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

Family Assessment Measure (FAM) and ProcessModel of Family Functioning

Harvey Skinner,a Paul Steinhauer,b and GillSitareniosc

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

Introduction

Families are complex, ever-changing systems. This complexitycreates many challenges for those involved in family assessment,therapy and research. For example, what emphasis should beplaced 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 CowleyRoad, Oxford, OX4 1JF, UK and 350 Main Street, Malden, MA 02148, USA.Journal of Family Therapy (2000) 22: 190–2100163–4445

a Professor and Chair, Department of Public Health Sciences, Faculty ofMedicine, McMurrich Building, University of Toronto, Toronto, Ontario, CanadaM5S 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, thereare 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 therelative focus on family history versus current functioning. Thesechallenges stimulated our work on developing the Process Model ofFamily 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. TheFamily Assessment Measure was designed to assess the sevenconstructs of the Process Model. The FAM is relatively unique inthat it provides indices of family strengths and weaknesses fromthree perspectives: the family as a system (general scale), variousdyadic 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 researchon family processes. This paper reviews the Process Model of FamilyFunctioning, describes the development of the FAM, providesguidelines on its clinical use, and then gives a synopsis of researchusing the FAM.

Overview

The Process Model of Family Functioning provides a conceptualframework for conducting family assessments (Steinhauer, 1987;Steinhauer et al., 1984). This model provides a means of organizingand integrating various concepts into a comprehensive yet parsi-monious framework. Both our Process Model and the McMasterModel (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 avariety of basic, developmental and crisis tasks (task accomplishment).Each task places demands that the family must organize itself tomeet. It is through the process of task accomplishment that thefamily attains, or fails to achieve, objectives central to its life. Theseinclude allowing for the continued development of all familymembers, 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 accomplishedincludes: (1) task or problem identification, (2) exploration ofalternative solutions, (3) implementation of selected approaches,and (4) evaluation of effects.

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

192 Harvey Skinner et al.


Figure 1 Process Model of Family Functioning


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

The kind of involvement which family members have with oneanother can either help or hinder task accomplishment. Involvementrefers to both the degree and quality of family members’ interest inone another. These two aspects may be used to describe five types ofaffective involvement including: the uninvolved family, a familywhich expresses interest devoid of feelings, the narcissistic family,an emphatic family and the enmeshed family. Other importantelements of affective involvement include the ability of the family tomeet the emotional and security needs of family members, and theflexibility to provide support for family members’ autonomy ofthought and function.

Control is the process by which family members influence eachother. The family should be capable of successfully maintainingongoing functions, as well as adapting to shifting task demands.Critical aspects of control include whether or not the family ispredictable versus inconsistent, constructive versus destructive, orresponsible versus irresponsible in its management style. Certaincombinations of these characteristics may give rise to four prototypestyles: rigid, flexible, laissez-faire and chaotic. Finally, how tasks aredefined and how the family proceeds to accomplish them may begreatly influenced by norms and values of the culture in general,and the family background in particular. Values and norms providethe background against which all processes must be considered.Important elements consist of whether family rules are explicit orimplicit, the latitude or scope allowed for family members to deter-mine their own attitudes and behaviour, and whether family normsare consistent with the broader cultural context.

The Process Model of Family Functioning emphasizes familydynamics; it is not a model of family therapy. This distinction recog-nizes that understanding families and treating families may requiresomewhat different skills. The Process Model emphasizes familyhealth as well as pathology. While it is important to identify dimen-sions that are relevant to family health pathology, the Process Modelalso 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




family system nor individual intra-psychic dynamics. Instead, basicfamily processes are considered with a clear acknowledgement thata 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 andTisdall, 1984).

The Process Model differs from its predecessor (FamilyCategories Schema) and the McMaster Model in three significantways. First, the Process Model goes beyond listing major parametersof 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 integratingfamily systems/psychological theories. Third, the Process Modelemphasizes the larger social system and family history (values andnorms), which are not stressed in the McMaster Model.

Family Assessment MeasureThe Family Assessment Measure (FAM) was developed according toa construct validation paradigm (Jackson, 1974; Skinner, 1981).This strategy involved an active interplay between specification ofthe theoretical model of family functioning and construction of aninstrument to measure concepts of the model (Figure 1). Thus, theFAM was aimed at providing an operational definition of constructsin 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 ratingof family functioning, seven measures relating to the ProcessModel and two response style subscales (social desirability anddefensiveness). An example of a general scale profile is given inFigure 2 for three family members. Note that the mother (aged48) and daughter (aged 19) identify several areas as problematic,especially communication and affective expression, although thefather (aged 51) rates family functioning to be in the normalrange (T scores around 50). He scores very high on social desir-ability and defensiveness which indicates that he is minimizingproblems.

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




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

• Self-rating scale (forty-two items, seven subscales): focuses on theindividual’s perception of his/her own functioning in the family.An overall index is provided along with seven measures relatingto 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 forpreliminary screening. In addition, brief FAM scales can be usedfor monitoring family functioning over time (e.g. during thecourse of therapy).

Depending on the number of scales used, the FAM generallytakes between twenty and forty-five minutes to administer and itmay be completed by family members who are at least 10–12 yearsof age. A brief FAM fourteen-item version can be completed inaround five minutes. Two methods of administration are available.



Figure 2 Example of a FAM general scale

Task Com Invol V&N DefnRole AffEx Cont SocDY


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

Clinical guidelines for using FAM

The FAM will never replace a thorough clinical assessment. In thereal world, however, most assessments are more or less incompletedue to time pressures. However, the FAM can provide a helpfuladjunct to clinical assessment:

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

2 by identifying areas of confusion, as when different familymembers 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 increasingmembers’ 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 clinicalassessment but are prepared to discuss when asked to explaintheir responses to the FAM, which offers a less threatening pointof entry;

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

7 by helping therapist and family define and agree upon goals fortreatment;

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




Directionality is not built into the FAM. A high score on theinvolvement scale, for example, could mean that the individualfeels: (1) distanced, excluded or rejected; (2) that other familymembers are too intrusive so that his/her boundaries areconstantly being invaded, or (3) that both of these are problemsat different times. Thus, while the FAM may pinpoint a problem inan aspect of family functioning, it is the clinician who mustpinpoint the nature and direction of that problem. It often helpsto include the family in this clarification process, thereby usingFAM responses to stimulate further exploration of problematicaspects of family functioning. Doing so often reveals that the samehigh score means very different things to different familymembers.

One of the most useful aspects of the FAM for the practising clin-ician is that by combining its three scales (general, self, dyadic) oneobtains a much richer and more detailed profile of the family thanby tapping only one level of family functioning. Used together, thethree scales are analogous to a CAT-scan, providing multiplecomplementary views of the family from different perspectives. Afamily of four, for example – assuming all members are old enoughto complete the FAM, which is accessible to the average child whohas completed Grade 5 – would provide twenty overlappingAsnapshots@ of the family: four general scales, twelve dyadic scales,and four self scales. Each of these captures a different aspect offamily functioning, and each dyadic relationship is described byboth participants in the dyad.

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

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




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 toformulate hypotheses about the family’s structure and functioning.The nature of the individual clinical problem (e.g. depression) alsoneeds to be taken into account. A hypothesis, of course, is just ahypothesis; only when it has been clinically confirmed is it a fact.But the generation, proving and disproving of such hypothesesoffers an opportunity to move beyond surface issues towards therepeating and underlying themes of which those incidents aresymptomatic. For example:

• If a teenager and a parent both report significant problems incontrol and values and norms, one might hypothesize a pattern ofrepeated power struggles based on conflicting values.

• If one partner’s dyadic scales reported major problems in roleperformance and involvement while the other did not, one mighthypothesize either that one partner (usually the wife) cravesmore intimacy while the other is resisting her pressure for greatercloseness; alternately, one partner (usually the husband) mightbe 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 thatfall below 30 (i.e. two standard deviations below the norm)suggest that the individual’s scores on the clinical scales (usuallyhighly elevated) are being distorted by very high levels ofpersonal 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 aprofile is a poor prognostic sign, unless it can be used to helpthose involved accept more responsibility for their own behavi-our. (For example, a family therapist used one such situation to suggestthat he did not consider a couple good candidates for marital therapy,since they both reported major problems in the marriage (dyadic) but sawthemselves as having no problems (self). The couple responded by movingbeyond the defensive manoeuvring typical of the assessment to convince thetherapist that they were prepared to change. Thus began a very successfultherapeutic encounter for a couple that had not benefited from severalprevious courses of treatment.)




Those who use only the FAM’s general scale may be surprised tofind normal ratings in some families that appear highly problematicin clinical assessments. This usually occurs in families that attributetheir problems to one or more individuals – whom they labelpatient(s) – rather than to the family as a unit. If the identifiedpatient accepts the family’s definition that he is the problem, hisgeneral scale scores may also fall within the average range. If dyadicscales were administered to such families, they would show mostmembers reporting disturbed relationships with the identifiedpatient but satisfactory relationships with each other. If self scaleswere administered as well, only the identified patient would reportmajor weaknesses. On the other hand, if the identified patientrejected the family’s labelling him as the problem, his general scaleswould report major problems in family functioning while those ofthe other family members fell within the average range.

The interpretation of discrepancies between two familymembers’ ratings of the same aspect of family functioning canprovide 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 notyet been established through research what level of discrepancyreaches clinical significance. The greater the discrepancy betweenfamily members’ ratings, however, the more likely that difference isclinically significant. Since ten points represents one standard devi-ation, a good rule of thumb is that as the difference between twofamily members’ ratings of a dimension approaches ten points, themore likely that discrepancy is to be clinically relevant. But even adifferential of five points (i.e. half a standard deviation) is probablyclinically 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 totreatment. Some relationships, individuals and aspects of familyfunctioning may get better, while others may stay the same or evenget worse (Woodside et al., 1995a). The dyadic and self scales ofFAM are more sensitive to change than the general scale. This isbecause a change in the general scale indicates a shift in overallfamily functioning, but does not pinpoint in which relationshipsthat change has occurred. A change in the self or dyadic scores,however, pinpoints one member’s rating of one dimension, which isnot diluted by a consideration of overall family functioning.




Finally, some families that are extremely defensive when therapybegins may show elevation of their clinical scales after what boththey and their therapist consider to be successful treatment. In suchcases, the higher scale scores indicate that the family is admittingmore problems – i.e. their denial has decreased – not that theirfunctioning has deteriorated (Shekter-Wolfson and Woodside,1990).

Summary of FAM research

Research on the FAM spans twenty years. The following sectionoutlines key elements of this research including an overview of thenormative and clinical data, as well as information regarding thereliability and validity of the FAM.

Normative data

Normative data for the FAM is based on 247 normal adults andsixty-five normal adolescents, constituting control groups at a vari-ety of health and social settings. The mean age of the adults was 38.6years (SD = 8.5); 43% were men and 57% were women. Over half(53%) of the adults had completed at least some post-secondaryeducation. 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 livingtogether for an average of fifteen years (SD = 8.6) and 86% werelegally married. About 30% of the wives and 20% of the husbandshad been previously married.

Data for numerous clinical groups exist for the FAM, docu-mented in Skinner et al. (1995). Data are also available for familieshaving a variety of special circumstances (e.g. children with socialphobia, 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 dataobtained from the family were compared only to the normativenon-clinical data, then certain areas of functioning may appearproblematic relative to normative families where there is no cystic




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 whichindividuals respond to items on the same subscale. Alpha valuesbetween .60 to .80 are usually considered satisfactory, and valuesabove .80 are generally considered excellent. Overall FAM ratingsyield substantial alpha coefficients: adults: .93 general scale, .95dyadic relationships, .89 self-rating; children: .94 general scale, .94dyadic relationships, .86 self-rating. Since the reliability of a



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)


measure is influenced by the number of items, some decrease inreliability should be expected for the much briefer subscales. Mostsubscale reliabilities are quite respectable, although a few subscalesfor 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, andthen were mailed a packet of booklets and asked to complete theirforms independently. On average, the time between completion ofthe two FAM questionnaires was twelve days. Participants wereinstructed to complete the general scale using the ‘past week’format (‘Describe your family during the PAST WEEK using the scalebelow’). The median test–retest reliabilities for the FAM subscaleswere: .57, mothers; .56, fathers; and .66, children. These reliabilityestimates 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 aconstruct, since the construct can never be measured perfectly.Because it cannot be directly assessed, validity must be inferred. To saythat 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 extensivelyresearched, and its validity has been supported using a number oftechniques. 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 FAMhas been frequently used to examine differences among types offamilies. The findings indicated that, when there is a strong a priorireason to believe the groups differ in terms of family functioning,FAM differentiates between groups.

Jacob (1991) investigated forty-nine families that contained analcoholic father, forty-eight families with a depressed father andforty-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




the normal group. A Multivariate Analysis of Variance Analyses(MANOVA) was conducted to test for the statistical significance ofthese differences. The overall multivariate test (Wilks Lambda)indicated a significant (p < .01) difference among the three familytypes. Virtually all the FAM scales significantly differentiated theclinical 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’ familieswere 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 legalproblems. For problem families, there were 108 fathers, 131mothers and 151 children. For non-problem families, there were305 fathers, 348 mothers and 359 children. A multiple discriminantfunction analysis was conducted to determine whether the FAMsubscales would significantly differentiate between the groups.Problem families, in general, reported more family dysfunction inthe areas of role performance and affective involvement. Non-problem families had a slight tendency to score higher in socialdesirability 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 adistressed relationship (n = 38) and those involved in a non-distressed relationship (n = 28). Participants were obtained from anoutpatient clinic or a private practice and were all undergoing treat-ment for some type of relationship difficulty. Determination as towhich relationships were distressed and which non-distressed wasmade on the basis of scores obtained on the dyadic adjustment scale(Spanier, 1976). The distressed group had significantly higher FAMself-rating scores (indicative of more problems) on severalsubscales: task accomplishment, role performance, communica-tion, affective expression, involvement, control, and values andnorms. The FAM subscales significantly discriminated betweendistressed and non-distressed relationships.

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




Bloomquist and Harris (1984) administered the FAM generalscale and MMPI special family scales to 110 undergraduates atseveral colleges in the Chicago area. Bloomquist and Harris founda strong relationship between MMPI special family scales and FAMsubscale scores. The MMPI ‘family problems’ special subscale hadparticularly high correlations with FAM subscales for task accom-plishment, role performance, communication, affective expression,involvement, and values and norms. Similarly, the MMPI ‘familydiscord’ and ‘family attachment’ special subscales had particularlylarge 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 werecorrelated with measures of family idealization, cohesion andexpressiveness from the Family Adaptation and CohesionEvaluation Scales (Olson et al., 1983), the Family Environment Scale(Moos, 1974; Moos and Moos, 1981), and the Family Concept QSort (van der Veen, 1965). Correlations between the FAM andthese 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 othermeasures of family functioning to a sample of 138 mothers ofprimarily white middle-class families. The three measures were: theFamily 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: Epsteinet al., 1983). Because of the overlap in focus of these instruments,correlations between the FAM and these other measures should bereasonably high. The main correlations obtained are summarized inTable 2. With FACES, correlations with cohesion were high, but withadaptability they were low. With the FES, correlations were high withcohesion and conflict; moderate with expressiveness, intellectual-cultural orientation, active-recreational orientation, and organiza-tion; and mostly negligible with independence, achievementorientation, moral-religious emphasis and control. With the FAD, allcorrelations were high and significant. On the whole, FAM wasfound to have high and significant correlations with appropriatedimensions of these related measures.

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




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



TABLE 2 Correlations between the FAM and other measures

Family Assessment Measure

TA RP Com AE Inv Con VNFACES

Cohesion -.49** -.55** -.44** -.48** -.48** -.50** -.39**Adapt. .04 .05 .06 .10 -.05 -.03 .03FESCohesion -.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* -.17Achieve. .10 -.15 .10 .12 -.06 .02 .05Intellect. -.27** -.32** -.21* -.31** -.27** -.25** -.29**Active. -.23* -.22* -.23* -.24* -.15 -.23* -.17Moral. -.17 -.20* -.09 -.18 -.06 -.17 -.11Organiz. -.33** -.48** -.39** -.34** -.29** -.38** -.34**Control .04 -.07 -.06 -.03 -.03 .01 .01FADPrb.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 < .05FACES: Family Adaptability and Cohesion ScalesFES: Family Environment ScaleFAD: Family Assessment Device


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

Trute et al. (1988) describe a project which developed aprogramme monitoring strategy in the Family Therapy Departmentat the Children’s Home of Winnipeg, Canada. A clinical evaluationapproach was adopted to assess service effectiveness, definedprimarily in terms of improved family functioning. The monitoringof these services extended over a three-month period. FAM ques-tionnaires were completed by sixteen families at the initiation oftherapy and at the termination of services over the three-monthreview period. The participants consisted of sixteen mothers andnine fathers. The FAM results indicated that fifteen of the sixteenfamilies showed improvement in functioning. In addition, femalefamily 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 ofthe FAM in monitoring treatment effectiveness. Responses from asample of ninety-one bulimic patients and their families wereexamined before and after treatment. Ratings of family function-ing improved significantly over the course of treatment althoughratings 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 therapeuticeffects.

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

In our experience, the dyadic scale results are most likely toshow change during and after treatment as the dynamics of specificdyad relationships are explored. Further research is needed toprovide empirical and experience-based guidelines for using theFAM in planning and monitoring interventions. More work is alsoneeded on adapting the FAM for use with special populations andsettings.




Conclusion

The measurement properties of FAM are quite respectable, giventhe inherent complexity and challenges in family assessment.Reliability estimates are very good in most contexts. Validity of theFAM is supported by research done in a variety of clinical and non-clinical settings. This empirical evidence, reinforced by experiencesof clinicians and researchers in a number of countries, suggests thatFAM serves its purpose in providing a rich source of information onfamily 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 publishedby MHS describes FAM’s development, interpretation, clinical usesand research (Skinner et al., 1995). Information on obtaining FAMis also available on their website (www.mhs.com). Several FAMscales have been translated into different languages for specificprojects (e.g. French, German, Spanish, Portugese, Japanese,Hebrew). Contact Gill Sitarenios at MHS for further information onthese translations. A FAM clinical rating scale has been developedfor assessing the seven constructs of the Process Model from an‘outsider’s’ perspective. This scale is still under study and may beobtained by contacting Harvey Skinner at the University ofToronto.



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

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