Journal of Family Therapy ( I 988) 10: I 7-32

Family assessment: developing a formal assessment system in clinical practice

Ian Wilkinson,* M. B. Barnett,* Lynda Delft and Val Pirie*

In a previous paper, we reviewed the literature on family assessment and set out some principles that can be derived from previous work. This paper describes the development of a system for family assessment which uses these principles and then gives a brief account of the practical difficulties encountered in applying such a system. (Empirical data on the system will be presented in subsequent papers as they become available.)

Introduction

As a small and fairly typical child psychiatry department, we encounter a number of difficulties in our work. One way of resolving some of these difficulties has been to focus on the assessment process in a departmental research project, which has helped to examine our theories and working methods together. A further tangible result has been to produce some assessment procedures which can be best described as a multi-system multi-method assessment (Cromwell and Peterson, 1983). The following account of the procedure will of necessity appear sketchy; an introduction to the system is normally given as a two-and-a-half-day workshop.

In a companion paper to this, Wilkinson (1987) reviewed the literature on family assessment and suggested a number of useful principles for family assessment in a clinical context. These principles underly our procedures and we will simply re-state them.

Accepted version received March 1987. * Department of Child and Family Psychiatry, Darlington Memorial Hospital,

tDepartment of Child and Family Psychiatry, Dryburn Hospital, Durham DHI

‘7

Darlington DL3 6HX.

5TW, England.

0163-4445/88/010017 + 16 $03.00/0 0 1988 The Association for Family Therapy

18 I. Wilkinson et al.

Having a central theme such as a coherent theory of family functioning and therapy. Adopting a broadly based systems theory approach, i.e. one which allows holistic analysis but does not neglect examination of the parts and their relationship to the whole system. Using a common language, i.e. widely recognized and validated concepts referred to in everyday terms. Using the best principles from various theoretical perspectives (if it is possible without destroying the central theme). Using both subjective and objective methods of assessment. Integrating these methods of assessment to form an efficient ‘package’. Incorporating a structured interview format with an integrated rating scale. Incorporating some element of task enactment to clarify important family processes. Incorporating a method of coding family transactions (if possible. Identifying family strengths as well as problems. Using a dimensional rather than a categorical analysis. Using operational definitions and behavioural descriptions to clarify concepts. Using genuinely ‘transactional’ perspectives on the whole family.

Perspectives and theories: ‘multi-system’ analysis In this context, multi-system refers to the use of a number of different ways of looking at the problem situation. This involves using a ‘holistic analysis’ as described by Keeney and Cromwell ( 1977), which evaluates the parts of the system, the whole system and their interrelationship.

The particular analyses of family problems that we use is shown in Figure I , As shown, a basic analysis of four major ‘systemic levels’ is used which we think are most appropriate for child-focused family problems. These consist of an examination of the particular problems of the child or children as individuals, of the parenting system, of the parent-child relationships or parenting style, and of the family system as a whole (often termed ‘family dynamics’ or ‘family processes’ ).

Within each systemic level, the major task has been to choose a set of problem dimensions which will (a) provide clear and meaningful distinctions between problem dimensions on each systemic level and

Family assessment in clinical practice I g

Systemic level Problem dimensions

Chlldren I ) Chlld health (physical)

(slbling subsystem) ( 2 ) Chlld development

( 3 ) Emotional dlsturbance

(4) Relatlonshlps

( 5 ) Conduct

Parentlng system ( I ) Physical health

(executlve subsystem) ( 2 ) Psychologlcol health

( 3 ) Morltol partnership

(4) Parentlng history

(5) Parents-soclol

Parent-chlld interaction

(Interface major subsystems)

Whole famlly ( I ) Closeness and dlstance

(total system) ( 2 ) Power hlerarchles

( 3 ) Emotlonal atmosphere and rules

(4 ) Famlly development

Figure I . Summarized structure of Darlington family assessment procedures: perspectives and problem dimensions used.

(b) enable a clear understanding of complex problems through the use of descriptors of key aspects of the family system.

Throughout the systemic levels, problem dimensions have been chosen which are based upon commonly acknowledged concepts which are solidly supported by the literature. The importance of many of these concepts is self-evident. The choice of others is discussed at greater length in a draft manual for the system (Wilkinson e ta l . , 1985). To give two examples of support in the literature, the five dimensions chosen for the analysis of the child systemic level is supported by the work of Hoghughi et al. (1980), who used a similar (though not identical) analysis in a system devised for a problem-oriented assessment of children in residential care. The dimensions chosen for the whole family analysis are based upon Fisher’s review (1976) of this topic. Throughout the dimensions, efforts have been made to avoid jargon and to develop a ‘common language’.

By using this kind of analysis, a theoretical approach is generated which can be summarized as an integration of a number of theoretical influences (e.g. behavioural, cognitive, dynamic, structural and

20 I. Wilkinson et al. strategic) with an essentially social and developmental philosophy underlying it. The key ideas which integrate these influences into a coherent entity are ones that view psychological aspects of problems as social phenomena. In particular, the individual and the family are understood in relation to psychological development in the individual’s life span and the life-cycle of families.

Although it is not within the scope of this article to give a full description of the theory underlying the system, a brief understanding of the theory underlying the approach may be attempted by focusing upon the four ‘whole family’ dimensions and their interrelationship with each other. The first two dimensions are clearly ‘structural’ descriptors of family functioning. Firstly, what are the patterns of closeness and distance within the family? Are there significant degrees of under- or over-involvements in the family? This dimension is perhaps best understood in terms of Bowlby’s ‘attachment theory’, in which the importance of a balance between closeness and security versus distance and autonomy are clearly discussed (Bowlby, 1977). The patterns of attachment that an individual has in childhood will clearly affect his or her relationships in later life, for better or worse, and these patterns of closeness and distance can be clearly observed in families as a whole. Terms such as enmeshment and disengagement have been used to reflect consistent overall patterns, but most families consist of a mixture of over- and under-involvement and balanced relationships. It is important to examine the overall pattern closely. Secondly, power hierarchies refer to issues of dominance, leadership, decision-making and responsibility. Clearly, these are major issues within family life and the importance of this dimension is self-evident. Similar to closeness and distance, the nature and types of power hierarchies that a person experiences early in life will clearly influence their relationships later in life.

When applied to the current family situation, these structural descriptors (closeness and distance; power hierarchies) are also the best ways to understand the way the family works now.

The third dimension (concerning emotional atmosphere and rules) is a key dimension which is used to understand the particular idiosyncratic nature of a family and the individuals within it. Emotional atmosphere refers to the general emotional tone within the family. We assume that this is very significant because it gives us clear and direct information regarding the implicit rules in the family about how emotions are dealt with. (For example, the ‘pseudo-mutual’ family has an implicit rule, ‘Anger is a bad thing and must not be

Family assessment in clinical practice 2 I

allowed.’) A particularly disturbing or striking emotional tone, when the family members are all present, is often a clear indication that there is some rule about this emotion which is part of the problem. From a perspective of individual psychological development, each one of us learns a particular ‘set’ of emotional rules in childhood (which is subject to certain changes as we develop). Clearly, family members will often, but not always, share rules. These rules determine not only how we cope with life events as individuals, but also how we ‘meta- communicate’ and form social relationships (Watzlawick et al., 1967). Hence, the concept of emotional rules is a key concept which links individual characteristics with transactional phenomena in the family and particularly with the formation and maintenance of social relationships.

Finally, family development, as stated earlier, relates to the concept of the normative family life-cycle and how different the total pattern of problems appears from what might be expected. If the family as a whole seems clearly ‘stuck’ or ‘developmentally delayed’ (i.e. clearly concerned with tasks which are related to a much earlier stage of the family life-cycle), problems clearly load on this dimension. This dimension is effectively a global descriptor of ‘family psychological health’. (Family development is therefore a ‘meta-dimension’ and one would expect that a significant problem on this dimension will be likely to be accompanied by significant problems on several other problem dimensions.)

The way in which these four transactional dimensions link with each other and integrate is a critical aspect of the theory. As all individuals and families develop, they pass through transition points in the life- cycle and also experience various unplanned life events. At each of these points, structural changes in the family will be advantageous. In addition, certain emotional responses may be required in order to negotiate particular life events (e.g. grief in bereavement). At points such as marriage formation, matching of emotional rules and expectations of structure (i.e. power and closeness and distance) will be critical for the couple. Hence, the three other whole family dimensions, considered in relation to each other, give us a clear way of understanding the nature of the changes and adaptations that people make or fail to make at important points of individual and family development. If people fail to make a required change, they may eventually seek help to resolve the problems that arise. Hence, there is a very clear developmental perspective implicit in the theory, both in relation to individuals and the whole family system.

22 I. Wilkinson et al.

As a further illustration of the value of this scheme, it can be useful to distinguish between three ‘levels of severity’ in family problems. (This entails some necessary over-generalization, but this is unavoidable.) Certain kinds of ‘milder’ problems can be identified which are very typical of unresolved transition points in the life-cycle, and others are clearly caused by bereavements, separations or other traumatic life events. With recent onset, there is often a pattern of fairly specific problems and a fairly rapid response to therapy. Other problems can be identified which are typical of mid-range severity, where the ‘stuckness’ can be traced back to a previous stage of the current family (often marriage formation). Here, there is a pattern of a greater number of problems acknowledged but still a good number of healthy functioning dimensions of family life. Therapy may take more time, but if a reasonable contract is achieved it proceeds fairly smoothly. Finally, there are a third group of problems of greater severity where the ‘stuckness’ originates from earlier family systems. These transgenerational problems are exemplified by work with families where the parents were victims of child abuse or suffered an unresolved loss of parent(s) in childhood. Here, the pattern is often of global problems and also a slow, partial and uncertain response to therapy.

T o summarize, reference to the normal life-cycle will clarify many issues-particularly in relation to the expected and actual family structure. Given some understanding of the family’s emotional rules and some historical information, the key points at which the family’s problems arose can often be identified, along with strategies to remedy the problems. (Case examples are given as illustrations in the manual.)

‘Multi-method’ assessment: an integrated package of procedures Different methods of assessment (e.g. interviews and questionnaires) collect different kinds of information. Sometimes the results are consistent, sometimes they are not (but this discrepancy is often very important). A ‘multi-method’ assessment uses several methods of collecting and organizing the information available. Table I shows the components of our set of procedures. The structured interview and the rating scale are likely to be more popular with clinicians working under pressure who do not want a particularly elaborate or formal system. The other procedures will be of interest to workers wanting a more formal or more detailed evaluation (e.g. for admission procedures or research purposes).

Family assessment in clinical practice 2 3

TABLE I . Summarised structure o f Darlington f a m i b assessment procedures: components of ‘package’ used

Family perspective Observer perspective

Cognitive understanding Questionnaires Family rating scale*

Behaviour process Structured interview* Behaviour coding system(s)

*Basic clinical procedures

The structured interview At the heart of the assessment system is the structured interview which consists of a fairly explicit ‘script’ to assist the interviewer. The interview is in twenty-three sections, consisting of the sixteen problem dimensions set out in Figure I and seven additional sections which are equally important, e.g. ‘motivation’. The script consists of carefully worded introductions followed by ‘probe questions’ for each problem dimension. Some examples of probe questions and their introductions are given below.

Child health: ‘Now I’m going to talk about some general areas that can often be problems for parents. When children have health problems that can be very worrying. Have any of your children had any serious health problems?’

Family function, atmosphere: ‘Feelings are very important but they can be very difficult to communicate. Does anyone find it difllcult to show their feelings?’

Family function, Family development:

‘It’s often said that when two people marry, it’s also the marriage of two families. How do each of you get on with your in-laws?’

The interview is carefully structured in its sequence so that it moves in an easy and natural progressiop from simple aspects of problems to more complicated ones-and from less threatening to more threatening topic areas. ( In technical terms, the former progression reflects a move up through the ‘systemic levels’, i.e. from child focus to whole family focus.) This structure helps the clinician and family to discuss potentially sensitive topics in the first interview more easily. If the family begins to become highly stressed at some point, the clinician

24 I . Wilkinson et al. has some margin of error because of the gradual progression into areas of greater difficulty. She is thus more likely to be able to ‘ease-off if she suspects that the family might become stressed to the point of ‘no return’, i.e. there is a risk of them not attending in future. From the family’s point of view, this sequential progression can also help to begin the process of ‘reframing’ the problem by helping the family to understand the linkages between individuals, relationships and whole family phenomena. Assessment and therapy cannot be disinguished, and this assessment interview is designed to be potentially therapeutic.

The major purpose of the interview, however, is contract formulation. In other words, the interview is designed to enable the clinician to make a brief assessment of the various factors which are assumed to be of critical importance in formulating an effective intervention with a particular family.

These factors can be summarized as follows. ( I ) The clinician’s view of the problems. Without a clear and

comprehensive understanding of the problem, the clinician is clearly in danger of making an inappropriate, over-ambitious, ill-timed or otherwise inadequate intervention.

(2) Family view(s) of the problems. However efficiently the clinician understands the objective nature of the problems, this is to no avail if she cannot ‘sell’ her ideas to the family. In order to do this, and thus to make an explicit ‘contract’ with the family about any work that needs to be done, she must understand their ideas about what the problems are.

(3) Certain other family characteristics are critical in deciding which therapeutic contact will work best with a family. These are the family’s strengths, motivations and self-image.

The interview normally takes between an hour and an hour and a half, depending on the family characteristics and problems. I t is designed to be conducted with the whole family, although in clinical practice one can clearly be flexible about this. At the end of the interview, it is recommended that a break is taken to organize or discuss the information obtained, and, if possible, to formulate a treatment contract to offer to the family.

The rating scale

The use of the Darlington Family Rating Scale, which matches the content of the interview, will help to organize the information and

Family assessment in clinical practice 25

structure the clinical decision-making. Ratings are made for each of the sixteen problem dimensions. Some examples are given below.

Child health (physical): A Good or average health. B Minor persistent health problems. C Illness requiring specialist help. D Chronic illness or disability. E Life-threatening illness or serious disability. Emotional atmosphere: A Comfortable and supportive atmosphere. C Clear signs of emotional problems or statements about them. E Severely terse, hostile, or depressed atmosphere. Summary of family development: A One or two specific problems typical of present developmental

C Evidence of several problem areas in family life and unresolved

E Global problems with few healthy areas and/or evidence of

(Five-point scales are used where finer distinctions are possible, and

In addition to rating the sixteen dimensions, a summary page is

( I ) History (a) distant; (b) recent.

( 2 ) Family perceptions (a) problems;

(3) Family motivations and strengths. (4) Key (systemic) problems. (5) Therapeutic strategy (a) therapist’s understanding of problem;

stage.

tasks from previous stages.

strong transgenerational problems (e.g. child abuse on parents).

three-point scales where the judgements are harder to make.)

designed to guide decision-making using the following headings.

(b) therapeutic system.

(b) plan for next session; (c) explanation(s) to family.

Hence, the scale is a purpose-designed record and summary form as well as specifying certain types of judgements that should be made about the family.

The questionnaires The use of questionnaires enables some more detailed information to be collected in relation to family members’ views of the problem(s) in a more private context, which can result in problems being identified

26 I. Wilkinson et al.

which the interview does not reveal. They can also be administered at assessment, discharge and follow-up as an evaluation procedure. We have chosen a variety of questionnaires from the literature which give a broad but efficient coverage of different aspects of the family system. Normally, we ask each parent to complete them independently. We use the following.

( I ) A brief index of social support (derived from the work of Brown

( 2 ) Goldberg’s General Health Questionnaire; twenty-eight item

(3) Eyberg Child Behaviour Conduct Inventory (Eyberg and ROSS,

(4) Marital Satisfaction Index (based on one reported by Azrin et

(5) McMaster Family Assessment Device (Epstein et al., 1983). Usually a person can complete all of these questionnaires in about

and Harris, I 978).

version (Goldberg, I 978).

1 978).

al.,1973).

twenty minutes (depending on the level of literacy).

Behaviour coding

To provide information on the parent-child relationship, we use the Eyberg Behaviour Coding procedure (Eyberg and Robinson, I 981). This is a very elegant procedure which examines parent-child relationships by examining the type and quality of communications during fifteen minutes of play under three different conditions (child leads, parent leads and child tidies up). It can be viewed as a standardized task (enactment)with a built-in method of analysis. For adolescents, a similar approach is used but discussion tasks are used rather than play. In practice, each parent can complete this task while their partner fills in the questionnaires.

Integration

The interview and rating scale are fully integrated procedures with matching content. The other procedures are not fully integrated but were chosen as the best available instruments that could be used in our context to assist with the initial stage of validating the interview and rating scale. The next stages of our research will be concerned with developing matching self-report questionnaires and (perhaps) a coding system to complete the package. Because of this, the process of integrating the information that the system generates is currently more

Family assessment in clinical practice 2 7 complex that it would ideally be. A summary form has been used to show the main issues on one page. However, the complexity of the information obtained is daunting and is likely to be a factor in the low use of the whole package by most members of our team.

All of these procedures can be completed from two clinical visits by the family. The first involves the whole family in the structured interview, from which the rating scale is completed by the clinical worker(s). The second visit involves the parents and the identified (referred) child only. Each parent can complete the questionnaires while the other parent completes the play task from which the behaviour coding is scored. The information obtained from the questionnaires and coding can then be related to particular problem dimensions, and provides an alternative type of information to the rating scale.

Applying the procedures

The procedures have developed and evolved over the last five years. The rating scale and interview have been in routine use for about three years and were felt to be of sufficient value to justify a formal investigation of their efficacy. A small sample of families undergoing therapy has been recruited for which full data at baseline, follow-up and discharge are being collected using the whole assessment package. (Size of sample is limited by the ethical difficulties of using video at the assessment stage.) A matched group of non-clinical families are also being recruited for normative purposes. The aim is to generate basic validity and reliability data with some preliminary evidence for usefulness as a clinical instrument.

In addition, a focused training course in family assessment has been developed out of concepts arising from the assessment system. Hence, the system is also being evaluated as a training tool. This is done by giving trainee professionals two examinations of their case management skills. The examination is made in relation to a videotape of a family interview, which is shown to the trainees before completing the examination. Two videotapes are available, one to be used at baseline and one post-training (utilizing a cross-over design to control for qualitative differences in the interviews). The design of this training study can be summarized as shown below.

28 I . Wilkinson et al. Experimental group A:

Baseline management skills

Control group B: Baseline management skills

Control group C: Baseline management skills

Control group D: Baseline management skills

Training

No training

Placement experience in family-oriented unit

Training + experience in family-oriented unit

Post-training management skills

(Practice effect) management skills

Post-placement management skills

Post-placement + training management skills

This study is ongoing, and we hope formal data will be available soon. However, the difficulties of formal research in a setting like ours are many. We would, therefore, like to conclude this article by mentioning the major difficulties encountered and give some hints for our practitioners who may be considering using a more formal assessment system.

The first difficulty concerns the application of new technology (in the shape of video recordings) on a routine basis. The issues here are quite complex and involve both staff and family resistances, which may be difficult to distinguish in practice. In considering the former, the problem can be summed up by saying that while most professionals will recognize the potential value of video in giving feedback and evaluation of one’s performance, in practice some people seem to find it very difficult to expose themselves to criticism even within a supportive team atmosphere. (Perhaps it is partly a cultural problem, as we British tend to adopt a cooler and more critical attitude to everything than our American counterparts.) In summary, some people will adapt to the use of video very well (and will use it creatively), while others will find it a difficult barrier to overcome. As far as family resistance goes, the crucial questions are really ethical ones. Our own ethical position is based upon the need for properly informed consent.

Our code of practice for the use of video-recording equipment is a

Family assessment in clinical practice 29

conservative one, which is intended to prevent individuals or families consenting under duress. Although we value the use of video, we do not attempt to dissuade people who are reluctant to accept it. We have certainly experienced situations where people have reacted negatively to its use. We also believe it can affect behaviour in quite subtle ways, for instance to make some people who are in acute distress put on a more ‘coping’ front to the interviewers because of the camera’s presence (which symbolizes ‘the rest of the world’). Hence, we are careful to make some allowance for the reaction to video recording, and many referrals are not considered for the research because they are not judged suitable. Others are excluded because they expressed reluctance about the use of video. I n clinical practice, note that this does not mean that the structured interview and tasks cannot be used, merely that there will be a much less precise record of them. Indeed, this problem is really specific to formal research and can be overcome in normal clinical practice.

The second major obstacle to overcome has been convening the family unit for the structured interview. It is usually not too difficult to convene the identified patient and the parent(s), but convening the other family members can be difficult. (However, it is not always as difficult as i t might appear; the reader is referred to Carpenter and Treacher, I 983.)

In the event, we have found that the best way to overcome these two hurdles in practice has been to have a flexible Lengagement’ phase prior to the more formal assessment procedures. In many cases, this might consist of a preliminary interview with whoever attends the first appointment. This is spent defining the problem more precisely, explaining the assessment system and negotiating an ‘assessment contract’. In other cases, the engagement phase may be longer. For example, one case required a series of preliminary interviews with some family members and careful use of other professionals to convene a particularly reluctant member of the family. This second obstacle can be understood as the natural reluctance of (most) families to broaden the focus from the identified patient, even implicitly for assessment purposes. The interviewer therefore has the dual task of joining with the family members and establishing enough rapport despite this reluctance, while still following a structured format. This demands a great deal of the interviewer, and it has been noticeable how much better the structured interviews have been when the second author has been available to give live supervision. In general, we very much favour the use of some form of co-therapy or live supervision (see

30 I. Wilkinson et al. Smith and Kingston, 1980) in all therapy situations and the structured interview is no exception. While the interviewer focuses on following the format, the supervisor particularly watches for family reactions and helps to prevent the interviewer getting ‘sucked in’ to the family processes.

Finally, whenever new methods and techniques are used, it is to be expected that other skills and abilities will suffer, while the main strain of conscious effort is taken up with learning the new method. In other words, everyone will get worse before they gain the benefit of a new method. Indeed, it could be argued that the more complicated the method, the worse one will get. This is probably the biggest barrier that has to be overcome. The changes that are required in using this approach are quite substantial, and it is easy to abandon the approach in the face of these initial difficulties. This would be premature, as there are benefits to the approach which only become apparent as one persists with it.

As well as these general points, a specific problem arose when using the structured interview with two families who can be characterized as displaying ‘blanket denial’. Despite presenting for help, they gave a pattern of ‘ideal responses’ to the questionnaires in a way which was simply not congruent with our observation of them. Members of both families reported subsequently that they felt uncomfortable in the structured interview. We conclude simply that difficulties will be encountered in using these more formalized family assessment methods with families who have an ‘idealized’ view of themselves.

Similarly, problems can arise when using the adolescent task approach to a crisis situation. Where there is open conflict, the task will certainly precipitate a demonstration of this, and the clinician would be wise to consider carefully whether she wishes to risk doing this early in the involvement.

Moving on to the specific advantages of the system, it allows a much broader problem assessment at the outset which particularly helps to clarify issues of problem severity. The structured interview allows the interviewer to develop a standard of comparison, which is clearly useful. Apart from the exceptions discussed earlier, the interview has generally been well received and has often elicited positive comments from patients. The questionnaires are sometimes treated as a piece of mild eccentricity by some families, but several others use them very specifically as an alternative way of admitting to problems which are not acknowledged in the interview. In other cases, they are valuable in clarifying the globality/specificity of particular problems because of the

Family assessment in clinical practice 3 I

greater information they contain. The parent-child interaction task is also a very useful method of gaining clear, objective information. It has often been useful to replay the task (or indeed, parts of the structured interview) to members of the family during therapy.

Taking a broader view of the department’s work, the department has in theoretical terms become more ‘developmental-social’. The emphasis has shifted much more to problem-solving, with the problem being conceptualized in terms of psychological growth, development and personal relationships (rather that ‘symptom-oriented’ problem- solving). I t is also our general impression that the system has led towards a more ‘contractual’ style of working in which terminations tend to be explicitly discussed rather than occurring by drop-out.

It has to be admitted that much of this change has occurred indirectly, in the sense that only the first author uses all of the procedures for formal research. This is partly a matter of personal investment, since he is registered for a.higher degree. Other members of the department have used the principles and theory underlying the procedures, the coding system, the rating scale, the structured interview and the questionnaires (in rough order of popularity). The major obstacle to a more generalized use of the whole system in our context is seen as the sheer pressure of work generated by a reluctance to have formal waiting lists. This, in turn, stems partly from a wish not to turn children away and partly a fear that if we were more selective and reduced the intake of cases to provide a better service for fewer people, the department would be penalized because of the drop in ‘numbers’. We hope that under new management systems the reliance upon purely numerical performance indicators will change. Perhaps this is a good point at which to conclude, since it illustrates the point that the management of this kind of change in professional systems requires changes at all levels of the organization.

Acknowledgement

Thanks are due to the D.M.H. League of Friends, without whose generous donation of a video system this work would not have been possible.

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