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Alert others to
inherited wounds + unawareness |
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Introduction to Effective
Clinical Assessment of
Psychologically-wounded Persons
By
Peter K. Gerlach, MSW
Member NSRC Experts Council |
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https://sfhelp.org/pro/iftx/dx_basics.htm
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This article is one of a series on
professional counseling, coaching, and therapy with (a) low-nurturance
(dysfunctional) families and with (b) typical
of childhood
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
+ + +
Before
reading further, pause and reflect - why are you reading this? What do you need?
|
To better understand the context of, and rationale for, these
interventions, first scan (a) this overview of the [wounds +
unawareness] cycle, (b)
these introductions to
(in this site), false-self
and
and (d) this series of lay
articles on the phases and aspects of internal family systems
("parts") work. |
Premise - an "effective clinical assessment" yields
conclusions about a client's internal-family system of subselves, which promote (a) effective
intervention strategies and (b) lasting desired systemic changes, as
judged by the recovering client.
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 very effective every with all such
clients) - ___.
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.
Assess What?
This
model suggests that clinicians evaluate five key elements with any client
family:
-
themselves; and...
-
the
clinical metasystem ; and...
-
who
comprises the client's extended-family system, and...
-
basic and client-specific factors,
and defining related clinical
goals; and...
-
(a)
clinical-process
and (b) how the client reacts to interventions, over time.
Perspective on each of these factors:
1)
Assess themselves.
Clinicians and those who hire, assign, and supervise
them judge whether the involved service-providers meet these
for working
with divorcing-family and stepfamily clients.
The primary requisite (with any
client) is honestly assessing which
guide the clinician's
- in general, and with each client
family.
2)
Assess the
clinical metasystem. Each client family and clinician will be
elements in a unique
clinical metasystem - a system of interactive subsystems. For effective
outcomes, clinicians,
supervisors, case managers, consultants, and program directors need to want
to...
-
identify the interactive clinical subsystems that
affect the work
with any client family,
-
assess how
and functional (nurturing)
each subsystem is, and...
-
decide if and how to seek constructive change in any subsystem that impedes
effective clinical service to a given client family.
3) Define
"the client."
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 client family 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. unaware, wounded co-parents pass on psychological wounds and unawareness,
promoting low-nurturance families and spreading the toxic cycle and its effects.
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.
And
over time, effective clinicians will...
4) Assess The client's family system...
-
the
composition and
nurturance level (low > high) of the client's
system;
and....
-
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
nuclear-family's
and environment:
-
how are other
(e.g. religious, educational, civic, and legal) affecting
the client-family's nurturance level and presenting problems?; and...
-
do these systems
help or hinder interventions by the clinician?
And
over time, also assess...
-
the
client's main (a) presenting and underlying primary problems, (b)
the impact of any prior clinical experiences (not helpful < > helpful) and (c)
family-members' attitudes and expectations about this clinical service (probably won't
help > may help > probably will help);
And
clinicians need to
assess...
Finally, effective clinicians will continually...
5)
Assess the ongoing clinical
including how the client
adults are reacting to strategic interventions over time - i.e. do
their ruling subselves...
- allow
second-order (core attitude)
or...
- make only first-order (temporary, cosmetic) systemic changes, or...
- resist any
significant systemic changes to their boundaries, roles, rules, goals, values, and
memberships?
Premise: two or more people or personality subselves who communicate over
time evolve identifiable
that help or hinder filling their
Clinicians need to assess these
sequences as the work proceeds, and intervene
strategically to reduce or remove significant process-blocks.
Chronic
(process) blocks usually indicate wounds + unawareness + ignorances in the
clinician, any supervisor or case manager, and one or more participating client
adults.
Status check:
How do you feel about
this premise about what to assess clinically with average
low-nurturance family clients?
_ I agree totally, and want to weave
these premises into my work;
_ I agree with some of these five factors, and
will experiment with some or all of them to see what happens;
_ I have a different idea of how to assess
low-nurturance families, which works well enough for me now.
When to Assess these Factors
Effective
clinicians and co-workers will continually assess themselves and their
professional metasystems for
to work with these complex families, and acquire them
as needed. A primary responsibility of supervisors and case managers is to
honestly assess (a) themselves and (b) each clinician they work with for these requisites,
and take appropriate action.
Clinicians will assess many things about each client family system over time,
beginning with the first contact.
This assessment is evolving, organic
process,
because...
-
the client-family's people, roles, rules, (some)
values, boundaries and goals - and their environment -
constantly change as the family moves along its developmental path; and...
-
the elements of the clinical metasystem dynamically
change and interact with each
other and their common environment over time, shifting their members' beliefs, behaviors, boundaries, and priorities;
and...
-
each client contact reveals more information about the family system's
history, rules, roles, and dynamics, and how the participating family members are
reacting to recent clinical interventions.
Is There a Best
Way to Assess These Complex Clients?
After
26 years' clinical experience with hundreds of divorcing families and
stepfamilies, my bias is "yes."
Three
ways to assess a client family system over time are (a) direct observation, and
(b) making interventions, including asking questions and assigning "homework," and
(c) observing how family members
react. Questions can be verbal or written, as in an intake questionnaire and
worksheets Some cases will also include assessment information from other
human-service providers working with the client family members - e.g. teachers,
doctors, mediators, attorneys, social workers, law-enforcement professionals,
etc.
Each
clinician, supervisor, and case manager evolves a preferred way to assess
new and existing clients. The "best way" is to (a) clearly define
and then (b) use whatever mix of assessment techniques yields enough
systemic information to allow effective interventions with this client
family.
Common
assessment variables that shape the mix are...
-
assessment time frame - negotiating and maintaining a clinician-client
balance between focusing on the client's
past history vs. identifying and
filling present needs vs.
filling long-term future
needs;
-
who to assess:
-
one
or more persons'
-
a
relationship subsystem (e.g. mate-mate, parent-child, ex-ex, or
grandparent-adult child). This clinical model suggests framing this as two systems of
personality subselves interacting;
-
a one-home
nuclear system;
-
a
nuclear-family system
after parents separate or divorce;
-
the
extended (multi-generational) family system of genetically and
legally-related adults and kids, including all divorced parents and their
kin;
-
some or all client-adults' family trees, including co-parenting ex mates and
any new partners of theirs; or assess...
-
the
whole clinical metasystem that includes the client-family system.
As
the work progresses and the environment changes, clinicians may the scope of
whom they assess;
|
In general, including each divorced parent and their kin and any
new mate and stepkids in the client assessment (a) takes the
most time, and (b) promotes the most effective clinical
outcomes. |
-
what
systemic elements to assess:
|
+ system and/or subsystem boundaries
(closed to open to
diffuse)
+ relevant family values,
including adults'
priorities
+ overall and marital
communication and
problem-solving strategies
+ home / system structure |
+ home / family goals,
roles, and rules,
+ home / family spirituality (vs.
religion)
+ home / full-system nurturance
levels
+ family policies about anger,
grief, parenting, and money
+ the system's ability to change
and restabilize
+ adult knowledge of
selected topics |
-
What
problems (unmet needs) to assess:
-
one or more
current
client-identified stressors (problem-centered therapy),
-
one or more
unidentified current
systemic stressors - e.g.
ineffective communication and problem-solving, unfinished or blocked
grief, unclear or
conflictual co-parenting roles, ineffective child discipline,
unacknowledged ex-mate co-parenting barriers, etc.
-
one or more
unidentified long-term
systemic stressors client adults are ignoring or
unaware of - e.g. psychological
incomplete or blocked grief, unhealthy
and/or
policies;
unfinished or current marital affairs,
addictions, and unwise courtship choices. low home and/or family
nurturance levels
Premise - the latter
choice (a) takes the most time and effort, and (b) promotes the most effective clinical service
long term.
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
solving your present problems."
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?"
-
"One
to ten, how effective would you say the adults in your several 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 reveal a great deal about them as persons
and family members. This suggests 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 what - if anything - has changed
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 pre-legal (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.
Recap
This clinical model and article proposes five clinical-assessment domains
toward providing effective service to persons, couples, and complex
families. The domains are based on defining "effective assessment" as "a
clinician-unique mix of beliefs and techniques that yields enough
information to design effective interventions that fit each unique
client."
-
the clinician (assess for requisites); and...
-
the
clinical metasystem; and assess...
-
who
comprises the client's extended-family system, and...
-
general and client-specific
factors, including identifying
client-specific clinical
goals; and...
-
(a)
clinical-process
and
blocks; and (b) how the client reacts to interventions, over time.
These domains apply to all client systems. Each
of the six client types in this model has unique things to assess.
This article overviews variables that every clinician (including
supervisors, consultants, and case managers) will blend to form their unique
preferred method of client evaluation. From clinical experience since 1981, I
propose the best assessment choices in each variable for effective long-term clinical
outcomes with typical divorcing-family and stepfamily clients.
Assessment Resources
-
A summary
checklist of assessment factors for all six client-types
-
Sample intake forms for
divorcing-family and
stepfamily clients
-
An index
of all clinical articles in this non-profit site, and...
-
This
collection of assessment worksheets and checklists for clients
and clinicians, organized by client
Pause and reflect - did you get what you needed from reading this
article? If so, what do you want to do now with these ideas and
resources? If not, what do you need now?
+ + +
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Updated
October 05, 2015
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