Family Therapy: Assessment, Diagnosis & Treatment Planning when PTSD is a Factor

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 Their daughter frequently cries, as their mother is withdrawn and distant to them.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.

References:

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American Counseling Association, (ACA) (2005). Code of Ethics. American Counseling Association. Retrieved at: http://www.counseling.org/Resources/aca-code-of-ethics.pdf

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Kress, Erikson, Dixon, Rayle, Ford. (2005). The DSM-1V-TR and Culture: Considerations for counselors. Journal of Counseling and Development: 83.1, p. 97-104.

Hall, W.D., Lynsky, M. (2005). Is cannabis a gateway drug? Testing hypotheses about the relationships between cannabis use and the use of other illicit drugs. Drug and Alcohol Review, Vol. 24 (1), pp. 39-48.

Paniagua, F.A. (2005). Assessing and treating culturally diverse clients: a practical guide. (3^rd Ed.). Thousand Oaks, CA: Sage.

Nolen-Hoeksema, S. (2011). Abnormal Psychology. Fifth Edition. McGraw Hill Companies, Inc., New York, NY