The Case of Paul Webster
The process of treating mentally ill substance abusers is challenging as their treatment requires supplementary remedial actions of inherent mental disorders that are induced by bad past experiences, a negative attitude, some of the addicts have been found to lack motivation or are too narcissistic to agree to medical treatment. Therefore, the treatment of addiction and the mental disorders has to be conducted simultaneously.
Paul Webster has been evaluated as a chronic substance abuser with dual mental disorders of anxiety, depression and schizophrenic mental disorder. Miller states that anxiety, depression and personality disorders are all a result of substance abuse disorder which can be treated through pharmacotherapy and psychotherapy (2009, p327). Paul Webster has stagnated at the age when he was initiated into substance abuse and has since exhibited a common pattern of low self esteem, and a lack of focus and control.
Cummings, Hanberg and Slamon have claimed that the progress must be perceived in a MICA patients undergoing therapy, which can be categorized as consistent change where the patients exhibit an improvement in behavior and cognitive interaction or interrupted change in this kind of change the client has a setback after showing improvement in hisher sessions. Minimal change means there are plateaus in the improvement shown by the patient and though the improvement is slow, it is steady.
The traditional modalities of talk therapy have been clearly unsuccessful for Paul and it is suggested that inventive and creative modalities in therapy be employed to break the repetitive and destructive pattern of Pauls substance abuse and mental disorder. Supervised drama therapy sessions must include projective techniques and creative modalities i.e. Storytelling, phototherapy and the masks have also been recommended.
There are obvious advantages to using drama therapy in psychotherapy which are over and above talk therapy techniques. Talk therapy is the process wherein the patient talks about hisher problems with the psychiatrist and there is a dialogue between them based on therapeutic goals (New York magazine, 1993, p.35). However, Psychodrama, Drama therapy and Role Playing are known as action therapy and, according to Uhler and Parker, who are dealing with women patients of substance abuse, it was observed that
There was a greater involvement, dedication and satisfaction with the treatment that have shown a greater inclination to stay in treatment and complete the treatment.
Landy states that drama therapy has specific goals, therapy is tailor-made to the needs and requirements of the patient and thus it also has educational and recreational goals as well, and it has links to major psychotherapeutic theories and thus the patient is viewed to have a confluence of intuitions and feelings.
Langley recommends that the drama therapy sessions emulate psychodramatic sessions and emphasize on real life situations i.e. relationships with family or occupational situations and other means to encourage rational behavior patterns. Since heavy medication causes side effects , drama therapy sessions would be more effective if the sessions used alternative forms of therapy i.e. music.
According to Jones, there are nine processes to dramatherapy which include dramatic projection, therapeutic performance process, drama therapeutic empathy and distancing, personification and impersonation, interactive audience and witnessing embodiment, playing, life drama connection and transformation.
Role-playing sessions will encourage empathy with the roles being enacted by cohesion of the story with own real life experiences and events based on hisher life, with an aim to empathize with hisher motives and inclinations heshe can observe and perform other roles to assimilate and comprehend alternate prospects that are presented to him. Paul Webster could also play various games that reintroduce him to real-life situations and to simultaneously create a distance to mitigate the pain that he is suffering.
It is imperative that Paul Webster distances himself from the pain of his traumatic past a creative and symbolic distance has to be created between his reality and his imagery, his personal stressors, caused due to a feeling of hopelessness and failure that haunts most MICA patients can then be alleviated and he can assess his life in an objective manner.
Sessions based on puppetry or masks will aid in creatively distancing him from past traumatic experiences and by enacting performances behind masks, Paul can create a persona separate from himself which can then communicate symbolic experiences which had not been expressed in verbal therapy sessions.
The use of masks in drama therapy has been very effective in treating patients as they facilitate the process of role playing and allow the patients to introspect on their feelings and emotions while under the guise of masks they are able to confront issues that they would rather avoid.
The process of the mask therapy session would require that participants create their own masks as they are provided with the raw materials i.e. paper, beads, plastic, foil, feathers and paints, which then modulate into their alternate persona. The mask also brings out the confidence in the patient to have meaningful interaction with the other members of the group.
The process of these sessions has been described by Bedard-Bidwell and consists of these stages
The participant describes the feelings that arise with the construction process in from of the group. The Patient wears the mask and is free to make movements and sounds as he becomes the mask. The therapist engages the mask in role play and the possibility to explore and establish another aspect of themselves.
Landy however cautions that the use of masks can be extremely terrifying for people who are going through a high degree of emotional and mental disturbances, but in other circumstances, the masks allow the patients to transcend into observers role by encouraging them to take on other personalities.
Paul Webster can be encouraged to wear masks representing his grandmother and other relatives that he lost and while wearing those masks has to mimic their mannerisms and personality. By constructing these masks from scratch using everyday material Paul will distance himself from his own problems. He can also be induced to assess his addictive behavior and to comprehend the magnitude of the consequences of substance abuse on his life.
At the end of each session, the improvement in Pauls behavior must be evaluated and assessed. He will also be able to interact with other patients as he will feel that he is not talking to another patient and will feel more comfortable communicating with an unknown personality in a mask. There are various projective techniques that can bring conclusive results, however as Pauls disorder is characteristic to him, his therapeutic sessions have consequentially been tailor made aid in his recovery.
I would also recommend storytelling sessions as a part of Pauls therapy which would last for duration of an hour. Berger asserts that a well told story brings down barriers, is helpful in creating a bond with other patients, patients introspect and understand their own problems better, those who are defensive realize the mistakes that they are making and sometimes even take steps to make recovery.
Storytelling is one of the best methods in group psychotherapy it is often with patients that they have problems in revealing their troubles and in relating to other people, the process of storytelling can form a code of communication in the group as stories are shared amongst the patients. They are usually confused about their emotions and overwhelmed by their problems and the art of storytelling helps patients in understanding their problems and even makes them find possible solutions.
In therapy with Paul Webster, the therapist can initiate the session by narrating stories of MICA patients who have had similar problems of drug abuse and mental disorders Paul will be able to empathize with their successes at rehabilitation and their subsequent failures with his own setbacks, the stories must be told in a sequence which begins with the narration of the problems and should finally lead to stories where the patients have successfully rehabilitated themselves and have broken the pattern of subsequent relapse.
In these group storytelling sessions, Paul Webster should build constructive relationships with the participants by contributing to the process of storytelling and offering his opinions and feelings to the incidents being narrated.
Weiser explains that art is a symbolic language which communicates feelings that a patient is not able to express verbally Weiser, 2001, p,1 ). I have endorsed the use of phototherapeutic techniques as these are flexible and can be consequently improvised to suit the mental disorders suffered by a patient in comparison to the traditional verbal therapy techniques which are rigid and ineffective in treating MICA patients.
Phototherapy is Photography as a means of communication and Weiser asserts that the photographs must not necessarily have aesthetic value as long as it triggers memories, thoughts, feelings and information from the patient. Phototherapy is another cathartic psychotherapeutic technique which has along with other art therapies proven effective in treating patients with a history of depression and substance abuse.
Shechtman has substantiated this claim by describing that while conducting therapy sessions with children of Ethiopian origin it was noted that individuals who were engaged with photos, self-disclosed almost twice as much on a simple level and five times more on an intimate level( Shechtman Zaghon, 2004 , p.62). It also proved to be a trigger that facilitated group participants in revealing thoughts, fears and memories which otherwise would not have been disclosed during group therapy sessions.
Phototherapy, according to Kossolapow and Scoble, includes looking at images and photographs and eliciting responses from them (2003, p. 60) and it has been defined as
The use of photography and personal snapshots within the framework of formal therapy where trained therapists use these techniques during counseling session.
While working with patients with schizophrenia, photographs can be used as a means of therapeutic communication. Weiser explains that an individuals reality is constructed from his perception of himself which have formed by his personal experiences and memories. Thus phototherapy sessions can enhance on verbal therapy by analyzing various images and personal pictures which are related to the patient.
Paul Webster can be encouraged to bring in his own family photos and personal pictures for the therapy sessions. He must be shown pictures from his childhood in key points of his life and made to relate to each picture and the particular memories attached with them. Group photo therapy sessions could include selection of random photos and narrating stories attached to these pictures which would help in group cohesion and bonding.
Weiser believes that through personal photographs or through found photos, a symbolic self portrait of the patient can be constructed which might differ from the physical image that he projects (Weiser, 2001). Judy Weiser has laid special emphasis on these projective pictures and expounds, stating these found photos narrate a story which is based on the interpretation of the patient which gives the therapist and the patient tremendous insight into the problem and experiences of the patient.
Patients can get in touch with their own feelings and memories as they go through various pictures that represent important aspects of their lives. In photo therapy counseling sessions photos are thoroughly analyzed and even taken during sessions and given as homework to patients. The aim of this session is to make the patients reach, express and better understand their own memories and feelings and thus get a better picture of themselves.
Thus Paul Webster, during these sessions, can be made to click these found photos and the relevant information from these pictures can be analyzed and even used to make continuous evaluations of his improvement. As Paul Webster scrutinizes each picture along with his therapist, he will after a period of time be able to form a sequence of events which led to the substance and mental disorders. \
He will also be able to bring up memories of some happy events of his life with other relatives or friends, which he can focus on whenever he feels depressed about the incidents that took place in the past and the abuse that he suffered at the hands of his grandmother.
These sessions have to be carefully crafted in a manner that has been described by Emunah as an interconnection and progression of techniques with results that contain therapeutic and aesthetic possibilities.
Each of these sessions must be carefully planned and should be cohesive, structured and flexible. It must foster participation from the patients and be assessable in a quantifiable. Each of these sessions must also comprise of a report generated on Pauls daily progress which will culminate into a monthly and annual progress report.
Conclusion
The focus of these therapy sessions is to perceive a constructive improvement in the behavior and life of Paul Webster. As a mentally ill chemical abuser, Pauls journey towards rehabilitation will be unequivocally more excruciating and sluggish in comparison.
Paul Webster, at the end of these sessions, must feel empowered and resilient to battle substance abuse he must acknowledge his addictive behavior and the destructive pattern formed between substance abuse and his mental disorders
He must decisively reduce and abdicate from substance abuse establishing meaningful, social and personal relationships. Take timely medication for schizophrenia and depression demonstrate assessable improvements in habitual patterns and find meaningful employment of his skills and abilities
Though the process of improvement will be gradual, it should be steady and positive and Paul Webster should be allowed as many individual psychotherapeutic sessions as possible to instill in him the confidence and willpower to lead a substance free normal life. Continuous supervision is recommended even after he leaves the institution.
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