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Family Assessment Measure (FAM) and Process Model of Family Functioning

Harvey Skinner,a Paul Steinhauer,b and Gill Sitareniosc

This paper provides an overview of twenty years’ work in the development of the Family Assessment Measure (FAM), based on the Process Model of Family Functioning. The Process Model describes a conceptual framework for conducting family assessments according to seven key dimensions: task accomplishment, role performance, communication, affective expression, involvement, control, values and norms. The FAM provides measures of these dimensions at three levels: whole family system (general scale, fifty items), various dyadic relationships (dyadic scale, forty-two items) and individual functioning (self-rating scale, forty-two items). In addition, the general scale includes social desirability and defensiveness response style measures. Brief FAMs (fourteen items) are available for each scale as well. The measurement properties of FAM have been evaluated in a variety of clinical and non-clinical settings. Reliability estimates are very good in most contexts. FAM’s validity has been supported using a number of tech- niques. Overall, the weight of the evidence is that FAM’s effectively and efficiently assess family functioning and provide strong explanatory and predictive utility. This empirical evidence reinforces experiences of clini- cians, indicating that FAM provides a rich source of information on family functioning.

Introduction

Families are complex, ever-changing systems. This complexity creates many challenges for those involved in family assessment, therapy and research. For example, what emphasis should be placed on characteristics of individual members, their various inter- actions, or the family system as a whole? In addition to differing

 2000 The Association for Family Therapy and Systemic Practice

 The Association for Family Therapy 2000. Published by Blackwell Publishers, 108 Cowley Road, Oxford, OX4 1JF, UK and 350 Main Street, Malden, MA 02148, USA. Journal of Family Therapy (2000) 22: 190–210 0163–4445

a Professor and Chair, Department of Public Health Sciences, Faculty of Medicine, McMurrich Building, University of Toronto, Toronto, Ontario, Canada M5S 1A8. E-mail: [email protected]

b Professor Emeritus, Departments of Psychiatry and Public Health Sciences, University of Toronto.

c Director of Research, Multi-Health Systems, Toronto.

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individual, dyadic and whole system levels within the family, there are differing viewpoints from which assessments may be made rang- ing from insider (family members) to outsider perspectives (e.g. clinicians, researchers). Another important consideration is the relative focus on family history versus current functioning. These challenges stimulated our work on developing the Process Model of Family Functioning and the Family Assessment Measure (FAM) (Steinhauer et al., 1984; Skinner et al., 1995).

The Process Model provides a framework for integrating differ- ent approaches to family assessment, therapy and research. The Family Assessment Measure was designed to assess the seven constructs of the Process Model. The FAM is relatively unique in that it provides indices of family strengths and weaknesses from three perspectives: the family as a system (general scale), various dyadic relationships (dyadic scale) and individual family members (self-rating scale). The FAM was designed to be used as an assess- ment tool in clinical and community contexts, as a measure of ther- apy process and outcome, as well as for basic and applied research on family processes. This paper reviews the Process Model of Family Functioning, describes the development of the FAM, provides guidelines on its clinical use, and then gives a synopsis of research using the FAM.

Overview

The Process Model of Family Functioning provides a conceptual framework for conducting family assessments (Steinhauer, 1987; Steinhauer et al., 1984). This model provides a means of organizing and integrating various concepts into a comprehensive yet parsi- monious framework. Both our Process Model and the McMaster Model (Epstein et al., 1993) were derived from a common ancestor: the Family Categories Schema (Epstein et al., 1968).

The Process Model integrates seven basic constructs (Figure 1). The overriding goal of the family is the successful achievement of a variety of basic, developmental and crisis tasks (task accomplishment). Each task places demands that the family must organize itself to meet. It is through the process of task accomplishment that the family attains, or fails to achieve, objectives central to its life. These include allowing for the continued development of all family members, providing reasonable security, ensuring sufficient cohe- sion to maintain the family as a unit, and functioning effectively as

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part of society. The process by which tasks are accomplished includes: (1) task or problem identification, (2) exploration of alternative solutions, (3) implementation of selected approaches, and (4) evaluation of effects.

Successful task accomplishment involves the differentiation and performance of various roles. Role performance requires three distinct operations: (1) allocation or assignment of specified activi- ties to each family member; (2) agreement or willingness of family members to assume the assigned roles; and (3) actual enactment or carrying out of prescribed behaviours. Essential to the performance of these roles is the process of communication. The goal of effective communication is the achievement of mutual understanding, so that the message received is the same as the message intended. If the message sent is clear, direct and sufficient, then mutual under- standing is likely to occur. However, the process of communication may be avoided or distorted by the receiver. Thus, critical aspects of the reception phase include the availability and openness of the receiver to the message. A vital element of the communication process is the expression of affect (affective expression), which can

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Figure 1 Process Model of Family Functioning

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impede or facilitate various aspects of task accomplishments and successful role integration. Critical elements of affective expression include the content, intensity and timing of the feelings involved. Affective communication is most likely to become blocked or distorted in times of stress.

The kind of involvement which family members have with one another can either help or hinder task accomplishment. Involvement refers to both the degree and quality of family members’ interest in one another. These two aspects may be used to describe five types of affective involvement including: the uninvolved family, a family which expresses interest devoid of feelings, the narcissistic family, an emphatic family and the enmeshed family. Other important elements of affective involvement include the ability of the family to meet the emotional and security needs of family members, and the flexibility to provide support for family members’ autonomy of thought and function.

Control is the process by which family members influence each other. The family should be capable of successfully maintaining ongoing functions, as well as adapting to shifting task demands. Critical aspects of control include whether or not the family is predictable versus inconsistent, constructive versus destructive, or responsible versus irresponsible in its management style. Certain combinations of these characteristics may give rise to four prototype styles: rigid, flexible, laissez-faire and chaotic. Finally, how tasks are defined and how the family proceeds to accomplish them may be greatly influenced by norms and values of the culture in general, and the family background in particular. Values and norms provide the background against which all processes must be considered. Important elements consist of whether family rules are explicit or implicit, the latitude or scope allowed for family members to deter- mine their own attitudes and behaviour, and whether family norms are consistent with the broader cultural context.

The Process Model of Family Functioning emphasizes family dynamics; it is not a model of family therapy. This distinction recog- nizes that understanding families and treating families may require somewhat different skills. The Process Model emphasizes family health as well as pathology. While it is important to identify dimen- sions that are relevant to family health pathology, the Process Model also attempts to define the processes by which families operate. Hence, the model emphasizes how basic dimensions of family func- tioning interrelate. Finally, the model emphasizes neither the total

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family system nor individual intra-psychic dynamics. Instead, basic family processes are considered with a clear acknowledgement that a variety of factors (whether intra-psychic or situational) may influ- ence these processes. Thus, the Process Model encourages formu- lation at both the intra-psychic and system levels (Steinhauer and Tisdall, 1984).

The Process Model differs from its predecessor (Family Categories Schema) and the McMaster Model in three significant ways. First, the Process Model goes beyond listing major parameters of family functioning and stresses how each affects and is influ- enced by the others. Second, the Process Model addresses and in- tegrates three levels (intra-psychic, interpersonal, family systems), whereas the McMaster Model is not concerned with integrating family systems/psychological theories. Third, the Process Model emphasizes the larger social system and family history (values and norms), which are not stressed in the McMaster Model.

Family Assessment Measure The Family Assessment Measure (FAM) was developed according to a construct validation paradigm (Jackson, 1974; Skinner, 1981). This strategy involved an active interplay between specification of the theoretical model of family functioning and construction of an instrument to measure concepts of the model (Figure 1). Thus, the FAM was aimed at providing an operational definition of constructs in the Process Model. The FAM consists of four self-report com- ponents: • General scale (fifty items, nine subscales): focuses on the family

from a systems perspective. This scale provides an overall rating of family functioning, seven measures relating to the Process Model and two response style subscales (social desirability and defensiveness). An example of a general scale profile is given in Figure 2 for three family members. Note that the mother (aged 48) and daughter (aged 19) identify several areas as problematic, especially communication and affective expression, although the father (aged 51) rates family functioning to be in the normal range (T scores around 50). He scores very high on social desir- ability and defensiveness which indicates that he is minimizing problems.

• Dyadic relationships scale (forty-two items, seven subscales): focuses on relationships between various pairs (dyads) in the family. For

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each dyad, an overall rating of functioning is provided along with an assessment for each construct of the Process Model.

• Self-rating scale (forty-two items, seven subscales): focuses on the individual’s perception of his/her own functioning in the family. An overall index is provided along with seven measures relating to the Process Model.

• Brief FAMs (fourteen items): each version of the FAM (general, dyadic, self) has a corresponding short fourteen-item version. These can be used to obtain an overall index of family function- ing in situations where there is limited time available and/or for preliminary screening. In addition, brief FAM scales can be used for monitoring family functioning over time (e.g. during the course of therapy).

Depending on the number of scales used, the FAM generally takes between twenty and forty-five minutes to administer and it may be completed by family members who are at least 10–12 years of age. A brief FAM fourteen-item version can be completed in around five minutes. Two methods of administration are available.

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Figure 2 Example of a FAM general scale

Task Com Invol V&N Defn Role AffEx Cont SocDY

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First, family members indicate their responses on the Multi-Health Systems QuikScore Form. After completion, the Form can be read- ily scored and a standardized T-score profile created for visual display. No special keys or templates are needed since scoring keys are incorporated in the Form. Thus, the QuikScore Form is self- contained and includes all materials needed to administer, score and profile the Family Assessment Measure. Second, the FAM can be administered, scored and profiled using a computer software program designed for the Windows operating system. Computer- generated narratives can be used for interpreting FAM score profiles and individual item responses.

Clinical guidelines for using FAM

The FAM will never replace a thorough clinical assessment. In the real world, however, most assessments are more or less incomplete due to time pressures. However, the FAM can provide a helpful adjunct to clinical assessment:

1 by pinpointing gaps in the assessment, which can then be explored clinically;

2 by identifying areas of confusion, as when different family members perceive the same phenomenon quite differently;

3 by providing an independent and objective validation of the clin- ical assessment;

4 by emphasizing differences in perception, thereby increasing members’ awareness that they perceive their family differently: this offers a starting point for circular questioning (Penn, 1982; Tomm, 1986; White, 1988);

5 by allowing non-verbal members, especially resistant adolescents, to register dissatisfactions that they failed to raise in a clinical assessment but are prepared to discuss when asked to explain their responses to the FAM, which offers a less threatening point of entry;

6 by providing a concrete and visual illustration (by the peaks and valleys in the graph) of perceived areas of strength and weakness. This may help in communicating the assessment and contracting for treatment;

7 by helping therapist and family define and agree upon goals for treatment;

8 by providing an objective and quantitative measure of change in response to treatment.

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Directionality is not built into the FAM. A high score on the involvement scale, for example, could mean that the individual feels: (1) distanced, excluded or rejected; (2) that other family members are too intrusive so that his/her boundaries are constantly being invaded, or (3) that both of these are problems at different times. Thus, while the FAM may pinpoint a problem in an aspect of family functioning, it is the clinician who must pinpoint the nature and direction of that problem. It often helps to include the family in this clarification process, thereby using FAM responses to stimulate further exploration of problematic aspects of family functioning. Doing so often reveals that the same high score means ver y different things to different family members.

One of the most useful aspects of the FAM for the practising clin- ician is that by combining its three scales (general, self, dyadic) one obtains a much richer and more detailed profile of the family than by tapping only one level of family functioning. Used together, the three scales are analogous to a CAT-scan, providing multiple complementary views of the family from different perspectives. A family of four, for example – assuming all members are old enough to complete the FAM, which is accessible to the average child who has completed Grade 5 – would provide twenty overlapping Asnapshots@ of the family: four general scales, twelve dyadic scales, and four self scales. Each of these captures a different aspect of family functioning, and each dyadic relationship is described by both participants in the dyad.

The FAM can generate an unusually rich picture of a couple’s relationship if, in addition to the partners using the dyadic scale to describe their relationship with each other, they also complete: (1) self scales, which demonstrate how they see – or don’t see – their part in the couple’s problem; and (2) dyadic scales describing their relationships with any children whom they believe have emotional or behaviour problems. A comparison of how each parent views the relationship with the child – and how well the parent gets along with the child as compared to the partner – often illustrates the triangulation so frequent in the families of covertly conflicted parents.

The FAM can be interpreted either objectively or subjectively. Objectively, one compares the individual’s standardized scores to those of a non-clinical population as a percentile. However, when using it as an adjunct to a clinical assessment, the assessor is

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encouraged to go beyond the standardized scores to generate clin- ical hypotheses based upon them. The more experienced the clini- cian in the use of FAM, the more easily the scores can be used to formulate hypotheses about the family’s structure and functioning. The nature of the individual clinical problem (e.g. depression) also needs to be taken into account. A hypothesis, of course, is just a hypothesis; only when it has been clinically confirmed is it a fact. But the generation, proving and disproving of such hypotheses offers an opportunity to move beyond surface issues towards the repeating and underlying themes of which those incidents are symptomatic. For example:

• If a teenager and a parent both report significant problems in control and values and norms, one might hypothesize a pattern of repeated power struggles based on conflicting values.

• If one partner’s dyadic scales reported major problems in role performance and involvement while the other did not, one might hypothesize either that one partner (usually the wife) craves more intimacy while the other is resisting her pressure for greater closeness; alternately, one partner (usually the husband) might be fed up with what he sees as his wife’s nagging and control, while she does not consider this to be a problem.

• Performance (social desirability and defensiveness) scale scores that fall below 30 (i.e. two standard deviations below the norm) suggest that the individual’s scores on the clinical scales (usually highly elevated) are being distorted by very high levels of personal anxiety, depression and/or anger.

• The more the general and dyadic scales suggest major dissatisfac- tion while the self scales reflect few and only minor weaknesses, the more likely that individual is to consider others the problem (i.e. that he/she is fine), and expect them to change. Such a profile is a poor prognostic sign, unless it can be used to help those involved accept more responsibility for their own behavi- our. (For example, a family therapist used one such situation to suggest that he did not consider a couple good candidates for marital therapy, since they both reported major problems in the marriage (dyadic) but saw themselves as having no problems (self). The couple responded by moving beyond the defensive manoeuvring typical of the assessment to convince the therapist that they were prepared to change. Thus began a very successful therapeutic encounter for a couple that had not benefited from several previous courses of treatment.)

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Those who use only the FAM’s general scale may be surprised to find normal ratings in some families that appear highly problematic in clinical assessments. This usually occurs in families that attribute their problems to one or more individuals – whom they label patient(s) – rather than to the family as a unit. If the identified patient accepts the family’s definition that he is the problem, his general scale scores may also fall within the average range. If dyadic scales were administered to such families, they would show most members reporting disturbed relationships with the identified patient but satisfactory relationships with each other. If self scales were administered as well, only the identified patient would report major weaknesses. On the other hand, if the identified patient rejected the family’s labelling him as the problem, his general scales would report major problems in family functioning while those of the other family members fell within the average range.

The interpretation of discrepancies between two family members’ ratings of the same aspect of family functioning can provide useful information even in FAMs which are not elevated. For example, the greater the spread between the spouses’ ratings, the greater the likelihood of some, possibly covert, marital discord, even if one partner’s ratings fall within the average range. It has not yet been established through research what level of discrepancy reaches clinical significance. The greater the discrepancy between family members’ ratings, however, the more likely that difference is clinically significant. Since ten points represents one standard devi- ation, a good rule of thumb is that as the difference between two family members’ ratings of a dimension approaches ten points, the more likely that discrepancy is to be clinically relevant. But even a differential of five points (i.e. half a standard deviation) is probably clinically relevant if found on a number of different parameters.

One problem when assessing change in response to family ther- apy is that not all aspects of family functioning respond equally to treatment. Some relationships, individuals and aspects of family functioning may get better, while others may stay the same or even get worse (Woodside et al., 1995a). The dyadic and self scales of FAM are more sensitive to change than the general scale. This is because a change in the general scale indicates a shift in overall family functioning, but does not pinpoint in which relationships that change has occurred. A change in the self or dyadic scores, however, pinpoints one member’s rating of one dimension, which is not diluted by a consideration of overall family functioning.

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Finally, some families that are extremely defensive when therapy begins may show elevation of their clinical scales after what both they and their therapist consider to be successful treatment. In such cases, the higher scale scores indicate that the family is admitting more problems – i.e. their denial has decreased – not that their functioning has deteriorated (Shekter-Wolfson and Woodside, 1990).

Summary of FAM research

Research on the FAM spans twenty years. The following section outlines key elements of this research including an overview of the normative and clinical data, as well as information regarding the reliability and validity of the FAM.

Normative data

Normative data for the FAM is based on 247 normal adults and sixty-five normal adolescents, constituting control groups at a vari- ety of health and social settings. The mean age of the adults was 38.6 years (SD = 8.5); 43% were men and 57% were women. Over half (53%) of the adults had completed at least some post-secondary education. The mean age of the adolescents (under 18 years of age) was 15 years (SD = 3.6); 51% were male and 49% were female. Nearly half (48%) were in secondary school, 13% were in elemen- tary school, and 35% had completed secondary school. Present resi- dences were owned by 62% of the families. Spouses had been living together for an average of fifteen years (SD = 8.6) and 86% were legally married. About 30% of the wives and 20% of the husbands had been previously married.

Data for numerous clinical groups exist for the FAM, docu- mented in Skinner et al. (1995). Data are also available for families having a variety of special circumstances (e.g. children with social phobia, chronic pain among family members, anxiety disorders). Table 1 is an updated reference source for locating this research. These data are valuable because they provide important informa- tion relevant to evaluating family functioning in special situations. For example, if a family had a child with cystic fibrosis and data obtained from the family were compared only to the normative non-clinical data, then certain areas of functioning may appear problematic relative to normative families where there is no cystic

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fibrosis. However, when the FAM data are compared to other fam- ilies having a child with cystic fibrosis, it may be found that such chal- lenges to family functioning are fairly typical within this context.

Reliability

Coefficient alpha provides a measure of the consistency with which individuals respond to items on the same subscale. Alpha values between .60 to .80 are usually considered satisfactory, and values above .80 are generally considered excellent. Overall FAM ratings yield substantial alpha coefficients: adults: .93 general scale, .95 dyadic relationships, .89 self-rating; children: .94 general scale, .94 dyadic relationships, .86 self-rating. Since the reliability of a

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TABLE 1 FAM research with clinical samples

Population Reference

Cystic fibrosis – Child Cowen et al. (1985, 1986) Developmentally disabled – Child Trute and Hauch (1988) Foster children Kufeldt et al. (1994) Alcoholic – Father Jacob (1991) Clinical depression – Father Jacob (1991) Mentally handicapped – Child Reddon (1989) Schizophrenia – Child Levene (1991) Anorexia nervosa – Child Garfinkel et al. (1983) Bulimia nervosa – Child Woodside et al. (1995b) Bulimia nervosa – Child Woodside et al. (1995a) Bulimia nervosa – Child Woodside et al. (1996a) Bulimia nervosa – Child Garner et al. (1985) Social phobia – Child Bernstein and Garfinkel (1988) School phobia – Child Bernstein et al. (1990) School phobia – Child Bernstein and Borchardt (1996) Emotional problems – Child Hundert et al. (1988) Distressed spousal relationship Forman (1988) Pain/headaches – family members Thomas et al. (1991) Anxiety disorders among family Buchheim et al. (1990) Anxiety disorders among family Woodside et al. (1996) Adopted children Westhues and Cohen (1990) Chronically ill children Hauser et al. (1996) Suicidal behaviour – Child Adams et al. (1994) Manic depression – Parents Laroche et al.. (1987)

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measure is influenced by the number of items, some decrease in reliability should be expected for the much briefer subscales. Most subscale reliabilities are quite respectable, although a few subscales for the self-rating scale are low (see Skinner et al., 1995).

Test–retest reliability was examined in a study by Jacob (1995). The sample consisted of 138 families recruited from the commun- ity. The family members completed the FAM on one occasion, and then were mailed a packet of booklets and asked to complete their forms independently. On average, the time between completion of the two FAM questionnaires was twelve days. Participants were instructed to complete the general scale using the ‘past week’ format (‘Describe your family during the PAST WEEK using the scale below’). The median test–retest reliabilities for the FAM subscales were: .57, mothers; .56, fathers; and .66, children. These reliability estimates are considered good, given the small number of items (five) on each subscale.

Validity

There is no absolute way of knowing that a scale actually measures a construct, since the construct can never be measured perfectly. Because it cannot be directly assessed, validity must be inferred. To say that a scale, or an instrument, is valid rests upon the weight of accu- mulated evidence from a variety of sources using various methodolo- gies (Campbell and Fiske, 1959). The FAM has been extensively researched, and its validity has been supported using a number of techniques. Overall, the weight of the evidence gained from the liter- ature is that the FAM effectively and efficiently assesses family func- tioning and provides strong explanatory and predictive utility.

1 Discriminant validity: research examining group differences. The FAM has been frequently used to examine differences among types of families. The findings indicated that, when there is a strong a priori reason to believe the groups differ in terms of family functioning, FAM differentiates between groups.

Jacob (1991) investigated forty-nine families that contained an alcoholic father, forty-eight families with a depressed father and forty-nine families with a normal (non-clinical) father. Discrepancies between the groups were found on all three (general, dyadic, self) versions of the FAM with the clinical groups always scor- ing substantially higher (indicating more family dysfunction) than

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the normal group. A Multivariate Analysis of Variance Analyses (MANOVA) was conducted to test for the statistical significance of these differences. The overall multivariate test (Wilks Lambda) indicated a significant (p < .01) difference among the three family types. Virtually all the FAM scales significantly differentiated the clinical families from non-clinical (normal) families.

Skinner et al. (1983) conducted research examining the diagnos- tic power of the FAM-III general scale. The sample included ‘prob- lem’ families and ‘non-problem’ families. The ‘problem’ families were defined as those having one or more family members receiv- ing professional help for psychiatric/emotional problems, alco- hol/drug problems, school-related problems or major legal problems. For problem families, there were 108 fathers, 131 mothers and 151 children. For non-problem families, there were 305 fathers, 348 mothers and 359 children. A multiple discriminant function analysis was conducted to determine whether the FAM subscales would significantly differentiate between the groups. Problem families, in general, reported more family dysfunction in the areas of role performance and affective involvement. Non- problem families had a slight tendency to score higher in social desirability and defensiveness. The FAM was effective in differenti- ating the ‘problem’ families from those that were not classified as ‘problem’ families.

Forman (1988) divided participants into those involved in a distressed relationship (n = 38) and those involved in a non- distressed relationship (n = 28). Participants were obtained from an outpatient clinic or a private practice and were all undergoing treat- ment for some type of relationship difficulty. Determination as to which relationships were distressed and which non-distressed was made on the basis of scores obtained on the dyadic adjustment scale (Spanier, 1976). The distressed group had significantly higher FAM self-rating scores (indicative of more problems) on several subscales: task accomplishment, role performance, communica- tion, affective expression, involvement, control, and values and norms. The FAM subscales significantly discriminated between distressed and non-distressed relationships.

2 Construct validity. One way of assessing the merits of an instrument is to determine how it compares with other instruments designed to measure the same (or related) constructs. Several research studies have examined this type of validity in relation to the FAM.

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Bloomquist and Harris (1984) administered the FAM general scale and MMPI special family scales to 110 undergraduates at several colleges in the Chicago area. Bloomquist and Harris found a strong relationship between MMPI special family scales and FAM subscale scores. The MMPI ‘family problems’ special subscale had particularly high correlations with FAM subscales for task accom- plishment, role performance, communication, affective expression, involvement, and values and norms. Similarly, the MMPI ‘family discord’ and ‘family attachment’ special subscales had particularly large correlations with task accomplishment, affective expression, and values and norms.

Bloom (1985) administered a fifty-item version of the FAM ques- tionnaire to a sample of 212 college graduates. FAM scores were correlated with measures of family idealization, cohesion and expressiveness from the Family Adaptation and Cohesion Evaluation Scales (Olson et al., 1983), the Family Environment Scale (Moos, 1974; Moos and Moos, 1981), and the Family Concept Q Sort (van der Veen, 1965). Correlations between the FAM and these measures were significant, with idealization, r = .94; with cohe- sion, r = .82, and with expressiveness, r = .83.

Jacob (1995) administered the FAM along with three other measures of family functioning to a sample of 138 mothers of primarily white middle-class families. The three measures were: the Family Environment Scale (FES: Moos, 1974; Moos and Moos, 1981); the Family Adaptability and Cohesion Evaluation Scales (FACES: Olson et al., 1983); and the Family Assessment Device (FAD: Epstein et al., 1983). Because of the overlap in focus of these instruments, correlations between the FAM and these other measures should be reasonably high. The main correlations obtained are summarized in Table 2. With FACES, correlations with cohesion were high, but with adaptability they were low. With the FES, correlations were high with cohesion and conflict; moderate with expressiveness, intellectual- cultural orientation, active-recreational orientation, and organiza- tion; and mostly negligible with independence, achievement orientation, moral-religious emphasis and control. With the FAD, all correlations were high and significant. On the whole, FAM was found to have high and significant correlations with appropriate dimensions of these related measures.

3 Clinical validity. Numerous research studies have used the FAM in clinical contexts. The research presented below focuses on FAM as

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a tool for providing information relevant to family therapy, programme development and sensitivity to treatment effects. For example, Shekter-Wolfson and Woodside (1990) describe family therapy in a day hospital group treatment programme for anorexia nervosa and bulimia nervosa. Families were asked to complete a set of FAM questionnaires at the beginning and at the end of hospi- talization. An actual case study is given to illustrate concretely the way the FAM was used in treatment, and explains the significance of the scores on all scales and subscales. In the case study, the post- treatment FAM scores confirmed the family’s sense that there had

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TABLE 2 Correlations between the FAM and other measures

Family Assessment Measure

TA RP Com AE Inv Con VN FACES

Cohesion -.49** -.55** -.44** -.48** -.48** -.50** -.39** Adapt. .04 .05 .06 .10 -.05 -.03 .03 FES Cohesion -.45** -.63** -.45** -.38** -.43** -.47** -.33** Express. -.35** -.33** -.30** -.36** -.31** -.28** -.25** Conflict .58** .41** .54** .40** .34** .42** .43** Independ. -.11 -.03 -.24* -.11 -.21* -.23* -.17 Achieve. .10 -.15 .10 .12 -.06 .02 .05 Intellect. -.27** -.32** -.21* -.31** -.27** -.25** -.29** Active. -.23* -.22* -.23* -.24* -.15 -.23* -.17 Moral. -.17 -.20* -.09 -.18 -.06 -.17 -.11 Organiz. -.33** -.48** -.39** -.34** -.29** -.38** -.34** Control .04 -.07 -.06 -.03 -.03 .01 .01 FAD Prb.Sol. .50** .45** .49** .44** .50** .57** .51** Com .55** .53** .64** .73** .46** .60** .44** Coalition .57** .74** .54** .54** .57** .62** .51** Aff. Resp .51** .57** .49** .56** .63** .63** .53** Aff. Inv. .57** .70** .54** .59** .57** .69** .57** Beh Con. .38** .41** .50** .42** .44** .55** .51** General .69** .68** .69** .65** .73** .72** .67**

Notes: **p < .01, *p < .05 FACES: Family Adaptability and Cohesion Scales FES: Family Environment Scale FAD: Family Assessment Device

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been a change, and the family had hopes that things could improve more in the future. A recommendation for marital therapy and further family therapy was made and accepted by all parties, largely on the basis of the positive view of the FAM feedback.

Trute et al. (1988) describe a project which developed a programme monitoring strategy in the Family Therapy Department at the Children’s Home of Winnipeg, Canada. A clinical evaluation approach was adopted to assess service effectiveness, defined primarily in terms of improved family functioning. The monitoring of these services extended over a three-month period. FAM ques- tionnaires were completed by sixteen families at the initiation of therapy and at the termination of services over the three-month review period. The participants consisted of sixteen mothers and nine fathers. The FAM results indicated that fifteen of the sixteen families showed improvement in functioning. In addition, female family heads experienced significant increases in their overall satis- faction with family functioning and attitudes towards self-adjust- ment.

Woodside et al. (1995a, 1995b) demonstrated the usefulness of the FAM in monitoring treatment effectiveness. Responses from a sample of ninety-one bulimic patients and their families were examined before and after treatment. Ratings of family function- ing improved significantly over the course of treatment although ratings of patients and parents were different and complex. Woodside et al. (1996a) later also utilized the FAM in a longitudi- nal study. This study provides preliminary evidence of FAM sensi- tivity to more subtle and less substantive long-term therapeutic effects.

Recent studies also support the effectiveness of the FAM in capturing therapeutic change. For example, Johannson and Tutty (1998) assessed families before and after intervention to improve functioning in families where physical or psychological abuse existed. They found significant improvement on the FAM as well as a variety of other measures.

In our experience, the dyadic scale results are most likely to show change during and after treatment as the dynamics of specific dyad relationships are explored. Further research is needed to provide empirical and experience-based guidelines for using the FAM in planning and monitoring interventions. More work is also needed on adapting the FAM for use with special populations and settings.

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Conclusion

The measurement properties of FAM are quite respectable, given the inherent complexity and challenges in family assessment. Reliability estimates are very good in most contexts. Validity of the FAM is supported by research done in a variety of clinical and non- clinical settings. This empirical evidence, reinforced by experiences of clinicians and researchers in a number of countries, suggests that FAM serves its purpose in providing a rich source of information on family functioning.

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Availability

The FAM is published by Multi-Health Systems, 65 Overlea Blvd, Toronto, Ontario, Canada M4H 1P1. Tel: 416-424-1700, 1-800-268- 6011(Canada), 1-800-456-3003(United States), FAX: 416-424-1736, e-mail: [email protected]. A detailed manual published by MHS describes FAM’s development, interpretation, clinical uses and research (Skinner et al., 1995). Information on obtaining FAM is also available on their website (www.mhs.com). Several FAM scales have been translated into different languages for specific projects (e.g. French, German, Spanish, Portugese, Japanese, Hebrew). Contact Gill Sitarenios at MHS for further information on these translations. A FAM clinical rating scale has been developed for assessing the seven constructs of the Process Model from an ‘outsider’s’ perspective. This scale is still under study and may be obtained by contacting Har vey Skinner at the University of Toronto.

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