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Iranian Rehabilitation Journal, Vol. 12, No. 22, December 2014
Vol. 12, No. 22, December. 2014
54
Original Article
Effectiveness of Gestalt Group Therapy on Loneliness of Women
Caregivers of Alzheimer Patients at Home1
Hemn Saadati; Fateme Shoaee; Asrin pouryan; Emad Alkasir*; Leila Lashani
University of social welfare and rehabilitation sciences, Tehran, Iran
Masome Salehi
Alzheimer Society of Iran. Tehran, Iran
Rahman Moradi
Payam noor of bukan University, Bukan, Iran
Objective: Loneliness is a common experience of people, regardless of gender, age, socio economic and
cultural experience in the course of its life. The aim of this study was to examine the effectiveness of
Gestalt group therapy on the loneliness of Alzheimer’s caregivers.
Methods: In an experimental study with a pre- post test design and control group, women participants
were selected from Alzheimer Association of Iran. Total number of 50 women members was evaluated
according to inclusion/ exclusion criteria. 28 participants selected and were divided into two equal groups
randomly. Loneliness Scale was administered to both groups at the beginning. Gestalt therapy sessions
were applied to the intervention group, each session 90 minutes weekly and continued for 12 successive
weeks. The post-test data collected after the last session by administering Loneliness Scale. Data was
analyzed by using t-test for independent group.
Results: The results showed that the mean differences between the two groups were significant and gestalt
therapy decreased the loneliness of member of intervention group significantly. Loneliness scores of
intervention group in two sub-scales were also significantly lower in post-test compared to control group.
Discussion: Gestalt therapy can be helpful in enhancing positive emotions and decreasing loneliness in
Alzheimer caregivers which is one of the hardest emotions that these women threatens reduced and the
introduction of enhanced quality of life of the caregivers and hence increase the quality of care for
patients increased.
Keywords: Gestalt therapy, Loneliness, Alzheimer patients’ caregivers
Submitted: 12 Oct. 2014
Accepted: 07 Dec 2014
Introduction
Nowadays elderly population in many countries has
increased progressively (1,2) , and greater need to
provide better health care for the elderly is felt (3) .
Dementia is a chronic disease of old age and the
most common type of dementia, Alzheimer's disease
is a progressive disorder that can be characterized by
mental and behavioral disorders (4) . About 90% of
patients who are suffering from Alzheimer's disease
live in their home and in 80% of cases, the
responsibility of caring for these people is entrusted
to family members, especially women (5). Care of
elderly in family is common, but the primary
caregivers of the elderly and chronic patients usually
are women (6). Often the carrying and accepting
responsibility is a health and well-being risk for
caregiver (7). With regard to the care of patients
with disabilities, impaired physical and mental
health caregivers disrupts communication within the
family. Recently the awareness of the crucial role of
caregivers in long-term maintenance of patients has
increased and researches been done in the fields of
health problems, their caregivers and health
vulnerability (8) .
Caring for patients with dementia, particularly
Alzheimer's type is a component of the toughest and
most vulnerable type of caring of patients and
exhaustion due to maintenance for these patients,
from caring of other patients with chronic disorders
are more prevalent (9). Caregivers often face many
1. The article retrieved from project number 417 in student research committee, University of social welfare and rehabilitation science.
* All correspondences to: Emad Alkasir, email: < Emadalkasir@yahoo.com >
Iranian Rehabilitation Journal 55
challenges about home care; patient’s care in
addition to its own difficulties, with responsibilities
such as roles in the family, job and housekeeping.
These duties bring feelings of exhaustion and severe
stress, low self-efficacy and depression. As far as the
patient become more dependent to the caregiver, the
risk of chronic physical and mental disorders such as
anxiety, frustration, anger and irritation in caregivers
will increase. (10). In Beeson and Colleagues (11)
research, the women who care for Alzheimer's
disease were compared with men and the level of
loneliness was higher, the risk of depression and
problems in relationships with others was reported.
But problems ultimately was reduced the quality of
care for Alzheimer's patients at home. Sullivan (12)
found that interpersonal relationships has a stronger
position in the theory of relations. Sullivan
emphasized on the importance of relationships with
others, as it rooted in basic human needs and
proposed inefficiency in satisfying the need for
intimacy with others or interpersonal as loneliness.
Loneliness is a common experience in all people,
regardless of gender, age, socio economic and
cultural experience in life. Perlman and Peplau (14)
defined the loneliness based on the differences and
gap between level of social relations of individuals
with regard to its qualitative and quantitative
aspects. In their opinion, the basis of loneliness is a
gap between their aspirations and achievements in
interpersonal relationships and intimacy. The greater
distances causes loneliness grows (13). Single
people often suffer. They believe their loneliness is
due to their failure and not being able to control it.
They feel like they are in a situation that if a
problems arise they are not able to solve it and
nobody support them .Indeed it occurs only when
the Social Communications quantitatively and
qualitatively affected by the problem and the person
feels less social support. Loneliness leads to reduced
self-esteem (15), waver over the ability, in
interpersonal behavior, anxiety, lack of courage.
Risk taking show more (16) than the emotional and
affective states such as depression, anxiety and
anger are more vulnerable (17). Living in the present
and increasing human understanding by being
present with his emotions and cognition seems to
free human from all pain and suffering from mental
state. Perls (18) stats that a man with no contacts is
like neglecting the unfinished work and destroying
the current lives. This unfinished work is
unexpressed feelings such as resentment, anger,
guilt, grief, and unfinished needs to be considered as
unsolved problems that affect current consciousness
of human.
Gestalt therapy as an approach is based on current
consciousness and integration of mind, body and
emotions. The first task of Gestalt therapy is to
initiate awareness (18). This treatment type is
designed to help a person who deeply experiences
the moment and should be informed from its
thoughts, feelings and actions. The ultimate goal of
Gestalt therapy is awareness that itself is healing. In
Gestalt therapy, therapists should practice here and
now, experience, and awareness of what is going on
in space and time. They should attend to all of verbal
and nonverbal behavior in the therapeutic sessions.
This approach tries to remove the blocked awareness
of a person (19). In Gestalt therapy, the most
obvious way to increase the awareness of the clients
is telling their lives story for therapist and be aware
that the therapist listens. Verbal and nonverbal
expression as a reflection of what the meeting is to
listen to his client, to know how to experiment and
how greatly the world are invited (18) that it is very
easy to achieve this target group. Gestalt therapy
includes approaches of awareness based on present
and integration of mind, body and emotions. The
first task of Gestalt therapy is expansion of
awareness (19). This type of treatment is designed so
it helps people to go so deeply into the moment and
the thoughts, feelings and actions of information.
Participating in the group therapy provides the
opportunity to establish social relationships and
reduce feelings of loneliness for individual that
contribute to the promotion of mental health in
members. Draghic (20) beleives group therapy is one
of the most appropriate treatment methods to reduce
negative emotions such as depression and anxiety
disorders. As the society is a religious community,
and in many spiritual rituals living every moment
should be accompanied with the full knowledge and
participation (21). Gestalt group therapy can be very
helpful for the members of such society. The purpose
of this study was to determine the eeffectiveness of
gestalt group therapy on loneliness of women
caregivers of Alzheimer`s patients.
Methods
In an experimental study with a pre- posttest design
and control group, women participants were selected
from Alzheimer Association of Iran. Total number
of 50 women members was evaluated according to
inclusion/ exclusion criteria. The inclusion criteria
for the study included: 1) at least three years'
Vol. 12, No. 22, December. 2014
56
experience in home care of Alzheimer's patients, 2)
Persian speaking 3) appropriate listening and
speaking abilities 4) no history of psychiatric
hospitalization 5) no experience of grief over 6
months ago 7) signing informed consent to
participate in the study 8) not receiving any
treatment in mental ability which interfere with
memory or thinking. The eexclusion criteria
consisted of: 1) Simultaneous participation in other
psychotherapy sessions 2) cancel to continue
participation in the study, 3) three session absence.
Among the 50 persons who were qualified for the
study, 28 participants selected and were divided into
two equal groups randomly. Loneliness Scale was
administered to both groups at the beginning. Gestalt
therapy sessions were applied to the intervention
group, each session 90 minutes weekly and
continued for 12 successive weeks. The post-test
data collected after the last session by administering
Loneliness Scale. Data was analyzed by using t-test
for independent group. The instrument and materials
used in this study was Loneliness questionnaire: The
scale designed by Dehshir and colleagues (22) which
consisted of three subscales, "isolation from contact
with family", "isolation from contact with friends",
and "signs of emotional loneliness". The
questionnaire has a total of 38 questions on a five-
item Likert's range, 16 questions related to family
relationships, 11 questions related to relationships
with friends and 10 questions related to signs of
emotional loneliness. The internal consistency
reliability coefficient and retest total scale were
respectively (91/0) and (84/0). The validity of the
subscales is acceptable. Cranach’s alpha coefficient
for the total scale was 91/0, for subscale connection
with family 80/0, for loneliness subscales from
communicating with friends 88/0 and subscale signs
of emotional loneliness was 79/0.
Results
The mean and standard deviations of demographic
variables of experimental and control groups are
shown in table (1).
Table 1. Distribution of demographic variables between intervention and control groups
control group experimental group
N 14 14
Average age 50.3 (MD=2.4) 49.8 (MD=2.1)
Married 7 7
Marital status Widow 3 2
Persian Language 7 8
Ethnicity Azeri language 9 6
Lower secondary school 3 2
Diploma 6 6
Education
Bachelor 5 6
500000> 4 2
500000-1000000 7 7 Income
1000000< 3 5
In table (2), the mean and standard deviation of two
groups before and after the intervention and group mean
difference in pre-test and post-test is indicated.
Subtracting the mean pre-test and post-test in the
intervention group equals (Mean=-22.49) and the
standard deviation equals (SD=0.86). Subtracting the
mean pretest and posttest control group equals
(Mean=1.05) and standard deviations equals (SD=2.43).
Table 2. Mean and standard deviation, total score variable of loneliness in two groups
Group N Mean Standard deviation Error of the mean
pre-test 14 102.6 7.01 1.11
post-test 14 80.11 7.87 1.49
Intervention group
difference 14 -22.49 0.86 0.38
pre-test 14 99.18 5.22 0.96
post-test 14 100.23 7.65 1.72 Control group
difference 14 1.05 2.43 0.76
To compare two groups, and evaluate the
effectiveness of this intervention t-test of
independent groups was used (table 3) Thee
subtracting mean pre-test and post-test were
compared between the two groups. The results
indicated that the Gestalt group therapy due to
reducing loneliness in women participating in these
group.
Iranian Rehabilitation Journal 57
Table 3. Comparison of mean difference pre-test and post-test of groups
The mean difference between the two groups df T value Significance level
-23.54 26 10.85 0.00
P<0.01
Levine's test results show that the assumption of
equal of variances is confirmed (F=1.29, Sig=0.15).
After examining the assumption of equal variances,
we examined the T score. The comparison between
pre-test and post-test scores in both intervention and
control groups in table (3) (t=10.85) shows that
group therapy with gestalt therapy approach reduces
loneliness of participants. The comparison between
pre-test and post-test scores in both intervention and
control groups (t = 10.85) in table (3) and Specified
significance level (P <0.01) shows that group
therapy with Gestalt therapy approach is reduced
loneliness members of Intervention group. The
comparison of difference pre-test and post-test of
Loneliness subscales between the two groups is
shown in table (4).
Table 4. The comparison of difference pre-test and post-test of Loneliness subscales between groups.
Subscale Group mean
Standard
deviation
mean
difference df T value
Significance
level
experimental 2.13 1.29 Alone in family
relations Control -0.80 2.24 -2.93 26 1.61 0.07
experimental 11.52 2.02 Alone in
Friends relations Control 1.02 1.84 10.5 26 7.14 000
Experimental 9.12 1.29
Affective
syndrome Control 0.07 0.73 9.05 26 6.21 000
Discussion
As a result of the t-test for independent groups, it
shows a significant difference between mean of total
score in experimental and control groups, thus null
hypothesis is rejected. The two subscales of
loneliness in communicate with friends and
emotional symptoms significantly reduced in the
intervention group. In other words, it can be
concluded that the intervention of Gestalt therapy
decrease loneliness of women in Gestalt group
therapy. Verbal and nonverbal techniques in group
therapy structured in order to members of the group
with problems to regain their identity and stability.
The main objective of the experimental methods
such as Gestalt therapy is to help the client to
understand the necessity which no need to be
dependent on others and should be independent and
responsible person. And it is believed that when
obstacles in the way of awareness of individuals are
removed and unfinished tasks are completed, the
man reaches maturity (23). Gestalt therapy focused
on the present to complete unfinished tasks, the
unity of all being, self-regulation of organisms, and
particularly. Repressed excitement and meditating
on the past and future causes people to lose time and
mental energy and therefore regret about the past
and are unfinished and fear from the future. With
completing these unfinished tasks using treatment
techniques of gestalt therapy such as working on a
dream, heated seats, my relationship, and the empty
chair opposite poles. These tasks improve and
complete the unfinished tasks which caused a person
to be trapped in the past. Using this approach, in
team meetings, members learn to live in the present
as well as the application of methods helps the
export group members decline self-destructive,
therefore positive emotions can grow.
The present study demonstrates the effects of Gestalt
therapy on reducing loneliness of women caregiver
of Alzheimer's patients. Results of this research are
in line with by P. Vaio and Greenberg (24) findings
which discussed the unresolved emotional problems
in relationships with others, such as confusion of
interpersonal relations and loneliness. The results
obtained in this study are consistent with results of
Bahrami, Sudani and Honarmand (25) which
showed that Gestalt therapy reduced depression,
loneliness and increased self-esteem of divorced
women in the experimental group. Most of the
women who participated in this group therapy stated
that they had no desire to continue the sessions at the
beginning, but after caregiver's awareness of their
own arose, they were pushed forward to complete
the unfinished tasks. Regarding the relationship
between loneliness and self-efficacy(16), the results
of this study could be aligned with results of Saadati
and Lashani (26) in which they indicated that Gestalt
therapy increased the efficacy of divorced women.
Actually the tasks like identify unfinished
recounting memories in the present, raising
Vol. 12, No. 22, December. 2014
58
awareness of person here and now and acceptance of
one's self were the main treatment in the in Gestalt
therapy approach.
Conclusion
Duty of community is to promote the health and
safety of women's caregivers in order to improve
their quality of lives. This study shows that the
Gestalt therapy enhanced the quality of life of
caregivers and hence the quality of care for patients
increased. It also reduced the level of loneliness in
caregivers of chronic patients with Alzheimer's
disease. Further studies related to Alzheimer patient
caregivers are needed.
Acknowledgment
The authors will appreciate and grateful cooperation
and collaboration of Iran Alzheimer Center
particularly Ms. Haffarian. We are also thankful to
all patients who participated in this study.
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