A Case Study on an interpersonal issue in a family situation from a psychological perspective. By Andrew S. Heldt

An Assignment for the Master of Theology on Personal and Social Psychology Year 2: Semester 2

Outline
1. Assignment Question…………………………………….…………………..1 2. Introduction………………………………………………….……………….1 3. Case study – Description…………..……………..………………………….1 a) Early Childhood…………...………………………………...………..1 b) Adolescence……………….………………………………..………….2 c) Church and family relationships…………………………………….3 4. Case study – Analysis ……………………………………………………….5 5. Ongoing Development…………….………………………………...…….....8 6. Further action………………………………………………………………..8 7. Conclusion……………………………………………………………………11 8. Bibliography……………………………………………………………..…..12

Assignment Question Describe a case in your ministerial context related to the following: b) Interpersonal issues in a family situation Try to identify the various components that are important to understand this situation from a psychological perspective, making sure that you refer to the relevant psychological theory. Analyse this case in the light of what you have studied in this course. Finally, explain what action you plan to take in this situation, giving your reasons. How might what you have studied help you intervene effectively in this situation.

Introduction The area of psychology being vary vast, the scope of this paper is limited to the case study of an individual and the strained relationship within a family situation as occasioned by the person in question. This paper aims to describe the case at hand in a most in-depth manner as limited only to the knowledge of the writer with an attempt to understand it as best from a psychological perspective, considering relevant psychological theory and thought. The paper also aims to analyse the case with reflection on psychological development of the case with a special emphasis on family relationships, interpersonal issues affecting the same with a proper analysis. As with any given case in counselling or psychotherapy the paper will also present action taken and ongoing development with the perceived results and, as the case still progress will also aim to look to future intervention with a hope of being effective in the counselling effort and producing the relevant and necessary positive outcome. Though this papers concern is to do with interpersonal issues in a family situation, the writer is of the view that these issues are caused by a certain individual‘s deviant behaviour, and will therefore present briefly a case history of the individual in an attempt to analyse root causes. This paper will further follow the pattern of a combination of a historical case study and an observational case study and thereby seek to trace the development of the case at hand over a period of time as well as observe the case, which in this instance is an individual, and will be again mixed with participatory and non participatory observation. Case study – Description

a) Early Childhood The case at hand is that of a 40 year old man, married for nine years and who has a daughter aged 8, and who for the purpose of this paper will be referred to as ‗the patient‘. Born into a pastors family, he was the youngest of four children with one elder sister and two elder brothers, and had at a 1

very young age of 4 lost his mother and therefore grew up in a single parent home. His father, being a pastor admits that he was not able to give enough time to his children and also did not remarry. After interviewing the patient‘s brother, the writer has discovered that the patient was brought up mainly by his elder siblings, especially his sister and was a very pampered child. The patient is known to have occasionally exhibited violent behaviour from childhood which as observed by the writer, still persists. During his schooling and college the patient was known to have been very capable both academically and in various sports. One of his passions at school was that of playing cricket, and though he excelled at the game, his involvement in the sport came to an abrupt end when he was hit with the ball on the head, after which he has developed epilepsy. Till date he is an epileptic patient suffering from occasional seizures as a result of the same and has been on long term medication though there has been slight to no improvement in the condition.

b) Adolescence The patient pursued his studies in engineering securing a high percentage, then working for a while in a governmental organisation. Following this the patient went on to complete his studies in theology obtaining both a bachelors and masters degree and is known to have achieved a high standard in academics, though throughout his studies was plagued by bouts of epileptic seizures. Though the patient was well versed in the scriptures and seemed theologically sound, from the viewpoint of his siblings was not regarded very highly as he was known to have indulged in pornography and had many affairs, though the patient claims that this was the behaviour of his brother which indicates his tendency to believe things that are not true either of himself or of others and could to the extent of the writers knowledge be a classic example of ‗projection‘ with his tendency to attribute to others the negative traits of himself. Of projection, Antony comments, In projection we disown certain aspects of ourselves and assign them to others or environment just because those aspects do not coincide with our self –image. What we disown is put onto other people and we avoid taking responsibility for what we actually are. (Antony, D. John 2003: 281) This trait in the patient has been observed for over a period of years now, and has perhaps become part of the patient‘s psyche. Further, from the perspective of the family as an emotional and developmental unit, the patient has perhaps not had the chance to develop normally, as his development would have depended to a huge extent on his parents, and in the absence of his mother, and with his father rarely present, his normal development was stunted. Carter and Goldrick looking at the family life cycle

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point out the inter-dependence of each family member on the other in terms of what they call ‗developmental tasks‘. They list Hill and Duvall and comment, Hill and Duvall observed that each member of the younger, middle and older generations in the family has his or her own developmental tasks, and the successful achievement of one persons tasks depend on and contributes to the successful achievement by other family members of their appropriate tasks. (Carter and Godrick1980: 6) Looking at the case from this perspective, it appears that as the mother was not present to achieve her tasks, it negatively impacted the patient, who in turn is unable to achieve his developmental tasks.

c) Church and family relationships After completing his theological studies the patient went on to serve in the Church first as a youth advisor and then as a pastor for approximately ten years in total, and towards the end of this tenure got married. For reasons still unclear to the writer the patient left the Church. From his own perspective the patient explains that it was because he was treated unfairly and specifically targeted by being put in Churches where he could not speak the language of the congregation, that he chose to leave the church. He further adds that the politics and the practices of the clergy were appalling and with his inability to be part of the corruption, chose to leave the Church. From the writers own findings from speaking with clergy within the Church and other members it was pointed out by some that when the patient was a youth advisor he had caused more problems within youth fellowships than building up the youngsters. Others have opined that as he could only converse in English the extent of his placements were limited and was asked to leave. Currently the patient‘s siblings have severed all ties with him due to what one brother claims to be his bad behaviour. The patient however seems to be in a state of delusion believing his marriage to be the cause of his siblings cutting him out, which theory seems to have no basis. He claims to have been in a relationship with a foreigner prior to his present marriage and believes that because he did not marry this foreigner his brothers and sister being disappointed in the present marriage decided to have nothing to do with him. He has also caused a break in relationships with his extended family on his wife‘s side by deliberately stopping all interaction with them, believing that they have some hidden agenda against him. This has gone up to the extent that he forbids his wife to have any interaction or to even meet with her own parents. His child has no contact with either relatives from his family or his wife‘s, except with the patient‘s father who had lived with the patient for a short while. The writer is of the assumption after observing the patient for little over five years that he seems to live in his own make belief world, and reality, especially in terms of relationships is very obscure in his mind. His make belief world has further caused him to openly lie to people, 3

which the writer of this paper believes that he is unaware of. For instance he claims that he was forced into his marriage and was only allowed to see his wife on the day he married her, but people know him to have known her and her family much before they were married and in fact the marriage was a love marriage, and not an arranged one as he claims it to be. Furthermore he also accuses a prominent bishop for having intervened and getting him married without his consent, while also laying blame on his father who he claims also conspired along with the bishop in this arrangement, which he seems to believe was a plot against him. Furthermore the lies which he speaks also stem from the fact that he believes most people he knows have something against him and therefore has made up stories of wrong things they have done, thereby also causing breakdown in his relationships with others as well apart from his family. From a psychological perspective this may be viewed to an extent as an ego-defence mechanism which is related to anxiety. John Antony comments on ego-defence mechanism, When the ego is not in a position to control anxiety by rational and direct methods, it resorts to unrealistic methods, which are nothing other than ego-defence mechanism. Since the ego defences help one to cope with anxiety, it is not exactly pathological. They have an adaptive value if they do not become a way of life to avoid facing reality. Ego-defences operate on an unconscious level and they tend to deny or distort reality. Therefore these two characteristics of 1) denying, falsifying and distorting reality and 2) operating unconsciously are common to all the defence mechanisms. (Antony, D. John 2003:49) In this case there seems to be a pathological tendency as it seems to have become a way of life and has caused him to terribly distort reality. He seems to drift in and out of reality and distorts reality as it pleases him. Though John Antony views this as only a mechanism to cope with anxiety and does not qualify as pathological, the writer of this paper believes that in this particular case though it may have started off as a ego-defence mechanism, the line between this and pathological tendencies seems to have been crossed. He seems to be one who also projects his behaviour on to others wherein the things he has done he claims others have done, and then also works in reverse where he claims for himself the accomplishments of other people. His early adulthood and even extending into the present has also revealed his fascination with the occult world and pornography, though again he claims to be against both. However sources close to him reveal the opposite to be true, which further intensifies his dilemma. As can be expected, this behaviour and attitude of the patient has caused extremely strained relationships in the family setting, and not only between siblings and extended family members but also between husband and wife. It has been observed that though in social gatherings there is no 4

disharmony, within the home there are constant arguments between the patient and his wife with each constantly belittling the other. Case study – Analysis

The disturbing behaviour and attitudes of the patient has to a great extent caused damages in family relationships, even to severing of family ties with him. The patient has had violent episodes in the past even to the extent of kicking his sister‘s infant, when he was an adolescent. For the most part the patient is out of touch with reality as he often tells stories about himself and others that are not true. Though this may be initially seen as just lies, it has taken a destructive pattern where imagination of the patient has led him to do a lot of character assassination causing rifts and personal conflicts between many individuals. At present the siblings of the patient do not communicate with him and have cut off all relationships. Only his father maintains contact and he too feels he has failed in bringing up his son in the proper way. It is at present difficult to identify the exact nature or category of the patients illness, as he seems on some occasions to be in a right frame of mind, and it is difficult to know when he moves out, though he at no point considers his behaviour to be wrong. Perhaps it could be suggested that he suffers from a personality disorder but diagnosis is difficult as it is not overly obvious. As the patient struggles with Epilepsy having seizures occasionally and is on medication for the same over a prolonged period with doses being increased regularly there could be a chance he has developed a form of psychosis. Wolberg states, when considering panic situations in patients ―he may be manifesting a toxic psychosis as a result of taking too many drugs or because of a physical ailment‖ (Wolberg 1977:853) Perhaps in extremity it could be also argued that the patient is schizophrenic, as he seems to have developed this abnormal behaviour during his adolescent years, which is a classical time for onset of schizophrenia. ―Late adolescence and early adulthood are peak years for the onset of schizophrenia. In 43% of men and 23% of women diagnosed with schizophrenia, the condition arose before the age of 19.‖ (Cullen KR, Kumra S, Regan J et al., 2008, http://www.psychiatrictimes.com). Though it is difficult to pinpoint the exact starting point and development of the problems the roots of the problem can perhaps be traced to early childhood, where the patient lost his mother at a very young age and being the youngest child and was pampered by the father and allowed to have much of his own way in every aspect. It is relevant to note here that although he was very young when his mother died, prior to her death he was a very normal child, but though not overly obvious he did in fact become more violent from after her death. It seems that this seemingly developmental crises has in fact not been coped properly with. Clinebelle captures well the enormous effect and 5

intense seriousness of dealing with death when he addresses counselling in the crises of bereavement. He says, The loss of someone who has been a part of one‘s world of meanings and satisfactions is a psychological amputation. (Clinebelle, 1966:167-168) He also goes on to point out a coping mechanism and states, If the individual has learned constructive, reality oriented coping skills, his psyche will follow a somewhat predictable process of working through the mixture of powerful feelings associated with bereavement and making the adjustments required to live without the deceased. Lindemann called this process, by which the grief wound heals, the ―grief work‖ of the psyche. (ibid, 1966:168) It seems in this case the patient has never had the grief wound healed and now over a prolonged period is manifesting itself in psychotic behaviour, and also had in the initial stages when the death occurred when he was a child. Clinebelle views this as a person using the defences of denial and repression which enable one to avoid the pain of dealing with resentment, anger and guilt, thereby blocking the grief work. Further the case at hand seems to also exhibit a more complex level with perhaps a certain amount of Mania stemming from the denial and also anti social behaviour stemming from projecting ones anger on to the world. Hollingsworth when dealing with children‘s ability to grasp the reality of death goes on to show the ways in which loss can be handled two of which that are mentioned above fit the subject of the case. Though it was earlier believed that children don‘t have the capacity to grasp this reality it now does seem that they use some mechanisms to deal with it. Hollingsworth says, Child psychiatrists now believe that the personality of the child is not sufficiently developed to bear the strain of the work of mourning. Therefore the child‘s ego utilizes narcissistic mechanisms of self-protection to circumvent the mourning process, either by infantile regression expressed as anxiety or by the mobilization of defence forces intended to protect the ego from anxiety and other psychic dangers. (Hollingsworth, Charles E 1977:101) In this case there does not seem to have been any proper defence forces, and therefore the danger of becoming psychotic or developing anxiety have not been overcome. Though the anti-social behaviour and mania cannot solely be attributed to the negative handling of the death of the patient‘s mother, yet it has been a contributing factor to the same. A factor that could have played a role also is the fact that the patient‘s father being a pastor had perhaps not expressed his grief properly over the mother‘s death, and in turn has caused this negative impact on the child‘s health which he carries to this day, which as observed earlier is non achievement of developmental tasks of one family member causing problems for other family members. To an extent bottling up of his emotions also 6

could have lead to his misinterpretation of reality. Philip Bernard while elaborating the effects of bottling up emotion states, Sometimes, emotion that has been bottled up for a long time can lead to a person‘s view of the world being coloured in a particular way. They learn that people can‘t be trusted‘ or ‗people always let you down in the end‘. It is as though old, painful feelings lead to distortions that become part of that person‘s world view. (Bernard, Philip 1994:140) 2.1 The other contributing factor, could be the onset of epilepsy after being hit by the cricket ball. This is perhaps an accidental crisis for him and the combination of the two crises has led to his present state which the writer of this essay believes to be a psychotic condition. The epileptic attacks seem to be now triggered by stress which treating doctors of the patient attribute to long periods of intense study as the patient is overly indulged in long hours of reading, while ignoring to meet the needs of his family both physical and emotional. Doctors seem to suggest that the patient stresses over unimportant matters and slight conflict with others cause enough anxiety to create an epileptic attack. This issue of the epilepsy has caused the patient to stop working, and has not worked for a long period. This could also be caused due to the onset of schizophrenia, as schizophrenics have a combination of other conditions, which include long term unemployment. He is also not able to transport himself anywhere, therefore leaving his wife to both work and take care of him, by taking him to any place outside the home, for fear that he might have an attack while alone. This over dependence on his wife and also an overly strict control over her relationships to her own family has to a good extent also affected the balance in the family set up and is now also taking its toll on the child. These factors combined have formed the present state of delusion, which is all the more heightened by the subjects refusal to accept his state and being thus in a state of denial as well, hardly serves to help in the progress. This continuing behaviour has indeed a very negative effect on the family, especially now on the wife and young child. His wife having been denied the opportunity to even visit her own mother and brothers, has come to occasionally, under the guise of being caught up in traffic visit her family without letting her husband discover the same, for perhaps fear of a violent episode from him. This controlling attitude of the patient is probably what triggers the constant fights between the two in the house as well. Though there has to the knowledge of the writer been no physical harm done by the patient to either his wife or child, yet attitude and behaviour have played a significant role in causing family disorganisation and a breakdown in relationships.

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Ongoing development

Further action The case at hand as can be expected is seemingly very complex and the patients past seems to have left an unalterable scar on his personal and social life, and still continues in the present. However, at the outset of a proposed plan of action it would be most apt to note that ones past need not hinder ones possible future. Taylor, while emphasising this point states, So long as we are alive, we have not finished our development and growth. We are still ‗becoming‘. This means that we can look back in our lives to the past from which we can become free, and we can also look forward to the future towards which we are moving. Our past life influences us, but it need not hold us a prisoner. As we grow we can change direction, like a plant that turns towards the light, we can make decisions; we can respond to love; we need not remain as we are.(Taylor, 1983:36,37) As can be observed, it is only with this positive attitude, and reassurance can one move forward to suggest a plan of action for healing and recovery for the patient. Further, perhaps the best technique to implement is one that is termed in counselling as interactional therapies. Collins describes well this technique when he comments, At some point between the directive and permissive approaches are what might be called the interactional therapies. This term describes counselling in which the counsellor and counselee interact together more or less as equals. A Swiss physician named Paul DuBois used this approach around the turn of the century…He insisted that the physician treat the patient as a friend, not merely as an interesting case. (Collins, Gary 1977: 167) Keeping this in mind a relationship has been developed between the patient and his family, and the writer of this paper, and a friendship now formed and sustained for over two years. Though close bonds have been formed over these years and the writer has spent a tremendous amount of time talking to and listening to the patient, and his wife, there has been no step taken for implementing any therapy, though the listening to of the problems within the family and of the individual, is in itself a good degree of progressive therapy and counselling. One ought to know the problems and the persons involved before making any kind of diagnosis or suggesting any action. It is only as the friendship has developed was the writer able to make an analysis as listed above of the patient, and believes that though family tensions and pressures exist, first and foremost what needs to be dealt with is the patient‘s ongoing problem, which seem to be the root of family disharmony. Considering the fact that the early loss of the patient‘s mother must have triggered a crises that has not been overcome, which has caused serious family dysfunction, and a break in family 8

relationships, it would perhaps as a starting point be helpful for the patient to look at the breakdown in family ties and try reconciling with family members. How far can a grieving process or grief work be completed now, is at best speculative, due to the patients age and considering that the incident had taken place many years ago, and therefore if the patient‘s focus can be diverted to mending family relationships might be helpful. Just the reuniting of estranged family members might play a very crucial positive role on the health and wellness of the patient and his family. Clinebell, in his treatment of Crises Counselling suggests among others, a technique employed at the Benjamin Rush Center for Problems in Living in Los Angeles. He says, ―A fifth is to consider re-peopling his social world, and re-distributing the role relationships within the group‖. (Clinbell, Howard J., (Jr) 1966: 164). The writer believes this to be crucial and views it as a reconciliation with family and friends, which Clinbell termed as re-peopling. Considering this, one of the steps in the writers consideration, towards recovery of the patient is to encourage reconciliation with family. A further step that the writer wishes to pursue is that described again by Clinbell, as surrender. Though Clinbell views this as one which he calls ―conversion in the Christian faith‖, in this instance, it would be more of a re-conversion, as the patient already has been converted, but now needs to come back again. Further, Clinbell suggests that a person in surrender, hits bottom in the crises at a certain point, which is when he can surrender. Of surrender he notes, Surrender occurs at a deep, nonvolitional level of the psyche, suddenly or gradually. Somehow, under the impact of the crises, ones old self damaging defences stop functioning. A dramatic shift of intra-psychic forces occurs and is unmistakably evident in the new sense of openness, nearness to people, acceptance of the unchangeable in one‘s situation, and a realistic willingness to ―live and let live‖. (ibid, 1966: 165-166) Bringing the patient to ―hit bottom‖ will be a challenging task, and the writer is yet to conceive of a process to aid in getting the patient to surrender, and hopes over time that a path may be discovered. It is perhaps imperative to note here that the patients reaction to the crises also ought to be altered to assist him to surrender. Charles Stanley notes, ―the nature of our adversity alone does not determine its spiritual value in our lives. It is our reaction to it, the way we deal with it, that makes suffering valuable.‖ (Stanley, Charles 1989: 179). So far, it appears that the patient has dealt with his crises with a very negative reaction, and probably getting him to react in a more positive way will play a pivotal role. As of the present, the steps as traced above; that of befriending the patient, aiding in mending family relationships and seeking a way to help the patient ‗surrender‘ are ongoing, while the writer looks positively to the future of the patient, and a full recovery.

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The writer also believes that the patient‘s mind ought to be trained to think more clearly about the world around him. Tozer while reflecting on the sanctification of our minds notes, ―Feats of thinking may create reputation, but habits of thinking create character.‖(Tozer A.W. 2004:85) He goes on to describe how the world outside of us is merely the raw material for the world we create in our minds, and further moves to show that the thoughts of a Christian ought to be the same as that of Christs. He says, ― The spirit filled prayerful Christian actually possess the mind of Christ so that his reactions to the external world are the same as Christs.‖ (ibid:86). From this the writer further gathers the important role prayer should play to aid in thinking the thoughts God would have us think. Further, apart from prayer, God‘s word, the reading and meditating of it, should also be kept as a central point of focus to stay attuned to Gods thoughts. Robert Tilton says of the word of God, ― Meditating will give you understanding of how to do the will of God, which is the word of God in your life.‖ (Tilton, Robert 1983:59). This Tilton emphasizes is the necessary key to a successful life, which is what the writer aspires to develop in the patients life Though the writer is hopeful for a recovery, and a mending of broken family relationships, mindfulness ought also to be given that the writer is not a practicing Psychiatrist or professional counsellor and therefore is reserved if the problem of the patient might be more deep or even be linked to schizophrenia or other medical disabilities, which are out of the range for the writer. If indeed the patient can in fact be diagnosed with schizophrenia, medication and hospitalisation may be one answer. Increased dopamine activity in the mesolimbic pathway of the brain is consistently found in schizophrenic individuals. The mainstay of treatment is antipsychotic medication; this type of drug primarily works by suppressing dopamine activity. Dosages of antipsychotics are generally lower than in the early decades of their use. Psychotherapy, and vocational and social rehabilitation are also important. In more serious cases—where there is risk to self and others—involuntary hospitalization may be necessary, although hospital stays are less frequent and for shorter periods than they were in previous times (http://en.wikipedia.org/wiki/Schizophrenia) While mention needed to be given of a possible treatment out of the scope of the writers ability, the writer is hopeful that even in the worst case scenario, there is always hope, as the writer believes that “with God, all things are possible”(Matthew 19:26, NIV)

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Conclusion Though the paper set out to identify interpersonal issues in a family situation, which exists in the family and is set out briefly, the paper had to navigate to the root cause and observe the deviant behavior and attitudes of the patient, which in the view of the writer has been the cause of the problems. Therefore the paper has focused in the case study analysis on the patient and his condition, and has sought to present the best way forward, with existing counseling explained as well. As is evident, the patient’s mental state of mind seems to have developed over a long period of time beginning at the adolescent stage and deteriorating as time progressed. Also evident is the fact that many elements have been combined together co-incidentally to cause the current state, which has seemingly begun with the death of the patient’s mother and the fact that the grief work has not occurred or has very minimally been achieved, coupled with the patient becoming epileptic and then having all relationships cut off up till the point of bordering on schizophrenia. Despite the graveness of the situation, as with any counselling and therapy there ought to be positiveness to be able to begin to overcome any problem, and involvement with the patient and his family is also crucial to aid in effective counselling. Therefore, in view of this, friendships have been established over the years and between the writer, the patient and his family, and the writer hopes that this will be the beginning of a complete recovery. Though sceptical of the fact that the patient‘s situation, as it may be outside of the scope of the writer, the writer is still hopeful, leaning on the understanding and faith in God and His word that with God all things are possible, and so a complete recovery for the patient can never be ruled out. It is the writer‘s sincere hope that the patient is not a schizophrenic and that through proper therapy and counselling the patient will recover completely.

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BIBLIOGRAPHY

Antony, D. John 2003

Psychotherapiesin Counselling Tamilnadu, India: Anugraha Publications

Bernard et al 1994

Counselling Skills for Health Professionals, 2nd Edition London

Clinebelle, Howard (Jr) 1966

Basic Types of Pastoral Counselling Nashville: Abingdon Press

Collins, Gary 1977

How to be a people Helper: You can help the others in your life Santa Ana: Vision House

Cullen KR, Kumra S, Regan J et al 2008

"Atypical Antipsychotics for Treatment of Schizophrenia Spectrum Disorders". Psychiatric Times 25 (3) http://www.psychiatrictimes.com/schizophrenia/article/10168/1147536

Hollingsworth, Charles E 1977

Family in Mourning New York, Grune and Straton

Stanley, Charles 1989

How to handle Adversity Nashville, Tennessee: Oliver-nelson Books

Taylor, Harold 1983

Tend My Sheep New Delhi: ISPCK

Tilton, Robert 1983

God’s Laws of Success Dallas, Texas: Word of Faith Publishing

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Tozer, A.W. 2004

Incredible Christian Mumbai: GLS Publishing

Wolberg L R 1977

The Technique of Psychotherapy London: Academic Press, Inc

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