Possible Questions for the Initial Appointment
Most often we think of individuals as individuals. A family perspective is seeing the individual as a living branch in a tree. It may be helpful to visualize the families that ‘created this individual’ in their multi-generational unfolding. Try to think about yours. Start as far back as you know. Are they your grand-grand parents? Do you have knowledge of anything before? If so you are lucky. Almost all of what happened more than two generations ago is lost in the fog of times. Now imagine the movie going fast-forward, from your grand-grand parents, picture their lives, the kids, the challenges, the successes, the losses, then your grandparents, followed by your parents. And now you. When I do this exercise, I can always count that it will put me in a different state of mind. Not always super pleasant, but always different.
There is always some insight we can get from studying families and this is the main idea for this post.
1. Family structure
Family membership remains intact for life even if one no longer lives under the same roof. For most of us the relationships we have with our siblings are likely to represent our longest continuous commitments.
Even when a member experiences a temporary or permanent sense of alienation from the family, one can never fully relinquish family relationship. (“You’re always going to be my baby”; the former partner becomes the “ex”) .
The power of the family is such that despite the possible separation of members by vast distances, sometimes even by death, the family’s influence remains.
Build family genogram – grandparents, parents, aunts, cousins, siblings. Who is not there? (Consider estranged, deceased members).
All families must work at promoting positive relationships among members, attend to personal needs of their constituents and be prepared to cope with developmental or maturation changes as well as unplanned or unexpected crisis.
In general, all must organize themselves in order to get on with the day-to-day problems of living.
Are relationships generally positive? Is there a sense of mutual care? Do we feel a sense of basic competence on “getting stuff done”? How is the family adapting to developmental changes, or to crises.
A family can be traditional or innovative, adaptive or maladaptive, efficiently or chaotically organized. Ideally, the family will meet its collective needs and goals without consistently or systematically preventing particular members from meeting their individual needs and goals.
How is the family influencing our patient? Is the patient acting as if she wants to ‘be out’?
Some families are so depleted as a result of excess external or internal stress (poverty, migration to a country where the lack language skills or understanding of unfamiliar customs, serious health problems, legal issues, unforeseen accidents etc.) that they may need long-term community support to feel self-sufficient.
Is external need necessary?
2. Family patterns of interactions
Families typically display stable, sometimes collaborative, purposeful, and recurring patterns of interactions. They may go unnoticed by outsiders, they frequently are unstated, and they are not always understood by the participants themselves.
Nonverbal exchange patterns between family members represent subtle, coded transactions that transmit family rules and functions.
In family that function well these nonverbal interactions are subtle and barely visible. This is due, at least in part that the ‘nonverbal communication’ is successful to convey what is intended. In less functional families we often see an ‘excess of signaling‘ and visible signs of frustration as the sender and the receiver of messages are not on the same page.
Family members are dependent on one another not merely for money, food, clothing, and shelter but also for love, affection, mutual commitment, companionship, socialization, the expectation of long-lasting relationships, and fulfillment of other non-tangible needs. To facilitate the cohesive process, a family typically develops rules that outline and allocate the roles and functions of its members.
How are the roles in this family? Who is controlling or challenging who? How is it done and what is the reaction? Let us not forget, all families indoctrinate their members.
Shared family rituals are part of ongoing family interaction patterns that help ensure family identity and continuity. Rituals are symbolic actions that help families adapt to change and reaffirm group unity in dealing with life transition.
Are there any obvious identity forming rituals?
3. Family narratives and assumptions
A family is a maker of meaning. Our individual judgment about what is reality is, in no small way, a function of the beliefs and stories that the family and the culture provided us with. Throughout the course of its development, a family fashions and helps instill fundamental and enduring assumptions about the world in which it lives. The narratives of family recounts help explain and justify their interactive patterns.
Do we have unity or fragmentation, joining or divergence in meaning making? Most stories of ‘rebellion’ are stories in which a member of a family, or a whole generation tries to redefine what really matters.
Families develop a narrative about themselves which is derived largely from its history. Threads of this narrative are passed on from one generation to the next, and they become ‘family traditions’.
They maintain a history by telling and retelling their family story from one generation to the next, thus ensuring a sense of family continuity in shaping the expectations of members regarding the future.
Some stories are a bit ‘heroic’ and aim at telling how ‘good and strong we are’. Other stories speak of guilt, loss or trauma. Families can figure out ways to ‘put in perspective’ and thus ‘neutralize’ terrible events that occurred in the past like war, famine, murder or suicide. Other families are less successful and will raise their members in fairly toxic story-telling. When the family narrative was successful at detoxifying the past, the events are dealt with explicitly and symbolically. Trans-generational transmission of trauma is so pernicious also because its contents are only implicit, always kept in the shadows and no symbolic handling and healing is possible.
What seem to be the main threads in the family narrative? Who is the main story-telling member of the family? Who or what is the force maintaining the narrative?
The ways in which individuals and their families characteristically deal with their lives are based on family social constructions. The social constructions are unchallenged views of reality created and perpetuated in conversation with one another, possibly carried on over generations. (“This is who we are”) . Such views may act as blinders or restraints that prevent its members from noticing other aspect of their lives or seeing other behavioral options.
There is no true reality, only a family agreed upon set of constructions, created through language and relational knowing.
Is the family narrative, open/affirming/inquiring or distorting/blocking or idiosyncratic
4. Family resiliency
Not all families react to potentially disturbing and disruptive events in the same way. Some may experience prolonged distress from which they seem never to recover; others suffer less intensely and for shorter periods. For some families recovery may come quickly but the later begin to experience unexpected health problems or somehow never again enjoy life the way they once did.
How is the response to distress? Past examples of resilience and weakness/fragility.
Families have the potential for growth and repair in response to distress, threat, trauma, crisis, emerging stronger and more resourceful than before. A family as a whole, or one or more of his members may manifest dysfunctional behavior during periods of persistent stress, but family processes may mediate the person’s recovery allowing the family system to rally, buffer stress, reduce the chances of dysfunction, and support optimal adaptation.
Who are the more vulnerable members, and what is the family response to member vulnerability?
A relatively small set of global factor support resilience in children: connection to competent and caring adults in the family and community, cognitive and self-regulating skills, a positive view of oneself, and motivation to be effective in the environment.
Some families are more flexible in seeking solutions to problems, more purposeful in pursuing satisfactions, more adaptive to changing conditions, and better able to recover from misfortune or adversity than other families.
Key family processes in family resilience:
- a consistent and positive belief system = values and assumptions offering guidelines for meaning in future action (viewing disruptions as milestones in their shared life passages, without assigning blame, and recasting a crisis as a manageable challenge)
- the family’s organizational processes (how effectively organizes its resources) that provide the shock-absorbers when confronted with stress (remaining flexible, open to change, connected to each other)
- the family’s communication/problem-solving processes that are clear, consistent, and congruent and that establish a climate of mutual trust and open expression among its members (maintaining a shared range of feeling, shared decisions, creative brainstorming)
Are there caring and competent adults in family and community?
Are key family members having a positive view of themselves, are they capable of self-regulation, are they curious, tolerant, capable of “not knowing” and motivated to be effective?