Considerations of Family Functioning and Clinical Interventions.

Levels of family functioning are an important consideration in determining appropriate clinical and educational intervention approaches for families and older adults. Theoretical and applied approaches are reviewed with the emphasis on specific interventions that support different levels of family functioning and caregiving. Additionally, different dynamics within the family and their relations with aging family members are examined. This paper updates and expands discussions on levels of family functioning considerations by Sterns et al. using Blocher's theory of level of human effectiveness. Further levels of family functioning include the theories developed by Bowen's family systems theory. A present-day consideration is important for counseling, case management, caregiving, and treatment planning to assist families and their aging family member.

A Bit of History

There are a growing number of older adults and their families that need counseling. A growing number of specialized books on education and counseling with older adults appeared in the 1980s (e.g., Keller & Hughston, 1981; Sargent, 1980; Schlossberg et al., 1978), as well as numerous assessments of older adults (e.g., Kane & Kane, 1981). Although a number of these classic sources mentioned family therapy, only Herr and Weakland (1979) offered an extensive discussion regarding aging and the counseling of families during this early period of published scholarly research.

More recently, important sources have emerged regarding education and training for counseling older adults and their families (see Bengtson et al., 2016; Brown & Lent, 2000; Juntunen & Schwartz, 2016; Lichtenberg et al., 2015; Myers & Schwiebert, 1996). Scholars are rising to the challenge of translating counseling techniques to meet the needs of the individual older adult client. However, in family counseling, there is the unique challenge of translating traditional family approaches to meet the needs of older adulthood and/or multigenerational family issues. This paper builds on the earlier work of Sterns et al. (1984), and provides an updated look at education and training for counseling older adults and their families from the present day and into the future. The education and training gap in gerontology is a current and important issue for the present. Bergman (2018) have found that there is a shortage of professionals trained in gerontology and geriatrics not only in health care settings, but also in related fields such as psychology and mental health. Before we discuss educational approaches to counseling families with older adults, a brief review about the aging and the family is provided in the next section.

Aging and the Family

The life-span approach to human development emphasizes the changing individual in a changing environment with development as a lifelong process (Sterns et al., 1984). Behavior change processes can occur at any point in the life course (Baltes et al., 1980). According to the lifespan development perspective, an individual’s development is a lifelong process ranging from conception to death (Zacher et al., 2019). This perspective aims to link the individual’s development to earlier and later life events and processes, and to map individual (biological and psychological) and contextual (social, cultural, and historical) influences on their development. Therefore, when thinking of the family structure, there is a need to recognize the influence of personal developmental changes on family ties and reciprocally, the influence of family composition and relationship changes on individual and collective outcomes experienced by the family members (Blieszner & Voorpostel, 2017).

In more recent years, there has been a growing number of works specifically on families in later life (e.g., Burton, 2019; Dickinson & Sanders, 2018; Lichtenberg et al., 2015). The challenge professionals face when working with older adults and their families is to take the growing knowledge and sensitivity in gerontology and channel it into sensitive intervention/educational approaches (Baltes & Danish, 1980; Patrick et al., 2021).

There are some individuals who require assistance from their family members, or from staff in long-term care community settings and facilities. It was found that by 1975, 38% of older adults in the United States were 75 years or older (Sterns et al., 1984), however that number has now changed. In 2016, the estimated number of older adults in the United States over the age of 65 was 49.2 million (Roberts et al., 2018). More than half, or 58%, were between the ages of 65 and 74 years old. It has been found that most older adults are remaining at home long into old age. According to the Institute on Aging (2018), in 1900 only 100,000 Americans lived to be 85 or older. By 2010, that number increased to 5.5 million. Now, the Institute on Aging (2018) is estimating that by 2050, this age group will reach 19 million people. From an educational standpoint, it is vital that individuals caring for an older adult adhere to gerontological competencies.

Family Dynamics and Caregiving

Blieszner and Bedford (2012) defined family as a “set of relationships determined by biology, adoption, marriage, and, in some societies, social designation and existing even in the absence of contact or affective involvement, and, in some cases, even after the death of certain members” (p. 4). Within the family system, many older adults have been involved in the family for decades and play an important role in the functioning of the family system. According to Blieszner and Voorpostel (2017), many dimensions of family interaction patterns are transmitted across generations, with potential for fostering both the continuity of the family itself, and adaptation to internal and external changes that can have an impact on family interactions and well-being.

Looking more closely into intergenerational family relationships, Blieszner and Voorpostel’s (2017) theoretical framework of intergenerational solidarity and conflicts looks at the family as a social group. Within this perspective, solidarity is the basis for social order and a prerequisite for its continued existence. This approach puts the intergenerational relationships in adulthood at the core of the family, making them the central ties beyond the nuclear family. Therefore, through change, the family system could be thrown off balance, leading to poor family functioning.

According to Sterns et al. (1984), the relationship of family members to an older adult in need of support is a unique experience for many families. Over time, this may lead to the need to provide caregiving. Caregivers can be the older adult’s spouse, daughters, and other family members, and provide a variety of support such as housing, transportation, financial assistance, and personal care services such as bathing and dressing (Patrick et al., 2021). Current research shows by the age of 80, around 38% of older adults require help with self-care, mobility, and household tasks (Hawkley et al., 2020). This number is predicted to increase with increasing age such that 76% will require assistance by age 90. In many families, the primary caregiver is usually the individual who has the most responsibility for caring for the older adult. However, it is important to consider the ways in which the ability of the family to respond to the needs of the older adult, including the primary caregiver, is determined by the family’s level of functioning.

Caregiving is provided by both men and women; by spouses, children, and other relatives; and even by non-kin (Zarit & Heid, 2015). Statistically, wives outnumber husbands as caregivers, and daughters are the single largest group of caregivers (30.3%), whereas 11% of sons take on primary caregiving of their parents. The Institute on Aging (2018) further supports this finding by stating that up to 75% of all caregivers are women. However, according to Cheng and Haley (2020), it is well-known that caregiving responsibilities are often shared by multiple family members, and it is often thought that having multiple caregivers may relieve strain on the primary caregiver and affect family functioning. This strain that is mentioned is known as caregiver burden.

Caregiver burden is defined as the emotional, psychological, physical, and financial “load” assumed by the caregiver (Gaugler et al., 2000). When an individual needs support from a caregiver, it disrupts the pattern of interaction within the family. The level of family functioning will have consequences for the caregiver’s physical and mental well-being. Family caregivers face many challenges such as balancing their work, family, and caregiving responsibilities, and may also face financial hardship. For example, primary caregivers may have to quit their current job to take on the full-time care of their aging family member. Therefore, decreasing their household income and increasing the potential for financial hardship. Caregiver burden can also increase the caregiver’s risk of anxiety, depression, lower quality of life and can lead to an increase in health problems (Hawkley et al., 2020).

Depending on the level of cohesiveness within the family, the provision of caregiving can be well-coordinated by family members; families come to a decision with difficulty; the family is unable to act; or the family may respond in explosive crisis. The issue then becomes how professionals can support and work with the caregivers to overcome these negative effects, so they are able to care appropriately for their aging family member. Educational issues for caregivers include lack of education about general information regarding the aging process and other diseases such as Alzheimer’s disease, and lack of knowledge about tangible care services, respite, and emotional and financial support (Kokorelias et al., 2020). Interventions such as psychoeducation, mindfulness-based interventions, and multicomponent interventions such as combining different elements of respite, counseling and support groups, have been found to be effective when working with caregivers and their aging family member (Cheng & Haley, 2020).

Counseling Education Concepts

Due to the demographic change, there has been an increasing demand in the counseling profession to develop and implement more counseling competencies for the older adult population and their families across the life-span. This has caused a professional urgency, resulting in the need for professional advocacy on behalf of older adults and their access to counseling services (Fullen et al., 2019). Based on past knowledge and literature, Troll et al. (1979) have suggested several implications about families in later life. Some of their suggestions will be discussed below, as well as cutting-edge research on counseling considerations when working with families.

When working with the older adult population, it is imperative that professionals work with the individual to help them maintain their autonomy. According to Sterns et al. (1984), aging does not change an older person’s attitudes and preferences. It is critical that both the family and the older individual be involved in the treatment process. During this time, it is important for the family and professionals to focus attention to what the older individual wants regarding their needed assistance.

Gerontological Counseling Competencies

Another implication for counseling families is the professional’s multicultural competency. Research has shown that racial diversity among the older adult population is said to increase in the years to come, making the concept of multicultural competency more prevalent. Implications for aging men and women also pose a factor due to the different challenges they face such as role loss, poverty, and the increased likelihood of living alone.

Another area of importance is sexual orientation. More recently, older adult’s sexual orientation is being more recognized today as more individuals are becoming part of the LGBTQIA+ community. Due to this population’s history of discrimination, stigma, and stereotyping, it is important that providers and caregivers working with these individuals have knowledge of their history and are able to provide care with open-mindedness and provided support to the LGBTQIA+ community (Patrick et al., 2021).

According to Tomko and Munley (2013), mental health professionals that have multicultural competencies have a better understanding of clients from other cultures, especially in areas of awareness, knowledge, and skills in treating a diverse population. The counselor needs to be sensitive to the different dynamics within family functioning depending on the family’s cultural values. Those values may lead to different outcomes following cultural expectations.

Over the past four decades, there has been an evolution regarding the education and training of physicians, psychologists and counselors who meet the complexities of family counseling. This follows the concept that there are also additional qualifications and competencies that a professional should attain when working with the older adult population and their families (GeroCentral, 2021; Knight et al., 2009).

Levels of Family Functioning

It is important for professionals working with families and older adults to expand their knowledge regarding the dynamics of family functioning. In this situation, approaching treatment by assessing the individual’s and the family’s level of functioning can be a beneficial treatment method. One such concept was Blocher’s (1966) theory of “level of human effectiveness.” This concept contains five levels of human effectiveness: mastery, coping, striving, inertia, and panic. This theory was originally written to address an individual rather than the family and was adapted into a family systems theory approached by Sterns et al. (1984). This article looks to adapt that theory and extend the importance of educational and clinical competencies when working with families and older adults.

To compare each level of family functioning, we will use the example of a family attempting to make medical decisions regarding their aging family member who is starting to exhibit signs of dementia. In modifying this concept, Blocher’s (1966) levels were translated into the family functioning perspective. This model can be applied to families across different ethnic and cultural groups, however, the professional providing services must approach the treatment through a multicultural lens. This article will review Blocher’s (1966) theory based on the article by Sterns et al. (1984). Additional theories of family functioning that have been developed since that time offer support to Blocher’s (1966) theory such as Crittenden’s (1992) theory which focuses on work with children, and Bowen’s family systems theory as discussed in Papero (1990). Table 1 shows how these three theories align with each other, and each concept of the different theories will be described as they are discussed in each level. Considerations of levels of family functioning provide an understanding of why counseling may be effective with some individuals and not with others.

Table.1.

A Comparison of Levels of Family Functioning Between Multiple Theories.

Blocher	Bowen	Crittenden
1. Mastery		Independent and adequate
2. Coping	Triangle	Vulnerable to crisis
3. Striving	Triangle	Restorable
4. Inertia		Supportable
5. Panic	Differentiation of self	Inadequate

Mastery

Using Blocher’s (1966) theory, families effectively control large segments of their environments and can maintain continuity within the family and yet have the capacity to change when presented with new information (Sterns et al.,1984). This level is also supported by Crittenden’s (1992) Independent and Adequate level of family functioning which states families can meet the needs of the older adult family member by combining their own skills, help from friends and relatives, and services which they seek and use. This theory suggests that although all families experience crises and conflict, it is the way in which those family members resolve those conflicts that make them adequate. In the example above we have a family that is attempting to work cohesively regarding their aging family member who is starting to exhibit signs of dementia. A family working in the mastery level of functioning will be able to work together effectively alongside their aging family member to make healthy and effective decisions regarding their care needs. This is considered the optimal level of family functioning and needs minimal level of intervention due to the family members seeking appropriate information and are then able to take appropriate action.

Coping

Families operating at the coping level also have control of large segments of their environment and the ability to maintain continuity with the capacity to change, but often experience more anxiety and stress than families at the mastery level (Sterns et al., 1984). Families are still able to effectively make decisions, but there is more anxiety and emotional discomfort during the decision-making process. This level is also supported by Crittenden’s (1992) Vulnerable to crisis level which indicates that families need temporary help resolving unusual problems, otherwise the family functions independently and adequately. Examples can include the death or illness of an aging family member; however, it is not the crisis itself that makes families vulnerable to a crisis, it is the family’s response to the crisis that can make them vulnerable. This level is also supported in the work of Bowen’s family systems theory in his Triangle level which involves a relationship developed of three people where one individual can stabilize a two-person system (dyad), that is, experiencing anxiety (Haefner, 2014). Since the family members can maintain some level of control within the family unit, the family may have disagreements and emotional discussions, but will eventually come to effective decision making. Following our example of the aging family member exhibiting signs of dementia, the family members may initially have conflict with each other regarding the care that is required, however after seeking professional guidance from a third party such as a physician, social worker, or counselor, the family eventually will come together to make effective decisions.

Striving

Families have some control over long-term aspects of their environment and are attempting to gain more control, but they fail to deal effectively with the issues and problems in the family (Sterns et al., 1984). The family is also reluctant to face the reality of the situation and often employs delaying tactics in making needed decisions, so the issues of aging often become detrimental to the functioning and interpersonal relationships in the family. There are periods of extreme emotional discomfort, and therefore, the tendency is to move from crisis to crisis. Compared to our previous examples, this family is unable to accept the reality of the situation, and therefore chooses to ignore or deny the aging family member’s symptoms and behaviors, and continues to react to each sign and symptom as if they were individual events. This can lead to anxiety and contention within the family unit. This level is also supported by Bowen’s Triangle level, based on the concept of anxiety. According to Bowen’s theory, there is a constant “push-pull” force that has a low tolerance for anxiety (Papovic, 2019). Crittenden’s (1992) Restorable level states that families are multi-problem families who need several types of interventions in order to develop skills to make effective family decisions. This can be expected to last 1 to 4 years with active intervention.

Inertia

Families exhibit some control over the short-term segments of their environment, but because of denial of the reality of the situation or the lack of a commitment to long-term involvement, the family as a unit becomes unable or unwilling to lend support to its older member(s) (Sterns et al., 1984). Therefore, the family will withdraw physically and affectively from the relationship and place the responsibility for the care and support of the older adult(s) to others within or outside of the family. In this example, the family will start to distance themselves from the aging family member and place their care with someone else. This is due to the family’s lack of awareness or denial of their aging family member’s situation. They may tend to put their family member’s care in the hands of a senior living facility or place all the care on one family member. Crittenden’s (1992) Supportable level supports this theory which states that there are no rehabilitative services which can be expected to enable these families to be able to take effective action in caring for their family member. To be able to meet the basic needs of the family, specific on-going services may be required. Often, it is not that the families do not care, rather the families care too much. Therefore, they are unable to accept or deal with the changing status of their aging family member.

Panic

Families exhibit a loss of control over the immediate family situation with the attending loss of control of affective responses (Sterns et al., 1984). The family may be overwhelmed by the situation such as finding their loved one in an unchanged bed that was recently changed, and then berate the staff and then act with intense emotions and behaviors. Thus, the family finds itself in a state of explosive crisis in which effective rational behavior and communication is practically nonexistent. To continue with our example, the family in this level of functioning ultimately will continue arguing over their aging family member’s care without consideration of their needs and wants. The family will also feel a loss of control over the situation. Bowen’s Differentiation of Self level proposes that these families are un-differentiated and as a result, are unable to respond in ways that are constructive given the demands of the situation (Papovic, 2019). These families may also be very reactive, have a need to control the functioning of other family members, are less flexible and adaptive, and may be easily stressed into dysfunction. Crittenden’s (1992) Inadequate level also supports this level of functioning by stating that there are no services sufficient to enable these families to meet caregiving demands, now or in the future without considerable intervention.

Education for Effective Interventions

Once the level of family functioning has been identified, the next step in the process is to determine what type of therapeutic and educational intervention is needed. There are several treatment methods that can be utilized to accomplish this goal, and those can range anywhere from psychoeducation, social support, family/couples counseling, group, and individual counseling. All these treatment approaches can be tailored to each family and individual needs. Please refer to Figure 1 below to see the comparison of the clinical interventions linked with each of the levels of family functioning.

Figure 1.

Clinical interventions and the levels of family functioning.

Psychoeducation

Psychoeducation includes training in communication and problem solving, information about symptoms, biological theories of etiology, warning signs of relapse, and medication and treatment issues (Brown & Lent, 2000). This can be delivered via a classroom, counseling session, training opportunities, and are beneficial in both individual, group, and family counseling session. In a family counseling setting, it can assist family members in learning about changes that come with aging, so they are more aware of how to support and assist their aging relatives. Family psychoeducation as also been found to be helpful with older adults who may be suffering from severe mental illness. According to Aschbrenner et al. (2011), family psychoeducation is an evidenced-based practice for improving the course of mental illness and can be a powerful source for support of health management among older adults. This intervention would be beneficial to all levels of family functioning, however, would be most effective in families in the mastery and coping level of family functioning. For family members and caregivers, psychoeducation can include enhancing their caregiver skills, planning their activities, reorganizing the environment, and enhancing support systems (Boyacioğlu & Kutlu, 2016).

Social Support

It has been proven that social support in older adulthood has been linked to emotional and psychological well-being. According to Krause and Hayward (2015) many mental and physical health concerns in late life have been linked to social support. For example, the authors state that positive relationships with family members are associated with less anxiety and certain mood disorders in later life. In a family setting, counseling becomes imperative to the older adults and their family members in improving relational ties. However, not all cases are related to illnesses of the older adults, it may be related to dysfunctional family behaviors. Other cases may involve poor decision making not related to mental illness.

For counselors, two things are important when addressing an older adult’s social supports. The first issue is being able to identify the individual in the older person’s life that may be responsible for initiating negative interactions (Krause & Hayward, 2015). The second issue to address is educating the family caregivers in building social skills to effectively deal with and cope with these negative interactions. For families in the mastery, coping and striving level of family functioning, social support can be a very effective intervention.

Family Counseling

According to Sterns et al. (1984) the purpose of family therapy is to educate families in altering dysfunctional patterns of relating which inhibit the ability of the family to adjust to the aging of a family member. A family therapist appropriately includes all available family members in the therapeutic process. Family relationships are important to assess in family counseling since family relationships change over the life course, with the potential to share different levels of emotional support and closeness, and varying levels of stress over their lives (Thomas et al., 2017).

In a family counseling session, it has been found that exhibiting symptomatic behaviors reflects the family’s functioning (Friedlander & Tuason, 2000). Therefore, it is imperative to include all family members involved with the older adult to properly assess the family’s level of functioning. Families within the inertia, panic, and striving level of family functioning would benefit greatly from the interventions of family counseling.

Group Counseling

As with any population, group counseling has been found to be effective when working with the older adult population and is also an effective educational intervention when working with families within the coping, striving, and inertia levels of family functioning. Group counseling has been found to promote positive aspects of aging and to help families cope with the process of aging and developmental tasks (Corey et al., 2018). Some of the benefits of group counseling with families is getting the family issues resolved so they can make decisions that support the individual’s care and well-being. Group counseling has been extremely effective in helping families better understand the needs of their family member(s) experiencing cognitive change through educational and training exercises.

Individual Counseling

According to Sterns et al. (1984) the purpose of individual counseling is to assist a person in resolving personal problems which inhibit his/her ability to effectively support their family member(s). This therapeutic approach can be effective for the striving, inertia, and panic levels of family functioning due to the numerous therapeutic approaches that have been found effective when working with individuals and family members. Some of these therapeutic approaches include Cognitive-Behavioral Therapy (CBT), Interpersonal Therapy (IPT), talk therapy, art therapy, and many others (Vacha-Haase & Aeling, 2016). Other therapeutic approaches that can be utilized include person-centered counseling, where the family member is viewed as the expert in their life. The expected outcome of therapy is that the individual can now effectively support their older adult family member.

Counselors can also utilize interventions that promote the concept of successful family functioning. According to Hill (2016), counseling strategies involved with successful aging and positive aging include using a strengths-based approach to counseling, and addressing gratitude, forgiveness, and altruism.

An important indicator of the effectiveness of counseling includes the therapeutic alliance between the counselor and the family members. This also includes the counselor portraying unconditional-positive regard for their client(s) and meeting them where they are at in their process of acceptance and readiness to change.

Implications

Even though there has been more visibility of counseling families and their aging family member, there is still an educational and research gap in different models and theories specifically tailored to these issues. Research is still needed on the dynamics of families and their ability to effectively make decisions as a unit. Other implications deal with multiculturalism and socioeconomic status. Families from diverse backgrounds may be less likely to reach out to professionals outside of the family unit to seek additional assistance. It has been suggested by researchers that future interventions should be designed in a way that allows professionals working with families to incorporate cultural beliefs, values, and practices into intervention protocols (Cheng et al., 2020).

A family’s socioeconomic status may also be a barrier to families receiving interventions due to financial hardship. Future research would benefit from identifying additional educational and training programs and services that are affordable for all families in different economic statuses. Additional educational implications include older adults and their family’s lack of access and knowledge about local services tailored to caregiving needs, as well as older adult’s lack of access to counseling services and coordination of community services.

Conclusion

The major focus of this paper has been to indicate the different levels of family functioning in responding to the needs of an aging family member. Different treatment and educational interventions were discussed that can be utilized depending on the levels of family functioning, and to help the family cope with the demands of the caregiving situation. With each level of family functioning, specific interventions are encouraged due to the many different dynamics within the family and their relations with the aging family member. It is important that the kind of intervention is individualized to each family’s needs to promote effective family functioning and care of the older adult.

The process of aging not only affects the family member(s), but all the generations in their family. Not all families are created equal, thus it is important to determine their level of family functioning. Educational and counseling interventions appropriate for the level of family functioning will help to make it possible for the family to engage in appropriate decision making for their family member(s). Individuals providing counseling have the potential to play an important role in helping educate and train families to make appropriate appraisals and to take appropriate action in the care of their family member through the insight provided by the levels of family functioning approach.