We began the chapter by asking a series of questions: Is the presenting problem a function of the personality? A developmental delay? A failure in the developmental process? A normal repetition of the growth pattern? A product of an evolving identity? A fixation? A dependency reaction? Or regression?
We must end the chapter by stating that the answer most certainly depends upon the client, for the function of personality does not rest on one theory, one belief, or one therapeutic intervention. As humans, we are complex creatures, for we are not the same today as we were 10 years prior, nor will we remain unchanged by life's events 10 years into the future. Thus, a basic understanding of the norms of development can offer the clinician insight into the complexity of issues that may besiege a client at any given point in life. For the purposes of this book only three theorists, out of a host of researchers, are featured, because their models have been useful in assessing the difficult client. In the end, the clinician should seek the repetition of behavior that is calling out for mastery. The recurrence of behavior in clients' life stories; their behavior outside of the therapeutic hour; their self-concept, fears, and defenses; and of course the symbolism inherent in their art is what I refer to as a symbolic abundance of ideas.
As an example of how to apply the information, let's return to Figures 2.35 and 2.36. This patient, a regressed schizophrenic, had a propensity toward theft, flushing rolls of toilet paper down commodes, and hoarding found items. All of this information was offered by staff, and these habits were definitely a point of contention in the dorm where the client lived.
Therefore, if we refer to Table 2.3, even before speaking with the client we can hypothesize that he is fixated in the anal stage of development, which corresponds to Piaget's phase of symbolic play and Erikson's autonomy versus shame and doubt. This assertion of will also correlates with Table 2.2, where the anal stage of development (age 2.5) is much like age 11, when behavior worsens as the child grapples with feelings of mastery and his or her limitations. When I met with the client he created a snake (Figure 2.35) and stated, "I chose a snake because they like to steal and eat. It's my hobby—stealing." This verbal statement (even though it had the flavor of some oral incorporation needs) in concert with his propensity toward the toilet led me to believe that beyond his fixation in the anal stage his hoarding was more closely aligned with the need to collect. This assumption also corresponds with the age of 11 (as Table 2.2 pointed out); however, this client's collecting was disorganized, with the main focus on accumulating. Therefore, aligning this client with the age of 11 would gain importance (i.e., increasing his selectivity) when developing a treatment plan.
Arieti (1955) outlined four stages of the progression of the disease of schizophrenia. In the third stage he not only discusses hoarding but also indicates that an absence of symptoms prevails, as the client has learned to conceal his hallucinations and delusions, if only on a surface level. He states:
The schizophrenic seems to hoard in order to possess; the objects he collects have no intrinsic value; they are valuable only inasmuch as they are possessed by the patient. The patient seems almost to have a desire to incorporate them, to make them a part of his person. . . . The fact remains that this tendency is a non-pathognomonic manifestation of advanced schizophrenic regression. (pp. 356-357)
In Figure 2.36, two of eight drawings were offered to show this patient's continued collecting needs (i.e., as exemplified by the detailing and proliferation of weapons). At this juncture, it was becoming more and more apparent that this patient was "screaming" to collect, to possess. If we refer once again to Table 2.3, at best this regressed client corresponds to Piaget's stage of intuitive thought (age 5 to 7), and it is this age that is incapable of delaying gratification out of a fear that the opportunity will not arise again (hence the theft). When developing a treatment plan, one must meet the client within and slightly above his or her level of development to encourage further developmental growth. Thus, in this case the therapist chose ages 6 to 12: the stage of latency (Freud), concrete operations (Piaget), and industry versus inferiority (Erikson). As Table 2.3 indicates, the most appropriate therapeutic materials all pointed toward collecting and organizing, and the client was offered his choice of materials (he chose plastic models).
It was of the utmost importance for the client to complete this treatment plan with another person (to promote a sense of social participation and action) and for the clinician to follow through on statements in a timely manner (to circumvent the client's feeling that only one chance is available and to promote trust). However, the client was not merely presented with an array of models: He had to earn them through a token economy system and incorporate budgeting into his thinking. Consequently, if he was going to "incorporate" as part of his fixation and collect as part of his need to possess, he should do so in a manner that bespoke of mastery and production.
Ultimately, utilizing the steps outlined in this chapter, therapists can base treatment plans on not only knowledge of the client (their needs, fears, and defenses), but also knowledge of the existing literature by a wide range of researchers, clinicians, and theorists. This process does not merely identify; it also allows for focused interventions.
In the end Piaget believed that the individual must master emerging conflict in order to prepare for future growth and integrity. "Consequently, human development (human learning) is neither purely social nor purely maturational; rather development evolves from individuals' experience of themselves and the patterns of living" (Maier, 1978, p. 21).
It is this pattern of living that provides us with our self-concept, our identity, our abilities, and our worth.
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