Family Assessment & Intervention: The Crawleys of Downton Abbey

THE CRAWLEY FAMILY

An Application of 21st Century Family Nursing on a 20th Century Family California State University, San Marcos

INTRODUCTION

The Crawley’s are an aristocratic family of historical social status and wealth, living in a large estate called Downton Abbey in early 20th century Yorkshire, England. The family is directed by traditional values, but they are consistently forced to interact and adapt to an ever changing and modernizing society. Robert Crawley, the head of the household, and current possessor of the noble “Earl of Grantham” title, lives with his wife, Cora, and two of their three daughters, Mary and Edith. Five years ago, their youngest daughter, Sybil, died from complications following childbirth. Mary has one son, George, whose father died in a car accident on the day of his birth. Sybil’s baby, Sybbie, also lives at the estate along with her father, Tom. The family shares the house with a large staff whose lives intertwine in a multidirectional manner with the Crawley’s. The royal status of the Crawley’s within the community provides a complex array of exchanges between family members and amongst external sources.

PLEASED TO MEET YOU Robert is a 59-year-old man brought up in an extremely traditional household. While attempting to impart these traditions on his children, he is often confronted with situations that leave him unnecessarily carrying the brunt of the household stressors. He is a loving father, a caring employer to a plethora of household staff, and a comparable businessman. He must confront the realities of aging, and the dynamic interaction between his personal, intimate life and his professional, outward appearance.

From a developmental perspective, Robert appears to have successfully obtained Erickson’s Generativity stage over the opposing Stagnation. To be successful in Generativity, a person must feel like a contributor to society through work or some other means. These individuals have experience, wisdom, and confidence to actively participate in the world outside of them. In Robert’s case, he has raised a family who now has their own family, and he is positioning himself to pass on the “Earl of Grantham” title. He holds himself with confidence in title and family life.

Cora is the 57-year-old wife of

Robert. Coming from a wealthy family, she is a strong willed, opinionated, intelligent, and caring woman and mother to her children. She immigrated to England from America to marry Robert in a pecuniary union that evolved in to a loving and respectful partnership. She is committed to the life she and Robert have created together. She is active in the establishment of a community hospital following World War I, along with Robert’s distant cousin, Isobel. She helps manage the household by garnering personal relationships with the staff, and serving as a counselor to her family.

Developmentally, Cora has also succeeded in Erickson’s Generativity stage. She has helped rear a family that flourishes in many aspects.

Similarly, using her motherly experience in management, she confidently takes on the role of chairman of the hospital.

CHARMED, I’M SURE Mary is 34 years old, and the eldest daughter of

Cora and Robert. She is extremely strong willed, and places much of her energy in to the success of the family estate, often to the detriment of her own needs.

Mary gave birth to a boy, George, four years ago. On the day of George’s birth, Matthew Crawley, her husband and heir to Robert’s title, died in a car accident. George then became the heir to the title as the only male, a stipulation Robert’s father commanded in his will. Mary feels extremely tied to the estate, and believes like her father that she should be heir as the eldest born to Robert. Mary has recently met a gentleman, Henry, for whom she has feelings, but is reluctant to pursue as he enjoys racing cars, a reminder of her deceased husband. She takes on increasing responsibility in the running of the estate, and like her parents, has close relationships with the staff. Similar to her father, her worldview edges towards tradition over the emotionality of modern life.

Since the death of her first husband, Mary begins to struggle with Erickson’s Intimacy versus Isolation as she hides herself in her work rather than engage in the grief of losing a loved one. In this stage, individuals focus on the importance of finding love and intimacy through potential long-term partners. If not, they isolate themselves, experiencing loneliness and fear of dying alone. After meeting Henry, Mary seems to be, once again, on a path towards intimacy.

Edith, the 33-year-old middle daughter of

Robert and Cora, has always sought the love and companionship of a partner. Many of her past relationships has ended in tragedy. She and Mary have a competitive and resentful relationship that has impacted her own happiness. She is increasingly discovering her independence. Through the loss of her sister, Sybil, Edith found strength and self-confidence that had been otherwise absent. As she discovered her own voice amongst a dominating family, she met a man by whom she became pregnant. Three years ago, she gave birth to her daughter, Marigold. Marigold’s father died abroad before they were able to marry, causing Edith to keep her illegitimate daughter a secret from her family. Edith inherited a publishing company from this man. She was able to stay close to her daughter by allowing a couple on staff to adopt Marigold.

Eventually, she revealed the truth to her family, and Marigold was returned to her in the house. Through her work at the publishing company, she met Bertie with whom she has fallen in love.

Like Mary, Edith is navigating Erickson’s Intimacy versus Isolation stage of development. With a new sense of self and of confidence, Edith appears to have successfully overcome Isolation for Intimacy, meeting a partner with whom she shares mutual respect and adoration.

A SIBLING GAINED

Tom Branson is the widower of the Crawley’s third daughter, Sybil. Tom’s initial relationship with the family was as chauffer, but as he and Sybil developed a secret relationship, followed by Sybil becoming pregnant, Tom was reluctantly brought in to the family to protect Sybil and the family’s status. After the birth of Sybbie five years ago, and Sybil’s concomitant death, Tom took Sybbie to Boston. He and Sybbie recently returned to Downton Abbey after Tom’s deciding the importance of Sybbie being raised with her grandparents and aunts.

Tom is very much in to politics, and his fall squarely more liberal than the rest of the Crawley’s. He is originally from Ireland, where much of his politics originate. He has formed a strong sibling-like relationship with both Mary and Edith.

At 35, Tom falls in to Erickson’s Intimacy versus Isolation stage. However, after Sybil’s death, his focus shifted solely to his daughter. In fact, it appears that Tom may be developmentally ahead of his age. He seems to be engaged in a fatherly role even to those his age.

He has completely shifted social class, and works successfully with Mary and Robert on the wellbeing of the estate.

He seems to fall more in to the Generativity stage in his comfort and happiness with his life and how he contributes to society.

FAMILY GENOGRAM

FAMILY ECOMAP

CULTURE, RELIGION & COMMUNICATION Culture The history and sustained wealth and status of the Crawleys places them in a position of power among the staff they employ at the estate as well as within the community, and local and sometimes national governments. This power dictates and allows for an explicit display of privilege throughout their lives. However, the Crawleys make a point to help out those around them who are less fortunate, sometimes to a fault or without invitation. Through their close relationships with a live-in staff of butlers, maids, cooks, and chauffeurs, the family seems to nearly recognize the extent of their privilege.

They engage in traditional celebrations. Dinners are large events with multiple courses, in dressy attire, and are served to them by staff. These engagements are even more elegant when they host guests, a common occurrence. Guests include politicians, diplomats, renowned doctors, and other noble or elite members of society.

While traditional by decree and display, the Crawleys often engage in a feminist-like culture that was virtually unheard of in their patriarchal society. This may be influenced in part by Cora’s American roots.

Religion The Crawley’s nobility places them almost socially as Protestant. This seems to be less of a religious proclamation, and more of a nationality asserted by the family. They celebrate holidays and baptize their children and grandchildren under the Protestant church; however, this appears to be the extent of their religiosity. Tom, on the other hand, markedly defines himself as Catholic, a point of contention during his initial introduction to the inner Crawley circle. Per Sybil’s dying request, Sybbie was baptized Catholic by the request of Tom. This may have been Sybil’s acknowledgement of the importance of Tom’s spirituality over her family’s nationalism.

Communication Style

Verbal The family is direct with their use of language. Their elite status seems to have defined them as born leaders, and their language reflects this observation.

Robert utilizes his patriarchal role to assert his thoughts, especially with his daughters and in professional interactions. He is more reserved in his use of language when engaging with Cora, utilizing a more therapeutic tone. Cora, while direct, also uses therapeutic verbiage when engaging with her husband, daughters, and favored staff. Her directness appears when she feels slighted or in need of asserting power. Mary follows her father in her verbal interactions with Edith, certain members of the staff, and to many of her suitors. Edith speaks her mind often, though her communication style seems less commanding when she is discussing personal matters, as her emotions tend to overshadow the businesslike communication observed by her father and sister. Tom offers his opinions often, and is vocal about his interpretations of various situations. Like Cora, when speaking to his sisters in law, he utilizes a therapeutic tone, and offers objective advice. All members of the family utilize witty banter to express disapproval for someone who is not immediately present.

Nonverbal The Crawley’s all use nonverbal communication to express their true emotions. Robert expresses some disapproval through scoffs, eye rolling, and blatantly ignoring certain proclamations by his daughters. Cora often shows pity on her face. She uses her eyes to emphasize a point. Mary rolls her eyes more than any other family member. She purses her lips when she feels indignant. She will exit a situation when she is extremely disapproving. She also flirts with her eyes to get her way. Edith is much more emotive with her face than the rest of the family, revealing her softer nature. She tears up often, and withdraws when overwhelmed. Tom uses his stance to communicate nonverbally. He positions himself differently based on with whom he is speaking. The entire family exchanges private glances regularly indicating previously discussed secrets.

ROBERT’S CONDITION Robert suffered a ruptured gastric ulcer during an important dinner. He had been experiencing regular pain in his stomach for the three weeks prior to which Cora responded repeatedly with a plea for him to rest. Robert continued to minimize the pain until he experienced dramatic hematemesis while hosting the health minister of England. The Earl had to be rushed to the hospital for emergency gastrectomy.

The most common causes of peptic ulcers are now known to be the bacterium Helicobacter pylori (H. pylori), and the use of non-steroidal anti-inflammatory drugs (NSAIDS), a modern analgesic (Fashner & Gitu, 2015). NSAIDS were not in use in the early 20th century, limiting NSAIDS as a causative factor for Robert’s ulcer. When H. pylori was discovered, it was a new idea and an important finding for peptic ulcers. It is usually acquired in childhood via the fecal-oral route, and resides in the gastric mucosa for many years (Fashner & Gitu, 2015). H. pylori is so common, it is believed to colonize the gastric mucosa of half the world (Fashner & Gitu, 2015).

Epidemiological history reveals a birth-cohort phenomenon of peptic ulcer for people born between 1840 and 1890 in London.

While research cannot accurately define the cause, it is thought that the age of contraction of Helicobacter pylori (H. pylori) may have shifted due to improved hygiene at the time (Sonnenberg, 2006).

This shift affected sequelae of the H. pylori infection. Studies reveal that early contraction of H. pylori allowed for the body to react and protect gastric mucosa over many years (Overmier & Murison, 2013). Therefore, infections in adolescence left the individual prone to ulcer development (Susser & Stein, 2001).

Additional risk factors include smoking and drinking alcohol, both of which were popular during this period (Hopkins Medicine, 2013). Stress has been historically linked to peptic ulcers, but much research has moved away from stress as a factor. In contradiction, many new studies claim the importance of stress in its link to peptic ulcer. For example, one study offered data on the greater extent of damage of ulceration while patients were under stress, which they indicated was caused by the stressors impacting the body’s ability to repair (Overmier & Murison, 2013). Another study revealed that one in five cases of peptic ulcer are idiopathic, and specifically unrelated to H. pylori infection (Charpignon et al., 2013).

Robert is a regular smoker and consumes at least three drinks per night. He is also under constant stress related to the estate, his household, and grief from the loss of his youngest daughter, Sybil. As the patriarch of the family, he often burdens himself with every stressful situation. Further, his unwillingness to acknowledge the symptoms leading up to his ulcer’s rupturing may have impacted the outcome. All of these factors, coupled with the time period in which this peptic ulcer occurred, offer prime indicators as why Robert suffered this outcome.

A FAMILY SYSTEMS THEORETICAL APPROACH Family Systems Theory Family Systems Theory conceptualizes the family as a dynamic, interacting force in which each member affects the family as a whole unit, and conversely, the family as a whole unit affects each member independently (Kaakinen, Coehlo, Steele, Tabacco, & Hanson, 2015). The emphasis on circular interactions within the family system forms all of the functional and dysfunctional outcomes (Kaakinen et al., 2015).

Four primary concepts are utilized to aid the nurse in working with families with an overarching goal of maintaining or restoring stability to help the family achieve its highest level of functioning (Kaakinen et al., 2015): 1. ALL PARTS OF THE SYSTEM ARE INTERCONNECTED For the Crawley’s, Robert’s ruptured ulcer will impact the entire family for similar and diverging reasons. Given the closeness of the family, everyone will experience the stress that comes with fear and worry about the outcome of Robert’s health. Each individual has a specific relationship with Robert, and will thus be affected in subtly unique ways. Family trauma is likely a raw subject given that everyone has experienced the loss of an immediate member of the family, Sybil and Matthew. Depending on personalities and healthy or unhealthy grieving practices, each member may be impacted by the thought of losing another member differently. As head of the household, any upcoming meetings or decisions will have to be put on hold. For Mary, this may mean she will have to invest more time on work. For Cora, she will spend more time consoling her children and grandchildren. Edith will need to miss work to be closer to her family, and fill in for various roles as needed. Tom will likely step in to help with counseling as well as any duties that might be more appropriate for a male member of the family, given the time period. The staff may have to prepare special meals for Robert during the healing process. Other staff may need to work longer hours to care for Robert where he cannot. This will likely have financial impacts on the household. The grandchildren will Strengths & Challenges of the Family Unit have to be educated on what happened to their grandfather.

Strengths • Family is generally a cohesive unit 2. THE WHOLE IS MORE THAN THE SUM OF ITS PARTS • Financial Security allows for top-notch health The risk of temporary or chronic illness causes every member to be thrown in to care uncertainty of how this will affect their understanding of the family they know. If Robert • The family is self-therapeutic between its dies, what role(s) would each of them take? What would happen to the estate, a structure members doused in identity within this family system? Health problems can shift the entire • Everyone is willing to work hard towards the dynamic of a family, an idea that will make each member unsure of a system they have benefit of the system known so long.

• Verbal communication is direct 3. ALL SYSTEMS HAVE SOME FORM OF BOUNDARIES BETWEEN THE • Previous practice as a system in how to SYSTEM AND ITS ENVIRONMENT function with sudden illness As a noble, aristocratic unit, the Crawleys have many closed boundaries separating them • Tom has been accepted in to and functions as from external sources. They utilized one such closed boundary between them and the an active member of the system external community by keeping Robert’s illness a secret. This may serve them by • Close relationship with the staff preventing those looking to profit off of Robert’s perceived weakness since he is in a position of power. A more flexible boundary involved the Crawleys opening up to their Challenges staff in order to utilize them to fill in some of the gaps elicited by this unplanned illness.

• Mary and Edith’s resentment towards each 4. SYSTEMS CAN BE FURTHER ORGANIZED IN TO SUBSYSTEMS other Looking at the multiple subsystems, specific interventions can serve to improve individual • Pride may be self-limiting to Robert’s health relationships from this setting, and eventually the family as a whole. For example, the • Too much focus on the estate may interfere relationship between Mary and Edith is strained, and if the two operate as normal, it may with focus on health cause more dysfunction in an already unsettled system. Providing interventions for • Use of nonverbal communication to express improving their relationship may reduce the impact of Robert’s condition on the family. emotions limits emotive communication Similarly, working with individual family members to identify ways the staff may be able • Overreliance on the staff to provide activities to help, so that individual needs are met, may help to organize a stressful situation. of daily living Looking at Robert and Cora, it may be beneficial to identify ways in which Robert can better reflect upon Cora’s concerns and pleas to rest may improve their marriage and limit the stress Cora feels in regard to her husband’s health.

OUTCOMES & INTERVENTIONS

Problem: Risk for interrupted family process: Risk factor: shift in health status of family member Outcome: Identify ways to cope effectively and use appropriate support systems Interventions: •

Acknowledge the range of emotion and feelings experienced when health status of a family member changes Rationale: Nurses can better support caregivers regarding their perception of family support and expressive family functioning (Svavarsdottir & Sigurdardottir, 2013).

•

Encourage family members to list their personal strengths and available resources.

Rationale: Families provide main support network and family strengths are closely associated with the family use of resources (Coym, 2013).

Problem: Risk for compromised family coping: Risk Factor: family role change Outcome: Family will provide support and assistance to each other as needed to help with new role Intervention: • Incorporate family variables, including dyadic adjustment, into assessment protocols and intervention strategies Rationale: Pereira et al. (2012) revealed a positive relationship among dyadic adjustment, psychological morbidity, and family coping in clients and their partners, in that better dyadic adjustment predicted family coping in the client Problem: Risk for imbalanced nutrition: Risk factor: change in digestive process/absorption of nutrients secondary to gastrectomy surgery Outcome: Be free of signs of malnutrition throughout recovery time Interventions: • Educate family on nutritional needs of a post-gastrectomy patients • Encourage family to participate in and actively support dietary adjustments Rationale: Studies show that supportive intervention and promotion of family support lead to promotion of self-care behavior (Shahriari, Ahmadi, Babaee, Mehrabi, & Sadeghi, 2013).

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Anderson, K.H. (2000). The family health system approach to family health nursing. Journal of Family Nursing, 6(2), 103-119. Retrieved from https://doi.org/10.1177/107484070000600202 Charpignon, C., Lesgourgues, B., Pariente, A., Nahon, S., Pelaquier, A., Gatineau-Sailliant, G., & Courillon-Mallet, A. (2013). Peptic ulcer disease: one in five is related to neither Helicobacter pylori nor aspirin/NSAID intake. Alimentary Pharmacology & Therapeutics, 38(8), 946-954. doi: 10.1111/apt.12465 Di Saverio, S., Bassi, M., Smerieri, N., Masetti, M., Ferrara, F., Fabbri, C., Jovine, E. (2014). Diagnosis and treatment of perforated or bleeding peptic ulcers: 2013 WSES position paper. World Journal of Emergency Surgery : WJES, 9, 45. Retrieved from http://doi.org/ 10.1186/1749-7922-9-45 Fashner, J. & Gitu, A. C. (2015). Diagnosis and treatment of peptic ulcer disease and H. pylori infection. American Family Physician, 91(4), 236-242.

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Kaakinen, J., Duff-Gedaly, V., Hanson, S. & Coelho, D. (2015). Family health Care nursing: Theory, practice and research (5th ed.). F.A. Davis: Philadelphia.

Overmier, J. B. & Murison, R. (2013). Restoring psychology’s role in peptic ulcer. Applied Psychology. Health and Well-Being, 5(1), 5–27. Retrieved from http://doi.org/10.1111/j.1758-0854.2012.01076.x Shahriari, M., Ahmadi, M., Babaee, S., Mehrabi, T., & Sadeghi, M. (2013). Effects of a family support program on self-care behaviors in patients with congestive heart failure. Iranian Journal of Nursing and Midwifery Research, 18(2), 152–157. PMCID: PMC3748572 Sonnenberg, A. (2006). Causes underlying the birth-cohort phenomenon of peptic ulcer: analysis of mortality data 1911–2000, England and Wales. International Journal of Epidemiology, 35(4), 1090-1097. Retrieved from https://doi.org/10.1093/ije/dyl093 Susser, M. & Stein, Z. (2001). Civilization and peptic ulcer. International Journal of Epidemiology, 30, 13-17. Retrieved from https:// pdfs.semanticscholar.org/b35d/60af82aaf0e6fbc15e135325fef6a02d1e35.pdf

Image Refenerences (Untitled Downton Abbey logo). Retrieved from http://backgrounds4k.net/wp-content/uploads/2016/02/Downton-Abbey-free-download.jpg (Untitled image of Cora). Retrieved from https://vignette.wikia.nocookie.net/downtonabbey/images/c/c2/87.jpg/revision/latest? cb=20160707164650 (Untitled image of dinner toast). Retrieved from http://www.iefimerida.gr/sites/default/files/savoir1.png (Untitled image of Edith). Retrieved from https://vignette.wikia.nocookie.net/downtonabbey/images/d/d7/Edith_in_gold_with_headband.jpg/ revision/latest?cb=20160219164217 (Untitled image of family in front of castle). Retrieved from http://d2buyft38glmwk.cloudfront.net/media/images/canonical/downton-abbey-s6how-will-it-end-1920x1080.jpg (Untitled image of Mary). Retrieved from http://4.bp.blogspot.com/-0kdVv5ZXrh8/Voa5qFfaBPI/AAAAAAAAre4/hr4UqlnVusw/ s1600/3a26556b6a312c29e846a340b9c93168.jpg (Untitled image of Robert with drink). Retrieved from https://britishheritage.com/wpfiles/wp-content/uploads/2015/12/DA-HughBonneville.jpg (Untitled image of Robert). Retrieved from https://vignette.wikia.nocookie.net/downtonabbey/images/4/40/Robert_Crawley.jpg/revision/latest/ scale-to-width-down/79?cb=20151229210550 (Untitled image of Sybil). Retrieved from https://vignette3.wikia.nocookie.net/downtonabbey/images/e/e5/SybilCora.jpg/revision/latest? cb=20160219193750 (Untitled image of Tom and Sybbie). Retrieved from http://s1.ibtimes.com/sites/www.ibtimes.com/files/2015/02/25/downton-tom-maryromance.jpg (Untitled image of Tom and Syble). Retrieved from http://fungyung.com/downton-abbey-wallpapers.html Treatment of gastric ulcer. [Web Image]. Retrieved from https://www.epainassist.com/images/treatment-gastric-ulcer.jpg