes to you and says, "You need to convince my brother that my mom is not fine to be home alone. He's not thinking clearly. Tell him." She is trying to triangulate you.
• You saw a 5-year-old boy in clinic last week with his mother present who complained that he is misbehaving at home. At that visit she asked you to put him on ADHD medication. The boy is back in clinic today with his father who is against medication, claiming that the boy has no behavior problems when he's at the father's house. He has brought a letter from the boy's teacher stating that she feels the your patient does not have ADHD and does not need medication. Three people are being triangulated in this case example. Who are they?

Do your best to recognize triangulation and avoid taking sides when you can. The best way to maintain neutrality is not by choosing to not validate anyone's opinion, but by validating all opinions. In other words, instead of not taking sides, take everyone's side, and do so openly and transparently. Verbally acknowledge shared and differing perspectives, and offer insight into the disagreement if you can, but allow them to remain responsible for resolving their own conflict.

By the way, the three people being triangulated in the example above are you, the teacher, and the boy. This leads to another key point, which is that triangulation can occur without you being part of the triangle. For example, here's a different type of triangulation that you may need to recognize and intervene in:

• A 10-year-old boy lives with parents who aren't divorced, but probably should be. They fight all the time and recently it has become violent between them, especially on those nights when dad has been drinking. The boy has been having episodes of stomach pain, headache, vomiting, and bed wetting lately that remain medically unexplained despite multiple visits to your office and the emergency room. Interestingly, whenever the boy gets sick the parents stop fighting and unify in addressing their son's health problems. You are not surprised to learn that the boy's episodes usually begin when the fighting at home grows intense. He may not even be aware that he is triangulating himself between the combative parents to unify them around his health issues and create stability in his family system.

2. Circular Causality

Most of us have been taught to think in terms of linear causality, or "cause and effect". Cause A makes effect B happen, such as "Meningitis caused his fever". As a result, we sometimes try to identify and prescribe linear solutions. For example, "Antibiotics --> no meningitis --> no fever". This is not untrue, however, in complex systems such as families, it's often more accurate to explain and treat problems using circular causality, where A and B are both causes and effects of each other.

In family systems this is definitely true. Here are 3 examples:

• Overfunctioner - Underfunctioner

Your patient is in chronic pain. She reports that she cannot work because her lower back and knees ache unbearably when she stands. Her husband works two jobs and also cares for the domestic chores (laundry, cleaning, etc.) while she lays as comfortable as she can in her bed watching television. Is he over-functioning because she is under-functioning? Or is she under-functioning because he is over-functioning? Circular causality says it's likely both.

• Pursuer - Distancer

Your patient has uncontrolled diabetes. His wife is worried about the potential negative health consequences so she frequently reminds him to take his Metformin and stop eating sugary foods. She nags him, which is frustrating for him, so he just refuses to discuss his health with her to avoid the emotion. She pursues with threats, "You're going to have kidney problems just like my mom had you know." He distances by ignoring her. Is he ignoring this because she's pursuing it, or is she pursuing it because he's ignoring it? The answer: Yes.

• Aggressing - Apologizing

Your male teenage patient informs you that his father is very angry and yells a lot, though is not yet physically abusive. He states that apologizing helps calm his dad down in the moment, but also that his dad's aggression is getting worse the last few weeks. When you talk with the father about it he says that his son apologizing so quickly, even for things that aren't the son's fault, frustrates him. "I don't want him to be a weak little push-over like I was. I want him to be a strong man that can stand up for himself." Although you would not blame the son for his dad's aggression, you can recognize the circular causality in their pattern of behavior.

So what do you do with circular causality when you recognize it? Rather than try to figure out "who started it" in order to know where to stop it, instead treat all "causes" concurrently. Intervening in only one part of a system at a time may not work because of a system's resistance to change and natural pull toward homeostasis, which is described next:

3. System Stability (Homeostasis):

You may already know that changes in one organ of the body can cause changes in other organs. For example, in nephrotic syndrome the liver overcompensates for the kidney’s inability to filter proteins. The same type of thing happens in family systems, namely that members of the family adjust in order to maintain balance or homeostasis. For example, a teenage son now drives his sister to school because his mother's chemo treatments have her too ill to do it. Often members of the system push to resist change brought on by one member of a family. Below are two examples of this:

• Mareno and her wife Karen run a business together; however, Karen has recently been having frequent headaches and is spending a lot of time in bed. Karen says it is not a big deal, but Mareno calls the doctor and makes an appointment for Karen. Even though Mareno is not the one with the headaches, she makes the appointment and takes time off from the business to drive Karen to get her headaches checked out. Her behavior is an attempt to return the system to its regular mode of operation.
• Nikele is 13 years old and lives with her single mother and 8-year-old brother. Recently her mother was in an accident, and as part of her recovery she is in physical therapy two afternoons a week. Nikele is not happy about it, partly because she has to watch her brother instead of hanging out with her friends after school like she’s used to. One day her younger brother was ill and her mother skipped physical therapy to care for him. Nikele noticed, and the next few days when her mom was heading to therapy Nikele complained of not feeling well. Her behavior is an attempt to maintain homeostasis, or keep things in the family the way they were, even at the expense of her mother's much needed therapy.

4. Family Shared Belief System

Family members often share a worldview. The beliefs and attitudes of the parents are usually the first “lens” through which children learn to see the world. As children age and become more independent, they begin to challenge these beliefs to either reject them or make them their own. Shared beliefs often include rules, values, boundaries, and morals which the family ascribes to. They are often informed by health, illness, religion, culture, race, politics, sexuality, socioeconomic status, etc.

In some families, there is not a lot of freedom to deviate from the shared belief system. These families are often "emotionally enmeshed" (i.e. they have a high level of emotional reactivity, low individual autonomy, and lack differentiation between self and others). In these families the individual members struggle to express opposing views, sometimes even well into adulthood, for fear of upsetting the emotional stability of the system. For example:

Family-Centered Content Summary:

Whether you are a family doctor or not, any family-oriented healthcare provider needs to have the skills to discuss and understand how a patient's health affects and is affected by his/her family dynamics. Partnering with your patient's family as members of the healthcare team requires that you be able to understand these new partners health behaviors and decisions in their own context.

On the next page you will have an opportunity to observe a doctor discussing family-centered content with her patients and to use the FCOF to provide her feedback.

References

1. Cole-Kelly, K., & Seaburn, D. (1999). Five areas of questioning to promote a family-oriented approach in primary care. Families, Systems, & Health, 17 (3), 341.
2. Campbell, T.L, McDaniel, S.H., Cole-Kelly, K., Hepworth, J., & Lorenz, A. (2002). Family interviewing: A review of the literature in primary care. Family Medicine, 34 (5), 312-8.
3. McDaniel, S., Campbell, T. L., Hepworth, J., & Lorenz, A. (2005). Family-oriented primary care. New York: Springer.