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Treatment-resistant patients, individuals with multifaceted psychiatric problems who do not respond to current evidence-based treatment, pose unique challenges to treatment providers. Given that treatment resistance develops and is maintained within an interpersonal context, these patients often turn out to have treatment-resistant families with a set of complex, enduring, and problematic dynamics that interfere with the developmental tasks
and adaptive functioning of family members . Addressing resistance on the family level may enable changes in the individual patient. Studies suggest that individuals with complex psychiatric problems have better outcomes when their families are involved in the treatment process (Morey 2008; ). Indeed, extensive clinical experience has shown that family therapy that targets structural change within the system rather than symptom amelioration is an integral component of treatment with this population. As part of an effort to understand and measure structural change in treatment-resistant families, we came to ask ourselves this question: How is the construct of dynamic structural change measured in families?
With this question in mind, we surveyed the literature in search of assessment tools. Four commonly used observational family assessment instruments were considered: the Beavers Interactional Scale, the McMaster Model, the Circumplex Model, and the Global Assessment of Relational Functioning (Hampson and Beavers 2012). For the purposes of our study, however, we considered these problematic. As clinician-researchers, we felt that none of them accurately reflected our clinical experience working psychodynamically with families. They do not attempt to measure dynamic family processes such as the complementary use of unconscious defenses like splitting or projective identification. The absence of a dynamic domain precludes their use in measuring the effectiveness of psychodynamic assessment, intervention, and treatment in family th