Abstract
This case study will feature
a family experiencing a difficult transition. I will demonstrate how I would
assess, diagnose and treat the family unit which is being impacted by PTSD. This paper will apply a family
therapy model, and discuss how the DSM-1V-TR (APA, 2000) guidelines apply to
the case. I will include a diagnosis and an accompanying justification for said
diagnosis. Multi-cultural considerations will be applied, as well as my own
cultural biases. Ethical issues will be considered, and professional ethical
codes will be applied. Lastly, I will present a brief treatment plan which
addresses: the family’s main issues and concerns, goals for treatment, changes
which need to be made within the family system, and counseling interventions
which can be applied.
This case study features a family in
transition. Mom is a soldier who has just returned home after an overseas
deployment of 18 months. While she was absent, her mother-in-law moved in whom
the mother frequently has disagreements with, and her husband has lost his job.
Their children, a teen boy and a 9-year old girl, are having difficulty
adjusting to their mother’s return: the teen went missing for two days and his
father found marijuana in his room. Their daughter frequently cries, as their
mother is withdrawn and distant to them. Since the mother deployed, everything
has changed for this family, and not for the better.
In applying a family systems therapeutic
model to this case, family system’s theory views individual disorders as
symptoms of disturbances in family relations (Mash, & Johnston, 1996). Additionally,
cultural contextualism has influenced family theory (Szapocznik, &
Kurtines, 1993). In family therapy primary relational problems might include:
(1) parent-adolescent communication issues, (2) ineffective problem-solving
strategies, (3) sibling conflicts, and (4) coercive or abusive parent-child
relationships (Mash, & Johnston, 1996). Mash & Johnson (1996) state
that there are two different kinds of treatment approaches: (1) aesthetic, and
(2) pragmatic. Aesthetic approaches explore developmental etiology, while
pragmatic approaches are brief therapies which seek to reduce symptoms of
discord by altering family interaction. Though this family’s history is
important to factor in, taking a limited-therapy approach, or the pragmatic
path, will be most efficacious. Additionally, what is known as a “secondary
relational problem” is defined as the presence of a mental disorder or medical
condition; however, primary and secondary problems are usually connected (Mash,
& Johnston, 1996). In this family system I will assess all members of the
family for possible psychopathology, as any member of the family with a mental
disorder can prove challenging to family cohesion.
While a family
is a system comprised of individuals, it is the survival of the family unit
which may be threatened when a family presents in therapy. Psycho-therapeutics
has, in the past, attempted to emphasize the sum (family unit) over its parts
(family members). I propose that perceiving the family as a gestalt unto itself
is a “collectivist perspective,” while emphasizing the individuals within the
group is a decidedly westernized, individualistic perspective. It seems to me
that Family-Centered Therapy (Rogers, 1951) is an example of a
collectivist-oriented modality, wherein the family unit’s good will be weighed,
along with the individual member’s needs. Conversely, Gestalt Family Therapy
seems to be of the individualistic persuasion. The logic seems to be that if
the individual is happy, as a result, the group will be happier. I happen to
agree with Gestalt Therapy’s emphasis on drawing out the individual’s needs
within the family context. Bott (2001) reminds us that, “Families are made up
of people. To use the metaphor of saying a family is LIKE a system as a way of
conveying the rich interconnectedness of family members is quite different from
the dehumanizing process of treating it AS a system.” Gestalt Family Therapy
(GFT) is a structural therapy in that, “The therapist works primarily with the
nuclear family, and therapy is aimed toward altering the structure of the
interactions between various family members” (Hazelrigg, Cooper and Borduin,
1987). The philosophy of Gestalt Family Therapy is to develop each family
member’s awareness of: interactional patterns, and becoming responsible for
their own feelings, behavior, and needs. The role of the therapist in GFT is to
provide therapeutic techniques and experiments which can stimulate positive
change. “The family is an intimate system in which the behaviors of family
members are connected in a complimentary way. Connections among members may be
functional or dysfunctional, depending on the awareness, needs, and behaviors
generated through such family networks” (Lawe and Smith, 1986). Goals of GFT
are to enable family members to “represent themselves genuinely, and to accept
and respect that they are separate and different from each other” (Lawe and
Smith, 1986). Other goals include re-establishing contact between family
members, and expression of feelings which were suppressed or denied. In Gestalt
Therapy, the therapist works to improve individual family member’s
self-awareness, and the awareness of the impact the client is having on the
family system. In each family member’s quest to meet his needs, the therapist
uses techniques and experiments to assist the members in defining their needs,
expressing their needs, and improving intimate contact with other family members
(Lawe and Smith, 1986). “A general goal for the therapist is to assist members
in removing barriers they use to avoid being intimate” (Zinker, 1981). As is
typical of Gestalt Therapy, GFT explores the following themes: (a) What
feelings, perceptions and awareness do members have towards the family, each
other, and themselves? (b) How do members deny taking responsibility and
manipulate one another to get what they want? (c) What do members expect from
each other? (d) What unresolved conflicts do members have with each other?
Techniques which the Gestalt Family Therapist will use include: having all
members of the family interact, requesting the members speak directly to each
other, to intervene only when the interaction is at an impasse, identifying the
dysfunctional relational patterns, role playing and the Empty Chair technique.
How does the family know when therapy has been successful? “The resolution of
conflict, anxiety and guilt may be seen as a basic goal of Gestalt Therapy. The
more family members can clearly articulate their wants, needs, and
expectations, as well as to understand, accept and support each other, the more
the family is in harmony and balance…positive outcomes of therapy witness the
increase in the family member’s ability to be responsive to the needs of its
members. Members profit from therapy when they can forgive each other and let
go of the past in order to accept and love each other as they are, and not as
they think they “should be” (Lawe and Smith, 1986). Therapy is also seen as
successful when members take responsibility for their role in family
dysfunction, when conflict is resolved and resentments dissolved, and when each
member of the family feels safe to “be themselves” rather than trying to live
up to expectations of one another.
The Diagnostic and Statistical Manual
(DSM-1V-TR, 2000) labels clients with mental disorders which can be
stigmatizing (Corey, Corey, & Callahan, 1984). However, individual
diagnosis and family system therapy can work together for the benefit of the
family unit. Specifically, the American Counseling Association (ACA, 2005)
ethical code emphasizes, “Counselors take special care to provide proper
diagnosis of mental disorders.” Additionally, reframing the “medical model” of
diagnosis as presented in the DSM (APA, 2000) towards a culturally-sensitive
system of diagnosis will facilitate more accurate diagnosis (Zalaquett et al.,
2008). In applying the DSM’s criteria to this family system, I would diagnose
the mother as suffering from Acute Stress Disorder (ASD) (DSM-1V-TR, 2000, p.
471). The family members have noticed the mother displaying the following
symptoms (which are typical of ASD): exposure to a traumatic event (such as
combat), a subjective sense of numbing or detachment, difficulty sleeping,
irritableness, and social withdrawal. Her disturbance has lasted more than 2
days and has occurred within 4 weeks of the traumatic event. Additionally, the
teen boy may be smoking marijuana, which is illegal and a health hazard to a
young teen, and he also went missing for two days. The son’s truant behavior is
considered anti-social behavior, however, there is not a chronic history of it,
and therefore is classed as a relational problem rather than a mental disorder (DSM-1V-TR,
2000, V71.01). The father is experiencing worries related to unemployment which
would be considered an occupational problem (DSM-1V-TR, p. 741, V62.2). The
daughter is showing signs of bereavement because her mother is not responding
to her daughter’s needs for attention, which would be classed by the DSM-1V-TR
(APA, 2000, p. 740) as V62.82 Bereavement.
In rendering a culturally-sensitive
diagnosis, I would assess the following with this African American family: (1)
Family’s worldview or schema, (2) family’s cultural identity, (3) family’s
acculturation level, (4) cultural interpretation of symptoms, (5) impact of
environment on family, (6) cultural stigmas related to the problem, (7)
emphasize Axis 1V during diagnosis, and (8) adjust interviewing style to
accommodate the cultural norms (Kress et al., 2005). However I must be aware of
any personal biases I might have in working with African Americans, especially
stereotypes that I might apply.
The treatment plan I would apply would be
to approach this family utilizing Gestalt Family Therapy in a pragmatic
framework, and to strive to be culturally-sensitive. The focus of therapy will
be: (1) To psychoeducate the family in regards to the mental health disorder
their mom is experiencing, (2) to address the son’s anti-social behavior, (3)
to psychoeducate the family on the father’s concerns regarding unemployment,
and to address the daughter’s grief about her mother. The main treatment goals
would be to: (1) schedule therapeutic treatment for the mother to reduce the
ASD she is experiencing, (2) gain agreement with the son to discontinue
marijuana use and to ask permission of parents when spending time with friends,
(3) enlist the father in career counseling, (4) encourage the daughter to
express her feelings of grief to her mother. More specifically, the overall
changes which need to be introduced are: improved communication and time spent
between mother and family, more effective parenting skills with son, career
exploration and interviewing skills for the father, and expression of grief
experienced by the daughter.
Specific counseling interventions that
would be effective for this family-in-transition include: (1) Psychoeducation
regarding ASD: Reading the diagnostic criteria of ASD to the family from the
DSM-1V-TR (2000) would allow all family members to understand that mom is
experiencing a reaction from combat, and it is treatable. This will help the
family members, and especially her daughter, to depersonalize their mom’s
withdrawal and irritability, (2) Psychoeducate regarding marijuana use: drug
usage in young teens predicts heavier drug use as an adult (Hall, &
Lynskey, 2005), (3) Suggest a course of Career Counseling for the father, utilizing
a culturally-sensitive career counseling procedures (Paniagua, 2005),
including: discussion of racial differences as it pertains to the workplace,
including the family’s church in the counseling process, and emphasizing
strengths rather than deficits, (4) Facilitate grief recovery work between
mother and daughter utilizing Gestalt Therapy techniques, as “healthy grief” is
experienced and then released. If not expressed, individuals become fixated on
loss. Once grief is expressed, more energy and motivation to live is freed up,
and one may move forward and positively resolve one’s grief, (5) Assess and treat
the mother’s ASD by: Assessing for suicidal thoughts, intrusive thoughts about
the trauma, nightmares of trauma, anxiety or depression caused by the trauma,
and concentration difficulties or dissociative states (DSM-1V-TR, APA, 2000).
Treatment of trauma states has been shown successful by application of
Systematic Desensitization (Nolen-Hoeksema, 2011, p. 42).
In summary, this is a family who, due to
the stresses which the mother’s deployment has caused the family system, is
struggling to remain cohesive since deployment and subsequent transition back
into the family. Seeing this family as a unit in therapy will encourage them to
express their feelings and thoughts to one another, which have likely been
suppressed due to the distance which the mother’s military burden placed on all
of them. The long-term therapeutic goal for this family is to re-introduce them
to one another, as nearly two years have passed since the mother was deployed,
and in that time changes within each individual family member has occurred.
Each member will be encouraged to express their needs to one another, and
solutions to meet those needs will be explored. Family agreements will be made,
to ensure that positive changes will be lasting and honored among family
members.
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