Eric K. Mason
Family Counseling: Case Study
The following case study describes three different approaches for providing family counseling—namely, from the Structural, Strategic, and Brief-Solution Focused perspectives. The case study is based on a case history of a family, with which I was presented. Below I have listed the major issues and concerns for the family.
Issues and Concerns for Family
- Kay’s history of drug and alcohol abuse
- Kay’s pregnancy
- Conflict between Kay and her mother, Brenda
- Kay’s parenting abilities
- Kay’s relationship with her seven-year-old daughter, Renee
- Financial issues for Kay and her family
- Kay’s unemployment
- Housing for Kay and her children
- Renee’s relationship with her father
Kay is the family’s identified patient (IP). She has a history of poly-substance abuse (crack-cocaine, marijuana, and alcohol). Kay recently completed a 28-day inpatient, detoxification program, which was precipitated by her desire to be clean and sober during her pregnancy. She is approximately six months pregnant. To my knowledge, Kay is currently clean and sober.
Kay lives with her mother off and on, though her relationship with her mother is strained. Kay recently became unemployed. Her relationship with her unborn baby’s father recently came to an end, as well.
Kay has one daughter, Renee, who is seven-years-old. Kay’s mother, Brenda, stated that she is Renee’s primary caretaker. Renee’s sees her father rarely, mainly during the holidays. Kay reported a history of substance abuse in her family (grandfather, one aunt, and two uncles), but nothing else is known about the other members of her family (e.g., whether or not Kay has siblings).
After completing her 28-day detoxification program, Kay presents with a desire to engage in family counseling. Brenda and her daughter have also agreed to participate in family counseling. The following section addresses the family’s issues and concerns from the perspective of structural family therapy. Some of the information provided below will be inferred for the sake of describing a viable scenario for structural family therapy. In other words, some liberty is taken, as the case history only provided a limited amount of information.
Structural Family Therapy
The family is currently seeking help as a result of Kay’s substance abuse. Neither Kay nor her family have received family therapy prior to their visit. Kay received therapy and counseling while in the 28-day detoxification program.
Kay’s mother, Brenda, reports doing her best to help her daughter. This includes trying to “motivate” Kay to stop using by “constantly informing her of the dangers drugs, and letting her know that she is not being a good parent to her daughter.” Brenda also states that she “sticks her neck out for Kay to keep her out of legal trouble; covered for her so that she would not lose her job; loans her money; watches over her daughter (Renee), so that social services will not take her away.” Brenda went on to say that “she has always had to take care of Kay, and that she wishes Kay would just grow up. I’m getting old, and I don’t make much money working as a cashier. I love my granddaughter, but I didn’t plan on becoming a mother again at my age.”
Kay is the symptom bearer of the family. Per Brenda, Kay began using drugs and getting into trouble in high school when Brenda and her husband (Kay’s father) were divorced. Brenda felt that her ex-husband is partially to blame, as “he wanted to be Kay’s friend instead of her parent.” During the assessment, Brenda claimed that Kay has always kept her preoccupied with her problems and that Kay is probably the reason she never got remarried.
Kay admits to using drugs in high school, but only recreationally. She stated that she did not start to develop a problem till about two years ago. Kay feels that she did not get into a lot of trouble in high school, but that her mother always overreacted to little things. Kay, admits, however, that she did not like school and that she would have rather hung out and partied with her friends than do well in school. She never graduated, as a result
According to Kay, she began to develop a drug problem after her husband left her and Renee about two years ago. Kay stated that she could not afford to live on her own and had to move back in with her mother. She feels that her mother’s constant nagging about her poor decisions (such as “running with the wrong crowd,” dropping out of school, etc) made her depressed and led to her going out to bars and drinking. Kay stated that she soon made new friends and found a new boyfriend. Kay revealed that her new friends and boyfriend used drugs more than just recreationally, and that she was soon doing the same. Kay confessed to having a “full-fledged drug problem” after about two years of regular use.
Kay is worried that her drug problem will become even worse, since the father of her unborn child recently left her. Kay is also bothered by potential birth defects her unborn child may suffer if she continues to use. She states that she does not want to lose her seven-year-old daughter, and that she would like “to get out from underneath her mother’s thumb.”
Kay has no desire to reunite with the father of her unborn child or any of her old friends. She feels that they are bad influences for her, as they continue to use drugs. Kay is an only child and there are no other family members involved in Kay’s life (besides Brenda and Renee). Kay wishes her father was still alive, because she would have the option of living with him instead of her mother (Kay’s parents were divorced). Kay said that her father was always more supportive than her mother, even though he was not around a lot. Brenda visits with her siblings on holidays, but otherwise has very little contact with any family member outside of Kay and Renee.
Renee stated that her mother was gone a lot and that she wished she was around more often. She also expressed a desire to see her father more often. She confirmed that her grandmother was her predominate caretaker by stating that she took her to school, washed her clothes, made food for her, etc. Renee appeared well adjusted, saying that she liked school and had many friends.
One can see from the family map that Kay’s position in the family needs to be restructured. Kay has assumed a position in the family that places her in a sibling-like relationship with her own daughter. Assuming Kay maintains her sobriety, the goal would be to restructure the family so that Kay is occupying more of a mother role to her daughter. In so doing, the connection between Kay and her daughter would also need to be strengthened, while the connection between Brenda and Renee may need to be normalized (i.e., reduced from a strong connection to a typical connection).
Brenda is obviously the dominant figure in the family. As long as Kay is living at Brenda’s home, she may remain the dominant figure to a certain extent. However, it would be more appropriate to have Kay and Brenda be of more equal dominance. This would allow them to cooperate and function as the parental unit to Renee. To increase this cooperation, the conflict between Kay and Brenda would need to be reduced as much as possible.
Under ideal circumstances, Renee’s father, perhaps, should be invited to family therapy. Although he is minimally involved in Renee’s life, it may be appropriate to try to increase his parental role (provided he is not abusive, etc.). During the first few family therapy sessions, more information about Renee’s father should be discovered.
Kay’s symptoms function in a way that binds the family together. As long as Kay is having problems, Brenda may remain over involved in her life. Brenda’s enabling behaviors, which include providing Kay with money, taking care of Renee, and helping her to avoid the negative consequences of her drug use also serves to keep Brenda over involved. Perhaps, Brenda wants to be needed and wants to feel as if she still serves an important role in Kay’s, as well as Renee’s life.
The family is functioning reasonably well, given the circumstances. For example, Brenda is relatively supportive, and Kay is motivated to stop using. The family is receptive of help, with permeable boundaries. However, the boundaries between the family subsystems are more rigid, with Brenda wanting to maintain dominance over Kay and Renee (rather than allowing Kay to be the parental figure to Renee).
- Assigning Tasks: Have Kay spend more one-on-one time (without Brenda) with Renee. For example, doing activities together three times a week after Renee gets home from school (go to the park, roller skating, go to library, etc.). This would help to strengthen their connection, allow her to assume the parental role, while also decreasing the connection between Brenda and Renee.
- Marking Boundaries: In order to allow Brenda to assume the role of grandmother–instead of mother–to Renee, I would encourage Brenda not always to be available as a babysitter to Renee. For example, Brenda could agree to baby sit a maximum of three times per week. When she was not babysitting, she would be free to engage in other things, such as social activities (which may, in turn, decrease her desire to be overly involved in Kay’s life).
- Reframing: I would reframe Kay’s perception of her mother’s nagging as proof that her mother is very concerned about her welfare.
- New Talk: I would encourage an enactment in which Brenda reframed her nagging and instead express her hopes that Kay and Renee would live a happy, productive, and fulfilling life.
- Unbalancing: I may somewhat align with Kay to increase her power within the family.
- Education and Guidance: I would inform the family of potential withdrawal symptoms and methods for maintaining sobriety, such as attending AA or NA, attending individual counseling, possible relapse triggers, etc.
Strategic Family Therapy
The assessment process for strategic family therapy would be similar to the one for structural family therapy (above). In using strategic family therapy, I would focus more on Kay’s symptoms (i.e., her drug and alcohol abuse), rather than restructuring the family. In other words, if Kay’s problems were “fixed” then the family problems may diminish, as well. Therefore, the goal would be for Kay to maintain her sobriety. The family’s goal would be to help Kay maintain her sobriety.
In using strategic family therapy with Kay and her family, I feel that using straightforward directives would be the best approach. Some techniques, such as prescribing the symptom, would not be appropriate for Kay, due to her pregnancy. The straightforward directive I would use follow.
- Straightforward Directives: These directives would be aimed at keeping Kay clean and sober. This may include encouraging Kay and Brenda to attend support groups, such as AA or NA, as well as attend individual counseling and continue family therapy. Other directives could include having Kay attend parenting classes and having Kay be more involved in Renee’s life (encouraging Kay to participate in activities with Renee). I would also encourage the family to work together to ensure Kay’s sobriety. That is, I would help Kay and Brenda develop the best possible plan for ensuring Kay’s sobriety.
Solution-Focused Brief Therapy
Solution-Focused Brief Therapy is very hopeful in nature. In using this approach, I would encourage Kay and Brenda to realize that change is a possibility. In so doing, they would be allowed to focus on a hopeful future, rather than dwelling on a regrettable past.
First, I would find out what Kay and her family want out of life. Most likely, Kay would want to maintain her sobriety, be a good parent to Renee and her unborn child, and establish financial independence (which would allow her to attain her own housing). Secondly, I would look for what is working for Kay. She is currently clean and sober, which is very positive and hopeful. What is more, she has a strong desire to maintain her sobriety, which is why she decided to come to family therapy. Attending therapy and counseling has obviously helped Kay become clean and sober, so I would encourage her to continue to be involved in therapy and counseling, as well as support groups, such as AA or NA. Thirdly, I would discourage Kay from engaging in things that did not work for her (e.g., associating with her old friends or significant others who use, going out to bars, and relying on Brenda too much).
- Getting by Questions: What has worked for Kay in the past? What motivated her to attain sobriety? How has she maintained her sobriety so far? How has she been financially independent in the past? She was employed until recently. How did she get her last job?
- Scaling Questions: On a scale from one to ten, how would you rate your current problems, such as drug use and conflict with Brenda? One being no problem, ten being a huge problem.
- Exception Questions: When are you better able to cope with your problems? That is, when does Kay get along better with her mother, and when is it easier for her to avoid using drugs? I would encourage her to be specific (i.e., specific locations that allow her to cope more easily, times when she does not want to use, and people who do not encourage her to use).
- Miracle Question: I would ask Kay what her life would look like if she woke up tomorrow and all her problems were solved. Kay may answer that she would have no desire to use drugs, be financially independent, and be a better mother.
- The Task: Have Kay and Brenda identify (between sessions) times that they were not experiencing conflict with one another.
- The First Step: Have Kay and Brenda identify the first thing they would notice that was different when Kay and the family were back on track.
The case study above identified and described three different approaches in which to provide family therapy. First was structural family therapy which had the goal of restructuring the family dynamic in order to make it more flexible. Secondly, strategic family therapy dealt primarily with treating the symptoms of the identified patient. Lastly, solution-focused brief therapy focused mainly on what was currently working in the family, as well as on hopeful solutions for the future.