Monday, January 4, 2010

The Use of Autobiography as therapy

Introduction

This paper is an exploration of a Gestalt approach in the therapeutic process with seniors, as incorporated in the field of autobiography. My work with seniors (Jilks, 2007a) has led to this avenue of research, which I hope to apply to future practice. An increasing population of seniors has required that we rethink the demands made upon the health care system and better prevent mental health issues, rather than remediate them. Recent research (Canadian Broadcasting Corporation, 2007), and government policy agenda (LHIN, 2007) in the area of Aging at Home will mean that with seniors no longer be requiring Long-Term Care (LTC) homes, require some support to physically, socially and emotionally manage their lives in their own homes. It is apparent from Canadian research (Fenton, Cole, Engelsmann, & Mansouri, 1994) that older clients suffer silently from depression. This paper will present a strategy to combat the vagaries of old age, allow the senior to taste, embrace and revisit their lives, and present the benefits of the treatment afforded by a Gestalt-based autobiographical process.
The benefits of new techniques to utilize a modern concept of autobiography are presented beginning with theoretical perspectives, implications for clients, implications for therapists, and conclusions from the research. I will refer to the therapist using the female gender, the client the male, to simplify this work and make clearer the dance of therapist and client

Theoretical Perspectives

The early work of psychoanalysts, behaviourists, and Gestalt therapists, has influenced more recent developments. The field of psychodynamic and behavioural models of therapy has reformed with new post-modern knowledge, thought, research and understandings. The Gestalt approach to therapy was influenced by revolutionary changes in science, philosophy, religion, psychology, art, literature, and politics (Yontef & Jacobs, 2008). Client-centred and Gestalt therapy demands that the therapist responds with congruency to the client, in a team-based approach. The therapist is taken off her pedestal and the client was removed from the couch, with client-generated data being seen as valuable and intrinsic to the therapeutic process. This approach has been both experimental and subjective, something new to the psychological world that had striven to become more objective, scientific, and accepted in a world peopled by those who espouse clinically-based experiments to prove their work.
As Yontef said (1993) there are no ‘shoulds’ in therapy. Gestalt therapy is a process-based therapy that focuses on perceptions, feelings and action. It is crucial that a dialogue be created between therapist and client. The phenomenology in the client-therapist relationship became valued within this approach. In this dialogic therapeutic relationship the therapist is given license to feel what the client feels, without losing herself in the process (Yontef & Jacobs, 2008). The therapist recognizes the client as being other, but accepting that as the therapist studies the client, she will be changed in the process. In this respect, the relationship mimics that of the student and teacher. During this relationship both will be changed and will learn through the challenges or demands required by a unique individual who requires individual and unique strategies.
Yontef (1993) states four requirements for therapeutic relationships: inclusion, presence, commitment to dialogue, and dialogue that is lived. For those for whom dialogue is difficult, Gestalt techniques can incorporate various facets of the arts: drama, visual art, music, movement, sand play and various means by which the therapist engages the client. In Gestalt therapy the client is encouraged to move towards self-realization using internal and external senses, to be self-responsive and self-supportive. Existential therapy, such as the Thematic Apperception Test, the empty chair technique, and other work designed to focus on the here and now, and on human interrelationships, focuses work on directly experienced suffering in the present in an open-ended Gestalt practice (Yontef & Jacobs, 2008).
For clients, family members and therapists reading and writing autobiographies have been found to be helpful in understanding issues, and clarifying courses of therapy (Sommer, 2001).  To that end, there are publications that have resource lists of autobiographies available for those who suffer from mental health issues (Norcross, Sommer, & Clifford, 1998). Sommer advocates for the sharing of stories on the part of clients. Stories can offer us consolation for suffering and, rather than aiming for happy endings, they help us work through our present reality, as it is shaped by our past. It is an active reconstruction that integrates past and present to develop optimism for the future. It helps the client to restore, maintain or enhance a sense of personal meaning and facilitates two meaning-making processes: transcendence, to rise above a current situation and to transform, through cognitive restructuring. 

Implications for Clients

Bacigalupe (1996) suggested that fostering written autobiographical responses by the client is a creative response for institutional, cultural, ethnic, class and gender discrimination. Rather than the therapist writing about the client, she can engage the client in a dialogue unfiltered by the language of academia, and give the client his voice. In post-modern family therapy, this infuses the therapeutic relationship with more equality, making the client and therapist co-participants in the process. Some therapists use a letter writing approach (Bastien,  & Jacobs, 1974; McAllister & Wolff, 2002).
In education it has become tradition, if not expected practice, to require students to write journals (Jilks, 1998; Jilks, 2005; Jilks, 2006). Much can arise from journaling in that the writer can open up, with uncensored freedom, to develop thoughts and reveal emotions in a safe manner, much in the way that reading a suspense novel is much less scary than viewing a movie in its raw, bleeding colour. The benefits of journal writing, aside from the expectation of literacy, provide much in the way of therapy. Adams (1990) found that self-expression, stress reduction, and stronger relationships could result from journal writing. In the safety of the client-therapist relationship a client can pursue issues, create dialogues, freeze-frame emotional events, explore roads not taken, and imagine goals.
In an exploration of existential predictors of psychological well-being Fry (2000) explored expressions of well-being with frail seniors. Health complications of the frail elderly have been the topic of an increasing number of funding dollars (LHIN, 2007). Prevention of cognitive disabilities includes keeping the mind alert, as well as physical exercise to keep the body healthy. The situation of the aged holds a special difficulty for those who have lost some meaning in their lives: loss of relationships (at work, or the loss of a spouse), work productivity, financial conditions of retirement and old age, the inability to be as mobile, as well as physical demands of the aging process, with a loss of choice of home or activities that results in a frustration that is palpable in Long-Tern Care group settings. Fry found a significance of an existential paradigm that incorporated religious activity, private prayer, and an affirming psychological and spiritual wellbeing.

Implications for Therapists

For some clients for whom face-to-face discussion is difficult, and social interaction has been an issue, the field of the arts presents a safe vehicle for an exploration, while helping the therapist better understand the client. For others, auditory, visual or kinesthetic learners, allowing the client to rehearse or present their stories on paper, using multi-media or visual arts,   presents an opportunity to begin a session feeling comfortably prepared.
Stone (n.d.) lists 45 therapies and the 72 methods of counselling in which one can be trained. There are many choices for the therapist who wisely keeps a portfolio of choices from which to begin engaging the client. Traditionally the therapist has spent her time writing about the client, rather than to or for the purpose of engaging responses. The purpose of writing has been to prescribe, educate, communicate and clarify directives, or post-session information for a team or a report. Writing for, to and with the client holds promise for exploring the client’s psychological well-being.
Over time, before free access to writing materials, humans have told and retold their stories through myths and legends around campfires. Shamans used tools and storytelling techniques to help teach and as tools to educate. First Peoples legends retell stories of their nation (Canadian Museum of Civilization, 2001). These stories allowed humans to revisit, and restore peace and harmony to their world, to re-examine and dramatize the human condition. The telling of an autobiography helps the client find a firmer footing in the present, as he is able to look back and differentiate between past and present.
It is through keeping meaning in our lives that we find a meaningful existence.  To restore meaning requires that the therapist find a technique by which we value our existence. The client and the therapist become pattern-makers (Epston, 1986), changing from pattern-finders as the view of history helps the client understand his present. Using this process the therapist need not consider: if a client reads files and clinical notes, would he understand or appreciate what I have written? With the client co-writing his story, it becomes more authentic and transforms the therapeutic relationship, reframing the process.
Part of the work with clients includes work with their families. As a caregiver for parents in palliative care, work must be undertaken with this group of individuals. For seniors with dementia, there is impact on the senior, as well as the family, who might have to advocate for those who cannot speak for themselves. Using autobiography can help caregivers engage in reflexive dialogue, share care planning, and work through the bereavement process to construct emotional and physical care strategies in a negotiated clinical response to current life situations (Keady, Ashcroft-Simpson, Halligan, & Williams, 2007). Reflexive accounts, such as the aforementioned, assist the client (in this case the daughter as caregiver) to identify issues that concern professionals involved in the palliative care process. Integrating narrative approaches helps client and therapist negotiate new ways of working in mental health care.
Clark (2004) found that early recollections are widely integrated in personality and innovative directions are being included in investigations into recollections, cultural differences, and early memory metaphors that all add to the reference points available to the analyst. O’Reilly and Edgar (1987) offer a five-phase Therapeutic Memoir Technique to confront and reinterpret mistaken beliefs and shape the therapeutic process: Introductory, Exploration, Confrontation, Reinterpretation and Redirection, using photographs from the formative years to illustrate constructs in early recollections. These photographs can be used to shape writing practice, or enable those with limited writing skills, to work with a therapist in a different medium.

Strategies

Using journal prompts (Jilks, 2006) the client can identify issues they would like to explore. Several writers, including Goldberg (1986, 1990, & 1993), recommend 5 minute timed writings during which time the writer responds to a prompt until the time is exhausted. This type of writing opens up the mind to inner feelings and emotions, without censorship or criticism. The client must be guided to let go of concerns around the mechanics of writing, i.e., spelling, penmanship or grammar, to simply produce a free-flowing thought. While some clients are asked to report and record data to the therapist (Bacigalupe, 1996), this type of writing, which may be autobiographical in nature, demands something more from the client. This empowers the client and gives them ownership of the process.
There are several methods from which to choose, i.e., Epston, 1986.  A widely popular text, The Freedom Writer's Diary (Gruwell, 1990) demonstrates the beauty and simplicity of sharing our stories and the therapeutic benefits and the self-confidence that ensues as the facilitator can accept and better understand life experiences of the writer in a Gestalt approach. It opens up the inner imaginings to both client and therapist, as they take their journey together along the path of self-discovery.
Traditionally, writing in the elementary panel has consisted of creative writing assignments that do little to produce personal narratives. As adults most of our writing is expository, rather than narrative. Writing about life experience brings the best of both worlds. Autobiography gives meaning and place to experiences and firmly guides a process. Blogs have become a frequent practice for seniors who want to share their life experiences (Garfield, 2007). The therapist is wise to tap this strategy previously used by the young, to assist those in their twilight years to share ideas, explore their feelings and communicate. For this reason, some educators are taking the process further by the addition of e-portfolios. In projects, such as Ice storm ’98 (Jilks, 1998), students can write for a purpose, communicate their feelings, fears, beliefs and experiences in a safe, supervised environment. The writing process is a monologue that can illuminate and provide a therapeutic release (Ontario Ministry of Education, 2002) especially if used in conjunction with graphics and self-chosen illustrations that give time, colour, and place to our experiences.
Gutheil and Chernesky (2006) recommend a service-learning partnership between seniors and students studying geriatrics. Benefits accrued by having young people develop more positive attitudes and understandings of seniors. Having these students assist the senior in creating an autobiography as an effective means of promoting collaboration between the generations.

Conclusions

There is much published in the use of Gestalt-based work in art therapy (Sterns Books n.d.), psychodrama (Blatner, 2007), music therapy (Ashida, 2000; Bennett, & Maas, 1988; Lord, & Garner, 1993; Pollack, & Namazi, 1992) as metaphors of experience. It has been twenty-eight years since I last explored the field of psychology, sociology and the work of the existentialists. In hindsight, during my work as educator, writer (Jilks, 2007b) and researcher, it is apparent in the field of education that there is a profound influence in curriculum strategies from these fields. In the 70s we incorporate work in self-esteem and self-concept as our knowledge increased in devises methods to allow students to feel confident enough to take risks and participate thoroughly in the learning process (Canfield & Siccone, 1994). Over the years it has become acceptable and laudable for educators to do work with students in the areas of self-concept, self-esteem (Ontario Ministry of Education, 2004). My work with a Reading Buddies Program (Jilks, 2004) provided some basis for this type of work. It is possible to apply this knowledge and research to the senior’s population and integrate a holistic approach to case management. More work is required in issues such as the abuse of the elderly (Canadian Broadcasting Corporation, 2007). My premise is that autobiographical work can prevent, work through, or diagnose such issues.
One could take this process further using multimedia (Jilks, 2007a; Kadjer, 2003) to create an autobiography based on scanned photographs, creating movies with music, poetry and other personally meaningful artifacts, to redefine the present self. Recently, life-changing events, such as funerals and weddings, have included slideshows with family photographs. It would seem more logical to celebrate one’s life before the time of bereavement to celebrate a life well-lived.
Further research is required to further refine and develop this process-a topic for another paper. As humans take part in their quest for meaning, therapists can faciliate a process, created for individual clients, to ensure that healthy seniors may improve their quality of life. I have learned much in the course of this research and laud the opportunity to further develop my knowledge base.

References: see next post

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