F a m i l y S y s t e m Test (FAST): T h e R e l e v a n c e o f

P a r e n t a l F a m i l y C o n s t r u c t s for
Clinical Intervention

Thomas M. Gehring, PhD

Mich~le Candrian, MA
Daniel Marti, MS, MD
University of Zitrich, Switzerland
Olivier Real del Sarte, MA
University of Lausanne, Switzerland

ABSTRACt. On the basis of the Family System Test (FAST), family representations of
parents with healthy and biopsychosocially distressed children were compared, and
family structure changes in the context of interventions on the parent-level were de-
scribed. Results indicated that parental family constructs are related to offspring's
health and clinical intervention. Parents of psychiatric patients showed their families
to have low cohesion, and hierarchically unclear generational boundaries (i.e. unbal-
anced structure). As had been their wish at therapy onset, the family patterns they
indicated after completion of treatment were balanced.

KEY WORDS: FAST Representations of Parents; Mentally and Physically Distressed

Children; Therapy Evaluation.

Clinicians and researchers from various disciplines recognize the

family as an important system with regard to its members' physical
and mental health. Individual distress can be a cause as well as a
consequence of problematic interpersonal structures. Problem-solving
in child psychiatry and pediatrics should thus be extended to include
the context in which stressful patterns arise. There is substantiating
evidence that parenting style and marital well-being are related to
child development. 1'2 Parents' constructs of family relations therefore

Received January 6, 1996; For Revision February 1, 1996; Accepted March 13, 1996.
Parts of this paper were presented at the 4th Congress of the Swiss Psychological
Association, Bern, 1995. The authors are grateful to Deborah Vitacco, MA and Chris-
tina Mrkoci, MS for their critical reading of the manuscript.
Address correspondence to Thomas M. Gehring, University of Zfirich, Department of
Social Medicine, Sumatrastrasse 30, CH-8006 Zfirich, Switzerland.

Child Psychiatry and Human Development, Vol. 27(1), Fall 1996

9 1996 H u m a n Sciences Press, Inc. 55
56 Child Psychiatry and Human Development

provide important information on how to conceptualize preventive

and therapeutic interventions.
Family therapy attempts to support resources that facilitate the
ability to cope with stressful events. It focuses on altering the interac-
tion between family members and seeks to improve the development
of the family and its subsystems (e.g. distressed child, parents).
Studies using various methodological approaches demonstrate the ef-
fectiveness of family therapy for individual and relational problems2 ,4
However, it still remains to specify when and under what conditions
parent-oriented interventions are indicated to transform family struc-
tures and to influence child outcome.5 In order to plan clinical prob-
lem-solving processes on the parent-level, more insights into the cur-
rent family constructs and the wishes for changes are needed. 6
Cohesion and hierarchy are two basic dimensions that describe
structures of family systems. Cohesion refers to the emotional close-
ness between family members. Hierarchy has been defined as the
structure of influence or control. The major conclusion drawn from
nonclinical research is that well-adjusted families are characterized
by cohesive and moderately hierarchical patterns. 7 In contrast,
studies on families with biopsychosocially distressed members re-
vealed that families are likely to have low cohesive interpersonal
structures and unclear hierarchical generational boundaries} '9'1~
Figure placement techniques are useful tools for assessing percep-
tions of cohesion and hierarchy within the family and its subsystems
from a systemic approach. These clinically derived tools can be used
with children and adults in individual and various family settings.
The Family System Test} hereafter referred to as FAST, uses a
monochromatic board (45 cm x 45 cm) divided into 81 squares, male
and female figures (8 cm) representing the family members, and cy-
lindric blocks of three sizes (1.5, 3, and 4.5 cm). 11The degree of cohe-
sion is represented by the distance between figures. The degree of
hierarchy is portrayed by the blocks upon which the figures are ele-
vated (see Figure 1). To illustrate how cohesion is portrayed by the
FAST, the experimenter first places figures close to one another and
then moves them farther apart, while explaining what these patterns
mean in terms of cohesion, that is "how close family members feel to
each other." The experimenter then elevates the figures using blocks

~English, Dutch, French, Ita|ian, Spanish, Russian and Japanese translations of the
original German FAST manual may be obtained by contacting the first author. The test
materials can be ordered from SWETS test Services, NL-2160 SZ Lisse, Holland.
T. M. Gehring, M. C a n d r i a n , D. Marti, and O. R. del Sarte 57

FIGURE 1. FAST representation of cohesion and hierarchy in a family of five.

of various sizes, while explaining that the vertical differences corre-

spond to the differences in hierarchy, that is "the ability to influence
other family members." Respondents are told that they can use any of
the squares on the board and any number of blocks. Family members
are then asked individually to represent their interpersonal relation-
ships, while being in separate rooms (i.e. individual representation).
Afterwards they are brought together and asked to jointly portray
their family (i.e. group representation). After completion of the repre-
sentations, the experimenter records the location and elevation of
each figure. A family configuration is scored as "balanced," if the fig-
ures are placed within a 3 x 3 square area and the parental figures
are more elevated than those representing their offspring. All other
structures are scored as "unbalanced."
Psychometric properties and construct validity of the FAST were
reported by Gehring and his colleagues. 12,1~,14Clinical discriminant va-
lidity was established by the result that at therapy onset child psychi-
atric patients were more likely than nonclinical respondents to repre-
sent their family as having low cohesion and unclear hierarchical
generational boundaries (i.e. unbalanced structure). In addition, it
was shown t h a t after completion of treatment, children displayed
their families predominantly as balanced. 15However, the structure of
58 Child Psychiatry and Human D e v e l o p m e n t

family relations can only partially be captured on the basis of patient

data. 1~'~7For example, it should be clarified whether or not family per-
ceptions of parents are related to their offspring's health.
The purpose of this work was to compare FAST representations of
parents with healthy children and of parents with children suffering
from physical or mental disorders. Furthermore, family perceptions of
fathers and mothers of psychiatric patients were described in the con-
text of clinical interventions on the parent-level.

F a m i l y C o n s t r u c t s o f P a r e n t s a n d Children's H e a l t h

A recent study revealed that parents of nonclinical families gener-

ally portrayed relational structures as balanced. However, it was
found that fathers and mothers differed in their constructs, and that
high parental agreement could be associated with suboptimal family
functioning.TM
In order to examine whether parents' family constructs are related
to their offspring's health, mothers and fathers of nonclinical chil-
dren, of cancer patients, and of child psychiatric patients completed
the FAST individually and jointly. 19Results indicated that family rep-
resentations of the three groups varied depending on the clinical sta-
tus of the child (see Table 1). For example, in nonclinical families,
fathers were more likely than mothers to portray balanced structures.
For parents of cancer patients, a reverse pattern was found, and
mothers had a pervasive influence on the joint representation. In
families of psychiatric patients, parents, individually and together,
represented relational structures predominantly as unbalanced.
These findings suggest that parents' constructs differ depending on
their children's health and that family assessment should consider
multiple respondent data in various settings.

Table 1
Individual and Group Representations of Family Structures by Parents
of Clinical and Nonclinical Children (N = 120)a
Father Mother Group
Clinical Status
of Child Balanced Unbalanced Balanced Unbalanced Balanced Unbalanced

Nonclinical 75 25 55 45 63 37
Cancer 53 47 87 13 80 20
Psychiatric 17 83 17 83 17 83

"Data in percentages.
T. M. G e h r i n g , M. C a n d r i a n , D. M a r t i , a n d O. R. del Sarte 59

Attempted changes of family relationships by parents who referred

their child to psychiatry were examined at the onset of treatment. 2~
The question was to determine whether and on what level mothers
and fathers wished to change their family structure. Using the FAST,
parents were asked to represent their current and desired family re-
lations in individual and joint settings. Results indicated that parents
wish to change the family towards balanced structures. Analyses of
the divergence between current and desired family structures on the
subsystem-level (see Table 2) showed t h a t both individually and
jointly, parents wanted increased cohesion in the father-mother dyad
b u t no changes in the mother-child relationships. However, while
mothers reported that father-patient and father-sibling dyads should
be more cohesive, fathers indicated more cohesion in the sibling sub-
system, b u t no changes in the relations to their children. As to hier-
archy, only fathers wished a decrease of the patients' power. In the
group portrayals, fathers and mothers demonstrated a desire for a
change of their family structures. This suggests that parents are mo-
tivated for interventions focusing on transformations of family rela-
tionships.

Changing Family Constructs of Parents across Treatment

The following two studies investigated family constructs of parents

with children who suffer from developmental or psychiatric disorders.
FAST representations were completed at various points during the
clinical problem-solving process.

Table 2
Differences between Current and Wished-for Family Structures of
Parents at the Onset of Child Psychiatric Treatment (N = 20) a'b

Increase in Cohesion ~ Decrease in Power~

Father- Father- Father- Patient-

Respondent Mother Patient Sibling Sibling Patient

Father ** ns ns ** **
Mother ** ** ** ns ns
Group ** ** ** ns **
a**= significant difference between current and wished-for family structures.
bns = not significant.
~no significant differences were found for mother-child dyads.
dno significant differences were found for the power of fathers, mothers and siblings.
60 Child Psychiatry and Human Development

Steinebach focused on changes in family constructs of mothers with

a developmentally retarded child. ~1In order to establish a therapeutic
baseline, mothers completed representations of the current relations
by means of the FAST and questionnaires about patient development.
In accordance with their responses in the questionnaires, mothers
portrayed predominantly unbalanced family structures. While all pa-
tients had cognitive-behavioral training, mothers who indicated in-
creased levels of family stress received additional consulting. One
year later, after the completion of clinical interventions, the assess-
ment procedure was repeated with both groups. Results showed that
mothers generally displayed family structures as balanced, a result
which correlated with the patients' outcome. However, those mothers
who received additional child guidance sessions were even more likely
to report transformations to balanced patterns. This finding substan-
tiates the systemic hypothesis that suggests a relationship between
family constructs of mothers and their involvement in treatment.
A recent pilot study investigated family constructs of mothers and
fathers who received time-limited parent therapy because of their
children's psychiatric problems. 22 The therapeutic approach consid-
ered both parents as active partners of the professionals. In order to
evaluate the effects of interventions on the perceived family function-
ing, parents were asked to individually and jointly portray their cur-
rent family relations with the FAST. The assessment included three
points in time, n a m e l y before therapy, i m m e d i a t l y after, and 6
m o n t h s after completion of therapy (follow-up). Results revealed
changes of family constructs in the course of treatment and in the
follow-up (see Table 3). At therapy onset, both parents characterized
the family as unbalanced, whereas reassessment at the end of ther-

Table 3
I n d i v i d u a l a n d Group Representations of F a m i l y Structures by P a r e n t s of
Psychiatric P a t i e n t s Across Therapy and Follow-up (N = 20)

Father Mother Group

~ m e of
Assessment Balanced Unbalanced Balanced Unbalanced Balanced Unbalanced

Before
therapy 2 8 2 8 3 7
After
therapy 9 1 9 1 9 1
Follow-up 8 2 6 4 7 3
T. M. Gehring, M. C a n d r i a n , D. Marti, and O. R. del Sarte 61

apy indicated a clear shift towards balanced structures. In the follow-

up, similar to nonclinical samples, fathers tended to represent bal-
anced family patterns more often than mothers.

Discussion

The presented studies are based on FAST representations of par-

ents with nonclinical children and children with psychiatric and de-
velopmental or physical disorders. Family representations are inter-
pretations that refer to subjective realities, but they are influenced by
factors such as individual health and interpersonal structures. 8'9'13'14
Although descriptive in nature, the data of this research suggest that
parental family constructs are related to the biopsychosocial status of
the offspring. In concrete terms, parents of psychiatric and develop-
mentally retarded patients represented their family structures pre-
dominantly as being unbalanced and therefore problematic. This re-
sult is in accordance with previous investigations and therefore
s u b s t a n t i a t e s the claim that there is an association b e t w e e n chil-
dren's mental health and family functioning. 3'12 However, it still re-
mains unclear whether poor adjustment of children m a y be the effect
of family problems (e.g. low cohesion or hierarchy reversals), or
whether the family problems m a y be a consequence of the offspring's
illness. Most likely, rather than being two separable outcome mea-
sures, they are interdependent processes that are related to multiple
intervening mediators.
Parents' attempt to change family relationships has been consid-
ered important for the planning of clinical interventions. 23 In this re-
search, differences between current and wished-for family structures
of parents with a psychiatric patient have been analyzed. Results in-
dicated that they wished changes towards balanced family structures.
On the basis of a recent study with child psychiatric patients, one can
assume that parents are more likely to attempt family changes than
their mentally disturbed offspring. 8 However, mothers wanted more
cohesive father-child relations, whereas fathers focused on a decrease
of the patients' power. Notably, both parents wished increased cohe-
sion in their relationship. This is in accordance with other studies
demonstrating that marital conflict generates emotional distance and
can therefore interfere with optimal parenting, and that parenting
problems in turn may create difficulties for children. 1,2,2" Our data
suggest that mothers and fathers of mentally disturbed children are
62 Child Psychiatry and Human Development

motivated for interventions focusing on family structures and that

both parents should thus be taken into account in the clincial prob-
lem-solving process.
Changes of parents' current family constructs were studied across
the treatment of child psychiatric and developmental disorders on the
parent- and patient-level. Results showed that in both settings from
the onset to the end of therapy, parents reported a shift towards bal-
anced patterns and therefore an improvement of family structures.
This is convergent with previous child psychiatric outcome studies
focusing either on reports of patients who received individual treat-
ment or on reports of parents and patients who had family therapy. 1~,1~,~6
Our preliminary findings, however, do not explain how parental inter-
ventions effect the patients' outcome, and therefore more research is
needed. In other words, as predicted from the systemic approach,
structural and individual changes m a y occur across various treat-
ment settings, but it remains to clarify under what condition a spe-
cific family-level is indicated for an optimal problem-solving in child
psychiatry.
Parents of children with cancer, similar to nonclinical ones, in gen-
eral reported balanced family structures. This is in accordance with
recent research which showed that family members of cancer patients
have positive constructs about health and interpersonal relations? ~
However, in nonclinical families, f a t h e r s were more likely t h a n
mothers to represent relational structures as balanced, whereas a re-
verse pattern was found in families with a cancer patient. The result
that fathers of nonclinical families represented relationships to be
more functional than the ones represented by their partners can be
ascribed to traditional family roles and rules. TM In line with this as-
sumption, one can argue that mothers are more exposed to family-
related hassles and therefore perceive more problems than fathers
who, in turn, m a y have a tendency to idealize the family from their
outside perspective. The fact that mothers of cancer patients charac-
terized their families predominantly as balanced was not expected
and needs further explanation. It can be assumed that because of the
children's severe illness mothers are very engaged in the care for
their offspring as well as in providing a lot of emotional support. As a
consequence, they might experience the family as a protective context
for the patient and their psychosocial involvement as an important
and satisfying t a s k ? s The finding that fathers of cancer patients per-
ceived their families relatively often as unbalanced m a y be due to
their experience that mothers' intensive engagement with the patient
T. M. Gehring, M. C a n d r i a n , D. Marti, a n d O. R. del Sarte 63

can stress other family relations. Finally, convergent with previous

research, our findings showed that in psychologically well-adjusted
families, parents have distinct relational constructs and that mem-
bers with a positive view tend to influence the joint representation
more strongly than others. TM Thus, systemic planning of preventive
tasks with nonclinical families and families with a severely physically
ill offspring should include the perspective of both mothers and fa-
thers.~9,8~
Future research designs should consider interactional observation
and treatment-outcome variables on different levels of the family sys-
tem. This would help to specify criteria for the indication of family-
oriented problem-solving strategies in prevention and therapy. The
FAST permits the planning of systemic interventions in individual
and family settings as well as the monitoring of structural changes
that occur in the clinical context. The versatility of this tool contrib-
utes towards a rapprochement between practice and research and, in
consequence, promotes our understanding of family organization.

Summary

This research is based on family constructs of mothers and fathers

with distressed and nondistressed children as assessed by the FAST
in individual and group settings. First, family representations by par-
ents of healthy children, of cancer patients and of psychiatric patients
were compared. Second, family structure changes in the context of
parental interventions were described using prospective and longi-
tudinal designs. Results showed that family perceptions differed de-
pending on offspring's health and clinical intervention. Parents of
healthy children as well as parents with a child suffering from cancer,
relatively often showed the family as cohesive, and, regarding hier-
archy, with clear generational bounderies (i.e. balanced structure).
However, fathers of nonclinical families were more likely to portray
balanced structures than mothers. With parents of cancer patients, a
reverse pattern was found, and mothers had a pervasive influence on
the joint representation. In families of psychiatric patients, parents
individually as well as jointly represented the relational structures
predominantly as being little cohesive, and judged the hierarchy to
have no clear generational bounderies (i.e. unbalanced structure). At-
tempted changes as assessed by the differences between current and
wished-for interpersonal structures at the onset of intervention, indi-
64 Child Psychiatry and Human D e v e l o p m e n t

cared that both parents wanted balanced family patterns and in-
creased cohesion in their relationship. However, mothers wished more
cohesion in the father-child dyads, whereas fathers reported that the
patients' power should decrease. Convergent with their wishes at
therapy onset, parents represented the family as balanced after com-
pletion of treatment. The findings of this research suggest that par-
ents' interpersonal constructs as derived from FAST are related to
offspring and family outcome and that multi-respondent data from
different system levels provide relevant information on how to con-
ceptualize preventive and therapeutic interventions.

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