The Grape family in the movie “What’s Eating Gilbert Grape” consists of five siblings: Larry, Amy, Gilbert, Arnie, and Ellen. The mother and father are now deceased. The father committed suicide sixteen years ago in the family’s basement at the age of forty. The mother recently passed away from complications due to morbid obesity, her age unknown.

This is a Caucasian family that was raised in Endora, Iowa. The older brother Larry has moved away and disconnected himself from the family.

Amy and Ellen recently moved to Des Moines Iowa leaving Gilbert and Arnie still living in Endora. Family Problems

After Gilbert’s father committed suicide his mother went into a deep depression and could not cope with the day to day activities in her family. It was during this time that Gilbert became the head of the household and the primary caregiver not only to his younger siblings but to his mother as well. In dysfunctional families with deficient parents, the children are often robbed of their childhood and learn to ignore their own needs and feelings (Forward, 1989).

A complete shift in roles took place because his mother was mentally not capable of giving her children the needed protection, support, or care. According to Minuchin, (1974), the role reversal develops when families are unable to maintain hierarchical generational boundaries in which the parents’ guide and nurture their children and the children seek comfort and advice from their parents.

Arnie was diagnosed with mental retardation/developmental disability and was not expected to live past the age of ten. Mental retardation is significant subnormal cognitive functioning with a deficiency in age appropriate adaptive behaviors such as communication, social skills, and self-care (Papalia, 2008). It is estimated that less than one percent of the population is diagnosed with mental retardation/developmental disability (Papalia, 2008). Having survived to the age of eighteen, Arnie’s primary care is given by his brother Gilbert.

The presenting problem in this family is that Gilbert is experiencing caregiver stress syndrome. Caregiver Stress Syndrome are actual physiological, psychological, and emotional symptoms that is a direct result of emotional strain of attending to the all the needs of the dependent child or adult (England, 2000). Gilbert gets frustrated with his caretaking responsibilities of Arnie to the point he has physically assaulted his brother. Both brothers also have unresolved grief from the suicide of their father and the recent death of their mother. Both sisters also moved away immediately after their mother’s death leaving Gilbert without support in the caretaking of Arnie. Family Strengths

Resiliency can be defined as the ability to recover from adversity stronger and more resourceful (Walsh, 2006). Resiliency is the common theme throughout this family as they have endured the father’s suicide, the mother’s depression, morbid obesity, and subsequent death, the loss of their “old” mother, the disconnection of family members, and Arnie’s disability. Although there is dysfunction in this family, they work hard to sustain what they have. There is a strong bond and commitment to take care of one another.

When the mother was still alive there was a connection between all siblings to take care of her and to make sure her needs were met. There was also a commitment to make sure Arnie stayed out of trouble and did not hurt himself. They tried to provide Arnie with some kind of normalcy in his life, i.e. throwing him an eighteenth birthday party. External and Internal Family Resources

While there is turmoil and stress in taking care of Arnie, he is an internal strength for this family. In looking at this family through the Bowen Family Theory, triangulation is formed between two antagonistic individuals also, linked to a third party that creates the calming effect between all individuals that are in conflict (McTiller, 2009). It is often this third party that provides a sense of homeostasis within the family unit. Homeostasis is a concept relating the balance and equilibrium within the family unit that regulates and maintains the system cohesion (Hepworth, 2010). There is consistent turmoil between Gilbert and his sisters regarding Arnie. During this time of turmoil Gilbert leaves the family but always returns because of Arnie, creating the family homeostasis once again.

The Grape family does have an advantage to be exposed to external factors due to the fact they grew up in a small town and the town does know of the family’s history and current circumstances. At Gilbert’s place of employment, Lamson’s Grocery, Mr. and Mrs. Lamson provide emotional support to Gilbert as well as supervision for Arnie while Gilbert works. Gilbert also recieves support from his two childhood friends, Tucker and Bobby. Tucker also helped Gilbert to make repairs on his house for his mother’s emotional support while she was alive. He currently provides emotional support and guidance as needed to Gilbert. Evidence-Based Practice Literature Research

Through the evidence-based search, a large amount of information was found regarding caregiver syndrome, mental retardation/developmental disabilities, family therapy with the mentally disabled, role reversals within the family unit, grief therapy with the mentally challenged and best therapies for the family unit with mental handicaps. An evidenced based search was conducted on Google Scholar and through the University of Southern California’s library. The best interventions gathered through both databases are: psycho education, cognitive behavioral family therapy (CBFT), social skills training, and grief therapy with the developmentally disabled.

The therapy that was chosen for the Grape family is a multisystem approach. A combination of CBFT and psycho education will be implemented. The Cognitive Behavioral Family Therapy is based on a reciprocal and cyclical paradigm and promotes self-talk to develop their own cognitions in regards to family expectations, individual roles within the family, and how these impact the behaviors in the family unit (Shulman, 2012). The CBFT can address the grief and loss associated with the unresolved grief and any grief associated with the sisters moving out of the home.

Psychoeducation will provide illness specific information and tools to manage any issues that Gilbert may be experiencing in the caregiving duties of Arnie. It has been shown through numerous studies that psychoeducation as an intervention is associated with improved functioning and quality of life, decreased symptomology, and positive outcomes for all within the family unit (Lukens, 2004). The psychoeducation within this family unit can address stress appraisal and coping to reduce the caregiver stress syndrome. Detailed Intervention Strategy

In the initial stage of therapy it is important to build rapport and an alliance within the family through the joining stage (Hepworth, 2010). This session will include Gilbert and Arnie. Given Arnie’s disability, it would be easier to engage this family within the familiar setting of his home. Joining with Arnie will be a crucial part to keep him engaged and to further the alliance with this family.

In the first stage of therapy besides rapport building, information gathering will be conducted such as: collection of relevant history, treatment policies, and acknowledgment of the presenting problems. Strengths will be identified along with different resources and the family goals of the treatment itself. It is this earlier treatment that individuals are introduced to the wholeness of the family system, family schemas, relationship scripts, and the family constitution (Schwebel, 1992). This step in therapy will not take place in just one session, but, can take multiple sessions to accomplish.

Once the goals of the first therapeutic interventions are accomplished, the next step will be assessment. The assessment phase lasts the whole duration of the therapeutic intervention. Within this step the family related cognitions are constantly identified. With the identification of these cognitions, the behaviors and thoughts that result from them can be addressed.

It is this step that the family learns the dysfunctional schemas that promote chaos and turmoil within the family unit and alters them to a more functional state. Although Amy and Ellen do not live close by to physically be in the session, in this phase they can participate in the sessions via telephone. They are still an important part of this family and can provide Gilbert with support during the caretaking process and the reorganization of the family dynamics. By virtue of the relationship, with regular contact between family members, they can help to manage the presenting illness and promote the progress toward personal goals (Murali, 2002).

The subsequent stages in CBFT include the personal application of the concepts and the cognitive change. It is through these stages that the individuals will learn to identify the specific negative schemas and to recognize when they are being employed. When one recognizes a personal pattern of behaviors they can work towards positive change.

The psychoeducation would take place throughout all of the sessions conducted. The purpose of this intervention is to give knowledge to the specific areas of difficulty for this family. Through the psychoeducation both Gilbert and Arnie can learn and understand what their role is in the family unit as well as the community. Through psychoeducation Gilbert can learn behavioral interventions with Arnie. Changing the way Gilbert interacts and reacts to Arnie can change the way Arnie acts and reacts. This can reduce the amount of stress between the family unit and the community. Theoretical Rationale Underpinning Intervention Strategy

Within the Cognitive-behavioral perspective, it is believed that schemas affect the individual’s mental health. When applying this to the family structure, Epstein, Schlesinger, and Dryden (1988) define this as the longstanding and relatively stable assumptions that he/she holds about the way the world works and his/her place within that world. According to Baucom and Epstein, there are two specific family related schemas: assumptions and standards. The assumptions are the conceptions of objects and events that do exist and the standards are the conception of the characteristics that should exist (Schwebel, 1992).

These schemas do not emerge overnight. They begin in the family of origin and are learned throughout all interactions within the family. This is the case within the Grape family. This distressed family has incompatible schemas and cognitions that actually promote unhappiness and conflict instead of resolving it. It is the intent of CBFT to raise awareness of the family related cognitions and the effects of these cognitions on feelings, behaviors, and the family dynamics (Schwebel, 1992).

Psychoeducation is also an effective therapeutic intervention with the Grape family. The family psychoeducation is used to combine clear, accurate information combined with training in problem solving, communication skills, coping skills, and the development of social supports. The only thing that this family knows is the current communication methods they have created to communicate with Arnie.

They have not been taught how to communicate with him, how to problem solve when things get hectic, or to develop any coping skills. The core foundation of this therapeutic intervention is that the family joins together to manage the symptoms and to understand the illness itself. The longer the family is in treatment the better and more lasting the effects of treatment are (McFarlane, 2003). Through psychoeducation the family will be a part of the solution rather than a part of the problem. Issues with Joining and Engagement

There are several issues with joining and engagement with the Grape family. Gilbert is more withdrawn. Getting him to feel comfortable enough to express his feelings might be difficult at first because he is used to keeping him thoughts and feelings to himself. Gilbert has always dealt with the struggles without outside Helpance or help. He might give some resistance to the changes that are going to take place. Making any family changes are difficult so when the old patterns of communication are identified and challenged, Gilbert may become defensive of the old patterns and resist the new.

Another issue with the joining and engagement of this family is Arnie’s cognitive functioning level. He has to be engaged on his level where he can understand. The approach has to be easy so as to not overwhelm or scare him. If he gets scared he may run away or withdraw. Being able to engage Gilbert will enable the therapist to gain insight on how to engage Arnie.

Anticipated Progress

The anticipated progress of Arnie and Gilbert Grape through family therapy is very positive. Through the use of CBFT and psychoeducation, Gilbert will have a reduction of stress caregiver syndrome and will be able to manage the stress, anger, and anxiety that stems from it. He can maintain the close bond that he has with Arnie in a more positive and healthy manner. Coping mechanisms will be in place to deal with the day to day stressors in the caregiver role. There will be external supports for Gilbert to utilize through this process and the family unit as a whole can move forward in a more empowered and balanced environment.

When the unrealistic expectations are changed into realistic ones, the family dynamics change. Gilbert will be able to learn about Arnie’s disability and modify his approach and methods of dealing with any behavioral issues. When approaching Arnie differently and through teaching behavior modification, Arnie will be able to engage in activities that present less risk to his safety and well-being. Having Arnie engaged with external resources will not only give Gilbert time away but, will enhance Arnie’s social skills.

References
Baucom, D. &. (1990). Cognitive behavioral marital therapy. New York: Brunner/Mazel. Bowen, M. (1972). On the differentiation of self: family interaction. New York: Springer Publishing Company . England, M. (2000). Cargiver strain: considerations for change. Nursing Diagnosis, 11(4), 164-175. Epstein, N. S. (1988). Cognitive Behavioral Therapies with Families. New York: Brunner/Mazel. Forward, S. (1989). Toxic parents: Overcoming their hurtful legacy and reclaiming your life. New York: Bantam Books. Hepworth, D. R.-G. (2010). Direct Social Work Practice. Belmont: Cengage Learning. Lukens, E. M. (2004, 09). Psychoeducation as Evidence Based Practice: Considerations for Practice, Research, and Policy. (C. U. Work, Ed.) Brief Treatment and Crisis Intervention, 4(3). McFarlane, W. &. (2003). Family psycoeducation workbook. Pasadena: U.S. department of health and human services. McTiller, M. (2009). McTiller’s channel: Triangle
one. Retrieved 02 03, 2013, from Youtube: www.youtube.com/watch?v=RhiipKE4dyw Minuchin, S. (1974). Families and Family Therapy. Harvard University Press. Murali, T. &. (2002). Retrieved 02 08, 2013, from www.nimhans.kar.in Papalia, D. W. (2008). A Child’s World . Boston: McGraw-Hill Companies, Inc. . Schwebel, A. F. (1992). Cognitive-behavioral family therapy. Journal of Family Psychotherapy, 3(1), 73-91. Shulman, L. (2012). The Skills of Helping Individuals, Families, Groups, and Communities. Belmont: Cengage Learning.