Shore Case Study Case Study

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Categories and Phases of Loss and Grief for Nancy

Diagnostic Statement for Nancy

Nancy is obese and reports feeling anxious and depressed. Nancy has gained 15 pounds does not sleep well, has low concentration ability and is forgetful. Nancy has a social phobia and exhibits some signs of paranoid schizophrenia. In addition, Nancy has a back injury, which contributes, to her general feeling of ill health and results in not getting the exercise she needs. Nancy is a chain smoker. Nancy feels that she has lost control of her life. Nancy's son Michael has asthma. It appears that Nancy's husband suffers from some type of behavior disorder and is likely somewhat mentally retarded.

DSM-IV-TR (2000) Diagnosis

The multiaxial assessment includes analysis on the following five stated Axis:

(1) Axis 1: clinical disorders, pervasive developmental disorders, learning, motor skills and communication disorder

296.xx Major Depressive Disorder

301.0 Paranoid Personality Disorder

300.23 Social Phobia - generalized

(2) Axis 2: Personality disorders mental retardation;

(3) Axis III -- General medical conditions;

Obese

Back pain due to injury

(4) Axis IV: psychosocial and environmental problems

Husband does not hold down a job.

Problems with adopted teen aged daughter

12-year-old son behavioral problems in school.

This axis is for the reporting of psychosocial and environmental problems Axis IV is for reporting psychosocial and environmental developed

Axis V: Global assessment of functioning (GAF)

The functioning of this client is impacted by her home environment in which there is a great deal of argument among family members.

Client's obesity has her experiencing social phobia.

Problems in coping with teenage daughter.

Husband: delusional disorder

Family Therapy examines the symptoms of the family as they are occurring in the larger family context. Special techniques of family therapy include use of the genogram, which is a family tree that is constructed by the therapist that looks at past relationships and events and their impact on the individuals' current emotional technique. Systemic interpretation views depression as a symptom a problem in the larger family. Communication Training focuses on dysfunctional communication patterns within the family and correction of these after they are identified.

III. Treatment Plan

The family in this study will be assessed through use of the Family Sense of Coherence (FSOC) and Family Adaptation Scales (FAS). This instrument measures the sense of coherence and sense of adaptation of families. The FSOC and FAS are jointly developed 26-item and 10-item scales, which are designed for measuring the family, sense of coherence and sense of adaptation to both internal an external environment. Family coherence is defined "as an orientation that expresses confidence that internal and external stimuli and structured and predictable, resources are available to meet demands from those stimuli and the demands are worthy challenges." (Antonovky and Sourani, 1988) The theory that underlies both measures is that the higher the sense of family coherence, the treatment, the adaptation or satisfaction with its adaptation to the family's internal and external environments." (Antonovky and Sourani, 1988) The FSOC is scored on sliding scales from 1 to 7. Higher scores indicate a strong sense of coherence. Reverse score items are 1,3,5,6,9,10,13,15,18,21,22,24,25 so that 7 is always a higher score of coherence. The total scale score is calculated by summing all items after reverse scoring. The reliability of this scale is reported that both measures "have good to excellent internal consistency." (Antonovky and Sourani, 1988) The following figure displays the questions in the FSOC instrument.

Figure 1 -- FSOC Instrument

IV. Structural Family Therapy

Structural Family Therapy is the model chosen for treatment strategy. Structural family therapy conceptualizes the family as a living open system in which the parts of "functionally interdependent in ways dictated by the supraindividual functions of the whole. As an open system the family is subjected to and impinges on the surrounding environment. This implies that family members are not the only architects of their family shape; relevant rules may be imposed by the immediate group of reference or by the culture in the broader sense." (Antonovky and Sourani, 1988) The family as a living system is additionally in a constant state of transformation with transactional rules evolving over time as the family members negotiate the specific arrangements that are more "economical and effective for any given period in its life as a system. This evolution, as any other, is regulated by the interplay of homeostasis and change." (Antonovky and Sourani, 1988) Homeostatis is reported to designate the "patterns of transactions that assure the stability of the system, the maintenance of its basic characteristics as they can be described at a certain point in time; homeostatic processes tend to keep the status quo." (Antonovky and Sourani, 1988 ) It is reported that when viewed from the perspective of homeostasis," individual behaviors interlock like the pieces in a puzzle, a quality that is usually referred to as complementarity.

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" (Antonovky and Sourani, 1988 ) Change is reported to be "the reaccomodation that the living system undergoes in order to adjust to a different set of environmental circumstances or to an intrinsic developmental need. Marriage, births, entrance to school, the onset of adolescence, going to college or to a job are examples of developmental milestones in the life of most families; loss of a job, a sudden death, a promotion, a move to a different city, a divorce, a pregnant adolescent are special events that affect the journey of some families. Whether universal or idiosyncratic, these impacts call for changes in patterns, and in some cases -- for example when children are added to a couple -- dramatically increase the complexity of the system by introducing differentiation." (Antonovky and Sourani, 1988 ) The spouse subsystem is reported to coexist with "parent-child subsystems and eventually a sibling subsystem, and rules need to be developed to define who participates with whom and in what kind of situations, and who are excluded from those situations. Such definitions are called boundaries; they may prescribe, for instance, that children should not participate in adults' arguments, or that the oldest son has the privilege of spending certain moments alone with his father, or that the adolescent daughter has more rights to privacy than her younger siblings." (Antonovky and Sourani, 1988) It is reported that if one were to follow the family process over a brief time it is likely that one will be witness to the "homeostatic mechanisms at work and the system in relative equilibrium; moments of crisis in which the status quo is questioned and rules are challenged are a relative exception in the life of a system, and when crises become the rule, they may be playing a role in the maintenance of homeostasis. Now if one steps back so as to visualize a more extended period, the evolvement of different successive system configurations becomes apparent and the process of change comes to the foreground. But by moving further back and encompassing the entire life cycle of a system, one discovers homeostasis again: the series of smooth transitions and sudden recommendations of which change is made presents itself as a constant attempt to maintain equilibrium or to recover it." (Antonovky and Sourani, 1988) It is additionally reported in regards to conflict avoidance that the higher levels of this avoidance is seen in enmeshed families where the extreme sense of closeness, belonging, and loyalty minimize the chances of disagreement -- and, at the other end of the continuum, in disengaged families, where the same effect is produced by excessive distance and a false sense of independence. In their efforts to keep a precarious balance, family members stick to myths that are very narrow definitions of themselves as a whole and as individuals -- constructed realities made by the interlocking of limited facets of the respective selves, which leave most of the system's potentials unused. When these families come to therapy they typically present themselves as a poor version of what they really are." (Antonovky and Sourani, 1988) The therapist has to determine the position and function of problem behavior. AS well, the therapist must diagnose the structure of the perception of the system in regards to the problem.

The focus of family structural therapy is the current supportive relation between system and problem behavior. This model shared the idea of other systemic approaches that knowing the origins of a problem is not relevant for the process of therapeutic change. This model focuses on the "…current supportive relation between system and problem behavior. The model shares with other systemic approaches the radical idea that knowledge of the origins of a problem is largely irrelevant for the process of therapeutic change. The identification of etiological sequences may be helpful in preventing problems from happening to families, but once they have happened and are eventually brought to therapy, history has already occurred and cannot be undone. An elaborate understanding of the problem history may in fact hinder the therapist's operation by encouraging an excessive focus on what appears as not modifiable." (Antonovky and Sourani, 1988) This therapy model is stated to….....

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