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Empty nest syndrome vs empty nest trigger: psychotherapy formulation based on systemic approach - A descriptive case study *Naveen Grover and **Priyanka Dang *Asst Professor **Clinical Psychology Trainee Department of Clinical Psychology, Institute of Human Behaviour and Allied Sciences (IHBAS), Dilshad Garden Delhi 110 095 Corresponding author: Naveen Grover, R No 123, Academic Block, IHBAS, Delhi 110095. Email:
[email protected]. M- 9868396834 Abstract The description of process of psychotherapy in single case study is crucial to improve the art and craft of psychotherapy. However, despite widespread acceptance of its importance among academicians there is dearth of descriptive accounts of case studies. The present paper attempts to describe the process of assessment and formulation highlighting the possible traps professionals may fall prey to using case study method. The case study describes psychotherapy with a couple who came with the chief complaint of empty nest syndrome with one parent at the center of problem. The detailed evaluation led to an alternative formulation following system’s approach paving way for better management plan. The paper emphasizes the need to take a step back, especially in the cases of where “obvious” easy explanations are available. The time spent on the assessment could become a game changer, as happened in the present case. However, it has its own drawbacks as it may require significant time, energy and courage on the part of clients, therapists and systems. Key words: Case study; descriptive approach; empty nest syndrome; psychotherapy; family system.
*Blinded Manuscript Click here to download Blinded Manuscript: naveengrover.blindedMSdocx.docx Click here to view linked References 1
INTRODUCTION
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The family life cycle is defined as the period beginning with the formation of the emerging adult to joining of families through marriage, the addition of children, families with adolescents, launching children and families in later life (Carter and McGoldrick 1980). One of the key issues associated with the launching children stage of the family life cycle is the ‘empty nest’ (Carter and McGoldrick 2005; Lachman 2004). Empty nest syndrome is a feeling of distress parents may feel when all children of the family have launched out independently in their life. The feelings of distress could be more for women because her worth in the society is attached with the mothering role. The distress could be more evident when the woman is full time mother. The launching out could lead to depression, anxiety, guilt and stress. There have been concerns whether empty nest syndrome is a reality or myth (Raup and Myers 1989). The concerns could be due to the fact that sometimes ‘empty nest triggering dormant conflicts’ is passed on as ‘empty nest syndrome’. Theoretically there is difference between the two: empty nest syndrome means that major problem is launching out of the last child i.e. structural change in the system but ‘empty nest triggering dormant conflicts’ means major problem is avoidance/denial of presence of conflicts in the system with the help of children. As the last child moves out, the system may still try to remain in denial mode by calling it ‘empty nest syndrome’. Psychotherapy involves application of psychological principles to the psychological problems (Wolberg 1977). It is not that only psychologists make use of the psychological principles. The clients and their family members also use their own common sense formulations to solve problems. Most of the time, their formulations are based on the obvious facts related to immediate past. They may accept the first available explanation and if it is accepted by significant others, then there is no looking beyond. When these common sense formulations do not bring desired results, they may seek professional help. Like clients, professionals can also get into the trap of using the first available explanation and use the easily available label. Thus, one of the crucial components of psychotherapy training becomes to differentiate between common sense formulation and clinical formulation. The psychotherapy training needs to emphasize going beyond the obvious. It is to be appreciated that in human behavior there is no space for single factor unidirectional formulations. Co-responsibility, the idea that all parties in a social system contribute to a shared reality, is a difficult concept to grasp (Lappin 1988). Although the premise may sound simple and even obvious, it is by no means easy to apply. A careful detailed psychological assessment is warranted in psychotherapy cases before settling down for the formulation to grasp these concepts and ideas as it has significant management implications. In this context, the present psychotherapy case study illustrates the role of detailed psychological assessment in uncovering the erroneous
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use of empty nest syndrome. The index client and her relatives had formulated the problem as empty nest
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syndrome based on the temporal relationship between symptoms and the event of the last child leaving home. The fact that the relatives also believed in the empty nest syndrome explanation for their distress made it look more convincing. The family delayed seeking help believing in single factorial link between distress and empty nest. The delay exaggerated negative repercussions for the family system. The paper tries to achieve its objectives through descriptive account of a case study, similar to earlier attempts by Madan and Grover (2011) and Grover, Kaloiya and Singh (2008). The case study method is very useful in different fields of specialty, especially in psychology (Willing 2001) and plays an important role in the improvement of art and craft of psychotherapy. Similarly, the descriptive approach has a significant role in deciphering the data available and making meaning out of it (Willing 2001). Its acceptance among academicians is not doubted but there is significant lack of published scientific literature following the description of a single case study. In the present case study, a total number of 10 assessment sessions including intake session were held. There were three joint sessions with single therapist (60-90 minutes) and three sessions each in male-male and female-female pair (45-60 minutes). The initial 6 sessions were held at twice/week frequency. They were tapered off to once/week frequency later. The history is divided in different sections. Each section is immediately followed by comments for the ease of the readers to relate discussion and presented information. INITIAL PHASE OF ASSESSMENT The first contact and the chief complaint: 55 years old woman came to the hospital for depressive symptoms and suicidal ideation with her 60 years old husband. They both wanted ‘some treatment’ for wife. They believed that if she could get some work to keep her busy the things will be fine. They did try the same thing on their own but in vain. They heard about the services at hospital and wanted to check it out. The perfect picture: They had an arranged marriage at an early age. The husband family was highly educated given the standards of time of his marriage. The wife’s family was more orthodox than that of the husband family. They both reported that they had a perfect family life and reputation of a perfect couple. After marriage they had an extended family including mother-in-law, and mother-in-law’s sister. They tended well to the old age mother and sister before they died due to natural course of life. She adapted herself extremely well to the household activities and enjoyed homemaking. They had three children one girl and two boys. Their well educated, settled children and successful business were validating proof of their more than satisfactory life. They had their roles divided in an unsaid manner complimenting each other.
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The self-help formulation and solutions backfired: According to them the wife started exhibiting depressive
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symptoms when their third and last child left home for his job. The elder two children, a girl and a boy, were already married and settled abroad. They believed absence of children left her with no work and she started remaining sad and irritated. Thus, they tried to go out and spend time with each other to bring her depression down. The move backfired and gave rise to interpersonal conflict among them. The issue was then discussed among family and relatives. They all suggested keeping her busy because they also believed that absence of children left her with no work, which in turn is causing the problems. The idea of her visiting his workplace to keep busy created more rifts among them. The husband felt humiliated at workplace and wife felt humiliated at home front. The attempted solution became a problem. When things did not work out through self-help then they sought help of mental health services in private sector. They did not feel satisfied with the treatment as they felt medications may not be the solution. Finally, they reached the hospital (current contact), a territory care government mental health institute, for help. They had come with the expectations that something will be done with the wife to resolve the problem and they will continue with same earlier structure of life. Comments Culture played an important role in shaping their behavior as a ‘perfect couple’. In the present case study, they got the label of ‘perfect couple’ based on the role played by them as per their cultural expectations i.e. husband as successful breadwinner and wife as warm homemaker. In the Indian culture, emotional over-involvement in the form of taking care of old parents and making decisions for young children is perceived as duty and interpreted positively (Singh, Harley and Suhail 2013). In all probability, every culture perceives financial stability in the family system as positive. The rewards from their cultural environment about roles expected and their abilities to handle these expectations led to the formation of two distinct parallel role paths. A perfect couple, a perfect family and a significant temporal relationship between empty nest and symptoms: in other words, a perfect ground for committing errors in professional work. One can easily commit mistakes, like significant others did, overlooking the indications there were to take note of. For example, the fact that increased contact time after the launching out of their children triggered interpersonal conflict among them and that solutions based on the common sense formulation had backfired. Their inability to think of alternative hypothesis reflected poor problem solving skills (D’Zurilla and Nezu 2010) and rigidity in their thinking (Duncker 1945). Their expectations from therapy were to help them remain stuck to the structure which was adaptive at an earlier stage of the family life cycle but had become outdated in the current one indicating “poor fit or dissonance between individual and the environment” (Thomas and Chess 1984). It was discussed that their
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formulation might not be correct and expectations needed to be reviewed. They were suggested that there was a
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need for proper assessment to define the problem. They both agreed for the same. The couple was offered to go through the assessment phase of 2-4 sessions of 45-60 minutes each instead of starting with management (jumping the gun). The assessment was initiated with the objective to understand whether system was facing empty nest syndrome or empty nest was playing the role of a trigger propelling the dormant conflicts onto the surface. It was important to differentiate between the two hypotheses because empty nest syndrome hypothesis lends itself to a coping skills paradigm which might require life-style modifications adaptable to structural changes, whereas the hypothesis of ‘empty nest triggering dormant conflicts’ might require a systems approach requiring conflict resolution, reattribution and modification in perspective to past events. In the process of proving or disproving any hypothesis therapists need to be aware of the trap of self-fulfilling prophecy (Merton, 1968). The therapists need to walk the tight rope and not let the earlier information bring any bias into later assessment. In the present case, the assessment in the latter phase was carried out with an open mind, as far as possible, in the background of above mentioned factors. LATTER PHASE OF ASSESSMENT The façade of perfection is broken: In the assessment sessions, the wife reported neglect, lack of respect and love by the husband. She felt that he was too preoccupied with his work, which was not good for his health. She felt he did not care about her. According to her, he did not interact with her, got irritated very easily when she gave him any reasonable suggestion related to any day-to-day chores. She felt that her husband used outdated methods at his workplace and handled workers rudely. When she gave him suggestions to improve, which she felt were valid suggestions, he got angry. Although, she believed that he was a good person, but now she was finding it very difficult to live with him anymore. According to the husband, she kept nagging him all the time about keeping things in order, kept offering something to eat, came to his workplace and tried to do things in her ways. He offered her to own up responsibility for her suggestions so that the success and failure at the task could be attributed to her and not to him. But she backed out of owing up responsibility. According to him he enjoyed his work and it is not a stress causing factor for him, as felt by the wife He reported experiencing severe stress due to her repeated threats of leaving home or causing harm to self. Progress in assessment following systems approach: After three sessions with a single therapist, they were oriented about family as a system. The decision was made to follow assessment using principles of family system. Individual interviews were conducted by male-male and female-female pairs.
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Description of husband: Husband was an engineer by education and a workaholic. He created his business from
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scratch and had a reputation in the market of a shrewd businessman. He liked to do things in his own way, which, according to him, followed adequate reasoning. He believed in doing things by self and would not get easily satisfied when others were doing it. He drew satisfaction by being perfect at work and it got associated with his self-worth. He would closely monitor his employees for their work efficiency. He described himself as someone who did not interfere in others life. He felt that everyone needed to be accountable for their decisions. He could not forgive easily and kept grudges for long. Description of wife: Wife studied till graduation. She was dedicated to her family and took decisions on her children’s behalf. She always guided them about their life decisions. She drew satisfaction from overt appreciation and warmth and she used it as the measure of her self-worth. She described herself as emotional, ethical and altruistic in nature. She claimed that she taught the same virtues to her children. According to her, she brought them up unlike their father, who according to her was workaholic and detached. She was more driven by emotions than reasoning. Although, she was amenable to suggestions but she was firm in her belief system. Description of the system: They did not get time and opportunity to bond after marriage – but they perfectly complemented each other by dividing role responsibilities. They both did things in their own way. The wife shared an intrusive relationship with the extended family and children; the husband was intrusive at his work place. They both got appreciation for their intrusive behaviors. Husband and wife had an almost opposite philosophy of handling a job – husband more task-oriented and wife more emotion oriented. Wife’s emotional and psychological needs were fulfilled by the children and husband’s emotional and psychological needs were fulfilled by his work. Comments The façade of perfection was broken. The wife took off the veil and spoke about the distress on being treated as center of the problem. In the words of Gottman (1993), they went from being a traditional stable couple to an unstable conflictual couple. The assessment traced back the problem to the lack of fulfillment of the needs of developmental stages of family life cycle (Carter and McGoldrick 2005). It is important to highlight the probable role of culture in the genesis of the problem. The couple played at the hands of their cultural expectations in developing two distinct parallel role paths for themselves by dividing complimentary role responsibilities. These two distinct parallel role paths led to the process of mutual accommodation (Nichols and Schwartz 2004). Often these reciprocal and complementary functions become so ingrained that their origin is
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forgotten and they are presumed necessary rather than optional. As family transactions are repeated they foster
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expectations that establish enduring patterns (Nichols and Schwartz 2004), which may lead to interpersonal conflicts in the system. Throughout their life the couple remained immune to each other’s needs. They did not face demands from each other and did not get the opportunity to learn to provide to each other. Due to the empty nest, the wife started bringing in demands for fulfillment, earlier fulfilled by her children, to the husband. The unexpected new pattern of behavior threatened to destabilize the morphostatis of the system (Speer 1970; Lappin 1988). Minuchin and Nichols (1993) describe the family as being naturally inclined to continue with familiar patterns of interacting, even though developmental changes have made these patterns less functional. Change is regarded as being necessary for growth but there is resistance for change in the system. Sometimes families decide to keep operating at dysfunctional level, sometimes families are able to bring changes on their own and sometimes they may seek assistance if renegotiation cannot be achieved by their own efforts. Seeking assistance can be initiated or retarded by the cultural beliefs. CONCLUSIONS Reporting of description of process of psychotherapy is an important exercise to improve the art and craft of psychotherapy. The present paper describes the process of assessment, the most crucial component of psychological management, complementing Madan and Grover (2011) and Grover et al (2008) earlier case studies which presented the management process. The present paper brings into focus the need to take appropriate time for assessment and formulation. It highlights the traps which could mislead the entire formulation, and, thus, the management. It also shows that the acceptance of a formulation by the clients and their cultural environment is not the yardstick to judge its appropriateness, rather appropriateness of the formulation is decided by its ability to explain the phenomenon at hand and lend itself to effective management. References: Carter, B. & McGoldrick, M. (2005). The Expanded Family Life Cycle: Individual, Family, and Social Perspectives (3rd ed). London: Allyn & Bacon. Carter, E. A. & McGoldrick, M. (1980).The family life cycle: A frame work for family therapy. New York: Gardner. D’Zurilla, T. J. & Nezu, A. M. (2010).Problem-solving therapy. In K. Dobson (Ed.), Handbook of cognitivebehavioral therapies (3rd ed.; pp. 197-224). New York: Guilford. Duncker, K. (1945). On problem solving. Psychological Monographs, 58, Whole no 270.
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Gottman, J.M., (1993). A theory of marital dissolution and stability.Journal of Family Psychology, 7, 57-75.
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