Experiential Psychopathology - Dr John Howells

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II - Family Psychology & Family Psychiatry - Diagnosis

Investigation

Introduction

The general aim of investigation is to obtain a complete picture of the family’s functioning and dysfunctioning, assets and liabilities described in the historical sequence of the Past, the Present and the Future.

The dysfunction of the family is apparent in indicators. One or more of these come to the attention of the family, of an individual member or of the others. When there is sufficient discomfort, relief is sought and either the family, a part of it, or an individual member seeks help. Through the referral machinery already discussed the patient is sent to the family psychiatry service.

On the first appointment, either an individual, a part of the family or the whole family presents. Thus, the investigating procedure can be discussed as it appertains to (A) a family member, or (B) more than one family member, either a part or the whole family.

There are two main steps in the investigation:

1. To elucidate the indicators, the signs and symptoms, and so establish a diagnosis. This will be in terms of (i) psychonosis, (ii) an organic syndrome, (iii) mixed states. Psychonosis is the prime responsibility of the family psychiatry service. Mixed states will call for collaboration with others. Organic syndromes will be referred to other specialities within the medical services.

2. To elucidate the process of the experiential psychopathology that led up to psychonosis.

Built into the formal investigatory procedure is every device for enriching the rapport with the family. The golden road to the elucidation of the intimate, significant and meaningful psychopathology is a sustained deep rapport between the investigators and the family. To follow with precision the procedure suggested could yield, on its own, virtually no useful information. Rapport brings the procedure to life. It is at this point, rapport, that the machine can fail; it requires a warm, tolerant, understanding human relationship to touch and encourage the hurt, embarrassed chords of memory to express themselves. Rapport makes for security, security for communication, and communication for meaningful information.

A. When the Individual Presents

There are five steps:

I          Evaluation of the presenting symptom (the complaint).

II         Evaluation of the rest of the symptomatology

III        A. An examination for the signs of dysfunction in the individual: psychic, somatic.

            B. Special investigations.

IV        The diagnosis.

V         Evaluation of the process of individual dysfunction through interview procedures.

Step I. The complaint

This is the indicator of personal dysfunction that has reached the awareness of the individual to such a degree of notice, pain or anguish that help became imperative. As it is subjective, it is termed a symptom.

Typical complaints or presenting symptoms are:“I have headaches very badly now”;“I am scared, all the time”; “After meals, I have a severe pain in my stomach”; “I just can’t sleep at night any more”; “I feel I want to steal things”; “I just feel miserable”.

These complaints are likely to be elicited by the psychiatrist by such phrases as “What is it that you find wrong with yourself at the moment?” The patient is encouraged to give a full account of the nature of the complaint, its intensity, time of onset, etc.

The following points should be borne in mind in relation to the presenting symptom:

The Patient must be allowed and encouraged to describe his experience in his own words. It is his experience and it must not be distorted by suggestion from others.

The complaint is not the only indicator of dysfunction in the patient. It is the one that causes him to go for help.

The presenting symptom is physical in two-thirds of patients seen in general medical practice. Thus, careful diagnosis to differentiate organic from psychic syndromes is essential.

To some extent, the selection of indicator may be determined by the nature of the agency he consults; e.g. he is unlikely to consult a surgeon except with pain, or a marital problem clinic with anything other than a marital problem.

The presenting complaint may not be the most significant indicator. Its choice is dictated by the above factors.

The presenting indicator has a high chance of being one that is operative at the time of seeking help. More significant earlier indicators may have been forgotten.

In the case of a young child or infant, the parents have to speak for him.

Step II. Evaluation of the rest of the symptomatology

There are four subsidiary steps:

1.         The individual’s account of the rest of the symptomatology.

Even the least co-operative or insightful patient, when prompted by such remarks as “What else do you find wrong with yourself?” will be able to add to the presenting symptoms. He may go on, “Well, not only do I have headaches, but I don’t eat much nowadays, and my wife complains that I am reluctant to have intercourse with her, and I certainly feel low spirited”. Thus, he has already added anorexia, frigidity and depression to his list of symptoms. Further prompting with “And what else bothers you?” “Perhaps there is something else.” “In what way do you feel different?” etc., will add to the list.

Points to note are:

No one knows better than the patient where the shoe pinches if he is given time to describe his feelings. Thus, at this point, a subjective account is invaluable. The description must be in his own words, untampered by others. He is not invited to evaluate his own condition, but merely to describe it.

The patient recounts his own condition in his own language. This may often be more descriptive and more accurate than technical language. Certain phrases are highly characteristic of what is felt and of how the man in the street describes his highly significant experience. He may fail to grasp technical terms used by the psychiatrist later, or find them inadequate or limiting in describing his experience. He may use such phrases as: “It’s my nerves, doctor”; “I seem to have become highly strung”; “I would give anything for a night’s sleep”; “You see, my spirits are so low”. Such phrases would be highly indicative of a patient suffering from psychonosis in the United Kingdom. Such phrases have a connotation hallowed by time and the interchange over a long time with those who have suffered similar experiences.

In the case of a young child or infant the account is obtained from the parents.

2.         Formal systematic elucidation of the symptomatology.

The patient has described his dysfunctioning as well as he can in his own language. The psychiatrist now pursues further symptomatology by covering the field of symptomatology himself in a systematic fashion. It is commenced by such a phrase as “I would now like to ask you a number of questions”. This usually elicits much more information.

It should be noted that:

The area covered must include every aspect of organic as well as psychic dysfunctioning.

In the organic field every system of the body must be covered.

There are a number of charts of symptomatology available.

In the case of an infant or young child the account is sought from the parents.

3.         History of the development of the symptomatology.

By now, the symptomatology of the complaint, the expansion on symptomatology by the patient and the systematic enquiry by the psychiatrist can be collated into one list. The further question now is “How has this complex of dysfunctions developed through time?”

Useful questions are “How long have you felt like this?”; “When did you first feel like this?”; “Is it true to say that you have never felt like this before that time?”; “What started it off?”; “What makes it worse?”; “What makes it better?”; “Has it been like this all the time?”.

It should be noted that:

The disorder may date back a long time, even to childhood. Some factor has caused the patient to complain now or he is a lifelong attendee at psychiatric and medical clinics.

The disorder may be a recent phenomenon.

Its start may be vague, or sharply clear. In the former case there is a probability that it arises out of a long-standing disharmony of environment. In the latter, the precipitating trauma may be concrete and easily ascertained; on the other hand it may be different because the patient may have strong motivation for ignoring the precipitating factor.

The disorder may run a fluctuating course which may make a highly significant pattern. The adult patient may feel relaxed at weekends, but suffer during the weekdays, suggesting trauma t work; a child may be worse during holiday periods at home from boarding school, suggesting trauma in the family.

Persistent questioning may show that the disorder started further back than the date first given.

There may be a gap between the operation of the noxious agent and the onset of symptoms because: (i) the whole person may be so caught up in coping with an incident, e.g. a crash involving the death of a relative, that it is only later that its significance can be evaluated; or (ii) the pathology in a violent quarrel with father may antedate by some days the skin rash which is getting out of hand in the hot weather.

In the case of the infant and young child the account is obtained from the parents.

4.         History of the development of the person.

This is a systematic enquiry into the general life experience of that person and ends with an evaluation of his non-pathological personality as the result of that experience. From this final study the individual’s assets emerge.

Please note that:

The description of the present personality comes next and covers all except the evaluation of the disorder which has been previously described. It can be based on the description of the psyche given earlier.

In the case of a child or infant the account is obtained from the parents.

Step III: A. Formal examination of the individual for signs of psychopathology

Until now the description of the disorder has been dependent on material supplied by the patient, i.e. the patient’s indicators are termed symptoms. Now the psychiatrist undertakes a systematic examination to discern the signs of dysfunction; these are gathered independently of the patient.

It should be noted that:

The examination must embrace the somatic and psychic systems.

The somatic signs can be indicative of (i) pathology in any system; and (ii) pathology in the encephalon – these are often termed “mental” signs.

The signs of psychic dysfunction are often termed “emotional” signs.

Thus, a complete examination will elucideat signs of (i) general somatic pathology; (ii) signs of cerebral pathology; and (iii) signs of psychopathology.

The value of the examination will be enhanced by meticulous care and by long experience. There is an art of examination born of experience, ingenuity, rapport, and inventiveness.

Step III : B. Special investigations

The investigations undertaken in Step III : A are supplemented by special investigations. They are not usually undertaken as a routine, but arise out of the need to supplement the data garnered to date. The appropriate special investigations are suggested by the findings to date.

Points to note are:

Special investigations include examination for somatic and psychic pathology.

Special physical investigations will include radiological, biochemical, electroencephalographic, pathological techniques, etc.

Special psychic investigations will include a large number of psychometric techniques including those to assess ability, interest, aptitudes, character, etc. Most value comes from these investigations if the psychologist receives an adequate brief from the psychiatrist. Not to enumerate the areas of inquiry is as valueless as sending a patient to the radiologist with the request, “Please X-ray this patient”.

Play diagnosis will be essential in the case of a child unable to discuss his life situation in an interview. There are two steps here: (i) Play observation. The observer is trained to give an accurate systematic account of the child himself in a play situation. It calls for careful training of the observer. (ii) Play diagnosis. Here techniques are employed to evaluate the child’s experience within his own family and society, but especially within his own family.

It is much easier to undertake operation (i) or hastily move on to so-called therapy than to attempt the more difficult, but more useful, stage (ii). There has been a full-time two-year course in these procedures at the Institute of Family Psychiatry for 20 years.

It may be necessary to admit the patient of any age group to in-patient care for observation or special investigation.

Step IV. The diagnosis (the discernment)

The indicators, signs and symptoms, gathered to date are grouped together in a meaningful way to form a syndrome. In addition to the indicators, the fabric and the noxious agent are taken into account in a full diagnosis. It is supplemented by a background picture of the development and present status of the personality to which it applies.

Points to note are:

The diagnosis may indicate an organic syndrome.

(i)         This organic syndrome may be based on pathology of the encephalon, i.e. “mental” disorder which includes acute (eg delirium) and chronic (eg dementia) encephalonosis and which, according to the views of this author, also includes cryptogenic encephalonosis (ie what has included conditions hitherto termed schizophrenia and manic-depressive psychosis).

(ii)        The organic syndrome may be based upon a body system other than encephalon.

Although the primary pathology is physical, there may be a secondary psychonosis as a reaction to physical handicap, i.e. somato-psychic disorder.

The diagnosis may indicate psychonosis. It is usually accompanied by secondary physical pathology (termed psychosomatic disorder).

The differential diagnosis between the above conditions is made on the evaluation of the nature of the indicators. Psychic or emotional indicators denote a psychonosis but will usually be accompanied also by physical indicators (psychosomatic disorder). So-called “mental” indicators denote pathology of the encephalon. Purely physical indicators typical of dysfunction in a particular body system indicate a primary physical syndrome; if there are accompanying emotional indicators then these may be due to an accompanying psychonosis, or be a psychic reaction to the physical disability.

The diagnosis may indicate a mixed state of a number of primary and secondary syndromes of physical and psychic states, e.g.a psychonosis in a person suffering also from cancer of the bowel, which has sent off satellite carcinoma to the brain, and secondary anxiety precipitated in the patient by the attitude of the family. Here, there are a primary psychic syndrome, a primary organic disorder (the cancer of the bowel), a cerebral disorder (with “mental” symptoms and signs due to the carcinoma of the brain), and a secondary or reactive psychic disorder due to the family attitude. Mixed states call for a high degree of acumen and extensive experience on the part of the clinician.

It is these complex mixed states that separate out the ordinary from the great practitioners. The first duty of a specialist physician is to give an opinion; its value will depend upon his expertise as a diagnostician. In medicine a respected “opinion” has always been valued more highly than a therapist who, following well-trodden paths, may exert skill only at a technical level.

The diversity of mixed states can be judged from the list of possible conditions below:

 (i)        Somatic condition only.

Predominantly somatic disorder with associated psychiatric state reactive to the somatic (somato-psychic state).

Primarily somatic condition with coincidental psychonosis.

Primarily psychiatric condition with coincidental somatic state

Predominantly psychiatric condition including associated somatic symptoms, i.e. psychosomatic state.

Psychiatric condition only.

(ii), (iii), (iv), and (v) are mixed states.

It should be noted that (iii), (iv), (v) and (vi) above a person with a psychonotic personality or illness is liable to the following physical conditions:

Psychosomatic symptoms due to the psychic states.

Hysterical symptoms – simulated physical conditions responding to the psychic problem.

More chronic ill-health due to worsening of psychosomatic symptoms or aggravation of existing physical conditions.

More hypochondriasis, i.e. existing physical states are found more difficult to bear.

Psychonosis is not diagnosed by the absence of physical indicators, but by positive indicators of psychopathology.

There is no value in the traditional labels of anxiety states, obsessional states, reactive depression, neurasthenia, etc. They should be discarded. At the Institute of Family Psychiatry they were discarded 20 years ago with great benefit. Such inadequate labels arose because examination was often cursory and the patient was labelled by his presenting symptom, which was assumed to be his only symptom, and thus it was elevated into a disease category. Psychonosis is never monosymptomatic, as the whole personality dysfunctions. However, additional symptoms and signs will only emerge after careful history-taking. The indicators change with time, a person anxious today (anxiety neurosis), may seek more help next week by an attentions-seeking symptom (hysterical state) and failing to secure help may soon after become depressed (reactive depression). On each occasion, the patient is labelled by his presenting or most obvious symptom and the other symptoms are ignored. A detailed diagnosis should list all the manifest symptoms and signs of the syndrome at that time – when psychonosis will be seen to be polysymptomatic.

It is useful to describe the time element in the course of the psychonosis, thus – acute, chronic, recurrent, episodic, etc.

It is useful to indicate the degree of the psychonosis. This is impressionistic, but when carried out by an experienced clinician it has value in giving a measure of the general magnitude of the psychopathology, e.g. mild, moderate, or severe degree of psychonosis.

The diagnosis can indicate the general nature of the basic personality of the patient.

It may be useful to mention the psychic noci-vectors if known.

For record purposes the diagnosis can be brief, e.g. “acute, severe psychonosis in middle life in an intelligent woman of previously sound personality, precipitated by desertion by husband”.

A longer diagnostic formulation can give a more detailed account of the indicators of pathology, e.g. to the above could be added “She manifests apathy, anxiety, depression, insomnia, nightmares, irritability, suicidal tendencies, pruritus, amenorrhoea, and colitis”.

The diagnosis may at this point be:

 At this point the psychiatric service may have completed its task. The referring agency may have asked for a diagnostic opinion only. Thus, the individual is referred back to that agency.

At this point the patient will often require an opinion on his condition couched in terms suitable to his understanding and with the maximum explanation consistent with his interests.

Step V. To elucidate the psychopathological process

The aim here is to answer the following questions: What are the psychic noci-vectors and from what disharmonious attitudes did they arise? On what psychic fabric were they acting? What dysfunction did they lead to that produced the indicators that were observed? What caused the person to be referred with his presenting symptom?

Points to note are:

It is possible, however, for small beneficial change to spring from diagnostic interviews and thus for early therapy and diagnosis to run parallel. However, the two procedures should not be confused. Much of what is termed therapy proves to be diagnosis; if the two are separated it will be clear what little therapy is taking place and extra effort will be made to be more effective

Occasionally insufficient psychopathology emerges to explain the symptomatology. This is usually due to insufficient rapport. Extra causes may be the individual has learned to be evasive, due to previous unskilful diagnosis; conditions are not conducive to confidential discussion; the technique is faulty; enough time is not available; the basic psychic noci-vectors are particularly hurtful and embarrassing; or interpretation is being undertaken according to some dogma rather than experiential psychopathology.

(i)         There is no merit in roundabout play techniques if the child is willing to discuss his life situation in an interview.

(ii)        Time must be spent to build up rapport.

 Questions must be simple.

Indirect techniques are best, e.g. asking for an account of events such as a birthday, first day at school, last Sunday at home, etc.; the account can then be evaluated by the interviewer rather than by the child.

A child may react against the idea of admitting his faults and thus, instead of using a standard “good” or “bad”, one can employ two standards of “good”, e.g. “You have a nice mother. How would you make her even nicer?” or, “How would you make your school even better?”

A child’s experience is naturally limited and he can only offer an opinion in tune with his experience. To ask a child, grossly ill-treated at home and who has never been away from his family, whether he would like to live elsewhere will always elicit the answer “No” as he will naturally cling to the only family he knows. A child who has lived elsewhere may be remarkably frank and accurate in his opinion – thus, “As a matter of fact I much prefer to live with Granny” or even, “Why don’t you send me back to Granny?”

A child may reveal his dissatisfaction concerning the present in his hopes for the future – thus a question such as, “If anything you wanted could happen to you, what would you want?” may be very revealing – “I think I would like to manage on my own without women when I am a man” or “Never go to school”.

Children can also be asked to make lists in order of priority – thus, “If you had to go on a long journey in a car, who would you have to sit next to you. And who next, and who after her?” etc.

A child is not hurt primarily by phantasy, he is hurt by events. Phantasy may reveal the hurts as he may seek solutions or compensation in his phantasy. But he does not want just preoccupation with his phantasy; he wants change in the hurtful life events that they portray.

Elucidation of phantasy is not a direct technique as a recall of real life events by the child. Speculation about bad witches may be highly inaccurate as against a child’s explosive “I hate my mother”. Fairy castles can’t be changed; families can. Child psychiatry has suffered much from a preoccupation with phantasy and its disinterest with facts.

Occasionally, the rest of the family, preceding or present, due to a variety of circumstances, can only be dealt with through the presenting family member.

B. When the Family Presents

The same procedure applies if two or more members of the family present instead of the whole family.

There are five steps:

I           Evaluation of the presenting symptom (the complaint).

II         Evaluation of the rest of the symptomatology:

            Family’s account of the symptomatology,

            Formal evaluation of the symptomatology,

            History of the development of the symptomatology,

            History of the development of the family.

III        A.        Examination for the signs of family dysfunction: psychic, somatic. 
            B.        Special family investigations.

IV        The diagnosis.

V         Evaluation of the process of family dysfunction through interview procedures.

Step I. The complaint

This is the indicator of family dysfunction that has reached the awareness of the family (or part of the family) to a degree of notice, pain, or anguish when help becomes imperative; as it is subjective, it is a symptom.

Typical complaints or presenting symptoms are:“We just row all the time”;“Our family is breaking up”; Something is continually going wrong”; We are on our own and no one wants to know us”; “People succeed, we don’t”; “If I’m not ill, then someone else in the family is”; “Does anyone have as many accidents as we do?”

The complaints are likely to be elicited by the psychiatrist by phrases as “What is it that you find wrong with the family at the moment?”

The following points should be borne in mind in relation to the presenting symptom:

It is not the only indicator of dysfunction in the family. It is the one that caused the family to come for help.

The presenting symptom may be psychic or organic. More usually it will be psychic, as symptoms of physical ill-health are often interpreted by the family in the conventional sense of belonging to an individual.

The selection of a presenting symptom may be influenced by the agency referring the family to the psychiatric service, e.g. work failure ascertained by the industrial medical service.

The presenting complaint may not be the most significant indicator; it is the one which, for a variety of reasons, is paramount at that moment.

The presenting indicator has a high chance of being the one that is operative at the time of seeking help. More significant indicators may have been forgotten.

Families have symptomatology stamped on them by the preceding families. Thus, there may be a history of presenting symptoms over a number of generations, e.g. feeding problems, depression, delinquency, aggression, etc.

The family often has a spokesman who may, or may not, be presenting a consensus opinion.

Step II. Evaluation of the rest of the symptomatolgy

There are four subsidiary steps:

1. The family’s account of the rest of the symptomatology.

The family may need to be prompted by such remarks as “What else is wrong with the family?” so that further symptomatology can emerge. A family member may go on, “You see, it isn’t only that we all quarrel, but Jimmy (a son) and I are depressed, my husband and I don’t share the same bedroom any more, and our daughter never comes to see us. My husband is under the doctor’s care with his heart”. Thus, to the presenting symptom have been added a number of others – depression in two family members, marital discord, psychosomatic symptoms (frigidity in husband and wife, angina in father), parent-daughter discord. Further prompting is usually necessary with such remarks as, “And there other things wrong?” “In what way would you like to be better than you are at the moment?”

Points to note are:

No one knows better than the family the extent of its own dysfunction. Thus, a subjective account is invaluable. The family describes, the psychiatrist evaluates.

The family should be encouraged to give its account in its own language. Technical jargon which it may have picked up may not exactly describe what it experiences and so limits the account.

Tactful prompting will encourage all the family members, including the children, to add to the family account. Discussion will go on until a consensus is reached; in this fashion the symptoms may be given more detail and thus flavour, extent and conditions of operation emerge.

2. Formal systematic elucidation or symptomatology.

The family has described its dysfunction as well as it can in its own language. The psychiatrist now pursues further symptomatology by covering the field himself in a systematic fashion. This provides more information.

3. History of the development of the family disorder.

By now the symptomatology of the complaint, the expansion on the symptomatology by the family, and the systematic enquiry by the psychiatrist can be collated into one list. The further question is how this complex of family dysfunction developed through time.

Useful questions are: “How long has the family been like this?”; “When did you feel the trouble began?”; “Have you ever been a happy family?”; “What brought the change?”; “When is the family happiest?”; “When is the family most miserable?”.

Points to note are:

The history should start from the moment of the first contact between husband and wife, i.e. the first contact between the two preceding families as represented by their respective epitomes.

The dysfunction may date from the onset of contact between husband and wife, or may have emerged at any point subsequently.

There may be nodal points in the life of the family of especial significance, e.g. marriage of the parents, birth of the first child, birth of any of the subsequent children, change of occupation or location, death of relatives, advent of a third party, the last child leaving home, marriage of one of the children, retirement, etc.

The start of dysfunction may be vague or sharply clear. In the former case, it is probable that it arises out of mounting disequilibrium produced by the interaction of the preceding families in their representation in the parents, their epitomes. In the latter, the precipitating trauma may be concrete and easily ascertained, e.g.it may date to the time when the family returned to live close to a preceding family.

The family disorder may run a fluctuating course whose pattern is significant, e.g.the family is harmonious as long as the only child is not at home, or during holiday periods there is harmony as the family is away from a preceding family.

Persistent questioning may reveal that the disorder started further back than the date first given. Not infrequently it dates right back to courtship.

4. History of the development of the family.

This is a systematic enquiry into the life experience of the family and ends with an evaluation of the non-pathological aspect of the family psyche as it is today, as the result of their life experience. From this latter study the assets of the family emerge, and they are of great value in management.

Points to note are:

The evaluation of the life experience of the family can be covered by a framework that starts at courtship and ends at the present.

The examination in (a) can include, under Dimension of the Individuals, a history of each individual’s experience in his preceding family and his personality structure now. It should be noted that the evaluation of the children in the family under Dimension of the Individuals is an account of their experience in the present family .

The description of the present state of the family covers all except the evaluation of dysfunction, already dealt with. It can be based upon the description of the family psyche given earlier in this bookI.

Step III:A. Formal examination of the family for signs of psychopathology.

Until now the description of the family disorder has been dependent on material supplied by the family, i.e. it has been concerned with symptoms. Now, the psychiatrist undertakes a systematic examination of the family to discern the signs of dysfunction; they come from an objective examination from outside.

Points to note are:

The examination must embrace the physical as well as the psychic aspects of the family.

Each dimension of the family will be covered in this examination – including signs in the Dimension of the Individuals.

The examination may extend over a long period of time. At first the material coming from the family may be false, as the family is not behaving naturally, or because the observer is not yet attuned to its mode of behaviour. As time goes by and rapport develops, the family behaves naturally. Thus, early assessments are amended as time goes by unti the picture is a settled one.

The value of the examination will be enhanced by meticulous care and by long experience. There is an art of examination born of experience, rapport and ingenuity. Trainees must spend many hours analysing video tapes on set schedules and discussing the analysis with experienced supervisors. After some time the evaluation of material will become automatic and accurate.

Step III:B. Special family investigations.

The investigations undertaken in Step III:A are supplemented by special investigations. They are not undertaken as a routine, but arise out of the need to supplement the data garnered to date.

Points to note are:

Special investigations include the examination of somatic and psychic pathology.

Special physical investigations will include radiological, biochemical, electronencephalographic, pathological techniques, etc.

Special psychic investigations will include a large number of psychometric techniques. Among these is the Family Relations Indicator, which has been found of great value at the Institute of Family Psychiatry.

In the Dimension of the Individuals in the family it may be necessary to employ play techniques in the case of children. See Step III:B earlier for the investigation of the individual.

It may be necessary to admit the whole family into in-patient care for observation. Usually, admission for investigation is for a short period. Indicators for admission include: (i) urgency and the need for quick intensive evaluation; (ii) geographical factors – attendance on a regular basis as an out-patient may be impossible due to distance; and (iii) a difficult elaborate investigation involving a number of special investigations.

Step IV. Family diagnosis (the discernment).

The indicators, signs and symptoms, gathered to date are grouped together in a meaningful way to form a syndrome. In addition to the indicators, the fabric of the family and the various psychic noci-vectors are taken into account in a full diagnosis. This is supplemented by a background picture of the development and present status of the family to which it applies.

Points to note include:

The diagnosis may indicate a disturbance in the physical dimensions of the family. This may involve a part or the whole family. Included in the category of physical disorder it may be found that there is an acute or chronic encephalonosis, e.g. Huntingdon’s chorea, or one of the cryptogenic encephalonoses, such as encephaloataxia. There may be a secondary psychonosis as a reaction to a physical handicap.

Most frequently, the diagnosis is that of psychonosis of the family. It is often accompanied by secondary physical pathology, i.e. family psychosomatic disorder.

The diagnosis may indicate a mixed state of primary and secondary physical and psychic states, e.g. a family suffers from hereditary ataxia with secondary psychonosis, resulting from its difficulties of employment, and in addition father’s affectional involvement with a voluntary helper has precipitated an acute psychonosis reflected in dysfunction and indicators throughout the family. Thus, there are a primary physical syndrome (hereditary ataxia), a primary psychic syndrome (acute psychonosis), and a secondary psychonosis (reactive to employment problems).

Mixed states call for careful prolonged examination, acumen of a high order, and great experience. Many disturbed families may not respond to prolonged help of great magnitude because wrong assessment of the family makes it impossible to meet the need with accuracy.

Psychonosis of the family is not diagnosed by the absence of physical indicators, but by the presence of psychic indicators.

There is no value in labelling families by any of the traditional clinical label, e.g. anxious families, delinquent families, etc. In this undesirable practice, as in the individual field, families are labelled by the presenting syndrome. Symptoms are fleeting. Furthermore, psychonosis of the family is never monosymptomatic; the family is described in each of its dimensions and often displays a number of symptoms in each of the dimensions.

It is useful to describe the time element in the course of the psychonosis, thus – acute, chronic, recurrent, episodic, etc.

It is useful to indicate the degree of the psychonosis. This is impressionistic, but has value to an experienced clinician in giving a measure of the general magnitude of the psychopathology, e.g. mild, moderate, or severe degree of psychonosis.

The diagnosis can indicate the general nature of the state of the family in its premorbid state.

It may be useful to mention the noxious agents if known at this stage.

For some record purposes the diagnosis can be brief, e.g. “acute, moderate psychonosis in a family showing a mild degree of psychonosis from its inception and precipitated by interaction with the extended family”. A larger diagnostic formulation can give detailed account of indicators of pathology under each of the dimensions, e.g. the following indicators psychopathology were evident:

(i) The individuals (symptomatology can be added in each case):    

Marked degree of psychonosis in father

Moderate degree of psychonosis in mother

Moderate degree of psychonosis in son

Severe degree of psychonosis in daughter

Internal interaction:

Father-Mother relationship – negative hostile relationship

Father-Children relationship – marked mutual antipathy to daughter and somewhat less to son

Mother-Children relationship – grossly overprotective to both with rejection of daughter, and hostility of children towards mother

General: Father isolated by rest of family members; fragmentation of family imminent.

External interaction: Failure at employment with impending bankruptcy; school failure of daughter; delinquency of son; isolation of family.

Physical: Feeding difficulties in daughter; enuresis in son; gastric ulceration in father; frigidity in mother.

The family diagnosis at this point may be:

At this point the psychiatric service may have completed its task. The referring agency may have asked for a diagnostic formulation only. Thus, the family is referred back to the agency with the formulation.

At this point the family will usually ask for an opinion on its condition and this should be in terms couched to allow understanding and given with the maximum of explanation consistent with its interests. There is a tendency for clinicians to underestimate the intellectual grasp of the family and its capacity to tolerate and understand what is said to it.

Step V. To elucidate the psychopathological process in the family

The aim here is to ask the question, “What psychic noci-vectors arising from what disharmonious attitudes springing from the past and the present led to the family dysfunction which produced the indicator observed causing the family to attend with its complaint?”

Points to note are:

(a)        To elucidate the indicators is not the same operation as to elucidate the family psychopathology.

(b)        The understanding of the psychopathology should be based upon knowledge of experiential psychopathology as outlined earlier.

(c)        The explanation should extend back from the present family to the preceding families.

The way to the understanding of the dysfunctioning of the present family invariably lies with the understanding of the preceding families of the parents and the interaction of these families through their representatives in the present. The importance of this last sentence cannot be overemphasised. Thus, in a full investigation preceding families may require formal evaluation in the manner described here.

It may be of value to draw the preceding families into the investigation either alone as families, or with the present family. Thus, a family interview may consist of: (i) the present family; (ii) the present family and one preceding family; (iii) the present family and the two preceding families; (iv) collateral related families in addition to (iii).

It may be of value to draw the succeeding families into the investigation, either alone or with the present family. Thus, a family interview may consist of the present family with one or more succeeding families.

A family is the meaningful functioning group at that moment. Thus, it may include lodgers, relatives, servants, etc.

Most work will be undertaken in family group interviews. However, there may be times when it should be supplemented by individual or dyadic interviews. Need for an individual interview may arise if: (i) there is a marked degree of psychopathology in a family member; (ii) an individual can at that moment share the information only with the interviewer and not with the family. Equally, dyadic interviews may be required, either because of an especially pathological interaction or because the couple cannot share the same information with the rest of the family at that time. Individual or dyadic interviews may have to be undertaken with children and some of the features of an interview with children have been coveed under Step III:B of the individual investigation.

Family diagnosis must not be confused with family therapy. Family diagnosis is concerned with describing and understanding family events and not with changing them. Much of what is termed family therapy proved to be family diagnosis, i.e. no change is effected for the better. If the two procedures are kept separate, therapy will be more effective in that it will be apparent whether or not change is taking place. It is possible for therapy to run parallel with diagnosis, but the distinct nature of the two operations must always be kept in mind. If therapy is the aim, it is a useful practice for the therapist to ask himself, “What change for the better have I produced in the last (number) of interviews – and what proof have I that the interview effected the change rather than extra-interview events?” It can be a salutary exercise.

There is no value in obtaining more information than is necessary to understand the psychopathology of the family. Valuable, scarce, highly expensive facilities are wasted in uncovering irrelevant minutiae of information. Only experience teaches what is relevant. It is easy to meander on seeking endless information; this is a comfortable exercise which only hides the inability to use the information to the advantage of the family – the only justification for the exercise.

Family diagnostic interviews have many of the ingredients of family therapy interviews, thus prolonged discussion of the family interview will be left for the section on family therapy.

There are, however, some differences. It is permissible to be more directive in diagnosis. To listen and leave matters to the direction of the family is not enough. The whole family field, present and preceding, has to be explored and therefore there must be guidance. Sometimes the same area has to be reworked for greater clarification. Experience teaches the art of optimum direction. Rapport with the family is the great revealer.

Family diagnostic interviews normally last for at least two hours. This is necessary as there are more people requiring to talk than in an individual interview. For a dyadic interview at least 1½ hours should be allowed.

There are times when a whole day can be employed with advantage for a family interview. This is required if: (i) a point of crisis has been reached; (ii) urgent work is necessary: (iii) geographical difficulties make it impossible to work in any other way. There should, of course, be rest breaks during interviews lasting 1½-2 hours.

The number of interviews required will depend largely on the complexity of the problem. Thus, diagnostic interviews at weekly intervals lmay extend from three weeks to six months.

Not only what is said or done must be given due insight, but also what is not said or done by the family.

Occasionally the psychopathological process which emerges is not sufficient to explain the symptomatology. This may arise because rapport is inadequate – much the commonest cause – of the technique is inefficient; enough time has not been spent; the interview conditions are unsuitable for confidential discussion; the basic psychic noxious agents are particularly stressful or embarrassing; the family has learnt to evade by previous unskilful attention; or distortion by interpretation is in terms of some dogma rather than in terms of experiential psychopathology.

Having elucidated the psychopathological process, the work of the family psychiatric service may be over. The referring agency may have asked only for: (i) a family diagnosis; (ii) elucidation of the psychopathological process. Thus, at this point the family can be referred back to the agency.

At the completion of family therapy, it is sometimes useful to go through a formal evaluation as here, so that the present state of the family can be compared with its state before therapy.

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