Case study methodology and applications

¶ … Josephine seems to be at the precontemplation stage of change. This means that she is not yet ready to consider changing. The way in which she talks about her problems appear to indicate that she does not believe in her own ability to change her circumstances. There appear to be several obstacles to Josephine's ability to make the changes she seems to require. The first is her mother's cooking. Josephine's relationship with her mother is such that she cannot contemplate asking her to change her cooking. There is also a cultural aspect to Josephine's perceived difficulty, as she appears unwilling to impose upon her mother's sense of cultural tradition, which the latter appears to regard as important, especially in terms of cooking. Furthermore, the situation is perpetuated by Josephine's relative sense of powerlessness in making decisions about her eating habits, as she is constrained by her financial situation and unable to live on her own. This, along with the long-term nature of the problem, has created a situation in which Josephine appears to feel trapped and unable to escape.

Josephine appears very focused upon her body image and the desire to lose weight. She perceives her problem to be physical and situational rather than psychological. She appears completely unaware that her problem could relate to eating disorders and disturbances, which further inhibits her ability to move towards the contemplation stage of change.

Josephine's therapy will have to focus on the underlying issues of her eating habits, exercising habits, and purging before her desire to lose weight can be addressed. It is essential that the latter problem should be addressed in a healthy manner. This can only be done once Josephine's body image is restored to a more normal, healthy sense of self. Only once Josephine understands her psychological sense of her body to be at the heart of her problem, rather than her physical weight, will the therapist be able to help her move to the contemplation stage of change.

There are various ways in which I can establish rapport with Josephine. On the verbal platform I would attempt to create a safe and friendly atmosphere by avoiding subject jargon. Using jargon in a communicative situation with a client creates a barrier between the client and therapist which could impede the trust necessary to help the client move forward. Furthermore, I will ask questions in a straightforward and clear manner, encouraging Josephine to ask for clarification if she does not understand the questions. I would also convey patience, concern and acceptance by means of my verbal behavior. At no point would I make Josephine feel that her problems and concerns are not valid in my point-of-view.

It is also important to establish rapport in a nonverbal way. I will, for example, maintain friendly eye contact with Josephine. In addition, I will nod occasionally when she speaks to show that I understand what she is saying and feeling. Also, I will smile at appropriate intervals and maintain an attentive posture. Josephine needs to be assured that she has my full attention for the duration of her appointment with me.

While establishing rapport with Josephine is important, it is equally important to maintain personal boundaries in the relationship I will be cultivating with her. Physical contact, for example, should be limited to the minimum, although Josephine's emotional distress may lead to outbursts that would warrant a hand on her shoulder or holding her hand. I do not believe that it is appropriate for physical contact to go beyond this point.

It is important to recognize that, as a client, Josephine might view me as her therapist, even unconsciously, as an "ideal parent." Particularly relating to the situation with her mother, I might be in the role of gratifying her wish to be thinner, which she appears to perceive her mother as unable to do. Furthermore, she might see me as the ideal and understanding parent where she can wield a sense of power, which is unable to do with her own mother. There are two paradigms of powerlessness that need to be subordinate to the personal boundaries I should establish: the perceived powerlessness of Josephine's mother to provide her with the "ideal" meal or to understand the concept of the ideal meal; and the perceived powerlessness in herself to make her mother aware of this situation. My boundary then should be established in such a way as to discourage any attempts to manipulate me into validating Josephine's false perceptions of her own body as "overweight" or even "fat" as opposed to her conception of the ideal body type. My personal boundary needs to enable me to help Josephine towards a healthy body perception which should precede any attempts at changes in her diet.

Time is a naturally imposed boundary by the therapy situation. This enables me to help the client within a certain time frame. Since many of her perceptions will have to be changed, this is a good way to help her gradually towards a new frame of mind, without overwhelming her for prolonged periods of time.

The only boundary violation I would consider would be in terms of place and situation. Because of Josephine's specific therapeutic needs, I might invite her for dinner in a public setting such as a restaurant. Here I would be able to make her aware of the "normal" concept of a healthy diet by pointing to certain items on the menu that she can eat without guilt while also maintaining a healthy diet. I could also point towards certain restaurant patrons with healthy body types to make her aware of what this constitutes. This will only be during the later sessions, however, when I have ascertained that Josephine has at least entered the contemplation stage of change. First, my focus will be on making her aware of the flawed nature of her body perception and the nature of her eating disorder as a disorder in itself. If ever a restaurant setting is to be used for future therapy sessions, this would be on the strict premise of the therapeutic purpose. Furthermore, at least one family member -- perhaps ideally Josephine's mother -- would be approached for permission to use this kind of boundary violation for the purpose of continued therapeutic success.

Another personal boundary I will create is by means of language. At least during the first few months of therapy, I will address Josephine by her last name, providing a platform of some distance even while attempting to appear caring and understanding of her situation. This will facilitate my attempt to dissociate myself from the role as mother, particularly as Josephine appears to have concerns and issues with her mother that must be resolved before therapeutic success can be achieved. Too much linguistic informality early in the therapeutic relationship could adversely affect my attempts to help Josephine work towards a healthier body image. She needs to reach a point where she can feel satisfied that her body is healthy and fit without excessive concern about weight or the types and amounts of food that she consumes on a daily basis.