JOFT 22.

2 - Main Text 14/4/0 11:02 am Page 190

 The Association for Family Therapy 2000. Published by Blackwell Publishers, 108 Cowley
Road, Oxford, OX4 1JF, UK and 350 Main Street, Malden, MA 02148, USA.
Journal of Family Therapy (2000) 22: 190–210
0163–4445

Family Assessment Measure (FAM) and Process

Model of Family Functioning

Harvey Skinner,a Paul Steinhauer,b and Gill

Sitareniosc

This paper provides an overview of twenty years’ work in the development

of the Family Assessment Measure (FAM), based on the Process Model of
Family Functioning. The Process Model describes a conceptual framework
for conducting family assessments according to seven key dimensions: task
accomplishment, role performance, communication, affective expression,
involvement, control, values and norms. The FAM provides measures of
these dimensions at three levels: whole family system (general scale, fifty
items), various dyadic relationships (dyadic scale, forty-two items) and
individual functioning (self-rating scale, forty-two items). In addition, the
general scale includes social desirability and defensiveness response style
measures. Brief FAMs (fourteen items) are available for each scale as well.
The measurement properties of FAM have been evaluated in a variety of
clinical and non-clinical settings. Reliability estimates are very good in
most contexts. FAM’s validity has been supported using a number of tech-
niques. Overall, the weight of the evidence is that FAM’s effectively and
efficiently assess family functioning and provide strong explanatory and
predictive utility. This empirical evidence reinforces experiences of clini-
cians, indicating that FAM provides a rich source of information on family
functioning.

Introduction
Families are complex, ever-changing systems. This complexity
creates many challenges for those involved in family assessment,
therapy and research. For example, what emphasis should be
placed on characteristics of individual members, their various inter-
actions, or the family system as a whole? In addition to differing

aProfessor and Chair, Department of Public Health Sciences, Faculty of

Medicine, McMurrich Building, University of Toronto, Toronto, Ontario, Canada
M5S 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.

 2000 The Association for Family Therapy and Systemic Practice

JOFT 22.2 - Main Text 14/4/0 11:02 am Page 191

Family Assessment Measure 191

individual, dyadic and whole system levels within the family, there
are 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 the
relative focus on family history versus current functioning. These
challenges stimulated our work on developing the Process Model of
Family 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. The
Family Assessment Measure was designed to assess the seven
constructs of the Process Model. The FAM is relatively unique in
that it provides indices of family strengths and weaknesses from
three perspectives: the family as a system (general scale), various
dyadic 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 research
on family processes. This paper reviews the Process Model of Family
Functioning, describes the development of the FAM, provides
guidelines on its clinical use, and then gives a synopsis of research
using the FAM.

Overview
The Process Model of Family Functioning provides a conceptual
framework for conducting family assessments (Steinhauer, 1987;
Steinhauer et al., 1984). This model provides a means of organizing
and integrating various concepts into a comprehensive yet parsi-
monious framework. Both our Process Model and the McMaster
Model (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 a
variety of basic, developmental and crisis tasks (task accomplishment).
Each task places demands that the family must organize itself to
meet. It is through the process of task accomplishment that the
family attains, or fails to achieve, objectives central to its life. These
include allowing for the continued development of all family
members, providing reasonable security, ensuring sufficient cohe-
sion to maintain the family as a unit, and functioning effectively as

 2000 The Association for Family Therapy and Systemic Practice

JOFT 22.2 - Main Text 14/4/0 11:02 am Page 192

192 Harvey Skinner et al.

Figure 1 Process Model of Family Functioning

part of society. The process by which tasks are accomplished

includes: (1) task or problem identification, (2) exploration of
alternative solutions, (3) implementation of selected approaches,
and (4) evaluation of effects.
Successful task accomplishment involves the differentiation and
performance of various roles. Role performance requires three
distinct operations: (1) allocation or assignment of specified activi-
ties to each family member; (2) agreement or willingness of family
members to assume the assigned roles; and (3) actual enactment or
carrying out of prescribed behaviours. Essential to the performance
of these roles is the process of communication. The goal of effective
communication is the achievement of mutual understanding, so
that the message received is the same as the message intended. If
the message sent is clear, direct and sufficient, then mutual under-
standing is likely to occur. However, the process of communication
may be avoided or distorted by the receiver. Thus, critical aspects of
the reception phase include the availability and openness of the
receiver to the message. A vital element of the communication
process is the expression of affect (affective expression), which can

 2000 The Association for Family Therapy and Systemic Practice

JOFT 22.2 - Main Text 14/4/0 11:02 am Page 193

Family Assessment Measure 193

impede or facilitate various aspects of task accomplishments and
successful role integration. Critical elements of affective expression
include the content, intensity and timing of the feelings involved.
Affective communication is most likely to become blocked or
distorted in times of stress.
The kind of involvement which family members have with one
another can either help or hinder task accomplishment. Involvement
refers to both the degree and quality of family members’ interest in
one another. These two aspects may be used to describe five types of
affective involvement including: the uninvolved family, a family
which expresses interest devoid of feelings, the narcissistic family,
an emphatic family and the enmeshed family. Other important
elements of affective involvement include the ability of the family to
meet the emotional and security needs of family members, and the
flexibility to provide support for family members’ autonomy of
thought and function.
Control is the process by which family members influence each
other. The family should be capable of successfully maintaining
ongoing functions, as well as adapting to shifting task demands.
Critical aspects of control include whether or not the family is
predictable versus inconsistent, constructive versus destructive, or
responsible versus irresponsible in its management style. Certain
combinations of these characteristics may give rise to four prototype
styles: rigid, flexible, laissez-faire and chaotic. Finally, how tasks are
defined and how the family proceeds to accomplish them may be
greatly influenced by norms and values of the culture in general,
and the family background in particular. Values and norms provide
the background against which all processes must be considered.
Important elements consist of whether family rules are explicit or
implicit, the latitude or scope allowed for family members to deter-
mine their own attitudes and behaviour, and whether family norms
are consistent with the broader cultural context.
The Process Model of Family Functioning emphasizes family
dynamics; it is not a model of family therapy. This distinction recog-
nizes that understanding families and treating families may require
somewhat different skills. The Process Model emphasizes family
health as well as pathology. While it is important to identify dimen-
sions that are relevant to family health pathology, the Process Model
also 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

 2000 The Association for Family Therapy and Systemic Practice

JOFT 22.2 - Main Text 14/4/0 11:02 am Page 194

194 Harvey Skinner et al.

family system nor individual intra-psychic dynamics. Instead, basic
family processes are considered with a clear acknowledgement that
a 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 and
Tisdall, 1984).
The Process Model differs from its predecessor (Family
Categories Schema) and the McMaster Model in three significant
ways. First, the Process Model goes beyond listing major parameters
of 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 integrating
family systems/psychological theories. Third, the Process Model
emphasizes the larger social system and family history (values and
norms), which are not stressed in the McMaster Model.

Family Assessment Measure

The Family Assessment Measure (FAM) was developed according to
a construct validation paradigm (Jackson, 1974; Skinner, 1981).
This strategy involved an active interplay between specification of
the theoretical model of family functioning and construction of an
instrument to measure concepts of the model (Figure 1). Thus, the
FAM was aimed at providing an operational definition of constructs
in 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 rating
of family functioning, seven measures relating to the Process
Model and two response style subscales (social desirability and
defensiveness). An example of a general scale profile is given in
Figure 2 for three family members. Note that the mother (aged
48) and daughter (aged 19) identify several areas as problematic,
especially communication and affective expression, although the
father (aged 51) rates family functioning to be in the normal
range (T scores around 50). He scores very high on social desir-
ability and defensiveness which indicates that he is minimizing
problems.
• Dyadic relationships scale (forty-two items, seven subscales): focuses
on relationships between various pairs (dyads) in the family. For

 2000 The Association for Family Therapy and Systemic Practice

JOFT 22.2 - Main Text 14/4/0 11:02 am Page 195

Family Assessment Measure 195

Task Com Invol V&N Defn

Role AffEx Cont SocDY

Figure 2 Example of a FAM general scale

each dyad, an overall rating of functioning is provided along with

an assessment for each construct of the Process Model.
• Self-rating scale (forty-two items, seven subscales): focuses on the
individual’s perception of his/her own functioning in the family.
An overall index is provided along with seven measures relating
to 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 for
preliminary screening. In addition, brief FAM scales can be used
for monitoring family functioning over time (e.g. during the
course of therapy).
Depending on the number of scales used, the FAM generally
takes between twenty and forty-five minutes to administer and it
may be completed by family members who are at least 10–12 years
of age. A brief FAM fourteen-item version can be completed in
around five minutes. Two methods of administration are available.

 2000 The Association for Family Therapy and Systemic Practice

JOFT 22.2 - Main Text 14/4/0 11:02 am Page 196

196 Harvey Skinner et al.

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

Clinical guidelines for using FAM

The FAM will never replace a thorough clinical assessment. In the
real world, however, most assessments are more or less incomplete
due to time pressures. However, the FAM can provide a helpful
adjunct to clinical assessment:
1 by pinpointing gaps in the assessment, which can then be
explored clinically;
2 by identifying areas of confusion, as when different family
members 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 increasing
members’ 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 clinical
assessment but are prepared to discuss when asked to explain
their responses to the FAM, which offers a less threatening point
of entry;
6 by providing a concrete and visual illustration (by the peaks and
valleys in the graph) of perceived areas of strength and weakness.
This may help in communicating the assessment and contracting
for treatment;
7 by helping therapist and family define and agree upon goals for
treatment;
8 by providing an objective and quantitative measure of change in
response to treatment.

 2000 The Association for Family Therapy and Systemic Practice

JOFT 22.2 - Main Text 14/4/0 11:02 am Page 197

Family Assessment Measure 197

Directionality is not built into the FAM. A high score on the
involvement scale, for example, could mean that the individual
feels: (1) distanced, excluded or rejected; (2) that other family
members are too intrusive so that his/her boundaries are
constantly being invaded, or (3) that both of these are problems
at different times. Thus, while the FAM may pinpoint a problem in
an aspect of family functioning, it is the clinician who must
pinpoint the nature and direction of that problem. It often helps
to include the family in this clarification process, thereby using
FAM responses to stimulate further exploration of problematic
aspects of family functioning. Doing so often reveals that the same
high score means very different things to different family
members.
One of the most useful aspects of the FAM for the practising clin-
ician is that by combining its three scales (general, self, dyadic) one
obtains a much richer and more detailed profile of the family than
by tapping only one level of family functioning. Used together, the
three scales are analogous to a CAT-scan, providing multiple
complementary views of the family from different perspectives. A
family of four, for example – assuming all members are old enough
to complete the FAM, which is accessible to the average child who
has completed Grade 5 – would provide twenty overlapping
Asnapshots@ of the family: four general scales, twelve dyadic scales,
and four self scales. Each of these captures a different aspect of
family functioning, and each dyadic relationship is described by
both participants in the dyad.
The FAM can generate an unusually rich picture of a couple’s
relationship if, in addition to the partners using the dyadic scale to
describe their relationship with each other, they also complete: (1)
self scales, which demonstrate how they see – or don’t see – their
part in the couple’s problem; and (2) dyadic scales describing their
relationships with any children whom they believe have emotional
or behaviour problems. A comparison of how each parent views the
relationship with the child – and how well the parent gets along
with the child as compared to the partner – often illustrates the
triangulation so frequent in the families of covertly conflicted
parents.
The FAM can be interpreted either objectively or subjectively.
Objectively, one compares the individual’s standardized scores to
those of a non-clinical population as a percentile. However, when
using it as an adjunct to a clinical assessment, the assessor is

 2000 The Association for Family Therapy and Systemic Practice

JOFT 22.2 - Main Text 14/4/0 11:02 am Page 198

198 Harvey Skinner et al.

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

• If a teenager and a parent both report significant problems in

control and values and norms, one might hypothesize a pattern of
repeated power struggles based on conflicting values.
• If one partner’s dyadic scales reported major problems in role
performance and involvement while the other did not, one might
hypothesize either that one partner (usually the wife) craves
more intimacy while the other is resisting her pressure for greater
closeness; alternately, one partner (usually the husband) might
be 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 that
fall below 30 (i.e. two standard deviations below the norm)
suggest that the individual’s scores on the clinical scales (usually
highly elevated) are being distorted by very high levels of
personal 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 a
profile is a poor prognostic sign, unless it can be used to help
those involved accept more responsibility for their own behavi-
our. (For example, a family therapist used one such situation to suggest
that he did not consider a couple good candidates for marital therapy,
since they both reported major problems in the marriage (dyadic) but saw
themselves as having no problems (self). The couple responded by moving
beyond the defensive manoeuvring typical of the assessment to convince the
therapist that they were prepared to change. Thus began a very successful
therapeutic encounter for a couple that had not benefited from several
previous courses of treatment.)

 2000 The Association for Family Therapy and Systemic Practice

JOFT 22.2 - Main Text 14/4/0 11:02 am Page 199

Family Assessment Measure 199

Those who use only the FAM’s general scale may be surprised to
find normal ratings in some families that appear highly problematic
in clinical assessments. This usually occurs in families that attribute
their problems to one or more individuals – whom they label
patient(s) – rather than to the family as a unit. If the identified
patient accepts the family’s definition that he is the problem, his
general scale scores may also fall within the average range. If dyadic
scales were administered to such families, they would show most
members reporting disturbed relationships with the identified
patient but satisfactory relationships with each other. If self scales
were administered as well, only the identified patient would report
major weaknesses. On the other hand, if the identified patient
rejected the family’s labelling him as the problem, his general scales
would report major problems in family functioning while those of
the other family members fell within the average range.
The interpretation of discrepancies between two family
members’ ratings of the same aspect of family functioning can
provide 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 not
yet been established through research what level of discrepancy
reaches clinical significance. The greater the discrepancy between
family members’ ratings, however, the more likely that difference is
clinically significant. Since ten points represents one standard devi-
ation, a good rule of thumb is that as the difference between two
family members’ ratings of a dimension approaches ten points, the
more likely that discrepancy is to be clinically relevant. But even a
differential of five points (i.e. half a standard deviation) is probably
clinically 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 to
treatment. Some relationships, individuals and aspects of family
functioning may get better, while others may stay the same or even
get worse (Woodside et al., 1995a). The dyadic and self scales of
FAM are more sensitive to change than the general scale. This is
because a change in the general scale indicates a shift in overall
family functioning, but does not pinpoint in which relationships
that change has occurred. A change in the self or dyadic scores,
however, pinpoints one member’s rating of one dimension, which is
not diluted by a consideration of overall family functioning.

 2000 The Association for Family Therapy and Systemic Practice

JOFT 22.2 - Main Text 14/4/0 11:02 am Page 200

200 Harvey Skinner et al.

Finally, some families that are extremely defensive when therapy
begins may show elevation of their clinical scales after what both
they and their therapist consider to be successful treatment. In such
cases, the higher scale scores indicate that the family is admitting
more problems – i.e. their denial has decreased – not that their
functioning has deteriorated (Shekter-Wolfson and Woodside,
1990).

Summary of FAM research

Research on the FAM spans twenty years. The following section
outlines key elements of this research including an overview of the
normative and clinical data, as well as information regarding the
reliability and validity of the FAM.

Normative data
Normative data for the FAM is based on 247 normal adults and
sixty-five normal adolescents, constituting control groups at a vari-
ety of health and social settings. The mean age of the adults was 38.6
years (SD = 8.5); 43% were men and 57% were women. Over half
(53%) of the adults had completed at least some post-secondary
education. 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 living
together for an average of fifteen years (SD = 8.6) and 86% were
legally married. About 30% of the wives and 20% of the husbands
had been previously married.
Data for numerous clinical groups exist for the FAM, docu-
mented in Skinner et al. (1995). Data are also available for families
having a variety of special circumstances (e.g. children with social
phobia, 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 data
obtained from the family were compared only to the normative
non-clinical data, then certain areas of functioning may appear
problematic relative to normative families where there is no cystic

 2000 The Association for Family Therapy and Systemic Practice

JOFT 22.2 - Main Text 14/4/0 11:02 am Page 201

Family Assessment Measure 201

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)

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

 2000 The Association for Family Therapy and Systemic Practice

JOFT 22.2 - Main Text 14/4/0 11:02 am Page 202

202 Harvey Skinner et al.

measure is influenced by the number of items, some decrease in
reliability should be expected for the much briefer subscales. Most
subscale reliabilities are quite respectable, although a few subscales
for 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, and
then were mailed a packet of booklets and asked to complete their
forms independently. On average, the time between completion of
the two FAM questionnaires was twelve days. Participants were
instructed to complete the general scale using the ‘past week’
format (‘Describe your family during the PAST WEEK using the scale
below’). The median test–retest reliabilities for the FAM subscales
were: .57, mothers; .56, fathers; and .66, children. These reliability
estimates 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 a
construct, since the construct can never be measured perfectly.
Because it cannot be directly assessed, validity must be inferred. To say
that 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 extensively
researched, and its validity has been supported using a number of
techniques. 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 FAM

has been frequently used to examine differences among types of
families. The findings indicated that, when there is a strong a priori
reason to believe the groups differ in terms of family functioning,
FAM differentiates between groups.
Jacob (1991) investigated forty-nine families that contained an
alcoholic father, forty-eight families with a depressed father and
forty-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

 2000 The Association for Family Therapy and Systemic Practice

JOFT 22.2 - Main Text 14/4/0 11:02 am Page 203

Family Assessment Measure 203

the normal group. A Multivariate Analysis of Variance Analyses
(MANOVA) was conducted to test for the statistical significance of
these differences. The overall multivariate test (Wilks Lambda)
indicated a significant (p < .01) difference among the three family
types. Virtually all the FAM scales significantly differentiated the
clinical 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’ families
were 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 legal
problems. For problem families, there were 108 fathers, 131
mothers and 151 children. For non-problem families, there were
305 fathers, 348 mothers and 359 children. A multiple discriminant
function analysis was conducted to determine whether the FAM
subscales would significantly differentiate between the groups.
Problem families, in general, reported more family dysfunction in
the areas of role performance and affective involvement. Non-
problem families had a slight tendency to score higher in social
desirability 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 a
distressed relationship (n = 38) and those involved in a non-
distressed relationship (n = 28). Participants were obtained from an
outpatient clinic or a private practice and were all undergoing treat-
ment for some type of relationship difficulty. Determination as to
which relationships were distressed and which non-distressed was
made on the basis of scores obtained on the dyadic adjustment scale
(Spanier, 1976). The distressed group had significantly higher FAM
self-rating scores (indicative of more problems) on several
subscales: task accomplishment, role performance, communica-
tion, affective expression, involvement, control, and values and
norms. The FAM subscales significantly discriminated between
distressed and non-distressed relationships.

2 Construct validity. One way of assessing the merits of an instrument

is to determine how it compares with other instruments designed to
measure the same (or related) constructs. Several research studies
have examined this type of validity in relation to the FAM.

 2000 The Association for Family Therapy and Systemic Practice

JOFT 22.2 - Main Text 14/4/0 11:02 am Page 204

204 Harvey Skinner et al.

Bloomquist and Harris (1984) administered the FAM general
scale and MMPI special family scales to 110 undergraduates at
several colleges in the Chicago area. Bloomquist and Harris found
a strong relationship between MMPI special family scales and FAM
subscale scores. The MMPI ‘family problems’ special subscale had
particularly high correlations with FAM subscales for task accom-
plishment, role performance, communication, affective expression,
involvement, and values and norms. Similarly, the MMPI ‘family
discord’ and ‘family attachment’ special subscales had particularly
large 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 were
correlated with measures of family idealization, cohesion and
expressiveness from the Family Adaptation and Cohesion
Evaluation Scales (Olson et al., 1983), the Family Environment Scale
(Moos, 1974; Moos and Moos, 1981), and the Family Concept Q
Sort (van der Veen, 1965). Correlations between the FAM and
these 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 other
measures of family functioning to a sample of 138 mothers of
primarily white middle-class families. The three measures were: the
Family 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: Epstein
et al., 1983). Because of the overlap in focus of these instruments,
correlations between the FAM and these other measures should be
reasonably high. The main correlations obtained are summarized in
Table 2. With FACES, correlations with cohesion were high, but with
adaptability they were low. With the FES, correlations were high with
cohesion and conflict; moderate with expressiveness, intellectual-
cultural orientation, active-recreational orientation, and organiza-
tion; and mostly negligible with independence, achievement
orientation, moral-religious emphasis and control. With the FAD, all
correlations were high and significant. On the whole, FAM was
found to have high and significant correlations with appropriate
dimensions of these related measures.

3 Clinical validity. Numerous research studies have used the FAM in

clinical contexts. The research presented below focuses on FAM as

 2000 The Association for Family Therapy and Systemic Practice

JOFT 22.2 - Main Text 14/4/0 11:02 am Page 205

Family Assessment Measure 205

TABLE 2 Correlations between the FAM and other measures

Family Assessment Measure

TA RP Com AE Inv Con VN

FACES
Cohesion -.49** -.55** -.44** -.48** -.48** -.50** -.39**
Adapt. .04 .05 .06 .10 -.05 -.03 .03
FES
Cohesion -.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* -.17
Achieve. .10 -.15 .10 .12 -.06 .02 .05
Intellect. -.27** -.32** -.21* -.31** -.27** -.25** -.29**
Active. -.23* -.22* -.23* -.24* -.15 -.23* -.17
Moral. -.17 -.20* -.09 -.18 -.06 -.17 -.11
Organiz. -.33** -.48** -.39** -.34** -.29** -.38** -.34**
Control .04 -.07 -.06 -.03 -.03 .01 .01
FAD
Prb.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 < .05

FACES: Family Adaptability and Cohesion Scales
FES: Family Environment Scale
FAD: Family Assessment Device

a tool for providing information relevant to family therapy,

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

 2000 The Association for Family Therapy and Systemic Practice

JOFT 22.2 - Main Text 14/4/0 11:02 am Page 206

206 Harvey Skinner et al.

been a change, and the family had hopes that things could improve
more in the future. A recommendation for marital therapy and
further family therapy was made and accepted by all parties, largely
on the basis of the positive view of the FAM feedback.
Trute et al. (1988) describe a project which developed a
programme monitoring strategy in the Family Therapy Department
at the Children’s Home of Winnipeg, Canada. A clinical evaluation
approach was adopted to assess service effectiveness, defined
primarily in terms of improved family functioning. The monitoring
of these services extended over a three-month period. FAM ques-
tionnaires were completed by sixteen families at the initiation of
therapy and at the termination of services over the three-month
review period. The participants consisted of sixteen mothers and
nine fathers. The FAM results indicated that fifteen of the sixteen
families showed improvement in functioning. In addition, female
family 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 of
the FAM in monitoring treatment effectiveness. Responses from a
sample of ninety-one bulimic patients and their families were
examined before and after treatment. Ratings of family function-
ing improved significantly over the course of treatment although
ratings 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 therapeutic
effects.
Recent studies also support the effectiveness of the FAM in
capturing therapeutic change. For example, Johannson and Tutty
(1998) assessed families before and after intervention to improve
functioning in families where physical or psychological abuse
existed. They found significant improvement on the FAM as well as
a variety of other measures.
In our experience, the dyadic scale results are most likely to
show change during and after treatment as the dynamics of specific
dyad relationships are explored. Further research is needed to
provide empirical and experience-based guidelines for using the
FAM in planning and monitoring interventions. More work is also
needed on adapting the FAM for use with special populations and
settings.

 2000 The Association for Family Therapy and Systemic Practice

JOFT 22.2 - Main Text 14/4/0 11:02 am Page 207

Family Assessment Measure 207

Conclusion
The measurement properties of FAM are quite respectable, given
the inherent complexity and challenges in family assessment.
Reliability estimates are very good in most contexts. Validity of the
FAM is supported by research done in a variety of clinical and non-
clinical settings. This empirical evidence, reinforced by experiences
of clinicians and researchers in a number of countries, suggests that
FAM serves its purpose in providing a rich source of information on
family functioning.

References
Adams, D.M., Overholser, J.C. and Lehnert, K.L. (1994) Perceived family func-
tioning and adolescent suicidal behavior. Journal of the American Academy of Child
and Adolescent Psychiatry, 33: 498–507.
Bernstein, G.A. and Borchardt, C.M. (1996) School refusal: family constellation
and family functioning. Journal of Anxiety Disorders, 10: 1–19.
Bernstein, G.A. and Garfinkel, B.D. (1988) Pedigrees, functioning, and
psychopathology in families of school phobic children. American Journal of
Psychiatry, 145: 70–74.
Bernstein, G.A., Svingen, P.H. and Garfinkel, B.D. (1990) School phobia: patterns
of family functioning. Journal of the American Academy of Child and Adolescent
Psychiatry, 9: 24–30.
Bloom, B.L. (1985) A factor analysis of self-report measures of family functioning.
Family Process, 24: 225–239.
Bloomquist, M.L. and Harris, W.G. (1984) Measuring family functioning with the
MMPI: a reliability and concurrent validity study of three MMPI scales. Journal
of Clinical Psychology, 40: 1209–1214.
Buchheim, P., Cierpka, M., Scheibe, G. and Braun, P. (1990) Relationship patterns
of anxiety disorder patients: extension of clinical phenomenological diagnosis
to relationship levels. Praxis der Psychotherapie und Psychosomatik, 35: 95–110.
Campbell, D. and Fiske, D. (1959) Convergent and discriminant validation by the
multitrait-multimatrix method. Psychological Bulletin, 56: 81–105.
Cowen, L., Mok, J., Corey, M., MacMillan, H., Simmons, R. and Levison, H. (1986)
Psychologic adjustment of the family with a member who has cystic fibrosis.
Pediatrics, 77: 745–752.
Cowen, L., Corey, M., Keenan, N., Simmons, R., Arndt, E. and Levison, H. (1985)
Family adaptation and psychosocial adjustment to cystic fibrosis in the
preschool child. Social Science Medicine, 20: 553–560.
Epstein, N.B., Baldwin, L.M. and Bishop, D. (1983) The McMaster Family
Assessment Device. The Journal of Marital and Family Therapy, 9: 171–180.
Epstein, N.B., Rakoff, V. and Sigal, J. (1968) The Family Categories Schema.
Unpublished manuscript, Jewish General Hospital, Department of Psychiatry,
Montreal, Quebec, Canada.
Epstein, N.B., Bishop, D., Ryan, C., Miller, I. and Keitner, G. (1993) The McMaster

 2000 The Association for Family Therapy and Systemic Practice

JOFT 22.2 - Main Text 14/4/0 11:02 am Page 208

208 Harvey Skinner et al.

Model: view of healthy family functioning. In F. Walsh (ed.) Normal Family
Process (pp. 138–160). New York: Guilford Press.
Forman, B. (1988) Assessing perceived patterns of behavior exchange in relation-
ships. Journal of Clinical Psychology, 44: 972–981.
Garfinkel, P.E., Garner, D.M., Rose, J., Darby, P.L., Brandes, J.S., O’Hanlon, J. and
Walsh, N. (1983) A comparison of characteristics in the families of patients with
anorexia nervosa and normal controls. Psychological Medicine, 13: 821–828.
Garner, D.M., Garfinkel, P.E. and O’Shaughnessy, M. (1985) The validity of the
distinction between bulimia with and without anorexia nervosa. American Journal
of Psychiatry, 142: 581–587.
Hauser, E., Freilinger, M., Skyllouriotis, M. and Zacherl, S. (1996) Funktion und
struktur von familien mit chronisch kranken kindern [Function and structure
of families with chronically ill children]. Psychotherapie Psychosomatik Medizinische
Psychologie, 46: 379–384.
Hundert, J., Cassie, J.R.B. and Johnson, N. (1988) Characteristics of emotionally
disturbed children referred to day-treatment, special-class, outpatient, and
assessment services. Journal of Clinical Child Psychology, 17: 121–130.
Jackson, D.N. (1974) The dynamics of structured personality tests: 1971.
Psychological Review, 78: 229–248.
Jacob, T. (1991) Comparison of Alcoholic, Depressed, and Control Families using the FAM-
III. Unpublished manuscript.
Jacob, T. (1995) The role of the time frame in the assessment of family function-
ing. Journal of Marital and Family Therapy, 21: 281–286.
Johannson, M.A. and Tutty, L.M. (1998) An evaluation of after-treatment couples’
groups for wife abuse. Family Relations: Interdisciplinary Journal of Applied Family
Studies, 47: 27–35.
Kufeldt, K., Armstrong, J. and Dorosh, M. (1994) How Children in Care View their own
and their Foster Families using the FAM Scales. Unpublished manuscript.
Laroche, C., Sheiner, R., Lester, E., Benierakis, C., Marrache, M., Engelsmann, F.
and Cheifetz, P. (1987) Children of parents with manic-depressive illness: a
follow-up study. Canadian Journal of Psychiatry, 32: 563–569.
Levene, J.E. (1991) The Influence of Expressed Emotion and Family Interaction on the
Course of Illness in Schizophrenia. Doctoral thesis.
Moos, R.H. (1974) Family Environment Scales. Palo Alto, CA: Consulting
Psychologists Press.
Moos, R.H. and Moos, B.S. (1981) Family Environment Scale Manual. Palo Alto, CA:
Consulting Psychologists Press.
Olson, D.H., Russell, C.S. and Sprenkle, D.H. (1983) Circumplex model of marital
and family systems, 6: Theoretical update. Family Process, 22: 69–83.
Penn, P. (1982) Circular questioning. Family Process, 21: 267–280.
Reddon, J.E. (1989) Parental Stress, Coping, and Resources: Impact on Functioning of
Families with Mentally Handicapped Preschoolers. Ph.D. dissertation, Edmonton,
Alberta.
Shekter-Wolfson, L. and Woodside, D.B. (1990) Family therapy. In N. Piran and
A.S. Kaplan (eds) A Day Hospital Group Treatment Program for Anorexia Nervosa and
Bulimia Nervosa (pp.79–109). Eating disorders monograph series (3). New York:
Brunner & Mazel.
Skinner, H.A. (1981) Toward the integration of classification theory and methods.
Journal of Abnormal Psychology, 90: 68–87.

 2000 The Association for Family Therapy and Systemic Practice

JOFT 22.2 - Main Text 14/4/0 11:02 am Page 209

Family Assessment Measure 209

Skinner, H.A. (1987) Self-report instruments for family assessment. In T. Jacob
(ed.) Family Interaction and Psychopathology. New York: Plenum (pp. 427–452).
Skinner, H.A., Steinhauer, P.D. and Santa-Barbara, J. (1983) The Family
Assessment Measure. Canadian Journal of Community Mental Health, 2: 91–105.
Skinner, H.A., Steinhauer, P.D. and Santa-Barbara, J. (1995) Family Assessment
Measure – III Manual. Toronto, Canada: Multi Health Systems.
Spanier, G. B. (1976) Measuring dyadic adjustment: new scales for assessing the
quality of marriage and similar dyads. Journal of Marriage and the Family, 38:
15–28.
Steinhauer, P.D. (1984) Clinical applications of the process model of family func-
tioning. Canadian Journal of Psychiatry, 29: 98–111.
Steinhauer, P.D. (1987) The family as a small group: the Process Model of Family
Functioning. In T. Jacob (ed.) Family Interaction and Psychopathology. New York:
Plenum (pp.67–115).
Steinhauer, P.D. and Tisdall. G.W. (1984) The integrated use of individual and
family psychotherapy. Canadian Journal of Psychiatry, 29: 89–97.
Steinhauer, P.D., Santa-Barbara, J. and Skinner, H.A. (1984) The process model of
family functioning. Canadian Journal of Psychiatry, 29: 77–88.
Thomas, M.R., Roy, R. and Cook, A. (1991) Headache, backache, and family func-
tioning for a group of college students and their parents: a follow-up. Headache
Quarterly, 2: 307–312.
Tomm, K. (1986) Circular interviewing: a multi-faceted clinical tool. In D.
Campbell and R. Draper (eds) Applications of Systemic Family Therapy: The Milan
Method. Orlando: Grune & Stratton.
Trute, B. and Hauch, C. (1988) Building on family strength: a study of families with
positive adjustment to the birth of a developmentally disabled child. Journal of
Marital and Family Therapy, 14: 185–193.
Trute, B., Campbell, L. and Hussey, E. (1988) Monitoring Family Therapy Services at
the Children’s Home of Winnipeg. Series #06820. Winnipeg, Manitoba: University
of Manitoba, School of Social Work, Child and Family Services Research
Group.
van der Veen, F. (1965) The parent’s concept of the family unit and child adjust-
ment. Journal of Counseling Psychology, 12: 196–200.
Westhues, A. and Cohen, J.S. (1990) Preventing disruption of special-needs adop-
tions. Child Welfare, 69: 141–155.
White, M. (1988) The process of questioning: a therapy of literary merit? Dulwich
Centre Newsletter, Winter: 8–14.
Woodside, D.B., Shekter-Wolfson, L.F., Garfinkel, P.E. and Olmsted, M.P. (1995a)
Family interactions in bulimia nervosa II: complex intrafamily comparisons and
clinical significance. International Journal of Eating Disorders, 17: 117–126.
Woodside, D.B., Shekter-Wolfson, L., Garfinkel, P.E., Olmsted, M.P., Kaplan, A.S.
and Maddocks, S.E. (1995b) Family interactions in bulimia nervosa I: study
design, comparisons to established population norms, and changes over the
course of an intensive day hospital treatment program. International Journal of
Eating Disorders, 17: 105-115.
Woodside, D.B., Lackstrom, J., Shekter-Wolfson, L.F. and Heinmaa, M. (1996a)
Long-term follow-up of patient-reported family functioning in eating disorders
after intensive day hospital treatment. Journal of Psychosomatic Research, 41:
269–277.

 2000 The Association for Family Therapy and Systemic Practice

JOFT 22.2 - Main Text 14/4/0 11:02 am Page 210

210 Harvey Skinner et al.

Woodside, D.B., Swinson, R.P., Kuch, K. and Heinmaa, M. (1996b) Family func-
tioning in anxiety and eating disorders B: A comparative study. Comprehesive
Psychiatry, 37: 139–143.

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 published
by MHS describes FAM’s development, interpretation, clinical uses
and research (Skinner et al., 1995). Information on obtaining FAM
is also available on their website (www.mhs.com). Several FAM
scales have been translated into different languages for specific
projects (e.g. French, German, Spanish, Portugese, Japanese,
Hebrew). Contact Gill Sitarenios at MHS for further information on
these translations. A FAM clinical rating scale has been developed
for assessing the seven constructs of the Process Model from an
‘outsider’s’ perspective. This scale is still under study and may be
obtained by contacting Harvey Skinner at the University of
Toronto.

 2000 The Association for Family Therapy and Systemic Practice