Family Assessment Paper

Case Description:
Christine is a 46 year old female of Caucasian descent with what she describes as
American heritage. She presently resides with her six year old son, Connor, and her
adult brother John just moved out of their apartment due to a conflictual relationship with
her landlord. Connor has a noticeably darker skin tone that Christine, when asked she
identifies Connors ethnicity as Portuguese and White. Christine was diagnosed with
stage four colon cancer on June 19, 2012. Shortly after that she was informed that the
cancer had metastasized to her liver and cervix. The colon cancer has progressed to stage
four and she has been told that her prognosis is poor, at best she might have two years left
from the date of diagnosis. Christine is presently receiving Chemotherapy treatments
biweekly and is tentatively scheduled to begin radiation in January if her body responds
well to the Chemotherapy. As a result of the colon cancer, her large intestine had to be
resected, her colon removed and she now has a Colostomy Bag. According to
McGoldrick and Carters Family Life Cycle Stages this family is presently in stage three
or The Family With Young Children stage (Ashford, LeCroy, Lortie, 2006). During
this stage the family is expected to adjust marital systems so that they can meet the
childs needs, take on parenting roles and to realign relationships with other family
members such as grandparents.

Although Christine is not presently engaged in a relationship she has had to take on the
parenting role alone and has attempted to reach out to extended family members and
friends for support with no success.
Presenting Problem:
Christine was referred to my agency by Mercy Home Care and her Oncologist as
they felt that she was experiencing pressured speech and needed help with processing her
prognosis. My first session of in home therapy with Christine was approximately two
months ago. Upon meeting her for the first time she was incredibly cooperative
indicating that she had been in therapy approximately five years ago for depression. She
reported not being depressed now and exhibited symptoms of Anxiety throughout our
session. I asked Christine what her concerns were and what she would like to work on.
She informed me that her goals for therapy were to work on boundaries with her
extended family, more specifically, her two brothers and that she really just wanted
someone to talk to. After meeting with her several times now, I feel that there are
some additional areas of concern. First, Christine is incredibly energetic, constantly
talking, changing subjects frequently and really has no regard for when I try to speak. I
feel that she is utilizing her defense mechanisms to protect herself from feeling emotions
and potentially falling apart.
Secondly, Christine already identified that she struggles with maintaining boundaries
with her brothers but she also struggles to have appropriate parent-child boundaries with
her six year old son. Christine has been telling her son that she is NOT dieing and has
reported keeping him home from school when she is feeling poorly and cant walk him
to school. She has Connor sit in her bedroom with her most days and watch television

or do activities in her room daily. I think that to some extent shes is trying to keep him
close to cherish the time that they have together but my goals for her would be to set
appropriate boundaries where her needs are being met and in which he can still be a kid.
[good application of structural family therapy concepts. ]
Her behavior is already reflective in Connor as at times he acts incredibly parentified
telling her that its time for her to make dinner, take her medication or will identify how
the behavior of his adult uncles is not appropriate. The final area of concern is that
Christine does not have a strong support system. Both of her parents are deceased, her
brothers are both substance abusers that are presently in recovery and both sides of the
family have isolated themselves from her. Connors father passed away about four years
ago in an accident at Cape Cod and neither Christine or Connor have a relationship with
his fathers side of the family either, representing an emotional cutoff.
Genogram and Ecomap: See Attached
Summary of Family History and Dynamics/Communication Patterns:
Christines mother and father are both deceased. Her mother died when she was
five years old from a Cerebral Hemorrhage. When the Hemorrhage occurred her mother
was put on life support for over three months. Her father died almost ten years ago from
unknown causes. She reports that her father was physically abusive to her and her
siblings and that he was a very mean man. This may represent a transgenerational
pattern. Her father may have had a substance dependence problem too, and perhaps was
abusive when drinking.
Both her maternal and paternal grandparents are now deceased as well. She has two
younger biological brothers, Patrick and Jonathan. Patrick is 44 years old, a recovering
alcoholic who according to Christine has been in and out of recovery for years. He is
married and has one child who has Aspergers Syndrome. Christine says that her sister in
law is gossipy and only talks to her when she needs something. She states that her
nephew is aggressive toward Connor and as a result can be the result of many of their
disagreements. She states that she feels that they dont take the time to work with him
and look the other way when he does something wrong using her nephews Aspergers as
an excuse. Her second brother, Jon, is 40 years old and was living with her in her home
until two weeks ago when he was asked to leave by the landlord. John is not married and
does not have any kids. Christine reports that he is an Alcoholic and uses Heroin when
not in recovery. Upon meeting Christine she informed me that he was in recovery, but he
has since started drinking again. Upon being kicked out of the home, Jon asked Christine
if he could stay anyway, she considered it but then declined for fear that she would lose
her housing and become homeless. Jon became very upset telling her how horrible of a
person she is. Again, she considered to allow him to live with her illegally, but then
declined. This could be an indication of a low level of differentiation- an inability to
separate thoughts from feelings. Jon couldn't recognize the risk to her and was reacting
emotionally to his dependence.
About eight years ago Christine lost her job with the United States Post Office for
unknown reasons and became homeless. For almost four years she moved from hotel to
hotel, and job to job. She met Connors father during this time and unexpectedly became
pregnant. When she tried to tell his father that she was pregnant he disappeared leaving

her to fend for herself. When Connor was less than a year old she left him alone with a
hotel maid so that she could go to work. She stated that her brothers refused to watch
Connor and she thought it was better than losing her job and having to live back on the
streets. Eventually, Christine was able to secure housing and so normal life resumed.
This demonstrates remarkable determination and resilience- now evident in her
determination to extend her life through treatment.
Approximately four years ago she got word that Connors father had died in a boating
accident at Cape Cod. She attempted to reach out to his family with no success. She is
not presently working, is receiving TAFDC and Food Stamps for help with her expenses
and is in the process of applying for Social Security Benefits.
Family Communication
This family communicates with one another, just not effectively. There seems to
be an element of triangulation between Christine, Jon and Patrick. One relies on the
other, while ones addiction improves the other falls apart and so on. Given the
involvement of John and Patrick in Christine and Connors life I think its important to
identify the differences in communication styles between specific members. For example,
John and Patrick have a very symmetrical relationship, both have behaviors of substance
abusers and anger, that mirror the other. As a result of the closeness and shared
behaviors I think that they often form a coalition against Christine. Christine does not
seem to have a symmetrical relationship with either, nor does she have a complimentary
relationship with them.
However, I might venture to say that she and Connor have a very complimentary
relationship, where goodness of fit between parent and child comes in. Christine is very
assertive, talkative and animated. Connor on the other hand is laid back, will talk only
when necessary and can be somewhat subdued at times. This may be an indication of
replication of a pattern established in her childhood where the parent dominated and the
child's voice wasn't heard.
If we look at Strategic Therapy and Communications Theory we know that
families are always in communication with one another (Nichols, 2010). Communication
doesnt only happen with words, rather behaviors are considered to be a form of
communication as well. Christines family has difficultly expressing report and
command functions appropriately. For example: Christine might report to Patrick, You
know, your son is really being mean to Connor lately, its got to stop! Instead of
commanding this with a serious tone she might say it while she continues to allow
Connor to play with him or while laughing. Instead it conveys a lack of seriousness and
doesnt command a need for the behavior to stop.
Finally, Christine in particular practices conflict avoidance or when family
members shy away from addressing their disagreements. (Nichols, 2010, pg. 174) She
will regularly identify that she struggles with setting boundaries with her brothers but
then will fail to allow herself to deal with the issue for fear of a disagreement. Shed
rather allow her siblings to push the limits with her, sacrificing her happiness, rather than

speak to them for fear of an argument. This family does not talk about feelings directly
and constructively.
Differentiation of Family Members:
Nichols describes differentiation of self as the psychological separation of
intellect and emotions and independence of self from others. (Nichols, 2010, pg. 28) I
think that this entire family has not successfully obtained autonomy, or differentiation.
Starting with Christine, who prior to her Cancer diagnosis was reliant on her brothers to
care for her emotionally constantly seeking affirmation for her actions and seeking help
caring for Connor.
She in a way has been reliant on, and enmeshed with, them since she was very young,
being the caretaker for them, and now the reversal, them caring for her. Both of her
brothers continue to not be autonomous either, reliant on her for emotional stability and
seeking affirmation for their thoughts and behaviors. Connor is struggling to obtain
differentiation of himself in part a result of the enmeshment he has with his mother. This
seems to be a transgenerational pattern of low differentiation.
Christines guilt around her diagnosis and fear of leaving Connor behind does not
encourage Christine to allow Connor to develop independently. Her fear and inability to
process what is happening promotes the implementation of defense mechanisms, which
in turn results in her grasping to not allow Connor to be autonomous. Coming from a
model of enmeshment and low differentiation, this pattern is being replicated. She is
unable to think about his needs because she is reacting to her own feelings of fear of loss.
Family Structure:
Family subsystems appear to be divided in three ways. First there is the adult
sibling subsystem which Christine, Patrick and Jon exist within. Secondly, the parentsubsystem, in which Christine is the single parent, with no support from a co-parent and
the third subsystem is the child subsystem where Connor exists alone. Within the sibling
subsystem I feel that the boundaries are diffused which has resulted in the three siblings
being incredibly dependant on one another. The enmeshed relationship stems from their
childhood where Christine and her brothers had to care for one another without a parent
figure. Its resulted in a lack of independence and inability to feel comforted when they
are apart.
Within the parent subsystem I would again say that this subsystem has diffused
boundaries and therefore the parent and child subsystems are completely enmeshed, even
more so than the adult sibling subsystem
Christine has unconsciously created this to try to feel a sense of closeness and create a
sense of support for her and Connor both. As a result, Connor seems uncomfortable
playing in his room alone and doesnt have many friends. Within the parent subsystem
there are things that Christine should be doing on her own and not relying on Connor for.
For example: Connor is entirely aware of when his mother needs to take her medication
and which colored pill she takes when. He is aware of her appointments and reminds her
of them. He feeds himself and acts as his own caretaker at times. I feel that clear
boundaries are needed in order for Connor to not feel so enmeshed with his mother. I
have a hunch that the enmeshment between Connor and his mother didnt start as a result

of the cancer and has been occurring for years. This is a transgenerational pattern being
repeated, and most likely would be a problem without the cancer.
Christine informed me that at five years old Connor didnt want to go to school and that
she didnt want him to attend school yet either. Admittedly, she informed me that she
wasnt ready to let him go and that she wanted more time with him throughout the day
because she would miss him too much. To some extent, this is behavior that is within the
normal range, but for a mother with preexisting boundary issues I think its her recreating
the same enmeshed pattern that she has with her siblings with her son now.
The hierarchy between Christine and Connor is somewhat weak and ineffective. It does
not reflect the necessary authority of a parent. At times it is clear that she is the parent,
however she then sends him mixed signals by allowing him to be the caretaker. This in
turn can be confusing for him and often power struggles occur between the two.
How Are Symptoms Serving The Family?
Christines implementation of Ego Defenses is, in a way, serving the family quite
well. The implementation of defense mechanisms has occurred in response to enduring
traumatic experiences throughout her life. Her defenses have historically allowed her to
cope with previous events and is now helping her to cope with her diagnosis, poor
prognosis and to maintain a sense of homeostasis or general well-being within her and
Connors life. This is the way that Christine has been able to protect both herself and
Connor from feelings of pain, anger, sadness, discomfort and/or the processing how her
illness may impact their future lives. I think that she feels that by allowing herself to
process the experience it would be more detrimental than beneficial at this time.
Essentially, I think that she is utilizing her defenses as a survival tool and that from a
strengths based perspective I commend her ability to protect her family. Although I think
that her defenses are an appropriate reaction right now, I do not think that its sustainable
or helpful for Connors long term well being.
The main symptoms right now seem to be her subservient dependence on her family
members. This serves the family system by maintaining the dependent enmeshment of all
members who cannot deal directly with their problems but rather deny and avoid- she her
physical illness, her brothers, their substance dependence. Hopefully, in therapy, she will
be be able to learn to view her therapist as a person who both respects her and can
tolerate and support her expression of feelings. When this trust is established, we may be
able to begin discussing strengthening boundaries both between her and her brothers and
between her and her son.
Changes Needed:
In order for this family to increase functionality and help Christine process the
loss that has occurred in the past and the upcoming loss she will experience I think that I
might need to change the approach that I have been taking with her. Right now, I am the
only service provider in the home other than Mercy Home Care, thus I feel particularly
responsible to make a connection with this family. Up until recently I have been focusing
on getting Christine to be okay with her feelings. Last week she informed me that she
didnt want to feel them and that if she did she would fall apart and if she fell apart
Connor wouldnt be cared for. Ive accepted that I need to work with where she is and

not where I want therapy to go. Since that session weve been focusing on her strengths,
in particular her ability to implement her defense mechanisms and what that has meant
for her. Weve also completed the enclosed Genogram together and have found that
there are several issues around boundaries and enmeshment. Through using the
Structural Family Therapy (and some Strategic Therapy) Model we have been working
on identifying that boundaries have been incredibly diffused for many of her relationships,
the issues that exist within familial subsystems and the potential for coalitions to form.
As previously noted, the familys support system is relatively limited. As a result,
Id really like to work with the family to get some additional support. Christine is
receptive to the idea of having a team that specializes this area come into the home and
work with her and Connor together for family therapy, Connor individually and act as a
mentor for Connor. Id also love to have Christine to be with other people who are
experiencing the same thing as her and attend a support group. Christine, however, has
been resistant to this idea.

Works Cited
Ashford, J., LeCroy, C., Lortie, K. (2006). Human Behavior in The Social Environment:
A Multidimensional Perspective. Belmont, CA: Thomson Learning Inc.
Nichols, M. (2010). Family Therapy: Concepts and Methods (9th ed). Needham Heights,
MA: Allyn & Bacon: