This is a step by step guide to the comprehensive clinical MF examination. Although compressed, it’s long, so it is divided into two parts in separate knols…
Most of us “see only what we know.” (Goethe) This synopsis helps us both know and see. It presents an organized format to guide any clinician through a marital or family assessment. The format or ‘schema’ ensures that the major structures and functions common to all marriages and families are carefully scrutinized. These fall into discrete themes that flexibly encompass overlapping clusters of related, observable interpersonal data. Ten such themes comprise the schema. The schema gives us a comprehensive cross-sectional profile or snapshot. If used over time, a longitudinal – truly dynamic – picture automatically emerges from our initial snapshot. This rational approach to the clinical marital-family examination is applicable, worldwide, across every culture.
The family theorist’s most important diagram.
The yellow circle represents any couple or family right now, as it exists in the present. Embedded in linear time, it moves along the horizontal line (the far-from-equilibrium ‘arrow of time’) from its historical past (1) to a future (4) of frequently changing goals and relatively fixed purposes and values. In the present situation (3) all marriages or families are confronted with both permanently fixed as well as constantly changing circumstances: economic (SES), developmental, and crisis-exigencies. Variable contingencies are dealt with in a framework (2) of structural constraints (often imposed by the form, nuclear, single parent, etc., a marriage or family assumes) and functional realities (a few standard tasks: sexual, emotional exchanges, problem solving, power allocation, teaching/modelling, etc.). Woven through it all is communication – the universal ‘grammar’ of what actually goes on between people (in speech or gesture). (Pragmatic communication is the social equivalent of biology’s genetic code!) This all-encompassing format, as depicted above, applies to each and every variety of marriage and family, in every culture, on earth.
From it – interplaying with it – we have researched and devised a fluid, comprehensive (but very easily applied) diagnostic schema that enables anybody to clinically assess any marriage or family and while doing so, truly crack the family code. This simplified practical clinical schema is reproduced next. It is a key clinical tool and will be referred to repeatedly.
Definitions: A ‘marriage’ consists of two adults sharing shelter and sex. Marriages are emotionally intense. The family is more complex – in many ways. The prototypical nuclear family has two married partners and their natural offspring. Offspring also may be adopted or from previous marriages. Of note, ‘offspring’ nowadays are not necessarily dependent minors! The old-fashioned extended family still exists, but rarely in one place, under one roof. It includes grandparents and other involved relatives. In modern fact another style, the single parent family, is included under the family rubric. Outside the West the family may take other distinct cultural forms including polygamy. In Canada and some other countries gay or lesbian couples now can be legally married.
Glance over the Diagnostic Schema. Note that a huge amount of data is compressed onto one page. The schema is designed so that, as you become increasingly familiar with it, copious notes are unnecessary. Many items can be circled or simply ticked off. Have a copy of the schema 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. The schema made out in the first assessment session forms a superior baseline clinical record.
The ‘client’ in a family or marriage is termed the Identified Patient (IP). The IP is the symptom-bearer in the case of children and adolescents. In a distressed marital relationship the name of the initial complainant (often a harried or harassed wife whose husband may well be the real ‘sick-one’) is placed at top right. This usage may not seem fair but it’s sensibly expedient. But, bear in mind: a total family group or the marital relationship is always the real client!
A circular seating diagram is at upper left for jotting down those present. (The not-present box next to it is used to recall exactly who was not around during any particular session.) The counsellor is represented by a small triangle. This symbol represents the actual: Therapists are always at the apex of a triangle in any type of therapy (1:1, 1:2, 1:n). Voluntary seating provides an instant ‘Rorschach’ test. Have lots of chairs and invite the couple or family members to sit where they wish. It’s not a bad idea to have a couch, to see if the married couple (or parents) sit together—or what child wiggles between them. You can keep track of who moves where during therapy with little arrows. Extend this to real life: On the back of the schema, you might make floor plans of the 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, is 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.
At the bottom of the form major dysfunctional themes are jotted down. Alongside, and on the reverse, both ideal and practical treatment ideas may be listed. The schema concentrates the clinical mind. We often can start definitive treatment immediately. A fresh, blank form is used in each subsequent session. Taken together these sequential snap-shots provide us with a ready-to-hand overall dynamic picture. They also confirm or disconfirm our initial impressions.
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? Well, as Goethe said: We see only what we know.  Marriages are intense, families complex. Billions of bits of information bombard our every sense at the instant of contact. Such a seemingly meaningless blur of activity can be blinding. Unless some sense is quickly made of it all, we can fly blind by the seat of the pants and easily drift from session to aimless session. Many professionals unfortunately do, and such amounts to treatment without assessment which is tantamount to malpractice. 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 do not miss anything important. Furthermore, with use of a well-organized format, premature closure is less likely to happen. When closure is too early, treatment may go up blind alleys and be grossly erroneous. Out of the schema flows treatment that can be either open-ended or focused. It is usually correct. Always confident. And, when the time comes, faster. Its regular use can help anyone – from novice to master – assess couples and families as effectively as a doctor diagnoses a patient.
Treatment without ‘diagnosis’ is incompetence.
Diagnosis without treatment is neglect.
The way people affect each other by the message character of their actions, the way they confirm or disconfirm, inspire or drive one another crazy, is the core of a relatively new discipline: Communication. Communication is the universal glue that connects people – in the present – through speech and manner. (With writing we may pass information across time, from generation to generation.) I can credibly assert that communication is the marital-family therapist’s genetic code.     
In the cryptic figure at top right of the schema ‘C’ stands for style of communication. The arrows indicate that it affects everything, all themes. P1-4 represent the basic premises or ‘grammar’ of pragmatic communication:
P1 One cannot NOT communicate (even silence is a message).
P2 Message sent is not necessarily message received (due to garbled expression, multiple intervening channels between sender and receiver, misperceptions, etc.).
P3 Interpersonal exchanges are at two distinct levels – normally harmonious, always simultaneous – 1) the main or content message (often, but not always ‘stated’ i.e., verbal-digital) and 2) its modifying emotional metamessage (in ordinary conversation usually unstated, nonverbal/kinesic-analog). Foul-ups between levels give rise to contradictions and paradoxes (binds).
P4 Communication is cybernetically patterned. Relationships are cyclical and mutually reinforced. Cyclical feedback acts as both behavioral reinforcement and cybernetic control! A powerful application of this premise is in assessing power allocation in relationships (see Theme 7, pg. 23).
P5 The content of communication tends to ‘decay’ toward entropy. (This notion is theoretical, derived mathematically in physics, and is not included in the schema.)
It is important to emphasize that in marital-family (MF) work we are interested more in what goes on between people than what may be happening inside just one person’s head. Feelings and thoughts, hopes and memories are the rightful domain and focus of psychology and individual psychotherapy.
While a knowledge of ‘pragmatic’ communication is valuable in therapy, it is not at all essential to the use of the diagnostic schema. In fact, the schema stands on its own. Almost any interactive method dear to the MF clinician fits in. The occasions when a communication approach is preferred will be clearly specified as we go along. Now, without further ado, we cut to the chase with outlines of each of the themes in order.
THEME 0 – Overall Climate
One of the main reasons for including a ‘general climate’ category in the schema is to get the unhappy tendency to premature closure over and done with right off the bat. MF climate is the general impression a stranger gets, a cluttered flood of unsorted, but nevertheless valuable, information. Take a first impression as all people do, then reopen your mind.
All helping people usually want to help – and quickly – and tend to fall into the trap of formulating an opinion before they should. Then they become locked into it. Recognize the trend; deliberately resist any initial ‘final’ judgement! In general, disturbed marriages are intense, families complex. A whole family can be quiet and still or a bundle of noisy chaos. A couple might be in open conflict or fake ‘normality’ or emanate simmering tension. Ask yourself: Is the atmosphere tense? Is the couple silent? Do they face and speak to each other or tend to turn away and talk to you? If a family group, is it chaotic, with children climbing all over the place? Or, are things very controlled—do the kids sit in a row like little robots? How is everyone dressed? Use all your senses. Are they clean? Is there the gamy smell of unwashed children? Is there a sense of humour afloat?
There is a strong compulsion for angry and distressed people to launch immediately into diatribes against one another (the game of “Ain’t it awful!”) and then whine about how miserable they feel. Such is acceptable, even encouraged as ventilation, in 1:1 psychotherapy, but is anathema to constructive marital counselling and family therapy, as it leads to taking sides. It should be duly noted and quickly deflected. Incidentally, the common offer to ‘bury the hatchet’ is usually proffered by the ‘guilty’ party. One can agree to a truce, but don’t be hoodwinked! By the same token, pleas to ‘forgive and forget’ are always naive. Short of dementia forgetting is impossible; forgiving is a choice, but one first must know exactly what to forgive. That requires detailed (mutual) confession of specific wrongdoing—which, if care is not taken, may again start up the ‘Ain’t it awful’ game.
HINTS: Master therapists, seemingly without effort, often come up with a diagnosis and start treatment amidst initial chaos.  But, let the magic come later. Just jot down a phrase or a few words that come to mind. Capture an instant portrait of the marriage or family. Of course, this early approach is intuitive and quite unscientific, but you will soon systematically delve into and step by step sort out the details.
THEME 1 – Socioeconomic status (SES)
Three linked factors help define SES: 1) income and job, 2) educational level achieved, and 3) place and type of abode. With these indicators we can estimate five fairly distinct levels, ranging from upper to middle to lower social class. Class 3, the middle class, is further divided into upper-i, middle-ii, and lower-iii levels. Overall, it is a good enough method, possible to assess almost at a glance plus a question or two. After all, we are not doing a rigorous sociological survey. (Education also may be graded on a rough scale: no school-0, grade school-i, high school or part-ii, college and university-iii, PhD. or professional-iii+.)
Different social ‘classes’ can pose different kinds of problems: e.g., ennui/greed in SES1&2; a focus on material wishes in SES3; need-striving in SES4; destitution/deprivation in SES5. So-called skid row bums and bag ladies are in SES5 and rarely if ever are seen in MF work. Those with very low income and welfare recipients often living in subsidized housing ghettos, comprise SES4. Their problems are protean. Those in SES3 are nowadays increasingly caught in a financial squeeze; it’s hard to run the SUV—what with skyrocketing gas prices! College students, while often living at the SES4 level, are all in SES3. Upper SES3 and SES2 consists of professionals, independent businessmen, and rich celebrities. They usually are too secretive and busy to attend conjoint marital counselling or family group therapy and their marriages and families suffer all the more. Business magnates, royalty, etc., are in SES1. They most certainly have MF problems too, but generally prefer not to consort therapeutically with social inferiors.
Bad times can hit anybody and good times sometimes are a matter of birth or luck as much as hard work. An economic recession and job layoff can easily, almost overnight, bring a middle class couple or family down to SES4. Winning a lottery can suddenly shoot them up to SES3i; but it wont do the same for all; some people crudely act ‘low-class’ and spend it all in short order. A divorce, except for the very rich, almost always can be relied upon to reduce all members of a family by at least one SES notch while helping to keep their lawyers’ families in upper SES3. If you see a wide discrepancy in social class of origin between married partners, it could be a clue to trouble. An old rule of thumb was that women, but not men, could marry upwards. This is probably not true anymore, but, if there is a double social class leap in the relationship, e.g., a woman from class 4 marrying a class 2 man, beware. While such a couple may be very much in love, the cultural discrepancy, and all of the ways of living that go along, might be too great for them to surmount. The same is true for inter-ethnic liaisons.
HINTS: Keen observation, listening for subtle hints, and one or two discretely put questions can quickly establish the SES of a couple or family. In the schema the numbers 12345 refer to standard sociological class levels. Job, education, and home not only reflect material worth and social class level: Cross-referencing SES with other MF functions can confirm otherwise seemingly vague and obscure trends. It may cast a light on or give clues to cognitive style (T4), that is, quality of thinking, planning ability, impulse controls, and dealing with challenges or problems. SES may, as well, hint at traditions and values (T5), and so on. At first, just use your eyes. Leave questions till later. Circle the seemingly appropriate SES number, perhaps jot in a note about ethnicity, and move quickly on to other themes.
THEME 2 – Marital-family development and structure
Marriages and families, as shown in the schema, go through a developmental cycle of overlapping phases: FOO-1: families of origin. CS: courtship. H+W: man and woman alone together, married or common law. 1Ch: the addition of the first child – a quite critical stage. Ch rearing: the period of raising little kids and children. Teens: the period when the offspring are maturing and testing. Ch leaving: the time of leaving home. H+W: a couple, alone, again. D: death of one spouse, widowhood. FOO-2: families of offspring.
At the beginning of this ever-repeating process, the couple or young family relates backwards to their two original families of origin (FOO-1). This is the time of help and assistance from in-laws – or they may pose problems. At the end of the cycle the ageing couple is relating to the families of their offspring, grandchildren, new in-laws, etc. (FOO-2). The 8 phases between FOO-1 and FOO-2 overlap and blend into each other. Each developmental phase poses its own particular problems. For example, having little money, a new baby, or raising young children is quite different than being older and reasonably financially secure. Dealing with teens, retirement, and ultimately, death – each pose their own special problems. Over 300 different kinds of potential problems can be anticipated when MF development is considered.
There are life styles other than the ‘typical’ marriage and Western nuclear family. Basic MF structural organization informs development: One partner may be years older than the other, there may be a single mother, or a step-father and children from several prior families, the product of previous divorces. There may be in-laws present, a living-in elderly grandparent and so on. Note that childless couples forever remain at the left of the family cycle. I saw old-fashioned extended families, all living under one roof, in general practice only. Modern extended families happily still exist. They consist of three or more generations living separately, in frequent contact. Maybe this family form tends to remedy problems at source, early.  Structure may also be viewed in less obvious terms: evanescent groupings, power structure, or repeating patterns. MF power allocation is so important that it is dealt with quite separately as Theme 7. Groupings and patterns (dyads, triangles, coalitions) comprise Theme 10. As we shall later see, the latter is the core of focused assessment and several specific, definitive diagnoses.
HINTS: In addition to quickly estimating and circling the obvious – where the whole family is in its cycle – unobtrusively mark where each individual is in his/her personal growth and development. Note and document MF structure: e.g., single parent, elderly husband-young wife, afterthought children. You will then have a good clinical record with clues to problems to be expected and a template/guide to what accessory counselling you may need to do. Finally, deal cursorily with family development at first, the same as with overall climate and SES, and move promptly on.
THEME 3 – Urgency
Marriages and families can experience three types of urgency: they may be in the throes of a crisis, or the grip of an impasse, or have a true emergency. There are variations in degree of urgency as well as type.
An emergency in medicine is a biological threat to life or limb. Immediate help is mandatory. In MF work, an emergency is any threat to the continuation of a viable marriage or the integrity of the family group. Actual separation – of children from the family or between spouses – is the most powerful example of ‘death’ of a family as an intact group. Impending separation is less an emergency than a crisis. Domestic violence may be triggered by some crisis, but is in itself an emergency. Physical or sexual abuse and a child taken away for protection is an emergency. In each case the couple or family must be promptly seen and help started, right away. Serious exigencies – crises that cannot be predicted – may well be genuine emergencies. For example, loss of a home by repossession is a crisis; but, by fire in winter it constitutes a family emergency. Disasters and catastrophes that hit whole towns (floods, earthquakes, tornadoes) are in a category of their own, but are emergencies for each involved family. Anything that can be foreseen, by definition is not an emergency – until it happens. Anticipatory guidance can often reduce the psychological, if not the biosocial, impact.
A crisis is some disruptive social change short of an emergency. A distraught mother rushes her child to the hospital with a broken arm. The child has an emergency; the mother is in a crisis. In his great novel, Les Miserables, Victor Hugo took the convict, Jean Valjean, through one successive crisis after another. With timely help from ‘significant others’ he became progressively stronger and wiser. Researchers at Harvard, a century later, rediscovered the crisis concept.   Examples of potential family crises: loss of work, failing a year at school, starting kindergarten, winning a lottery. Unpleasant and even tragic situations, if predictable, likely lean more toward crisis than emergency. Sometimes a number of different crises, descending all at once, moves the situation up the ladder into the emergency category. If you have a couple or family in crisis, time is of the essence. A solid working acquaintance with crisis intervention is recommended for MF workers. Some kind of resolution within about six weeks is necessary to prevent the crisis from becoming a fixed or rigid impasse, characterized by grumbling and blaming or even a slide into visibly impaired mental health. A great deal more can be done in the first days of a crisis than in six months if the problem has been allowed to sit and has gone on to chronicity. If you suspect a genuine crisis, the family or couple should be seen within a week, at most two weeks, of its onset. While crisis intervention is a valuable method, crisis anticipation is even better. Both approaches combine prevention with active treatment.
A state of chronic impasse is the commonest situation we see in all dysfunctional marriages and families! Even in hot and yelling ones. Impasse occurs when the chance of the moment has been lost, that is, emergencies and crises have not been dealt with in a timely fashion and have deteriorated into painfully repetitive and predictable maladaptive patterns. As we will later see, while crisis characterizes symmetrical couples, impasses commonly occur with complementary couples whose relationship has ground down into fixed rigidity. To reiterate, we can realistically predict that counselling will take months, not weeks, once a rigid impasse has supervened.
People are conditioned to expect to be placed on a waiting list. But upsets and flaps flaring up as a crisis within an overall impasse are the commonest tickets of entry into counselling Capitalize on them. Try to quickly arrange an initial evaluative session to determine if the ‘crisis-in-an-impasse’ is bona fide. If so, treat it with standard crisis intervention techniques. If not, place the couple on a list with a view to later ongoing long term help. If at all possible avoid lengthy waiting lists. The neglected secret of cue theory is loose, easygoing, but clear organization. That means saving flexible loop-holes of free time to be used only for a shot at crises or emergencies. The notion that everyone should be seen in the exact order they apply is misguided; you will get bogged down and your reputation or that of your agency will suffer. The counsellor should personally, by phone or face to face, make the judgement of degree and type of urgency. Most people report the most long-standing problem (even a trivial event) as a crisis or even an emergency. This is usually the result of subjectivity and long neglected problems coming to a painful head. Unfortunately, or fortunately, depending on how you look at it, you must make the decision as to how soon couples and families will be seen. Most secretaries are not equipped to do so unless they are thoroughly prepped, by you, in your particular form of triage. My own rule of thumb is this: If an emergency is strongly claimed by phone, the receptionist puts the call through immediately. Then, even if I’m pretty sure the caller is exaggerating, I give the couple or family the benefit of the doubt. They are seen within a few hours or a day or two, depending. The picture comes out in half an hour or so face-to-face, and future appointments can be scheduled accordingly. Couples and families in ongoing treatment are seen in the evening. First-time appointments during the day. This is done deliberately, to protect committed couples from interruptions while exposing new ones to my own busy reality.
In the long run the squeaky wheel does not get the grease. The most hysterical caller is easily calmed down by a calm, concerned professional voice. I’m often most concerned about the self-effacing person or couple that plays down a crisis to a secretary. But, when all appointments are reasonably prompt, few serious mistakes are made.
HINTS: ‘Normal’ marriages and families seen by therapists are always in a crisis. Dysfunctional ones run the full gamut. In the schema you’ll notice that type and degree of urgency are closely related to the next theme, problem recognition and solving, and quite logically so. Amazingly, if you have been working wisely, you haven’t yet asked hardly a single question in this first session with the couple or family. Everything you already know was reported by phone; what you don’t know is seen directly as those present are settling down. Only a few moments have passed.
THEME 4 – Problem recognition and solving
Now is the time to get things rolling. The first few questions asked depend upon what is in front of you. The approach is determined by whether it is a family group or a married couple. Civility is absolutely essential, as clinical expedience is not always perceived as politically polite.
In marital counselling, without looking directly at either one or the other partner, ask a neutral, open-ended question: How may I help you? or What brings you here? Or some such. The important thing is to avoid any direct eye contact until one of the spouses starts talking. Then you will immediately learn who is the spokesman or spokeswoman – and other things, too. You’ll note if one defers to the other or if they begin to argue. (This is an indicator of complementarity or symmetry; addressed in Theme 7.) If a couple starts the game of mutual put-downs, stop it, stat! Else future prospects of constructive therapy will be compromised. (A useful trick is found under T6.) Closely discern a couple’s level of sophistication, that is, whether or not they phrase their difficulties in problematic or relational terms. (This latter will become clearer below.)
In family groups, by contrast, it is usually best not to do what has just been suggested for couples. Rather, look at, focus on and ask the youngest child present his/her age, interests, favourite games or TV programs, grade in school, etc. Then go on to the next youngest, and so on up the line. Give a minute or two of your undivided attention to each child. Leave the IP and parents to the very last. (Don’t be deflected by an anxious parent trying to get you down to business. If you give in you may be closing the door to all future input by the children.) In this way, pleasant conversation is encouraged, children are shown that their views are important, and you have avoided a predictable first-instant singling out and dumping on the family’s IP. If you allow any zeroing in on the IP right away, he or she will not find your office a haven. Also, a negative individual – monadic – orientation may get the upper hand. It then will be much more difficult to establish and sustain a true family orientation.
A common problem, for therapists, is getting the other side of a marriage or everyone in a family to attend, ‘sick’ or not. Constructive marital counselling can be done through just one partner, but it is always potentially dangerous.  By repeatedly listening to one spouse complain about the absent one, your nods and grunts of understanding can be misconstrued as agreement and negatively acted upon, fed back to the other with unpleasant results for each other, and you. Make active efforts to get both parties in. Obviously, the onus is on the original client, but you may, with permission, phone and try to persuade an absent partner to attend. When it comes to families, many parents still expect child guidance or individual play therapy. They would like to present an upset child and have you wave your magic wand and fix it. Do not get sucked in if you are sincerely oriented and committed to family group therapy. Stick to your guns. Some low key persuasion is quite acceptable. Do a bit of education about the efficiency and efficacy of family group therapy. Sometimes, later, after you have firmly established that you work within the total family framework, a child might be seen separately. First contact with an angry adolescent is an altogether different kettle of fish. Leave both parents in the waiting room and see the young person alone. After 15 minutes or so invite the parents in also. Never send the teen out while doing this.
Another problem for therapists, and it bears repeating, is a serious outbreak of marital hostility in the office. If such has started in a first session, set limits in a hurry! Or future constructive help may become almost impossible. Gradations of intervention: Some mildly coercive peacemaking is first, mandatory, then can come persuasive negotiation through appeal to good sense. If yelling and fighting gets too heated, even physical, in an office, and it does happen, insist that they stop it at once or leave. At almost all costs avoid calling the police to your office. The place of therapy must be preserved as a place where open fighting is reconditioned, redirected into words. And that means: none of it, absolutely no loud yelling or physical fighting allowed. If you do therapy on a home visit, and such is very good practice from time to time, while their home is always their home, it temporarily becomes your office and your civilized rules must apply.
A problem for therapists alone pertains to their own marriage. Often they are able to recognize and pinpoint their own marital difficulties. Less often are they able to correct them personally. The best advice is to seek help from an outside ‘subjectively-objective’ colleague. Having problems of your own does not disqualify you as a MF worker as long as you are doing something about them.
Heretofore we have been using the word ‘problem’ quite loosely. The use of words in MF work should be almost as precise as the use of numbers in engineering. The next few distinctions will make this point clear. There are two basic kinds of difficulties in marriages and families: instrumental and relational. 1. Instrumental problems have to do with security and sheer survival. They often boil down to material or money issues. 2. Damned if you do, damned if you don’t dilemmas and ad hominum disputes (I’m right because you’re stupid, stupid) are the chief ‘problems’ of all human relationships and, ipso facto, of the MF trade. Relational difficulties are usually much less clearly defined and more poorly understood than run of the mill instrumental problems. They are not readily recognized by the people involved. ‘Problems’ in this area stem from how well we see ourselves being seen, understood, and treated by others, and how well we see, understand, and treat those very others. Relationship difficulties involve feelings, roles, pleas, and a gamut of relatively ineffable existential issues. They often seem irreconcilable, unsolvable. The term ‘substantive issue’ is applied to the number-one concern, whether that be dilemma, disagreement-dispute, or straightforward instrumental problem. Below is a concise summary:
PROBLEMS: Mathematicians solve problems; it’s as simple as A to B; there is a right answer, all the rest are wrong. Medical examination and specific diagnosis clearly is a form of problem solving—correctly finding a disease to treat. In therapy, couples and families are usually pretty good at recognizing substantive instrumental problems. They might be hard to solve, but a solution there usually is, if looked for hard enough. Figuring-out is the cure. For example, if the problem is financial mismanagement, simple budget counselling sometimes helps. In the meantime, a visit to the local food bank may be in order. 
DISPUTES: Wherever one is in the world, angry relationship messes pose quandaries rather than solvable problems per se. People often phrase them in terms of disagreements and display them as fights. They usually are unable to clearly articulate such core issues as disconfirmation, or even simple repeating patterns! Futile attempts at ‘solution’ run the gamut of arguments and fights, withdrawal and separation, even getting emotionally ill. People rarely can talk things out at home on their own if sufficiently dysfunctional to need help. Most people with angry relationship difficulties let them alternately simmer and flare up. A few have sought help from relatives, friends, family doctors, clergymen, and so on, possibly to little or no avail. Disconfirming disputes can spiral up almost exponentially. They cannot be solved or even decided; they must be toned down and resolved. When all a couple wants to do is heatedly argue or be silent, it usually takes patience and all the skill of a dispassionate third party to get constructive talks going. Resolution through learning how to talk politely is the easiest and most ordinary ‘solution’.
DILEMMAS: Making the distinction between solvable problems and unsolvable dilemmas is absolutely critical in MF work. There are no right or wrong answers to ‘damned if you do, damned if you don’t’ dilemmas; instead, unpalatable choices are often required of the adult parties involved. When just one person is on the horns of a dilemma it is hard enough. When two people share the same dilemma and cannot agree or agree to disagree, the difficulties begin to bog things down. Lists of pros and cons don’t decide dilemmas, but they get people thinking and help clarify them. The ultimate remedy is tincture of time, taking responsibility, and making a tough decision.
Solve a problem, resolve a dispute, decide a dilemma.
As you can see or surmise, instrumental and relational complexities often get so mixed up together and almost totally confused, that just sorting them out must become your own first objective. Is this a problem? Is that a dispute? Is this a dilemma? In ordinary counselling, all that can be done at the outset is to document ‘problems’ as perceived by each individual. Even those that little children point out! At the beginning, a couple together is rarely able to clearly articulate their difficulties. If they could they’d already be resolved if not solved. A whole family is often a bundle of noisy or quiet chaos, as a group quite incapable of seeing things jointly. While their clients at first are hoping for pat answers in a ‘medical’ sense, good therapists will almost always be looking for the underlying dilemmas and the core of disputes. If you can make a clear distinction between instrumental problems, dilemmas, and disputes, you will more quickly get the marriage or family moving toward the appropriate solution, decision, or resolution. The good therapist, along with starting this sorting out process, will give credit for previous help sought, however ineffectual it may have been.
In the meantime, keep them talking civilly during sessions, not freezing each other out or fruitlessly carping and arguing. Recondition them by wearing them down! For relational dilemmas and disconfirming disputes, talking, and talking, and more talking is the surest ultimate cure! Get them to listen also. Getting an individual to freely talk is the psychotherapist’s stock in trade. Getting a married couple to openly talk with each other and truly listen to the other is the MF therapist’s stock in trade. They’ll eventually start making decisions and stop fighting regardless of what other tricky things you do or don’t do.
HINTS: In the shaded area, document the main instrumental problems and relational dilemmas or disputes that are recognized. Recognized by them, not by you. Insert your opinion beside theirs. Signify who brings the issue up – wife, husband, or both. Heed closely the observations of the children! They often are more keenly attuned than their parents. Note down how everyone reacts. Note the couple’s prevailing style of dealing with problems, dilemmas or disputes. Note whether they even notice dilemmas as such, or perhaps optimistically label them as solvable problems. Take ample time with dilemmas. Incidentally, it is noteworthy that ongoing dreams may give the perplexed person a clue to the ‘right’ choice!
THEME 5 – Sexuality
Love and sex run through many themes, especially values (T6) and affective exchanges (T9). Sex, to put it bluntly, is the universal playtime of the human species if all else fails. Lust (sex) and love (affection, romance, etc.) should blend together in harmony. If not, there is a problem.
Sex is a four-step physiological process: 1) Rising excitation (erection in men, lubrication in women), 2) Plateau (continuation of vascular engorgement in both), 3) Orgasm (rhythmic movements in the female, ejaculation in the male), and 4) Resolution (male refractory period, female variable). All of this must be orchestrated in sequential harmony – multiplied by two. That it ever works is a bio-psycho-social miracle! Evolution has been kind.
Physical sexual problems can be the main reason bringing couples into counselling, and problems in this area can underlie overall family dysfunction. It is an area that is explored with the adults, together or sometimes separately, without children present. All MF therapists should be familiar with at least the names of the six main sexual clinical syndromes, three affecting women (vaginismus, anorgasmia, general unresponsiveness) and three affecting men (impotence, premature ejaculation, retarded ejaculation).   
A number of other issues may require exploration: One partner’s sex needs may outweigh the other’s, giving rise to frustrations and resentments. ‘Love-sickness’ (twitterpation) is real and common. As we all now know, it is mediated by brain chemicals including PEA and endorphins – the chemistry of love. There may be feelings of jealousy that can progress to a genuine pathological syndrome of mistrust and extreme possessiveness. Triangles and extramarital affairs may or may not be voluntarily revealed. The emotions associated with rejection and loss represent a form of the abstinence syndrome. The clinician must ‘listen with a third ear’ for the many varieties of dysfunctional sexuality. 
If sexual abuse or incest has been the problem, it may be explored conjointly with forensic safeguards. Reporting of child abuse is mandatory in most jurisdictions. Such must be done very cautiously and sensitively or the family will be lost to therapy. They might fire you for making their mess ‘public’. The police and child welfare often take over completely, and the focus almost inevitably shifts from help for the victim and family to punishment of the perpetrator. I believe that independent therapists should stubbornly hold on to ensure a modicum of help for all.
HINTS: Viagra may be with us, but there is still much scope in MF work for dealing with sexual problems and all the issues surrounding love. My advice to the average counsellor is: refer all medical syndromes and handle the disputes and dilemmas of love, hate and rejection.
THEME 6 – Purpose and values
T6 is a turning point in the schema: The first half dozen themes are usually within the conscious awareness of any couple or parent. Interpreting T4 can be tricky, but from T6 on, most people are essentially blind to what really is happening between them. Within these latter themes lies hidden the ‘true diagnosis’. Master therapists can effect dramatic improvements without imbuing any particular knowledge, insight, or ‘outsight’ on the part of a married couple or family.  They quickly get to the core of things and give subtle or overt directives that start the therapeutic process right in the first session.  They are able to do this by deliberately or intuitively reading the signals sent out through themes 6 to 10. Zero to T3 can be roughly assessed by barely exchanging a word. Seasoned workers will cut to the chase and skip right away to T4, problem recognition and solving. In day to day work two more themes also need to be quickly evaluated at the outset: T8, role behavior, and T9, emotional exchanges.
Theme 6, purpose and values, is a cluster of closely related functions. The husband and wife are said to be the architects of their own family, and their family serves as the vehicle for society’s engendering of mores and values in their children. Ethnicity often colours all. Society’s more formal vehicles for imbuing values are the law and schools; its most effective traditional vehicle is religion. The honouring or dishonouring of appropriate religious and societal values indelibly paints a marriage and hence its family.  We’ll now take purpose and values separately.
Purpose: Most couples are able to give at best only vague reasons for getting together in the first place and having children. In other words, there usually has been no long term plan or set of goals clearly thought through. “We got married because we fell in love.” “We had to!” Sometimes the decision is not to have any children. Sometimes children are desperately wanted, but infertility has become the central marital problem. It is the rare couple or family that sets the very deliberate social goal of producing a President as did the Kennedy’s in the USA. But marriage and the family do have several inherent, not consciously designed, purposes as follow: 
Biological: a) to provide a forum for legitimate sex and, b) to procreate. Ask: “Are these spouses true lovers?” Acronym: PP – pleasure/procreation.
Psychological: Nurturance (affection, love) and control (guidance, discipline) are cohesive qualities. They enhance and cement ties between spouses and set the emotional stage for rearing children. It is noteworthy that people sometimes get married to be guided or reigned in by their partner, for purposes of outside control, but it might not be admitted at first. Consider this question: “Are these spouses companions and friends?” (We will define what ‘companion’ and ‘friend’ mean later on; think about these words in the meantime.)
Social-economic: a) From time immemorial the efficient making, saving and spending of money was at the core of many marriages and families. Less so now, but still a factor, as two can still eat more cheaply than one. b) Status and friends, high and low, conferred or aspired to, is a core social theme. c) Sense of family converts mere space to place. 
A very useful question to ask disaffected couples is, “What unique, good quality did you see in him/her that decided you to make him/her, of all other possible people in the world, your spouse?” This not only helps to get at purpose and values and lost hopes, but it sets a positive tone for therapeutic improvement. It is particularly helpful in stopping carping, blaming and name calling.  (A bit of fun and humour helps too.)
Ethnicity is not always immediately apparent. But, if it is, it is usually pretty obvious in dress, language, caste marks, etc. Traditional old world European, Asian, and African couples tend to steer their families away from Western-style therapies. Beliefs may mitigate avoidance of professionals of a different colour or religion. Firmly held values and contact with extended families and the ethnic community are inherently stabilizing. Some ethnic persons, however, while regularly attending a doctor’s office for physical problems, may be silently suffering severe MF difficulties. Often such is associated with acculturation in an alien society, but it can be that an individual is locked into a harsh, dictatorial marriage. Should an ethnic couple turn up, ostensibly about a child, the therapist might do a quick library study of their cultural background. Meanwhile, it is best to maintain a respectfully formal but warm stance. Hale and hearty American familiarity is ill advised with most ethnic couples and families.
Values have to do with broad cultural and narrower family backgrounds. For example, old-country Italian, Irish, German, or Islamic cultural values and styles may conflict with certain North American ideas of life. Even on this continent, Afro, French, and Hispanic styles differ. Intermarriage must deal with these issues. On the narrower front of family background, one family of origin may have engendered a strong work or religious ethic while the other spouse’s family of origin may have been more laissez-faire. Or, perhaps one spouse highly values the merits of education while the other emphasizes getting out to work early.
The values claimed by a family usually are readily trundled out. What they really believe and do may be quite different. Regardless, values become more deeply ingrained as the family grows older. Younger couples in counselling may still be hiding the truth from each other about the values they hold. When the honeymoon is over and differences start to show, there often are complaints like, “He isn’t the person I married,” or, “I didn’t bargain for this, the contract’s broken.” Obviously, then, marital and family difficulties can stem directly from differing values. Each couple, usually while in the early throes of child rearing, must forge an amalgam of their combined families of origin. A few important value-related topics follow:
Work and the work ethic and the division of labour: Are both adults working outside of the home? Do they share tasks at home? Are household tasks divided along traditional sexist lines? Does each feel fairly done by? What about the children: Are they learning to share work tasks? Do they have chores to do? Or, is it all too rosy for them? Maybe the family has maids and butlers and chauffeurs…
Play: How is time divided between work and play? If there is leisure time, how is it used and for what? Does the wife do her own thing, and the husband his, exclusively? They each should have some time alone, but there should be time together as a couple, and time together as a whole family. The apportioning of this can become a problem of priorities. Perhaps the couple and family have been swept up by the busy world and lost sight of the importance of having fun. On the other hand, there can be all too much leisure time and they don’t know how to use it well, or are getting caught up in each other’s hair. Too much time together, too much boredom. This sort of thing, too much leisure and not enough money to fill it with fun, can happen in welfare families, when people are laid off, or during the retirement years.
Sexual values may also require basic therapeutic-diagnostic exploration. The nuclear family circle is internally divided by imaginary lines as in the little circle at the bottom of the schema. The horizontal lines separate the generations, parents above, children below. Sex between husband and wife is normal and desirable. Any sexual crossing over of the horizontal broken line is dysfunctional, abusive. A vertical broken line is drawn between the children. Sibling sex, heterosexual or homosexual, is incestuous.
Thus, M-F purpose and values are a crucial part of assessment. The success of therapy itself may depend upon the worker’s understanding of what is important to the couple or family he/she is dealing with.
HINTS: Values – religious, ethnic, artistic, educational, work, play, sexual – and family purpose and are crucial and in many cases need to be delved into. Mostly, however, it is more feasible still to wait and watch. Again, skim over this theme at first. If the marriage or family has a consciously determined purpose, jot it down, tongue in cheek. It’s likely to be a rationalization. Keep an ear and eye out for apparent values and value conflicts while problem recognition (T5) is explored. Delve into specific areas at this time only if brought up and you also deem the issue highly significant. Do not get sidetracked, until, at least in your mind’s eye, you’ve reached Theme 10.
Themes 7-10, normality, integration, and notes 24-on, are continued in Knol CFC – Part 2.
Notes for Knol Part 1 are below.
NOTES & REFERENCES (1-23 of 32)
 Ordinarily we see only what we know. To know is to learn to observe and recognize what we observe. The schema, being open-ended as well as versatile, enables us to look for more than what we already know – to explore. Once we are in a mode of open-eyed looking, we may begin to discover what nobody yet knows. We then can put our new knowledge to the test through evaluation. I pieced this rational, common sense approach together over some decades of clinical work. Anyone, in this sense, can be a scientist. Hence an ‘ode’ to therapists: 1) Know to Observe. 2) Explore to Discover. 3) To confirm, Evaluate.
 Science looks at cells within organs and chemicals within cells. The CNS stores learning in memory. DNA stores information in genes and transmits it ‘mindlessly’. Underlying and organizing all things physical is evolution and the genetic code. Similarly, we have been able to break the family down into clinically manageable themes. Unifying these is communication, the family theorist’s genetic code. In the widest sense communication creates social evolution.
 Ruesch, Jurgen and Weldon Kees. Nonverbal Communication (Notes On The Visual Perception Of Human Relations), University of California Press 1959. This fine book is full of excellent photographs with good commentary. Ruesch was the pioneer of communication theory as applied to human relationships. He wrote a number of books on normal, disturbed, and therapeutic communication that are recommended reading for anyone seriously interested in exploring the subject. Ruesch displays a semantic cultural bent. One typical small observation on the idiosyncrasies of American communication: The Pilgrims left a legacy of prim righteousness (in the American group psyche) that conflicts with the free and aggressive residue of a cowboy culture. Thus we get fundamentalist religiosity side by side with punitive violence. I suspect these contradictory qualities infect and doom many marriages and families.
 Watzlawick, Paul PhD. An Anthology of Human Communication, Science and Behavioural Books, Inc., Palo Alto, CA 1964. This small booklet accompanies an audiotape that is an excellent introduction to pragmatic communication in the clinical setting.
 Jackson, Don D. MD, Paul Watzlawick PhD., Janet Helmick Beavin AB. Pragmatics of Human Communication, (A Study of Interactional Patterns, Pathologies, and Paradoxes). W. W. Norton Company Inc., New York 1967.
 Claude Elwood Shannon, Collected Papers, Edited by Sloane and Wyner, Institute of Electrical and Electronics Engineers, Information Theory Society, New York 1993. 1000 pages. Pragmatic communication corresponds with the mathematics of Information Theory. A fifth premise has little practical therapeutic use: The information in communication tends to decay toward entropy (or chaos). If any analogy to physics is perchance ventured, the 2nd Law of Thermodynamics, not energy conservation, applies.
 Transactional Analysis (TA) is preferred by many. Although an airtight scholastic system, it is easily applied, so its use in MF work is highly recommend. The popular book, Games People Play (The Psychology Of Human Relationships), by Eric Berne (Grove Press, Inc., New York 1964), is an enjoyable TA-starter. Any method used in marital counselling or family therapy should be primarily interpersonal, aimed at what goes on between people. TA does so. Pragmatic communication, while theoretically ideal, is very scientific and may be a bit austere for some people. Purely psychological theories are intrapsychic or mind theories, designed to discover what goes on inside just one person’s head. Their scope is thus limited to individual psychotherapy. Such approaches include psychoanalysis and Cognitive Therapy. Their use as an overall MF approach is not advisable, in fact is contraindicated.
 Haley, Jay. Problem-Solving Therapy (New Strategies for Effective Family Therapy), Harper Colophon Books, New York & London 1976. To paraphrase Haley: Response to treatment is the best diagnosis. While such may be narrowly correct, it is not a practical criterion for just anyone to follow.
 Kornhaber, Arthur MD. Between Parents and Grandparents, Berkley Books, New York 1987. This paperback is priceless and should be part of every family therapist’s library. It explains why there can be a wonderful kindred feeling between children and their grandparents. The distinctive and essential roles of any well-functioning grandmother and grandfather are clearly given. These are: 1) a living ancestor and historian, 2) a natural safety net for the children when the parents falter, 3) a hero, 4) a wizard, and 5) a crony. With these tempting tidbits I leave it to the reader to go to the source.
 Caplan, G. et al. Prevention of Mental Disorders in Children, Basic Books, New York 1961. Classic.
 Caplan, G. Principles of Preventive Psychiatry, Basic Books, New York and London 1964. Seminal.
 Seeing disputatious partners separately is to create spurious organizational problems, namely a triangle with you at the apex – without proper controls. You can unwittingly escalate their differences out of all proportion. Divorce lawyers wittingly do it all the time to drive people yet more apart. And get big fees!
 In the Third World four riders of the apocalypse—poverty, famine, disaster and pestilence—render any easy Western solution incommensurately difficult. It may well be that MF dysfunction can stem from massive chronic social problems in underdeveloped countries, but, my impression is that it doesn’t necessarily. If everyone in a society is afflicted, well-functioning internal buffers stabilize marriages. The same is not true in pockets of poverty surrounded by affluence. In the ghettos of advanced societies, the male head often is absent as security for an abandoned wife, and proper role models for boys and girls are notoriously missing.
 Masters, William & Virginia Johnson. Sex And Human Loving, Little, Brown & Co., Boston & Toronto 1986. In the 1940’s Kinsey shocked and enlightened the public (and professionals) about the realities of sexual behavior. “Kinsey did for sex what Columbus did for geography.” Masters and Johnson revolutionized the physiological understanding of sex. Their pioneering scientific work is the foundation of modern sex therapy.
 Kaplan, Helen S. MD PhD. The Illustrated Manual of Sex Therapy, The New York Times Book Co. 1975. This coffee-table sized book contains sensitive and beautiful line drawings by David Passalacqua.
 Stoppard, Miriam MD. The Magic of Sex, Dorling Kindersley, Inc., New York 1992. This popular book for the lay person “really tells men about women and women about men.”
 Berne, Eric MD. Sex in Human Loving. Simon and Schuster, New York 1970. A little gem. Discusses sexual games, talking about sex, wet words, etc. Virtually no mention, surprisingly, of TA. Very worthwhile as an adjunct in the assessment of sexuality in general. Does not cover the specific six sexual dysfunctions.
 Outsight, a term coined by me, is seeing and understanding what is going on between people. All MF therapists must develop this capacity. It is a social skill. Its counterpart, insight, is self-understanding. Each needs to be distinguished from empathy which is conveyed understanding of another person’s feelings.
 Ibid. Haley. Paradoxical injunctions by a master therapist may circumvent lengthy discussion and effect a cure. Essentially it is ‘reverse psychology’ wrapped in a bind. One of my own favourite approaches, before getting too gimmicky: Do a present-past switch; ask each spouse to recall aloud the things they saw in the other during courtship, what wonderful qualities decided them to marry this one person over all others in the world. That will make the other sit up and listen!
 McGoldrick, Monica et al. Ethnicity & Family Therapy, The Guilford Press, New York & London 1982. This book is essential reading for all MF therapists.
 Reiss, Ira L. Family Systems in America. Dryden Press, 2nd Ed. This sociology textbook posits 4 universal family functions-purposes: 1) Reproduction, 2) Sexual relations, 3) Economic cooperation, and 4) Socialization of offspring.
 Walden, Scott. Places Lost (In Search of Newfoundland’s Resettled Communities). Lynx Images Inc., Toronto 2003.
 The notion of ‘forgive and forget’ as a blank cure-all is as nonproductive in marital work as the religious assertion ‘it’s God’s will’ or ‘let us pray’. Forgiveness needs specific qualification in terms of ‘forgive what?’ Once detailed transgressions of the past are ‘forgiven’ a conditional present and future relationship is possible.
Questions? Please contact me. firstname.lastname@example.org