Introduction
“What is Eating Gilbert Grape?’ is a story of the Grape family who lives in a small town in Endora, Iowa. The family consists of Albert, Bonnie, Larry, Gilbert, Arnie, Amy, and Ellen (See Appendix A). According to the movie, Mr. Grape dies for unknown reasons, and Larry, the eldest son of the family, doesn’t live with the family. After the death of their father, each person in the family had to take on different roles, except Bonnie. Bonnie is a morbidly obese woman who is isolated and suffers from depression. She spends her days on the couch watching TV. The two daughters help around the house with cooking and cleaning: Amy, the eldest daughter, is very maternal. Ellen is a narcissistic and sarcastic teenager and has problems with Gilbert. The story is narrated by Gilbert Grape, who is the second eldest son of the family. Gilbert was forced to take on the role of “father” early age after the death of his father. Gilbert works at a small grocery store to support his family financially and cares for his mentally disabled brother, Arnie. Arnie is the youngest son of the family who is developmentally delayed and needs physical care.
Family Assessment
The Grape family seems to be a typical nuclear family, but indeed they each have their problems. The different roles that each person in the family take affects their family dynamics. Arnie and Bonnie are dependent on Gilbert and Amy for their basic physical needs, such as bathing. Bonnie is a loving, caring mother to her children, especially sensitive to Arnie; however, she feels emotionally overwhelmed and feels herself as a burden.
Additionally, disgraceful glances from the community had caused her to withdraw herself. Gilbert takes his brother Arnie wherever he goes, and Arnie always cheers him up. Gilbert, on the other hand, is torn between his family and his independence. As a coping mechanism, this crisis leads him to a love affair with a married woman, Betty. The Grape family is always Endora’s center of attention, especially Arnie and Bonnie. Arnie frequently climbs to the water tower, finally causing him to end up at the police station. On the other hand, the children in the town try to sneak and laugh at Bonny through the windows at every chance.
Bonnie broke the last straw when she left the house for the first time in seven years to save Arnie from the police station. Embracing glances from the people had deepened her depression which later caused her not to leave the house ever again. Cumulative problems cause huge stress on the family. The main character, Gilbert, sinks under the caregiver’s stress, which leads him to make another mistake and feel guilty later on. Besides these family problems, Gilbert had to face another problem; rising competition between Food-Land store chains and the small grocery stores. Gilbert adopted the grocery, in which he works as if it is his own to protect from going out of business. The ecomap in Appendix B further illustrates the relationship between employment and the Grape family. Public Health Nurse (PHN) will seek ways of gaining trust and build a relationship with the family. See Script.
“Hello, my name is ____. I’m a PHN from Endora Public Health Services. We visit families on a regular basis to see if they need any resources or referrals from the city of Endora. First of all, I would like to thank you for inviting me to your house and giving me this interview opportunity. If that is okay with you, may I ask you some questions?
After the nurse asks her questions and builds trust with the family, she can then ask for a follow-up appointment.
Theoretical Application
According to Bowen’s Family System theory, a family is a system, and each member plays a different role in it (Thompson, Wojciak, & Cooley, 2019). The theory explains family function from the perspective of eight concepts. They include triangles, differentiation of self, nuclear family emotional process, family projection process, multigenerational transmission process, emotional cutoff, sibling position, and societal emotional process (Thompson et al., 2019). Most of the presented concepts apply to the Grape family.
Triangles
One of the most significant concepts that can be traced in the family is triangulation. Ponappa, Bartle‐Haring, Holowacz, and Ferriby (2017) report that this concept is the central one Bowen presents. The original idea of triangulation is that a triangle consisting of three family members is the smallest emotionally stable unit of the family. A triangle has to be established due to tension and stress a family may experience; its purpose is to stabilize the relationships among family members (Ponappa et al., 2017). Thompson et al. (2019) note that triangles are often formed among two parents and a child as an intentional or an unintentional strategy to reduce anxiety within the marital subsystem. However, the effects of such an approach are not always beneficial, especially for children. For instance, Ponappa et al. (2017) report that triangulation may be associated with problems children may experience later in life, including those related to their emotional stability, mental health, and behavior.
In the Grape family, a triangle is formed between Gilbert, his mother Bonnie, and Arnie. With the help of Amy, Gilbert tries his best to take care of Arnie, assuming the role of a caregiver unwillingly. It is possible to see that the Grape family is challenged by several significant problems, including the death of the father and Bonnie’s mental state, due to which she does not leave the house and has become severely obese. For Arnie, the triangle is much needed at this stage of his life because he needs the support of the whole family. While he has no father and his mother cannot take part in his upbringing, Gilbert’s and Amy’s support is vital for him. At the same time, Bonnie is a part of the triangle, too, as she still plays a significant role in the family. She is presented as a sensitive and loving mother for her children while being unable to overcome her struggles.
Differentiation of Self
Differentiation of self is another significant concept that affects the Grape family, too. Rodríguez-González, Skowron, Cagigal de Gregorio, and Muñoz San Roque (2016) report that differentiation of self can be defined as an individual’s ability to manage emotional self-regulation in their relationships with others. In the Grape family, Gilbert has a high level of differentiation, while Bonnie shows a low one. The reason for it is that the problems in the family do not have a severe impact on Gilbert; he is emotionally stable and is focused on his brother’s needs. His mother, in her turn, is highly self-conscious and depends on other people’s acceptance and approval while also being unable to change anything because of her poor mental state. While Gilbert feels the burden his family places on him but stays calm in the face of all challenges.
Nuclear Family Emotional Process
The link between the relationships among the members of the Grape family and the concept of the nuclear family emotional process is evident, too. According to Thompson et al. (2019), this concept is associated with the relational processes within one generation of a family that result in problems within the family system. In the case of the Grape family, it is evident that the husband’s death has led to the dysfunction in Bonnie. The death of a spouse is an unresolved conflict that the woman has to experience and one that she cannot process. As a result, she distances herself from her children, forcing them to take care of Arnie. At the same time, her feeling of worthlessness leads to increased anxiety about his well-being. Bonnie lets Gilbert take care of his younger brother with special needs. It also shows that she may have unrealistic expectations of her children due to the emotional distance and the death of her spouse that she cannot comprehend fully.
Family Projection Process
This concept can be associated with the transmission of either a poor level of differentiation or emotional problems from a parent to a child (Thompson et al., 2019). The transmission in the case of the Grape family can be seen in the relationships of Bonnie and Gilbert. The woman’s inability to overcome the death of her husband leads to problems in her son, as he starts to take too much responsibility for the well-being of his brother. All children of the family become entangled in their mother’s emotional problems, which interferes with their life goals and plans. Such a problem may potentially lead to a decreased level of differentiation among children (Thompson et al., 2019).
Emotional Cutoff
The emotional cutoff is another concept relevant to the Grape family’s story. Thompson et al. (2019) report that this idea can be defined by the cases in which individuals try to separate themselves from their family members as a way to handle a challenging situation. Bonnie’s and Ellen’s behaviors show their attempts for emotional cut off from the family. Although none of these characters moves away from the family, it is evident that both of them are emotionally unavailable from their relatives. Ellen is sarcastic and narcissistic, which can be considered a sign of her abandonment issues resulted from the death of her father and a lack of her mother’s attention to her. Bonnie, in her turn, does not take part in Arnie’s upbringing while being concerned about his well-being. In the episode when the woman decides to stay inside the house during her younger son’s birthday party, the audience can see that she tries to distance herself from other family members. The reason for such a behavior is that Bonnie is aware of the burden her condition places on her children and tries to cut herself off their lives to avoid pain and emotional distress.
Sibling Position
The concept of sibling position applies to the Grape family as well. The core idea of this concept is that a person’s birth order is associated with predictable attitudes and behaviors (Thompson et al., 2019). It means that older siblings are more likely to take leadership positions than younger ones; the latter typically prefer to be followers. The Grape family exhibits a less typical model of sibling position, as Gilbert is not the oldest child but inherits the role of the caregiver. At the same time, it is possible to say that Amy, being the oldest daughter of Bonnie, becomes a mother for Arnie while Gilbert is the father. At the same time, the youngest child in the family, Ellen, does not show leadership qualities. From this perspective, the characters of the story show that Bowen’s sibling position is a relatable concept. All in all, it is possible to say that Bowen’s theory reveals that the family members experience difficulties, particularly because of the situation they are in. One of the problems that may affect them is the caregiver role strain, as they have to take care of Arnie while none of them may be mentally prepared for this role. The Family Nursing Diagnosis (FND) is designed to resolve this issue.
Nursing Process
Caregiver Stress FND applies to this family because it was evident that the Grape family encountered various challenges that had to be resolved, including the family members’ mental and emotional states. As mentioned above, Bonnie felt emotionally overwhelmed and depressed; both Bonnie and Arnie depended on Gilbert in some of the regular needs in addition to the symptoms Arnie experienced. The nurse and the family developed a mutual FND in the following way. First, the nurse asked the family members whether they were aware of the problems within the family system. The nurse helped the Grape family to identify the challenges they were willing to work on and the ones that had to be managed as soon as possible. Second, the nurse offered a possible solution (intervention) to the existing problems. The following results were achieved:
- FND: Caregiver role strain.
- Plan: The two primary family goals that should be achieved are the following:
- Patients’ mental health symptoms will decrease within eight months.
- The emotional burden of the caregiver role strain will decrease within eight months.
Interventions
Primary
Evaluate the need for professional assistance in improving the mental health state of all family members. Implement cognitive behavioral therapy for all family members and anger management training sessions for Ellen and Gilbert (Koslowski et al., 2016; Richards et al., 2016). Discuss the problem of obesity with Bonnie and develop a healthcare plan for her.
Secondary
Discuss the perceived challenges all of the family members encounter and the results they want to achieve after treatment. Listen to the expressed concerns, especially the one’s Gilbert, Bonnie, and Arnie address. Utilize a screening tool, such as the Health Impact Assessment, to identify the possible lack of nutrition and hydration and the outcomes of it. Perform the assessment of the family members’ coping strategies to analyze the acuteness of the problem.
Tertiary
Emphasize the significance of the appropriate family system and discuss the problems associated with the lack of it.
Tools
Observation, psychological examination, physical health assessment.
Evaluation
After the period of treatment and interventions, all family members reported significant improvements in her mental health state. Bonnie’s children reported a significant enhancement in her parenting skills as she started to spend more time with Arnie and became his primary caregiver. Bonnie’s weight has become lower; the woman has started to be physically active at least twice a week. Gilbert’s mental health state improved as well, as he gained more independence. Gilbert’s mental health state improved as well, as he gained more independence; the effects of the caregiver role strain have been eliminated, as the young man did not feel the pressure of being responsible for his brother anymore.
Development/Life Cycle
According to Erikson’s Developmental Theory, the current developmental role of Bonnie is to choose between generativity and stagnation (Knight, 2017). As the woman’s history shows, she has been experiencing stagnation, as she has little connection with others, does not contribute to the life of her children, and does not engage in productive and meaningful work. It is evident that stagnation affects not only Bonnie but other family members negatively, as they have to take care of her and do not receive her support. The lack of her presence in children’s lives is particularly harmful to Ellen and Arnie, as they are the youngest children; Ellen has already been showing signs of frustration.
Gilbert’s developmental role is the choice between intimacy and isolation, as the young man is 24 years old (Dunkel & Harbke, 2017). It is possible to say that currently, he is more oriented towards isolation than intimacy, which is evident from his inability to build relationships with Becky at first. Gilbert’s leaning towards isolation may hurt other family members, too, as as a result, he can be unable to maintain healthy relationships with the family due to poor emotional connection with them. Currently, Amy is also at this developmental stage; however, she has resolved the conflict between intimacy and isolation successfully. She is good at building positive relationships with others, including Bonnie, Gilbert, and Arnie. It has a positive impact on other family members because she can make everyone feel comfortable and loved.
Arnie is an eighteen-year-old young man, which means that his current developmental role is the choice between identity and role confusion (Knight, 2017). It is possible to say that currently, he is at the stage of role confusion, as he does not have an opportunity to develop a strong sense of identity because he is highly dependent on Gilbert and Amy. The lack of identity may affect other family members, too, as he does not understand what his and his family’s values are, how his behavior can hurt others, and what problems his relatives may experiences, thus, being apathetic. Ellen has the same developmental role as Arnie does, as she is not much younger than he is. It is possible to say, however, that she does not show the signs of role confusion. She is narcissistic and seems to reflect on her life a lot. In the current situation, Ellen’s strong sense of identity may not be beneficial for the family, as she attempts to discover her adult self by not behaving well. However, in the future, a sense of self may help the girl to set clear values and goals.
Health/Illness Management
According to Garris and Weber (2018), Bowen’s family systems theory is significant for disease prevention, especially in cases of mental illnesses. The reason for it is that Bowen’s work describes how a family can manage conflicts and establish closeness among all relatives. Son (2019) adds that the theory can help family members to see the dynamic in their relationships, which are closely associated with the manifestation of depression among individuals. Notably, mental health problems are not the only issues that affect the family. For instance, Bonnie is severely obese, which means that the general lifestyle of the family may be unhealthy.
The generational transmission can affect health management in the family significantly; it is illustrated by the Genogram presented in Appendix B (Thompson et al., 2019). For instance, Bonnie does not take care of herself, which may lead to the outcome in which her children avoid self-care, too. In addition, they may develop a decreased ability to manage stressful situations as well. It means that the family should undergo healthcare assessment regularly and attend educational training aimed at improving its ability to function as a system. Moreover, as shown in Appendix B, genetic transmission affects the family highly as well.
The ecomap presented below shows that the Grape family has decreased community support due to the lack of assistance from the extended family, the local population’s disapproval, and the limited access to health care. The positive behaviors the family may implement for prevention include undergoing regular health check-ups, attending educational sessions, and undergoing counseling. The negative ones include continuing to preserve the existing family system and avoiding admitting the problems associated with the physical and mental health of family members.
Conclusion
Bowen’s theory was helpful for framing the issues presented in the Grape family. With the help of the theory, the identification of the tendencies, such as the problems with the differentiation of self in Bonnie or the challenges associated with the nuclear family emotional process, was successful. It is possible to say that it was challenging to develop a diagnosis for the family because many of its members show depressive symptoms, while the caregiver role strain is the cause of these signs. Bowen’s theory showed a high level of effectiveness because it allowed for reviewing the problems the Grape family encounters from various perspectives (Thompson et al., 2019; Son, 2019; Rodríguez-González et al., 2016). For instance, it helped to explain Amy’s and Gilbert’s roles from the viewpoint of siblings’ positions, along with the causes of Bonnie’s emotional cutoff. By looking at the results of the analysis through Bowen’s theory, it is possible to say that the FND diagnosis was applicable because taking care of Arnie was one of the most significant challenges family members encountered. The results of interventions showed that the goals of diagnosis and treatment were mutual because both the nurse and the family members were interested in the improvement of their physical and emotional symptoms.
The ethical dilemma the nurse experienced was that the family was distressed by taking care of one of the children, and it was unethical to ask them to stop assisting Arnie in his daily tasks. At the same time, it was crucial to reduce the impact of caregiving on Gilbert and Bonnie. With the suggested interventions, it was possible to help Bonnie to be more involved in her son’s life and reduce the pressure other children had experienced. Thus, the suggested interventions were feasible because they have eliminated the symptoms the Grape family had had. The primary lesson learned from the experience is that the cause of the depressive symptoms in a family may not be exclusively negative; sometimes, the individuals try their best to help their loved ones. Another lesson is that caregiving may take many physical and emotional powers, and no one should be forced to take care of others alone to avoid adverse outcomes.
Appendix A: Grape Family Genogram
Appendix B: Ecomap
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