CASE EXAMPLE:

THE CASE OF GEORGE’S

ANXIETY
BOWENIAN FAMILY THERAPY
HAYALEE JOY C. VICENTE-ESTOYA
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SESSION 1
• George, 42-year-old Caucasian male, referred by psychiatrist for psychotherapy
on depression and anxiety
• Occupation: Doctorate-level manager in grant-funded educational foundation
• Duration of depression: Two years
• Onset of depression: Linked to promotion to high-pressure, low-autonomy
middle-management position
• Past year: Worked with employee assistance counselor, providing some relief of
depressive symptoms but remaining anxious
• Difficulty not taking on problems of employees
• Marital status: Married for 12 years, happy and secure in marriage
• Children: Two daughters, ages nine and five, doing well, supportive wife
• Recent difficulty maintaining boundary between work and home, bringing stress
home
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SESSION 1
• Often returns to office in evening to work on projects and calm anxiety
• Family history: No anxiety disorder; mother described as unhappy; overinvolved
relationship with mother during childhood; father withdrew to workshop during
teen years, closer relationship with mother
• Siblings: Two younger brothers, ages 34 and 32, all doing well, graduated from
college, in stable relationships
• Negotiating therapeutic contract toward end of first session
• Medication: Antidepressants and benzodiazepine prescribed
• Goal of therapy: Address personality issues to eventually stop medication use
• Previous depressive episode during junior year in college, when moved out of
house
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5

• Significant patterns in the genogram revolve around George’s

relationship with his parents

• Father withdrew from family during George’s teenage years, spending

more time away, working overtime, and tinkering in a workshop

• George felt father was avoiding his mother

• George had an overinvolved relationship with his mother, feeling elected

to serve as her companion when his father became less involved

• Continued throughout high school and college years

• Initially stayed at local community college for first two years of college
because not ready to move out; later corrected to staying home because
mother was not ready for him to move out
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• Therapist suggests neither George nor either of his parents was ready for
him to move out

• Current relationship with mother sometimes strained

• Mother adds "helpful advice" or encourages attending the church George

grew up in during phone calls

• George and his wife have chosen different denominations for religious
practices, his mother tries to make him feel guilty for not raising his
daughters in the "right church"

• Talks to both parents at the same time on the phone, indicating a strong
triangle between him and his parents

• Encouraged to write letters to each parent individually, not one letter to

both, to address emotional triangles and dynamics
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SESSION 3
• A significant decrease in George’s anxiety was reported in the third session
• Able to stay out of employee conflict, resulting in less stress at work
• Employees resolved conflict themselves when George stayed out of it
• George used self-soothing skills, and talked to himself with a supportive
voice
• The previous critical voice he heard was his mother’s
• Exploration of George’s relationship with his parents in session
• Wrote separate letters to each parent but found them too superficial to send
• Concerned confronting mother would worsen her depression
• Father handles mother’s depression by withdrawing and engaging in
activities outside home
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SESSION 3
• George unable to express anger despite appearing angry; his parents unable
to accept negative feelings from him during his teen years
• George withdrew into music as an expression of feelings
• Discussion on setting boundaries with parents, especially the mother’s
constant advice-giving
• George is anxious and tearful discussing setting boundaries, he feels it would
express ingratitude toward parents
• Therapist suggests writing separate letters to express gratitude and set
boundaries, George agrees but finds it difficult
• George agrees to bring a draft of letters to the next session
• Anxious about talking to just one parent on the phone, open to the idea of
writing separate letters
• Homework assignment: Write separate letters to each parent expressing
gratitude and setting boundaries
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SESSION 4
• George arrives at the session with drafts of letters to each parent

• Reports feeling significantly less depressed between sessions, and

wonders if medication is starting to work

• Therapist attributes improvement to setting better boundaries and

emotional self-care, along with medication

• George shares difficulty writing letters, tearful at several points but

allows himself to feel emotions

• Anxiety diminishes as he writes letters over several days

• Letter to father discusses abandonment, expresses a desire to be closer

in future, extends an invitation to talk in person
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SESSION 4
• Letter to mother longer, discusses abandonment and feelings of
inadequacy from her advice-giving

• Confronts mother for pattern of offering praise followed by criticism

• Examples of mother's criticism provided, such as praising

achievements but adding qualifiers

• George fearful of parents' response to receiving letters, thought they

were for his benefit and not to be sent

• Therapist asks what he's afraid of, George fears losing relationship
with parents
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SESSION 4
• Therapist emphasizes healthy relationships allow honest
communication

• George tearful and quiet as session ends, therapist asks him to consider
what it would take to send letters

• George unsure what it would take to send letters, feels comfortable

sharing feelings with wife and daughters

• Describes having family meetings to discuss issues with daughters,

therapist notes positive aspect of not needing parents' emotional
maturity in relationship with daughters
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SESSION 5
• Session held three weeks later after George's work-related travel

• Conflict with wife over expenses related to renovations to living room discussed

• George felt abandoned and unappreciated due to his wife's concern about the project cost

• Started project as a surprise when wife was away, hurt when she raised concerns upon return

• Withdrew from wife for several days, experienced a slight increase in depression and anxiety

• Used medication and positive self-talk to pull out of depressed mood, previously would have
been in bed crying for weeks

• Recognized the similarity of feelings to adolescence when his mother criticized him
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SESSION 5
• Took responsibility for feelings and sought resolution with the wife instead of dwelling on the hurt

• Productive conversation with wife, both took responsibility for emotional reactivity

• Agreed not to take parental roles during arguments, instead be peers

• Therapist praises innovation and positive change in relationship

• George decides to discuss his relationship with his mother in person, the therapist offers to invite her for
the session but George declines

• George feels he can talk to his mother on his own and wants a session to plan a conversation

• Family reunion in three weeks provides an opportunity for discussion with the mother

• Feeling much better, requests follow-up session in two weeks

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SESSION 6
• George reports feeling not at all depressed or anxious between sessions
• Attributes newfound ability to not be drawn into conflict at work to feeling good about himself
without immediate approval from staff
• Reports deeper connection with wife, several long talks about future of family and made decisions
based on conversations
• Wife will cut back work to half time to spend more time with children, despite financial burden, feel
good about decision
• Better relationship with daughters, taking separate outings with each to develop better relationship
• Shifted from feeling self-conscious with daughters to feeling more at ease, no longer concerned about
others' opinions
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SESSION 6
• Prepares for talk with mother in last half of session, approaching her from position of love with goal
of closer relationship
• Decides not to approach mother out of anger or seek explanation for past behavior
• Requests to speak with mother alone, without father present, writes her requesting time alone
• Mother responds with phone call inquiring what's wrong, George sets boundary and says he wants to
talk about their relationship
• Mother initially angry but apologizes when George doesn't engage with her anger, looks forward to
talking further
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SESSION 7
• George arrives in good spirits for session, discusses reunion with mother
• Conversation with mother went better than expected
• Mother acknowledged tendency to criticize, discussed struggles with perfectionism and emotional
abandonment by father
• George set limit by telling mother to work out issues with father, mother took responsibility for relationship
with husband
• Agreed to work on being closer, mother agreed to try not to criticize, both expressed concern about mother
falling into old pattern
• If mother criticizes, George agreed to confront her
• Mother expressed desire to be closer to grandchildren, admitted possibly avoiding George due to fear of
criticism
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SESSION 7
• Therapist mostly listens, gives positive feedback to support change in relationship with mother
• George reports no depressive or anxiety symptoms, job still stressful but able to maintain healthy
perspective
• Comfortable taking medication for now, grateful for therapy "coaching"
• Wants to follow up in four weeks for wellness check and possibly work with wife on discussing finances
• Review course of therapy, reinforce positive changes in differentiation and setting boundaries in
relationships
• Offered option to return sooner if needed
• George thanks therapist for help, session ends
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George's therapy journey highlights several key aspects of
his life and relationships:

1. Therapeutic Relationship Development and

Assessment: The initial sessions focus on establishing
rapport, assessing George's situation, and identifying
areas of concern, particularly his struggles with anxiety
at work and difficulties in his relationship with his
parents. His secure and satisfying marriage initially
leads to his wife not being brought into the assessment
process.

2. 2Work on Emotional Triangles: George shows

progress in detaching himself from triangles at work
but remains entangled in one with his parents. The
therapist educates George about emotional triangles
and works with him to address this dynamic, providing
coaching on setting boundaries and fostering healthier
relationships with his parents.
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3. Progress and Setbacks: George experiences both

progress and setbacks throughout therapy. He initially
feels better after addressing his relationship with his
parents through letter writing but faces challenges in
sending the letters. Subsequent regression occurs, but
George demonstrates self-awareness and a willingness
to address issues, such as withdrawing from his wife.

4. Focus on Family of Origin: George actively works to

create a different family dynamic than the one he
experienced growing up. He recognizes the need to
change his relationship with his parents and prepares to
approach them in a constructive manner, seeking to
disrupt intergenerational transmission processes.
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5. Reinforcement of Positive Changes: The therapist

reinforces George's progress and successes in therapy,
acknowledging his efforts to improve his relationships
and emotional well-being. George's request for follow-
up sessions with his wife indicates a commitment to
further enhancing their relationship.

Overall, George's therapy journey underscores the

importance of addressing family dynamics, setting
boundaries, and fostering healthier relationships to
promote personal growth and well-being. Through
therapy, George gains insights and skills to navigate
challenges and create positive changes in his life and
relationships.
THANK
YOU