The Cycle of Family Function:

A Conceptual Model for Family Medicine

Gabriel Smilkstein, MD
Seattle, Washington

Information gained from family studies requires integration in

the educational matrix of family medicine. To facilitate this
activity a model that synthesizes major theories and definitions
is presented. This paper describes a conceptual model that
includes components that have been identified as basic to the
recognition and understanding of the family in trouble. It is
proposed that knowledge of family function as represented in
the model, the Cycle of Family Function, will, in turn, help the
physician assess and manage problems presented by patients
who are victims of stress related to family problems.

Assessment and m anagement of family dys­ Definition of Terms

function is an area of study that has been ascend­ An agreement on the meaning of family is es­
ent during the past decade.1-7 In family medicine sential for any discussion about this biopsychoso-
the aim has been to use these studies to develop a cial unit. A review of the literature of various sci­
body of knowledge that will allow physicians to entific disciplines reveals that each has interpreted
approach the patient’s family problems with the the family to meet its own needs (Table 1).
same competency they apply to biomedical The physician also requires a definition of fam­
problems.8-16 To facilitate the utilization of knowl­ ily that is discipline specific, ie, a definition that
edge from family studies, a model is needed that clarifies structure and function of the family which
demonstrates the interrelationship of components is intimately associated with the patient whose
that are critical to an understanding of the family problem is under study.
in trouble. Biomedical problems, such as genetic abnor­
The Cycle of Family Function is a conceptual malities, are best understood by establishing a
framework that presents an empirical view of the structural definition of the family (Table 2). In
responses that may result when a family experi­ order to study psychosocial issues, however, the
ences a stressful life event. It offers the student, physician requires a definition of family that per­
resident physician, and family physician a com­ mits an understanding of family function as per­
mon language with which to discuss family func­ ceived by the patient (Table 3). The study of the
tion, as well as a form at that addresses the data biomedical and psychosocial problems of the pa­
base needed to assess and care for the family in tient within the context of the family requires,
trouble. therefore, that both structural and functional com ­
ponents be included in the definition of family.
The definition of family that applies to the con­
ceptual model described in this paper is as follows:
the family is a basic societal unit in which mem­
From the Department of Family Medicine, University of
Washington School of Medicine, Seattle, Washington. Re­ bers have a commitment to nurture each other
quests for reprints should be addressed to Dr. Gabriel emotionally and physically. The commitment is
Smilkstein, Department of Family Medicine RF-30, School
of Medicine, University o f Washington, Seattle, WA 98195. usually one to share resources such as time, space,
0094-3509/80/080223-10$02.50
® 1980 Appleton-Century-Crofts

THE JOURNAL OF FAMILY PRACTICE, VOL. 11 NO. 2: 223-232, 1980 223

CYCLE OF FAMILY FUNCTION

Table 1. Framework of Family Definitions Drawn from the Disciplines

of Anthropology, Sociology, and Psychology

Institutional: Focuses on the origin and evolution o f the fam ily

institution w ith comparisons over space and tim e
of its relationships to different societies and
cultures 17
Structural/
Functional: Defines fam ily by the relationships o f its members
to each other and existing social systems.
Concentrates on how fam ily systems are organized
and operate 18
Developmental: Views o f the fam ily as a recognizable social
institution consisting of interacting personalities,
changing through time. It focuses attention on the
longitudinal career of the fam ily and its life-
cycle 19

Table 2. Structural Definitions of Family

Family of Orientation: The nuclear fam ily in which a person has

had the status of child20
Family of Procreation: The nuclear fam ily in which a person has
or had the status of parent20
Extended Family: Any grouping whose members are related by
descent, marriage, or adoption; broader
than the nuclear fa m ily20
Joint Family: Various groups o f nuclear families,
usually related biologically, who
share property rights20
Polygamous Family: Two or more nuclear fam ilies affiliated by
plural marriage (eg, one man and tw o
women and progeny)21

and finances, and is made betw een two or more Terms used in the Cycle of Family Function are
adults with or without children, and single adults defined in Table 4. These definitions represent an
with children. Family m em bers usually function in empirical synthesis of concepts from the writings
a setting where there is a sense of home. of medical and social scientists who have contrib­
An understanding of the family in trouble re­ uted to the study of the family. Students and prac­
quires that a definition be established for the fam ­ ticing physicians m ust have an understanding of
ily in health. A family in health is one whose mem­ the vocabulary that is basic to the study of family
bers perceive it as cohesive and offering the nur- function. A comm on language will encourage ex­
turem ent and resources that are necessary for per­ change that will enhance the growth and refine­
sonal growth and sustenance in the face of life’s m ent of the family physician’s ability to assess and
challenges. manage the family in trouble.

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 CYCLE OF FAMILY FUNCTION

Table 3. Family Definitions Dependent upon Roles of Members

Family: Any socially sanctioned relationship between

nonsanguinely related, cohabitating adults of
opposite sex, with or without children, which
satisfies felt needs, mutual, symmetrical, or
com plim entary22
Any cohabitating domestic relationship which
is or has been sexually consequential, ie,
resulting in gratification of partners or
in reproduction23
Cohabitation: A heterosexual couple without a legal contract
who consistently share a living facility24
Commune: A relationship of individuals who agree to
make life commitments as members of one
particular group rather than through many
different groups25
Group Marriage: A multilateral marriage in which each of
three or more people considers himself or
herself to have a primary relationship with
at least two other individuals in the group26

Family Resources • Religion offers satisfying spiritual experiences as

well as contacts with a likeminded extrafamilial
The Cycle of Family Function (Figure 1) is a
support group.
model that reflects the m anner in which family
• Economic stability is sufficient to provide both
member interaction ebbs and flows in response to
reasonable satisfaction with financial status and an
the impact of life events. The impact of a stressful
ability to meet the economic demands of usual life
life event on a family in health will serve as a start­
events.
ing point in the study of the conceptual model of
• Education of family members is adequate to
the Cycle of Family Function.
allow members to solve or comprehend most of
A nurturing family m aintains equilibrium by
the problems that arise within the format of their
utilizing its intrinsic resources on a day-to-day
lifestyle.
basis to meet the needs of its members. Stressful
• Environmental conditions are such that the fam­
life events, however, induce a m easure of disequi­
ily is favored by clean air and water, and space to
librium that requires a special coping response on
satisfy its needs for work, play, and home life.
the part of family m em bers. At these times family
• Technical resources, in this case medical care,
resources are put to the test. The major family
are available through channels that are easily es­
resources are social, cultural, religious, economic,
tablished and have previously been experienced
educational, environm ental, and technological (eg,
satisfactorily.
medical). These resources are considered effective
in a family when the following conditions are met:
• Social interaction and comm unication are evi­
Case Illustration 1
dent among family m em bers. Family members
also have well-balanced lines of communication to Mrs. M., a 58-year-old married woman with
extrafamilial groups such as friends, sport groups, four children, was informed she had breast cancer.
clubs, and other comm unity organizations. Her husband of 30 years, who accom panied the
• Cultural pride or satisfaction can be identified, patient to the physician’s office for the biopsy re­
especially in distinct ethnic groups. port, was visibly upset by the news. He regained

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CYCLE OF FAMILY FUNCTION

Table 4. Definition of Terms Used in the Cycle of Family Function

Equilibrium : A state of fam ily homeostasis in which member

interaction results in em otional and physical
nurturem ent, thus prom oting grow th o f fam ily
members and the fam ily unit27'30
Stressful Life Events: A life experience that requires the fam ily's
use of resources fo r coping or adapting not
usually required by the fam ily members for
the management of daily activities31-36
Crisis: A state of fam ily disequilibrium that results
from failure to identify resources adequate to
allow fam ily members to cope w ith a stressful
life event37-42
Disequilibrium : A state of impaired functioning, nurturing, or
role com plim entarity in which a fam ily, fo r the
tim e being, can neither escape nor solve
problems w ith their custom ary problem
solving resources30-4346
Resources: Those assets that serve the process of fam ily
nurturing and fall in the general categories
of fam ilial and extrafam ilial social, cultural,
religious, economic, educational, environmental,
and medical support systems4-5-38-47-50
Adaptation: The process by which fam ily members utilize
their resources to effect a resolution of a
stressful life event and return to nurturing
fam ily function or equilibrium 51-53
Maladaptation: The process by which a fam ily in crisis or
disequilibrium chooses abnormal defense
mechanisms to achieve some measure of
equilibrium in fam ily function54-62
Pathological
Equilibrium : A state of impaired interaction or nurturing within
a fam ily that follow s the utilization of abnormal
defense mechanisms to escape from anxiety of
unresolved fam ily crisis. Families in patholgical
equilibrium may have members who are so
isolated from their fellow members that
they cannot receive help, or individuals who
are so adhesive to their fam ily members
that independent function is
paralyzed3-29-38-43-44

his com posure and listened with Mrs. M. to the associated with a strong social support group of
physician’s information on the course of action to friends and neighbors. A fter her surgery Mrs. M.
be taken. The M .’s had a close family unit, and received some com fort from her friends and her
their long-term residence in the comm unity was husband; how ever, it was her children who

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 CYCLE OF FAMILY FUNCTION

Family in
functional " .Stressful
life event(2)
equilibrium (1
(Functional or nurturing)"

Adaptation
[co p in g ] (5)

Resources
adequate (4)

Family in
disequilibrium (3).
S
Resources inadequate (6)

/ Extra f a m ilia l'/

Crisis (7) —
resources (8 )

Maladaption
Pathological defense
mechanism (9)

Terminal Pathological Stressful

disequilibrium equilibrium (10) life event (IF
Figure 1. The Cycle of Family Function: A model for family response to
stressful life events

seemed to understand her situation best. Mr. M. sires for the benefit of family members under
adjusted his work schedule so he was able to stress.
spend more time with his wife. Mrs. M. eventually
became a volunteer in the American Cancer Soci­
ety’s home visiting program for breast cancer pa­
tients. Mrs. M. required only limited support from
Variation in Response to Stressful Life
her physician in order to cope with the problem of
Events
cancer.
Those families whose resources are adequate There is evidence that stressful life events re­
and whose coping behavior is appropriate63 are quiring social readjustments may lead to illness
capable of adaptation, and return to functional and that “ the greater the magnitude of life change,
equilibrium through the use of such coping behav­ the greater the risk of illness----- ” 34"35 M asuda and
iors as: sharing points of view, pooling resources, Holmes,36 chief architects of this theory, caution
making appropriate role changes, adjusting the that when relating life changes to illness in indi­
routine activities of work, study, and play, tolerat­ viduals, significant variability may be expected.
ing tension and discomfort when required, and ap­ They state that, in general, there is concordance in
propriately postponing personal activities or de­ cross-national and cross-cultural rank ordering of

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 CYCLE OF FAMILY FUNCTION

Table 5. Resources Examined by Nuckolls et al49

in Assessing Patient's Assets

Self: Ego strength, loneliness, adaptability,

trust, hostility, self-esteem, crying,
perception of health
Marriage: Duration o f marriage, marital happiness,
concordance of age and religion
Extended Family: Relationship of subject w ith own parents,
siblings, and in-laws; confidence in
em otional or economic support, if needed
Social Resources: Adjustm ent to com m unity, friendship patterns,
and support
Definition of Pregnancy: Extent to which pregnancy was desired or
planned, feelings about pregnancy and
childbirth, confidence in physician, fear
of labor, anticipation of baby, confidence
in outcome

life events; how ever, “ the individual’s percep­ lated a conceptual fram ework for the factors that
tions of the significance and impact of life events make families prone to crisis. He stated that: “A,
are clearly tem pered by the uniqueness of his na­ the event, interacting with B, the fam ily’s crisis­
ture and environm ental experiences.” Factors meeting resources, interacting with C, the defini­
identified by M asuda and Holmes as influencing tion the family m akes of the event, produces X,
the Social Readjustm ent Rating Scale are age, the crisis.”
m arital status, sex, ethnicity, education, and fre­
quency of experiences.
The value of relating both psychosocial stresses
and resources to outcom e in health care was noted
by Nuckolls et al49 in a study of complications of Case Illustration 2
pregnancy. The study revealed that taken alone, Mrs. B., a 26-year-old married mother of one,
neither life stresses, as m easured by Life Change called a physician at 2:00 a m to report that her
Units score,32-36 nor resources (Table 5) were sig­ child had a cold and that she did not know what to
nificantly related to complications of pregnancy. do. Mrs. B .’s own physician was not available,
H ow ever, when these variables were considered and the physician on call had had no previous con­
conjointly, women who had experienced major life tact with Mrs. B. or her family. The physician on
stresses but had high resource scores had only a call obtained a data base that revealed symptoms
third of the complication rate of women with equal of a mild upper respiratory tract infection. The
values for life stresses but low resource scores. physician’s initial reaction was to berate Mrs. B,
for calling at 2:00 a m with a minor problem, but he
recognized in Mrs. B .’s voice a heightened meas­
ure of anxiety. Based on this observation, he
Transition into Crisis asked Mrs. B. why she had called for a problem
that was apparently minor. After some hesitation
Hill,38 a sociologist who has made seminal con­ Mrs. B. replied in tears that she had lost a baby
tributions to the study of family function, form u­ two years before in a crib death, and the baby who

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 CYCLE OF FAMILY FUNCTION

died went to sleep with symptom s of a mild cold. totally unprepared for the sexual experience or its
It is important to recognize that the physician consequences. She decided to have an abortion, a
wh0 wishes to understand the family’s crisis decision shared by her parents at a family confer­
clearly must investigate factors “ A ,” “ B ,” and ence. The physician used the family conference to:
•‘C ” Analysis of the stressful life event alone will (1) clarify the immediate medical problems; (2)
not adequately facilitate resolution of the crisis.31 suggest measures that might be taken by the family
Information must also be obtained on family re­ to prevent a similar episode; and (3) facilitate a
sources and function, as well as what Kluckholn47 discussion that would mute the father’s anger and
calls the family’s orientation to the stressful life reunite the family.
event that induced the crisis. Elucidation of a fam­ If a family is seen early in the development of a
ily’s orientation to a crisis is im portant to the fam­ crisis, the physician may play the role of counselor
ily physician, for it will help clarify the family’s in helping family members identify familial and
explanatory model or sociocultural view of an ill­ extrafamilial resources needed for adaptation and
ness or psychosocial crisis.53 Knowledge of the crisis resolution. More frequently, the physician is
patient’s explanatory model is valuable to family sought late in the development of family dysfunc­
physicians for it establishes the congruence of the tion, and the family crisis is compounded by the
patient’s view with that of the physician. Lack of pathological defense mechanisms that have been
congruence may lead the family physician to at­ incorporated into the interaction between family
tempt to resolve a family crisis with resources that members.
the patient may consider inappropriate. The con­
sequences are usually non-compliance and pro­
longation of the crisis state.60'66

The Use of Pathological Defenses

In order to relieve the stress and pain of the
Families with Inadequate Resources chaotic feelings that result from a family crisis,
When families lack adequate resources, the family members, unable to find resources with
consequence of stressful life events may be crisis. which to appropriately cope, adopt some form of
Identification and assessm ent of psychosocial ego defense. Some primary defenses described by
crisis are vital functions of the family physician, Anna Freud54 are listed in Table 6. Of these, the
for a family physician is frequently the extrafamil- most common defense mechanisms the physician
ial resource whom family members call upon to will identify in patients are somatization and pro­
assist in resolving a crisis.67 jection.

Case Illustration 4
Case Illustration 3 Ronald, an eight-year-old with asthm a, was
Ms. S., a 15-year-old high school student, re­ brought to the family medical center by his mother
ported to her m other that she had been having who complained that her son’s asthm a was out of
unexplained nausea. A visit to the family physi­ control. A review of Ronald’s chart revealed that
cian established that Ms. S. was eight weeks preg­ although he had had asthma for six years, his use
nant. It was learned that the patient had been hav­ of the clinic had escalated during the past year. He
ing unprotected intercourse for about six months had missed three to four days of school per week
with a high school boyfriend. The patient's and had appeared in the clinic almost biweekly. A
mother’s initial reaction was one of disbelief. She review of his biomedical status failed to reveal any
also feared her husband’s response. The mother cause for the worsening of this asthma.
admitted that she and her daughter had never dis­ A consultation was sought with the clinic phy­
cussed sexual m atters. In private consultation sician responsible for family studies. This was
with Ms. S., the physician established that she was done because the resident physician felt that the

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 CYCLE OF FAMILY FUNCTION

Table 6. Psychological Defense Mechanisms Utilized by Family

Members When Resources are Inadequate or Inappropriate
for Managing a Family Crisis*

Avoidance Postponing
Conversion Projection
Denial Rationalization
Displacement Repression
Identification Somatization
Introjection Transference
Masking

*These defense mechanisms may be used at tim es by highly functional

families. In dysfunctional fam ilies the duration of use of these defense
mechanisms is prolonged and the mechanisms chosen are usually
more pathological (eg, denial)

m other was noncom pliant. The resident physician m other was bringing him to the office, but she was
reported that each time the m other brought in the saying, “ Look at m e.”
child, she said she had stopped R onald’s m edica­ In general, society approves the use of the phy­
tion because she thought he was improved. This sician for the m anagement of somatic complaints,
pattern persisted in spite of the instructions given Thus, family m em bers who seek relief from the
by the physician to continue base-line medica­ anxieties of unresolved family crises frequently
tions. convert their anxieties into somatic complaints or
The consultant’s psychosocial history revealed project their anxieties on a member of the family
that about a year ago the family had m oved from who becom es the identified patient. Family mem­
one part of the city to another. This necessitated bers who bring their anxieties to a physician in the
leaving long-time neighbors and friends. About the form of somatic problem s are consciously or un­
same tim e, R onald’s father had started a job that consciously hoping for recognition and resolution
involved many new stresses. Family history re­ of their psychosocial problem s.60'62,67'69
vealed that during the past year there had been an
increase in m inor disagreem ents which on occa­
sion had erupted into major argum ents. Family
argum ents tended to recede w henever Ronald’s
asthm a w orsened. Ronald’s father apparently
exerted a great deal of pressure on his spouse to be Pathological Equilibrium and Terminal
more effective in controlling Ronald’s asthm a. A Disequilibrium
review o f the fam ily’s resources revealed that in Pathological equilibrium exists in those families
their new home they felt quite isolated. They also which have accum ulated a series of unresolved
reported that the fam ily’s energies had been de­ crises and have incorporated into their family sys­
pleted as a result of Ronald’s chronic illness. (At a tem pathological defense mechanisms that allow
later interview it was discovered that Ronald’s some m easure of family nurturing to continue even
parents had also been experiencing progressive though function is m arkedly impaired.
sexual dysfunction.) Families in pathological equilibrium will not
Family counseling was initiated to help the only be marginal in their nurturing but they will
family deal with their unresolved problem s includ­ usually be sym ptom atic. The physician may rec­
ing their sexual dysfunction. It was evident that ognize m em bers from families in pathological
many of the fam ily’s problems were being pro­ equilibrium since they will frequently report such
jected onto Ronald as the identified patient. His symptom s as depression, fighting, scape-goating.

230 THE JOURNAL OF FAMILY PRACTICE, VOL. 11, NO. 2,1980

 CYCLE OF FAMILY FUNCTION

Table 7. Behavioral Symptoms Seen in Families in "Pathological Equilibrium"*

Anger Depression Postponing

Arguing Distorting Running Away
Badgering Evading Refusing
Coercing Holding Grudges Scape-Goating
Complaining Isolating School Failure
Defiance Lying Silence
Demanding Non-Participation Withholding
Delinquency Ordering

‘ These symptoms may be found at tim es in highly functional families. In families in pathological equilib­
rium, the duration and severity of the symptoms are markedly accentuated and prolonged

criticizing, or arguing (Table 7). Although treat­ The model demonstrates how, following a stress­
ment of symptoms may be appropriate to ease the ful life event, the outcomes of family function are
pain that such behavior generates, it should be influenced by family resources, coping behavior,
recognized that the symptom s reflect the family’s extrafamilial resources, and defense mechanisms.
pathological equilibrium, and therapy, if desired The integrated view that is featured in the Cycle
by the family or family m em ber, should be di­ of Family Function will serve to clarify the
rected at the cause. If therapy is desired, the phy­ assessment and management of family function for
sician should facilitate the identification of the the student, teacher, and practicing physician.
stressful life events, resource deficiencies, and
coping styles that triggered the dysfunctional
process. The physician who has identified the
etiology of a family’s problem s will be in the best
position to assist the family in improving its level
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