This
article introduces effective clinical
assessment of
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
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
and
and (b) satisfies the primary needs of
the professionals involved, over time.
|
Reality check:
rate your current ability to assess
typical
and
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
for these client families is
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
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
for working
with
low-nurturance client families and persons.
The primary requisite is honestly assessing which
guide the clinician's
- 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
A broader definition of "the client" includes the unborn generations
descending from client-family adults and their adult children.
This model proposes that
families produce
progeny,
who co-create high-nurturance families, who ... continue this cycle. Currently,
the
seems to be our American norm
- i.e.
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
(a subjective judgment);
the degree of
between key
(a) subsystem members, and between (b) subsystems (none > weak > strong);
the key
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
(low > high);
-
group-member
in calm and
stressful times (toxic > healthy; inconsistent > consistent);
-
adults and kids feeling and expressing
current (a) emotions
and (b)
-
avoidances,
and aggression among
group members (problem/s > no problem/s);
-
interpersonal bonding, and
major
personal and group
(broken bonds);
-
group-member antagonisms, alliances, coalitions,
and
-
typical reactions to personal, subsystem, and
systemic
(nurturing > toxic);
-
openness to systemic
(consistently open >
variable > consistently resistant);
-
personal, subsystem, and group
and
(consistently effective >
consistently ineffective)
-
personal and group
(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
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
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
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
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
(low > moderate > high);
and...
-
Assess each
adult client's (a) motivation and (b) ability to
make second-order (lasting) systemic
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...
+ + +
The Web address of this
five-page outline is
https://sfhelp.org/pro/dx/basics.htm