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While nurse practitioners initially work with the identified patient, Murray Bowen maintains it is the reciprocal functioning of all the members of the family which contributes to the emotional intensity of the patient. The emotional symptoms of an individual are an expression of the emotional symptoms of the family, which are often embedded in patterns of behaviors from past generations. The purpose of this paper is to facilitate understanding Bowen's theoretical concepts of family systems theory and apply these concepts to a family in therapy.
Issues in Mental Health Nursing, 35:835–841, 2014
Copyright © 2014 Informa Healthcare USA, Inc.
ISSN: 0161-2840 print / 1096-4673 online
DOI: 10.3109/01612840.2014.921257
An Application of Bowen Family Systems Theory
Judy Haefner, DNP, RN
University of Michigan–Flint, Nursing, Flint, Michigan, USA
While nurse practitioners initially work with the identified pa-
tient, Murray Bowen maintains it is the reciprocal functioning of
all the members of the family which contributes to the emotional
intensity of the patient. The emotional symptoms of an individual
are an expression of the emotional symptoms of the family, which
are often embedded in patterns of behaviors from past generations.
The purpose of this paper is to facilitate understanding Bowen’s
theoretical concepts of family systems theory and apply these con-
cepts to a family in therapy.
A family-focused nurse practitioner works with families in a
variety of settings, such as community mental health, inpatient
hospitals and outpatient clinic sites – both mental health and
pediatric clinics. The emotional dysfunction of an individual
disturbs all of that person’s relationship systems, especially the
family system (Bowen, 1978). An assessment of the child and
adolescent also requires an assessment of the family structure
of that child or adolescent. Murray Bowen offered the view that
the driving forces underlying all human behavior comes from
the push and shove between family members striving for a bal-
ance between distance and togetherness (Wylie, 1990). Nurses
working with families likely already adhere to Bowen’s as-
sumption that the emotional health of the individual, especially
children and adolescents, cannot be separated from the family.
The Bowen Family Systems Theory model provides a frame-
work to view the individual as part of the family. The purpose
of this paper is to explain the key concepts of the Bowen Family
Systems Theory, to provide nurses and other individuals work-
ing with children or adolescents (presenting as the symptomatic
patient) a framework to view the roles of family members, their
communication patterns, and structure of a family in therapy,
and finally, an application of these concepts to a specific family.
Murray Bowen, developer of the Bowen Family Systems
Theory, was a pioneer of family psychotherapy. His work at
Menninger Clinic in Topeka, Kansas (1946–1954) focused on
Address correspondence to Judy Haefner, University of
Michigan–Flint, Nursing, 303 East Kearsley Street, Flint, Michigan
48502–1950, USA. E-mail:
enmeshed relationships between patients with schizophrenia
and their mothers. He transferred his research to the National
Institute of Mental Health (1954–1959), where entire families
lived on the ward with the patient. Observation of relationship
patterns of these families led to the development of family the-
ory. He ended the live-in project at NIMH and focused on the
development of the family systems theory, concluding, ‘It was
clear that all families were pretty much alike’ (Bowen, 1978,
p. xv). Bowen continued to develop his theoretical concepts
and refine his theory at Georgetown University Medical Center
and founded the Georgetown Family Center in 1975. His trans-
generational approach had the view that current family patterns
and problems tend to repeat over generations. Each family has
an emotional system, which seeks ways to reduce tension and
maintain stability. His work continues to evolve through the
Bowen Center for the Study of the Family at Georgetown.
Bowen’s theory consists of a system of eight interlocking
states that describe the inevitable chronic emotional anxiety
present in family relationships and concludes that chronic anx-
iety is the source of family dysfunction (Table 1). The key con-
cept of this theory is differentiation of self and emotional fusion,
which refers to the ability of a person to distinguish him/herself
from the family of origin on a personal and intellectual level
(Bowen, 1978). Differentiation of self is the ability of individu-
als to function autonomously by making self-directed choices,
yet remain emotionally connected to important relationships. ‘A
poorly differentiated person is trapped within a feeling world
... and has a lifelong effort to get the emotional life into liv-
able equilibrium’ (Bowen, 1976, p. 67). Autonomy is at one
end, which is the ability to clearly think through a situation –
separating emotions from rational thought. The opposite end is
undifferentiated ego mass, which implies emotional dependence
on the family of origin ‘emotional stuck-togetherness of fam-
ilies’ – regardless of the geographical distance (Brown, 1999;
Bowen, 1976, 1978). Balancing togetherness and individuality
is a continuum.
Bowen (1978) referred to dysfunctional family relation-
ships between family members as fusion. Bowen proposed
that the level of chronic anxiety correlated with the level of
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Eight interlocking forces that shape family functioning
Differentiation of self While social groups are important, the family has the primary impact of developing a sense of
self. The poorly-differentiated self requires acceptance and approval of others for thinking,
acting, and saying. A well-differentiated self, while acknowledging the importance of family
and social groups, is able to withstand conflict, rejection, and criticism and separate
emotionally and intellectually from the family of origin. It is the degree of fusion and
differentiation. Persons with low differentiation are less flexible and more emotionally
dependent on others.
Triangles A three-person relationship that can stabilize a two-person system (dyad) experiencing anxiety.
The assessment of anxiety is fundamental to the Bowenian approach. When tension between
two people develops, anxiety can be relieved by bringing in a third person. The tension is
diffused but the triangle also has the potential to make ‘an odd man out.’ Bowen states
‘emotional forces within the triangle are constantly in motion’ as the triangle moves back and
forth between dyads with one person as the outsider. Bowen believes the most common
pattern is the father–mother–child triangle, with the tension being between the parents, the
father moves to the outside position. Spreading the tension can stabilize a family system but
does not resolve the source of the tension.
Nuclear family emotional
Four basic patterns of emotional functioning in a single generation: marital conflict,
dysfunction in one spouse, impairment in one or more children, emotional distance. Bowen
maintains these emotional patterns operate in intact families, single-parent, step-parent, and
all other nuclear family systems. How a family reacts to stress are replicas of past generations
and will continue to repeat in future generations. Bowen encourages a careful history of
present generation patterns and a reconstruction of past generation patterns of emotional
functioning. He asserts these patterns will be predictors of the same patterns for generations
to come.
Family projection process The primary process where parents pass along their emotional problems to a child. Children
inherit strengths as well as problems from parents. The projection process is three steps: (1)
the parent focuses on the child, fearful there is something wrong; (2) the parent interprets the
child’s behavior as confirming this fear; (3) the parent treats the child as if something is
really wrong with the child. Bowen maintains this is associated with maternal instinct and
initiates as anxiety in the mother during infancy and childhood, and gradually develops into
major symptoms during adolescence.
Emotional cut-off Family members unable to reduce or manage their unresolved emotional issues with parents or
other family members totally cut-off emotional contact by moving away geographically or
rarely going home. These unresolved emotional issues generally center on unresolved
attachment and differentiation of self. Bowen asserts this running away does not indicate
emotional independence but rather this person tends to see the problems being with the
parent rather than with self.
transmission process
The family projection process continues through multiple generations. Small degrees of
differentiation between parents and children occur through conscious teaching and
unconscious shaping of the development of children. Children learn the patterns of emotional
process similar to their patterns but with small differences. Bowen suggests these family
traditions and family ideals can be either supportive or detrimental.
Sibling position Bowen gives credit to William Toman, who developed a sibling profile for each position in a
functioning family. Bowen incorporated these ideas into his theory that the oldest child tends
toward leadership position and the youngest child tends to follow. Knowing the spouses’
sibling position influences marriage choices and likelihood of divorce.
Societal regression (societal
emotional process)
An application of Bowen theory to social organizations. He states society parallels anxiety on
stress on the family. As the family experiences more chronic and sustained anxiety, it
regresses to a lower level of functioning. When society experiences chronic stress, such as
population explosion, diminishing natural resources, and pollution to the environment,
society also has a similar regressive adaption.
Adapted from Bowen (1978) and Bowen Center for the Study of the Family Georgetown Family Center, http://www.thebowencenter.
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differentiation of self. He proposed that people with high chronic
anxiety needed to manage their anxiety, and generally used four
mechanisms: (1) marital conflict; (2) health or emotional prob-
lems; (3) health or emotional problems of a child; or (4) triangu-
lation of other people into the relationship. All families choose
differently from these four strategies but the purpose was always
to reduce the level of chronic anxiety experienced by the adults
(Miller, Anderson, & Keala, 2004).
Emotional fusion describes a person’s reactions within a rela-
tionship. People in a fused relationship react emotionally with-
out being able think through or talk about choices with the other
person. The level of anxiety a person experiences is determined
by external stress. The greater the fusion, the less flexibility a
person has for adaption to stress from outside sources. Persons in
a highly fused relationship experience significant anxiety due to
the fear of rejection if the independent decision or action could
potentially cause emotional separateness. A state of chronic anx-
iety exists if family members do not have the capacity to think
through their responses to relationship dilemmas but continue
to react emotionally to them. A person’s sensitivity to these
themes has been transmitted from one generation to the next.
Bowen (1978) believed a family that is unable to differentiate
but remains fused will respond to a crisis in a ‘feeling process’
and be unable to respond intellectually. A person who is able
to self-differentiate possesses the ability to adapt to changes of
their environment and thereby experience less emotional stress
(Brown, 1999; Bowen, 1978).
Triangling is central to Bowen’s theory. Triangling occurs
when anxiety and tension experienced between two persons is
passed on to a third person in the family. A couple experiences
anxiety as they try to balance differentiation of self with estab-
lishing a supportive emotional relationship. The couple is able to
communicate safely when they pull in the third person, thereby
shifting the anxiety away from their relationship and on to the
third party. Bowen did not believe triangling was necessarily
dysfunctional but became problematic when the third person
distracted the dyad from resolving their tension. Bowen (1978)
also believed these patterns of triangling tended to repeat across
generations as learned patterns of behavior.
Six additional concepts of Bowen Family Systems Theory
are: (1) the nuclear family emotional system, the impact of un-
differentiating and dysfunctional fusion on the emotional func-
tioning of a family that leads to (a) marital conflict, (b) polariza-
tion of a spouse, or (c) psychological impairment in a child; (2)
multigenerational transition process, coping strategies, themes,
and roles in a triangle that are passed from generation to genera-
tion; (3) the family projection process, whereby parents transfer
their anxiety and their level of differentiation to children – the
child responds to the anxiety and then is mistaken for having a
problem and becomes the identified patient; (4) sibling position
credited to Walter Toman (1961), theorized the importance of
birth order for impacting the development of personality charac-
teristics and suggested that the more closely a parent identified
with a child in the same sibling position as him/herself indi-
cated the likelihood of triangulating to detour tension from the
parental dyad; (5) emotional cut-off, the emotional withdrawal
from family members in an attempt to break emotional ties and
regulate unresolved attachment; (6) societal regression, society,
like the family, contains opposing forces of differentiation and
individualization (Brown, 1999; Bowen, 1978). These concepts
were originally developed during Bowen’s work with individu-
als with schizophrenia and their families and have been adapted
for clinical practice and continue to influence the development
of other family system theories (Miller et al., 2004).
The identified patient of this family was Austin, a 14-year-
old boy, who had received outpatient and inpatient mental health
treatment since age 7 years. His parents reported explosive
tantrums, poor sleep averaging 2–5 hours nightly, and described
his mood as anxious with unexplained episodes of crying. He
had been hospitalized twice since the age of 7 and had diagnoses
of Attention Deficit Disorder, Oppositional Defiant Disorder,
and Mood Disorder (NOS); his medications included sertraline,
aripiprazole, and lisdexamfetamine. Oppositional behavior in-
cluded destroying property in the family home. Austin punched
holes in walls and doors, shredded a mattress with a knife, and
verbally threatened his mother. His parents separated before he
was born and never married. He and his mother lived alone for
the first 7 years of his life, with support from maternal grand-
parents. His father had no contact. When Austin was 7 years of
age, he requested to meet his father. This was facilitated, and
culminated in his parents marrying 4 years ago. His parents re-
ported a supportive marriage, denied conflicts, and presented as
concerned and supportive of Austin. They stated Austin had a
good relationship with both parents. However, through discus-
sion, it was acknowledged that Austin and his father were in-
creasingly antagonistic and provocative towards each other, and
interactions between them escalated into verbal confrontations
and arguments. Austin stated he had friends at school, partic-
ipated in sports, but struggled academically – often receiving
failing grades. Psychological testing by a licensed psychologist
revealed Austin scored in the borderline range for IQ. Mother
had a diagnosis of bipolar disorder but did not take medica-
tion; a paternal grandmother and a cousin also had diagnoses of
bipolar. This family was seen for eight sessions.
Whereas, the first dyad in the family is traditionally the cou-
ple, by the time Austin’s father joined the family, Austin and
his mother had relationship roles based on a single family struc-
ture, with an established parent–child dyad. Austin’s mother
had also experienced the stressors of a single parent household
that included financial pressures, childcare solutions (support
from maternal grandparents), and limited time and energy for
social activities, all without any support or involvement of the
father (Pasley & Garneau, 2012). When Austin’s father joined
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the family, parental and couple dyads were established, which
stressed the parent–child dyad between Austin and his mother.
It was noted that during treatment sessions, all talking oc-
curred between Austin and his mother, always seated together
on a sofa. His father sat alone on a chair, often with his head
facing the floor. While it seemed the father was listening, he
did not participate in discussions outside of brief statements.
Although he was Austin’s biological father, he was not a partic-
ipant for the first 7 years of Austin’s life. It would be reasonable
to think of Austin’s father as assuming the role of step-father.
His parental role was greatly influenced by the parenting style
already established by Austin’s mother. The father’s attempts to
alter these established patterns of behavior were met with sig-
nificant resistance by Austin, resulting in his father becoming
less involved (Pasley & Garneau, 2012). Research indicated that
children in step-parent relationships engaged in higher levels of
conflicts with both parent and step-parent and were more af-
fected by conflicts arising from parent/step-parent conflicts that
lead to hostile parenting (Shelton, Walters, & Harold, 2008).
The Nuclear Family Emotional System for the White
Whereas, Austin and his mother were able to regulate emo-
tions between themselves, when his father became a part of the
family, anxiety increased between all family members, as they
redefined their roles and developed new family rules. There was
a breakdown of rules and boundaries between the mother and
Austin. He was confused about the changes to the mother–child
dyad and to his new role as a child in a father–mother–child
triad. His role was significantly altered in the reconstituted fam-
ily and this created a source of intense anxiety for him. Bowen
(1978) observed that when anxiety is low, most relationships
appear symptom free. Symptoms present themselves when anx-
iety is increased due to tension in the system, thus blocking the
differentiation of self.
When examining the nuclear family emotional system,
Bowen recommended focusing on the undifferentiated emo-
tional functions of the family. In this family, all family members
were trying to define their roles and boundaries of the relation-
ships. The father was trying to establish his role as a husband
and father but was delegated a back seat in decision-making, by
the mother. Similarly, the mother, while giving voice to shared
parenting, continued to decide the consequences of Austin’s
destructive behavior and direction of therapy.
Triangulation and Differentiation of Self
The White family experienced significant anxiety and fusion,
and triangulation developed as they tried to decrease this stress.
The timeline of Austin’s behavioral and emotional problems
correlated with his father joining the family. As Austin’s mother
and father attempted to strengthen and consolidate their roles as
husband and wife, anxiety built between them. There are levels
of differentiations in marriage. A successful marriage is more
likely when the spouses have similar levels of differentiation.
Differentiation is not tied to gender but rather the position that
each had in their families of origin and likely played a major
influence in the choice of the other person as a partner (Bowen,
1976). Bowen called this adaption of differentiation ‘borrowing
and trading of self’, as partners attempt to gain a dominant role
in the relationship. Triangulation developed, as Bowen’s theory
suggested, when they avoided confrontation and discussion of
their own marital difficulties by focusing on their son. The par-
ents projected their undifferentiation on to the child. Although
triangulation may diminish the anxiety in the marital relation-
ship, Bowen asserted it paradoxically increased the anxiety of
the third person, very often the child (Austin), and this caused
the child to exhibit symptoms of distress. Miller et al. (2004)
asserted the child was most vulnerable to be triangulated by
either parent and was a potential casualty of the nuclear family
emotional process.
The Whites were unwilling to discuss the reasons they had
not established a marriage or lasting relationship initially and
whether conflicts from that earlier time influenced their current
behaviors and relationship, resulting in ‘spillage’ on to Austin.
Austin’s parents agreed that family was an influence to Austin’s
emotional health, but they were resistant to investigate their re-
lationship and its impact on Austin’s emotions and acting out
behavior. However, based on Bowen’s theory, Austin’s behavior
was likely his attempt to cope with his position in the triangle
and his confusion over the role he was expected to play as a
buffer for his parent’s anxiety. With the focus on Austin, his
parents avoided addressing their own relationship problems. It
was also possible that using Austin’s emotional and behavioral
problems facilitated communication between his parents and
filled a void that would otherwise be present and thus contribute
to more spousal anxiety. This family had participated in numer-
ous therapy sessions in the past with the primary intent ‘to fix
Austin.’ Bowen viewed the family as a system that interacted
and impacted the individual family members. The parents would
likely benefit from an exploration of their relationship for its im-
pact to Austin. Therapy could assist the parents to understand
how their own growth and changes influenced Austin’s position
in the family structure and changed his behavior.
Family Projection Process
As his parents negotiated their relationship, Austin was con-
fused over the redefined rules and roles of his relationship
with his parents. Other explanations for Austin’s behaviors may
be two-fold. First, Austin had a genetic bipolar predisposition
to bipolar disorder from his mother. Second, the question of
whether his mother had unresolved emotional concerns about
her own family of origin’s attitude and management of her men-
tal health when she was a child. She reported her parents did not
seek treatment for her and she recalled the impact of her symp-
toms to her own emotional wellbeing. Did this lead her to being
over focused to seek treatment for Austin in response to her own
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experiences? When Austin’s parents married, the exclusiveness
of the mother–child dyad was lost and through his mental illness
treatment therapy sessions, this dyad was re-established.
Nurse practitioners can use many of Bowen’s therapy tech-
niques during family therapy sessions. Family systems therapy
begins with a family evaluation of their emotional processes,
closeness, distance, triangles, and tensions that are still unre-
solved from the family of origin. The ideal method of working
with a family using the Bowenian theory is to have several gen-
erations participating. However, a genogram as a graphic rep-
resentation of family relationships, physical and mental health,
and substance abuse can help hypothesize patterns of interaction
and give insight to development of behaviors. Bowen (1978) rec-
ommended the use of a genogram to organize multigenerational
In clinical practice, the goal of Bowen’s family systems ther-
apy is to assist family members to move towards differentiation
of self and away from blaming and emotional reactivity. The
role of the therapist is to connect with the family, facilitate fam-
ilies to be active in the healing process, and all the while avoid
being drawn into a triangle. The therapist should emotionally
connect with the family but avoid telling family members what
they should do or try to fix the family problems (Kerr & Bowen,
1988). Staying neutral and objective may require vigilance on
the part of the therapist to avoid overt emotional responses or
unintended tendency to side with one family member or an-
other (Papero, 1990). Bowen viewed the role of the therapist
was to direct family conversations during therapy and facilitate
families to accept personal responsibility for change, and not
passively wait for ‘a cure’ from the therapist.
A therapist following Bowen’s techniques asks questions of
the adult members about the child’s actions but encourages ‘I’
when speaking about the problems without attacking or de-
fending other family members. The intention of this technique
is to have the parents express their feeling about an incident.
This technique emphasizes the importance of maintaining clear
boundaries by distinguishing between objective and subjective
statements. The family system therapist encourages differentia-
tion of family members through ‘I’ questions/statements that do
not attack or defend other family members. These personal state-
ments are meant to facilitate greater ‘ownership’ of their own
emotional responses and minimize attributing blame to others
or the source of the conflict (Bowen, 1978). The therapist facili-
tates parents to recognize the development of their own patterns
of emotional processes that are attributable to their own family
of origin and if dysfunctional, how they contribute to the current
family emotional process (Brown, 1999). It was Bowen’s con-
tention that differentiated people used ‘I’ statements more often
in conversations and ‘We’ statements were indicative of possible
triangulation (Miller, Anderson, & Keala, 2004). Bowen (1976)
asserted using ‘I feel’ allowed a person to express an opinion
without sounding false or insincere. It was observed that Mrs
White frequently used ‘we’ when talking about Austin’s symp-
toms and the parent’s reaction. Mother was the spokesperson
and father consistently agreed with her opinions.
During therapy, the White family was encouraged to use ‘I’
statements as a method to decrease emotional reactivity and in-
crease differentiation. ‘I’ statements were used with the Whites
to discuss their response to Austin carrying a kitchen knife to
school and threatening another student. Instead of focusing on
the ‘wrongness’ of Austin’s behavior, Mr and Mrs White were
asked to make ‘I’ statements about their reactions and emotions
associated with the action. Parents were encouraged to ‘own’
their thoughts and feelings, rather than project and blame Austin
and Austin’s friends, who he said encouraged him to bring the
knife to school as protection. Individual self-focus during clini-
cal sessions was a means to reduce anxiety, facilitate person-to-
person relationships, and investigate problematic interactions.
Austin was encouraged to talk directly to both parents, instead of
making statements to the therapist. He was encouraged to use ‘I’
statements to express his thoughts and feelings instead of voic-
ing a general complaint about a parental rule or action (he usu-
ally addressed his mother). Bowen recommended the therapist
steer clients away from emotional responses, which he believed
hindered differentiation of self, but encouraged an externaliz-
ing thinking mode for each family member by discussing their
thoughts, reactions, and impressions. Bowen (1976) stated the
core of his theory was the degree to which people can distinguish
between the ‘feeling process’ and the ‘intellectual process’. He
believed many families have great difficulty distinguishing be-
tween subjective feeling and objective thinking.
A basic premise of Bowen’s therapy is to assist in dissolution
of the dysfunctional triangling process by enabling clients to
become aware of the emotional processes they are using and
encourage examining these behaviors (Farmer & Geller, 2005).
De-triangling was accomplished, Bowen (1976) believed, by
helping the family members recognize the process by which it
occurred. Open-ended questions, using who, what, where, and
when, help identify triangles. Bowen encouraged the therapist to
minimize the involvement of children as a way to maneuver the
parents away from using the child as the triangle person for the
problems between the parents (Brown, 1999). Bowen therapy
might exclude the child from therapy to focus on the adults
who have greater influence on the family system. Excluding the
child prevents the parents from using the child as a replacement
person between them (Brown, 1999).
A useful Bowenian strategy is coaching or teaching family
members to observe the patterns of their behaviors when anxi-
ety and tension between members escalate. Another therapeu-
tic technique is dialogue, which facilitates family members to
make suggestions about future courses of action and changes to
their current established reactionary behavior (Farmer & Geller,
2005). Dialogue was used with the White family to provide an
opportunity to ‘do something different’ and to move away from
a pattern of responses that resulted in confrontations and anger
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and towards behaviors less emotional and reactive. Families are
encouraged to communicate in less reactive and emotional re-
sponses to their own anxiety and the anxiety of other family
members. The goal of a strategic intervention is not to change
relationships but to express a calm and neutral stance that pre-
vents anxiety and tension that occurs when members take sides
in the relationship.
Bowen believed his early work with families and schizophre-
nia had application to any family with a child showing psycho-
logical disturbance (Bowen, 1966). Further work by Wynne
and Singer (1963), colleagues of Bowen, looked at the shifting
boundaries of families with members who had significant men-
tal disorders and introduced the term pseudomutuality, mean-
ing these families gave the appearance of a mutual, open, and
understanding relationship without actually having such a rela-
tionship. Pseudomutuality was a way to manage the conflict and
hide the true relationships of families which were distant and
lacked intimacy. An identified patient of the family helped per-
petuate the myth that this member had the identified emotional
dysregulation and that the other family members were normal.
Application of Bowen’s family systems theory provides an
organized analysis of relationships and tools to improve com-
munication between members, recognizing that these triangles
exist in various levels of dysfunction in all families. No family
is free from the influence of society, race, gender, and income.
There is a vertical movement of anxiety/stress from parents to
children but also a horizontal movement between couples and
between each adult’s families of origin. Applying a philosophy
with guiding principles allows a holistic assessment approach.
It also provides guidelines when therapy is not proceeding as
expected. Although the symptomatic child is the identified pa-
tient, Bowen maintained that the family’s emotional system was
the source of the problem (Bowen, 1978). Helping family fo-
cus on examining their communication processes rather than
placing blame or ignoring underlying sources of family anxiety
offers family members skills to change behaviors and facilitates
a calmer non-reactive emotional climate.
Few clinicians working with families hold to one particular
theory but use selected concepts and techniques from a variety of
models. While the Bowen Family Systems Theory is discussed
here, other family therapy theories from other social science
disciplines have been aligned with the nursing theories.
The Family Assessment and Intervention Model integrates
general systems theory with Neuman’s Health Care Systems
Model. The family is viewed as a dynamic and open system.
This theory focuses on what causes family stress and how the
family reacts to stress. When a family member experiences a
stressor that threatens the family unit, the whole family feels
threatened and forms protective defenses. Families vary in their
ability to adapt and reconstitute as they try to restore balance
to the family system. The nurse practitioner encourages the
family to concentrate and build on strengths as well as identify
problem-solving strategies.
Family Systems Stressor-Strength Inventory is an assessment
tool developed by Berkey and Hanson (1991). It divides assess-
ment into three sections: general family system stressor, specific
family system stressor, and the family strengths (Berkey & Han-
son, 1991; Hanson & Mischke, 1996; Hanson 2001; Hanson &
Kaakinen, 2005).
The Friedman Family Assessment Model (Friedman et al.,
2003) is a nursing-based model that integrates general systems
theory with developmental theory on a structural-functional
framework. It is often used in community and public health
settings. It assesses the family as a whole, with a focus on fam-
ily as a subunit of society. It provides examples of questions
the nurse can ask that assess developmental stage, environment,
power structure, and coping style of the family. The structure
of the family for this model refers to how the family is orga-
nized and interacts with members (Friedman, Bowden, & Jones,
General systems theory, cybernetics, communication theory,
change theory, and biology of recognition are all components
of the Calgary Family Assessment Model (Wright & Leahey,
2009). General systems and family system theory concepts em-
phasize the family as a whole is greater than its parts, and change
that affects one member affects all members of the family im-
pacting balance and stability. Among the concepts taken from
cybernetics theory is that families possess self-regulating abil-
ities and a feedback process that can occur simultaneously at
many levels. Communication theory concepts include: (1) all
non-verbal communication is meaningful; (2) all communica-
tion has two major channels – verbal and non-verbal and two
levels – content and relationship; and (3) a dyadic relationship
has varying degrees of symmetry and complementarity. Nurs-
ing interventions help families manage change for balance and
stability. Assessment of families using the Calgary Model is
organized into three major categories: structural, family devel-
opmental, and functional. Structural assessment consists of the
family composition, rank, subsystems, and boundaries of the
family. Family development includes assessment of the family
life cycle or stage, tasks, and attachment. The third assessment
area, family functioning, includes activities, health care, power,
belief system, alliances, and coalitions. Family strengths, not
deficits, are the focus areas of therapy. The interventions are
specific to the family structure, function, and process (Wright
& Leahey, 2009).
Other topics of clinical sessions were Austin’s own anxiety,
as he established his relationship with his father and anxiety ex-
perienced by both Austin and his mother during the breakdown
and re-establishment of rules of their relationship. Austin’s striv-
ing for differentiation of self had become complicated due to
his becoming part of a triangle, as his parents experienced stress
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and anxiety during their relationship transition. During other
sessions with the White family, attempts were made to investi-
gate past multi-generation influences (grandparents) on current
patterns of parenting and family belief systems about treatment
for mental health. These influences and other relationship pat-
terns tend to repeat over generations (Brown, 1999).
Austin had participated in various forms of therapy since
he was about eight. The focus was always determining how to
change and ‘fix’ Austin. This was the first therapy that shifted
the focus to the family and how the patterns of behavior had
shaped Austin and more importantly, how ‘fixing’ Austin in-
volved assisting the family to become aware of their patterns
of behavior and evaluate the impact to not only the identified
patient but the other family members. While this discussion
oversimplifies the Bowen Family Systems Theory, the goal is to
provide nurse practitioners, and others working with families, a
direction for organizing the complex behaviors of family mem-
bers into a framework to understand the relationship of parts
to the whole, the need for stabilization of the family system,
and that the family is the sum of its parts. It provides the nurse
practitioner and other clinicians with a framework to assess the
family for patterns of behavior.
Declaration of Interest: The authors report no conflicts of
interest. The authors alone are responsible for the content and
writing of the paper.
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... It is also a more critical family event. 3 According to Bowen family systems theory, 4 cancer diagnosis and related clinical treatment of a family member may cause patients and their families to be in a state of adverse and high stress, and ultimately affect the stability and balance of the whole family system. 5 Previous studies on family stress of patients with breast ...
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Objective: The aim of this study was to assess the reliability and validity of the Chinese version of the Family Resilience (FaRE) Questionnaire among patients with breast cancer in China. Design: It was a cross-sectional study, which involved translation, back-translation, cultural adjustment and psychometric testing of a 24-item FaRE Questionnaire. Setting: Three tertiary hospitals in Zhengzhou, China: respectively are the First Affiliated Hospital of Zhengzhou University, Second Hospital Affiliated to Zhengzhou University and Henan Provincial People's hospital. Participants: A total of 559 patients with breast cancer volunteered to participate in the study PRIMARY OUTCOME MEASURES: Data analysis was performed using the IBM SPSS software V.21.0 and AMOS software V.21.0. Cronbach's α coefficient was used to examine the internal consistency. The test-retest reliability was calculated using the intraclass correlation coefficient on 30 participants. The content validity index was calculated based on the values obtained from six expert opinions. Construct validity test was performed using factor analysis including exploratory factor analysis and confirmatory factor analysis. Results: For the Chinese version of FaRE Questionnaire, the Cronbach's α coefficient of the total questionnaire was 0.909, and Cronbach's α coefficients of four factors were 0.902, 0.932, 0.905 and 0.963, respectively. The test-retest reliability index of the total questionnaire was 0.905. The Scale-Content Validity Index was 0.97, and Item-Content Validity Index ranged from 0.83 to 1.00. The questionnaire included 24 items, exploratory factor analysis extracted four factors with loading >0.4, which could explain 72.146% of the total variance. Confirmatory factor analysis showed the Chinese version of FaRE Questionnaire had an excellent four-factor model consistent with the original questionnaire. Conclusion: The Chinese version of FaRE Questionnaire has acceptable reliability and validity among patients with breast cancer in China. It can effectively assess family resilience and provide basis for personalised family resilience interventions for patients with breast cancer.
... The DFG therapist possesses the competence required to transform this knowledge concerning NDD symptoms into practical guidance for families, in order to help them in their daily lives. DFG involves using traditional theory-based elements stemming from family therapy as an open dialogue (Seikkula & Trimble, 2005), reflection (Weingarten, 2016), and systems therapy (Haefner, 2014). ...
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Objectives Previous studies have highlighted the need to offer targeted interventions to strengthen the wellbeing of family members in families with children with neurodevelopmental disorders (NDD). Interventions for this target group require research and development. The purpose of this study was to test a new family intervention: Dialogical Family Guidance (DFG). Methods Families of children with NDD were randomized into an intervention group that was delivered DFG and a comparison group provided with ordinary clinical treatment. The Family Functioning, Family Health and Social Support (FAFHES) and the DFG instrument were used to collect data at baseline and after 3 months. Repeated measure analysis of variance (ANOVA) was used as an analytical strategy. Results There was a significant within-subjects effect of time on family health and social support, indicating that family health and social support increased in both groups over time. There was also a significant between-subjects effect of group and interaction between time and group on social support, indicating that social support increased more in the intervention group than in the control group. Managing in daily life and the relationship between parents were associated with family functioning and family health. Conclusion DFG can strengthen parental experiences of social support. Managing in daily life, relationship between parents, practical guidance, psychoeducation, dialogue, and receiving positive feedback on parenting were strengthening factors during DFG. However, the results of this study must be considered as only preliminary, as they relate only to parental perceptions of the intervention effects. Trial registration NCT04892992 (retrospectively registered).
... This study has some important implications for counselors and mental health practitioners and researchers. The FCFI scale was developed based on the prevalent premise in family counseling that the family is a unit (Haefner, 2014;Minuchin, 2018), meaning that mental health outcomes should be measured with familial perspective in mind. Within this perspective, anxiety, and fear shift among family members within the basic unit of parents and children and other close family members. ...
The Fear of COVID-19 Familial Infection (FCFI) scale examines parents’ fear levels of infecting their families with COVID-19. Principle component analysis and confirmatory factor analysis in a sample of parents (N = 582) revealed two factors: Fear of infecting others and Others’ Fear of being infected by me.
... The level of differentiation of each person indicates his ability to separate intellectual and emotional processes [8]. Different studies have shown that self-differentiation training programs, aiming at reducing chronic anxiety [9,10], increasing family functioning, coping with stress, anxiety, and depression in married women [11], and increasing marital satisfaction [12,13] affects marital conflicts among married women [9]. BFST found and successfully implemented the interventions targeting marital conflict [14], sexual problems [15], and adolescent identity development [16]. ...
Background: Marital satisfaction is a basis of other social organization health. The aim of this study was to investigate the effectiveness of the self-differentiation training based on the Bowen Theory to increase marital satisfaction. Methods: The research method was semi-experimental and the pre-test-posttest design with the control group. In this intervention, the population of this study was selected by the convenience sampling method and 38 married women were randomly assigned to the experimental (n= 12) and control (n= 12) groups in Tehran in 2018. The Differentiation of Self Inventory (DSI) and Marital Satisfaction Inventory (MSI) were completed by married women. The control group received no training. The intervention included 10 sessions of self-differentiation training based on the Bowen theory. Twelve women participated in this semi-experimental project selected by convenience sampling as an experimental group and twelve women as a control group. The brief couple-based therapy was taught in 10 sessions based on techniques of Bowen therapy and four components of differentiation. The data were analyzed by SPSS v. 23 software. Results: There was a significant difference between the post-test scores of the experimental and control groups. In addition, training based on the DST approach could significantly increase marital satisfaction (t= 21.62, df= 22, P
Cognitive–communication difficulties are often associated with dementia and can impact a person's ability to participate in meaningful conversations. This can create challenges to families, reflecting the reality that people living with dementia rarely have just one regular conversation partner, but interact with multiple family members. To date, there is limited evidence of the impact of changes in communication patterns in families. A family systems approach, with foundations in psychology, can be used to explore the impact of communication difficulties on multiple different family members, including the person living with dementia and potential coping strategies used by individuals, together with the family as a whole. A systematic review of primary qualitative research was conducted to identify and examine research exploring communication and interaction within families living with dementia. Studies were identified through a comprehensive search of major databases and the full‐text articles were subject to a quality appraisal. We conducted a thematic analysis on the literature identified to consider the role of families in supporting communication for people with dementia. The searches identified 814 possible articles for screening against the eligibility criteria. Nine articles were included in the final review. Three major themes emerged from the analysis of the included studies: (1) ‘identities changing’ reflected how interactions within the family systems impacted on identities; (2) ‘loss’ reflected the grief experienced by families due to changes in communication; and (3) ‘developing communication strategies’ highlighted strategies and approaches that families affected by dementia may use organically to engage in meaningful interactions and maintain connection. Only one study explicitly used a family systems approach to understand how families manage the changes in interaction resulting from dementia. The findings may usefully inform the clinical practice of speech and language therapists in terms of communication strategies and coping mechanisms that may be advised to facilitate connection in families living with dementia. Further research using a family systems approach to exploring communication in dementia may help to support the implementation of family‐centred practice as recommended in policy. There is increasing recognition of the impact of dementia on whole families and the need for family‐centred interventions to enhance quality of life. However, much of the research to date that explores communication within families affected by dementia examines interaction between dyads, largely overlooking the roles and skills of other familial communication partners. To the authors’ knowledge, there has been no previous review of the literature using a family systems approach, which has the potential to inform clinical practice of those working in dementia care. The review examines and understands what is known about the approaches used by families affected by communication changes resulting from dementia to preserve connection. It collates the evidence from qualitative studies examining approaches and strategies used by individual conversation partners, including people with dementia, as well as the family system as a whole, to facilitate meaningful interactions, and proposes recommendations for clinicians working in this field. Furthermore, we consider the potential benefits of using a family systems approach to understand the context of people living with dementia and how this could enhance communication, personhood and well‐being. This review highlights practical conversation strategies and interactional approaches that may serve to enhance communication and preserve relationships between people with dementia and their family members. Such techniques have the potential to be advised by Speech and Language Therapists working in dementia care as part of tailored, relationship‐centred care and support that they provide.
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This article addresses ways in which some strategies from Applied Behavior Analysis (ABA) approach contribute to the understanding and increasing of workplace performance and motivation. In this study, we provide the conceptual background, meta-analyze available studies about behavioral approaches, applied in organizational settings, and we describe various factors that influence motivation, including individual learning histories, motivating operations and keys for delivering positive reinforcement effectively. The paper concludes with a discussion of the implications for the practice of entrepreneurial leadership and for further research, offering practical suggestions for improving motivation and productivity in organizational settings.
Background Cancer not only affects cancer patients’ quality of life but also their family caregivers’. A WeChat-based Dyadic Life Review Program was developed by our research team for people with advanced cancer and their family caregivers to improve their quality of life. Aim To explore the feasibility and preliminary effects of the WeChat-based Dyadic Life Review Program on people with advanced cancer and their family caregivers. Methods A feasibility randomized controlled trial was conducted. Both quantitative and qualitative data were collected. A total of 47 advanced cancer patient-family caregiver dyads was recruited. Twenty-six dyads were randomized into the experimental group, and 21 dyads into the control group. The experimental group engaged in the WeChat-based Dyadic Life Review Program twice a week for 4 weeks. Results For qualitative results, five themes emerged: (1) accepting and enjoying the program; (2) increasing communication with one another; (3) feeling grateful for each other; (4) providing emotional support to each other; and (5) releasing caregivers’ stress. In terms of quantitative results, quality of life ( Z = −4.06, p < 0.001; t = 4.30, p < 0.001), family adaptability( Z = −3.01, p = 0.003; Z = −3.29, p = 0.001), and family cohesion( Z = −4.14, p < 0.001; Z = −3.88, p < 0.001) of people with advanced cancer and family caregivers were improved, and family caregivers’ care burden ( t = −2.50, p = .018) was decreased in the experimental group compared with the control group post-test. Conclusions The WeChat-based Dyadic Life Review Program is feasible and acceptable for people with advanced cancer and their family caregivers. It has the potential to improve their quality of life, adaptability and cohesion, and reduce family caregivers’ care burden.
This article addresses ways in which some strategies from Applied Behavior Analysis (ABA) approach contribute to the understanding and increasing of workplace performance and motivation. In this study, we provide the conceptual background, meta-analyze available studies about behavioral approaches, applied in organizational settings, and we describe various factors that influence motivation, including individual learning histories, motivating operations and keys for delivering positive reinforcement effectively. The paper concludes with a discussion of the implications for the practice of entrepreneurial leadership and for further research, offering practical suggestions for improving motivation and productivity in organizational settings.
This study examines the 21-year longitudinal impacts and predictive effects of family caregiver transition and the presence of family caregiving on the clinical status of persons with schizophrenia (PwSs) in a rural area of China. Using panel data derived from the Chengdu Mental Health Project (CMHP), 250 dyads of PwSs and their family caregivers were investigated in 1994 and 2015. The Positive and Negative Syndrome Scale (PANSS) and the Global Assessment of Functioning (GAF) were utilized. The generalized linear model (GLM) approach was used. The results of this study showed that more severe symptoms in PwSs were found to be significantly predicted by older age and nonmarried status at baseline. Compared with “spousal caregiving in two waves,” the PANSS score was significantly higher in the “transition into sibling caregiving” group. A higher degree of psychosocial functioning was found to be significantly predicted by marital status, shorter duration of illness, and better mental status. Compared with “spousal caregiving in two waves,” the GAF score was significantly lower in the “transition into parental caregiving” group. The presence of family caregiving was not a significant predictor of the severity of symptoms or psychosocial functioning in the PwSs. In conclusion, this study shows the 21-year predictive effects of family caregiver transition on the mental status of PwSs but not the presence of family caregiving. Psychosocial interventions and specific guidance should be provided to family caregivers to enhance their quality of caregiving and improve the prognosis of PwSs during long periods of home care. Resumen es En este estudio se analizan los efectos longitudinales a 21 años y los efectos pronósticos de la transición de los cuidadores familiares y la presencia de cuidado familiar en el estado clínico de las personas con esquizofrenia en un área rural de China. Utilizando datos de panel extraídos del Proyecto de salud mental de Chengdu (Chengdu Mental Health Project, CMHP), se investigaron 250 díadas de personas con esquizofrenia y sus cuidadores familiares en 1994 y 2015. Se utilizó la Escala de síndrome positivo y negativo (Positive and Negative Syndrome Scale, PANSS) y la Evaluación global del funcionamiento (Global Assessment of Functioning, GAF). También se utilizó el método de modelo lineal generalizado. Los resultados de este estudio demostraron que los síntomas más intensos en las personas con esquizofrenia fueron pronosticados principalmente por la edad avanzada y el estado de soltería en el momento basal. En comparación con el grupo de “cuidado de los cónyuges en dos intervalos”, el puntaje de la PANSS fue considerablemente más alto en el grupo de “transición al cuidado de los hermanos”. Se descubrió que principalmente el estado civil, la duración más corta de la enfermedad y un mejor estado mental pronosticaron un grado más alto de funcionamiento psicosocial. En comparación con el grupo de “cuidado de los cónyuges en dos intervalos”, el puntaje de la GAF fue considerablemente más bajo en el grupo de “transición al cuidado de los padres”. La presencia de cuidado familiar no fue un factor pronóstico importante de la intensidad de los síntomas ni del funcionamiento psicosocial en las personas con esquizofrenia. En resumen, en este estudio se muestran los efectos pronósticos a 21 años de la transición de los cuidadores familiares en el estado mental de las personas con esquizofrenia, pero no la presencia de cuidado familiar. Deben ofrecerse intervenciones psicosociales y orientación específica a los cuidadores familiares para mejorar su calidad de cuidado y mejorar el pronóstico de las personas con esquizofrenia durante los periodos prolongados de cuidado en el hogar. 摘要 本研究考察了对中国农村地区精神分裂症患者的长达21年的照顾时间里,家庭照顾者的变化和家庭照顾的存在对患者临床状况的长期性影响和预测作用。数据主要来自成都心理健康项目(CMHP)的长期随访数据,分别于1994年和2015年对250对精神分裂症患者及其家庭照顾者进行了调查。本研究采用了阳性和阴性综合征量表(PANSS)和整体功能评估(GAF),采用了广义线性模型(GLM)分析的方法。本研究结果表明,年龄越大和非婚状态对精神分裂症患者更严重的症状有显著的预测作用。与 "配偶照顾 "相比,"过渡到兄弟姐妹照顾 "组的PANSS得分明显更高。研究发现,婚姻状况、较短的病程和较好的精神状态能够较多地预测较高程度的社会心理功能。与 "配偶照顾 "相比,"过渡到父母照顾 "组的GAF得分明显较低。家庭照护的存在并不是预测精神分裂症患者症状严重程度或社会心理功能的一个重要因素。综上所述,本研究显示,21年的家庭照顾者的变化对精神分裂症患者的精神状态有预测作用,但对是否存在家庭照顾则没有影响。非常有必要为家庭照顾者提供社会心理干预和具体指导,以提高他们的家庭照顾质量,改善精神分裂症患者在长期家庭照顾中的预后。
Developed in the early 1960s by Aaron Beck and Albert Ellis in the USA, mostly for the short-term treatment of patients suffering from emotional disorders, cognitive psychotherapy has rapidly expanded both in its scope and geographically. In fact, when attending recent European conferences relating to psychotherapy, for example, those organized by the European Association of Behaviour Therapy and the European Branch of the Society for Psychotherapy Research, the 13th International Congress of Psychotherapy, and the two international conferences on cognitive psychotherapy which took place in Lisbon in 1980 and in Umea in 1986, one could not but become aware of the active interest in cognitive theory and practice on the European continent. It is stimulating to find that cognitive approaches to the understanding of human emotion and behaviour, which find their origin in the writings of the ancients as well as in eighteenth-century philosophers, principally Kant, are no longer a strictly transatlantic movement. As the chapters of this handbook demonstrate, researchers and clinicians from many different European countries have been devel­ oping the theoretical aspects of the cognitive theory of the emotional disorders and applying it in their practice. These chapters can of course represent but a sample of all the work being carried out, but we hope that they will be both informative and stimulating to researchers and therapists on both sides of the Atlantic.
This paper will give an overview of Murray Bowen's theory of family systems. It will describe the model's development and outline its core clinical components. The practice of therapy will be described as well as recent developments within the model. Some key criticisms will be raised, followed by a case example which highlights the therapeutic focus of Bowen's approach.