This paper presents a clinical case study and treatment plan for a family experiencing multiple psychosocial stressors, including grief, mental health challenges, and interpersonal conflict. Using a DSM-IV-TR multiaxial diagnostic framework, the paper identifies major depressive disorder, social phobia, and paranoid personality disorder in the primary client. The treatment plan employs the Family Sense of Coherence (FSOC) and Family Adaptation Scales (FAS) to assess family functioning. Structural Family Therapy is selected as the primary intervention model, with Transgenerational Family Therapy incorporated as a complementary approach. Key therapeutic strategies—including joining techniques, reframing, genogram use, and differentiation of self—are outlined alongside cultural competency considerations and grief-focused objectives.
The primary client is obese and reports feeling anxious and depressed. She has gained 15 pounds, does not sleep well, and has low concentration and forgetfulness. She has a social phobia and exhibits some signs of paranoid schizophrenia. In addition, she has a back injury that contributes to her general feeling of ill health and prevents her from getting the exercise she needs. She is a chain smoker and feels that she has lost control of her life. Her son has asthma, and her husband appears to suffer from some type of behavioral disorder consistent with mild intellectual disability.
The DSM-IV-TR (2000) multiaxial assessment includes analysis across five axes:
Axis I – Clinical Disorders: 296.xx Major Depressive Disorder; 301.0 Paranoid Personality Disorder; 300.23 Social Phobia (generalized).
Axis II – Personality Disorders and Intellectual Disability: Relevant personality disorder features and possible intellectual disability in the husband.
Axis III – General Medical Conditions: Obesity; back pain due to injury.
Axis IV – Psychosocial and Environmental Problems: Husband does not maintain stable employment; problems with an adopted teenage daughter; 12-year-old son exhibiting behavioral problems at school. This axis is used for reporting psychosocial and environmental problems that may affect the diagnosis, treatment, or prognosis of mental disorders.
Axis V – Global Assessment of Functioning (GAF): The client's functioning is significantly impacted by her home environment, which involves frequent arguments among family members. Her obesity contributes to social phobia, and difficulties coping with the teenage daughter further strain her functioning. The husband presents with features consistent with a delusional disorder.
Family therapy examines the symptoms of the family as they occur within the larger family context. Special techniques include the genogram—a family tree constructed by the therapist to examine past relationships, events, and their impact on current emotional functioning. Systemic interpretation views depression as a symptom of a problem in the larger family system. Communication training focuses on identifying and correcting dysfunctional communication patterns within the family.
The family in this study will be assessed using the Family Sense of Coherence (FSOC) and Family Adaptation Scales (FAS). These instruments measure the sense of coherence and sense of adaptation of families. The FSOC and FAS are jointly developed 26-item and 10-item scales designed to measure the family's sense of coherence and its sense of adaptation to both internal and external environments. Family coherence is defined "as an orientation that expresses confidence that internal and external stimuli are structured and predictable, resources are available to meet demands from those stimuli, and the demands are worthy challenges" (Antonovsky & Sourani, 1988).
The underlying theory holds that the higher the family's sense of coherence, the greater its adaptation and satisfaction with its internal and external environments (Antonovsky & Sourani, 1988). The FSOC is scored on sliding scales from 1 to 7, with higher scores indicating a stronger sense of coherence. Reverse-scored items are numbers 1, 3, 5, 6, 9, 10, 13, 15, 18, 21, 22, 24, and 25, so that 7 always represents the highest coherence score. The total scale score is calculated by summing all items after reverse scoring. The reliability of both measures has been reported as having "good to excellent internal consistency" (Antonovsky & Sourani, 1988).
Structural Family Therapy is the model chosen for the treatment strategy. Structural family therapy conceptualizes the family as a living open system in which the parts are "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" (Antonovsky & Sourani, 1988).
The family as a living system is also in a constant state of transformation, with transactional rules evolving over time as family members negotiate 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" (Antonovsky & Sourani, 1988). Homeostasis is described as 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" (Antonovsky & Sourani, 1988). 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" (Antonovsky & Sourani, 1988).
Change is described as "the reaccommodation 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" (Antonovsky & 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" (Antonovsky & Sourani, 1988).
If one observes the family process over a brief period, one is likely to witness "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" (Antonovsky & Sourani, 1988). In regard to conflict avoidance, higher levels are seen in enmeshed families, where an extreme sense of closeness, belonging, and loyalty minimizes 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. Family members in these situations often cling to narrow self-definitions, and "when these families come to therapy they typically present themselves as a poor version of what they really are" (Antonovsky & Sourani, 1988).
The therapist must determine the position and function of problem behavior, as well as diagnose the structure of the family's perception of the problem. The focus of structural family therapy is the current supportive relationship between the family system and the problem behavior. This 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" (Antonovsky & Sourani, 1988).
This therapy model holds that the problems brought to therapy are "ultimately dysfunctions of the family structure" and therefore seeks a therapeutic solution in the modification of such structure. "This usually requires changes in the relative positions of family members: more proximity may be necessary between husband and wife, more distance between mother and son. Hierarchical relations and coalitions are frequently in need of a redefinition. New alternative rules for transacting must be explored" (Antonovsky & Sourani, 1988).
The primary goal of structural family therapy is "the restructuralization of the family's system of transactional rules, such that the interactional reality of the family becomes more flexible, with an expanded availability of alternative ways of dealing with each other. By releasing family members from their stereotyped positions and functions, this restructuralization enables the system to mobilize its underutilized resources and to improve its ability to cope with stress and conflict. Once the constricting set of rules is outgrown, individual dysfunctional behaviors, including those described as the presenting problem, lose their support in the system and become unnecessary from the point of view of homeostasis. When the family achieves self-sufficiency in sustaining these changes without the challenging support of the therapist, therapy comes to an end" (Antonovsky & Sourani, 1988).
Among the goals and objectives of the treatment plan is the aim for the primary client to accept that she will not be able to work in her former capacity again, and that her husband should be encouraged to maintain stable employment. Her husband was not expected from the beginning of their marriage to be the primary breadwinner, and because of this lack of expectation he was never grounded in his own professional goals. However, he has held the same job for some time and does appear to be progressing in his employment stability.
The client is still experiencing grief for the loss of her grandmother, as is her daughter, and the family needs therapeutic support in processing this grief. SIMO's categories of loss include four specific categories: (1) loss of a significant person; (2) loss of a part of the self; (3) loss of external objects; and (4) developmental loss. The client is presently experiencing both the loss of a significant person—her grandmother, who was a central stabilizing figure in her life—and the loss of a part of herself due to her inability to work in the same capacity as before. She has also experienced a loss of self related to her weight gain and the resulting negative body image. Accordingly, the treatment plan will include interventions and strategies to assist the client in developing a positive self-image despite the changes she has experienced.
Structural Family Therapy involves therapeutic change described as a process that "transpires in a special context, the therapeutic system…offers a unique chance to challenge the rules of the family" (Colapinto, n.d.). Colapinto notes that in practice, structural family therapy has been most commonly applied to families in which a child is the identified patient, though its application to adult-centered problems is an area of continued development (Colapinto, n.d.).
The focus of structural family therapy is the encouragement of proactive, healthy change for the family, emphasizing structure, subsystems, and boundaries. The therapist acts as a change agent in facilitating this reorganization. The therapist must also be sensitive to the family's multicultural perspectives, including cultural values, beliefs and practices, race, ethnicity, religion, gender, level of acculturation, customs, behavioral expectations, and socioeconomic status. Families often do not recognize that their structure is shaped by the cultural beliefs of their members. As Gladding (2007) writes: "In some families, structure is well organized in a hierarchical pattern, and members easily relate to one another. In others, there is little structure and few arrangements are provided by which family members can easily and meaningfully interact" (p. 203). To ignore cultural perspectives "is to devalue ethnic and ethical guidelines, offend the family or individual members, or it may exacerbate the original issue that brought them to therapy" (Colapinto, n.d.).
"Grief, self-image, and employment-related treatment goals"
"Joining, reframing, genogram, and multicultural strategies"
"Rationale for combined therapy model selection"
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