Considerations of systemic (family and relationship) issues in a counselling case study

Introduction

The systemic approach to psychotherapy involves drawing from different approaches of therapy and, it is often useful when counselling family groups and/or individual cases within such groups. The key factor of this approach is to acknowledge the individual as a relational being that can only be understood as part of a social system (Vossler, 2016). In this approach, the focus is shifted away from the individual and towards its relationships and social interactions within the family group. As such, there is no ‘right’ way to interpret a situation but, instead, different perspectives to understanding it; conflicts that emerge can often lead family members to be ‘stuck’ in their interactions, thus requiring counsellors to draw from multiple approaches towards the development of multiple hypotheses. In this essay, the fictional case study of Davide and the relationship with his sister Rosa will be discussed to illustrate how a systemic approach to therapy might be more advantageous than any individual approach in resolving their relational conflict. Starting with a description of the case study, a discussion of possible interpretations and a few hypotheses will follow, with a further discussion on how a systemic approach would benefit the resolution of this hypothetical scenario.

Case study

Davide is a 66 years old man originally from Palermo, Italy, and has lived in the suburbs of West London for the past 30 years. He has recently moved in with his sister Rosa following a particularly difficult divorce that separated him from his only son. Davide used to be a restaurant owner for the past 25 years but has been forced to retire as the business did not survive the competition from the high street. Davide and Rosa migrated together to the UK in the 1980s, and they are from a strict catholic upbringing. She is younger by 5 years and has had a history of alcohol and heroin abuse that started after their relocation. Rosa has been relying on Davide for financial support for most of her life as she was never able to hold a job long enough to be independent. They were raised by their single mother and never met their father as he abandoned the family soon after Rosa’s birth. Their mother then passed away when Davide was in his early twenties, and he has looked after his sister ever since. He had been divorced before when he married young, with a local girl from Palermo, and it ended abruptly when he discovered she became pregnant out of an affair entertained with a childhood friend of theirs. This was the single motivator behind their migration. He then remarried a woman of Caribbean origin he met in the UK, and together they had a child. Years later she filed for divorce for unreasonable behaviour due to Davide spending most of his time absorbed by his business and never taking any real-time off; he was working 7 days a week with shifts of 15 hours a day at the time. After moving to the UK, Davide has never developed any real friendships other than with his ex-wife. The closure of his business followed soon after the divorce; he briefly attempted to return to the workforce as a cabbie driver for an online company, but lacked motivation and stopped soon after. Around the same time, he started having heated arguments with Rosa almost daily. According to his GP, Davide has lost significant weight in the past 6 months and has developed irregular sleep patterns often being unable to sleep at all for days in a row. He has also been experiencing episodes of panic attacks whenever outside of the house. Davide also reported being in a depressed mood most of the time and now feels unable to leave his room as moving anywhere requires considerable effort. Moreover, for the past six weeks, Davide has been experiencing suicidal thoughts.

Case study discussion

To understand Davide’s situation, a sociocultural perspective is required as he is originally from a small town in the south of Italy, where certain values about what it means to be a man are instilled from an early age. Qualities such as being hardworking, upholding one’s honour and patriarchy are at the core of Italian masculinity both in Italy and outside of the country’s boundaries (Perrotte, 2000). Thus, his inability to fulfil such standards inherited from his culture would potentially influenced his self-esteem and overall mental well-being. With his manhood in question, Davide may be unable to adequately react and adapt to the adverse circumstances he finds himself in. His age is also a factor to consider as, in combination with his perception of himself as a hard-working man, he is unable to return to the workforce in a way that he sees dignified. Moreover, as both he and Rosa experienced being migrants, being outsiders without speaking the language at first, they would have encountered a degree of difficulty in integrating into communities that could have impacted their ability to develop meaningful social connections. As Rosa was dealing with her own struggle to integrate, her path towards alcohol and heroin abuse could be explained by having made the wrong type of connections within the framing of this forced change of environment. Davide’s relationship with his sister is also affected by the lack of a father figure in their lives. Studies indicate that such absence can impact the economic and social as well as emotional well-being of children throughout their lives (McLanahan, Tach & Schneider, 2013). Moreover, since the death of their mother, Davide would have filled the role of a parent in Rosa’s life, altering their sibling relationship. It must be noted that southern Italy, particularly Sicily, is known to promote a strict hierarchical family structure where women are to ‘know their place’ from an early age (Cucchiari, 1990). Due to having moved to the UK at the cusp of cultural change, Rosa may not have benefited from the shift in perception of her womanhood and change of expectations of her gender. By swapping the familiar role of the caring brother to that of the surrogate father, Davide may have imposed his direction in life to Rosa, limiting her choices. By behaving in an overly protective manner, he removed that level of relationship that exists between accomplice siblings that would have been crucial for the development of her independence. Without that crucial emotional support, replaced by Davide’s role as a guardian in Rosa’s life, she was perhaps unable to fully experience freedom in adulthood (Namyslowska & Siewierska, 2010). Rosa’s path towards alcohol and heroin abuse can be, therefore, seen as the logical adaptation to a circumstance that was not of her choosing. Similarly, Davide might have felt that he had no choice but to help his sister, fuelling further his sense of responsibility towards her. Often, acts of love can be misunderstood as an imposition of control when that love is not communicated adequately, as in the case of Ryan from the documentary analysed in the module material (The Open University, 2016). Ryan’s perception of his mother trying to fulfil her role was perceived as an impediment to his freedom, leading to him aggressively resenting her and thus resulting in their damaged relationship during his teenage years.

Another aspect to consider is Davide’s trust issues that emerged following his first divorce as it would have impacted his ability to build new social relationships and friendships necessary to integrate into any community he would be part of. By developing a self-defence mechanism that did not allow him to trust anyone to get too close to him and his family, he also missed the opportunity to have the support that comes from such relationships. As his reaction to that event was to put literal distance between him and his past, it would have undoubtedly affected his identity in such a way that it influenced his behaviour for the remaining of his life. As a further defence mechanism, Davide would have found comfort in pouring all his energy into his work and becoming a workaholic. As the existential psychotherapist Yalom (1980 ) suggests, placing himself as the ‘ultimate rescuer’ would be a way to overcompensate and take control over his life (Yalom, 1980), albeit in the most dysfunctional manner that jeopardised his second marriage. Davide, therefore, feels he has no choice but to continually `sacrifice` himself for Rosa by providing financial support in the role of parent and elder brother.

Working with this client systematically

The first issue to address is that Davide would fit the diagnosis for ‘major depressive episode’ according to the criteria set in the DSV-IV. It is important to note, however, that these symptoms did not occur in a vacuum. They are the result of the deterioration and alteration of Davide’s social and personal relationships which have significantly impacted his perception of the world and of himself. Losing his business would have impacted his self-esteem, particularly due to how much of his time he spent working in it, as well as the breaking up of his second marriage and the separation from his only child. His recurring heated arguments with his sister, for whom he provides, are also to be considered in understanding the origin of his depressive mood. Therefore, systematically, this case would have to be approached from multiple perspectives.

Approaching this case systematically involves the participation of his sister Rosa, as their relationship is now identified by their arguments rather than by their biological bond and history. Davide and his sister are now `stuck` in a pattern of behaviour that is leading to an increasing conflict and are unable to resolve it on their own. Indeed, families can get `stuck` when unable to adapt to the changing demands of the `family life cycle` (Carter & McGoldrick, 1999). Since moving in with Rosa, Davide, partly due to his patriarchal upbringing and partly out of feeling a lack of control in his life, may have behaved in an increasingly overprotective and controlling manner towards his sister leading to their relationship spiralling outside of their normal roles.

During the course of systemic treatment, they would benefit from the practice of `reframing` both their relationship and their interaction. At present, Davide feels that his sister is being ungrateful towards him whilst she blames him for using her state of helplessness as an excuse for controlling and limiting her freedom. Another tool available to the systemic counsellor is that of engaging in circular questioning during the assessment phase. As Vossler (2016) notes, the answers can have illuminating effects and offer the potential to change their interaction (Vossler, 2016). Moreover, role-playing with the help of a team of counsellors would be beneficial for them as observers, as it would offer them a perspective of how the other feels in regards to their circumstances. As they are both resentful of the circumstance they find themselves in, they perhaps lack the ability to understand or see one another without the filter of their own narrative due to their excessive emotional investment in them. A team of counsellors would help by suggesting alternative narratives to their own. Indeed, as Vossler (2016) notes further, there are no `correct` assumptions about a situation, but there are multiple hypotheses that would be useful to trigger the change necessary for relationships to improve.

Davide and Rosa’s case can also be approached from a humanistic perspective as his depressive mood, loss of motivation and her feeling entrapped in a situation, not of her choosing, would be understood as a state of incongruence. Their idea of themselves is at odds with the reality of the situation they find themselves in, thus leading them to a loop in which the concept of the self is being threatened. This, in turn, leads them to feel increasingly anxious and vulnerable, potentially blocking them from getting ‘unstuck’ as they are incapable of understanding the cause of their pain.  

Conclusion

In conclusion, this fictional case study has illustrated the importance of approaching therapy by acknowledging the relationship of individuals and the social interactions that occur first in the family as well as the social environment surrounding them. Davide and Rosa have both found themselves in circumstances not entirely of their own choosing and were unable to adapt to changing demands of the family life cycle; their interaction deteriorated due to their inability to adequately communicate their intentions leading them to be both ‘stuck’ in their own narratives and, therefore, unable to make the necessary changes towards a resolution on their own. Approaching cases like this systematically allows the counsellor to adequately attend the full sphere of factors that lead individuals like Davide and Rosa towards the deterioration of their mental well-being, as all perspectives are considered as well as offering the benefit from different therapeutic approaches towards a path of improvement and, hopefully, resolution.

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References

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