Alderian and Gestalt Approaches - Case Study Example

The case of Julia 1. Preliminaries The case of Julia can be addressed by at least 250 perspectives in psychotherapy (Myers, 2002 citing Parloff, 1987). Subscribing to the view of Frank (1982), Myers defined psychotherapy as the “planned and emotionally charged interaction between a trained socially-sanctioned healer and a sufferer” (2002, p. 2). Many years ago, Small had established that psychotherapy can cure or alleviate various types of ailments even if the ailment is conventionally believed to arise from non-psychological roots (1980, p. 90-234). Corey (1996) conceded that the main perspectives in psychotherapy include the Alderian and Gestalt approaches. Wade and Tavris identified family therapy as a major psychotherapeutic approach along with other kinds of psychotherapeutic approaches (1998, p. 625-633). However, they emphasize that, in practice, psychotherapists are eclectic or that they are “borrowing a method from here, an idea from there, and avoiding strong allegiances to one theory or school of thought (Lambert & Bergin, 1994, as cited by Wade & Tavris, 1998, p. 632). For instance, psychoanalytic perspectives can be incorporated into the family therapy perspective. Corey had stressed that one important concept is “repression” which is a defence mechanism of the ego (1996, p. 5). Repression excludes unpleasant experiences from a person’s memory. Viewed from this perspective, a treatment can lie on the identification of a repressed memory. For instance, this can mean that we can alter our behaviour based on our discovery of the original motives for our current behaviour. The behaviour persists but we no longer recall the original motives or the original driving forces for our choice of that behaviour. The aim of psychoanalytic psychotherapy is to make the unconscious conscious (Corey 1996, p. 111). The important role of a therapist psychotherapist is for patients to have an insight into their experiences that were repressed by the ego so they can have a control over their behaviour. Alderian psychotherapists or the psychodynamic approach to psychotherapy, however, rejected Freud’s emphasis on biological and instinctual cravings. The Alderian focus is past experiences not biological and instinctual cravings. However, the catch is that Alderian psychotherapists focus on sibling relationships and on a person’s position in the family. Corey says the Alderian psychotherapeutic processes cover identifying mistaken goals and faulty assumptions and these are followed-up by a reorientation of the patient to imbibe constructive goals (1996, p. 139). Myers differentiated further Alderian from the Freudian approach: in the Algerian approach, the therapist talks to patients face-to-face, once a week, and for only a few weeks or months (2002, p. 503). In contrast, in the Freudian approach, the therapist talk to the patient out of the line of sight (not face-to-face/unseen), several times weekly, and for several years (Myers, 2002, p. 503). In Gestalt psychotherapy, the basic goal is for clients to gain awareness on what they are experiencing (Corey 1996, p. 224). The role of psychotherapists is to design experiments that will allow patients to gain self-awareness. Of course, other psychotherapeutic approaches are available. One such approach is existential psychotherapy. Existential psychotherapy rejects a deterministic view. The perspective is identified with Viktor Frankel and Rollo May. There is also the person-centred psychotherapy associated with Carl Rogers. The stress of the perspective is for clients or patients to appreciate themselves and overcome a feeling of helplessness (Corey 1996, p. 204). Reality psychotherapy, that is associated with William Glasser, stresses on making patients realize that they can choose what they think, feel, and experience. Cognitive-behaviour psychotherapy that is associated with Albert Ellis, blame is seen as the root of emotional disturbances and the goals of the psychotherapist are to reduce the patient’s tendency to blame oneself or others (Corey, 1996, p. 321). However, this does not seem to be even remotely relevant for our case. Myers (2002, p. 504) adds to Corey’s list humanistic psychotherapy. In humanistic psychotherapy, the therapist emphasizes on boosting a person’s sense of self-fulfilment by helping him towards self-awareness and self-acceptance. However, based on the case narration, this does not also seem very relevant for our case. We intend to use family therapy for our case. 2. Family therapy Family therapy has been advocated as the main mode of treatment for anorexia nervosa since the 1970s (Steinhausen, 2002, p. 1284). In the 1950s, treatments relied on neuroleptics while in the 1960s, treatments relied on other forms of psychotherapy (Steinhausen, 2002, p. 1284). The primary goal of family therapy is to modify individual habits and family patterns by working with couples (as applicable), families, and other individuals to identify and change patterns that appear to be a problem (Wade & Tavris, 1998, p. 633). Family therapists hold that members of the family have contributed or can actually be contributing to a current state of behaviour of their family members. Thus, behaviour when it is a problem is a problem not of an individual alone but is a family problem and could have arisen because of the status of relationships within a family and with individuals close to the family (Wade & Tavris, 1998, p. 629). According to Tavris & Wade, efforts to isolate and treat one member of the family without the others, are doomed to fail because each member may have mistaken views about each other that contribute to the persistence of an undesired behaviour and the mistaken view are only corrected if members of the family express the views among themselves. Unfortunately, family members are often now aware of how they influence each family member. The family therapist facilitates discussions within the family and, in addition, observes how members of the family interact with each other (Wade & Tavris, 1998, p. 630). For the family therapist, a child “may cling to the illness as a way of expressing anger, keeping the parents together, getting the parent’s attention, or asserting control” (Wade & Tavris, 1998, citing Luepnitz, 1988). A variation in family therapy is multidimensional family therapy that is considered most successful for adolescents (Wade & Tavris, 1998, p. 630). In multidimensional family therapy, there are four targets: the adolescent, the parent, the interaction between the adolescent and the parent, and the other influences on the adolescent outside the family (Wade & Tavris, 1998, p. 630). The investigation of the family therapist need not stop in one generation of the family as the therapy can execute the investigation across generations of a family. The family therapist can be solution focused or strategic, meaning that the analysis may or may not cover several generations (Wade & Travis, 1998, p. 631). One family therapy technique that may be used is the narratives or “the stories that people tell about their lives” (Wade & Travis, 1998, p. 631). A family therapist can also use paradoxical techniques. For example, one method for the treatment of insomnia that works is an instruction for the patient to wake up early and scrub the floor in an effort to show that the insomnia was a product of excess energy and that the client has control over the insomnia (Wade & Travis, 1998, p. 632). Even when a family therapist cannot treat the whole family, the family therapist can treat individuals in a family-systems perspective (Wade & Travis, 1998, p. 632). This implies that one can improvise as needed. Wade & Travis stressed that therapists from all schools of thought in psychotherapy may adopt at least one perspective from family therapy: some therapy problems respond best to treatment in groups (1998, p. 633). As mentioned earlier, psychotherapists tend to be eclectic in methodology as well as in the use of perspectives. 3. Case highlights We highlight the most important data that can have an important bearing in designing our therapy. First, we note that the Julia has lived her entire life in the same house. This implies that the family, her immediate neighbours, and her friends near her home are the most important persons to cover by the therapy---as feasible and as consistent with the client requests for privacy. Second, we note that the client is 17 years old and an adolescent. This implies that the multidimensional family therapy or its improvisation may work for the case. Third, the client articulates that her parents are generally getting along very well and this may imply that we need to focus on a possible marital problem between the parents as a possible source of a possible illness. Fourth, the parents have a busy schedule although the client perceives that her parents, especially their mother, have been trying to give the children more time. Fifth, we note a very important datum: the client is deeply concerned with pleasing her parents, especially her mother, based on the client’s narration of her case. Sixth, we note that the mother is closely monitoring Julia, suggesting that probably the mother is continuously giving Julia explicit as well as implicit approval, in words or action, on anything Julia does. Seventhly, for a high school student, an age usually characterized by rebelliousness and adolescent’s attempts towards independence, Julia tends to follow her parents’ wishes (such as in her parents’ wish that Julia does something athletic and not to hang out with boys). Eighth, we note that the family is not openly demonstrative of their love for one another (hugging is not done at home, for example) and Julia’s love for her parents and mother only find expression in her ability to please her or them in their wish. Ninth, she did not know whether she was actually overweight, but she took a weight reduction program. Tenth, the client is not sure of the cause of her current problems but believes that the problems have something to do with her college life. Eleventh, the client expressed that it was pressure from her coach, teammates, and herself that first led her to diet. However, it is also possible that the client expressed her problem in this manner because she wants to protect her parents from possible pressures and inquiries that will be done or asked by therapists. Twelfth, perhaps a key point in her life that made her diet is that because of being “overweight”, she was doing “poorly” in athletics and had believed that her coach was disappointed in her. Thirteenth, considering that the narration began with a qualification that Julia is 17 years old and the narration mentioned that she was 17 years old when she started the diet, the case of “excessive weight loss” only happened a few months ago or less than a year. When she started dieting, she was 5’6” and 145 pounds. She was 130 pounds when she began college. Fourteenth, the client know exactly what can reduce her weight: diet drinks, pasta without sauce, sticking to diet food (salads, cereal, and yogurt as food in the dining hall “bordered on the inedible anyway”), and complete elimination of dessert. Fifteenth, Julia’s commitment to her weight loss program was reinforced when she believed that her coach was pleased. 4. Preliminary diagnosis The narration suggests that Julia is most likely afflicted with anorexia nervosa. At the same time, probably the more appropriate way of articulating Julia’s situation is that her situation is consistent with the symptoms of anorexia nervosa. Patient UK, a patient information publication group based in Rawdon, Leeds, England, defined anorexia nervosa as an eating disorder (2009). According to Patient UK, an individual with anorexia nervosa deliberately loses weight and the weight loss can become severe and life threatening. Treatment for the ailment may need medication, self-help measures, and behavioural therapy (Patient UK, 2009). According to Patient UK, individuals with anorexia nervosa usually weigh 15% or more below the expected body mass index (BMI) for their age, sex, and height. In Patient’s UK example, if one is 66 kilograms and 1.7 meters tall then his or her BMI is 66/(1.7 x 1.7) or 22.8 BM. Further, according to Patient UK, a normal BMI for an adult is 20-25. Patient UK said that below or above the range implies that one is under or overweight (2009). Adults with anorexia have a BMI below 17.5. According to Patient UK (2009), people with anorexia nervosa think they are fat when actually they are very thin. Further, according to Patient UK (2009), people with anorexia nervosa may vomit secretly, try hard to conceal their thinness by wearing baggy clothes, and tend not to be truthful on what they eat. Other symptoms of anorexia nervosa include irregular periods, tiredness or weakness resulting from vomiting or excess laxatives, muscle spasms, and osteoporosis. Patient UK (2009) has stressed that there are no tests for diagnosing anorexia but a doctor may employ blood tests to check for anaemia or low glucose level and prescribe electrocardiography for assessing complications that can arise from anorexia nervosa. According to Patient UK, anorexia may take weeks or months to improve if managed with treatment (2009). However, the same organization said that it might take several years for people with anorexia to become completely better (Patient UK, 2009). Steinhausen found that of 5,590 patients discovered to have anorexia nervosa, 20% are chronically ill and the rate is indicative for the population of patients at a given time (2009, p. 1284). Steinhausen (2001) also found that the rate of mortality among known patients of anorexia nervosa is 5.0%; chance of recovery is 46.9% among known cases, chronic cases at an incidence of 17.8% of all cases, rate of neurotic or anxiety disorder at 25.5%, and obsessive-compulsive disorder at 12.0% (p. 1285). However, of the 5,590 known cases he investigated in 2001, some 46.9% recovered from the ailment. 5. Literature related to anorexia and family therapy Citing several scientific studies, Eisler et al. (2002) has authoritatively asserted that “family therapy is an effective treatment for anorexia nervosa”. More than that, since the late 70s, family therapy “has gradually established itself as an important treatment approach in eating disorders, particularly with adolescent anorexia nervosa (Eisler et al., 2002, p. 291). Family therapy can be used singly or in combination with other forms of treatment (Eisler et al., 2002, p. 294). In earlier years, the aim of family therapy was to alter the way how the family function (Eisler et al., 2002, p. 292). However, we have pointed out in section 2 of this work that family therapists need not alter the whole family function but only harness the cooperation of family members in modifying the behaviour of an individual family member. Meanwhile, according to Szapocznik (2001), family therapy has a good track record as a psychotherapy. Szapocznik (2001) said that the use of family therapy, especially strategic family therapy, led to a “proven” 42% improvement in conduct problem, 75% reduction in the use of marijuana, and 58% reduction in association with antisocial peers. Family therapy helps children and adolescents who display rebelliousness, truancy, delinquency, and substance use (Szapocznick, 2001). Earlier, Eisler et al. (2007), based on 80 patients, has found that family therapy improved outcomes in patients with early onset and short history anorexia nervosa (p. 1025). 6. Strategies used in related cases Speaking for the Centre for Family Medicine based in the University of Miami, Szapocznick for a strategic family therapy (2009): 1. Organize a counsellor-family team composed of the counsellor and family members. The counsellor must convince family members on the need for them to work together in a therapy. 2. Diagnose family strengths and see how strengths can be harnessed in assisting the ailing. Assess weaknesses in family relations that must be addressed to assist the ailing. 3. Formulate a therapy strategy. 4. Implement the therapy strategy. According to Centre for Family Medicine, some of the protective factors that must be strengthened include family bond, self-concept, appropriate parental involvement, parent-child communication, and conflict resolution (2009). On the other hand, the risk factors that must be addressed include poor tolerance for frustration, unconventional beliefs or attitudes, early and antisocial behaviour. 7. Preliminary case analysis The position of this writer is that the Julia may be in the process of asserting her independence from her parents. In the past, the parents were the source of her need for approval. However, in the process of moving to adulthood, the elders at schools including her coach, were becoming the source of her need for approval. Most likely, the case can be quickly solved because it has probably been existing for only a few months. Studies on anorexia we have discussed earlier also appear to indicate that when anorexia is not yet chronic, there is a high chance for success in treatment. 8. Intended strategy and basis While the Julia’s case as narrated, definitely exhibit a case consistent with the anorexia nervosa, it is the author’s position to verify the situation as treatment based on symptoms is implemented. First, this author would attempt to verify the narrative using a clinical assessment based on the body mass index discussed earlier. Second, as feasible and subject to parental consent and Julia’s agreement, the author would convince the patient and the parents to seek a medical opinion as some of the physical symptoms may be similar with parasite infection, “hidden” goitre, and other ailments. The author is aware, however, that parasite infestation and goitre though possible are unlikely for the case. Evidence based on narrative appears very strong that the ailment is likely anorexia nervosa. Third, simultaneous with the first and the second, the author would organize two teams. One team will be a counsellor-and-Julia’s family team and the other team would be her closes friends or acquaintances at school. The counsellor-and-Julia’s family team would schedule a series of conversations with Julia regarding her situation. The conversations would focus on acquiring mutual understanding between and among family members. The most important family members that must dialogue are Julia and her parents. Of course, Julia and her sibling will be also encouraged to meet and dialogue. The other team that is based in Julia’s school would be composed of key individuals that can likely influence Julia: her coach, closest classmates, roommates, and friends. However, the formation of a team would depend on the consent of Julia’s parents. It appears fine for the counsellor to get the parental consent of Julia for the formation of a team in school because Julia is legally a minor. Most important, the counsellor would be dialoguing with Julia as her counsellor or psychotherapist. The counsellor can take off from the concept of the body mass index as the reference point for excess weight. Julia believes that her weight is excessive. The counsellor can demolish the correctness of her belief based on scientific studies on what constitute excessive weight. Moreover, the counsellor can also explain to Julia the facts of anorexia nervosa: the incidence, the mortality rate, the symptoms, the dangers, and the risks. The counsellor can also emphasize to Julia that individuals who are afflicted with anorexia nervosa tends to deny that that they are getting thinner and tends to hide that their bodies are getting too thin. Fourth, the two teams led by the counsellor would be requested to meet regularly for some time to assess Julia’s situation and see if progress are being made. In one-to-one conversations and dialogues with Julia, the main emphasis of the counsellor would be on the following: 1. That Julia becomes aware of her situation. 2. That Julia acquires new goals: advancement without sacrificing her weight based on the BMI index and interacting with people more and deriving pleasure from the interaction. 3. The counsellor will not contest Julia’s mistaken notion that she is not fat because the study of Hodes et al. (1991, p. 359) indicate that the strategy does not work. Instead, the counsellor will attempt to convince Julia to maintain the appropriate body mass index or BMI based on her age and height. 4. That Julia strengthens her bond with her family. 5. Through psychoanalytic techniques, conducted in a conversational way, the counsellor would attempt to lead Julia to her self-awareness of the possible underlying reasons for her ailment. In conversations with Julia’s family, the counsellor would emphasize to her parents the following: 1. That the parents, both the mother and father, should attempt to interact more frequently with Julia even if the situation is now different (that is, Julia is in college and can be away from home in long periods). 2. That the parents support the counsellor in the work to have Julia realize her situation, acquire new goals, and strengthen her bonds with her family. In the conversations with the team organized in school by the counsellor, the counsellor will suggest to members, especially to Julia’s coach, that they take Julia’s apparent case of anorexia nervosa more seriously. The counsellor must request the coach to assign new goals for Julia based on her situation and the new goal must be right weight and not weigh reduction. References Atkinson, R., Atkinson, R., Smith, E., Bem, D. & Nolen-Koeksema, S. (2000). Introduction to psychology. Harcourt Incorporated. Beitman, B. Goldfried, M., Norcross, J. (1989). The movement towards integrating psychotherapy: An overview. 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