Effectiveness of Gestalt therapy on self awareness among patients with schizophrenia was examined through Quasi experimental pretest posttest with control group design. Purposive samples of 16 patients with schizophrenia who had low self awareness were randomly assigned into experimental and control group for the study. Gestalt therapy was intervened to the patients with Schizophrenia. Situational self awareness scale was used to assess the level of self awareness before and after gestalt therapy. The data gathered were statistically analyzed to test the hypotheses. The result revealed that there was a significant difference in the level of self awareness before and after gestalt therapy. Hence, the study concluded that gestalt therapy is found to be an effective therapy in improving the level of self awareness among the patients with Schizophrenia.
Effectiveness of gestalt therapy on self awareness among patients with SCHIZOPHRENIA AT selected hospital, coimbatore
Schizophrenia is a mental disorder characterized by a disintegration of thought processes and of emotional responsiveness. The onset of symptoms typically occurs in young adulthood, with a global lifetime prevalence of about 0.3-0.7%. Schizophrenia is a severe form of mental illness affecting about 7 per thousand of the adult population, mostly in the age group 15-35 years. Though the incidence is low (3 per 10,000) the prevalence is high due to chronicity (W.H.O., 2008).
Schizophrenia is altering one’s sense of self, denote the awareness of one’s physical body and mental state. It encompasses one’s personality, perceptions and emotions. It also reflects one’s conscious decisions and actions. A sense of self is to combine one’s inside awareness with one’s outside awareness. Inside everyone’s nervous system lies the I-Function. This is the experience of I or the self in the brain. The I-Function includes more or less of the nervous system depending on how much is connected and functioning properly. It is having a sense of the self-experiencing.
Self Awareness is having a clear perception of personality including strengths, weaknesses, thoughts, beliefs, motivation, and emotions. Self Awareness allows to understand other people, how they perceive us, our attitude and our responses to them in the moment. Self awareness is one of the attributes of emotional intelligence and an important factor in achieving success. An improvement in self awareness is able to make changes in the thoughts and interpretations in mind. Changing the interpretations in mind will allows to change emotions.
The Nurse-client relationship and team work between the nurse-patient will help the patient to increase self awareness, maturity and knowledge during the process (Hildegard Peplau, 1952). The nurse must demonstrate active listening skills, apply therapeutic communication techniques, provide guidance and support in the process of self-discovery, maintain professional boundaries and self-awareness to successfully implement the counseling role (Gastmans, 1998).
Disturbance in sense of self observed in psychotic disorders act as a secondary marker of basic disturbance more than the poor social functioning (Nelson et al., 2009). Fuchs and Schlimme (2009) proposed that in schizophrenia the weakening of the basic sense of self, the disruption of implicit bodily functioning and the disconnection from intercorporeality with others are manifestations of a fundamental disturbance of the bodily self or a disembodiment.
Demetriou’s theory, one of the Neo-Piagetian theories of cognitive development states that, Self-awareness develops systematically from birth through the life span and it is a major factor for the development of general inferential processes. Moreover, a series of recent studies showed that self-awareness on cognitive processes participates in general intelligence with processing efficiency functions such as working memory, processing speed and reasoning.
A holistic nursing model of self-awareness consists of four interconnected components: psychological, physical, environmental and philosophical. The psychological component includes knowledge of emotions, motivations, self-concept, and personality. Being psychologically self-aware means being sensitive to feelings and outside events that affect those feelings. The physical component is the knowledge of personal and general physiology as well as of body sensations, body image and physical potential. The environmental component consists of the socio cultural environment, relationship with others, and knowledge of the relationship between humans and nature. The philosophical component is the sense of life having meaning. A personal philosophy of life and death may or may not include a spiritual being, but it does take into account responsibility to the world and the ethics of behavior. Together these components provide a model that can be used to promote the self-awareness, self-growth of nurses and the patients for whom they care (Campbell, 1980).
Gestalt therapy is a phenomenological-existential therapy founded by Frederick and Laura Perls in the 1940s. It teaches the phenomenological method of awareness, in which perceiving, feeling, and acting are distinguished from interpreting and reshuffling pre-existing attitudes. Explanations and interpretations are considered less reliable than what is directly perceived and felt (Gary Yontef, 1993).
Gestalt therapy helps clients develop their own support for desired contact or withdrawal and improve the self awareness (L. Perls, 1978). Gestalt therapy works for understanding by using the active, healing presence of the therapist and the patient in a relationship based on true contact. Transference, explored and worked through as it arises, is not encouraged by the Gestalt therapist (Polster, 1968).
In Gestalt therapy, the patient quickly learns to make the discrimination between ideas and ideation, between well-worn obsession pathways and new thoughts, between a statement of experience and a statement of a statement. The Gestalt goal of pursuing experience and insight which emerges as the Gestalt emerges is more potent than insight given by the therapist, does help the patient and the therapist draw and maintain these important distinctions. (Applebaum, 1976)
The techniques adopted from Gestalt therapy which improves the self awareness are empty chair technique, guided fantasy, making rounds and rehearsal exercise. In empty chair technique, when the client is in hot seat and enact a role of other person it will help the client to be aware of the others. The use of the two-chair technique is to resolve splits. A split as a verbal performance pattern in which a client reports a division of the self process into two partial aspects of the self or tendencies. Two-chair operations conducted have been found to facilitate an increase in the depth of experiencing and index of productive psychotherapy and to lead to resolutions of splits with populations seeking counseling (Greenberg, 1999).The guided fantasy will help the client to be aware of past events. Making rounds will help the client to socialize well with others and which in turn improve the awareness of surroundings. Rehearsal exercise will help the client to change his or her maladaptive behaviour and which in turn help them to be aware the correct behaviour.
1.1. NEED FOR THE STUDY:
Schizophrenia affects about 24 million people worldwide as of 2011. 90% of people with untreated schizophrenia are in developing countries. More than 50% of persons with schizophrenia are not receiving appropriate care.
Schizophrenia affects around 0.3-0.7% of people at some point in their life. It occurs 1.4 times more frequently in males than females and typically appears earlier in men in the peak ages of onset are 20-28 years for males and 26-32 years for females. Schizophrenia occurs at similar rates worldwide, its prevalence varies across the world, within countries, and at the local and neighborhood level. It causes approximately 1% of worldwide disability adjusted life years.
It is about 10 million Indian citizens approximately 10-20 per 1000 population are affected by many serious mental disorder at any point in their life time. 20-30 million people in India need attention, with the above statistics one can expect approximately 2 million people suffering from Schizophrenia at any given time (WHO, 2008). It is expected that 45 million people will be affected with Schizophrenia in the next decade, as the care for chronic mentally ill had shifted from mental hospitals to community (Kulhura, 2007). Nearly 7 lakh people are affected with Schizophrenia in Tamil Nadu (Nambi, 2009).
Human personality is compared to a floating ball at any given moment, only a portion is exposed while the rest is submerged. Unawareness is the result of the organism’s not being in touch with its external environment due to its being mostly submerged in its own internal environment or fantasies or not being in touch with its inner life due to fixation on the external (Simkin, 1976). Similarly, awareness of self is lacking in client with Schizophrenia and it will be improved with the help of Gestalt therapy. Awareness and dialogue are the two primary therapeutic tools in Gestalt therapy. Awareness is a form of experience that may be loosely defined as being in touch with one’s own existence that what actually present.
A patient with low levels of self-awareness is likely to be unmotivated and set unrealistic goals, display poor judgment and fail to see the need for compensatory strategies, let alone apply them in everyday life. Individuals with higher levels of self-awareness are more likely to be active participant in rehabilitation, experience stronger therapeutic alliances and achieve better rehabilitation outcomes in terms of level of community integration (Fleming, 2012).
The lack of self awareness develops incapacity to understand the true situation for individual and unable to be aware of mistake that has been committed or being blamed without any mistakes done. It makes the individual to hold back from developing self-management, social awareness and relationship management skills. Lack of self awareness will cause excess stress to family member and confront the angry reaction. Client with low self awareness may involve in occupation but they are unaware that where they fail in workplace and unable to set achievable goal at work or evaluate their work performance in a realistic manner. So, it impairs one’s own vocational confidence.
The aim of Gestalt therapy is the awareness development, the freely ongoing gestalt formation where what is of greatest concern and interest to the organism, the relationship, the group or society becomes gestalt, comes into the foreground where it can be fully experienced and coped with so that then it can melt into the background and leave the foreground free for the next relevant gestalt. (Laura Perls, 1973)
The greater sense of emotional wellbeing being was associated with awareness into need for the treatment. A study published in this area suggested that increasing the hope of persons with schizophrenia may directly and positively increase both their quality of life and the usefulness of their self awareness into their illness. (Hassonohayon et.al., 2009).
Even though the gestalt research literature on Gestalt therapy is sparse, studies that showed increased self-actualization and positive self-concept following Gestalt therapy groups (Harman, 1984).
The Greenberg studies related specific acts and change processes in therapy with particular outcomes. Their research distinguished three types of outcome (immediate, intermediate and final) and three levels of process (speech act, episode and relationship). They studied speech in the context of the type of episodes in which it appears and they studied the episodes in the context of the relationships in which they occur (Greenberg, 1986)
The use of the two-chair technique is to resolve splits. A split as a verbal performance pattern in which a client reports a division of the self process into two partial aspects of the self or tendencies. Two-chair operations conducted have been found to facilitate an increase in the depth of experiencing and index of productive psychotherapy and to lead to resolutions of splits with populations seeking counseling (Greenberg, 1999).
A study conducted on effects of two-chair dialogues and focusing on conflict resolution found that Two-chair dialogue appeared to produce a more direct experience of conflict and encouraged the client in a form of self-confrontation that helped create a resolution to the conflict (L. S. Greenberg and H. M. Higgins, 1990).
A number of studies that compared the behavior of gestalt therapists with that of other therapists. Brunnink and Schroeder compared expert psychoanalysts, behavior therapists and gestalt therapists. He found the gestalt therapists provided more direct guidance, less verbal facilitation, less focus on the client, more self-disclosure, greater initiative and less emotional support. They also found that the interview content of gestalt therapists tended to reflect a more experiential or subjective approach to therapy (Harman, 1994).
Numerous literature review reported that Gestalt therapy is specifically effective in improving Self awareness. It is recognized as an effective therapy in the improvement of Self awareness. During the posting in psychiatric ward by interaction and observation, the researcher recognized the lack of Self awareness in client with chronic schizophrenia. Hence the researcher developed interest to improve the self awareness among client with chronic schizophrenia. Therefore the researcher has adopted Gestalt therapy to improve self awareness and help them to lead a happy and healthy life.
1.2. STATEMENT OF THE PROBLEM:
EFFECTIVENESS OF GESTALT THERAPY ON SELF AWARENESS AMONG PATIENTS WITH SCHIZOPHRENIA AT SELECTED HOSPITAL, COIMBATORE.
To assess Self awareness among patients with Schizophrenia.
To administer Gestalt therapy among patients with Schizophrenia.
To assess Self awareness among patients with Schizophrenia after Gestalt therapy.
1.4. OPERATIONAL DEFINITONS:
It refers to change in the level of self awareness after the implementation of Gestalt therapy among the among patients with schizophrenia
1.4.2. Gestalt therapy:
Intervention provided to the patients with schizophrenia based on the Gestalt therapy techniques such as empty chair technique, guided fantasy, making rounds and rehearsal exercise as for one month period as weekly one session as of four in total.
1.4.3. Self Awareness:
It refers to ability of the person to aware about oneself in that particular situation and in particular environment. It was assessed by Situational Self awareness scale (Govern and Marsh, 2001).
1.4.4. Patients with Schizophrenia:
It refers to clinically diagnosed patients with schizophrenia hospitalized in Krishna nursing home who has illness more than 2 years with low self awareness belongs to the age group of 20-50 years.