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Bowen Family Systems Theory and Practice: Illustration
and Critique
By Jenny Brown
This paper will give an overview of Murray Bowen’s theory of family systems. It will describe the model’s
development and outline its core clinical components. The practice of therapy will be described as well as recent
developments within the model. Some key criticisms will be raised, followed by a case example which highlights
the therapeutic focus of Bowen’s approach.
This is the author’s version of the work. It is posted here by permission of Australian Academic Press for personal use, not for redistribution. The
definitive version was published in Australian and New Zealand Journal of Family Therapy (ANZJFT) Vol.20 No.2 1999 pp 94-103).
Introduction
Murray Bowen's family systems theory (shortened to 'Bowen theory' from 1974) was one of the first
comprehensive theories of family systems functioning (Bowen, 1966, 1978, Kerr and Bowen, 1988). While it has
received sporadic attention in Australia and New Zealand, it continues to be a central influence in the practice of
family therapy in North America. It is possible that some local family therapists have been influenced by many of
Bowen's ideas without the connection being articulated. For example, the writing of Guerin (1976, 1987), Carter
and McGoldrick (1980, 1988), Lerner (1986, 1988, 1990, 1993) and Schnarch (1991, 1997) all have Bowenian
Theory at the heart of their conceptualisations.
There is a pervasive view amongst many proponents of Bowen's work that his theory needs to be experienced
rather than taught (Kerr, 1991). While this may be applicable if one can be immersed in the milieu of a Bowenian
training institute, such an option, to my knowledge, is not available in this country. Bowen's own writings have
also been charged with being tedious and difficult to read (Carter, 1991). Hence it seems pertinent to present this
influential theory in an accessible format.
Development Of The Model
Murray Bowen was born in 1913 in Tennessee and died in 1990.
He trained as a psychiatrist and originally practised within the psychoanalytic model. At the Menninger Clinic in
the late 1940s, he had started to involve mothers in the investigation and treatment of schizophrenic patients. His
devotion to his own psychoanalytic training was set aside after his move to the National Institute of Mental Health
(NIMH) in 1954, as he began to shift from an individual focus to an appreciation of the dimensions of families as
systems. At the NIMH, Bowen began to include more family members in his research and psychotherapy with
schizophrenic patients. In 1959 he moved to Georgetown University and established the Georgetown Family
Centre (where he was director until his death). It was here that his developing theory was extended to less
severe emotional problems. Between 1959 and 1962 he undertook detailed research into families across several
generations. Rather than developing a theory about pathology, Bowen focused on what he saw as the common
patterns of all 'human emotional systems'. With such a focus on the qualitative similarities of all families, Bowen
was known to say frequently, 'There is a little schizophrenia in all of us' (Kerr and Bowen, 1988).
In 1966, Bowen published the first 'orderly presentation' of his developing ideas (Bowen, 1978: xiii). Around the
same time he used his concepts to guide his intervention in a minor emotional crisis in his own extended family,
an intervention which he describes as a spectacular breakthrough for him in theory and practice (Bowen, 1972 in
Bowen, 1978). In 1967, he surprised a national family therapy conference by talking about his own family
experience, rather than presenting the anticipated formal paper. Bowen proceeded to encourage students to
work on triangles and intergenerational patterns in their own families of origin rather than undertaking individual
psychotherapy. From this generation of trainees have come the current leaders of Bowenian Therapy, such as
Michael Kerr at the Georgetown Family Center, Philip Guerin at the Center for Family Learning, Betty Carter at
the Family Institute of Westchester, and Monica McGoldrick at the [Multicultural] Family Institute of New Jersey.
While the core concepts of Bowen's theory have changed little over two decades, there have been significant
expansions: the focus on life cycle stages (Carter and McGoldrick, 1980, 1988) and the incorporation of a
feminist lens (Carter, Walters, Papp, Silverstein, 1988; Lerner, 1983; Bograd, 1987).
The Theory
Bowen's focus was on patterns that develop in families in order to defuse anxiety. A key generator of anxiety in
families is the perception of either too much closeness or too great a distance in a relationship. The degree of
anxiety in any one family will be determined by the current levels of external stress and the sensitivities to
particular themes that have been transmitted down the generations. If family members do not have the capacity
to think through their responses to relationship dilemmas, but rather react anxiously to perceived emotional
demands, a state of chronic anxiety or reactivity may be set in place.
The main goal of Bowenian therapy is to reduce chronic anxiety by
1. facilitating awareness of how the emotional system functions; and
2. increasing levels of differentiation, where the focus is on making changes for the self rather than on
trying to change others.
Eight interlocking concepts make up Bowen's theory. This paper will give an overview of seven of these. The
eighth attempts to link his theory to the evolution of society, and has little relevance to the practice of his therapy.
[However, Wylie (1991) points out in her biographical piece following Bowen's death that this interest in
evolutionary process distinguishes Bowen from other family therapy pioneers. Bowen viewed himself as a
scientist, with the lofty aim of developing a theory that accounted for the entire range of human behaviour and its
origins.]
1 - Emotional Fusion and Differentiation of Self
2 - Triangles
3 - Nuclear Family Emotional System
3a. Couple Conflict
3b. Symptoms in a Spouse
3c. Symptoms in a Child
4 - Family Projection Process
5 - Emotional Cutoff
6 - Multi-generational Transmission Process
7 - Sibling Positions
1 - Emotional Fusion and Differentiation of Self
'Fusion' or 'lack of differentiation' is where individual choices are set aside in the service of achieving harmony
within the system.
Fusion can be expressed either as:
* a sense of intense responsibility for another's reactions, or
* by emotional 'cutoff' from the tension within a relationship (Kerr and Bowen, 1988; Herz Brown, 1991).
Bowen's research led him to suggest that varying degrees of fusion are discernible in all families. 'Differentiation',
by contrast, is described as the capacity of the individual to function autonomously by making self directed
choices, while remaining emotionally connected to the intensity of a significant relationship system (Kerr and
Bowen, 1988). Bowen's notion of fusion has a different focus to Minuchin's concept of enmeshment, which is
based on a lack of boundary between sub-systems (Minuchin, 1974). The structural terms 'enmeshment' and
'disengagement' are in fact the twin polarities of Bowen's 'fusion'. Fusion describes each person's reactions within
a relationship, rather than the overall structure of family relationships. Hence, anxiously cutting off the relationship
is as much a sign of fusion as intense submissiveness. A person in a fused relationship reacts immediately (as if
with a reflex, knee jerk response) to the perceived demands of another person, without being able to think
through the choices or talk over relationship matters directly with the other person. Energy is invested in taking
things personally (ensuring the emotional comfort of another), or in distancing oneself (ensuring one's own). The
greater a family's tendency to fuse, the less flexibility it will have in adapting to stress.
Bowen developed the idea of a 'differentiation of self scale' to assist in teaching this concept. He points out that
this was not designed as an actual instrument for assigning people to particular levels (Kerr and Bowen, 1988:
97-98). Bowen maintains that the speculative nature of estimating a level of differentiation is compounded by
factors such as stress levels, individual differences in reactivity to different stressors, and the degree of contact
individuals have with their extended family. At one end of the scale, hypothetical 'complete differentiation' is said
to exist in a person who has resolved their emotional attachment to their family (ie. shifted out of their roles in
relationship triangles) and can therefore function as an individual within the family group.
Bowen did acknowledge that this was a lifelong process and that 'total' differentiation is not possible to attain.
2 - Triangles
Bowen described triangles as the smallest stable relationship unit (Kerr and Bowen, 1988: 135). The process of
triangling is central to his theory. (Some people use the term 'triangulation', deriving from Minuchin (1974: 102),
but Bowen always spoke of 'triangling'.) Triangling is said to occur when the inevitable anxiety in a dyad is
relieved by involving a vulnerable third party who either takes sides or provides a detour for the anxiety (Lerner,
1988; James, 1989; Guerin, Fogarty, Fay and Kautto, 1996). An example of this pattern would be when Person A
in a marriage begins feeling uncomfortable with too much closeness to Person B. S/he may begin withdrawing,
perhaps to another activity such as work (the third point of the triangle). Person B then pursues Person A, which
results in increased withdrawal to the initial triangled-in person or activity. Person B then feels neglected and
seeks out an ally who will sympathise with his/her sense of exclusion. This in turn leads to Person A feeling like
the odd one out and moving anxiously closer to Person B. Under stress, the triangling process feeds on itself and
interlocking triangles are formed throughout the system. This can spill over into the wider community, when family
members find allies, or enemies to unite against, such as doctors, teachers and therapists.
Under calm conditions it is difficult to identify triangles but they emerge clearly under stress. Triangles are linked
closely with Bowen's concept of differentiation, in that the greater the degree of fusion in a relationship, the more
heightened is the pull to preserve emotional stability by forming a triangle. Bowen did not suggest that the
process of triangling was necessarily dysfunctional, but the concept is a useful way of grasping the notion that the
original tension gets acted out elsewhere. Triangling can become problematic when a third party's involvement
distracts the members of a dyad from resolving their relationship impasse. If a third party is drawn in, the focus
shifts to criticising or worrying about the new outsider, which in turn prevents the original complainants from
resolving their tension. According to Bowen, triangles tend to repeat themselves across generations. When one
member of a relationship triangle departs or dies, another person can be drawn into the same role (eg. 'villain',
'rescuer', 'victim', 'black sheep', 'martyr'). For example, in my own family of origin I found myself moving into the
role of peacemaker after the death of my mother, who had mediated the tension between my father and brother.
This ongoing triangle served to detour the anxiety that had been played out between fathers and sons in the
family over the generations.
3 - Nuclear Family Emotional System
In positing the 'nuclear family emotional system', Bowen focuses on the impact of 'undifferentiation' on the
emotional functioning of a single generation family. He asserts that relationship fusion, which leads to triangling,
is the fuel for symptom formation which is manifested in one of three categories. These are:
a. couple conflict;
b. illness in a spouse;
c. projection of a problem onto one or more children.
Each of these is expanded below.
3A. COUPLE CONFLICT
The single generation unit usually starts with a dyad - a couple who, according to Bowen, will be at approximately
equal levels of differentiation (ie. both have the same degree of need to be validated through the relationship).
Bowen believed that permission to disagree is one of the most important contracts between individuals in an
intimate relationship (Kerr and Bowen, 1988: 188). In a fused relationship, partners interpret the emotional state
of the other as their responsibility, and the other's stated disagreement as a personal affront to them. A typical
pattern in such emotionally intense relationships is a cycle of closeness followed by conflict to create distance,
which in turn is followed by the couple making up and resuming the intense closeness. This pattern is a
'conflictual cocoon' (Kerr and Bowen, 1988: 192), where anxiety is bound within the conflict cycle without spilling
over to involve children. Bowen suggested the following three ways in which couple conflict can be functional for
a fused relationship, in which 'each person is attempting to become more whole through the other' (Lederer and
Lewis, 1991).
1. Conflict can provide a strong sense of emotional contact with the important other.
2. Conflict can justify people's maintaining a comfortable distance from each other without feeling guilty about it.
3. Conflict can allow one person to project anxieties they have about themselves onto the other, thereby
preserving their positive view of self (Kerr and Bowen, 1988: 192).
3B. SYMPTOMS IN A SPOUSE
In a fused relationship, where each partner looks to the other's qualities to fit his / her learned manner of relating
to significant others, a pattern of reciprocity can be set in motion that pushes each spouse's role to opposite
extremes. Drawing from his analytic background, Bowen described this fusion as 'the reciprocal side of each
spouse's transference' (Kerr and Bowen, 1988: 170). For example, what may start as an overly responsible
spouse feeling compatible with a more dependent partner, can escalate to an increasingly controlling spouse with
the other giving up any sense of contributing to the relationship. Both are equally undifferentiated in that they are
defining themselves according to the reactions of the other; however the spouse who makes the most
adjustments in the self in order to preserve relationship harmony is said by Bowen to be prone to developing
symptoms. The person who gets polarised in the under functioning position is most vulnerable to symptoms of
helplessness such as depression, substance abuse and chronic pain. The over functioning person might also be
the one to develop symptoms, as s/he becomes overburdened by attempts to make things 'right' for others.
3C. SYMPTOMS IN A CHILD
The third symptom of fusion in a family is when a child develops behavioural or emotional problems. This comes
under Bowen's fourth theoretical concept, the Family Projection Process.
4 - Family Projection Process
In the previous two categories the couple relationship is the focus of anxiety without it significantly impacting on
the functioning of the next generation. By contrast, the family projection process describes how children develop
symptoms when they get caught up in the previous generation's anxiety about relationships.
The child with the least emotional separation from his/her parents is said to be the most vulnerable to developing
symptoms. Bowen describes this as occurring when a child responds anxiously to the tension in the parents'
relationship, which in turn is mistaken for a problem in the child. A detouring triangle is thus set in motion, as
attention and protectiveness are shifted to the child. Within this cycle of reciprocal anxiety, a child becomes more
demanding or more impaired. An example would be when an illness in a child distracts one parent from the
pursuit of closeness in the marriage. As tension in the marriage is relieved, both spouses become invested in
treating their child's condition, which may in turn become chronic or psychosomatic.
As in all of Bowen's constructs, 'intergenerational projection' is said to occur in all families in varying degrees.
Many intergenerational influences may determine which child becomes the focus of family anxiety and at what
stage of the life cycle this occurs. The impact of crises and their timing also influences the vulnerability of certain
children. Bowen viewed traumatic events as significant in highlighting the family processes rather than as actually
'causing' them.
5 - Emotional Cutoff
Bowen describes 'emotional cutoff' as the way people manage the intensity of fusion between the generations. A
'cutoff' can be achieved through physical distance or through forms of emotional withdrawal. Bowen distinguishes
between 'breaking away' from the family and 'growing away' from the family. 'Growing away' is viewed as part of
differentiation - adult family members follow independent goals while also recognising that they are part of their
family system. A 'cutoff' is more like an escape; people 'decide' to be completely different to their family of origin.
While immediate pressure might be relieved by cutoff, patterns of reactivity in intense relationships remain
unchanged and versions of the past, or its mirror image, are repeated. Bowen proposes that:
If one does not see himself as part of the system, his only options are either to get others to change or to
withdraw. If one sees himself as part of the system, he has a new option: to stay in contact with others and
change self (Kerr and Bowen, 1988: 272-273).
'Cutoffs' are not always dramatic rifts. An example of a covert emotional cutoff would be one family member
maintaining an anxious silence in the face of another's anger. The pull to restore harmony overwhelms the ability
to stay in contact with the issue that has been raised.
A central hypothesis of Bowen's theory is that the more people maintain emotional contact with the previous
generation, the less reactive they will be in current relationships. Conversely, when there are emotional cutoffs,
the current family group can experience intense emotional pressure without effective escape valves. This family
tension is like 'walking on eggshells', as issues which remain unresolved from the cutoff are carefully avoided.
Triangling provides a detour, as family members enlist the support of others for their own position in relation to
the cutoff.
6 - Multi-generational Transmission Process
This concept of Bowen's theory describes how patterns, themes and positions (roles) in a triangle are passed
down from generation to generation through the projection from parent to child which was described earlier. The
impact will be different for each child depending on the degree of triangling they have with their parents.
Bowen's focus on at least three generations of a family when dealing with a presenting symptom is certainly a
trademark of his theory. The attention to family patterns over time is not just an evaluative tool, but an
intervention that helps family members get sufficient distance from their current struggle with symptoms to see
how they might change their own part in the transmission of anxiety over the generations. As Monica McGoldrick
(1995: 20) writes in applying Bowenian concepts:
By learning about your family and its history and getting to know what made family members tick, how they
related, and where they got stuck, you can consider your own role, not simply as victim or reactor to your
experiences but as an active player in interactions that repeat themselves.
7 - Sibling Positions
Employing Walter Toman's (1976) sibling profiles, Bowen considered that sibling position could provide useful
information in understanding the roles individuals tend to take in relationships. For example, Toman's profiles
describe eldest children as more likely to take on responsibility and leadership, with younger siblings more
comfortable being dependent and allowing others to make decisions. Middle children are described as having
more flexibility to shift between responsibility and dependence and 'only' children are seen as being responsible,
and having greater access to the adult world. Bowen noted that these generalised traits are not universally
applicable and that it is possible for a younger sibling to become the 'functional eldest'. Bowen was especially
interested in which sibling position in a family is most vulnerable to triangling with parents. It may be that a parent
identifies strongly with a child in the same sibling position as their own, or that a previous cross generational
triangle (eg. an eldest child aligned with a grandparent against a parent) may be repeated. If one sibling in the
previous generation suffered a serious illness or died, it is more likely that the child of the present generation in
the same sibling position will be viewed as more vulnerable and therefore more likely to detour tensions from the
parental dyad.
Helping the client understand and think beyond the limitations of their own sibling position and role is a goal of
Bowenian family of origin work. Clients are encouraged to consider how assumptions about relationships are
fuelled by their sibling role experience. As with other aspects of Bowen's theory, the impact of gender and
ethnicity on sibling role is not considered. For example, there is no exploration of how a family's ethnicity
influences which birth order position and which gender is more valued, or how the gender of any sibling position
tends to influence whether the role is primarily relational (female), or task oriented (male).
The Model In Clinical Practice
Bowen's is not a technique focused model which incorporates specific descriptions of how to structure therapy
sessions. The goal of therapy is to assist family members towards greater levels of differentiation, where there is
less blaming, decreased reactivity and increased responsibility for self in the emotional system. Perhaps the most
distinctive aspects of Bowen's therapy are his emphasis on the therapist's own family of origin work, the central
role of the therapist in directing conversation and his minimal focus on children in the process of therapy.
Bowen views therapy in three broad stages.
1.
Stage one aims to reduce clients' anxiety about the symptom by encouraging them to learn how the
symptom is part of their pattern of relating.
2.
Stage two focuses adult clients on 'self' issues so as to increase their levels of differentiation. Clients are
helped to resist the pull of what Bowen termed the 'togetherness force' in the family (Bowen, 1971 in
Bowen, 1978: 218).
3.
In the latter phases of therapy, adult clients are coached in differentiating themselves from their family of
origin, the assumption being that gains in differentiation will automatically flow over into decreased anxiety
and greater self-responsibility within the nuclear family system.
Clinical Practice : The Role of the Therapist
The role of the therapist is to connect with a family without becoming emotionally reactive. Emphasis is given to
the therapist maintaining a 'differentiated' stance. This means that the therapist is not drawn into an over
responsible / under responsible reciprocity in attempts to be helpful. A therapist position of calm and interested
investigation is important, so that the family begins to learn about itself as an emotional system. Bowen instructs
therapists to move out of a healing or helping position, where families passively wait for a cure, 'to getting the
family into position to accept responsibility for its own change' (Bowen, 1971 in Bowen, 1978: 246).
Bowen warns of the problems of therapists losing sight of their part in the system of interactions, where they may
be inducted into a mediating role in a triangle with the family. Hence there is a high priority given to
understanding and making changes within the therapist's own family of origin. In training, the emphasis is on the
trainees' level of differentiation, and not on therapeutic technique. The therapist's resolution of family of origin
issues is reflected in the:
...ability to be in emotional contact with a difficult, emotionally charged problem and not feel compelled to preach
about what others should do, not rush in to fix the problem and not pretend to be detached by emotionally
insulating oneself (Kerr and Bowen, 1988: 108).
Clinical Practice : Therapist Activity
The therapist is active in directing the therapeutic conversation. Enactments are halted so as to prevent the
escalation of clients' anxiety. Clients are asked to talk directly to the therapist so that other family members can
"listen and 'really hear' without reacting emotionally, for the first time in their lives together" (Bowen, 1971 in
Bowen, 1978: 248). Bowen himself would avoid couple interaction in the room and concentrate on interviewing
one spouse in the presence of the other. Bowen clearly avoided asking for emotional responses, which he saw
as less likely to lead to differentiation of self, preferring mostly to ask for 'thoughts', 'reactions' and 'impressions'
(Bowen, 1971, in Bowen, 1978: 226). He called this activity 'externalizing the thinking of each client in the
presence of the other' (Bowen, 1975 in Bowen, 1978: 314).
Clinical Practice : Children in Bowen's Therapy
A surprising feature of Bowen's family therapy is his tendency to minimise the involvement of children. While
Bowen might include children in the beginning stage of therapy, he would soon dismiss them, focusing on the
adults as the most influential members of a family system (Bowen, 1975 in Bowen, 1978: 298). Excluding a child
from therapy responsibility is viewed as a detriangling manoeuvre. When parents cannot use the child as a
'triangle person' for issues between them, and the therapist resists taking the replacement role in the triangle,
parents can begin differentiating their respective selves from one other.
Clinical Practice : Family Evaluation
The beginning sessions in Bowenian therapy focus on information gathering in order to form ideas about the
family's emotional processes, which concurrently provides information to family members about the presenting
problem in its systemic context. The presenting problem is tracked through the history of the nuclear family and
into the extended family system. A multigenerational genogram is a useful tool for recording this information
(McGoldrick and Gerson, 1985; Kerr and Bowen, 1988: 306-313). The therapist looks for clues about the
emotional process of the particular family, including: patterns of regulating closeness and distance, how anxiety is
dealt with in the system, what triangles get activated, the degree of adaptivity to changes and stressful events,
and any signs of emotional 'cutoff'. Information collected is acknowledged to be extremely subjective, especially
when extended family are discussed; but stories about past generations are viewed as useful clues to the roles
people occupy in triangles and the tensions that remain unresolved from their families of origin. If for example, a
member of the extended family is described as 'the rebel', the therapist explores what events gave rise to this
label, who else has occupied this role across the generations and how triangles formed around family crises
involving 'rebellion'. Calming family members' anxiety in the early stages of therapy might involve helping them to
make connections between the development of symptoms and potent themes in a family's history. Another aim
will be to loosen the central triangle that has formed around, and maintains, the presenting problem. Teaching
clients about systems concepts as they operate in their own family is part of therapy at this stage. This does not
mean attempting to convince people to do things differently but to encourage family members to see beyond their
biases so that it is possible for them to consider each person's part in the family patterns.
Clinical Practice : Questions that Encourage Differentiation
The therapist asks questions that assume that the adult client can be responsible for his / her reactiveness to the
other. An example would be, "How do you understand the way you seem to take your child's acting out so
personally?" In response to such questions, family members are encouraged to take an 'I' position where they
speak about how they view the problem, without attacking, or defending against, another family member (Bowen,
1971a in Bowen, 1978: 252; Goodnow and Lim, 1997). Clients are taught to make personal statements about
their thoughts and feelings in order to facilitate a greater sense of responsibility in a relationship. For example, an
accusatory statement such as, 'You are so selfish to cause this much worry for your parents!', is shifted to, 'I am
really concerned that this might affect your school grades'. The parent is encouraged to 'own' their worries, rather
than to project their anxieties through blaming statements. Developing such a 'self-focus' is said to be crucial in
lowering anxiety and enabling 'person to person' relationships where each family member can think about the
part they play in problematic interactions.
Clinical Practice : Creating a Multigenerational Lens
Bowen's multigenerational model goes beyond the view that the past influences the present, to the view that
patterns of relating in the past continue in the present family system (Herz Brown, 1991). Hence the therapist
uses questions to encourage clients to think about the connection between their present problem and the ways
previous generations have dealt with similar relationship issues. For example, if the onset of a symptom followed
a death in the family, the therapist asks about how grief has been dealt with in previous generations. Questions
seek to uncover family belief systems as well as the way relationships have shifted in response to loss. Tracking
symptoms and exploring related themes over at least three generations makes it more difficult for individuals to
blame one another for individual deficiencies. As therapist and family members see how patterns repeat over
generations, it is possible to identify the 'automatic' reactions of family members towards each other:
The ability to act on the basis of more awareness of relationship process (not blaming self or others, but seeing
the part each plays) can, if done repeatedly in important relationships, lead to some reduction in emotional
reactivity and chronic anxiety (Kerr and Bowen, 1988: 132).
Clinical Practice : Detriangling
This is probably the central technique in Bowenian therapy. The client is first helped to recognise both the subtle
and the more obvious ways that they are 'triangled' by others, and the ways in which they attempt to triangle
others in their turn. The therapist uses questions to facilitate the family members' awareness of their roles in
family triangles. Simple open ended tracking questions, using what Herz Brown (1991) terms the four 'Ws' (who,
what, when and where) help clients to become 'detectives' in their own interpersonal systems. It is often very
difficult for family members to identify the triangles they participate in, and the sometimes covert ways in which
they detour anxiety. An example would be a client who was struggling to understand her negativity towards her
father. When questioning included her mother's role in these emotions, the client began to see that her view of
her father was influenced by her position in a triangle. As her mother's ally in this triangle, she viewed her father
as the inadequate husband who left her mother feeling needy.
Once triangles have been identified, family members are helped to plan ways of communicating a neutral position
to others, leaving the dyad to communicate directly with each other. The goal is for a family member to find a less
reactive position in the face of the other's anxiety. This will require different stances in different systems, ranging
from refusing to discuss the deficiencies of another behind his/her back, to reversing one's usual reaction in a
triangle. For example, when the predictable pattern in the family system is to keep distance between those who
haven't been able to work out their problems, the therapist helps a family member to plan strategies that shift
their usual role in maintaining the avoidance. The family member might encourage more involvement between
the conflictual twosome, or change the subject when invited to discuss the conflict. Reversal is a key detriangling
technique. When for example a family member A complains about how uncaring another person is, person C
reverses the predictable sympathetic response, substituting a casual comment about how considerate person B
seems for not putting demands on A's time and energy. Unlike a strategic intervention, the goal of any
detriangling stance is not to change the other's relationship but to express one's neutrality about it. A calm and
thoughtful neutral stance prevents one from anxiously reacting to the tension of another relationship by 'taking
sides'.
Clinical Practice : Coaching: Family Therapy with an Individual
Another distinguishing feature of Bowen's model is its validity in working with a single adult. The term 'coaching'
describes the work of the therapist giving input and support for adult clients who are attempting to develop
greater differentiation in their families of origin. Clients should feel in charge of their own change efforts, with the
therapist acting as a consultant. Bowen thought that a person's efforts to be more differentiated would be more
productive when the focus shifted away from the intensity of the nuclear family to the previous generation. The
emphasis is on self-directed efforts to detriangle from family of origin patterns. An individual's efforts can modify a
triangle, which in turn ripples through to change in the whole extended family.
Bowen described 'coaching' as 'family psychotherapy with one family member' (Bowen, 1971 in Bowen, 1978:
233). This therapy takes on the flavour of teaching, as clients learn about the predicable patterns of triangles. The
therapist supports their efforts in returning to their families to observe and learn about these patterns. Clients
practise controlling their emotional reactivity in their family and report their struggles and progress in following
sessions. During family of origin coaching, clients use letters, telephone calls, visits and research about previous
generations to gain a systemic perspective on their family's emotional processes and a sense of their own
inheritance of these patterns. The therapist prepares clients for the anxiety they will encounter if they shift from
their customary roles in their families of origin. Any such changes will inevitably disturb the predictable balance of
family patterns and therefore heighten anxiety and resistance.
Change is viewed as a three step process where:
a. one takes a new position,
b. family members react and
c. the new stance is maintained in the face of pressure to revert to the original position (Herz Brown,
1991).
Bowen (1978) emphasised that it is what happens in step 'c' that really determines whether change occurs.
Current Developments
Bowen's model has been adopted and developed by many prominent therapists. Rather than attempt to
summarise all of these developments, I shall focus on the applications of the model by Betty Carter and Monica
McGoldrick which have influenced the practice of the Family Institute of Westchester in New York and the Family
Institute of New Jersey.
Since the early 1980s, the work of Carter, McGoldrick and their colleagues has expanded Bowen's framework to
include attention to the family life cycle (Carter and McGoldrick, 1980, 1988.) As well as the 'vertical' flow of
anxiety through the generations, Carter included an assessment of 'horizontal' stress as families move through
various stages of the life cycle. Vertical and horizontal patterns converge, as multigenerational tensions impact
on the ways that life cycle tasks and disruptions are negotiated. The stress of life cycle changes affects the
choice of family of origin issues focused upon in the current generation. Using a life cycle perspective, symptom
development is viewed in the context of an unresolved adjustment to a life cycle task.
Acknowledging the significance of gender, race, ethnicity and class on a family's progression through life cycle
stages was an important development in family assessment (eg. McGoldrick, Pearce and Giordano, 1982; Carter
et al., 1988; McGoldrick, Anderson and Walsh, 1988; Herz Brown, 1991). This much broader focus provides what
Carter has called a 'multi-contextual lens'.
These variables are part of the context of the family's 'horizontal' story and underlie the potent themes of a
family's multigenerational legacy. Patterns of gender across the generations are viewed as powerfully
contributing to the roles that people occupy in the family emotional system. The inclusion of gender sensitivity in
a Bowenian framework means that the therapist helps clients to look not only at patterns of relating over the
generations but also to critique the roles they occupy in relationships. Such a focus is not confined to the family
system's gender expectations but includes questions that look for connections to socially defined gender roles.
Betty Carter, in developing her work from the women's project (Carter et al., 1988), has outlined how Bowen's
key concepts (fusion, differentiation and triangles) need to be viewed differently from a feminist position. Gender
roles will determine the way men and women express fusion, with women socialised to be dependent and
approval seeking and men socialised to withdraw and emotionally 'cut off'. Carter asserts that the concept of
fusion can easily be misused to pathologise the 'over-involved female' while overlooking the distant male. With a
'gender sensitive lens', a Bowenian therapist validates rather than pathologises the relational concerns of women
and explores ways that men can take responsibilities in this sphere. The distancing of a male will be seen not
only as a symptom of lack of differentiation but also as a socially prescribed reaction.
Likewise, the nature of a relationship triangle is influenced by gender related behaviour. Carter illustrates the
different ways a therapist might view a triangle with and without the feminist lens. The triangle of a husband in a
distant position, with his wife and mother in conflict, would be viewed by a feminist Bowenian therapist as 'a case
of two women bumping into each other as each tries to carry out her family responsibilities in the face of the
man's withdrawal' (Carter et al., 1988). Interventions will respect the women's roles and dilemmas and focus on
how the husband can choose to be more involved in both significant relationships. Without such a lens, the
detriangling strategy would typically be to have the husband set more boundaries with his mother - which has the
effect of preserving the gendered stereotype of the 'possessive' mother in law.
The therapist is challenged to recognise that no intervention is free from societal constructs in regard to gender
and power (including race, ethnicity, class and sexual orientation) so that 'every intervention will have a different
and special meaning for each sex' (Carter et al., 1988). Thus therapists expand their questioning to ask about the
relational impact of each spouse's income and ethnicity. The organisation of child care and housework is also
explored. Therapists are encouraged to challenge men's excuses that work prevents family involvement and
women's expectations about financial support (Carter, 1996). An awareness of the impact of therapists' own
value system on their therapy is also stressed (Carter, 1992).
For Bowenian therapists in the nineties, the core of Bowen's theory of symptom development and change
remains unaltered. What has been added is attention to how wider socio-political issues of power and hierarchy
are played out as couple or family problems. A broad range of systemic techniques such as restorying and
circular questioning can readily be incorporated into the model (Carter and McGoldrick, 1988).
Critique Of Bowen's Model
Bowen's model of family therapy is perhaps most distinctive for its depth of evaluation beyond symptoms in the
present. Its focus on emotional processes over the generations and on individuals' differentiation within their
systemic context offers family therapists a multi-level view that has usually been reserved for psychodynamic
therapies. Bowen's model pays attention to the emotional interaction of therapists and their clients and expects
that the process of therapy must in some way be applied to the therapists' own lives, so that they are able to
remain meta to the client family system.
A number of Bowenian therapists acknowledge that the wider focus of Bowen's model can be a drawback in that
many clients want only to address symptom relief in the nuclear family (Young, 1991). For the Bowenian
therapist, symptom reduction is seen only as the ground work from which families can proceed less anxiously
towards working on detriangling and improved levels of differentiation. Herein lies a clear danger of discrepancies
in client and therapist goals.
While Bowenian therapy has been embraced by some leading feminist therapists, such as Betty Carter and
Harriet Goldhor Lerner, it has also received its share of criticism from a feminist perspective. Deborah Leupnitz
(1988) points out that Bowen, along with other male family therapy pioneers, has paid rather too much attention
to the mother's contribution to symptom development in the child. Some support for this can be found by
scanning the index to Kerr and Bowen (1988), where 'fathers' do not warrant a category yet 'mothers' are
referenced in relation to families of schizophrenics, levels of differentiation in the child, and their role in triangles
(Kerr and Bowen, 1988: 395). [The index to Bowen's own collected papers, Family Therapy in Clinical Practice,
however, includes one reference to 'fathers' and none to 'mothers': Eds.] A perceived over-investment by a
mother in her child is seen as a sign of undifferentiation.
Unlike the current feminist therapists who use the Bowenian model, Murray Bowen (along with many of his
Georgetown colleagues) failed to contextualise maternal behaviour. Patriarchal assumptions about male / female
roles and family organisation are not acknowledged or critiqued, which leaves women vulnerable to having their
socially prescribed roles pathologised. Women are readily labelled as 'over concerned', and their active, relational
role in families too easily labelled as 'fused' and 'undifferentiated'. There is no questioning of societal norms that
can be seen to '[school] females into undifferentiation by teaching them always to put others' needs first'
(Leupnitz, 1988: 43).
The women's project in family therapy asserts that a model such as Bowen's pressures the woman to 'back off'
while placating and courting the distant male (Carter et al., 1988). Carter asserts that this is not only biased
against women but disrespectful of men since the model assumes men's limitations in terms of emotional
engagement in therapy and family relationships. An ongoing challenge for feminist Bowenian therapists is to
reconstruct a therapy language of intimacy and attachment that is not misused to imply dysfunction (Bograd,
1987; Carter et al., 1988).
Another criticism that flows from the biases of Bowen's 'male defined' terminology, is that his is a therapy lacking
in attention to feelings (Luepnitz, 1988). It is asserted that Bowen's therapy focuses on being rational and
objective in relation to emotional processes, which relegates to a low priority the expression of emotions in
therapy. My own experience of this model, with its invitation to explore the 'tapestry' of one's family across the
generations, is that it is an emotionally intense therapy. While Bowen may emphasise the goal of helping the
client learn about their family's emotional processes, in practice it is the experience of the emotions, embedded in
family of origin relationships that is a key motivator for the client to undertake family of origin work. I recall Betty
Carter, in asking a man about his relationship with his own father, tapping deeply into emotions that motivated
him to make changes in his ways of relating.
Case Example
The Barret family were referred for family therapy by the individual therapist of the sixteen year old anorectic
daughter, Tanya. Tanya had been hospitalised by her doctor the previous month when her weight levels were
considered life threatening. To date the family had not been involved in her treatment but were now feeling that
they could no longer remain on the sidelines when the risk levels were so high. Hospitalisation had also
intensified family reactivity, with Tanya blaming her father for allowing her freedom to be taken away, both
parents feeling angry that she could allow herself to fall so low, and her nineteen year old sister questioning how
Tanya could put her family through so much worry.
Stage 1: Calming the system
When a family member is exhibiting life threatening symptoms, it is not realistic to expect that anxiety can be
lowered to non reactive levels. In the case of the Barret family my goal was to take the focus away from Tanya's
weight sufficiently to enable the family to explore each of their roles in the anxious family patterns. The other
systems involved in her treatment were framed as providing her with support and monitoring the risk of her
symptoms. She received individual therapy where the therapist focused on supporting her through adolescent life
cycle tasks. Her doctor was responsible for monitoring her medical condition and weight gain. Family sessions
could therefore concentrate on family process in dealing with Tanya's eating patterns.
Stage 2: Nuclear family issues
Locating the presenting problem in the broader family context revealed that the family was in the process of
negotiating some significant changes. Around the onset of Tanya's pronounced weight loss, her older sister,
Roslyn, had moved away from home to begin medical studies at university. Roslyn had previously been
considered the rebel of the family but was now clearly labelled as the 'golden girl' who would make them all proud
with her academic success. Family roles and the theme of economic success were identified. Mr. Barret had
recently received a promotion which necessitated moving to another city. Mrs. Barret had left her job as a nurse
and had not been working for the nine months following the family move. Gender themes were becoming evident
as Tanya spoke of how personally she was identifying with her mother's loss of professional role. While there
were numerous family changes that could inform hypotheses about her symptoms, my primary focus was the
operation of family triangles in dealing with anxiety. Tanya expressed her triangled role in her parents' issues as
she spoke about their emotional life. She described the stress of her father's work and reported passionately on
her mother's loss of status since giving up her nursing job. She perceived her mother's life as empty, and she
herself felt similarly empty and directionless.
The fusion in nuclear family relationships was striking, with family members reacting to either comfort or criticise
each other. During the sessions, the six year old daughter Liz passed tissues to those who looked upset, or
distracted by using puppets from the play box to bring some humour into the room. I reflected to the family just
how closely 'wired' to each other's feelings they all were and how readily they seemed to switch from their own
issues to focus on the emotional intensity of others. Questions were asked that encouraged an awareness of this
fusion, for example:
[To Tanya]. 'I know you've become an expert at being the emotional voice for your parents but what would you
say, just this once, if you could speak for your own needs?'
[To Mr. Barret]. 'Do you have any sense of when you first started to take Tanya's symptoms so personally - as if
they were directed at hurting you?'
Mrs. Barret spoke of how their eldest daughter Roslyn had complained of feeling suffocated by being at home
and how they had hardly seen her during her last few years of high school. When Roslyn was at home her
relationship with her father had been highly conflictual. Now that she was at medical school Mr. Barret spoke of
how proud they all were of her. He had tears in his eyes as he spoke of how Roslyn now had the chance to
achieve what he had not been able to. Each of the children, to varying degrees, appeared to be triangled into
their parents' emotional issues. While Roslyn and Liz were currently occupying symptom-free roles in diffusing
parental anxiety, Tanya seemed stuck in a symptom-focused dance with her parents' neediness.
Nuclear family triangles were tracked around family members' responses to Tanya's eating patterns. A typical
sequence would be:
Mrs. Barret watching Tanya's eating behaviour closely, with Tanya becoming increasingly withdrawn.
Mrs. Barret would accuse Tanya of bingeing and purging, with the latter responding in tears, saying that nobody
in the family would trust her.
Mr. Barret who had been hearing a daily account of his wife's suspicions, would begin yelling at Tanya, saying
what a disappointment she was to him.
Mrs. Barret would feel sorry for her daughter and move closer in support.
At this point, when Tanya's symptoms threatened to increase distance and tension in the marriage, Mrs. Barret
would suggest ways to her husband and daughter about how they could make up.
Tanya continued to refuse to eat with the family but would set up a joint outing for herself and her Dad.
Stage 3: Expanding the view to previous generations
While seeking to draw out the repetitive patterns in the current family experience, I also look for ways to connect
present tensions to multigenerational themes.
Exploration of both parents' family of origin revealed potent themes that fed into the intense struggle of the
nuclear family triangle between Tanya, her father and her mother. While ever Mr Barret and Mrs Barret could
worry about her, they did not have to address the relationship disappointments that they had hoped would be
mended through their marriage.
A key task of ongoing therapy was to help the parents separate these unresolved family of origin issues from
their interactions with Tanya. Both parents had been in the same middle child position as Tanya, which had
intensified their identification with her. Reflecting on their own adolescence and their relationship with their
parents helped Mr Barret and Mrs Barret to assume a more objective stance towards their daughter. Mrs Barret
was able to stop herself encouraging Tanya to look after her father following an argument. Mrs Barret was also
able to see how her striving to create a different relationship from the distant and critical one she had with her
own mother was getting in the way of her being able to set any limits with Tanya. Mr Barret was able to start
viewing Tanya as a separate person from himself or his father and was thus more able to notice her unique
strengths. This shift was a particularly painful journey for Mr Barret, who recounted his memories of his alcoholic
father, who had died in an emaciated state after choking on his own vomit. The parallel to Tanya's symptoms
helped to make sense of his intense reactivity in their relationship.
Tanya was able to hear that her parents' reactions were more about where they had come from than about what
kind of a daughter she was. During therapy she struggled to cope with the shift in family patterns. She was
excluded from the triangle with her parents where she had occupied a pivotal role in helping to regulate their
closeness. To assist with this shift, some sessions were held with her and her older sister Roslyn, so that the
sisters could establish a connection as young adults sharing similar life cycle tasks, rather than being their
parents' caretakers. A couple of months down the track, she mentioned that she had been writing to Roslyn and
that they were sharing information about boyfriends that their parents were not privy to.
After about five months of therapy, her weight had increased to a level which put her out of the medical risk
category. At this time Mr Barret and Mrs Barret felt that they wanted to focus on some of their own family of origin
issues as a couple and individually. Tanya was busy rehearsing for a school play in which she had the female
lead, so she asked if she could take a break from family sessions and let her parents come on their own.
Conclusion
At a time when family therapy is rediscovering its psychoanalytic roots (Quadrio, 1986; Luepnitz, 1988; Flaskas,
1993; James, 1992), it is important to be clear about the distinctions between psychodynamic and Bowenian
approaches. While both models are comprehensive in accounting for many aspects of human experience, the
essential difference is that Bowen's focus is not the intrapsychic experience of the individual. It focuses on the
structure and workings of the system so that the individual can forge a different systemic role. While in
psychoanalysis, self understanding comes through the vehicle of the therapist / client relationship, in Bowenian
therapy it comes from the between-session, planned action of the 'self in the system'.
In giving an overview of Bowen's model, this paper risks oversimplifying its in-depth formulation of family process.
My aim has been to summarise Bowen's core concepts and to give a flavour of how these influence the focus of
therapy. One needs to be mindful however, of potential pitfalls when using a family of origin model. Bowen's
focus on the distant to solve the proximate may take families on therapeutic paths which go beyond their request
for the shortest possible road to symptom relief. Without recent significant socio-political additions, Bowen's
theory decontextualises relationship patterns that are powerfully informed by gender, ethnicity and class.
Those who adhere to a Bowenian framework speak of the appeal of its attention to complex family patterns in
both vertical and horizontal time. Perhaps what is most distinctive about Bowen's theory amongst systemic
therapies, is that it directs therapists to consider their own roles in their families of origin so that they can
personally experience the theory in order to appreciate its clinical application.
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Family Tapestry, NY, Norton.
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Acknowledgment
The author wishes to thank Kerrie James for ideas helpful in the writing of this article.
Coming to grips with family systems theory in a collaborative,
learning environment.
info@thefsi.com.au
http://www.thefsi.com.au
SESSIONS
Case Histories
Editors
Sara-Beth Plummer
Sara Makris
Sally Margaret Brocksen
Published by
Laureate International Universities Publishing, Inc.
7080 Samuel Morse Drive
Columbia, MD 21046
www.laureate.net
Director, Program Design: Lauren Mason Carris
Content Development Manager: Jason Jones
Content Development Specialist: Sandra Shon
Production Services: Absolute Service, Inc.
Editorial Services: Christina Myers
Copyright © 2014 by Laureate International Universities Publishing, Inc.
All rights reserved. No part of this publication may be reproduced, distributed, or transmitted in any form or by any means, including
photocopying, recording, any information storage and retrieval systems, or other electronic or mechanical methods, without the prior
written permission of the publisher, except in the case of brief quotations embodied in critical reviews and certain other noncom
mercial uses permitted by copyright law. For permission requests, write to the publisher, addressed “Attention: Content Development
Specialist,” at the address above.
Editors
Sara-Beth Plummer, PhD, MSW
Walden University
Sara Makris, PhD
Laureate Education, Inc.
Sally Margaret Brocksen, PhD, MSW
Walden University
Contributors
Marlene Coach, EdD, MSW, ACSW, LSW
Walden University
Eileen V. Frishman, MSW, ACSW, LCSW-R, CH
Mary E. Larscheid, PhD, MSW, LICSW
Walden University
Vanessa Norris, MSW, LCSW
West Chester University
Sara-Beth Plummer, PhD, MSW
Walden University
Stephanie C. Sanger, MA, MSS, LSW
Assistant Director, RHD, Tri-County Supportive Housing
Eric Youn, PhD, LMSW
Walden University
iii
Contents
Introduction
1
Part 1: Foundation Year
2
The Hernandez Family
3
The Parker Family
6
The Logan Family
9
The Johnson Family
11
Part 2: Concentration Year
14
The Levy Family
15
The Bradley Family
17
The Petrakis Family
20
The Cortez Family
23
Appendix
26
Reflection Questions
27
The Hernandez Family
27
The Parker Family
28
The Logan Family
30
The Johnson Family
31
The Levy Family
32
The Bradley Family
33
The Petrakis Family
35
The Cortez Family
36
Trademarks and Disclaimers
38
iv
Introduction
T
he following eight cases are based on the true experiences of social workers in the field, although names and
other identifying circumstances have been changed. The narratives in this book, combined with filmed repre
sentations of scenes inspired by the cases, provide you an opportunity to use true-to-life cases as an experiential
learning tool. Whereas some academic programs, professors, or instructors may offer an occasional glimpse into
past social work experiences, this book and these cases weave through multiple courses in your foundation and
concentration year. Like in true-to-life practice, you will follow these cases through a variety of circumstances, prac
tice behaviors, and learning opportunities. This unique format for a social work program enables you to integrate
and connect the expected learning outcomes for each course. Each case either explicitly or implicitly offers content
on practice skills, research, human behavior theory, and policy. Further, you will see that each family’s concerns can
be addressed across all levels of practice, from micro to mezzo to macro.
Approach this book as a series of cases to which you have been assigned during your first professional experi
ence in social work. We encourage you to use a critical eye to analyze the approaches provided. Remember that
each practitioner has his or her own lens or perspective that guides his or her practice and these cases, written in
the voices of each individual social worker, offer you authentic, varied perspectives. As you review and dissect these
cases, consider your own lens and perspective as a future social worker.
The families described in these cases have been connected to social work services in myriad ways. Look closely at
how each family member is introduced to the social worker and at the services and interventions that follow. Through
reading these cases and then watching them come to life on video, you will see the skills used by social work practi
tioners. Carefully identify for yourself how the social worker engages, assesses, and intervenes with his or her client.
The social workers who provided these cases offer some of their own personal thoughts about these cases as
a series of reflection questions. Use the answers to the questions, posed to the social workers as they wrote these
stories, to gain additional insight into the decisions they made to address their clients’ concerns. Reflect on the ques
tions and answers as a way to consider whether you would have addressed the client or clients in the same manner.
Imagine your first day of practice, preparing for your first client meeting. On your desk is a folder with the last
name of the client on the tab. You open the folder to find a case history for your client—perhaps it details family
background, medical history, or an accounting of interactions with other agencies. This book is like that folder,
preparing you for the client you will soon meet.
1
PART 1: FOUNDATION YEAR
2
The Hernandez Family
J
uan Hernandez (27) and Elena Hernandez (25) are a married Latino couple who were referred to the New York
City Administration for Children Services (ACS) for abuse allegations. They have an 8-year-old son, Juan Jr.,
and a 6-year-old son, Alberto. They were married 7 years ago, soon after Juan Jr. was born. Juan and Elena were
both born in Puerto Rico and raised in Queens, New York. They rent a two-bedroom apartment in an apartment
complex where they have lived for 7 years. Elena works as babysitter for a family that lives nearby, and Juan works
at the airport in the baggage department. Overall, their physical health is good, although Elena was diagnosed with
diabetes this past year and Juan has some lower back issues from loading and unloading bags. Both drink socially
with friends and family. Juan goes out with friends on the weekends sometimes to “blow off steam,” having six to
eight beers, and Elena drinks sparingly, only one or two drinks a month. Both deny any drug use at all. While they
do not attend church regularly, both identify as being Catholic and observe all religious holidays. Juan was arrested
once as a juvenile for petty theft, but that has been expunged from his file. Elena has no criminal history. They
have a large support network of friends and family who live nearby, and both Elena’s and Juan’s parents live within
blocks of their apartment and visit frequently. Juan and Elena both enjoy playing cards with family and friends on
the weekends and taking the boys out to the park and beach near their home.
ACS was contacted by the school social worker from Juan Jr.’s school after he described a punishment his parents
used when he talked back to them. He told her that his parents made him kneel for hours while holding two encyclo
pedias (one in each hand) and that this was a punishment used on multiple occasions. The ACS worker deemed this
a credible concern and made a visit to the home. During the visit, the parents admitted to using this particular form
of punishment with their children when they misbehaved. In turn, the social worker from ACS mandated the family
to attend weekly family sessions and complete a parenting group at their local community mental health agency.
In her report sent to the mental health agency, the ACS social worker indicated that the form of punishment used by
the parents was deemed abusive and that the parents needed to learn new and appropriate parenting skills. She also
suggested they receive education about child development because she believed they had unrealistic expectations of
how children at their developmental stage should behave. This was a particular concern with Juan Sr., who repeat
edly stated that if the boys listened, stayed quiet, and followed all of their rules they would not be punished. There
was a sense from the ACS worker that Juan Sr. treated his sons, especially Juan Jr., as adults and not as children.
This was exhibited, she believed, by a clear lack of patience and understanding on his part when the boys did not
follow all of his directions perfectly or when they played in the home. She mandated family sessions along with the
parenting classes to address these issues.
During the intake session, when I met the family for the first time, both Juan and Elena were clearly angry that
they had been referred to parenting classes and family sessions. They both felt they had done nothing wrong, and
they stated that they were only punishing their children as they were punished as children in Puerto Rico. They said
that their parents made them hold heavy books or other objects as they kneeled and they both stressed that at times
the consequences for not behaving had been much worse. Both Juan and Elena were “beaten” (their term) by their
parents. Elena’s parents used a switch, and Juan’s parents used a belt. As a result, they feel they are actually quite
lenient with their children, and they said they never hit them and they never would. Both stated that they love their
children very much and struggle to give them a good life. They both stated that the boys are very active and don’t
always follow the rules and the kneeling punishment is the only thing that works when they “don’t want to listen.”
They both admitted that they made the boys hold two large encyclopedias for up to two hours while kneeling
when they did something wrong. They stated the boys are “hyperactive” and “need a lot of attention.” They said
they punish Juan Jr. more often because he is particularly defiant and does not listen and also because he is older
and should know better. They see him as a role model for his younger brother and feel he should take that respon
sibility to heart. His misbehavior indicates to them that he is not taking that duty seriously and therefore he should
be punished, both to learn his lesson and to show his younger brother what could happen if he does not behave.
During the intake meeting, Juan Sr. stated several times that he puts in overtime any time he can because money
is “tight.” He expressed great concern about having to attend the parenting classes and family sessions, as it would
interfere with that overtime. Elena appeared anxious during the initial meeting and repeatedly asked if they were
going to lose the boys. I told her I could not assure her that they would not, but I could assist her and her husband
through this process by making sure we had a plan that satisfied the ACS worker’s requirements. I told them it
3
SESSIONS: CASE HISTORIES • THE HERNANDEZ FAMILY
would be up to them to complete those plans successfully. I offered
The Hernandez Family
my support through this process and conveyed empathy around their
response to the situation.
Juan Hernandez: father, 27
Together we discussed the plan for treatment, following the
Elena Hernandez: mother, 25
requirements of ACS; they would attend a 12-week Positive Parenting
Juan Hernandez Jr.: son, 8
Program (PPP) along with weekly family sessions. In an effort to
reduce some of the financial burden of attending multiple meetings
Alberto Hernandez: son, 6
at the agency, I offered to meet with the family either just before
or immediately after the PPP so that they did not have to come to
the agency more than once a week. They agreed that this would be helpful because they did not have money for
multiple trips to the agency, although Juan Sr. stated that this would still affect his ability to work overtime on that
day. I asked if they had any goals they wanted to work toward during our sessions. Initially they were reluctant to
share anything, and then Elena suggested that a discussion on money management would be helpful. I told them
I would be their primary contact at the agency—meeting with them for the family sessions and co-facilitating the
PPP group with an intern. I explained my limitations around confidentiality, and they signed a form acknowledging
that I was required to share information about our sessions with the ACS worker. I informed them that the PPP is an
evidenced-based program and explained its meaning. I informed them that there is a pre- and post-test administered
along with the program and specific guidelines about missed classes. They were informed that if they missed more
than three classes, their participation would be deemed incomplete and they would not get their PPP certification.
Initially, when the couple attended parenting sessions and family sessions, Juan Sr. expressed feelings of anger
and resentment for being mandated to attend services at the agency. Several times he either refused to participate
by remaining quiet or spoke to the social worker and intern in a demeaning manner. He did this by questioning our
ability to teach the PPP and the effectiveness of the program itself, wanting to know how this was going to make
him a better parent. He also reiterated his belief that his form of discipline worked and that it was exactly what his
family members used for years on him and his relatives. He asked, “If it worked for them, why can’t that form of
punishment work for me and my children?” He emphasized that these were his children. He maintained throughout
the sessions that he never hit his children and never would. Both he and Elena often talked about their love for their
children and the devastation they would feel if they were ever taken away from them.
Treatment consisted of weekly parenting classes with the goal of teaching them effective and safe discipline skills
(such as setting limits through the use of time-out and taking away privileges). Further, the classes emphasized the
importance of recognizing age-appropriate behavior. We spent sessions reviewing child development techniques to
help boost their children’s self-esteem and sense of confidence. We also talked about managing one’s frustration
(such as when to take a break when angry) and helping their children to do the same.
Family sessions were built around helping the family members express themselves in a safe environment. The
parents and the children were asked to talk about how they felt about each other and the reason they were mandated
to treatment. They were asked to share how they felt while at home interacting with one another. I thought it was of
particular importance to have them talk about their feelings related to the call to ACS, as I was unsure how Juan Sr.
felt about Juan Jr.’s report to the social worker. It was necessary to assist them with processing this situation so that
there were no residual negative feelings between father and son. I asked them to role-play—having each member act
like another member of the household. This was very effective in helping Juan Sr. see how his boys view him and
his behavior toward them when he comes home from work. As a result of this exercise, he verbalized his newfound
clarity around how the boys have been seeing him as a very angry and negative father.
I also used sessions to explore the parents’ backgrounds. Using a genogram, we identified patterns among their
family members that have continued through generations. These patterns included the use of discipline to maintain
order in the home and the potentially unrealistic expectations the elders had for their children and grandchildren.
Elena stated that she was treated like an adult and had the responsibilities of a person much older than herself while
she was still very young. Juan Sr. said he felt responsible for bringing money into the home at an early age. He was
forced by his parents to get working papers as soon as he turned 14. His paychecks were then taken by his parents
each week and used to pay for groceries and other bills. He expressed anger at his parents for encouraging him to
drop out of high school so that he could get more than one job to help out with the finances.
Other sessions focused on the burden they felt related to their finances and how that burden might be felt by
the boys, just as Juan Sr. might have felt growing up. In one session, Juan Jr. expressed his fears of being evicted
and the lights being turned off, because his father often talked of not having money for bills. Both boys expressed
sadness over the amount of time their father spent at work and stressed their desire to do more things with him
at night and on the weekends. Both parents stated they did not realize the boys understood their anxieties around
4
SESSIONS: CASE HISTORIES • THE HERNANDEZ FAMILY
paying bills and felt sad that they worried about these issues. We also
Key to Acronyms
took a couple of sessions to address money management. We worked
together to create a budget and identify unnecessary expenses that
ACS: Administration for
might be eliminated.
Children Services
It was clear that this was a family that loved each other very much.
PPP:
Positive
Parenting Program
Juan Sr. and Elena were often affectionate with each other and their
sons. Once the initial anger subsided, both Juan Sr. and Elena fully
engaged in both the family sessions and the PPP. We assessed their progress monthly and highlighted that progress.
I also was aware that it was important to learn about the Hernandez family history and culture in order to under
stand their perspective and emotions around the ACS referral. I asked them many questions about their beliefs,
customs, and culture to learn about how they view parenthood, marriage roles, and children’s behaviors. They were
always open to these questions and seemed pleased that I asked about these things rather than assumed I knew the
answers.
During the course of treatment they missed a total of four PPP classes. I received a call from Elena each time
letting me know that Juan Sr. had to work overtime and they would miss the class. She was always apologetic and
would tell me she would like to know what they missed in the class so that she could review it on her own. During
a call after the fourth missed parenting class, I reminded Elena that in order to obtain the certificate of completion,
they were expected to attend a minimum of nine classes. By missing this last class, I explained, they were not going
to get the certificate. Elena expressed fear about this and asked if there was any way they could still receive it. She
explained that they only had one car and that she had to miss the classes when Juan Sr. could not go because she
had no way of getting to the agency on her own. I told her that I did not have the authority to change the rules
around the number of classes missed and that I understood how disappointed she was to hear they would not get
the certificate. When I told her I had to call the ACS worker and let her know, Elena got very quiet and started to
cry. I spoke with her for a while, and we talked about the possible repercussions.
I met with my supervisor and informed her of what had occurred. I knew I had to tell the ACS worker that they
would not receive the certificate of completion this round, and I felt bad for the situation Juan Sr. and Elena and
their boys were now in. I had been meeting with them for family sessions and parenting classes for almost three
months by this point and had built a strong rapport. I feared that once I called the ACS worker, that rapport would
be broken and they would no longer want to work with me. I saw them as loving and caring parents who were trying
the best they could to provide for their family. They had been making progress, particularly Juan Sr., and I did not
want their work to be in vain.
I also questioned whether the parenting and family sessions were really necessary for their situation. I felt there
was a lack of cultural competence on the part of the ACS worker—she had made some rather judgmental and
insensitive comments on the phone to me during the referral. I wondered if there was a rush to judgment on her
part because their form of discipline was not commonly used in the United States. In my own professional opinion,
some time-limited education on parenting and child development would have sufficed, as opposed to the 3-month
parenting program and family sessions.
My supervisor and I also discussed the cultural competence at the agency and the fact that the class schedule may
not fit a working family’s life. We discussed bringing this situation to a staff meeting to strategize and see if we had
the resources to offer the PPP multiple times during the week, perhaps allowing clients to make up a class on a day
other than their original class day.
I met with Elena and Juan Sr. and let them know I had to contact the ACS worker about the missed classes.
I explained that this was something I had to do by law. They told me they understood, although another round of
parenting classes would be a financial burden and they had already struggled to attend the current round of classes
each week. I validated their concerns and told them we were going to look at offering the program more than once
a week. I also told them that when I spoke to the ACS worker, I would also highlight their progress in family and
parenting sessions.
I called the ACS worker and told her all the positive progress the parents had made over the previous 3 months
before letting her know that they had missed too many classes to obtain the PPP certificate. The ACS worker was
pleased with the progress I described but said she would recommend to her supervisor that the parents take the
PPP over again until a certificate was obtained. She would wait to hear what her supervisor’s decision was on this
matter. She said that family sessions could end at this point. In the end, the supervisor decided the parents needed
to come back to the agency and just make up the four classes they missed. Elena and Juan Sr. were able to complete
this requirement and received their certificate, and the ACS case was closed. They later returned on their own for a
financial literacy class newly offered at the agency free of charge.
5
The Parker Family
S
ara is a 72-year-old widowed Caucasian female who lives in a two-bedroom apartment with her 48-year-old
daughter, Stephanie, and six cats. Sara and her daughter have lived together for the past 10 years, since
Stephanie returned home after a failed relationship and was unable to live independently. Stephanie has a diagnosis
of bipolar disorder, and her overall physical health is good. Stephanie has no history of treatment for alcohol or
substance abuse; during her teens she drank and smoked marijuana but no longer uses these substances. When
she was 16 years old, Stephanie was hospitalized after her first bipolar episode. She had attempted suicide by swal
lowing a handful of Tylenol® and drinking half a bottle of vodka after her first boyfriend broke up with her. She has
been hospitalized three times in the past 4 years when she stopped taking her medications and experienced suicidal
ideation. Stephanie’s current medications are Lithium, Paxil®, Abilify®, and Klonopin®.
Stephanie recently had a brief hospitalization as a result of depressive symptoms. She attends a mental health
drop-in center twice a week to socialize with friends and receives outpatient psychiatric treatment at a local mental
health clinic for medication management and weekly therapy. She is maintaining a part-time job at a local super
market where she bags groceries and is currently being trained to become a cashier. Stephanie currently has active
Medicare and receives Social Security Disability (SSD).
Sara has recently been hospitalized for depression and has some physical issues. She has documented high
blood pressure and hyperthyroidism, she is slightly underweight, and she is displaying signs of dementia. Sara has
no history of alcohol or substance abuse. Her current medications are Lexapro® and Zyprexa®. Sara has Medicare
and receives Social Security benefits and a small pension. She attends a day treatment program for seniors that
is affiliated with a local hospital in her neighborhood. Sara attends the program 3 days a week from 9:00 a.m. to
2:00 p.m., and van service is provided free of charge.
A telephone call was made to Adult Protective Services (APS) by the senior day treatment social worker when
Sara presented with increased confusion, poor attention to daily living skills, and statements made about Stephanie’s
behavior. Sara told the social worker at the senior day treatment program that, “My daughter is very argumentative
and is throwing all of my things out.” She reported, “We are fighting like cats and dogs; I’m afraid of her and of
losing all my stuff.”
During the home visit, the APS worker observed that the living room was very cluttered, but that the kitchen was
fairly clean, with food in the refrigerator and cabinets. Despite the clutter, all of the doorways, including the front
door, had clear egress. The family lives on the first floor of the apartment building and could exit the building without
difficulty in case of emergency. The litter boxes were also fairly clean, and there was no sign of vermin in the home.
Upon questioning by the APS worker, Sara denied that she was afraid of her daughter or that her daughter had
been physically abusive. In fact, the worker observed that Stephanie had a noticeable bruise on her forearm, which
appeared defensive in nature. When asked about the bruise, Stephanie reported that she had gotten it when her
mother tried to grab some items out of her arms that she was about to throw out. Stephanie admitted to throwing
things out to clean up the apartment, telling the APS worker, “I’m tired of my mother’s hoarding.” Sara agreed with
the description of the incident. Both Sara and Stephanie admitted to an increase in arguing, but denied physical
violence. Sara stated, “I didn’t mean to hurt Stephanie. I was just trying to get my things back.”
The APS worker observed that Sara’s appearance was unkempt and disheveled, but her overall hygiene was
adequate (i.e., clean hair and clothes). Stephanie was neatly groomed with good hygiene. The APS worker deter
mined that no one was in immediate danger to warrant removal from the home but that the family was in need of
a referral for Intensive Case Management (ICM) services. It was clear there was some conflict in the home that had
led to physical confrontations. Further, the house had hygiene issues, including trash and items stacked in the living
room and Sara’s room, which needed to be addressed. The APS worker indicated in her report that if not adequately
addressed, the hoarding might continue to escalate and create an unsafe and unhygienic environment, thus leading
to a possible eviction or recommendation for separation and relocation for both women.
As the ICM worker, I visited the family to assess the situation and the needs of the clients. Stephanie said she
was very angry with her mother and sick of her compulsive shopping and hoarding. Stephanie complained that
they did not have any visitors and she was ashamed to invite friends to the home due to the condition of the apart
ment. When I asked Sara if she saw a problem with so many items littering the apartment, Sara replied, “I need
all of these things.” Stephanie complained that when she tried to clean up and throw things out, her mother went
6
SESSIONS: CASE HISTORIES • THE PARKER FAMILY
outside and brought it all back in again. We discussed the need to
The Parker Family
clean up the apartment and make it habitable for them to remain
in their home, based on the recommendations of the APS worker. I
Sara Parker: mother, 72
also discussed possible housing alternatives, such as senior housing
Stephanie Parker: daughter, 48
for Sara and a supportive apartment complex for Stephanie. Sara
Jane Rodgers: daughter, 45
and Stephanie both stated they wanted to remain in their apartment
together, although Stephanie questioned whether her mother would
cooperate with cleaning up the apartment. Sara was adamant that she did not want to be removed from their apartment and would try to accept what needed to be done so they would not be forced to move.
Stephanie reported her mother is estranged from her younger sister, Jane, because of the hoarding. Stephanie
also mentioned she was dissatisfied with her mother’s psychiatric treatment and felt she was not getting the help
she needed. She reported that her mother was very anxious and was having difficulty sleeping, staying up until all
hours of the night, and buying items from a televised shopping network. Sara’s psychiatrist had recently increased
her Zyprexa prescription dosage to help reduce her agitation and possible bipolar disorder (as evidenced by the
compulsive shopping), but Stephanie did not feel this had been helpful and actually wondered if it was contributing
to her mother’s confusion. I asked for permission to contact Jane and both of their outpatient treatment teams, and
both requests were granted.
I immediately contacted Jane, who initially was uncooperative and stated she was unwilling to assist. Jane is
married, with three children, and lives 3 hours away. At the beginning of our phone call, Jane said, “I’ve been
through this before and I’m not helping this time.” When I asked if I could at least keep in touch with her to keep her
informed of the situation and any decisions that might need to be made, Jane agreed. After a few more minutes of
discussion around my role and responsibilities, I was able to establish a bit of rapport with Jane. She then started to
ask me questions and share some insight into what was going on in her mother and sister’s home.
Jane informed me that she was very angry with her mother and had not brought her children to the apartment
in years because of its condition. She said that her mother started compulsively shopping and hoarding when she
and Stephanie were in high school, and while her father had tried to contain it as best he could, the apartment was
always cluttered. She said this had been a source of conflict and embarrassment for her and Stephanie all of their
lives. She said that after her father died of a heart attack, the hoarding got worse, and neither she nor Stephanie
could control it. Jane also told me she felt her mother was responsible for Stephanie’s relapses. Jane reported that
Stephanie had been compliant with her medication and treatment in the past, and that up until a few years ago, had
not been hospitalized for several years. Jane had told Stephanie in the past to move out.
Jane also told me that she “is angry with the mental health system.” Sara had been recently hospitalized for
depression, and Jane took pictures of the apartment to show the inpatient treatment team what her mother was
going home to. Jane felt they did not treat the situation seriously because they discharged her mother back to the
apartment. Stephanie had been hospitalized at the same time as her mother, but in a different hospital, and Jane had
shown the pictures to her sister’s treatment team as well. Initially the social worker recommended that Stephanie not
return to the apartment because of the state of the home, but when that social worker was replaced with someone
new, Stephanie was also sent back home.
When I inquired if there were any friends or family members who might be available and willing to assist in
clearing out the apartment, Jane said her mother had few friends and was not affiliated with a church group or
congregation. However, she acknowledged that there were two cousins who might help, and she offered to contact
them and possibly help herself. She said that she would ask her husband to help as well, but she wanted assurance
that her mother would cooperate. I explained that while I could not promise that her mother would cooperate
completely, her mother had stated that she was willing to do whatever it took to keep living in her home. Jane
seemed satisfied with this response and pleased with the plan.
I then arranged to meet with Sara and her psychiatrist to discuss her increased anxiety and confusion and the
compulsive shopping. I requested a referral for neuropsychiatric testing to assess possible cognitive changes or
decline in functioning. A test was scheduled, and it indicated some cognitive deficits, but at the end of testing, Sara
told the psychologist who administered the tests she had stopped taking her medications for depression. It was
determined Sara’s depression and discontinuation of medication could have affected her test performance and it
was recommended she be retested in 6 months. I suggested a referral to a geriatric psychiatrist for Sara, as she
appeared to need more specialized treatment. Sara’s psychologist was in agreement.
Because they had both stated that they did not want to be removed from their home, I worked with Sara and
Stephanie as a team to address cleaning the apartment. All agreed that they would begin working together to clean
the house for 1 hour a day until arrangements were made for additional help from family members. In an attempt
7
SESSIONS: CASE HISTORIES • THE PARKER FAMILY
to alleviate Sara’s anxiety around throwing out the items, I suggested
Key to Acronyms
using three bags for the initial cleanup: one bag was for items she
could throw out, the second bag was for “maybes,” and the third
APS: Adult Protective Services
was for “not ready yet.” I scheduled home visits at the designated
ICM: Intensive Case Management
cleanup time to provide support and encouragement and to interservices
vene in disputes. I also contacted Sara’s treatment team to inform
SSD: Social Security Disability
them of the cleanup plans and suggested that Sara might need additional support and observation as it progressed. Jane notified me
that her two cousins were willing to assist with the cleanup, make
minor repairs, and paint the apartment. Jane offered to schedule a date that would be convenient for her and her
cousins to come and help out.
We then discussed placement for at least some of the cats, because six seemed too many for a small apartment.
Sara and Stephanie were at first adamant that they could not give up their cats, but with further discussion admitted
it had become extremely difficult to manage caring for them all. They both eventually agreed to each keep their
favorite cat and find homes for the other four. Sara and Stephanie made fliers and brought them to their respective
treatment programs to hand out. Stephanie also brought fliers about the cats to her place of employment. Three of
the four cats were adopted within a week.
During one home visit, Stephanie pulled me aside and said she had changed her mind—she did not want to
continue to live with her mother. She requested that I complete a housing application for supportive housing stating,
“I want to get on with my life.” Stephanie had successfully completed cashier training, and the manager of the supermarket was pleased with her performance and was prepared to hire her as a part-time cashier soon. She expressed
concern about how her mother would react to this decision and asked me for assistance telling her.
We all met together to discuss Stephanie’s decision to apply for an apartment. Sara was initially upset and had
some difficulty accepting this decision. Sara said she had fears about living alone, but when we discussed senior
living alternatives, Sara was adamant she wanted to remain in her apartment. Sara said she had lived alone for a
number of years after her husband died and felt she could adjust again. I offered to help her stay in her apartment
and explore home care services and programs available that will meet her current needs to remain at home.
8
The Logan Family
E
boni Logan is a 16-year-old biracial African American/Caucasian female in 11th grade. She is an honors
student, has been taking Advanced Placement courses, and runs track. Eboni plans to go to college and major
in nursing. She is also active in choir and is a member of the National Honor Society and the student council. For the
last 6 months, Eboni has been working 10 hours a week at a fast food restaurant. She recently passed her driver’s
test and has received her license.
Eboni states that she believes in God, but she and her mother do not belong to any organized religion. Her father
attends a Catholic church regularly and takes Eboni with him on the weekends that she visits him.
Eboni does not smoke and denies any regular alcohol or drug usage. She does admit to occasionally drinking
when she is at parties with her friends, but denies ever being drunk. There is no criminal history. She has had no
major health problems.
Eboni has been dating Darian for the past 4 months. He is a 17-year-old African American male. According to
Eboni, Darian is also on the track team and does well in school. He is a B student and would like to go to college,
possibly for something computer related. Darian works at a grocery store 10–15 hours a week. He is healthy and
has no criminal issues. Darian also denies smoking or regular alcohol or drug usage. He has been drunk a few times,
but Eboni reports that he does not think it is a problem. Eboni and Darian became sexually active soon after they
started dating, and they were using withdrawal for birth control.
Eboni’s mother, Darlene, is 34 years old and also biracial African American/Caucasian. She works as an adminis
trative assistant for a local manufacturing company. Eboni has lived with her mother and her maternal grandmother,
May, from the time she was born. May is a 55-year-old African American woman who works as a paraprofessional
in an elementary school. They still live in the same apartment where May raised Darlene.
Darlene met Eboni’s father, Anthony, when she was 17, the summer before their senior year in high school.
Anthony is 34 years old and Caucasian. They casually dated for about a month, and after they broke up, Darlene
discovered she was pregnant and opted to keep the baby. Although they never married each other, Anthony has
been married twice and divorced once. He has four other children in addition to Eboni. She visits her father and
stepmother every other weekend. Anthony works as a mechanic and pays child support to Darlene.
Recently, Eboni took a pregnancy test and learned that she is 2 months pregnant. She actually did not know
she was pregnant because her periods were not always consistent and she thought she had just skipped a couple
of months. Eboni immediately told her best friend, Brandy, and then Darian about her pregnancy. He was shocked
at first and suggested that it might be best to terminate. Darian has not told her explicitly to get an abortion, but
he feels he cannot provide for her and the baby as he would like and thinks they should wait to have children. He
eventually told her he would support her in any way he could, whatever she decides. Brandy encouraged Eboni to
meet with the school social worker.
During our first meeting, Eboni told me that she had taken a pregnancy test the previous week and it was positive.
At that moment, the only people who knew she was pregnant were her best friend and boyfriend. She had not told
her parents and was not sure how to tell them. She was very scared about what they would say to her. We talked
about how she could tell them and discussed various responses she might receive. Eboni agreed she would tell her
parents over the weekend and see me the following Monday. During our meeting I asked her if she used contracep
tion, and she told me that she used the withdrawal method.
Ebon...
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