If they exist, what importance does the client place on meeting family expectations? Ask: “How would you describe the kind of life your family wants for you? What kind of life do you want for your own children? Have you ever done something that disappointed your parents? Would you tell me about it? Have you ever argued with your parents? What happened? What happens when your children argue with you?” What are the discrepancies between family expectations and those of the other systems the client interacts with? Ask: “I’m wondering if you ever feel as if you have to act differently at work than you do at home or with your neighborhood friends. What happens when you act as you do at work when you’re home?” Community environment is the third domain of culture and context. This domain involves structural aspects of the community where the client currently lives . For those who have recently immigrated, it also involves comparisons with former community environments and conditions under which migration occurred . For example, Sandhu, Portes, and McPhee reported less stress involved with voluntary migration as opposed to those who were forced to migrate, whereas involuntary minorities may view engagement with the dominant community as a threat to their identity, and thus resist accessing supportive structures .

The sociopolitical climate must also be considered in assessment of community environment. There is always the possibility that racism , bias, and discrimination contribute to community related stress.

Here are some things to listen for and ask about as you gauge your client’s community environment.

Concluding comments should be brief, reassuring, and upbeat. Again expressing your respect for their choice to come in, your appreciation for their work, or noting events upcoming in the week can be good transitional termination talk.

FORMAL COUPLE AND FAMILY ASSESSMENT PROCEDURES Numerous couple and family assessment devices exist. It is beyond the purpose of this article to provide detailed descriptions of these devices. Therefore, instead of providing an exhaustive review of couple and family assessment procedures, we have listed some of the most popular instruments and procedures, along with their original references, in Table 12.1.

Interviewing Couples and Families Table 12.1. Couples and Family Assessment Instruments

Instrument and Citation General Description

Family Environment Scale The assumption underlying this measure is that environments, , Moos and Moos, 1986 such as families, have unique personalities that can be measured in much the same way as individual personality. Thus, the 90 item family environment scale seeks to measure the unique social climate within the family.

The Family Genogram, The family genogram is a procedure that enables therapists to McGoldrick and Gerson, graphically represent family structure. It is very popular among 1985 family therapists. The genogram is essentially a visual map of family relationships. It contains factual information such as names, ages, deaths, divorces, etc., as well as relationships.

Marital Satisfaction Inventory This instrument is a self report designed to assess marital in, D. Snyder, 1981 teraction and marital distress. It includes 11 subscales . The inventory should be completed by both partners and results are graphed on a single pro?le so that partner differences can be identi?ed, discussed, and addressed in counseling.

Exercise training for high risk patients should be held in a hospital or venue with immediate access to full resuscitation services and a member of staff trained in advanced life support.

There should be a policy to ensure that all staff update resuscitation and AED training annually and hold regular practice drills for emergency procedures.

Patient screening and management Comprehensive assessment, risk strati?cation and exercise prescription must initially be undertaken with each patient and reviewed and revised as required.

There should be local protocols de?ning inclusion and exclusion criteria for the exercise group, a medical consent procedure to participate in exercise and clinical guidelines for excluding a patient with the following contraindications from exercise :

• Unresolved/unstable angina;

• New or recurrent symptoms of breathlessness, palpitations, dizziness,

swelling of ankles or signi?cant lethargy;

• Resting systolic blood pressure >200mm/Hg and diastolic >110mm/Hg;

• Signi?cant unexplained drop in blood pressure;

?Tachycardia >100 beats per minute; ?Fever and acute systemic illness; All patients should have an exercise induction, be closely observed throughout exercise and for 15 minutes after the cool down is completed.

Venue, equipment and environment Ensure that adequate accident and injury insurance cover is in place to conduct an exercise group if the venue is outside hospital premises.

10. Ensure that access points to the venue are safe and unobstructed, with emergency exits clearly signed and ?re evacuation procedures in place.170 Exercise Leadership in Cardiac Rehabilitation 11. Ensure that toilets and changing facilities have an emergency call system in place.

Considering that a diverse population is usually more likely to survive environmental change than a uniform one, it would be odd to label the deviants from the mean in the population of that time and place, presumably ones who had fewer surviving offspring for one or two generations, as “sick.” Natural and adapted traits in one environment may be unadapted and look unnatural in the next. For example, height is favorable for finding and reaching things in trees but probably unfavorable for finding and picking things up off the ground. Large size helped people emerge victorious in fights but if the six billion humans alive today were all pygmies we might not be eating, burning and mining the environment out from under us. Conversely, the tendency to obesity in times of plenty can kill people when that plenty is constant and save them when feast alternates with times of famine.

Other purported foundational criteria for “favorable functioning” of whole individuals, whether modeled as machines or otherwise, are also disputable. Is “favorable” functioning reproductive fitness as measured in the second generation? If so, then any characteristic leading one to be a semen donor would be, at present, the epitome of health. Is it survival potential? Ability to influence and control others? Capacity to accumulate wealth? Ability to experience euphoria? And what if an environment is one that most of us would identify as defective? Is perfect adaptation to assembly line work, slavery or war something that should be valorized as healthy? When healthy bodily function is modeled on the proper operation of a machine, the metaphor, a widely influential one, is described by Mark Johnson as follows:

The Body Is A Machine

The body consists of distinct, though interconnected parts.

People with strong immune responses to parasites may be more susceptible to allergies.

Brain workings are especially difficult to assess apart from their relation to social needs. Are deviations from the best memory, the best mathematical ability, and the most verbal ability well characterized by comparison to dysfunctional machines? If our brains are depicted as machines, are there not instead many perfectly well running but different machines among them? Within limits, function which might otherwise be labeled pathological can facilitate specialization. Depressives are cautious, prudent and prone to suicide. Euphorics are innovators, overoptimistic and prone to accidents and bankruptcy. Obsessives make good doctors, hysterics good actors, mild sociopaths good spies, extroverts good salesmen, introverts good poets, hyperactives brave soldiers, etc. So good function with regard to the structure and makeup of some organs, depends upon what an environment demands as well as upon what environment is selected, when there is the option of choosing. And assessment of what an environment demands or what environment to choose is in the province of clinical judgment and the judgment of the patient.

The use of “well adapted” as the marker for “functional” invites other difficulties. This criterion requires us to privilege some historical, social or evolutionary state of affairs, presumably a relatively stable one, as the “state of nature” or”norm determining state” to which we should be best adapted. But even if we could agree on what that “state of nature” or “norm determining state” was, we would have to decide if uniform populations or diverse ones were optimally healthy then.