Introduction

Bowen family systems theory was developed in the early 1960s by Dr. Murray Bowen. He began his training in psychoanalysis during the late 1940s as a psychiatric resident at the Menninger Clinic in Topeka, Kansas. However, after a few years passed, Bowen became dissatisfied with the lack of scientific precision in psychoanalysis and began to develop an interested in examining family emotional process. He continued his research at the National Institute of Mental Health, and later went on to establish the Georgetown Family Center at Georgetown University Medical School in order to develop a comprehensive family theory (Wylie, 1991). I was first introduced to Bowen family systems theory through my field supervisor, who uses this theory in the Dual Recovery Intensive Outpatient Services (IOS) Program for chemically dependent adults with mental health diagnoses. Throughout the first four months of field work, I viewed video lectures on Bowen theory and attended weekly lectures on the theory's concepts, which were delivered and facilitated by my field instructor. I also began to read various articles and books on this theory on my own in order to further my knowledge. Now, as I reflect over the past semester and a half, I realize that I have gained a greater understanding of both the theoretical concepts as well as clinical approaches which are applications of the theory. To illustrate this learning, I will summarize a few general principles in Bowen family systems theory, describe the theory's eight basic concepts, provide a brief description of my field placement program, and then discuss my work with an individual client by applying this theory.

Bowen family systems theory can be summarized by a few general principles or statements. One main, overarching concept is that the family is an emotional system, or an emotional unit. This means that family members are emotionally interdependent and function in reciprocal relationships with one another. Therefore, the functioning of one member cannot be completely understood if taken ". . . out of the context of the functioning of the people closely involved with him" (Kerr, 1988, p. 37). In addition, Bowen asserted that the family system is composed of interlocking relationships that are ruled by counterbalancing life forces. These biologically-rooted life forces are the instinctual, yet competing forces for togetherness and separateness, or individuality, which are evident in both animal and human development. Bowen also taught about the effect of anxiety on the family system. Anxiety, defined as an organism's response to a real or imagined threat, is present in all living things (Kerr, 1988), and also is referred to as heightened reactivity (Gilbert, 1992). Anxiety can be acute or chronic. Acute anxiety is generally a short-term reaction to a real threat. Chronic anxiety usually occurs as a reaction to ". . . imagined threats and is experienced as having no end in sight. Chronic anxiety often strains or exceeds people's ability to adapt" (Kerr, 1988, p. 47). Increased levels of both acute and chronic anxiety lead to symptom development as family members react to this disturbance in the balance of the emotional system (Kerr, 1981).

Bowen theory views both symptomatic and non-symptomatic clients as highly reactive to their families of origin. Furthermore, present difficulties in the family system are generally impacted by previous generations of family history. The goal of Bowen theory, therefore, is for clients to become less bound to, but not cut off from, their family of origin. This is accomplished by reflecting upon and accepting the emotional process in one's own family, as well as by establishing real, person-to-person relationships with members of the immediate and extended family. This approach directs attention to achieving a more objective and neutral view of family emotional process, family relationships, and anxiety manifestations over many generations. It also leads to an emotional shift away from individual pathology towards understanding the individual within the emotional system and acceptance of the family process. In Bowen theory, all symptoms, such as mental illness, physical illness, substance abuse, or social problems, illustrate ". . . a failure of adaptation by the system and are exaggerations of normal processes". This view eschews the labeling of "pathology", which can cloud one's perception of the underlying system forces (Kerr, 1981, p. 235). In addition, Bowen used family diagrams to map out the ebb and flow of emotional process in generations of family members (Kerr & Bowen, 1988). Furthermore, the family diagram utilizes symbols to represent various family members and the nature of their emotional connections, including whether those relationships are close, distant or conflictual.

The Eight Basic Concepts of Bowen Family Systems Theory

Bowen family systems theory consists of eight basic concepts. One of the basic concepts is the Nuclear Family Emotional System, under which is subsumed several additional terms. According to this concept, the family functions as a unitary whole, "governed by the interplay of two counterbalancing 'life forces', forces that family systems theory has defined as individuality and togetherness" (Kerr & Bowen, 1988, p. 58). When anxiety in the system increases, there is heightened reactivity, and the pressure for togetherness increases as well. This pressured togetherness is termed as fusion. "The greater the fusion, the more difficulty coping with or keeping emotions in balance." This can be reflected in ". . . an impaired ability to be aware of and express feelings or in an inability to control volcanic outbursts of emotions" (Kerr, 1981, p. 238). This togetherness force can be seen in approval-seeking, conforming, and dependent behavior as well as its opposite, seeking disapproval and rebellion against the perceived wishes of others. Therefore, fusion, or unresolved attachment to one's family of origin can be played out harmoniously (with the family seen as "ideal") or discordantly (with the family seen as "horrible") (Kerr, 1981). According to this theory, highly fused individuals have "few firmly held convictions and beliefs, are either dogmatic or compliant, and seek acceptance and approval above all other goals" (Skowron & Friedlander, 1998, p. 235). Fusion is also reflected in poorly defined boundaries between oneself and others. A binding sense of responsibility for the well-being of others or the assumption that someone else is responsible for one's own well-being is an example of such a boundary problem (Kerr, 1981).

Within the nuclear family emotional system, various relationship patterns are utilized to minimize, or bind, anxiety in the system. These patterns often become symptoms of the imbalance in the emotional system (Kerr, 1981). One such pattern in distancing, which is one way to ease the tension created by fusion or togetherness forces. Distancing can be accomplished through various means, including substance abuse, geographic separation, overworking, or periodic silences between individuals in a relationship. "Ultimate forms of distance are cutoff, divorce, or suicide" (Gilbert, 1992, p. 55). The other common patterns are: marital conflict, spouse dysfunction, and child dysfunction. Conflict in the marital relationship often is used in order to create emotional distance from the spouse (Kerr, 1981). One unintended, positive by-product of such conflict, however, is that it can protect the children from becoming the focus of parental anxiety. Anxiety can also be reduced by one spouse consistently capitulating to the demands of the other. Over time, and with heightened anxiety, such compromise will eventually impair one spouse's ability to function, manifested in physical illness, emotional illness, or some other acting-out behavior. In a similar manner, anxiety could be manifested in symptom development in a child. Furthermore, depending on the family's pattern of functioning and the level of anxiety, all three of these nuclear family processes could be present in one family system.

The second basic concept is Differentiation of Self. Bowen, as cited by Skowron & Friedlander (1998), defined differentiation as "the ability to distinguish thoughts from feelings and to choose between being guided by one's intellect or one's emotions" (p. 235). Differentiation describes the measure or ratio of individual energy tied in relationships. At lower levels of differentiation, a greater percentage of energy is bound in relationships. With higher the levels of differentiation, a greater percentage of energy is reserved to direct one's own functioning (Kerr & Bowen, 1988). Differentiation refers to one's ability to adhere to one's own inner convictions, regardless of others' support, while also refraining from pressuring others to change their beliefs and actions (Kerr, 1981). Bowen developed an illustrative model, called "the scale of differentiation", to convey the idea that individual differentiation exists on a continuum, from 0 to 100. One hundred was seen as theoretically attainable, but realistically impossible. However, he also cautioned that this scale should not be equated with psychiatric diagnoses, since symptoms can occur in both higher differentiated and lower differentiated people. The difference is that more differentiated individuals will have a quicker recovery, and shorter course, whereas less differentiated individuals are less adaptable under stress and thus experience more emotional and physical symptoms (Skowron & Friedlander, 1998). Differentiation should not be confused with selfishness, since a selfish attitude may define self boundaries, but fails to respect the boundaries of others (Kerr, 1981). Nor does differentiation mean that one must be unfeeling, or rejecting of relationships. Rather, it "allows for flexible boundaries that permit emotional intimacy and physical unions without fear of merger", (Skowron & Friedlander, 1998, p. 235) or loss of one's singular identity. Bowen also used the phrase "taking an I Position" when referring to differentiation, which represented the basic self position, maintaining a clearly defined, non-negotiable sense of self. He believed that if one worked on differentiating from one's family of origin, one would subsequently have a greater ability to "be a self" in the nuclear family (Kerr, 1981).

A third concept is Relationship Triangles. Triangles are the basic building blocks of an emotional system (Gilbert, 1992), and are more flexible and stable than a two-person relationship system (Kerr, 1988). When anxiety or tension increases in a relationship, the "more uncomfortable" person will move to reduce anxiety by attempting to bring a third person into the situation (Kerr, 1981). This allows anxiety to be shifted around the system, reducing the possibility that one relationship will become emotionally overwhelmed (Kerr, 1988). The other partner in the original dyad now becomes the outsider to this new togetherness. If this occurs during a period of high tension, the outside position is preferred. When anxiety is low, people often prefer the feeling of togetherness in fusion. Interlocking or adjoining triangles develop if more people become involved. Triangles are driven by heightened emotional reactivity; therefore, the potential for triangling activity is greater when the level of anxiety increases. Once anxiety is reduced, the activity of the triangles will be reduced as well. However, the basic connections, or pathways, are still present and available for reactivation in the future (Kerr, 1981). Moreover, these connections typically outlive the people who participate in it; if one person in the triangle dies, another person often replaces him/her (Kerr, 1988).

Family Projection Process is a fourth concept in the theory. This is an extension of the pattern of child dysfunction in the nuclear family emotional process. Family projection, or parental overinvolvement, describes the manner by which lack of differentiation in the parents is often transmitted to the children. As mentioned in the discussion of nuclear family emotional processes, anxiety from fusion and tension in the marital dyad can be deflected when a parent focuses on one or more children. As Bowen noted in his early research on schizophrenia, the most commonly occurring relationship pattern in families with schizophrenia is one in which the mother concentrates a great deal of her emotional energy on one child. The father either distances from the fused pair, or supports the fusion by being in sympathy with it. The focused-on child, then, absorbs the parental anxiety. Having one child as the focus shields the other children from parental anxiety, since the parents worry about the others less and respond to their needs in a more realistic manner. Projection could produce a range of relationship characteristics, from extremely positive to extremely negative or conflictual. In turn, the child may demonstrate a wide range of behavior, from the driven overachiever to the rebellious underachiever, the loner, or the dependent follower (Kerr, 1981).

A fifth concept is Multigenerational Transmission Process. This concept illustrates that serious physical, emotional or social dysfunction in the current family generation is an end product of emotional patterns and process that have been compounding in the family for several generations. This concept is an expansion of the family projection process. Multigenerational Transmission Process occurs because, according to Bowen's theory, people marry others whose level of differentiation is generally equivalent to their own level. Then when parents project their anxiety onto a child, their undifferentiation is transferred to the child, which lowers that child's level of differentiation in comparison to the rest of the family members. The focused-on child may subsequently marry someone with a lower level of differentiation, and the pattern repeats in subsequent generations.

When families are viewed in this manner, serious mental illness, like

schizophrenia can be thought of not as a disease, but as an outcome of the way natural systems operate. . . [and] is a by-product of a long series of compromises the system has made. . . that stabilized the whole at the expense of some of its parts (Kerr, 1981, p. 248).

This view depathologizes mental illness, since such conditions actually serve a stabilizing function in the family system.

A sixth concept in Bowen family systems theory is Sibling Position. Walter Toman's research on sibling positions, published in 1961, helped Bowen clarify his own thinking about the effects of birth order and sibling position on families (Kerr, 1981). Toman, as cited by Kerr & Bowen (1988), stated that certain birth order positions had specific functions associated with them which eventually become part of an individual's personality characteristics. For example, an oldest child may tend to be responsible, and may develop leadership skills, whereas a youngest may tend to be more playful, and more dependent upon others. These functional expectations transcend socioeconomic status, culture, and ethnicity, and have a predictable impact on personality (Kerr, 1981). The spacing of the children is also significant; a gap of five or more years between siblings often reduces the predictability of the characteristics related to each position (Kerr & Bowen, 1988). In addition, the degree to which an individual has been wrapped up in the family projection process also affects the impact of sibling position on personality features (Kerr, 1981).

Emotional Cutoff is the seventh concept, added to the theory in 1976 (Kerr & Bowen, 1988). People commonly react to unresolved fusion in their families of origin and the anxiety such fusion creates by insulating or cutting themselves off emotionally from the family. This cutoff can occur through geographical or physical distance, limiting contact with family to brief and infrequent visits, through internal withdrawal, or through avoidance of emotionally charged issues while in the presence of the family. Such distancing, or cutoff, could also include not speaking to or even looking at other family members for extended periods (Kerr, 1981). Over several generations, ". . . the lines of the family which experience increasing fusion will be the lines also experiencing greater and greater degrees of emotional cutoff between segments of family and family members" (Kerr, 1981, p. 249).

The eighth, and last of Bowen's basic concepts is Societal Emotional Process. Just as families experience the counterbalancing forces of individuality and togetherness, these forces are in operation in societies as well. As societal anxiety increases, so does the pressure and activity of togetherness forces. This gradually erodes the level of differentiation in the society, which seems to compromise functioning based on individuality (Kerr, 1981; Kerr & Bowen, 1988). When anxiety is low, individual rights are valued, without pressure towards conformity or to eradicate differences. However, as anxiety increases, concern for the whole is lost as subgroups begin to fight amongst each other and "will attack the larger structure with its demands to the point of even destroying the larger structure" (Kerr, 1981, p. 252). According to Bowen, the increasing rate of divorce, crime, government instability and "other parameters are symptoms of this ever-intensifying emotional process" (Kerr, 1981, p. 251).

Field Program Description

The following case analysis examines the family system of a client from my field placement agency, which I will briefly describe. The IOS Program is divided into three phases. Clients in the first phase meet five days per week for three to five weeks. The second phase clients meet three days per week for three to five weeks; the third meets one evening per week for a minimum of twelve weeks. Bowen family system theory is the theoretical base for much of the clinical work. The IOS program provides case management, individual therapy, discussion groups, family-of-origin exploration groups, and psychoeducational groups. Program staff members also conduct random urine screening of all clients and psychiatric service providers offer medication monitoring. All new clients review and sign a contract, which explains the program's guidelines. These guidelines include program attendance requirements, compliance with urine screening, and completion of weekly self-help attendance logs.

Case Study: Phil

My individual client was Phil, a twenty-seven year old, African-American male. (The client's name has been changed for confidentiality.) He was referred to the program by a community-based, case management agency. His DSM-IV diagnosis was schizophrenia, paranoid type and cannabis dependence. Phil had a history of minor assault charges since his teenage years. He also had a seven-year history of cannabis abuse, but reported being substance free since October 1999. When he entered the program he denied the presence of any active psychotic symptoms, and was reportedly taking antipsychotic medication as prescribed. His first psychiatric hospitalization occurred five years ago while he was incarcerated at the county jail for distribution of controlled substances. He stated that he first experienced auditory hallucinations after several months of solitary confinement. According to his psychiatric records, which do not mention the solitary confinement episode, Phil reportedly began to have delusions and told correctional staff that his cellmate was a Satan-worshipper who had cast a spell on him. He also reported auditory hallucinations at that time. The second hospitalization occurred after he had finished his jail sentence and had returned home. His records state that his mother called the psychiatric screening center after Phil exhibited bizarre, destructive behavior, and reported auditory hallucinations. At the time of the second hospitalization he admitted that he had not been taking his medication. Phil currently resides with was his mother, Ruth, and her domestic partner, James.

Phil began Phase I of the IOS program and was assigned to a medication clinic psychiatric service provider for medication monitoring. As with all other clients, he attended the various groups five days a week, and was assigned to me for individual "coaching", as Bowen called it, once a week. Since both the phases and the entire program are time limited, we referred Phil to more long-term services in the community. Early in the program, he stated that he would like to re-enter the workforce, and was interested in construction. He had prior work experience in this field, which he reportedly enjoyed. Therefore, we referred him to the State Division of Vocational Rehabilitation (DVR) for vocational/career assistance. He mentioned that he wanted to keep himself busy, so that he could "stay out of trouble", and was concerned about how he could occupy himself in a productive manner in the other, less intensive phases. For this reason, we referred him to a "Partial Care Program" offered by my field agency. The Partial Care Program is a day program for chronically, mentally ill adults. It provides case management, vocational training, and job coaching/placement.

As mentioned earlier, most of the staff and all of the student interns use Bowen family systems theory in IOS program group and individual sessions. Staff conduct initial family evaluation interviews, as well as ongoing group and individual work. According to the theory, the evaluation interview is comprised of five sections: 1) history of the presenting problem; 2) history of the nuclear family; 3) history of the father's extended family system; 4) history of the mother's extended family system; and 5) conclusion (Kerr, 1981). Bowen "believed that pushing people to express feelings did two things: produced distorted or pseudo-emotional responses and retarded movement towards differentiation and improved functioning". In his experience, he found that when he was successful in using fact-based questions to stimulate thought, "anxiety would be lowered and an undistorted flow of expressed emotion would occur" (Guerin, 1991, p. 46). Using theory to guide my practice, I followed the same approach, asking fact-focused questions to obtain the family history. In group and individual sessions I worked towards taking the focus off of the client's symptoms and encouraged the client to describe the emotional climate of the family, since every family member reacts to and contributes to the anxiety in the family. Moreover, according to the theory, blaming self, blaming others, or hoping to change others is not a very productive focus, although it usually serves the function of binding anxiety in the system. I also discussed multigenerational process during group and individual sessions and, when appropriate, asked clients if they have any motivation to reconnect with family members from whom they have become cutoff. If the answer was no, then the family issue was put aside for the moment, but was picked up again in later sessions. If the answer was yes, Bowen often would suggest starting with the relationship that is least emotionally charged (Kerr, 1981). As the sessions progressed, I attempted to maintain a research attitude and avoided side-taking in order to remain detriangled (Kerr, 1981; Titelman, 1998). I also helped clients to anticipate emotional reactions from family members or close friends who often try to undermine one's efforts to be more differentiated (Kerr, 1981). Bowen also encouraged the use humor at times to neutralize polarized statements or positions expressed by clients in individual or family sessions (Titelman, 1998), which I attempted to utilize as well.

The following information was gathered from Phil's first family-of-origin interview. (See attached Appendix for the family diagram unavailable at this time .) Phil stated that Ruth and James have been together since he was young, but are not married. He denied any current or past substance abuse between them. Ruth works for the county transportation department. He reported that his mother was the "backbone" of the family, who "keeps him in the house and won't let him see his old friends" so that he "stays out of trouble". James is currently unemployed and is on disability, although Phil did not know what kind of work James did in the past or how long he has been on disability. Phil reported that Ruth had five children, all of whom have different fathers. The family did not maintain contact with any of these men; furthermore, Phil stated that he did not know any information about his mother's relationships with any of them, including his own father. Phil's oldest sister, Mildred, lives in Georgia with her two sons. Marvin lives in New Jersey. He has used drugs and alcohol in the past, and was previously incarcerated for a sexual assault charge, although Phil said that Marvin "didn't do it". He stated that was unaware of any current use. Randy also lives in New Jersey, is divorced, and has abused substances in the past. Ann is transient, and has moved in and out of the family home over the years. She was a go-go dancer for several years, although Ruth strongly disapproved of this occupation. He said that Ann was planning to move back in with the family and get a warehouse job. Ann's four children live with James, Ruth and Phil because Ruth has temporary custody. Phil did not have any idea when or why Ruth obtained custody. Phil said that when he was a child, Ruth and James spoiled him by buying him whatever he wanted because he excelled at basketball. He said that his siblings were very jealous of this, and it created a great deal of tension between them, especially between Phil and Ann. However, he described his current relationship with Ann as close.

Phil reported that he has two children, Kasey and Jevon. Jen, Kasey's mother, will not allow him to see Kasey because she reportedly is jealous that he had another child. He sees Jevon weekly, since he babysits on Sundays when Stacey, Jevon's mother, goes to work. Phil said that he has only seen his father, Calvin, once, and does not know anything about him. He reported that all of his siblings were born "down South", but he was born in New Jersey when his mother came North. Phil said that he does not know when Ruth came to New Jersey or the reason for her move. Phil's maternal grandfather lives in Georgia, but Phil does not know his name, never met him, and does not know anything about him. Nor does he know anything about his maternal grandmother, or his mother's siblings, except for Raymond, Ruth's brother, who lives nearby. James' mother and siblings all live in the local vicinity, and Phil has more regular contact with them. In fact, Phil reported that he has a close relationship with James' mother, Eva, who often talks with him and gives him money. In addition, he stated that Marvin and Randy do not visit his parents anymore because Ann's children are so unruly and uncontrolled; this behavior causes Ruth a great deal of worry and stress. When asked about James' response to the children's behavior, Phil stated that James escapes the chaos by leaving the home each weekend to gamble and smoke with his friends. When asked about Ruth's reaction to James' behavior, Phil stated that she does not say anything to James. However, Ruth often complains to Phil about James' behavior, and reportedly allows James to stay away each weekend as long as he brings his gambling winnings home.

During family of origin interview sessions and individual sessions, Phil gave information that provided me with a basic understanding of Phil's family. Over time he began to gain greater clarity about the family relationships and was able to recall additional family history details. Cutoff has been a recurrent pattern in his family, reflecting a multigenerational transmission process. This is evident by Ruth's serial relationships, her geographic cutoff from her family of origin, Phil's lack of information and contact with his maternal or paternal family, lack of contact with his siblings' fathers, the general lack of long-term, stable relationships among Phil's siblings, Ann's serial relationships and loss of custody, and Phil's lack of contact with his daughter. In addition, Phil, who is his mother's youngest child, clearly was the focus of the family projection process, and seems to be quite fused in his relationship with his mother. Phil reported that his mother confides in him when she feels worried or upset about various situations, and that his mother "needs him" in the home for support and assistance with the children. The primary triangle in his family includes Phil and his mother, with James as the outsider. This triangle was clearly illustrated for me during one conversation I had with Phil. During a session, Phil mentioned that he and his mother were looking for a new apartment. I asked about James. He added, "Oh. He'll come, too", as if he had completely forgotten about James' existence. Phil's family system fits the common pattern of projection in a family with a schizophrenic child, as described earlier. Also, Phil reported that in recent years James has begun to favor Ann in many ways, by giving her money, and bailing her out (often literally) of various legal and interpersonal difficulties. These are things he does not do for Phil. It appears that Ruth and James have dealt with anxiety in their relationship by focusing on their children and grandchildren. In addition, Phil reported that both he and Ruth favor Ann's youngest child, Janae, just as he was favored by his parents and grandparents. Therefore, favoring the youngest child seems to be another multigenerational pattern in his family.

I have had ten sessions with Phil since he entered the program. Initially, Phil presented with flattened affect and unclear speech, partly due to his use of slang. He was over six feet tall, muscular, and often was casually dressed (sweatshirts, sweatpants, construction boots). Although we were able to gather some family history information from him, Phil's memory and reporting skills appeared to be weak. He had difficulty giving information in chronological sequence and had poor insight, which seemed to be indicative of his intellectual functioning. He reported that he did not know why he was referred to the program, although he knew his mother wanted him to stay out of trouble.

In the first session, Phil seemed somewhat uncomfortable, as evidenced by a slightly anxious facial expression, and some intermittent foot tapping. He only spoke in response to direct questions, using short sentences. In order to help him feel more at ease, I employed the use of humor and minor self-disclosure (i.e., comparing the size of his family to mine). These techniques were effective in engaging Phil. I was surprised to observe a change in his affect over time. As he became more comfortable, he began to display a fuller range of affect, including smiles, and laughter; he occasionally made humorous comments as well. Bowen used fact-focused questions, with which he hoped to prod people's thinking about important family issues and events (Guerin, 1991). Therefore, I approached the sessions with a "research attitude" and continued to ask him questions about his current circumstances and his understanding of his family's emotional process.

Bowen believed that promoting better levels of differentiation in a client system and a reduction of anxiety is dependent upon the therapist's ability to maintain his/her own differentiation when working with the family, by working on his/her own family of origin issues, and to manage his/her own anxiety (Wylie, 1991). This focus on the therapist's level of differentiation is central to Bowen's theory, and is the most critical aspect in being able to coach a client towards differentiation. Bowen believed that therapists needed to experience the emotional shift themselves in order to be fully grounded in the theory and to see its benefits. For this reason, I have eagerly begun working becoming more neutral about my own family-of-origin. I have been able to gather some information about my family through discussions with my parents. I have also gained insight through discussions with my field instructor in supervision, staff debriefing sessions, and personal reflection. There is a significant amount of cutoff in my own family, largely due to geographical distance. Both sets of my grandparents are from Jamaica, and have lived in numerous places in the Caribbean as well as in the United States. Currently, my maternal grandparents and most of my aunts and uncles live in Florida. My father immigrated to the United States on his own as a young man; his siblings currently reside in the Caribbean and in England. This cutoff has led to increased focus upon me and my siblings, particularly by my father. As the eldest daughter, I was explicitly encouraged to be responsible and to be achievement-oriented. In response, I overfunctioned in my family, and occasionally viewed myself as an extension of my parents, caring for my siblings and enforcing the household rules when my parents were not present. I also have realized that I still have a tendency to overfunction in my relationships, especially when I am feeling anxious.

Reflecting upon my family of origin has helped me to have a greater appreciation for clients' efforts to become more differentiated, and to become more self-aware. Initially, I felt uncomfortable about working with Phil because of his presentation, his looming size, and his assault history. I had never worked with a client diagnosed with schizophrenia before; therefore, some of this fear was also due to my own unfamiliarity and prejudice about the diagnosis as well as my own past experience as a victim of assault. However, after I admitted this to myself, and openly acknowledged my fears in discussion with my peers, I was able to manage my own anxiety and focus on the work with Phil. One thing that I observed about myself was that at times I drew back from asking questions that would require Phil to think more deeply about an issue. I think that this may be partly due to my own desire to spare him from any emotional discomfort, or make the session "easier". This could be seen as my attempt to overfunction for him, which I have a tendency to do, as mentioned earlier. I think that it also could be due to my own anxiety level, and my inability to listen closely at those times of personal anxiety.

One incident was a particularly significant learning experience for me. During one session, Phil told me that he and his stepfather spank his nieces and nephews with a belt when they are disobedient and unruly. He stated that he spanks them on the buttocks, although they are clothed when this occurs. I inquired about any physical signs of injury, such as cuts or bruises, which he denied. Immediately following this session, I informed my field instructor. He stated that although we were required to report this information to the state child protection agency, he wanted to avoid cranking up the family's anxiety and prevent an angry backlash against the client. Therefore, he recommended that we meet with Phil and his parents first. In our meeting, I began by telling the family that Phil had shared about his love for his nieces and nephews and his frustrations with their behavior. I restated Phil's comments about the spankings, and told them that the state's guidelines do not advise spanking with an implement because of the potential for injury. I also mentioned that those guidelines also require that we report this information so that the family can receive the attention and assistance needed to address the children's behavior. Overall, Phil's parents were quite pleasant and receptive to the information. They did not appear to be frightened or threatened by the discussion at all. By conducting this family meeting before making a report to the state agency, and by approaching this sensitive issue in a calm manner, my supervisor and I were able to avert an anxious response in Phil and his parents. I thought that this was a very successful intervention because we fulfilled our legal obligation, yet preserved the therapeutic relationship with the client and his family.

Over time, Phil seemed to develop some insight into his family emotional process, as evidenced by his statements about the family relationships and his occasional use of Bowen terminology as well. He identified and described his relationship with his mother and James as a triangle. He also identified himself as the focused-on child, and pointed out a multigenerational pattern of favoring the youngest child. However, he did not see his overwhelming dependence on his mother as a source of anxiety, and was unable to see his own underfunctioning behavior as problematic. Due to lack of transportation, his family members were not able to participate in any sessions with me. Phil's transportation to the program was paid by Medicaid and provided by the county. However, these institutions do not operate from a systems perspective; they view the client as an individual, not as a family, and do not provide transportation for other family members. However, if the circumstances were different, I would have worked with Ruth as well, either through individual or joint sessions with Phil. She seems to be the strongest, and perhaps most motivated, person in the system, and therefore, has more power to effect change than Phil does. In the initial joint session, I would tell Ruth that Phil gave me some of the information in the previous session, but I wanted to gain a better understanding of their problem and fill in some of the information and dates that Phil could not remember or did not know. I would ask for specific dates of symptom development and exacerbations. I would ask about the history of her relationship with James, and the present functioning of each of her children, including the grandchildren which reside in the home. I would also ask about James' siblings, his family stability, the quality of his contact with his family members, and his parents' health, educational, occupational, and marital histories. I would then ask the same about Ruth's family. I would tell Ruth that Phil has said that she is the family backbone, which is a heavy, and potentially overwhelming responsibility. I would ask Phil's mother if she would be willing to meet with me on a regular basis to talk more about what could be done to help the entire family. According to Bowen's theory, family work does not need to draw in all family members because one person's change, or steps towards greater differentiation, will affect the entire system, particularly if sessions occur with the most motivated person in the family (Bowen, 1985). In addition, since Phil has been the symptomatic, focused-on child in his family, seeing Ruth individually would give her greater opportunity to work on herself. By working with Ruth, I believe that Phil would experience greater stability and increased levels of independence as Ruth began to define a self. I also think that Ruth would be able to reduce her overfunctioning behaviors and eventually find greater relief from the stress of carrying the family.

Conclusion

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