Abstract
Treatment-resistant patients, individuals with multifaceted psychiatric problems who do not respond to current evidence-based treatment, pose unique challenges to treatment providers. Given that treatment resistance develops and is maintained within an interpersonal context, these patients often turn out to have treatment-resistant families with a set of complex, enduring, and problematic dynamics that interfere with the developmental tasks and adaptive functioning of family members (Schwartz 2007). Addressing resistance on the family level may enable changes in the individual patient. Studies suggest that individuals with complex psychiatric problems have better outcomes when their families are involved in the treatment process (Morey 2008; Schwartz 2007). Indeed, extensive clinical experience has shown that family therapy that targets structural change within the system rather than symptom amelioration is an integral component of treatment with this population. As part of an effort to understand and measure structural change in treatment-resistant families, we came to ask ourselves this question: How is the construct of dynamic structural change measured in families?
With this question in mind, we surveyed the literature in search of assessment tools. Four commonly used observational family assessment instruments were considered: the Beavers Interactional Scale, the McMaster Model, the Circumplex Model, and the Global Assessment of Relational Functioning (Hampson and Beavers 2012). For the purposes of our study, however, we considered these problematic. As clinician-researchers, we felt that none of them accurately reflected our clinical experience working psychodynamically with families. They do not attempt to measure dynamic family processes such as the complementary use of unconscious defenses like splitting or projective identification. The absence of a dynamic domain precludes their use in measuring the effectiveness of psychodynamic assessment, intervention, and treatment in family therapy.
We decided, then, to develop our own instrument, closely informed by our clinical work at the Austen Riggs Center, a psychoanalytically informed residential center specializing in work with treatment-resistant patients, in hopes of accurately capturing how we think about families and their treatment. Briefly, our family work begins with an assessment from systemic and psychodynamic perspectives, including intergenerational, interpersonal, developmental, and intrapsychic influences. During a patient’s evaluation period, family history is gathered from the patient and various family members, and the family’s dynamics are assessed in an initial family meeting. After the evaluation and as negotiated with the patient and the family, social workers engage the family in liaison contacts, meetings, and family therapy.
As we developed our instrument, we kept in mind certain phenomena repeatedly observed in our clinical work, the contributions of psycho-dynamic theory, and the concept of second-order change (Watzlawick, Weakland, and Fisch 1973) with its emphasis on change in the structure of the system rather than symptom amelioration. Our instrument is in a preliminary phase of development and is presented here in hopes of reflection and feedback.
Methods
We constructed the instrument through a circular, iterative process of individual writing, group discussion, and review of medical records. We began by individually listing clinical concepts that seemed consistently important for structural change in families. These lists were then reviewed, debated, and combined by the group. We then took this combined list of concepts and compared it with family assessments from the medical records. These assessments consist of a multigenerational family history, an account of family contacts and meetings during the evaluation phase, and a family formulation. We selected records in which a family assessment had been fully completed, and the case had not involved a clinician in our research group, without regard to the patient’s presenting problem or family constellations and history. In the course of several iterations of this cycle, the list was refined and expanded, capturing both family pathology and health. We looked for terms capturing both how family members functioned individually and as a system, how they initially presented, and how they might need to grow.
Once our list of concepts reflected the phenomena documented in the records, we began grouping related terms under umbrella concepts and placing them along a rough developmental scale, using Vaillant’s classification system (Vaillant, Bond, and Vaillant 1986) of mature, immature, and pathological ego defenses as a prototype. This preliminary scale in hand, we once again selected family assessments from medical records, rated the same assessments independently, and compared results. This revealed two problematic areas. First, while we had general agreement on the meaning of our terms, it became clear that more precise definitions would be required for raters to accurately apply them. Second, the family formulations and descriptions of family work varied according to clinician style and family presentation, lacking a consistency that would be needed to apply our instrument across the board. Despite this, we felt that the scale was beginning to robustly describe the clinical phenomena we witnessed: where families struggled, where interventions might be targeted, and how families might grow.
Findings
The Dynamic Family Functioning Instrument, as we are tentatively calling it, consists of a grid of twelve blocks: four domains of functioning each divided into three developmental subsets. The domains are family affect, family defenses, family autonomy, and family structure. Affect includes the capacity to experience, express, and empathize with a range of affect, both individually and as a system. Family defenses, which correlate with ego defenses, are unconscious mechanisms used in interlocking ways by the family to cope with reality and manage anxiety; these mechanisms range from denial and projection to humor and altruism. Family autonomy addresses how intimacy and separation are negotiated, the degree to which family members may follow their own pursuits while remaining attached to the family unit. Family structure addresses how a family negotiates boundaries and rules, and how they construct family narratives.
The developmental subsets include mature, immature, and pathological. Although the developmental range is defined differently for each domain, the pathological range is marked by rigidity, denial of reality, and reliance on using other family members as objects to manage one’s own psychological challenges. The mature range is marked by emotional range, flexibility, and warmth, even in times of stress.
Discussion
As we have noted, the Dynamic Family Functioning Instrument is at a preliminary stage. The next phase entails operationally defining each term within the scale and illustrating it with a clinical vignette to ensure reliability, specificity, and validity. We continue to debate how to place items in our developmental framework, and how to integrate the instrument with our clinical documentation to enable ongoing research. Nevertheless, we believe that the Dynamic Family Functioning Instrument already elucidates both manifest phenomena and unconscious defenses and has promise for assessment, treatment planning, and evaluation. Our group has already found it to be a unifying lens through which hypotheses about effective family treatment may be articulated and tested. For example, we hypothesize that the unconscious complementary defenses used in families regulate their functioning in the other domains of affect, autonomy, and structure. Therapeutic interventions targeting family defenses may therefore be the most potent, enabling growth across all the domains.
We hope our instrument will be used in collaboration with colleagues researching treatment resistance on the individual and group level. By including both traditional family therapy and psychodynamic concepts, we have tried to bridge a divide between individual and family work, linking the dilemmas of the individual and the family historically and in the here and now, on conscious and unconscious levels. Family and individual work have often seemed at odds with each other, perhaps in part because we have not been able to articulate and measure an individual’s pathology in the light of the family’s developmental needs. The Dynamic Family Functioning Instrument attempts to bridge that gap, measuring how family work can complement or enable an individual’s work in therapy.