Family Systems II: Case Conceptualization and Genogram

Case Conceptualization 

What is the problem? 

The primary problem affecting the family is that Pam has been diagnosed with anorexia nervosa. The eating disorder was only diagnosed a few months ago and it has caused major concern with the parents who have sought assistance from a therapist. The initial intervention provided by the therapist was that the patient be admitted to an inpatient facility for individuals with eating disorders. The Murray and Fran identified this as an extreme decision for their teenage daughter. The family is concerned with the health of Pam as she has significantly lost weight and could potentially lead to the development of significant illnesses other than the disorder. 

What triggered the problem? 

The Johnson family identify themselves as a close family that shares in the joys and sadness of one another. However, it is clear that there has been a significant drift from the individual members. The males and females in the family interact separately where George, Oliver, and Murray bond through sports while Fran and Pam bond together. Pam does not feel close to her brothers as she does not share the bond they have through sports as she has never been athletic which may have triggered the eating disorder. It is possible that the lack of a close relationship with the father also triggered a self-defeating body image leading to the development of the disorder. 

What is the maladaptive pattern? 

Pam has usually shared a close relationship with her mother Fran, but she does not share the same with her father, Murray. This behavior is also evident with her brothers as she does not feel at all close to them. The only time she gets to share in their fun activities is during family group events like the recent trip to a theme park in Orlando, Florida. Her recent diagnosis of anorexia nervosa has made her relationship with her family members worse as they only view her on her weight issues and what exactly she is eating. 

What is the predisposition of the clients? 

The Johnson family believes in the traditional gender roles of each member. It is for this reason that Fran despite completing her Associates in education did not go into the workforce instead focusing on building her family. Murray seems to reinforce this belief by identifying that he focuses more on his two sons and their needs so that Fran can pay attention to the needs of Pam. It seems there is no sense of partnership between the couple in raising their children together. 

What perpetuates the problem? 

Murray is seen to joke that since Pam and Fran are the only females in the family, it is only natural that they had an extra-close relationship. Murray instead gravitates towards his two sons with whom he can play sports with them. This move perpetuates avoidance between Pam and Murray that worsens the relationship distress between the two. It is evident that Pam’s transition to high school had significant effect on her evidenced by her declining grades. It was concerning that the decline did not seem to bother her and Fran’s action of pushing Pam to do better led to a more strained relationship. This would make her feel even more alone despite being surrounded by loved ones. The concern is that admitting Pam to an inpatient facility only worsens the feeling solitude or outcast. 

Cultural Identity 

The Johnson family is seen to have a general Christian background despite the different denominations of their parents. Murray was born into a Protestant family while Fran is generally from a Catholic background. In this practice, the two have been raised to gravitate towards the traditional gender norms. In this case, Murray was brought up to become close with his father, Milton. He extended the same practice to his children by keeping the male children close to him and detaching himself from his daughter. As Christians, the parents feel the need to support their children in all aspects of their life. In this case, Murray and Fran have sought the assistance of a family therapist as they wish to understand the distress that Pam undergoes and share the burden in helping her overcome it. 

Acculturation  

The Johnson family is experiencing significant problems due to acculturation stress. The members seek to identify the importance of keeping up with their distinctive roles in the family. It is evident that the members are unable to abide by the modern ways of the society. Although it is common that a father and mother gravitate towards children of their respective genders, in the modern world, this has changed as it dictates that parents show significant effort to care and guide their children without preference. The lack of familial contact between the father and the daughter is the cause for loneliness on the latter. Pam feels that she does not share significant similarities to her brothers, which are the cause for her strained relationship with her father. 

Cultural Considerations 

It is evident that the cultural practices of the parents, Murray and Fran, have had significant impact on the lives of their children. Murray’s father, Milton gravitated towards him due to his love of fixing the different machinery in the appliance store and the fact that he was the only child. It comes as no surprise that he does not share his affection to all his children choosing to pick his sons as his favorite or at least his responsibility. He feels that Fran would be better equipped to raise and provide guidance to Pam. Fran’s upbringing is also dysfunctional and may have contributed to the development of the problem. The lack of affection between her parents and leaving all parenting responsibility to her mother made her take up a similar role. Fran is struggling due to a lack of relationship with her mother, Nancy. Following the death of her father Horace ten years ago, she moved to soth Florida and only gets to see her twice a year. It is also evident that the Johnson family does not have awareness of eating disorders as a serious illness. The brothers and the parents alike have been treating Pam differently since she was diagnosed with the condition. This behavior only makes her feel worse as she further questions her position in the family. 

Treatment Conceptualization 

Problem 

The Bowen Natural Systems therapy is a therapeutic model that has provided effective measures of developing an accurate understanding of the stresses affecting a client in the context of the family as a whole. It is evident that each member of the Johnson family presents some significant emotional “stuckness” that may have led to the development of Pam’s disorder. The following is depicts the various problems experienced by the members as per the Bowen natural systems theory. 

Murray (39) 

Believes that the wife is responsible for taking care of daughter. 

Gravitates towards his sons and avoids his daughter. 

Lacks understanding of Pam’s eating disorder. 

Fran (38) 

Believes she is the primary caregiver of the children. 

Strained her relationship with her daughter. 

Makes comments about Pam not eating enough at the dinner table. 

Has made Pam’s disorder as the center of their relationship 

Pam (17) 

Poor eating habits for nearly three years. 

Lacks a close relationship with her father. 

Has a distant relationship with the brothers. 

He feels like an outsider in the family. 

Her relationship with her mother has become strained in recent times. 

Oliver (15) 

Lacks a significant relationship with Pam. 

Does not share any similarities with the sister. 

Does not engage in group activities with her. 

George (13) 

Lacks a close bond with Pam as he does with Oliver. 

Began to treat Pam differently following her diagnosis. 

Has done little to support her sister since her diagnosis. 

Goals  

The main goal of incorporating the Bowen therapy model is to ensure reduced chronic anxiety through increased awareness of how emotional systems function and increased differentiation levels. Some of the goals are distinct to the individual while others are different. 

Murray 

To create a better relationship with his daughter. 

To participate in parenting responsibilities of his daughter. 

Develop knowledge on anorexia nervosa. 

Implement appropriate support strategies for his daughter’s condition. 

Fran 

Create a partnership with husband on parenting. 

Develop knowledge on anorexia nervosa. 

Understand emotional distress affecting Pam. 

Provide support to Pam as she recovers from the condition. 

Pam 

She should develop coping mechanisms for her disorder. 

She will learn to express her feelings to other family members. 

She will develop a more positive body image. 

Oliver 

He will begin to create a long lasting bond with his sister. 

He will show support as she recovers and manages the condition. 

George 

He will seek to establish a close relationship with his sister. 

He will treat support Pam as she seeks to recover from her condition. 

Focus  

The focus of the treatment conceptualization is not on Pam, but on the parents and her siblings. It is evident that the family members have played a major role in the emotional distress that Pam has been feeling which has influenced her poor eating habits. As a result, the parents are expected to become more effective leaders of the family so as to provide the patient an environment where they can thrive. Murray in particular should be able to connect with his daughter and develop a more positive relationship instead of avoidance. The focus will also be on chronic anxiety which Bowen believes is the source of family dysfunction. 

Strategy  

The Bowen natural systems theory will incorporate three major strategies as a means of ensuring improved functioning of the family. The first aims to reduce anxiety in the client on the symptom by assuring them that it is part of their relating patterns. The second involves focusing on the self issues that the individual members of the family are experiencing to increase levels of differentiation. Finally, the latter phases of therapy will involve teaching the parents to differentiate themselves from the families from which they come from. In this practice, it is believed that differentiation results in high self-responsibility and reduced anxiety in the nuclear family. 

Interventions  

The therapist will play an integral role in the therapeutic treatment of the Johnson family. To begin with, it is essential that the therapist connects with the family members without becoming emotionally reactive by maintaining a differentiated stance. In this regard, the professional should not bear an over or under responsible reciprocity when making an attempt to be helpful. Instead, he or she should maintain a calm and interested position of investigation to help the members learn about themselves as an emotional system. The therapist should also abandon healing or helping responsibility when it appears families are passively waiting for a cure. The members should get into a position where they recognize and accept responsibility for undertaking any form of change. 

Obstacles  

The treatment process is not a smooth process as the family and the therapist alike may encounter numerous obstacles to reducing anxiety. In some cases, the therapist may lose sight of the position they should play in the system of interactions. This is possible when they are given a mediating role in the triangle with the family. The professional should change their individual family of origin and as a trainee emphasis is laid on level of differentiation not therapeutic technique. Another obstacle is when the family passively waits for a cure from the therapist rather than take charge of their own change. 

Cultural considerations in treatment 

The treatment conceptualization should take into consideration cultural practices that the family experienced. It is evident that the parents’ family of origin has had a significant influence on the nuclear family issues. Murray was born as an only child and was the center of attention from only one parent, his father. In the same way he has gravitated towards his sons in the process neglecting his daughter. Fran on the other hand, has always played the role of a caregiver from a young age as she took care of her younger siblings. In this regard, she does not mind being the primary caregiver to her children. She has also not experienced a positive interaction with her mother over the recent years as she moved to south Florida following Horrace’s death. Fran and the children only get to see her twice a year. 

Prognosis  

Pam’s eating disorder, anorexia nervosa, is seen to be a result of poor body image. It is evident that she feels like an outcast in her own family primarily because she does not receive the attention of her father. Murray would prefer to spend time with his two sons as he shares a lot with them and can barely interact with Pam. Since the diagnosis, the condition has gotten worse as the family members seem to focus on it when they interact with her. In this way, they are a constant reminder that she is far from normal. 

Concepts of Theoretical Model 

Scale of Differentiation of Self 

This is the foundation of the Bowen theory as it identifies the ability to ensure a separation between thinking and feeling through the guidance of rational capacity. The individual should maintain a solid sense of self to resist social pressure while maintain close and meaningful relationships with others. 

Emotional Triangles 

Anxiety is a common issue in the family unit usually felt in a two-person relationship. The individual feeling the discomfort more will inolve a significant person to reduce the tension. A triangle is the smallest stable relationship unity that involves third parties like hobbies, memories, friends, and relatives. 

Nuclear family Emotional Process 

The incidence of chronic anxiety may result in the four significant patterns: reactive distance, marital conflict, reciprocal functioning, and projection of problem onto a child. The individuals may distance themselves physically or by silence to avoid discomfort. Marital conflict may arise in this case where behavior such as being critical, focusing on the fault of others, and accusing each other is a common practice. Reciprocal functioning is the behavior shown by one of the parents as they seem to be handling the situation well while the other becomes the yielding partner. The parents become particularly concerned with the problems affecting the child in the projection of problem onto a child. In this way, the child reacts to them when they continue to focus on him. 

Sibling Position 

According to the Bowen theory, sibling position has significant influence on the personality and characteristic behavior patterns of the individual. The eldest children take up leadership traits and high sense of responsibility while the youngest ones are care free, dependent, and unconventional. The middle child feels neglected and is a mediator of relationships. 

Multigenerational transmission process 

In this incidence, it is evident that the incidence of chronic anxiety, themes, roles, and patterns are passed on from one generation to the next through the projection process. In each generation the child receiving the most focus will experience a lower level of differentiation of self as opposed to that one who is least focused. 

Emotional Cutoff 

With the intent of coping with tension and anxiety in the relationship, individuals may use emotional cutoff or extreme distancing. The practice may be actual by physically moving away or emotional by isolating themselves from the other. It is evident that emotional cutoff creates more problems than is necessary. 

Societal emotional process 

The theorist noted that the emotional processes mentioned are evident in the larger society. Depletion of natural resources, natural disasters, unemployment, and political instability are all conditions of chronic stresses that arouse a more anxious social climate as they call for increased togetherness and less room for individuality. 

Family projection process 

The family projection process is seen where the parents transmit their problems onto the child and expose him or her to their immaturity or anxiety. The child is unable to separate feelings from thinking making him or her emotionally dependent, blaming others, seeking recognition and approval, and may feel responsible for the happiness of others or the reverse. 

References 

Brown, J. (1999). Bowen family systems theory and practice: Illustration and critique. Australian and New Zealand Journal of Family Therapy, 20 (2), 94-103. 

Haefner, J. (2014). An application of Bowen family systems theory. Issues in Mental Health Nursing, 35 (11), 835-841. 

Kerr, Michael E. “ One Family’s Story: A Primer on Bowen Theory .” The Bowen Center for the Study of the Family. 2000. http://www.thebowencenter.org . 

Reiter, M.D. (2014). Case conceptualization in family therapy . Boston, MA: Pearson Publishers. ISBN: 978-0-13-288907-0 

Sperry, L. & Sperry, J. (2012) Case conceptualization: Mastering this competency with ease and confidence . New York, NY: Routledge Taylor & Francis Group. ISBN: 978-0-203-11001-0