Help clients understand and break the lethal [wounds + unawareness] cycle

Introduction to Effective Assessment of Low-nurturance Family Clients
p. 1 of 5


Who, What, and How to Assess

By Peter K. Gerlach, MSW
Member NSRC Experts Council

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The Web address of this five-page outline is http://sfhelp.org/pro/dx/basics.htm

        Clicking links here will open a new window or an informational popup, so turn off your browser's popup blocker or accept popups from this nonprofit, ad-free site . If the windows distract you, read the article before following any links.

        This article is one of a series on effective professional counseling, coaching, and therapy with (a) low-nurturance (dysfunctional) families and with (b) typical survivors of childhood neglect and trauma. These articles for professionals are under construction.

        This series assumes you're familiar with:

        Before continuing, pause and reflect - why are you reading this article? What do you need?

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        This article introduces effective clinical assessment of six types of multi-problem, low-nurturance  family clients. Articles on each client type provide perspective and context. The article responds to these questions:

  • What should clinicians assess with these six types of complex families?

  • When should they assess the client? And...

  • Is there a best way to assess?

        To get the most from this article, first read...

the introduction to this series for human-service professionals;

this perspective on human systems;

these slide presentations outlining normal personality subselves and psychological wounds and the [wounds + unawareness] cycle that stresses typical families. If the slides don't display properly, see this.

the basic premises underlying this site and model;

this overview of the clinical model based on this cycle; and read...

these basic premises about human behavior and the clinical process, and...

this summary of general and client-specific assessment factors.

Premise - an "effective clinical assessment" (a) promotes interventions leading to permanent improvements in the client-family's nurturance level and wholistic health, and (b) satisfies the primary needs of the professionals involved, over time.

        Reality check: rate your current ability to assess typical divorcing-family and stepfamily clients effectively on a scale of one (I'm totally ineffective) to 10 (I'm consistently very effective) - ___.

        Think of a multi-home, multi-generational divorcing family or stepfamily that you know fairly well, (like yours?) and keep them in mind as you read. Before exploring who, what, and how to assess with these clients, let's look at some...

Perspective and Implications

        Past vs. present focus - each clinician evolves a stylistic balance between gathering historical information about a client family ("Tell me how you two met and courted.") and learning how well their system is operating in the present. Also, participating family members vary in their needs to explain or explore the past (e.g. to vent, clarify, and/or grieve), vs. focusing on filling current needs ("problem solving"). Premise - the clinician can note this past / present-focus choice early in the work, and ask the client members to help balance their joint focus as the work unfolds - e.g. "Please tell me if you feel we're spending too much time on your past or future, and not enough time on filling your present needs."  

        Initial client assessments and the way they're made are interventions themselves. Typical co-parents will have not have considered some questions the clinician or intake worker asks. Examples:

  • "Do you each include both of your children's biological parents as co-equal members of your current family?"

  • "Who comprises your current family, and who leads it now? Do all your members agree on this?"

  • "Does each adult and child in each of your children's homes consider you all a stepfamily?"; and...

  • "On a scale of one to ten, how well do you feel all your kids and adults have grieved their losses from your divorce?" "How about grief-progress on the major losses from your re/marriage and cohabiting?"

  • "On a scale of one (very ineffective) to ten (very effective), how effective would you say the adults in your related homes have been in  resolving important family problems?

  • "One to ten, how would you rank the recent co-parenting teamwork and harmony among your nuclear-stepfamily's homes? Would the other co-parents agree with you? Would each child?"

        Client family-members' verbal and non-verbal responses to questions like these indicate a lot about them as persons and family members. This suggests the value of well-designed, skillfully-presented assessment questions.       

        Asking the same assessment questions later in the work can provide clients and clinician/s a useful measure of whether anything has changed significantly since the work began.

        Selected assessment questions can be used as useful homework assignments on several levels: e.g. ask participating co-parents to poll absent family members for answers, and note how they respond and what they report (or don't). 

        Case by case, qualified clinicians will choose whether to (a) limit their assessment to current client-family functioning, or (b) also assess over time how well-prepared client co-parents are to master probable future stressors they don't expect (e.g. loyalty conflicts, relationship triangles, and stepchild testing). This is specially relevant for divorcing biofamilies, and courting stepfamilies. Recall that this clinical model proposes that one of five interactive hazards for these client families is unawareness and lack of knowledge.

        For assessment suggestions unique to each client type, follow these links:

        Step back from all the details above, and appreciate the multi-element concept of "effective clinical assessment of a complex client family." The assessment process is an dynamic blend of cognitive + intuitive + unconscious + spiritual senses and perceptions that is unique to each clinician. Typical professionals are often only partially aware of their assessment concept and practice.

         Where true, this silently promotes providing only partially effective client service. The purpose of this article is not to dictate "how to assess these clients," but to raise your awareness of the process and possibilities, and promote clarity on - and wise choices in - your own model of clinical assessment

        Option - use ideas in this article to design one or more in-service seminars, clinical performance-evaluation criteria, and/or case-management or consultation discussion topics.

Assess What?

        This model suggests that clinical professionals evaluate five key elements with any client/case:

  • themselves (for clinical requisites);

  • who comprises the client's family system?, and assess...

  • the current clinical metasystem: i.e. the client's extended family system + any social subsystems significantly affecting that family now; and evaluate...

  • clinical-process sequences and patterns, and...

  • how the client system reacts to strategic interventions, over time.

        Perspective on each of these elements:

        1)  Assess themselves. Clinicians and those who hire, assign, and supervise them should judge whether the involved professionals meet these four requisites for working effectively with low-nurturance client families and persons. The primary requisite is honestly assessing which subselves guide the clinician's personality - in general, and with each client family.

        2)  Who comprises the client's family system? This model defines the primary client - regardless of who participates in clinical work - as all genetic and legal (in-law) members of a multi-home divorcing family or nuclear stepfamily. The client system also includes living and dead children and non-relatives who significantly impact the system's functioning genetically and psychologically in the clinician's (vs. the co-parents') opinion. Ignoring or discounting some members of the client's extended family promotes ineffective service and unintentionally lowering the family's nurturance level.

        How does this compare to your current definition of "my client or patient"? Notice your self talk...

        A broader definition of "the client" includes the unborn generations descending from client-family adults and their adult children. This model proposes that high-nurturance families produce wholistically-healthy progeny, who co-create high-nurturance families, who ... continue this cycle. Currently, the reverse seems to be our American norm - i.e. unaware, wounded co-parents pass on psychological wounds and unawareness, promoting low-nurturance families and spreading the toxic cycle and its effects in our society. From this view, each client includes scores or hundreds of living and unborn people and those they will influence.

        Notice your reaction to this idea.

        An implicit policy decision every clinician and clinical organization makes is whether to focus largely on preventing family stress, wounding, and divorce; or to focus narrowly on empowering each client family to learn how to fill their unique set of needs (problem solve) more effectively. Paradox: stress prevention is far more useful to our culture long term, and rarely earns enough money to pay for clinical operations without far-seeing humanitarian benefactors.

        3)  Assess the current clinical metasystem. Each client family and clinician are elements in a unique system of interactive subsystems (metasystem). Common environmental subsystems include schools, church communities, support groups, the local law enforcement and family-law systems, client-employer organizations, mental-health programs and agencies, and state and national clinical-certification organizations. For effective outcomes, clinicians, supervisors, case managers, consultants, and program directors must want to...

identify each social subsystem that significantly affects the work with a given client family (a subjective judgment),

assess how informed and functional (nurturing) each subsystem is (low to high), and...

decide how to react to any subsystem that impedes effective clinical service to a given client family.

        "Assess a system" means to objectively compare its elements, dynamics, and stabiklity against a model of systemic functionality. The key elements in any human system (two or more people in relationship) include the people + degrees of bonding + roles + rules + boundaries + structure + developmental stage. Brief perspective on these:

the people who comprise the system, each of whom is a subsystem of personality subselves. Clients and clinicians may agree or not on the criteria for deciding who comprises a subsystem. For best situational and long-term clinical outcomes, include any person who has recently had a significant effect on the client-system's nurturance-level (a subjective judgment);

the degree of bonding between key (a) subsystem members, and between (b) subsystems (none > weak > strong);

the key roles, rules, and meta-rules (rules about rules) that govern (a) each subsystem - e.g. marital, co-parental, sibling, grandparental, and aunt/uncle subsystems; and (b) the whole metasystem. Identify the main roles and rules that affect the system's behavior in calm and stressful times; and assess which group member/s usually set and enforce these rules.

        Key systemic rules to assess over a series of sessions include...

  • group nurturance (low > high);

  • group-member priorities in calm and stressful times (toxic > healthy; inconsistent > consistent);

  • adults and kids feeling and expressing current (a) emotions and (b) primary needs;

  • avoidances, assertion, and aggression among group members (problem/s > no problem/s);

  • interpersonal bonding, and grieving major personal and group losses (broken bonds);

  • group-member antagonisms, alliances, coalitions, loyalties, triangles, and cut-offs,

  • typical reactions to personal, subsystem, and systemic stress (nurturing > toxic);

  • openness to systemic change (consistently open > variable > consistently resistant);

  • personal, subsystem, and group communication and problem-solving (consistently effective > consistently ineffective)

  • personal and group spirituality (vs. religion) - nourishing > toxic > none; and...

  • rules about (a) setting rule-consequences and (b) enforcing them (effective > mixed > ineffective).

        Other key systemic elements to assess are...

the boundaries in and between each subsystem - permeable > rigid, stable > erratic, enforced or not, and effective or not in promoting systemic balance and harmony;

the system's structure - a composite of many of these interactive elements (stable > unstable; and functional > dysfunctional; and...

the system's developmental stage (early > middle > late) and progress (healthy > toxic).

        Let's use this framework to describe a way to clinically assess a client's metasystem: their (a) family system + (b) any significant social subsystems affecting their family's development and nurturance-level now.

3A) Assess the Client's Extended-family System

        Each of the six types of client families served by this model have common and unique systemic traits to evaluate over time, starting with the first contact or intake process. The scheme above and the self-improvement Lessons underlying this model allow systematic assessment of any person and client family. Follow the links for key assessments for each Project. Common clinical interventions based on these assessments are also described by Project.

Universal Assessment Factors (all clients)

  • What type of client this is? Each type has some unique factors to assess; and...

  • Who referred this client? If a family-court judge did, see this. And assess ....

  • the attending client's main (a) presenting (surface) and (b) underlying primary problems, and (c) their main problem-solving strategies (ineffective > effective); Option - at the start of each session, assess whether each attending person needs to vent, get affirmation / explain and/or defend / learn, and/or problem-solve; and mediate any major conflicts among these needs (a problem-solving intervention);

  • Assess the impact of any prior clinical experiences on the family (toxic > not helpful > somewhat helpful > vary helpful); and evaluate...

  • family-members' attitudes and expectations about this clinical service (probably won't help > may help > probably will help); and learn...

  • what is the client-family's recent nurturance level? (low > moderate > high); and...

  • Assess each adult client's (a) motivation and (b) ability to make second-order (lasting) systemic changes. Low tolerance for or motivation to try safe, beneficial systemic changes usually indicates false self dominance.

Family-system Assessments, by Client Project

Best Assessed During Courtship

Lesson 1 - assess client adults for psychological wounds and family nurturance level

Lesson 2 - assess for effective-communication and problem-solving knowledge and skills

Lesson 7 - assess stepfamily clients for:

  • acceptance of their identity and what it means

  • unrealistic role and relationship expectations

  • blocked grief and unhealthy grieving policies

  • their long-term family goals and a mission statement, and...

  • their risk in making up to three unwise commitment choices - specially if either partner has existing kids and/or grandkids;

Assess Any Time

  • client-couples' (a) primary-relationship strengths and stressors and (b) stability, and (c) their current strategies for resolving significant need-conflicts;

  • assess committed-stepfamily clients for (a) a coherent, informed plan to merge three or more extended-biofamilies over several years, and for (b) the status of their merger; 

  • assess (a) the degree of recent teamwork among client-family co-parents, and (b) how effective they are now in filling all family-members' primary (vs. surface) needs;

  • assess (a) the client-adults' attitudes about seeking and accepting family supports, (b) key personal and family supports needed now, and (c) the effectiveness of any current family supports on maintaining or improving the family's nurturance level. 

  • assess the client family on _ the recent balance personally, maritally, home and/or nuclear family, and extended-family; and _ the degree of satisfaction and enjoyment family adults experience in managing and developing their family - specially if they're a stepfamily.  

Continue with assessment details on each of these...

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Updated September 29, 2015