102 CHAPTER 3
Assessing Social Factors
Symptoms arise in a context, and part of a thorough clinical assessment is collecting
information about social factors. To some extent, the context helps the clinician or
researcher understand the problems that initiated the assessment: How does the
patient function in his or her home environment? Are there family factors or com-
munity factors that might infl uence treatment decisions? Is the patient from another
culture, and if so, how might that affect the presentation of his or her symptoms or
infl uence how the clinician should interpret other information obtained as part of
the assessment?
The importance of social and environmental factors in making an assessment
is illustrated by Arthur Kleinman (1988) in examples such as this: If a man has lost
energy because he has contracted malaria, has a poor appetite as a result of anemia
(due to a hookworm infestation), has insomnia as a result of chronic diarrhea, and
he feels hopeless because of his poverty and powerlessness, does the person have
depression? His symptoms meet the criteria for depression (as we shall see in Chap-
ter 6), but isn’t his distress a result of his health problems and social circumstances
and their consequences? Summing up his experiences as depression might limit our
understanding of his situation and the best course of treatment.Family Functioning
As noted in Chapter 2, various aspects of family functioning can affect a
person’s mental health. This was certainly true of the Walls family, where Rex’s
drinking and irresponsibility led Rose Mary to become overwhelmed and to
“shut down”—staying in bed for days and crying. Similarly, their marriage
appeared to have a role in Rex’s drinking problem: While living on the streets of
New York, Rex developed tuberculosis and was hospitalized for 6 weeks, during
which time he became sober. A hospital administrator helped him obtain a job
as a maintenance man in a resort in upstate New York; Rose Mary didn’t want
to leave the city, so he went without her. He worked and lived at the resort for
almost three seasons and continued to stay sober while he was there—his lon-
gest stretch of time without a drink. As winter came, Rose Mary called him and
persuaded him to come back to the city to be with her; he resumed drinking as
soon as he returned (Walls, 2005).
In order to assess family functioning, clinicians may interview all or some
family members or ask patients about how the family functions. Some clinicians
and researchers try to assess family functioning more systematically than through
interviews or observations. One tool for doing so is the Family Environment Scale
(Moos & Moos, 1986), which requires family members to answer a set of ques-
tions. Their answers are integrated to create a profi le of the family environment—
how the family is organized, different types of control and confl ict, family values,
and emotional expressiveness. Such information helps the clinician or researcher
to understand the patient within the context of his or her family and identifies
possible areas of family functioning that could be improved (Ross & Hill, 2004).
Another family assessment tool that focuses on family functioning is theFamily
Adaptability and Cohesion Scales,Version 3 (Olson et al., 1985), which consists of
20 questions about family adaptability and cohesion that are answered by one or
more family members.
Researchers have studied families in which one member has a particular type of
disorder and compared these fi ndings to those from families without such a member
(Cook-Darzens et al., 2005). For example, in one Chinese study, researchers gave
versions of both the Family Environment Scale and the Family Adaptability and Co-
hesion Scales to families that had a member with schizophrenia and families that
had no member with schizophrenia. Families with a member with schizophrenia had
more confl ict and were less cohesive (Phillips et al., 1998). As with other assessment
tools, however, an individual’s or a family’s data should be compared to norms of
people from similar cultural backgrounds.