In the following case, the focus is on the relevant topic in order to demonstrate treatment of a teenager who was a victim of abuse by his father and came to the doctor for treatment. The following contains the content of the conversations between the doctor and the teenager following the intervention of the school advisor who turned to the family doctor in order to prevent the continuation of this pattern of abuse.

In presenting this case, the doctor does not profess to give the full and detailed picture of the treatment of this teenager. Therefore, conversation between the doctor and teenager will be presented partially; these conversations emphasize the role that the doctor plays in stopping the cycle of family violence. It is a therapeutic attempt to shed this family’s pattern of abuse to which it has become accustomed.

Background

Danny is a student in 9^th grade, 14 years old, who lives with his father and older brother. The teen’s mother left the house five years earlier. She is in contact with her children from time to time. The parents are divorced. Danny is a bright and outstanding student, and excels in various sports.

Referral by family doctor

Danny was summoned to my room. He had gone around with a black eye for several days. The teacher tried to find out the reason for his injury and he responded tersely that a door had fallen on him during renovations in the apartment. The school advisor also received a similar answer, which was hard to accept since it is obvious that a falling door does not really cause a black eye. Therefore, he was summoned to me after the school advisor approached had me. I decided to talk to him about different things in order to indirectly arrive to the topic of his injury.

It is important to say that for the last few years, Danny and his brother have come to my clinic, along with their father, for continued treatment after a series of visits to the Emergency Room. Each time the boys were there for external injuries that, according to the medical reports, happened as a result of sports injuries or other coincidental injuries. In the current instance, there was a formal referral from the school counselor who claimed that there seemed to be a more “complicated” story behind the latest injury–a black eye.

Conversation

Doctor: Do you like school?

Danny: Sort of.

Doctor: What do you like about it?

Danny: I didn’t say I liked it.

Doctor: So what does ‘sort of’ mean–explain it to me.

Danny: Sort of is sort of. That’s it. (Complaining)

Doctor: What subject are you good at in school?

Danny: Almost all of them (pause). But that does not mean that I like all of them.

Doctor: So what do you like?

Danny: I really like Bible lessons.

Doctor: Strange, I thought that you were a sportsman and that you like sports. So what about sports interests you?

Danny: (ignoring the sports issues and answering) Because it has interesting analysis, you have to think.

Doctor: So you like to think?

Danny: Enough so (contemplative)

Doctor: So what else do you like?

Danny: I like all subjects that require thinking.

Doctor: So thinking is important to you.

Danny: Especially.

Doctor: But I heard from your family that you are outstanding in sports. I was told that you are really the pride of the school.

Danny: Yes (modestly).

Doctor: Do you also like sports?

Danny: No, not really.

Doctor: Interesting.

Danny: Not only do I not like sports, I really hate sports!

Doctor: Why?

Danny: I hate aggression. Sports is aggressive! (decisively)

Doctor: What is aggression?

Danny: Aggression is being forced to do something.

Doctor: Like what?

Danny: Like sports.

Doctor: Tell me, Danny, who forces you to do sports in school?

Danny: (Silence. Chuckles)

Doctor: So who forced you to do sports?

Danny: Definitely not the school!

Doctor: So who then?

Danny: Who is able to force me?

(Silence).

Doctor: (Silence).

Doctor: How does forcing you to do sports affect you?

Danny: It makes me hate sports.

Doctor: Yes, I understand you.

Danny: No one can understand me! (With a shred of anger)

Doctor: How does it affect you Danny, that no one understands you?

Danny: (silence)………I feel alone.

(Silence), a lot of loneliness

Doctor: Where do you feel this loneliness?

Danny: What do you mean?

Doctor: Where do you feel this loneliness in your body?

Danny: Here, in my heart (motions to his heart).

Doctor: I understand, (silence). Be there Danny, feel the loneliness.

Danny: Believe me, doctor; I feel it all the time.

Doctor: So it is hard.

Danny: Yes, very.

Doctor: (silence).

Danny: Sometimes I think there is no one in this world that understands me (in a quiet voice).

Doctor: Why do you think that I cannot understand you?

Danny: Maybe you can try to imagine that you understand, but you definitely do not understand! (with certainty)

Doctor: What don’t I understand?

Danny: Understand is understand! But you can’t feel like I do. (Quietly)

Doctor: What does it mean to feel like you do? What do you feel, Danny?

Danny: (silence)

Doctor: Is it difficult for you to say what you feel?

Danny: (silence)

Doctor: (silence)

Danny: I get too much. (Quietly)

I get and I get….and it’s hard! (Quietly)

Doctor: What do you get, Danny? What do you mean?

Danny: (silence)

Doctor: You mean get hit?

Danny: Yes. (Softly)

Doctor: That is very hard.

Danny: Yes.

Doctor: Which sport causes you to get hit?

Danny: You really don’t understand! (With a chuckle)

Doctor: So explain it to me!

Danny: What are you talking about getting hit in sports?

Doctor: So it is not from the sports.

Danny: No! (Quietly)

Doctor: So there are injuries in sports but this is not from the sport itself?

Danny: Yes.

Doctor: I am trying to understand.

(Silence)

Doctor: Help me understand, Danny. I understand that you are being hit but not from the sports?

Danny: Yes. (Silence)

Doctor: So someone hits you in school when you are playing sports?

Danny: It’s not in school!

Doctor: Why should they hit you if you are outstanding in sports?

Danny: Because I’m not good enough! (Angrily)

Doctor: Not good enough at what?

Danny: At sports! (Angrily)

Doctor: So now I understand. Someone hits you when you play sports and this person is not satisfied because you are not good enough at sports.

Danny: Yes.

Doctor: That is not easy.

Danny: No. Not at all!

Doctor: What does it mean that it’s not easy for you?

Danny: That I am alone, and that I also get hit, and I’m sick and tired of everything!

Doctor: So what are you thinking of doing about it?

Danny: (silence)

Doctor: (silence)

Danny: Last time I hit him back.

Doctor: So that’s why you have a black eye.

Danny: Yes. (Quietly)

Doctor: So the black eye didn’t come from a door that fell on you like you said earlier.

Danny: Correct. (Quietly)

Doctor: Hmm… (Wonders to himself)

Doctor: So what do you think the solution is, to hit?

Danny: That is definitely not a solution. (Quietly)

Doctor: So what is a solution?

Danny: I don’t know. I really don’t know what to do with him.

Doctor: What to do with who?

Danny: With my fucking father.

When Danny said that his father was physically abusing him, I devoted time to examining his field of experience, to discovering the significance of his words. Danny’s posture was stiff, his face muscles were tense and his voice was shaking. He also avoided making eye contact with me. I paid attention to the words that he was saying, to the content of the things he was saying, through the words, but also to the movements of his body and I realized that this disclosure regarding his situation was especially difficult for him [1].

It should be emphasized that I was cautious during the conversation not to interrogate Danny too much and to allow things to come out in to the pace and manner that he chose to explain them. During the entire conversation, the cynicism that accompanied Danny’s words was apparent, the black humor that in and of itself causes deep disturbance. I tried not to push Danny to give answers to questions that interested me greatly, such as who is his physical abuser?

One should not dwell on the reasons that led to the incident. Rather, should focus on the future and the present, and on the awareness of how to live one’s life with a different reality [2,3]. Just as we refer to the “here and now” in the Gestalt therapy [4]. Pearls refer to this approach that believed that we experience an event through life itself and not through causativeness. The goal is to lead a person to wholeness, completeness, forgiveness and the opening of new doors.

Nevertheless, the doctor must emphasize that only he himself is receiving the responsibility for his own fate and his own life and, therefore, the change must be his change. The doctor just guides him and leads him toward change, but the brunt of the work belongs to the individuals who must internalize it because man has free choice. This freedom is fundamental to the individual’s fulfillment of selfrealization. Therefore, the decision is his alone [4-6]. Indeed, the doctor helps them to operate at their best to develop and understand themselves, and to deepen their knowledge about their feelings and intellect. But the real work is their responsibility alone.

The holistic thinking that a transformative doctor adopts is meant to get him to use different tools in order to focus the doctor parties on their ability to change, on the need for change, and on his responsibility to take substantive action in order to achieve a different, more freeing reality. The doctor is supposed to function in different areas during the process, which is versatile, and to utilize a range of aspects and tools to promote the growth.

The more that the doctor guides and encourages awareness of his needs, the more he leads him to growth and to an understanding of how to end the conflict.

Unlike Maslow [7-9], who referred to the shared needs common to all mankind, the Gestalt approach refers to the scale of a person’s individual needs in each one’s personal hierarchy of needs is different from person to person according to one’s circumstances and developmental stage. Therefore, this approach requires awareness and recognition-the ability to understand which scale a person belongs to– as the next required step is the ability to make a change.

Humanistic psychologists emphasize man’s potential for growth and development [7-18]. Therefore, an important stage in reaching this development is a person’s self-awareness and his awareness of his environment. Indeed, a good psychotherapist is one who guides a person inwards–to his desires, wants, emotions, and his interactions with his environment.

The understanding that a person establishes a continuous process of communication with himself, with his feelings, desires and wants, is a gateway to understanding that a person’s interactions with his environment are influenced by the person’s motivations, needs and circumstances.

Each person processes and organizes things differently and the meaning of things is personal to him. Therefore, self-awareness is the primary condition for all negotiations at the center of the conflict. The doctor is supposed to create an accepting, safe and respectful environment that enables self-reflection and introspection that leads the patient to achieve their positions while showing sensitivity to both sides, in a different kind of experience. This process is carried out by encouraging each side to connect to all the components of their personalities–in other words, to achieve self-awareness [1,4,6].

The doctor uses his tools to not only offer content, but to convey his unique style and body language in order to be accepted by the parties without conditions or judgment and to create a personal closeness between him and the patient. His goal is to enable a dialogue or debate inwards. He encourages the parties to try, to examine options, to express himself but first and foremost to listen, sometimes even to repressed and hidden voices.

The focus of the work is always to enable the party to achieve a proper level of self-awareness in order that he should be able to identify his true weaknesses and recognize faulty communication patterns that may have been necessary to protect him in the past but are no longer necessary in the present. The goal is to help the patient to look at his relationships anew and to arrange them in a manner that is suited to him and that enables him to lead a life free of worry, negativity and conflict [4,5,19].

It is very important to me to befriend the teenage patient and to try to uncover his spiritual and emotional world. Beyond my job as a doctor to whom a teenage with an injured face was sent, I tried to examine the psychological state of the patient and to understand the series of strange injuries that had happened lately to the children of this family.