Clinical Outcome Measures for Families
Global Assessment of Relationship Functioning (GARF)
Brief description of the GARF. The GARF is a therapist-rated device for indicat- ing functioning or a family or other ongoing relationship on a continuum ranging from a low of 1 to a high of 100. The continuum is divided into five categories: 1 to 20 = chaotic; 21 to 40 = rarely satisfactory; 41 to 60 = predom- inantly unsatisfactory; 61 to 80 = somewhat unsatisfactory; and 81 to 100 = satisfactory. It is the only family-oriented measure included in the pages of the DSM-IV/DSM-IV-TR, and is located in Appendix B (American Psychiatric Association, 2000). GARF is analogous to GAF (Global Assessment of Func- tioning Scale), which is a measure of individual symptomatic distress and functioning; both are coded on Axis V. When assessing or rating a relationship,
the clinician is asked to consider three dimensions of relational functioning:
Problem Solving, Organization, and Emotional Climate.
Yingling and colleagues (1998) have slightly modified the dimensions Interactional/Problem Solving, Organization, and Emotional Climate, making them subscales that are scored separately, along with an overall GARF score.
The psychometric properties and additional information about GARF are dis- cussed in chapter 6.
The GARF as an outcomes measure. Considerable published research and clinical reports are available in which GARF is utilized as an outcomes measure.
Most of these reports involve GARF in pre- and posttreatment measurement (Yingling, Miller, McDonald, & Galwaler, 1994a, b, 1998; Hampson, Henny, &
Beavers, 1996; Ross & Doherty, 2001). With regard to ongoing assessment of outcomes, Yingling and colleagues (1998) discuss five case examples of the use of GARF as a treatment outcomes monitoring measure. These couple and family cases provide session-by-session ratings of overall GARF scores and subscale ratings for therapy lasting from 7 to 10 sessions. These case discussions are par- ticularly valuable because data from the ongoing monitoring are utilized by the therapists to modify treatment focus and interventions.
Systematic Assessment of Family Environment (SAFE)
Brief description of the SAFE. The Systematic Assessment of Family Environ- ment (SAFE) was developed by Yingling in 1991 along with field testing of the GARF (cf. Chapter 8 for a filler discussion of this instrument). It is a 21-item global assessment instrument for measuring three relational subsystem levels of the family system using two functioning factors for each subsystem level.
The three subsystems are: dyadic marital–executive subsystem; parent–child subsystem; and extended family subsystem. Organizational Structure and Interactional Processes are the two factors assessed for each subsystem. Scor- ing yields ranges for four family types: competent, discordant, disoriented, or chaotic (Yingling, 1996). SAFE is user friendly and available in a Spanish ver- sion as well as a cartoon version for use with children under the age of 10 (Yingling et al., 1998). Validity is reported as .74 and .82 (Yingling et al., 1998).
The SAFE as an outcomes measure. The SAFE provides information that can easily be incorporated into a treatment plan. Relatively little has been published about using SAFE for pre–posttreatment evaluation of change or ongoing monitoring of family therapy. Nevertheless, Yingling and colleagues (1998) report collecting serial data on GARF and SAFE for monitoring treat- ment outcomes. The ease of administration makes this instrument a valuable outcomes measure with families.
CLINICAL OUTCOMES ASSESSMENTOF COUPLESAND FAMILIES 123 Self-Report Family Inventory (SFI)
Brief description of the SFI. The Self-Report Family Inventory (SFI) is a 36- item self-report family instrument developed by Beavers and Hampson (1990) and is based on the Beavers systems model of family functioning. It measures five family domains: health/competence; conflict resolution; cohesion; leader- ship; and emotional expressiveness. The SFI correlates highly with two well- regarded therapist observational rating scales: the Beavers Interactional Competence Scale and the Beavers Interactional Styles Scale. Spanish and Chinese versions are also available. The psychometric properties and addi- tional information about SFI are discussed in chapter 5.
The SFI as an outcomes measure. Some research in which the SFI has been utilized as an outcomes measure has been published. These reports involve the SFI in pre- and posttreatment measurement (Hampson & Beavers, 1996a, b; Hampson et al., 1999). Apparently no research or other published reports describe the use of the SFI as an ongoing measure of clinical outcomes;
however, the ease of administration and brevity of the instrument (only 36 items) make it particularly valuable for monitoring session-by-session outcomes.
Clinical Outcome Measures for Couples
This section includes two well-regarded instruments with considerable potential in clinical outcomes measurement and monitoring: the Dyadic Adjustment Scale and the Marital Satisfaction Inventory—Revised.
Dyadic Adjustment Scale (DAS)
Brief description of the DAS. The Dyadic Adjustment Scale (DAS) is a 34-item self-report instrument for assessing dyadic or relationship adjustment. This instrument was developed by Spanier (1976) to measure the quality of adjust- ment of couples and other dyads. The DAS comprises four scales: Dyadic Satisfaction, Dyadic Cohesion, Dyadic Consensus, and Affectional Expression.
It is one of the first and most extensively utilized relational instruments in clinical practice. A shorter, 14-item version is also available. The psychometric properties and additional information about DAS are discussed in chapter 7.
Spanier developed the instrument on the assumption that the quality of relational adjustment was the key indicator of the viability of a relationship. He defined marital quality as “how the marriage functions during its existence and how partners feel about and are influenced by such functioning (Spanier, 1979, p. 290). The DAS has consistently distinguished couples with better adjust- ment from those who are more dissatisfied with their relationship, including couple with a greater likelihood of divorce (Prouty et al., 2000). Well over 1000 research studies have been published involving the DAS. Although the
instrument has evolved over the years, it remains one of the most commonly used measures of couples adjustment by researchers and clinicians.
The DAS as an outcomes measure. The DAS has a long history of use as an outcomes measure. Considerable research has been reported on its use as a pre–posttreatment assessment tool in studies of therapeutic efficacy and effec- tiveness with couples (Adam & Gingras, 1982; Brock & Joanning, 1983;
Jacobson, 1984; Jacobson & Follette, 1985; Latham, 1990; Prouty et al., 2000). Even though neither this research nor other published reports describe the DAS as used as an ongoing measure of clinical outcomes, the brevity of the instrument—particularly the 14-item version—makes it an attractive choice for monitoring session-by-session outcomes.
Marital Satisfaction Inventory—Revised (MSI-R)
Brief description of the MSI-R. The Marital Satisfaction Inventory—Revised (MSI-R) is a 150-item self-report instrument developed by Snyder (1997). The earlier version, MSI (Snyder, 1981), was well regarded and one of the most often used relational inventories in research and clinical practice. The MSI-R has 13 scales:
• Global Distress
• Affective Communication
• Problem-Solving Communication
• Aggression
• Time Together
• Disagreement About Finances
• Sexual Dissatisfaction
• Role Orientation
• Family History of Distress
• Dissatisfaction With Children
• Conflict Over Child Rearing
• Inconsistency (validity scale)
• Conventionalization (validity scale)
The MSI-R is useful as a diagnostic and a therapeutic tool, as well as a screen- ing instrument. Psychometric properties of and additional information about MSI-R are discussed in chapter 7.
The MSI-R as an outcomes measure. The MSI-R is typically used in the initial phase of therapy in discussing the couple’s presenting concerns and in formulating treatment goals. However, it can also be utilized before and after therapy, in a pre–posttreatment fashion, to evaluate overall treatment out- comes (Snyder & Berg, 1983; Iverson & Baucom, 1988; Snyder, Wills, &
Grady–Fletcher, 1991; Snyder, Mangrum, & Wills, 1993; Frank, Dixon, &
Grosz, 1993). Snyder & Aikman (1999) also note the value of using MSI-R
CLINICAL OUTCOMES ASSESSMENTOF COUPLESAND FAMILIES 125 serially throughout the course of treatment in the evaluation of change and for revising treatment goals and interventions. The instrument “can be readminis- tered at multiple points during treatment to evaluate and consolidate gains that the couple has made and to identify residual areas of distress for further work. This idiographic approach to outcome evaluation emphasizes within- partner change across time” (Snyder & Aikman, 1999, p. 1198).
Protocol for Utilizing Ongoing Assessment Method
The following six-step protocol can be useful in utilizing the GARF, SFI, SAFE, DAS, and MSI-R when measuring and monitoring clinical outcomes with couples and families.
1. Initially interview the couple or family.
2. Choose and administer specific inventories.
3. Collect collateral data (relevant work, school, medical records, etc.) and other interview data.
4. Review assessment data and plan treatment.
5. Monitor ongoing clinical outcomes and modify treatment accordingly.
6. Evaluate pre- and posttreatment outcomes, if feasible.
Well-executed interviews of the couple and family (Step 1 and Step 3) are essential in providing sufficient data and background information to develop and implement an effective treatment plan and intervention strategies. At the present time, the decision of which inventories and rating scales (Step 2) to use to measure and/or monitor clinical outcomes is much less complex than the protocols suggested by Bagarozzi (chapter 7) or Yingling (chapter 8). For example, Bagarozzi advocates a four-step funneling or filtering process that progresses from choosing global measures to focused measures. Because of the limited number of suitable potential inventories and scales (i.e., ease of administration and reasonable cost), the clinician might decide to utilize the SFI and GARF or the SAFE and GARF with families, and the GARF and DAS or MSI-R with couples.
Step 5 reflects the basic reason for monitoring outcomes, for example, ses- sion by session, every third session, and so forth. In this step, outcomes data transform into valuable feedback information that the clinician can utilize to modify the course and duration of treatment in terms of focus, modality, and intervention strategies. As a result of this feedback and subsequent treatment
“course correction,” couple or family therapy becomes more closely tailored to couple or family need and circumstance. Presumably, this should lead to more effective and efficient treatment. Finally, the clinical value of outcomes mea- surement can be evaluated in Step 6 by examining overall pre–posttreatment effects on the given outcome measures, inventories, and/or scales.