0
Bishop Nathan B. Epstein Lawrence M. Baldwin
Duane S.
Structuring a Family Assessment Interview
SUMMARY
The Problem Centred Systems Therapy of
the Family and the McMaster Model of
Family Functioning on which it is based
have been used by family physicians and a
variety of health professionals. This paper
Dr. Epstein and Dr. Bishop were
formerly at McMaster University
and respectively hold visiting
appointments of professor and
assistant professor there. Dr.
Epstein is currently professor and
chairman of the Section of
Psychiatry and Human Behavior at
Brown University. Dr. Bishop is an
associate professor and Dr. Baldwin
is an assistant professor in the same
department. The three direct the
Brown/Butler Family Therapy
Research Program. Reprint
requests to: D. S. Bishop, MD,
Butler Hospital, 345 Blackstone
Boulevard, Providence, RI. 02906,
USA.
FAMILY PHYSICIANS have be-
come increasingly aware of the
need to understand the family as a sys-
tem with biological, psychological,
and social aspects. Such an under-
standing contributes significantly to
their skills as physicians; conse-
quently, many family physicians are
seeking methods of increasing their
skills for understanding and working
with families.
In this paper we present a model for
understanding the family as a system
and an approach for carrying out suc-
cessful family assessment interviews.
The approach has been described in
detail elsewhere.1 We have applied
1534
outlines aspects of the models that are
useful in structuring a family assessment,
plus some of the benefits gained through
using such a family oriented approach.
(Can Fam Physician 1980; 26:1534-1537).
these models in family practice set- because we overestimate our patients'
tings,2' 3 as have many of our family knowledge of the way we work. For
practice colleagues,4-'1 to families this reason, at every step of the family
with disabled members,12 to normal assessment interview, we openly share
families, and to families seen in psy- our understanding of what has tran-
chiatric outpatient clinics.13 spired with the family; we make sure
The treatment model14 has clear, the family understands our reported
operationally defined steps. When perceptions and agrees with them, and
used by beginners, the model produces
reasonably effective results. It also TABLE 1
provides a sound structure for the work Stages and Steps of
of more experienced therapists. Effec- Problem-Centred Systems Therapy
tive negotiation of the stages requires a Assessment
minimal repertoire of family interven-
tion techniques. Most family physi- Orientation
cians already have sufficient basic Data gathering
skills in this area as a result of their Problem descriptions
previous training and experience. Clarification and agreement
on a problem list
The treatment model consists of
four stages, each containing several Contracting
distinct steps. Table 1 outlines the
model. In this paper we will focus on Orientation
only the assessment stage. Table 2 Outlining options
Negotiating expectations
provides a summary of the assessment Contract signing
process in more detail. This is a good
introduction to the treatment model; a Treatment
more complete description can be
found elsewhere.15 Orientation
Clarifying priorities
Setting tasks
Family Assessment Task evaluation
As helping professionals, we often
take too much for granted and assume Closure
that patients understand what we are Orientationof treatment
doing. The potential effect of this as- Summary
Longterm goals
sumption is to dehumanize patients- Follow up (optional)
not because we are unsympathetic, but
CAN. FAM. PHYSICIAN Vol. 26: NOVEMBER 1980
we obtain their agreement to go on be-
fore proceeding. This act of collabora-
tion is respectful, engages the family,
and makes clear that they have a major
responsibility in the process. This also
leads us to start each stage of the inter-
view process with an orientation. The
initial orientation is more detailed and
sets the tone for all that follows. Later
orientations indicate to the family that
we are shifting in direction or focus.
Orientation
To start the orientation, we clarify
what all family members expect will
happen during the session, why they
think they are here, how they think the
session was arranged and what they
hope will come out of it. This often
provides useful information and helps
avoid later resistance.
Example:
Dr.: I'd like to find out from each of
you what you thought was going to
take place here today . . . Okay, I'd
also like to know why you think all the
family is here. Also, I'd like to know
what you'd like to see come out of this
session-what do you particularly
TABLE 2
A Guideline for Family Assessment
Areas Covered
1. Orientation
Their expectations
Our expectations
Rationale for seeing the family
2. Data Gathering
a. Presenting Problem (for each
problem)
Nature and history of problem
Affective/emotional components
Precipitating events
Who is involved and how
b. General Family Functioning:
McMaster model dimensions
Problem solving
Roles
Communication
Affective involvement
Affective responsiveness
Behavior control
c. Other Investigations-
biopsychosocial: medical
d. Any other problems?
3. Problem List
Family's list
Doctor adds his
4. Problem Clarification
Obtain agreement on list from above
CAN. FAM. PHYSICIAN Vol. 26: NOVEMBER 1980
want to see addressed or have an an- you have any questions? . . . Is that
swer to? OK then? . . . Can we go ahead with
my finding out more about your fam-
We then briefly outline our ideas, in- ily?
cluding why we understand the family
is there, what we already know about Data Gathering
them in general, what we plan to do,
and what we hope to achieve, and we This step covers gathering data
obtain their permission to do so. We about the presenting problem(s),
also explain our rationale for seeing overall family functioning, additional
them as a family. investigations, and other problems.
Presenting Problem
Example:
Here it is important to gather suffi-
Dr.: Fine, now I have your ideas, cient data so that the doctor develops
let me go over mine. I asked you all to an accurate picture of the nature and
come in because I need to have a clear history of each problem. In doing so,
idea of how you function as a family. we explore factual and historical de-
This gives me a much better under- tails, the affective components of the
standing of the entire picture and so problem, any precipitating events,
helps me to work out with you how who is mainly involved with the prob-
things can be more helpful for John lem and in what way.
and all of you. I know you had con- At the end of this step, we feed back
cerns about John getting upset and our understanding of their presenting
being hard to manage. That obviously problem and make sure we have a
affects all of you and not just John.
clear picture of it.
Part of the reason it is important for
me to meet with all of you is that I Example: Summary of presenting
know the way a family operates problem
strongly influences what happens to
each family member. Even if that's not Dr.: At this point, I'd like to make
the case, when one family member is sure that I'm seeing things correctly.
having trouble, it also affects other We seem to agree that (1) John has
family members. So, for both of those been harder to manage particularly for
reasons I need to have a clear picture you, Mom. John, you and your sister
of how you function as a family before both notice Mom and Dad disagreeing,
deciding on possible treatments. but this upsets you more than your sis-
ter and you take off-which gets you
The orientation to this point reflects into even more trouble. (2) You,
an interview associated with a present- Mom, feel your husband has not been
ing problem. However, the assessment supporting you; not just with John but
interview can also be done as part of also in dealing with the other children
gathering baseline information about a and (3) Dad, you've been down be-
family that is new to your practice. cause of changes at work and don't
Under such circumstances, we would feel your wife is understanding of that.
suggest simply stating that you wish to The effect is you feel you're failing not
gather information about the family as just in the work area, but also as a hus-
it is important to your understanding of band and father. All of this has re-
each of them and in any help you cently developed within the past six
might give them in the future. months and was not the case pre-
viously. Dad' s job change seems to be
Example: the biggest stress for the whole family.
Dr.: I'm going to jump around a bit Do I have it right to that point?
to find out about your family, and ask
questions in a number of areas. Some Overall Family Functioning
may not seem related to John's prob- This next step moves from an as-
lem, but they are important for me to sessment of the presenting problem to
know about. I'll clarify as I go along to an exploration of overall family func-
make sure that I am getting a correct tioning. We first orient the family to
impression of how you operate as a this change in focus with a statement
family. At this point I don't know such as, "Now I'd like to switch and
where we are going to go; however, at get some ideas about how you gener-
the end-of the session I will summarize ally operate as a family. Is that all
where we seem to be at that point. Do right?"
1535
 It is here that we use the McMaster
model of family functioning. 16 The
family is assessed on the six dimen-
sions of problem-solving, communica-
tion, roles, affective responsiveness,
affective involvement and behavior
control. The assessment focuses on de-
lineating the strengths and shortcom-
ings in each area.
The important point is that this stage
focuses on assessing overall family
functioning and helps to avoid devel-
oping formulations based only on data
related to the family's presenting prob-
lems. Impressions about presenting
problems are by their very nature more
likely to be negative.
In this article, we present the assess-
ment of only one of the six dimensions
of family functioning-problem solv-
ing.
In assessing a family's problem-
solving, we consider how the family
handles affective and instrumental
problems, and how well they negotiate
six steps of problem solving. The steps
are:
1. Problem identification
2. Communication with the appro-
priate resource
3. Consideration of alternatives
4. Decision and action
5. Monitoring the action which has
taken place
6. Evaluation of the problem solving
process.
Example:
Dr.: What problems have come up
for you as a family in the past two or
three weeks? Tell me more about that.
What was it like for you to face that?
(affective component) Who first no-
ticed the problem? Whom did you
tell?
We might then summarize.... So,
if I am clear, one problem was . . .
and Mom, you first noticed it and told
Dad. Do you all agree that was the
way it was? Is that the way it goes with
most problems?
When you knew, then what hap-
pened? What ideas did you come up
with?
We continue in a similar fashion to
access the family's handling of each
step of the problem solving. At the end
we make a general statement which
summarizes the family's problem solv-
ing ability.
Example: Summary of problem solv-
ing-
1536
Dr.: OK, if I see things correctly, that come up around feelings and emo-
you handle mechanical and instrumen- tions.
tal difficulties that arise wth ease. You Mom, you usually notice when
have a bit more trouble with problems someone is upset and usually talk to
TABLE 3 Summary of Dimension Concepts
Problem-solving
Two types of problems
instrumental and affective
Seven stages to the process
1. Identification of the problem
2. Communication of the problem to
the appropriate person(s)
3. Development of action alternatives
4. Decision of one alternative
5. Action
6. Monitoring the action
7. Evaluation of success
Postulated
Most effective when all seven stages
are carried out
Least effective when cannot identify
problem (stop before step 1)
Communication
Instrumental and affective areas
Two independent dimensions
1. Clear and Direct
2. Clear and Indirect
3. Masked and Direct
4. Masked and Indirect
Postulated
Most effective: clear and direct
Least effective: masked and indirect
Roles
Two family function types
-necessary and other
Two areas of family functions
-instrumental and affective
Necessary family function groupings
A. Instrumental
1. Provision of Resources
B. Affective
1. Nurturance and Support
2. Adult Sexual Gratification
C. Mixed
1. Life Skills Development
2. Systems Maintenance and
Management
Other family functions:
-adaptive and maladaptive
Role functioning is assessed by
considering how the family allocates
responsibilities and handles
accountability for them.
Postulated
Most effective when all necessary
family functions have clear allocation
to reasonable individuals(s), and
accountability built in.
Least effective when necessary family
functions are not addressed and/or
allocation and accountability not
maintained.
Affective Responsiveness
Two groupings
-welfare emotions and emergency
emotions
Postulated
Most effective when full range of
responses are appropriate in amount
and quality to stimulus
Least effective when very narrow
range (one or two affects only) and/or
amount and quality is distorted, given
the context
Affective Involvement
Six styles identified
1. Absence of involvement
2. Involvement devoid of feelings
3. Narcissistic involvement
4. Empathic involvement
5. Over-involvement
6. Symbiotic involvement
Postulated
Most effective
-empathic involvement
Least effective:
-symbiotic and absence of
involvement
Behavior Control
Applies to three situations
1. Dangerous situations
2. Meeting and expressing
psychobiological needs and drives
(eating, drinking, sleeping,
eliminating, sex and aggression)
3. Interpersonal socializing behavior
inside and outside the family
Standard and latitude of acceptable
behavior determined by four styles
1. Rigid
2. Flexible
3. Laissez-faire
4. Chaotic
To maintain the style, various
techniques are used and implemented
under role functions (systems
maintenance and management)
Postulated
Most effective: flexible behavior control
Least effective: chaotic behavior
control
CAN. FAM. PHYSICIAN Vol. 26: NOVEMBER 1980
your husband about it. However, you list of significant problems. First, the for clear decision making.
don't feel that you really get through to family is asked to indicate the prob The approach presented is well
him and because of that, the two of lems they would identify now that a suited for use in training programs.
you are not able to go on and make de- detailed assessment has been com- With this in mind, we have developed
cisions about how to handle the situa- pleted. We then add any difficulties a number of videotapes and written
tion effectively. This leads to the two we have noted during our evaluation of materials for use in training.
of you getting into arguments and that the presenting problem, general as- We are also developing instruments
affects the children, as we have dis- sessment of the family, special investi- to assess family functioning. This will
cussed previously. gations, and other identified problems. allow us to test the importance of a
The list should highlight the major knowledge of family functioning in
An understanding of the family's issues, but be comprehensive. family practice and the efficiency of
capacity and abilities in problem solv- family treatment in such a setting. )
ing is very useful for the family physi- Problem Clarification
cian. It is important, for instance, to References
The final step in the assessment 1. Epstein NB, Bishop DS, Levin S:
know that one spouse characteristi- process is to obtain partial or complete
cally may bring difficulties to the fam- agreement on problems listed by the McMaster model of family functioning. J
Marriage Fam Coun 1978; 4:19-31.
ily physician without discussing them family and/or the physician. The fam- 2. Epstein NB, Levin S. Bishop D: The
with his or her partner! ily usually agrees to the list if the phy- family as a social unit. Can Fam Physician
Assessments of the family's com- sician has been active in clarifying and 1976; 22:1141-1413.
munication patterns, role functioning, obtaining agreement all along, and has 3. Epstein NB, Levin S: Training forfam-
ily therapy within a faculty of medicine.
affective responsiveness, affective in- reported well on the results of the other Can Psy Assoc J 1973; 18:203-208.
volvement and behavior control have investigations. Some disagreements 4. Comley A: Family therapy and the fam-
similar utility and practical implica- can arise and we have described else- ily physician. Can Fam Physician, Feb
tions. These assessments should be where how these can be handled. 15, 16 1973; 19:78-81.
completed at this stage of the interview 5. McAuley RG: Family practice: A pro-
posed solution to the problem of meeting
process. Table 3 provides an outline of Practical Issues the medical needs of the community. Can
the basic concepts for all six dimen- Completion of a family assessment Med Assoc J 1967; 96:1036-1039.
sions; their nature and assessment are using the above guideline will provide 6. Gilbert JR: The primary physician: A
discussed in more detail elsewhere.16 the practitioner with a solid under- unique role. Can Med Assoc J 1972;
106:1007-1010.
standing of the family's strengths and 7. Gilbert JR: A psychiatry training pro-
Additional Investigations shortcomings, as well as a list of the gram for training physicians. Can Fam
Data gathered up to this point deter- key problems to be addressed. Reason- Physician March 1971; 17:61-62.
mine the need for any further investi- able decisions can then be made about 8. Weston W: Emotional problems-A
family affair. Can Fam Physician 1972;
gations. Assessments might include: further treatment and the person most 18:60-64.
developmental history of individuals, appropriate to carry this out. 9. Epstein NB, McAuley RG: A Family
pediatric examinations, laboratory and We cannot emphasize strongly Systems approach to Patients' Emotional
X-ray studies, and other psychological enough the need to complete a full and Problems in Family Practice, in Medalie
JH (ed): Family Medicine, Principles, and
investigations. It is important to point thorough assessment. Physicians Applications. Baltimore, Williams & Wil-
out that even though a family assess- would not begin treatment or make de- kins, 1978.
ment is being performed, this should cisions on physical problems without 10. McFarlane AH, Norman GR, Spitzer
not preclude consideration of individ- first gaining a full understanding of the WO: Family medicine: The dilemma of de-
ual psychopathology or medical diffi- situation; the same applies to psycho- fining the discipline. Can Med Assoc J
1971; 105:397401.
culties. social issues. 11. McFarlane AH, O'Connell B, Hay J:
It is, however, important to focus Several meetings might be required Demandfor care model: Its use in program
first on the family assessment, then to for the assessment. Families seem to planning for primary physician education.
make decisions about other investiga- tolerate quite well the idea that deci- J Med Educ 1971; 46:436442.
12. Bishop DS, Epstein NB: Family prob-
tions. Family physicians with whom sions should not be made until the as- lems and disability, in Bishop D (ed): Be-
we have worked state that a clear dis- sessment is complete. The length of havior Problems and the Disabled. Balti-
tinction between doing the 'family sessions can vary depending upon per- more, Williams and Wilkins, 1980, chap
work' and 'medical/psychiatric work' sonal preference and availability of 13.
is important if they are to do both well time. 13. Epstein NB, Bishop DS, Baldwin LM:
McMaster model of family functioning: A
and not be led off track. view of the normalfamily. Normal Family
Conclusion Processes, New York, Gilford Press, in
Other Problems We feel family physicians have suf- press.
Finally, we ask if there are any other ficient skills to carry out the process 14. Epstein N, Bishop D, Levin S: Prob-
significant problems or difficulties that described above. Completion of all lem centered systems therapy of the family.
J Marriage Fam Coun, in press.
we have not touched upon. If there the steps in the assessment produces 15. Epstein NB, Bishop DS: Problem Cen-
are, we explore them in appropriate valuable information about family tered Systems Therapy of the Family, in
detail. problems, and family strengths. The Gurman A, Kniskern D (eds): Handbook of
information is gathered in close colla- Family Therapy. New York, Brun-
Problem Description boration with the family. This fosters ner/Mazel, in press.
16. Epstein NB, Bishop DS: Problem cen-
We start this step by indicating to cooperation in subsequent treatment tered systems therapy of the family. J.
the family that we wish to develop a plans and the knowledge gained allows Marital Fain Therapy, in press.
CAN. FAM. PHYSICIAN Vol. 26: NOVEMBER 1980 1537