Assessment

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Family assessment, an extension of conventional individual psychiatric assessment, adds a broader context to the final formulation. Built up over a series of interviews, the range and pace of the enquiry depends on the specifics of the case. Its four phases are history from the patient, a provisional formulation concerning the relevance of the family, an interview with one or more family members, and a revised formulation.

In some cases, it is clear from the outset that the problem resides in the family group (see above), thus rendering the phases below superfluous. History from the patient

The most effective way to obtain a family history is by constructing a family tree. Apart from showing the family structure, it allows further information to be added summarizing important events and a wide range of family features. Scrutiny of the tree also provides a source of noteworthy issues to be explored and, eventually, of clinical hypotheses.

Personal details can be recorded for each family member such as age, date of birth and death, occupation, education and illness, as well as critical family events (for example, migration, crucial relationship changes, notable losses, and achievements), and the quality of relationships.

An excellent discussion of the family tree—its construction, interpretation, and clinical uses—is presented by McGoldrick and Gerson ( Fig !).(33,'

Fig. 1 Genogram conventions.

Useful principles are to work from the presenting problem to the broader context, from the current situation to its historical origins and evolution, from 'facts' to inferences, and from non-threatening to more sensitive themes.

Commonly, questions are preceded by a statement such as: 'In order to understand your problems better I need to know something of your background and your current situation'. This can be enriched by questions that allude to interactional patterns: 'Who knows about the problem? How does each of them see it? Has anyone else in the family had similar problems? Who have you found most helpful, and least helpful thus far? What do they think needs to be done'. Attitudes of family members can be explored in this manner and light shed on the clinical picture.

The presenting problem and changes in the family

Questions aimed at understanding the current context include: 'What has been happening recently in the family? Have there been any changes (e.g. births, deaths, illness, losses). Has your relationship with other family members changed? Have relationships within the family altered?'

The wider family context

At this point a broader enquiry flows logically—in terms of other family members to be considered, and in the timespan of the family's history. Other significant figures, who may include caregivers and professionals, should not be forgotten.

Apart from information about the extended family's structure, questions about the family's response to major events can be posed: for example, 'How did the family react when your grandmother died? Who took it the hardest? How did migration affect your parents?'

Relationships should be explored at all levels, covering those between the patient and other family members and between those other members themselves. Conflicted ties are particularly illuminating. Understanding the 'roles' taken by members is also useful: 'Who tends to take care of others? Who needs most care? Who tends to be the most sensitive to what is going on in the family?'

Asking direct questions about family members is informative, but a better strategy is to seek the patient's views about their beliefs and feelings and to look for differences between members—'What worries your mother most about your problem? What worries your father most?' Several lines of enquiry may reveal differences.

• Pursuing sequential interactions: 'What does your father do when you say your depressions are dreadful? How does your mother respond when your father advises you to pull up your socks? How do you react when she contradicts your father?'

• 'Ranking' responses: 'Everyone is worried that you may harm yourself. Who worries most? Who is most likely to do something when you talk about suicide?'

• Looking for relationship changes since the problem: 'Does your husband spend more or less time with you since your difficulties began? Has he become closer or more distant from your daughter?'

• Hypothetical questions dealing with imagined situations: 'How do you think your relationship with your wife will change if you don't improve? Who would be most likely to notice that you were getting better?'

Triadic questions help to gain information about relationships which go beyond pairs; for example: 'How do you see your relationship with your mother? How does your father see that relationship? How would your mother react to what you have told me if she were here today?'

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