Running head: CASE CONSULT FAMILY PAPER

Jennifer Bertocchi

Case Consult Family Paper

SSWG 8102 Section 002

Clinical Practice with Individuals, Families, and Groups II

Mondays 5:30 – 8:00 PM

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CASE CONSULT FAMILY PAPER
FAMILY DESCRIPTION

The purpose of this paper is to practice planning and implementing an assessment and

intervention strategy for a family experiencing conflict and distress that draws on one of the

family therapy models discussed in class. The family in this case consult paper will be referred to

as the Everglade (E) family and is based off the case study “Long Distance Family Conflict,” by

the Council on Social Work Education (n.d.).

Mr. Everglade – also referred to as Mr. E throughout this paper – was referred to

counseling and social work services by his oldest daughter, Theresa. Mr. E is an 84-year-old,

Caucasian man who is currently living alone on his diary farm in a small farming town outside of

Lancaster, PA, where he has lived for over forty years. Six months ago, Mr. E’s wife passed

away suddenly from a stroke. Before her death, Mr. E had spent the last several years of his

wife’s life serving as her primary caregiver. Per his daughter Theresa’s reports, Mr. E struggled

greatly with the loss of his wife, and reportedly became more socially isolated after her death. In

addition to becoming more depressed and isolated, Theresa also reports that her father’s physical

health has begun to decline, and he is currently being advised not to work on his farm or drive

anymore. Theresa also reports that Mr. E is “becoming more confused, neglecting his personal

hygiene, and allowing the home to become cluttered and dusty” (Council on Social Work

Education, n.d., p. 1). He is also easily offended by suggestions that he might need help caring

for himself, as he reports that he has done a good job caring for his family all this time and

therefore can continue to take care of himself.

Mr. Everglade and his wife had six children together – all of them are grown now with

families of their own. Three of the adult children live out of state, and the other three (including

Theresa) live within an hour’s drive of their parents’ home. Theresa – who appears to be her
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father’s unofficial/informal caregiver – comes to Mr. E’s house once a week to help with chores,

groceries, and provide some company. Theresa reports conflict and disagreements among her

and her siblings regarding what is best for their father’s care. Theresa and Mr. E’s oldest child,

John, want Mr. E to move into a retirement community so that he will be socially engaged and

have meals prepared for him, but the younger three siblings (who all live out-of-state) are

hesitant to create another loss in their father’s life by “ripping him out of his home and placing

him somewhere he does not want to be.” Per their reports, they do not want to upset or anger

their father unless it is absolutely necessary, and currently Mr. E does not see his health as poor

enough to warrant moving.

Theresa also reports that there is a lot of arguing over who gets to make decisions for

their father. John, who is the oldest, seems to assume that it is his duty to be the decision maker

among the siblings, but Theresa argues that she has been the one providing most of his hands-on

care currently and visits with him the most. During the initial family session with everyone

present, there were a handful of jabs made towards the younger children who moved out-of-state

for not maintaining better contact with their father and for not offering more direct, hands-on

support for his care. The younger siblings then argued back that their older siblings are too

controlling, and always just assume that they know what is best for everyone. After this

encounter, Mr. E expressed feeling the most frustrated because he felt like none of his children

were consulting him on what he wanted to do with his life.

After the first session with the family, some presenting issues were immediately clear,

which will be discussed in the next section. However, strengths and resources of the Everglade

family were also apparent. First, this family cares deeply about the health and well-being of one

another, as evidenced by their willingness to try family therapy. And while their current
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communication styles appear to be fractured and passive-aggressive, they all presented with a

willingness to be open-minded to change and new perspectives. Additionally, in a community

context, the family has access to other potentially helpful resources and support. For example,

Mr. E and his family used to be active members of a local church, and Mr. E currently rents his

farm out to local farmers – both offer a small but local sense of community outside of the

immediate family which can offer additional support.

PRESENTING ISSUES OF THE FAMILY

There are a handful of presenting issues that are present within the Everglade family,

both on the individual and the family level. For Mr. E, there are concerns about his physical and

cognitive health – specifically his ability to continue living on his own. This is likely causing

anxiety for both him and his children. He also appears to be struggling with depression – likely

due to the loss of his wife, increased social isolation, and the loss of meaningful self-roles (like

caregiver, husband, father, and worker). He also appears to hold some resentment or pain

towards distant or cut-off relationships with his adult children, and that is being expressed as

anger towards his children who he now sees as being “more intrusive.” On a family level, there

appears to be questions about new, transitioning family roles, as well as conflicts embedded in

the old roles (i.e., parent-child positions and sibling positions). Each family member is also likely

still learning how to cope with the grief and loss of their mother, and this likely affects their

relationships with others in the family. There is also likely some anxiety felt by all the children

regarding the basic self-care capacity and safety of their father living alone. And in trying to

cope with all this anxiety, grief, anger, etc., the siblings and the father have lost their ability to

communicate effectively with each other and differentiate.

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Based off these presenting issues, I would plan to address four treatment goals during our

time together. First, I would help the family learn better communication skills so they can more

effectively communicate their needs and concerns to one another, as well as learn to set healthier

boundaries. We would also work on achieving greater levels of differentiation for each family

member, so there can be less blaming, decreased anxiety and reactivity, and increased

responsibility for self in their family emotional system. We would also work to increase the

families’ insight and understanding of their problems and the resources available to them to help

lower the anxiety that is currently present in the family system. Lastly, I would like to work

individually with Mr. E to support him through a difficult life transition and help him learn to

accept new family roles. More specifically, we would work on finding a balance between his

emotional and rational thinking and help him learn to differentiate and function effectively both

within and apart from his family.

LITERATURE REVIEW

In a study by Victor and colleagues (2000) which was cited in Mason’s (2014) literature

review, it was found that older aging adults “consistently ranked relationships with family and

friends second only to health as the most important area of life” (Mason, 2014, p. 14). However,

additional research has also shown that as older adults continue to decline in health and cognitive

ability, they tend to lose contact with friends and become more dependent on the family for

companionship (Mason, 2014). When older adults do not feel supported by their families, they

report increased stress and isolation as a result. This appears to be a similar issue with Mr. E,

who stopped attending church regularly when his wife passed away and has since become more

isolated and depressed, but also reports feeling frustrated and confused as to why his older

children would want to put him in a nursing home. Qualls (1999) found that there is often a great
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deal of interpersonal tension and inflexibility within families when they need to make decisions

regarding older adults’ care (i.e., deciding on nursing home placement), and this

tension/inflexibility makes it more difficult for families to “solve problems, relate intimately

together, and meet individual needs” (p. 977), as appears to be the issue with the Everglade

family. Similarly, Mason (2014) found that adult children often struggle to agree on new family

roles regarding positions of power and decision-making, and therefore these transitions tend to

affect the dynamics of the whole family.

Given the presenting issues of the Everglades, I decided I would utilize family emotional

systems theory – also known as family systems theory – to leverage change at the individual and

family level for this family. This theory felt contextually relevant to this family because family

emotional systems theory “provides a comprehensive conceptual framework for understanding

how emotional ties within families…influence the lives of individuals in ways they often fail to

appreciate and may tend to minimize” (Walsh, 2013, p. 113). Thus, this theory allows me to

work with Mr. E as an individual client but in a family context, understanding that issues related

to his well-being often must involve the family. In other words, interventions utilizing family

systems theory will allow me to be both patient-centered – considering the needs and concerns of

Mr. E – while also allowing me to be family focused and address the problems regarding the

family’s dysfunction. Research has shown that normal life transitions can create problems in

functioning for individuals and families, and as families enter new stages of transition, they may

have trouble coping and adjusting. This is often the case when families deal with grief/loss and

must identify new family and individual roles as a result, as is the current case with the

Everglade family. Walsh (2013) argues that family systems theory can be especially effective in

helping family members “understand the heightened anxiety and emotional tumult that creep into
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a family with aging or dying members” (p. 131), which would be both relevant and beneficial to

the Everglade family in their new life transition.

As both Brown (1999) and Qualls (1999) explain, family emotional systems theory

examines the interactions within families that are creating problems and works to assist all

family members towards greater levels of differentiation and insight so they can communicate,

express themselves, restructure roles and subsystems as necessary, and function more effectively

- both individually and as a family unit. According to Sutphin and colleagues (2013), the causes

of a family’s problems are circular, and therefore utilizing a theoretical approach that alters

communication patterns and interactions and redefines family roles and subsystems will

empower the family to listen and support each other in their day-to-day needs. Lastly, I chose

this theoretical model because, as Walsh (2013) explains, family systems theory offers broad

interventions which can be altered to meet unique family concerns and have been found to be

appropriate when working with families concerned about elderly members, as well as family

experiencing problems related to depression, fusion, and emotional cutoff – all of which the

Everglade family appears to present with. The Everglade family also has some current structural

stability, which is necessary for me to be able to help family members explore any patterns of

behavior that may be contributing to their presenting problems (Walsh, 2013).

IMPLEMENTATION PLAN

While I would want to work with Mr. E and all six of his adult children as much as

possible, that is unrealistic given that three of his children live out-of-state and all his adult

children now have families, jobs, and lives of their own. Knowing that therapy is never meant to

be an additional burden, I would ask that the entire family agree on one day, once-a-month for

six months, to meet either in person or over Zoom for a two-hour family session. During those
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large group family sessions, I would focus on systems issues, like communication skills,

detriangulation, lowering system anxiety, role restructuring, boundary setting, and increasing

emotional and rational insight for all family members. I would also want to work with the family

in various subgroups and individually as necessary and appropriate. For example, I would

continue to work with Mr. E individually and weekly for grief counseling, differentiation, and

learning adjustment skills to a new life transition of old age. Together, we could also continue to

assess and monitor his psychological symptom status to help him and his family make

appropriate decisions regarding his self-care capacity and safety. I would also try to work

individually with Theresa for a few sessions (perhaps just two or three sessions), using that time

to discuss her issues related to setting boundaries, feelings of guilt for her father’s health and

loneliness, enmeshment, and emotional distance/resentment towards her siblings. I would like to

have a few subgroup sessions during the six-months working together that would allow me to

work with the out-of-state siblings and a subgroup working with the siblings who live nearby –

sometimes mixing members of both groups together to form a new, small group. I would utilize

these small subgroup sessions to help teach all the adult children about detriangulation, better

communication skills, and restructuring skills. In doing so, I would disrupt some of the triangles

the family currently has and be opening them up to new, more functional alliances. In all these

various interactions with family members, I would be mindful to ask questions that encourage

the members to discuss among each other while I sit on the sidelines and support.

There are a few strategies Walsh (2013) discusses in his review of family emotional

systems theory that I believe would be particularly useful when working with the Everglade

family to help them achieve better communication, function, and insight. First, is the use of

genograms. According to Walsh (2013), genograms lay out family relationships, patterns, and
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problems more clearly to members because they allow us to see visually the current family

structure (including roles, rules, triangles, and boundaries) and the impact of life events, life

transitions, and relationship patterns across generations. In our first full family session together, I

would want the Everglade family to create their genogram, and then look for where and how

triangles and roles operate within the family. This would ideally lead to increased insight into

how certain behavior roles and alliances support or inhibit family member functioning. For

example, Brown (1999) discusses the importance of family members recognizing and

understanding sibling positions, and how their roles as the oldest, middle, or youngest child may

limit them or cause friction within the family. This may explain why John (the oldest) feels he

must be the decision-maker and does not consult his younger siblings on issues regarding their

father’s health and finances, and why the younger siblings feel comfortable letting John have

such control. In recognizing and discussing such roles, the family members are “encouraged to

consider how assumptions about relationships are fueled by their sibling role experience” and

may open space for members to think beyond the limitations of their own family position to offer

their own ideas for enhancing family functioning (Brown, 1999, p. 6).

Another similar strategy that could build off the work of the genogram would be

detriangulation. Once the family is aware of their triangles and alliances, I would encourage the

family to try new ones that may be more functional. In all group sessions, I would encourage the

family members to speak directly to one another, practice using “I” statements, and even

experiment with role reversals. By doing this, I believe I would be teaching the family members

more effective communication skills as well as teaching them empathy and insight about why

other members feel and behave the way that they do. For example, I would encourage the

siblings to take turns being a caregiver, and if possible, have one of the siblings fill in Theresa’s
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role for providing hands-on support with Mr. E one weekend. This may help show the other

siblings the stress Theresa has felt lately and may explain why she has felt resentful towards her

siblings for not offering more direct support aside from the occasional phone call. Similarly, I

may ask some of the more distant children to put themselves in their father’s shoes and think

about how a lack of communication from them may lead Mr. E and the others to make

assumptions that are not true but feel valid and hurtful. According to Brown (1999), the goal of

the strategy of detriangulation is for family members to think about other ways of

communicating a neutral position and to find a less reactive response in the face of the other’s

anxiety. This strategy also leads to reflective discussions that work to increase insight about “the

effects of relationships on one’s personality and behavior” (Walsh, 2013, p. 125), which would

be beneficial for all members of the Everglade family to recognize and understand.

A final strategy from family emotional systems theory that I would want to implement

with the Everglades would be continuing to work individually with Mr. E. Brown (1999)

reminds clinicians that clients should feel in charge of their own change efforts, but may need

additional support, input, and coaching while attempting to develop greater differentiation from

their families. Walsh (2013) adds that once a client can observe and recognize their roles in

triangles and detriangulate, they have the space to develop new or different relationships with

others. In the case of Mr. E, this could mean developing improved relationships with his more

distant children, or perhaps creating new relationships with people outside of his family unit –

perhaps members of his old Church or new people he would meet if he were to move into

retirement community. By supporting Mr. E’s efforts to learn to differentiate and find balance

between his rational and emotional thinking, both within and apart from his family, it is my hope

that he will develop more positive feelings about his ability to have an independent existence.
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References

Brown, J. (1999). Bowen Family Systems Theory and Practice: Illustration and Critique. Journal

of Family Therapy, 20(2), 94-103.

Council on Social Work Education. (n.d.). Case Study: Long Distance Family Conflict.

Mason, D. J. (2014). The Family's Voice: Caregiving for an Older Adult (Doctoral dissertation,

St. Catherine University, 2014) (pp. 1-58). St. Paul, MN: SOPHIA Master of Social

Work Clinical Research Papers.

Qualls, S. H. (1999). Family Therapy with Older Adult Clients. Psychotherapy in Practice,

55(8), 977-990.

Sutphin, S. T., McDonough, S., & Schrenkel, A. (2013). The Role of Formal Theory in Social

Work Research: Formalizing Family Systems Theory. Advances in Social Work, 14(2),

501-517.

Walsh, J. (2013). Family Emotional Systems Theory. In Theories for Direct Social Work

Practice (3rd ed., pp. 113-145). VA: Cengage Learning.