Family Diagnosis/DSM-IV

As the only truly systemic family relations diagnostic tool to be included in the DSM-IV, the GARF was developed by leaders in the field of family assessment. It was intended to be simple to learn and use. However, a basic understanding of family systems functioning seems to be necessary in order to accurately interpret the rating. In the DSM-IV (1996) appendix describing the GARF, the dimensionalized scale (1–100) is grouped into five twenty-point categories ranging from, at the top of the scale, "81–100 Overall. Relational unit is functioning satisfactorily from self-report of participants and from perspectives of observers" (p. 758) to "1–20 Overall. Relational unit has become too dysfunctional to retain continuity of contact and attachment" (p. 759) at the bottom. These ratings are based on three basic variables that describe system functioning (DSM-IV 1994, p. 758):

• Problem solving—skills in negotiating goals, rules, and routines; adaptability to stress; communication skills; ability to resolve conflict.
• Organization—maintenance of interpersonal roles, subsystem boundaries, and hierarchical functioning; coalitions and distribution of power, control, and responsibility.
• Emotional climate—tone and range of feelings; quality of caring, empathy, involvement, and attachment/commitment; sharing of values; mutual affective responsiveness, respect, and regard; quality of sexual functioning.

These variables may be considered the organizational structure of a system with certain rules about who does what, when, where, and why; the communication processes that develop, sustain, and adapt those structural guidelines; and the emotional result of family members feeling safe, supported, heard, and understood. Lynelle Yingling and her colleagues (1998) helped pilot test the GARF for the DSM-IV, and continued research on the GARF in the doctoral clinic for Ph.D. interns in family therapy at Texas A&M University-Commerce. Clinical experience indicated that the GARF had greater usefulness when the three variables were measured separately rather than being combined as a global rating as directed in the DSM-IV. Models of family therapy intervention strategies can be correlated with each of the variables. When the organizational structure is unstable or rigidly distorted, working to get the structure realigned and stabilized is the goal of therapy. Examples of distortion are the parentification of children, unequal spousal power resulting in overt or covert power struggles, and adults still being tied to their biological parents in a child role rather than free to act as adults. When the structure is functioning normally but the communication skills are weak, focusing on learning to communicate effectively is the therapeutic goal. Several models have been developed to enhance open, clear, understandable, and accepted communication among family members. When both of those system dimensions are in need of help, all relevant goals for system change are integrated into the therapy. When the system is functioning normally, the Axis I symptoms of depression/substance abuse (from not being able to communicate fears and feel heard), anxiety (from organizational instability), and conduct disorder/family violence (from organizational distortion) will likely disappear. Axis II personality disorders (possibly from being raised in a chaotic family system) are much more difficult to eliminate because the relational patterns have been deeply engrained in the developmental process during childhood.