This is a step-by-step guide for examining any couple or family group.
We see only what we know. Goethe
The blind leading the blind by Bruegel
I now present a format to guide us through a full-fledged clinical examination.i This format or ‘schema’ is a framework to ensure that the major functions common to all kinds of marriages or family groups, however structured or idiosyncratic to a particular culture, are scrutinized. Nothing known is left out. And there’s room left over to document anything that might be new. All marital-family functions (and structure) fall into discrete but flexibly overlapping clusters of related data or ‘themes.’ Some ten such themes (T1-10) comprise the diagnostic schema. In this chapter we’ll look at the schema as a whole. Individual themes are dealt with in detail in subsequent chapters The schema is organized as follows:
Name, date, seating.
0: General climate. C—P1-4: Communication style.
Then, theme-clusters T 1-10.
T1: Socioeconomic status.
T2: Family development and basic structure (form or type).
T3: Urgency—type and degree.
T4: Problem recognition and solving (cognition).
T5: Purpose and values.
T8: Role behavior.
T9: Emotional exchanges and cohesion.
T10: Organizational groupings and patterns.
Then, slots T+ open theme and N-MF ‘normal’ function.
Finally, there is a summary box for Rx purposes.
You may wonder why so organized and comprehensive an approach? Isn’t it more natural to just sit and informally gab—to be non-directive, guided by the couple or family’s vicissitudes as they unfold? That is what is done by most marriage counsellors and family therapists, isn’t it? Goethe put it well: We see only what we know. If we don’t know what to look for, we can be, to put it kindly, almost amblyopic, sightless, blind. This is especially so when dealing with marriages and families. Why?
Marriages are emotionally intense. Families are complex. Billions of bits of information bombard our every sense at the instant of contact. Such a seemingly meaningless blur of activity can be confusing, blinding. The consequences may be profound. Unless some sense is quickly made of it all, we can fly blind by the seat of the pants and easily, unwittingly, drift from session to aimless session. Many therapists unfortunately do, and such amounts to treatment without assessment, without any semblance of ‘diagnosis,’ which is incompetence tantamount to malpractice. We see only what we know.
It is important to realize that an organized format does not impose itself on the couple or family being assessed. You can let them do as they wish if that is your style. The schema simply ensures that you observe or tease out key information – that you don’t miss anything important.
Furthermore, with use of an organized schema, premature diagnostic closure is less likely to happen. When closure is too early, treatment may go up blind alleys and be grossly erroneous. Thus, out of the schema flows treatment that can be either open-ended or focused. Usually correct. Always confident. And, when the time comes, faster.
Lastly, regular use of this method of observation and recording can help anyone, from novice to master, assess couples and families as effectively as a doctor examines and diagnoses a patient. Diagnosis is a medical term denoting both process and result in looking for disease in a medical patient. A cause or treatment may or may not be a known. Use of the term in the marital-family context does not mean that we are hung up on the medical model. It is simply a good word to convey an idea. The words symptom and sign also can be helpful. Symptoms are subjective complaints, signs objective observations. In this book the words dysfunction and disorder replace syndrome and disease. Assessment, examination, and evaluation are used synonymously. Management, treatment, therapy, counselling and help also are arbitrarily interchanged unless specific usage is indicated.
A Dry Run Through the Clinical MF-Schema
The patient (or client) in a family or marriage is termed the identified patient (IP): The IP, when seeing a family, is the family’s symptom-bearer, usually in the case of adolescents and children, but it could be a parent. In marital work, the complainant, the primary spouse seeking marital help, is designated as the IP.
Glance over the MF-schema now (next page). Note what a huge amount of data may be compressed onto just one page. The schema is designed so that, as you become increasingly familiar with it, later copious notes are unnecessary. The schema made out in the first session forms a comprehensive diagnostic baseline. At the bottom of the form major dysfunctional themes are jotted down and on the reverse both ideal and practical treatment ideas may be listed.
Always have a copy before you as you see the couple or family, but don’t bury your nose in it. Simply jot points down from time to time. Make cryptic sketches; develop a shorthand. The idea is not to seem obsessive, simply thorough; the couple or family will appreciate it.
A circular seating diagram is at the upper left for jotting down those present. The small triangle below the circle represents the counsellor. Voluntary seating provides an instant ‘Rorschach.’ So have lots of chairs and invite them to sit where they wish. It’s not a bad idea to have a couch – to see if the couple or parents sit together beside each other. Or what child wiggles between them. You can keep track of who moves where using little arrows. (On the back of the schema, you might make a floor plan of the couple’s entire house to show who spends most time where. Is the wife in the kitchen a lot? Husband in front of the TV? Or vice versa? Or a particular teenager retreating to his/her room? Include pets in the portrait. If a family eats together, make a map of the seating around the table and compare it with how they arrange themselves in your office. Etc.) The not-present box is used to recall exactly who was not around during any particular session. You can meet almost anywhere with a couple, but with a family group you should observe certain limits. Visit them at their home, but at a later time. Do not have a first session in a play therapy room. It is too child centred. In fact, it is not advisable to have any toys around until after the first get-together. When you do have some selected toys in the room they can and should be used as diagnostic tools, not as a means of diversion of restless children.
The C (for communication) surrounded by arrows is central to all relationship therapy. It is the engine that underlies and drives all and hence is hardly a special theme in and of itself. It links every theme. The designations P1,2,3,4 refer to four of the basic communication premises, which can be evaluated as communication ‘style’ as new-found skills develop.
In the next few chapters we’ll take each theme, one by one, in detail. For now, it is enough to know that early in the days of marital counselling and family therapy only three themes (not called that) were even recognized. They are asterisked in the schema: problem solving, emotional factors and traditional roles. During the last half century, I have observed many hundreds of ‘normal’ and upset families, collated reams of data, and found that several other themes began to emerge, to the tune of 10 to date. Most important, in my view, are the two themes that deal with
Patterns and Power. (My clergyman friend would prefer the theme on Purpose and values.) Well, the clinical diagnostic schema is a work in progress. Over the years, as it was being pieced together, a theoretical concept of the family emerged. Now, do recognize the next diagram?
It’s the original ‘big bang’ of family theory. In Chapter 1 it was depicted – in a more updated way – as the family theorist’s most important diagram. In it, the family is shown as an abstract variable structure with a cluster of fixed functions (2) travelling along the arrow of time, from its historical past (1) into a purposeful future (4). Right now, in the present (3), any given family at its current stage of cyclical development (Theme 3), is seen to rub against or intersect with ever-constant or ever-changing events. The conceptual thinking that underlies this diagram is based upon facts amassed over half a century, from marriages and families of many worldwide cultural backgrounds. The actual form of the clinical diagnostic schema has emerged, bit by bit, from it – and vice versa..Both the practical application and its theoretical framework are indeed a never-ending work in progress.
And of course, as noted earlier, pragmatic communication pervades everything. That only makes sense, as the way people confirm, inspire or drive one another crazy is through their words and actions, namely by means of communication. In order to deal professionally with couples and families some familiarity with both Communication and Information Theories is a must. But amazingly, too many therapists still try to treat marriages and families by applying psychoanalysis or some such. That is akin to a doctor approaching physical illness with voodoo instead of a knowledge of biology.
I once presented the idea of a rigorous marital-family examination to a group of clerics four decades ago in Sault Ste. Marie, Canada, and was greeted with scepticism – even hostility. The reason I was talking to a group of northern clerics was that I’d travelled up there alone to set up a community mental health program (instead of hospital beds – for the Ontario government), to discover that on-the-hoof mental health work was being done mostly by clergymen. Just one psychiatrist was already there, covering a population of over a hundred thousand people. So I figured their help, rather than resistance, might be necessary. Little did I know! One clergyman, much later (as my friend), summarized the reaction to my dissertation as, “What kind of person can this be, who would subject marriages and families, the last sacrosanct bastion of personal privacy, to such cold and heartless scrutiny?” On their closer personal acquaintance, with both me and the method, they soon found out that it was neither cold nor heartless. It was a shortcut to genuine understanding and sensible help.
But the obvious, as I found out in the Soo, is not always acceptable. So we need to justify examining a marriage or family in subjective human terms as well as in cool and practical scientific terms. Before that, however, I’m going to make a crucial distinction between comprehensive and abbreviated ways of doing things. To do so, I’ll tap into the medical model. Based in science, it is far superior to the clerical model which is based upon strict cultural tradition and sometimes blind faith.
Focused Versus Comprehensive Methods of Examination
We may rightly justify holding up medicine as an example of sound clinical problem solving leading to rational treatment. I do not recommend the ‘medical model’ per se, but do admire its rigorous approach to diagnostic assessment. Doctors take five distinct steps when doing a full medical:
The chief complaint orients the doctor as to what focus and direction to take: Susy’s got a rash all over her body (childhood infectious disease?); my ankles are swollen and I’m short of breath (heart trouble?); I’m having trouble sleeping (could be just about anything), etc.
A medical history (personal and family) fills in foreground and background. The history of the present illness is a specific rundown of what might underlie the present complaint. The background history can delve into many areas of health and sickness, including family history of various diseases.
The functional enquiry (a detailed verbal review of every bodily organ and system) is like a pilot’s checklist before takeoff. Basically, it consists of a long list of questions designed to discover clues to how well or poorly a body part is working.
The actual physical examination (complete or partial) is always intimately hands-on. Tools such as the thermometer, stethoscope, sphygmomanometer or opthalmoscope extend a doctor’s senses.
Laboratory blood tests, cultures and other investigations such as an X-ray or MRI may confirm or rule out various provisional hypotheses about diagnosis. A tissue biopsy, while an invasive step down the line, is still a part of the diagnostic investigation.
You’ll note that the first three steps are subjective, in that they depend upon the patient’s word for the truth of things. The last two steps are factually objective. Our marital-family examination is anchored in step four. It is the social equivalent of an objective physical examination. Hence it is called the marital-family examination.
Like a doctor’s physical, the marital-family examination may rely less on questions than on clear observations – of what we see as well as hear. In fact, almost the entire first half of the marital-family examination can be done in silence, the therapist’s silence. Of course this is hardly ever done. We shift back and forth from the initial complaint about the IP to the family’s history and values and goals. We further probe and sniff about with questions as in medical step three, the functional enquiry. We may leap ahead to step five, investigations, by asking for a marital self-test or an IQ rating of a particular child. We also may be either widely comprehensive or narrowly focused in our approach.
Here, first, is a medical example of the focused approach: If little Johnny, sitting on his mother’s lap in the doctor’s office, says, “My throat is sore,” the wise doctor gingerly approaches, penlight and tongue depressor in hand, and asks him to open his mouth. A quick good look is taken. A throat swab is deftly done. A provisional working diagnosis is made: ‘infected sore throat, possibly Strep.’ An antibiotic is started by educated guess. The bacterial culture soon confirms the infected throat, specifying it as ‘an acute Strep-throat.’ This is a definitive diagnosis. This is a focused assessment. It skips a lot of the above steps. It gets right to the point, to the crux of the matter.
On the other hand, if Johnny’s mother later complains that, despite the initial treatment, he has become feverish, tired, and displays a general malaise, the doctor will go through the entire five-step sequence, a complete and comprehensive approach. (Wouldn’t it have been ridiculous at that earlier point to do a rectal on poor little Johnny? Although the doctor knows better, even whipping out his stethoscope and having a listen to Johnny’s heart may be very briefly deferred.) Anyway, when the alien presence of beta-haemolytic streptococcus, a potentially dangerous bacterial germ, is found, a thorough approach is taken, including a complete head to toe physical exam. Every possibility is covered. All systems are checked out. It may be found that Johnny’s Strep throat has given him rheumatic fever. With adults, a wise and experienced physician might, from the patient’s general aura, suspect a cancer (or masked depression, a low thyroid, even Addison’s disease, or any other specific kind of chronic hidden illness). But, and this is the crux of the matter, he would not leap at such a conclusion and start any kind of unverified treatment—until he knows for sure what is really going on. With children and adults both, it then all becomes very formal: an extensive history is elicited in the consulting room; a detailed functional enquiry is done step by step along with the full physical in the examining room; X-rays and imaging are arranged at the hospital, lab tests at the lab…
Our schematic approach allows for this flexibility too – focused or comprehensive approaches. But we, as marital-family therapists, have it easier than the doctor. We can do it all in one room, all at one time! We can be either comprehensive or zero right in on a specific problem. Actually, we can be thorough at the very same time as focusing in – at no extra expense. Or effort! But, a focused diagnosis in marital-family work takes extra special knowledge and extra special care. We should not get locked into any sort of premature closure as we gauge the general marital-family climate! We will set aside our clever hunches – for now – and slog ahead step by careful step.
Let me reiterate for emphasis. In marital-family work the comprehensive approach takes precedence. It is virtually mandatory that beginners and learners stick with it. Otherwise crucial things will be left out. Once the clinician gets the hang of it, and has much experience, some slick shortcuts may be possible. In fact, as mastery develops, dramatic and almost instantaneous diagnoses start popping forth. Earlier, in Chapter 7, we looked at several kinds of family triangles with specific outcomes that nicely lend themselves this sort of astute diagnostic magic. Later in the book, several chapters are devoted to the wizardry of focused, ‘truncated’ examinations. In the meanwhile, however, the comprehensive and all-inclusive examination will be our tour de force.
Now, lest I sound like a crazed technocrat, I must say that some things are best said by great works of fiction. This is especially so when lovers and families are swept up in the sweep of cataclysmic events. In Boris Pasternak’s novel, Doctor Zhivago, Lara describes how the Russian revolution destroyed the family life of so many. Yuri asks her, “But what went wrong with your married life, if you were so fond of each other?” And she replies, “That’s a terribly difficult thing to answer. I’ll try and tell you. But you know it’s absurd for me to try to explain to you who are so wise what is happening to human life in general, and to life in Russia, and why families get broken up, including yours and mine. Goodness, it isn’t as if it were a question of individuals, of being alike or different in character, of loving or not loving! Everything established, settled, everything to do with home and order and the common round, has crumbled into dust and been swept away in the general upheaval and reorganization of the whole of society. The whole human way of life has been destroyed and ruined. All that’s left is the bare shivering human soul, stripped to the last shred, the naked force of the human psyche for which nothing has changed because it was always cols and shivering and reaching out to its nearest neighbour, as cold and lonely as itself…” All I can say about my little method of evaluation, is, when a therapist is faced with monumental tragedy, set it all aside and listen – and learn.
We shall now deal with another serious topic that just has to be considered someplace. It is related to a similar quandary about where reason leaves off and passion begins. This is a short chapter, at the very beginning of our learning to use the schema in real life, so let’s now get it over-with.
All Experience is Subjective.ii
We tend to think that subjectivity has to do with feelings and things artistic. And that objectivity is the essence of science and logic. Well, this ‘separation’ tendency, when applied to living beings, needs some serious qualification. For the two words are somehow linked together in meaningful application. But how exactly?
At the extreme left and right of this diagram are, hypothetically, complete degrees of objectivity and subjectivity respectively. As we move from both ends toward the middle of the horizontal axis each diminishes. And they do not join up at any one point – they always overlap. Dancing around almost as an afterthought in the graph are line representations of thinking and emotional feeling level.
Feelings are a most integral part of our being. When we gaze up at the night sky the dome of stars leaves us in awe. As we sit around a fireplace with our family on a cold winter’s day we feel comfort, security and warmth. The scientist looking through her microscope is interested and curious as well as cool and contemplative. The young doctor’s disgust (ugh!-reaction) at examining a homeless person’s suppurating sores quickly turns to compassion. The family therapist ‘cares‘ right from the start. If we don’t like what we are doing we may get unpleasantly bored. Each italicized word represents a feeling. Feelings – always subjective – are a most integral part of our being.
That being the case, how on earth then can we ever be objective? How can we be cool, detached and logical to the extent that we can perform a good physical or a well-tuned family examination? Without being biased. It’s a very good question.
My answer: Some people think that subjectivity and objectivity are absolute opposites.iii, iv, v Not so. They are simply relative, not mutually exclusive, stances. They are not necessarily even coextensive. Less subjectivity doesn’t make us objective. More objectivity doesn’t require that we lose our passion. Subjectivity is a natural human quality, whereas we have to train ourselves to be objective.
Actually, there are drawbacks to this. Everything in a marital-family group impinges upon us at once. The cacophony of data before our eyes can be overwhelming. But, it is all nicely in one spot and remains in one spot. The doctor, on the other hand, when doing a comprehensive assessment, is forced, by circumstances and tradition, to spread things out and sort them out over time, often in different places. Hence, s/he, while inconvenienced, is less likely to get bogged down or overwhelmed. Our main saving grace is rigorous self-discipline. And that is—to force order upon the data and oneself by using a comprehensive, systematic, schematic, diagnostic guideline. If we do this, being quite objective almost becomes simple!
Here is the key to the letters along the O-S (objectivity-subjectivity) axis, each of which represents a distinct relationship type: Mr = Material relationship (as with a physicist and atoms or a chemist and equations), Px = Diagnostic relationship (such as a medical psychiatric consultant), N = Normal relationship (as is usual between healthy and well-adapted people), Rx = Therapeutic relationship (as between doctor and patient or therapist and family), Dr = Dysfunctional relationship.
Everyone further to the right almost always is dealing with other humans. (But some love toy objects more.) Dealing with people, they cannot be other than spontaneously subjective and must really work at being objective. Children, for whom the world is almost always new in their own eyes, naturally are the most ebullient and spontaneous yet often surprise us with their capacity for clear objectivity.
Px: In the diagnostic section medical doctors attempt to avoid excesses of objectivity or subjectivity by invoking the Hippocratic Oath. They don’t want to fall off either end of the horizontal scale. Those professionals doing marital and family examinations can always increase their objectivity by using ‘uncommon sense’ and religiously adhering to our diagnostic schema. It keeps their thinking organized while still enabling proper empathy. Psychoanalysts perhaps can afford to be coolly analytical, but marital-family workers can only be warmly so.
N: Ordinary well-functioning people in their families and at work naturally guard against excesses of both analytical logic or totally uncontrolled negative emotion. Their thinking is common sense and their feelings are appropriately varied but predominately loving, contented, friendly, etc. Thinking and feeling level off here, are stable. In the event of normal grief or fear ‘normal’ people maintain their warmth. Thus ‘normal’ people are unconsciously subjective in their surroundings and work at being objective as needed. They intelligently experience music, literature, dance and art with equal feeling.
Rx: The most ubiquitous quality of any effective therapist is caring. Subjective feeling and empathy are absolutely essential to success. But high quality thinking (objectivity and ongoing assessment) should not be disregarded.
Dr: In dysfunctional relationships the emotional line on the graph splits to show pathological levels of anger, fear, lust, disgust, hate, depression, mania, violence, etc. Thinking, where it mostly counts, is irrational. In short, subjectivity is all too intense while reason and objectivity have gone partly or completely on vacation.
But what really ties them, objectivity and subjectivity, together? Answer: The balance between our reason and our passion. The way we think and how we feel vary in distinctive ways as we are more, or less, subjective or objective. That is to say, thought and emotion tend to vary inversely to each other as we move back and forth between being objective or being subjective. As we become less and less objective our thinking partly deteriorates. Here’s what the poet William Blakevi said about it:
Thought chang’d the infinite to a serpent, that which pitieth
To a devouring flame; and man fled from its face and hid
In forests of night: then all the eternal forests were divided
Into earths rolling in circles of space, that like an ocean rush’d
And overwhelmed all except this finite wall of flesh.
Then was the serpent temple formed, image of the infinite
Shut up in finite revolutions; and man became an Angel,
Heaven a mighty circle turning, God a tyrant crown’d.
The poem sounds terrible. It talks about the effect of objectivity upon the whole person or upon the whole of life. In the poem the word “thought” stands for objectivity. Thought should remain a part of the whole but instead spreads itself and meddles with the rest. It slices everything to bits. The first slice is between the objective thing (under scrutiny) and the rest. The world of the objective creature gets split into helpful things and hindering things. Helpful and hindering become Good and Evil. And the world is then split between God and the Serpent. And after that, more and more splits follow because the intellect is always classifying and dividing things up. The poem, thus, is a polemic against scientific pseudo-objectivity and rampant reductionism. By inference it extols the virtues of ecology, integration of the whole, of being holistic. It is very stern and serious. Blake, while in some ways right, was very angry, not a fun person.
If you got that, now you know and will see. In future when I suggest you be less subjective I mean tune up your critical thinking. When I suggest you be more objective I mean try to get your reason and your passion in better balance.
Important ideas can be glossed over in the dense underbrush of technical writing. I will highlight them in this key concepts section as we go along. It can help. I hope the presumption of telling you in a paragraph or two what you have just read rests well with you and works well for you.
First and foremost, we see only what we know.vii That is, without prior knowledge it is highly doubtful that we will recognize what is right in front of our nose. (…unless we are an original discoverer, creatively looking for what we don’t know. Research scientists try to do this.) The diagnostic schema is not just another clinical form. It encapsulates a complete method for assessing or profiling marriages and families. A theme is a logical cluster of related data. In some cases, as we’ll later see, it may lead to a definitive diagnosis.
You might ask, why is marital (dyadic) assessment combined with family (group) assessment in the single format of the diagnostic schema? Why not provide a separate format for each? First, the marital partners are the family architects, fulfilling society’s precepts for child rearing, and second, marriages and family groups both share most of the functions embodied in the schema. The notion of doing a rigorous marital-family examination, as effectively as a doctor does a physical, is a new idea. From that starting point consider the happy alternatives: Should our exam be leisured or fast (urgent), systematic or haphazard, comprehensive or focused? Analogies (with medicine) may help us better understand these diagnostic concepts.
The concept of three levels of orientation was earlier explored (Chapter 1); these are monadic (just one person), dyadic (two-person, marital), and the family group. Sensible, logical eclecticism, economically focusing on major sources of trouble, is recommended. In relationships, observation of interactions has priority over intrapsychic report. Or, in plain language: watch what actually is happening between the people you see right in front of you, rather than trying to indirectly surmise what might be (darkly?) going on inside a person’s head.
While using this diagnostic schema, learning to increase your objectivity without losing your passion is an important principle. In other words a cool, cold diagnostician (in our kind of work) is almost worse than none. A cool, cold therapist is. As we shall repeatedly see and I say, humour heals.
1. A fresh full-page schema – in paper form – is made available for use at every session, but only parts of it might be filled in. It all adds up over time, making a good ongoing clinical record. Obviously, the schema can be computerized, but please!, don’t do so while a couple or family is present. Paperwork is enough of a problem!
2. Taking notes during individual psychotherapy may be ‘bad form’ and inadvisable, but in marital and family work it is quite okay if done discretely. In this regard, convey the fact that you are a concerned and caring marital-family therapist who quite naturally gives as much priority to their relationships as to their psyches.
3. And always remember to approach distressed marriages and troubled families with a well-disposed sense of humour. For, when it comes right down to it, according to Hippocrates’ Oaf, “One new clown in town does more good than ten asses laden with medicine.”
i Hogg, W. Relevance of the Family in Medicine. Communications in Learning, Inc., 26 minute audiotape with visual component (1978). The notion of comprehensive family assessment was first presented in a closed circuit audiovisual network for physicians in Buffalo, NY and environs.
ii Bateson, Gregory. Steps To An Ecology Of Mind. New Jersey & London: Jason Aronson Inc. (1987). One cold night in January 2005 while reading this book (in the bathtub) my thinking was stimulated by this statement (page 47), “All experience is subjective.” Hence the little (added) section on objectivity-subjectivity.
iii Aristotle’s law of the excluded middle—‘something is either true or false; there is no third possibility’—is seemingly defied by the blending of ‘mutually exclusive’ objectivity and subjectivity. This apparent logical paradox is explained by our brain’s ability to handle the shared processes of thinking and feeling in parallel.
iv Aristotle. Organon.
v Guillen, Michael. Bridges to Infinity (The Human Side of Mathematics). Los Angeles: Jeremy P. Tarcher, Inc., distributed by Houghton Mifflin Company, Boston (1983).
vi Blake, W., 1794, Europe a Prophecy, printed and published by the author. (Italics added.) I credit Gregory Bateson for most of my insight into Blake.
vii Pierre Teilhard de Chardin (1955). The Phenomenon of Man. New York, London, Glasgow: Harper Collins (1961). The foreword of this classic, entitled Seeing, takes Goethe a long step forward.