use of the mediated learning experience and the working alliance: a...
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ATHABASCA UNIVERSITY
UNIVERSITY OF CALGARY
UNIVERSITY OF LETHBRIDGE
Use of the Mediated Learning Experience and the Working Alliance: A Case Study of an
Individual with Dual Diagnosis (Developmental Disability and Mental Illness)
BY
PATRICIA HAGARTY
A Final Project submitted to the
Campus Alberta Applied Psychology: Counselling Initiative
In partial fulfillment of the requirements for the degree of
MASTER OF COUNSELLING
Alberta
December 2004
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DEDICATION
The author would like to dedicate this study to all people suffering from developmental
disabilities and mental health issues. May your dual needs be recognized, acknowledged
and treated in a humane and compassionate manner.
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CAMPUS ALBERTA APPLIED PSYCHOLOGY:
COUNSELLING INITIATIVE
SUPERVISOR SIGNATORY PAGE
Faculty of Graduate Studies and Research
The undersigned certifies that she or her has read and recommends to the Faculty of
Graduate Studies and Research for acceptance, a final project entitled USE OF THE
MEDIATED LEARNING EXPERIENCE AND THE WORKING ALLINACE: A
CASE STUDY OF AN INDIVIDUAL WITH DUAL DIAGNOSIS
(DEVELOPMENTAL DISABILITY AND MENTAL ILLNESS) submitted by
PATRICIA M. HAGARTY in partial fulfillment of the requirements for the degree of
Master of Counselling.
___________________________
Dr. Paul A. Jerry
Project Supervisor
January 18, 2005
__________________________
Date
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CAMPUS ALBERTA APPLIED PSYCHOLOGY:
COUNSELLING INITIATIVE
Digital Thesis and Project Room Release Form
Name of Author: Patricia Hagarty
Title of Final Project: Use of the Mediated Learning Experience and the Working
Alliance: A Case Study of an Individual with Dual Diagnosis (Developmental
disability and mental illness)
Degree and Specialization: Master of Counselling: Counselling Psychology
Year this Degree Granted: 2005
Permission is hereby granted to Athabasca University Library’s Digital Thesis and
Project Room to have available an electronic (pdf) version of this final project.
The author reserves all other publication and other rights in association with the
copyright of this final project, and except as herein before provided, neither the final
project nor any substantial portion thereof may be printed or otherwise reproduced in any
material form whatever without the author’s prior written permission.
9215 Wedgewood Drive North
Grande Prairie, Alberta. T8W 2G5
____________________________
Student Address
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Abstract
This project is an exploratory, mixed method case study. Objective was to teach a man
with dual–diagnosis (developmental disability and mental illness) to learn anger
management and coping skills within a counselling context. An ABA phase change
design with theoretical grounding in Feuerstein’s Mediated Learning Experience (MLE),
integrated within the Working Alliance (WA) was used. Intent was to demonstrate the
WA, MLE, explore the efficacy and limitations of these interventions. Characteristics of
the MLE, symptomatology, level of the working alliance were measured using
interviews, Horvath’s Working Alliance Inventory (WAI-S), Symptom Checklist-90-R
(SCL-90-R), and the Adaptive Behavior Assessment System (ABAS). Although
limitations exist, results suggest individuals with dual diagnosis may benefit from the
WA process grounded in MLE.
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ACKNOWLEDGEMENTS
I am indebted to Julie, Nina, Don, Scott, Paul and Doreen for their patience, support,
flexibility, and expertise in making this study possible.
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TABLE OF CONTENTS
Introduction…………………………………………………………………………..1
Personal Theory & Grounding Context for the Study……………………………….3
Rationale……………………………………………………………………………..5
Review of the Literature………………………………………………....…………...6
The Realm of Disability……………………………………………………...6
The Disability Rights Movement………………………………….…………8
Normalization & Social Role Valorization……………………...…………..11
The Working Alliance………………………………………...…….…….....12
Efficacy of the Working Alliance…………………………………………....14
Mediated Learning Experience……………………………………………....15
Counsellor as Mediator……………………………………………………....17
Links Between Cognition, Education & Emotions………………………......22
Bridging the Working Alliance & The Mediated Learning Experience….….24
Client Context…………………………………………………………………….….25
Procedures……………………………………………………………………….…...27
Methodology…………………………………………………………….…...27
Qualitative Treatment Data………………………………………………….....…….32
Sustaining the Working Alliance…………………………………........…......32
Intentionality & Reciprocity………………………………………..…..….....34
Mediation of Meaning………………………………………………....……..34
Transcendence…………………………………………………….......……...35
Results & Summary……………………………………………………….......……..36
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Pre-Test Data………………………………………………………………......36
Symptoms Checklist-90-R………………………………….…..……...37
Adaptive Behavior Assessment System Data……………………........37
Working Alliance Inventory……………………………………….......39
Content Analysis (Qualitative) Pre-Treatment Interview………….......40
Post-Test Data…………………………………………………………….…....41
Symptoms Checklist-90-R………………………………………...…...41
Adaptive Behavior Assessment System…………………………..…...42
Working Alliance Inventory…………………………………….….….43
Content Analysis (Qualitative) Post-Treatment Interview………..........44
ABA Phase Results……………………………………………………………......…...46
Pre-Post SCL-90-R Results………………………………………………………..…. 48
Pre-Post ABAS Results………………………………………………..…….……........49
Limitations………………………………………………………………………..….....49
Conclusion…………………………………………………………...............................50
References………………………………………………………………………............54
Appendices……………………………………………………………………………...60
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LIST OF TABLES
Table 1: Self-report treatment ratings for ability to manage & cope with difficult
situations. ……………………………………………………………………….……….36
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LIST OF FIGURES
Figure 1: Working Alliance Model………………………………………………………14
Figure 2: Working Alliance Skills Taxonomy…………………………………………...19
Figure 3: A phase: Pretreatment baseline data…………………………………………...46
Figure 4: B phase: Treatment data (13 weeks)…………………………………………..47
Figure 5: A phase: Post-treatment data (chart) ………………………………………….47
Figure 6: SCL -90-R data (pre & post-test scores)………………………………………48
Figure 7: ABAS data (pre & post-test scores)…………………………………………...49
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Introduction
This research is a clinical exploration with theoretical grounding in Feuerstein’s
Mediated Learning Experience (MLE) Model, while integrating a counseling concept, the
Working Alliance (WA). The main objective is to teach an individual with dual
diagnosis (developmental disability and mental illness) to learn anger management and
coping skills. Another objective was to determine the efficacy of these interventions with
this population in order to assist individuals with developmental disability and mental
illness in reaching their potential and increasing quality of life. The WA is the
underlying foundation that promotes and sustains the mediated learning environment.
This alliance is the relationship that encourages mutual trust and respect, highlighted by
mutual agreement on goals and tasks (Bordin, 1979). Solid working alliances create
opportunities for client self-exploration while empowering the client to take risks in
learning new strategies for working through problems (Hiebert, 2002).
The Mediated Learning Experience (MLE) presents an opportunity to integrate
“tasks that need to be learned or responded to-within an interpersonal context” (Falik,
2000, p. 314). The interpersonal relationship encourages clients who have disabling
conditions to excel at their own pace, and “describes a quality of interaction between a
learner and a person, whom we shall call a mediator”(Feuerstein, 2002, p. 1).
Feuerstein provides three (3) characteristics that define the MLE. First, intentionality and
reciprocity whereby the counselor “interposes himself or herself intentionally and
systematically between the [client] and the content of their experiences. At the same
time, both [mediator] and [client] reciprocate with shared intentions” (Ben-Hur & Meir,
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1998, p. 4). Secondly, Ben-Hur and Meir further indicate that transcendence considers
the changes in how the client learns and thinks. “Such changes must transcend the
content and context of the MLE” (p. 5) to make generalizations to other environments
and situations. Third, mediation of meaning is the “successful product of emotional and
cognitive excitement. The MLE provides “the [client] with emotional excitement of
learning and the feeling of competence” (p. 7) thus reaching potential.
There is a general lack of research about disabling conditions, and how these
conditions can be overcome to enhance the fulfillment of personal potential through a
mediational learning experience and an empowering working alliance. Disabilities of a
developmental, physical and mental nature are considered independently rather than
collectively. For each type of disability there is a corresponding approach to treatment,
and for every social system there is a different language (Michailakis, 2003).
Furthermore, disabling conditions have been observed predominantly through a medical
and pathological lens.
A review of the literature related to disabling conditions, as well as literature on a
therapeutic–working alliance that can benefit the way in which the learning potentials for
the disabled individual is enhanced will be provided. Reaching this point has been a
journey of self-exploration and has resulted in my making a commitment to my theory of
people, life and change by presenting four important domains of disability interest. A
personal prologue and rationale that characterizes my theory of being in the world--a
theory that values ongoing learning and assisting others to be all they can be will be
provided as well as a review of historical perspectives on disability from the disability
rights movement to the recent concepts of normalization and social role valorization. In
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addition, a discussion about the development of an alliance between counsellor and client
that sets the stage for change and learning will be initiated. Finally, an introduction to
mediated learning experiences, and how they may be integrated into a working alliance
will be described and concepts will be developed to show the linkages between cognition,
education and emotion that support their integration. This conceptual integration creates
a context to assist individuals living with disabling condition(s), to learn and grow
socially, psychologically, and independently. In other words, this is the exploration of
treatment efficacy of the integration of the Mediated Learning Experience and the
Working Alliance. The aim is to demonstrate to the research community that people with
both developmental disabilities and mental health issues may be served and benefit from
a counselling process that integrates mediated learning and the working alliance to
enhance quality of life.
Personal Theory & Grounding Context for the Study
For many years I have been interested in disabilities and in the exploration of
building individual potential. I am intrigued by the extent to which people with
disabilities are affected socially and personally by their disabling conditions. This
intrigue further expands my interest in their ability (or lack thereof) to live life that is rich
in quality and opportunity for development that is meaningful for the individual and
respected by others.
My personal theory is based on the idea that the more a practitioner can learn
from the knowledge of others, the more skillful the practitioner can be. “Personal theory
is full of integrated knowledge that combines learning from other information sources,
such as content knowledge learned from other meta-theory” (Jarvis, 1999, p. 145). My
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philosophical assumptions are grounded in the notion that human beings want to be
accepted, nurtured and understood (Balint, 1952; Hagarty, 2002). They are based on the
premise that human beings have an “actualizing tendency” that is present in the
motivation to realize one’s own full “capacity to accept self and others to reach goals”,
and to realize the potential for happy and fulfilling living (Raskin & Rogers, 2000, p.
133). My theory also asserts that individuals who can define themselves and their own
freedom to “cultivate individuality” (Ellis, 2000) are more able to validate increases in
self-esteem and self-worth. The ability to reach one’s full potential is a sign that one has
created self-efficacy and has a place where self-determinism prevails (Hagarty, 2002).
Unfortunately, it seems that “self-determination has been identified with people with
disabilities only since 1988” (Ward & Meyer, 1999, p 1).
The nature of change resulting from the application of my theory is based on the
premise that behavioral and social learning “emphasizes a corrective learning experience
in which clients acquire new coping skills, improve communications, or learn to break
maladaptive habits and overcome self-defeating emotional conflicts” (Wilson, 2000, p.
216). This means that the counselor assists the individual by teaching alternative ways of
responding in the environment and empowers the individual to reach his or her full
potential (Hagarty, 2002). The counsellor is a guide, a teacher, a collaborator, and
mentor to the client. Feuerstein, Rand & Rynders (1988) consider that as a result of
change through interactions with the mediator (counselor), any resistance that may occur
prior to a mediated learning process can be lessened by virtue of the emotional impact
instilled by the learner.
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Rationale
My personal theory has laid the foundation upon which to advocate for
psychology as a profession to become more informed about counselling strategies and
approaches that meet the needs of people with disabilities, and in assisting them in
becoming accepted, respected, and equal members of society.
Seemingly the psychological community agrees that an important goal for
research on disability and community rehabilitation is to advance the quality of life of
persons with disabilities (Tate & Pledger, 2003, p. 294). Tate and Pledger add that over
the past five decades research on disabilities and community rehabilitation has not
received much priority. What needs to happen is the offering of methodology to create,
evaluate and maintain appropriate interventions to improve the lives of the disabled. I
advocate for more research in the field of disabilities to further knowledge and create
interventions that can assist the disabled person to achieve his or her own unique
potential. This project is an active demonstration of my commitment to this aim.
An extension that compliments the concept of the mediated learning experience
and the construct of a working alliance is consideration of client rights, client strengths
and ultimately the grounding concepts of normalization and social role valorization
(Wolfensberger, 1998). Each of these concepts includes the idea that no matter how
marginalized people are either culturally, ethnically, socially, physically and/or mentally,
there is a need and societal obligation to promote inclusion, independence, acceptance
and education in order to assist in the promotion of valued existences for people with
disabling conditions, and those who are marginalized and oppressed in society. The goal
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is to teach and assist people to become empowered to achieve their individual potentials
and maintain a quality of life that is equal to the rest of society.
The therapeutic principles in counselling are based on the idea that individuals are
human beings who have something to contribute to themselves and society. When
supported and empowered to realize or actualize potential through achievement, the
individual can benefit from the rewards life has to offer. The MLE and WA are good
examples of this notion. My personal theory postulates that human beings want to be
accepted, nurtured and understood (Hagarty, 2002).
The following is a review of the disability literature and associated issues over the
past two decades. A conceptual analysis of the Working Alliance and the Mediated
Learning Experience is also presented. This theoretical review leads to the current
research project, which uses a single case study to demonstrate the integration of the WA
and MLE in a therapeutic context with an individual who has both developmental
disability and mental illness.
Review of the Literature
The Realm of Disability
Throughout the past 25 years disability has been compartmentalized through the
application of various models of disability. Current disability research reveals that there
is no agreement on a definition of disability (Michailakis, 2003). Michailakis indicates
the traditional or medical model has long influenced perceptions of disability. This
model views the individual as being limited or incapable of performing regular activities
because of some functional malady. It focuses on the individual as being broken, a
failure, defective or impaired. Hence, it is the “individual who lacks certain capacities
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that are necessary to attain full autonomy” (p. 210). The medical model’s roots are based
on a model of “illness” whereby the person is “released from social obligations and
receives special treatment, provided there is evidence of active efforts to get well”
(Parsons, 1958 cited in Quinn 1998, xix). The person is pathologized.
Interventions based on this model are intended to cure, and make the assumption
that the person deviates from the normal rather than having an ability to adapt to the
environment (Finkelstein, 1991 cited in Quinn, 1998). Oliver (1996) calls this model
“the personal tragedy theory of disability” (p. 33). In this sense tragedy implies an
inability to overcome obstacles of living and therefore, the client remains pathologized.
The social model of disability considers the disabling condition and the “person in
his or her environment: the focus is on a socio-ecological approach”(Pledger, 2003, p.
283). This model focuses on the external factors that can potentially influence the
disabling experience. The social model sees the problem as embedded in society rather
than in the individual and focuses on the “amelioration of social and environmental
barriers to full social, physical, career and religious participation” (French, 1993 cited in
Quinn, 1998, p. xx). In essence, it is social barriers to inclusive living for the disabled
that must be addressed instead of using monetary resources to segregate this population
(Finkelstein, 1991 cited in Quinn, 1998). Therefore, counselling opportunities need to be
available. Pledger (2003) discusses additional models that are seemingly an extension of
the social model. The “Nagi” model of disability “posits that pathology should not be
viewed as the singular determinant of individual functioning; functional limitation is an
expression of the extent to which the environment restricts or is able to accommodate
disability characteristics” (Pledger, 2003, p. 282).
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Oliver (1996) suggests a model that fits between the medical and the social
models. He contends there is “no such thing as the medical model of disability” (p. 30),
but rather an individual one in which medicalization is but one component. He also
addresses the success of the social model and expands the notion of other models such as
the psychological, charity and administrative models. While the literature has no
meaningful explanations of these models he does indicate that even those with disabilities
including himself have questioned the social model. Ultimately, Oliver argues that we
cannot make the assumption that the social model does everything for the disabled and it
cannot fully explain disability. Summarily, the realm of disability continues to be
plagued by inefficient models that cannot accurately portray what it means to be disabled
and how society should respond.
The Disability Rights Movement
Historically, people with any type of differences from the norms of society,
including the disabled, have not enjoyed a positive image. (Funk, 1987 cited in Ward &
Meyer, 1999) notes “that the inferior economic and social status of people with
disabilities has been viewed as the inevitable consequence of the physical and mental
differences imposed by disability” (p. 2). Even in Biblical terms the Old and New
Testaments provide the message that “disability is a sign of God’s disfavor or is brought
on by sin” (Shapiro, 1993 cited in Ward & Meyer, 1999, p. 3). Shapiro further suggests
that historically there has always been evidence of the wrongful mistreatment of people
with disabilities. Segregation, whereby people are institutionalized due to negative social
attitudes and corresponding need to isolate them, has been a common historical response
(Ward & Meyer, 1999).
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Throughout the 1920’s, 1930’s, 1940’s and 1950’s, advocacy groups emerged to
promote self-reliance of the disabled. The advances in some programs began to blossom
with the attempt at “humanizing” disabled people as a result of the presence and
advocacy of disabled Vietnam veterans (Ward & Meyer, 1999). “Humanization is
defined as recognition that disabled people have human needs and characteristics, and
that public policy must be designed to reflect and further this human potential” (Shapiro,
cited in Ward & Meyer, 1999, p. 8). The first among the steps of this evolutionary
process was an increase in opportunities for children with disabilities to receive
education. The second step that influenced the social and political arena was initiated by
the disability rights movement, which made independent living a priority. Additionally,
people with disabilities began to recognize their own oppression and marginalized status,
which triggered the creation of a group identity. Disabled people emphasized that they
too have a “common social experience associated with other people with similar
disabilities and people with other disabilities” (Ward & Meyer, 1999, p. 4).
The birth of self-advocacy was created within the disability rights movement by
people with developmental disabilities who were also rebelling against oppression and
marginalization (Ward & Meyer, 1999). Ward and Meyer discuss other movements,
including the People First Movement which sprang up in an effort to perpetuate the
notion of self-determination which grew out of the principle of normalization, and which
was then expanded by the works of Wolf Wolfensburger in the 1980’s and early 1990’s
to include social role valorization.
McCarthy (2003), in his qualitative study, interviewed participants with various
disabling conditions. He began by discussing the beginning of the disability rights
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movement. He speaks of Ed Roberts, a polio survivor, who relied on an electrically
powered wheel chair, an iron lung and a personal aide to gain formal admission to the
University of California. He says “in retrospect, [this event] is perceived by many as the
beginning of the disability rights movement” (p. 209). However, even 40 years later
there appears to be an inability to acknowledge the attitudinal strides that marginalized
people with disabilities have made. Attitudinal changes have taken place as a result of
“aspirations and assertiveness beginning with Roberts’ idea that despite significant
physical and [emotional] dependencies, he too should be given the opportunity to
experience that rite of passage to independence” (p 210).
While the disability rights movement has opened many doors to independence
and social acknowledgement there are criticisms about the movement’s lack of diversity
– in particular, its lack of acknowledgement of “hidden disabilities” (McCarthy, 2003).
McCarthy notes that individuals with sensory disabilities seem to dominate the
movement, but it has not done a good job of “recruiting people with hidden disabilities
(e.g. back problems, heart conditions, brain injuries, cognitive or psychiatric conditions)
and opening up its programs to them” (p. 218). As a result, this group continues to be
served by the medical and rehabilitation system.
When looking to the future of the disability rights movement McCarthy sought
out responses from his participants. It seems the future goal is for creating a momentum
for self-actualization and “group pride” as a major theoretical approach to be used by
scholars. This has also been the sentiment of “insiders making observations on public
perceptions about disability” (p. 220). Other participants suggested the future importance
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of accessible tools for independence and integration within everyday society. Ultimately,
all participants in this study agree the emphasis needs to be on:
Altering the individual’s beliefs and societal values that throughout
history have contributed to the psychological and/or economic
judgment that a life with a disability is worth less investment and
protection than one without an identified disability. This situation
provides the disability community and the rehabilitation professions
with serious work on which to collaborate for social change and a
better world for us all (McCarthy, 2003, p. 220)
Normalization & Social Role Valorization
The concept of normalization appeared in North American psychology
approximately 30 years ago and became increasingly recognized through the work of
Wolf Wolfensberger in the early 1970’s (Flynn & Lemay, 2001). Initially this concept
focused primarily on people with mental retardation and grew into the improved concept
of social role valorization that impacted ways in which psychologists thought about
human service provision to this population. As a result, normalization was used by
“educational psychologists to justify mainstreaming” (p. 4).
Early ideas regarding normalization were built on the foundation of a human
rights framework. The concept was meant to achieve an ideal that “normal” living is
equal for people with intellectual impairments (Flynn & Lemay, 2001). In the 1980’s
however, it was decided that normalization was at risk of misinterpretation, so the
concept of social role valorization was introduced. This concept used role theory and
“stressed the relationships between personal competencies, social expectations, and social
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perceptions” (Flynn & Lemay, 2001, p. 4). However, both the concepts of normalization
and social role valorization have lingered in the minds and theories of those who work in
the field of community rehabilitation. These concepts have remained because they have a
continuity of significance in terms of their “framework for thinking and acting in ways in
which various services, including the psychological, are carried out” (p. 4).
After providing a historical basis on which further exploration of disabilities and
reaching potentials can take place, it is important at this time to move onto critical aspects
of building working alliances with disabled clients and focus on learning experiences,
cognition and emotion.
The Working Alliance
The WA is a construct that is based on the strong therapeutic relationship between
a therapist and the client. This alliance is characterized by the integration of respect,
trust, equality and collaboration. This process is highlighted by three guiding factors:
mutual agreement on goals, mutual agreement on tasks to meet those goals, and
collaboration based on mutual trust and respect (Bordin, 1975; Hiebert & Jerry, 2002).
Solidified working alliances create opportunities for client self-exploration while
empowering the client to take risks in learning new strategies for working through
problems (Hiebert, 2000). The working alliance entails a number of counsellor skills
that need to be mastered in order to be effective. Numerous skills are used to enhance the
meaningfulness of the interaction, to engage people in a collaborative and respectful
manner, and to clarify and provide feedback and skills of attending to the client (Hiebert,
2002).
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In considering client change it is important to understand the unique strategies
that are required to meet counselling goals. Hiebert (2002) states “it is useful to have a
taxonomy for categorizing counseling goals and client change strategies”(p. 18).
Counseling intervention goals in the WA consist of relationship building, problem
solving/decision making, skill training, personal coping and self-management.
The WA allows clients to achieve overall functioning potentials innate in all of us
(Hagarty, 2002).
(Bachelor, 1995 cited in Roughly, 2003) suggests that over the past decade “the
psychodynamic concept of the therapeutic alliance has been the focus of renewed
interest” (p. 1). He encourages three different types of client-therapist relationships: a
nurturing alliance, an insight-oriented alliance, and a collaborative alliance. While these
are important relationships, if a client has limited cognitive ability, or both a mental
illness and cognitive deficits (as a result of a disabling condition), perhaps the nurturing
and collaborative alliances would be most appropriate. The nurturing alliance provides
the therapeutic foundation that increases trust, respect, positive regard and the
collaborative alliance is important to share goals and aspirations with the client and his or
her support system. Essentially, the client takes ownership of his or her own destiny.
The following chart (See Figure 1) represents the steps in creating and
maintaining a Working Alliance.
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Figure 1. Model of the Working Alliance
Based on Hiebert & Jerry, 2002
Efficacy of the Working Alliance
There is evidence that supports the benefits and importance of the WA in
promoting successful outcomes in counselling. Generally, “in dozens of studies, the
working alliance itself has been found to be correlated positively with a broad range of
psychotherapy outcomes and, overall, appears to be a relatively strong predictor of client
change” (Hanson, Curry, & Bandalos, 2002, p. 660). Results of a study conducted by
Horvath and Symonds (1991) suggested that the WA is a “robust variable” linking the
therapy process to successful outcome (cited in Fong & Shaw, 1997, p. 3). Halston,
Brook, Goldberg, and Fish (1990) reported that the strength of the working alliance is
significantly related to consumer satisfaction (cited in Fong & Shaw, 1997). Finally, the
Working Alliance Inventory (WAI) is a measurement instrument designed by Horvath
and Greenburg (1989). Their instrument is designed to measure the quality of the WA.
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Specifically, the WAI is a self-report measurement tool that can be used by the client and
the counselor. Participants are asked to rate the extent to which they agree or disagree
with a series of items/statements. Not only have positive research studies reflected the
benefits and significance of the WA, this is a useful measurement tool to evaluate and
hence assist counsellors in creating even better alliances with their clients (Hagarty,
2002).
(Saunders, 2000 cited in Roughley, 2003) compares the relationship, and the
effectiveness of counselling. He indicates that bonding with the client is important, but
on the other hand he suggests that “although the strength of the therapeutic bond does
appear to be directly related to treatment effectiveness, this does not imply that increasing
the bond will cause a better outcome” (p. 1).
Finally, (Meara & Patton, 1994 cited in Roughley, 2003) indicate that alliance
difficulties do occur. In the population on which I am focusing, there may be
considerable fear of the counsellor, the counselling process and even the work that may
be involved in reaching one’s potential (Roughley, 2003). As a result the willingness of
the client must be considered over and above the needs of the parent and/or guardian. If
such a situation were to arise the counsellor would have the opportunity to initiate a
collaborative solution. This collaboration would be inclusive of the identified goals and
the tasks of the therapeutic intervention (Bordin, 1979).
Mediated Learning Experience
The MLE builds a foundation for cognitive development and change through
interpersonal and focused intervention (Falik, 2000). It is also “a special quality of
mediated interaction between the child or [adult] and environmental stimuli”(Kozulin &
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Presseisen, 1995, p. 69). This is further achieved by the intervening of an “intentional
adult between the stimuli of the environment and the child [or adult]” (p. 69). “Through a
mediated learning experience the opportunity presents itself to integrate the tasks that
need to be learned or responded to, the nature of the respondents’ skills, attributes and
functions” (Falik, 2000, p. 314) within the interpersonal context of parent, teacher,
mentor, aide or therapist. Falik describes this experience as not unlike the WA concept in
which there is the development of an authentic and binding relationship that is essential
for human existence, without which opportunities for reaching one’s full potential cannot
be acquired. This is an interpersonal relationship that encourages clients who have
disabling conditions to excel at their own pace and become accepted members of society.
In essence, “we need environments where the self is recognized but is allowed (and
stimulated) to change” (p. 314). Therefore, Feuerstein’s MLE asserts an optimistic vision
about human destiny (Feuerstein, 2002). In essence, the mediated learning experience
“describes a quality of interaction between a learner and a person, whom we shall call a
mediator” (Feuerstein, 2002, p.1)
The characteristics of the MLE integrate the perspective of mediational distance
(Feuerstein & Falik, 1999). These characteristics are intentionality, reciprocity,
transcendence, and mediation of meaning. The involvement of all four characteristics is
required to define an interaction as mediational in nature. Intentionality allows the
mediator to modify three aspects of the interaction. The mediator makes the environment
functional for the client who is the learner and then modifies or intentionally uses
techniques such as WA skills, homework or testing to establish a mutual relationship
(Min, 2003). Reciprocity involves the initial dialogue between mediator and client which
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sets a foundation for learning and allows the client to have autonomy or control of the
here and now (Min, 2003). Essentially, the focus is on the “mediator and learner seeing
each other at the same level” (Feuerstein, 2002, p. 2). Transcendence moves beyond the
obvious interaction and teaches the client to defer the reinforcement of the immediate
situation or environment. This means that there is a “bridging” that occurs as the client
learns to generalize what he or she has learned to other situations (Feuerstein, 2002).
Mediation of meaning includes the motivational level and asks the question “why and for
which purpose?” This involves two aspects: client concentration on the experiences of the
learning process and stimulation or motivation for the client to actively reach out and
search for personal meaning and potential (Min, 2003). In the mediation of meaning, the
counsellor “interprets for the learning the significance of what the learner has
accomplished – the mediator also mediates feelings of accomplishment” (Feuerstein,
2002, p.2).
Counsellor As Mediator
When combining the WA and the MLE it is important to see similarities and
complementarities. Essentially, the interpersonal contact between counsellor and client is
mediational because it influences a process between “an active and involved human
[client] and another human who is experienced, intentioned, and who interposes him or
herself between the client and the external resources of stimulation and responding”
(Falik, 2000, p. 315). The counsellor becomes the mediating agent. The counsellor as
mediator is flexible and adaptable and plays a facilitative role in cognitive enhancement
for the client (Feuerstein & Falik, 1999). The mediator focuses on how the learner or
client problem-solves. Likewise, in the counselling context the client is one who has a
18
need and the counselor acts intentionally and in a focused manner to assist the client in
meeting his or her goals (Falik, 2000).
The MLE is the intervention that elicits change. It “transcends, connects, and
deepens experience” (Feurestein & Falik, 1999, p. 8). It allows the learner (client) to
consider his or her own values and perceptions of the world, and helps to enhance the
relational experience with another (the counselor). Further, this process has a number of
factors that tie into the experience. These include: the nature of the tasks in which the
client is to respond, the cognitive abilities of the client, and the interpersonal and
environmental conditions to which the client is exposed. Additionally, the WA skills
taxonomy can be seen as identifying the techniques required for actual learning.
Specifically, structuring skills provide meaning and predictability to a session. In the
MLE, structuring skills and engagement skills are important for establishing an
interpersonal connection with the client. Falik (2000) indicates:
When the relationship is that of counselling, elevating purpose
beyond the social incidental, its focus requires attention to
dimensions of interpersonal interviewing skills, assessing the present
concerns of the client, understanding the dynamics of behavior and
change, and the acquisition and use of a repertoire of techniques and
appropriate interventions (p. 309)
The following (Figure 2) is an outline of the skills taxonomy.
19
S K I L L T AX O N OM Y B R I E F D E S C R IP T OR
Structuring Skills These skills are used to provide an organized and meaningful focus to counselling sessions.
Structuring the
physical setting
This skill refers to arranging clients, counsellor, chairs, special materials to be used, etc. in a way that promotes
the desired type of interaction.
Overviewing This skill is a short statement at the beginning of the counselling session, or at transition point within a
counselling session, that outlines the major focus or activities that are to follow. This helps the client understand
the structure of the session and develop realistic expectations as to what the session can accomplish, and helps
to ensure that the agenda is received by a “prepared mind.”
Giving information This skill involves factual statements that inform the client about events, circumstances, situations, etc.
Transitions This skill is the use of statements that signal a change in topic or direction in an interview. Sometimes a
summary is followed by an overview as a transition. Other times a short statement indicates a transition by
simply stating a desire to change direction or topic.
Summarizing This skill involves statements that review or drop together the essence of several client statements. Summaries
can encapsulate the meanings, values, or beliefs, or the affect that the client has expressed. These statements
often occur at the end of the counselling session, or at a transition point within the session. Summarizing helps
the client recall and organize events that have occurred earlier in the session and can also help to capture the
bottom-line meanings or affect that the client has expressed and that serve to wrap up a particular portion of an
interview.
Engagement Skills These skills are used to encourage client involvement, commitment, and engagement in the counselling
process, and to promote client practice of behaviours, thoughts, and feelings.
Closed Questions This skill involves the use of interrogative sentences designed to obtain confirmation – lead naturally to a “yes”
or “no” response.
Open Questions This skill involves the use of interrogative sentences designed to obtain information – do not lead naturally to a
“yes” or “no” response.
Declarative Probes This skill involves the use of declarative sentence forms that elicit client information in an open-ended fashion.
Calling for a
Demonstration
With this skill, the counsellor is requesting the client to show (as opposed to explain) an example of a behaviour
that is in question. For example, the counsellor might ask the client to repeat out loud examples of the self-talk
that the client finds themselves using in a given context.
Describing
Inconsistency
This skill has the counsellor describing to the client observed inconsistencies in some aspect of the
conversation. Discrepancies may be defined in a number of ways. These include noting the difference between
a stated vs. an actual value, what the client says vs. what they actually did, how a client says he/she feels vs.
how their body language suggests. It can be particularly useful to make use of the client's actual words/language
(i.e., paraphrase) when describing the inconsistency.
Reacting Skills These skills are used to give clients feedback about their verbal or nonverbal behaviour.
Reflecting meaning This skill involves rephrasing the meaning portion of a client’s communication. The statement answers the
question, “What did the client mean by that?”
Reflecting affect This skill involves rephrasing the affective portion of the client’s communication. The statement answers the
question, “What is the client feeling now?”
Paraphrasing verbal
content
This skill involves rephrasing the content portion of a client’s communication. This statement answers the
question, “What did the client say?”
Descriptive praise This skill involves making specific statements to the client, describing positive instances of client behaviour.
Corrective feedback This skill involves making specific statements to the client, describing behaviours, thoughts, and feelings that
are not consistent with the counselling objectives.
Counsellor self-
disclosure
This skill involves using personal examples to give the client feedback that other people share similar
experiences, thoughts, or feelings.
Process
observing/immediacy
This skill involves the counsellor noting some change or shift in the client's posture, tone of voice, general
presence or shift in topic/content (not preceded by a Structuring skill) and providing feedback with the intent of
drawing it to the client's attention.
Attending Skills These skills demonstrate that both parties (the counsellor and the client) are involved in the process.
Presence This skill involves using an open, relaxed posture, and non-verbal cues that convey the impression that the
counsellor is concerned about, cares about, or is attempting to understand what the client is saying.
Silence (deliberate) In some counselling contexts, there are moments when the “most appropriate” response from the counsellor is
silence – a moment of listening and waiting and being present with the client while they process their current
experience. [Note: this is different from the counsellor being inactive or ‘scrambling’ for a response (and thus
silent).]
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Figure 2. Working Alliance Skills Taxonomy.
Based on Hiebert & Jerry, 2002.
This taxonomy is divided into four categories of skill. The first are Engagement
skills, where the counsellor uses information gathering questions such as closed and
open-ended questions, declarative probes, leading questions, confronting and
encouraging client responsibility in an effort to engage the client in the counselling
process. The second category is Structuring skills used to enhance meaningfulness and
organization to the counselling session. For example, setting and sharing objectives,
providing an overview of the session, providing information, transitions and summarizing
the session to assist the client in determining a beginning and end to the session. The
third are Reacting skills where the counsellor provides the client feedback in various
ways such as reflecting meanings, reflecting client affect, perception checking and
incorporating the language of the client. These skills allow the counsellor to ensure that
he or she is accurate in his or her understanding of the client’s issues. The final category
are the use of Attending skills where the counselor demonstrates that he or she is actively
involved in the counselling process. Some examples of this skill include paraphrasing
and non-verbal behavior (Hiebert, 2002).
The boundaries of the MLE allow for these conditions to occur and guide the
creation of specific interventions that are purposeful and restorative (Falik, 2000).
Reactionary skills or skills for clarifying and providing feedback to the client are
necessary within the MLE to enhance the counsellor’s understanding of verbal or non-
verbal communication while offering descriptive praise and reinforcement (Hiebert,
2000). Consequentially, Feuerstein’s development of the MLE theoretically and
practically builds a “bridge” from the working alliance skills taxonomy (outlined above)
21
to the MLE skills that are part of the intervention, thus creating an adhesive bond (Falik,
2000).
Once again, the WA compliments the MLE because the counsellor intentionally
uses his or her taxonomy of skills that “contribute to the creation of a therapeutic
condition, the nurturance and facilitation of a change potential” (Falik, 2000, p. 311).
This mediational potential builds a relationship in which the counselor can enhance
decision-making by implementing the following sequence of questioning: “what does the
counselor do or say, when is it said or done, and how it is said or done?” (p. 311). This is
important for the interpersonal process that also takes place within a working alliance.
Finally, the WA skills taxonomy is seemingly synonymous to the MLE characteristics of
reciprocity and intentionality, transcendence and mediation of meaning, as stated above.
These approaches can be seen to be extensions of the social model of disability
and may help to further justify the use of the WA and the MLE in the context of
disability. Furthermore, from a holistic point of view, the social model embraces the
MLE and the WA in a manner in which social components can be expanded and
modified through the process of counselling. Coles (2001) in his interpretive study of the
experiences of people with intellectual disabilities and various other impairments,
emphasizes that the disabled can be served at least promisingly through the social model
and that interventions based on this model can be effective. Coles’ conclusions
“uncovered some clear examples of how the social model of disability might translate
into practice” (Coles, 2001, p. 509). Examples include: creating respectful relationships
(through the counseling process), advocacy (through the collaboration of goals and
mutually agreed tasks, and acceptance (unconditional positive regard).
22
Links between Cognition, Education & Emotions
When providing psychological services to a client with limited cognitive abilities
it is important to work from the premise that cognition can be adapted and changed over
time (Feuerstein & Falik, 1999). These adaptations can allow clients to have better
control of their environment and make generalizations among objects, events, places and
situations. Cognition is important because it provides the counsellor a starting point in
determining “what to focus on, when to focus, and in what ways to focus” (p. 5).
The medical model has not paid much attention to people with learning
disabilities and cognitive deficits. Research based on the medical model suggests that
academic inquiry “has pulled down the shutters on positive ideas and expectations of
people with learning difficulties” (Hopkins, 2002, p. 2). The effects of this research bias,
perpetuates the masking of lives of individuals with disabilities (Coles, 2001).
Recent literature on adult basic education concludes that very little is understood
about how to work with adults with disabilities in that context. In addition, the research
indicates that “what is more important is the realization that many people in Adult Basic
Education programs are disabled and the research literature contains distressingly little
guidance to help the professional and the student (White & Poison, 1999, p. 2). Jepsen
and Von Thaden (2002), examined results of mediated cognitive education used in
special education classrooms. Mediated cognitive education is likened to mediated
teaching whereby the teacher is the mediator. The goal of mediated cognitive education
is to “introduce cognitive functions and strategies that are inherent in learning through
mediated teaching” (Jepsen & Von Thaden, 2002, p. 202). Another goal of this
educational format is to “strengthen cognitive functions and increase student’s
23
application of cognitive strategies across settings” (p. 207). In other words, interventions
are modified to fit the student’s current ability in an effort to assist in cognitive
generalization across environments. The foundation of this approach is theoretically
grounded on interventions that directly stimulate cognitive processes. In their study they
investigated the effectiveness of mediated cognitive education with students having
developmental delays. They reported improvement from pretest to posttest in
intelligence, accomplishment and adaptive functioning. Furthermore, the results
reinforced the efficacy of cognitive education training. They suggest that the MLE has
been effective “in helping children with developmental disabilities, and to integrate into
mainstream society”(p. 202). “The mediated learning experience has been closely linked
to the relationship between cognition and learning” (p. 202). Essentially, this mediated
way of teaching focused on the idea of “learning-to-think-to learn” (p. 207).
When considering how knowledge is to be created to assist the disabled
population, Anderson, Krathwohl, Airasian, Cruikshank, Mayer, Pintrich, Raths &
Wittrock (2001) outline two knowledge dimensions that could serve this population in
reaching potentials. “Procedural Knowledge” is based on the premise of “knowledge of
how to do something” (p. 27). It focuses on “criteria used to determine when to apply a
procedure” (Anderson et al, 2001, p. 29). Additionally, procedural knowledge takes the
form of a series of steps to be followed that can be taught to the client. A second
dimension involves the “Application” of a procedure: implementing the step-by-step
procedure of an unfamiliar task. It focuses on performing exercises or solving problems
and is therefore similar to procedural knowledge (Anderson et al, 2001). Implementing
24
these knowledge dimensions creates an opportunity to learn both basic and advanced
skills to reach potential.
The emotional capacity of clients is inextricably linked to cognition (Zajonc,
2000, Zajonc & Markus, 1982). This considers the “affective-motivational-attitudinal
dimensions of human experience” (Feuerstein & Falik, 1999, p. 6). Essentially, the
primary question to be asked is “why do we do what we do?” The balance of emotions
and cognitions are integrated and provide energy to the client whereby he or she can
reach beyond the learning experience and move into new knowledge and adaptation.
This involves the taking of risks and investigating potentials (Feuerstein & Falik, 1999).
This mediation assisting the client to recognize his or her productivity, potential and
significance can be one of the most gratifying ways for the client to recognize his or her
cognitive capacity and self-awareness.
When taking into consideration the development of competence and feelings of
competence, the process is largely facilitated and mediated by the counsellor who
positions him or herself between the client and the agreed upon task. In this manner the
counsellor assists the client in succeeding and encouraging a sense of accomplishment
and competence (Feuerstein, Rand & Rynders, 1988). This results in increased cognitive
and behavioral potential, and elicits positive emotions of competence.
Bridging the Working Alliance & Mediated Learning Experience
Based on the preceding discussion it seems feasible that Feuerstein’s MLE has a
high compatibility function to the process of counselling. It is noted that Feuerstein’s
inclusion of cognitive functions can be associated with social, affective and behavioral
contexts. Furthermore, Falik (2000) indicates that cognitive psychology and related
25
therapies that extend to the existential and humanistic domains seem to fit well with the
MLE framework. In essence, a complementary bridge has been formed in which further
research needs to occur.
The value of this research is embedded in the need for dual-diagnosed individuals
to become recognized and included within the therapeutic realm of counselling
psychology. The psychological community agrees that an important goal of research on
disability and community rehabilitation is to advance the quality of life of persons with
developmental disabilities (Tate & Pledger, 2003, p. 294). With this as a foundation, the
following project reflects these possibilities.
This project is a single case study of a 22 year old client who presents with a
developmental disability, mental health issues and physical disability. For confidentiality
purposes the name of the client is withheld and only pertinent information will be used to
address the integration of the WA, MLE, and clinical outcomes. The client was provided
the opportunity to choose an alias for purposes of this project and will be referred to as
“Danny.”
Client Context
“Danny” is a 22 year old male who currently resides in a group home with two
other roommates. As a behavior consultant I had been working with Danny for a period
of time prior to inviting him to participate in this research. The circumstances that
brought Danny into service were his weekly angry outbursts and his inability to cope with
environmental situations around him, both in his residential setting and whenever he had
home visits. Danny is an only child from a family that consists of his biological mother
26
and stepfather. The family has resided in a somewhat rural area of northern Alberta since
Danny was born.
His mother indicated that Danny was born with Microcephaly that presented with
symptoms of psychomotor retardation. When Danny was a youth he was physically
active and participated in many sports related activities. However, Danny was struck by
a vehicle while sitting on his bike at a pedestrian cross-walk. His left leg was severely
damaged. After spending approximately a month in hospital his leg was saved, however,
the result was a leg deformation that makes it difficult for Danny to walk.
His mother also reported that as a child Danny had always had difficulty in
handling his anger to a point where she had to physically restrain him until he calmed
down. After his lengthy recovery from the car accident, Danny’s parents and caregivers
report that he became angrier resulting in verbal, physical and destructive rages. The
combination of his mental disability, his cyclic mood swings and the inability to function
physically as he once had, appear to have increased the intensity of these behaviors.
Danny is currently taking psychotropic medication under the supervision of a
psychiatrist, with regularly scheduled visits once every three months.
Client information was provided in the first recorded semi-structured interview.
During the interview both Danny and his mother shared their stories and reactions to the
multitude of circumstances that brought Danny into residential services. One reason for
bringing Danny into service was the hope that one day Danny could live a semi-
independent life. At the commencement of this research, Danny was engaged and was in
the process of moving into a new home with two new roommates.
27
Procedures
Methodology
Ethical clearance and consents from all stakeholders were in place prior to the
commencement of this research. This research project was a clinical exploration, using a
mixed method single case study design (Creswell, 2003). This in vivo project focused on
the provision of a counselling intervention to an individual who has been dually
diagnosed with a developmental disability and mental illness. The participant, Danny,
was invited to make a commitment to one counselling session a week for a period
between 12-16 weeks. Specifically, Danny was invited to become fully involved in
recognizing his style of anger, learning ability, and skills potential by taking part in the
intervention tools and strategies that were created for this skill development intervention.
Pre and post-test interviews (See Appendix A) were conducted and audio taped for
qualitative purposes.
An ABA phase change design was used (Mertens, 1998). The A phase included
pre-treatment (baseline) data collected over an 18 month timeline prior to the beginning
of this research. During the baseline phase, the Adaptive Behavioral Assessment System
(ABAS), the Symptoms Checklist-90-R (SCL-90-R), and the Working Alliance
Inventory (WAI-S) was administered to achieve a baseline for functional ability,
symptomatology and level of the WA. Specifically, adaptive behavior “reflects a
person’s competence in meeting independent needs and satisfying the social demands of
his or her environment” (Sattler, 2002, p. 190). While further research is needed to
recognize the usefulness of this instrument, Sattler suggests “the ABAS is a valid and
reliable instrument for assessing adaptive behavior of children and adults (p. 207). The
28
ABAS measures 10 domains of adaptive functioning skills (e.g, self-care, work) of
children and adults aged 5 to 89 years. The scores in each domain are normed by age and
includes individuals with developmental disabilities, as Sattler indicates “this should not
be a problem in evaluating most [individuals] with developmental disabilities” (p. 207).
The scores are then converted to standard scores for comparison purposes. This
measurement tool consists of three forms: The Teacher Form completed by the
teacher/aide or in Danny’s case his residential staff, The Parent Form completed by his
mother, and the Adult Form which Danny filled out himself. Danny required that I read
each question to him as he indicated it would be easier for him to understand the question
and to minimize the time required to complete it.
The Symptoms Checklist-90-R (SCL-90-R) is a multidimensional self-report
inventory that screens for a number of psychological problems and symptoms. The SCL-
90-R is a measurement tool that is beneficial in demonstrating progress in treatment over
time (Pearson Assessments, 1996-2004). In addition, the norm groups include: adult
non-patient, adult psychiatric outpatient and inpatient, and adolescent non-patients. This
checklist encompasses nine symptom dimension scales consisting of: somatization
obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic
anxiety, paranoid ideation, and psychoses. The SCL-90-R is a questionnaire that is
validated by more than 940 studies demonstrating its reliability, validity and utility
(Pearson Assessments, 1996-2004). Furthermore, this assessment is a measure of
current, point-in-time psychological symptoms (Croft, 1999).
The Working Alliance Inventory (WAI) is available in long and short formats.
For the purposes of this study the short version (WAI-S) was used. The WAI is “one of
29
the first instruments of its kind” (Hanson, Curry, & Bandalos, 2002, p. 660). These
authors suggest four reasons for its usage in measuring the working alliance. First, the
WAI is the most popular measure used. Second, the WAI is a self-report instrument that
is easily administered and quickly completed by the therapist and client. Third, the
inventory is based on theory. Fourth, scaled scores are shown to have common variances
with other measures of the WA. Specifically, the long format is a 36-item self-report
measure of the relationship between counsellor and client. The WAI has three subscales
including: Goals, Tasks, and Bond. The Goals subscale measures the degree of
agreement on identified goals and outcomes between the client and counselor. The Tasks
subscale measures “the extent to which a client and therapist agree on the in-counselling
behaviors and cognitions that form the substance of the counselling process”, and the
Bond scale measures the degree of mutual trust and acceptance between counselor and
client (Horvath & Greenberg, cited in Hanson, Curry & Bandalos, 2002, p. 661). The
short format (WAI-S) is a condensed 12-item self-report measure of WA and also
includes the same subscales as the long format and measures identical constructs. These
same subscales are scored on a 7-point scale ranging from 1 (never) to 7 (always), as a
result, the higher the score the higher the positive rating of the WA (Hanson, Curry &
Bandalos, 2002). In a study conducted by Busseri and Tyler (2003) they revealed that
“results support the reliability and validity of WAI-S subscale and total scale scores
derived from client and therapist ratings. This study provided the first direct evidence
that the WAI-S scale is interchangeable with the full-scale WAI” (p. 197). Similarly,
Hanson, Curry and Bandalos (2002) reported that the WAI and the WAI-S scores are “to
a great extent” reliable and “easily meet professional standards of acceptability”(p. 668).
30
The B phase included the treatment integration of the MLE and WA. This
consisted of teaching anger management and coping skills to a point at which the client
presented a comfort level in self-regulating his own behavior. Self-regulation was
defined as the ability to identify when anger and coping skills are needed to prevent the
outburst itself, or to decrease the intensity, frequency and duration of outbursts.
Mediated treatment tools included the following: an anger diary, self-talk/coping skills
techniques, visual cue cards, time out techniques, incident reports, frequency counts of
outbursts and ability to maintain self-control, inviting his support staff with him (with
client consent), reading aloud, drawing illustrations, providing sufficient response time
and the use of simple, concrete language. The anger diary, self-talk/coping skills
techniques, visual cue cards depicting step-by-step ways to walk away from a volatile
situation, and time-out techniques such as breathing and relaxation were modified to fit
Danny’s abilities from various skills resources, and incident reports and frequency count
data sheets were created independently by the researcher. The researcher utilized and
mediated these tools throughout the counseling sessions with assistance from Danny’s
staff only when needed.
The final A phase did not involve treatment sessions, but represented the post-
treatment baselines of treatment efficacy (acquisition of knowledge, retention of skills,
changes in symptomatology) demonstrated after a four week period. The WAI-S, ABAS
and SCL-90-R were repeated post treatment. Reliability was addressed by using repeated
measures of the treatment i.e. weekly to ensure dependability. To determine validity and
decrease researcher bias, member checks were conducted with the residential staff every
session to determine accuracy of data collection.
31
Data collection in pre-treatment (A), treatment phase (B), and post-treatment
outcomes (A) were gathered to measure ability to manage anger, coping ability, and self-
regulation. Coping relating to anger was defined as poor adaptation to environmental
stimuli for example, chaotic places, roommates and difficulties with his fiancé. Angry
outbursts were specifically defined as incidents of yelling, stomping, swearing, slamming
doors and turning up music. A symptoms checklist (SCL-90-R) an adaptive behavior
assessment system (ABAS) and semi-structured interviews were used. Other data
collection tools included scaling questions, incident reports, working alliance inventory,
and audiotapes of the initial and final sessions. Audio taped sessions were transcribed
and a content analysis was conducted to establish content validity. Visual analysis of data
was conducted using graphs that summarize baseline, mid-treatment and post treatment to
ensure confirmability. Social validation considering the value and acceptance of the
treatment process (Mertens, 1998) was gleaned from the post-test semi-structured
interview (See Appendix A) in the final session.
All sessions were conducted at the researcher’s office free from distractions. For
continuity the same residential staff was present with Danny during all sessions and
Danny’s mother was welcome to sit in on the sessions if her time permitted. Danny was
also invited to monitor his behavior (with the assistance of his support staff) in order to
develop self-regulation and collect data. The residential staff was asked to compile
residential based data throughout the research. Danny was also invited to engage in
weekly sessions and homework for out of session skill practice. Homework was
conducted with Danny by his residential staff on a nightly basis for fifteen minutes prior
to retiring for the night. This involved reviewing the skills learned in session, practicing
32
them and conducting problem solving (via the anger diary) in an effort to determine what
could have been done to cope and decrease anger in a situation and to determine what
could be done next time Danny found himself in similar situations of unease and anger.
The homework portion of the treatment was integral to skill development, as people with
dual diagnosis may require the extra assistance and support needed for the acquisition of
skills, as a result, homework could prove to be a useful prosthesis to counselling.
Similarly, frequency and intensity of the homework assignment would need to be flexible
and open to negotiation between the client and counsellor, based on staff support
availability within residential group homes. Additionally, counsellors who endeavor to
provide counselling services, would want to promote and advocate for support staff
commitment in assisting the client in skill development while outside of the sessions.
This approach would enhance the opportunity for the client to learn within the actual
environments he or she needs to practice and acquire skills.
A qualitative content analysis of the audio taped interviews, contact notes of the
sessions, and client reflections on weekly progress was conducted to determine how the
counselling intervention was experienced emotionally, cognitively and behaviorally.
Qualitative Treatment Data
Sustaining the Working Alliance
Throughout the sessions a collaborative WA was sustained between Danny and
myself. The primary sustaining ingredient to our relationship reflected the mutual trust
and respect, as well as the collaboration that ensued throughout the treatment phase of
this study. This alliance is congruent with Horvath & Symonds (1991) suggestion that
“the positive collaboration between client and therapist as one of the essential
33
components for success in therapy” (p. 139). In many ways this alliance could be
considered similar to a relationship resembling a student and teacher (Bordin, 1979). As
mediator of the learning process, the researcher offered therapeutic tools for Danny to
utilize in order to meet our agreed upon goals of anger management and increasing his
ability to cope. Offers where made for Danny to investigate or create some of his own
strategies to be incorporated. Through open communication and offering unconditional
positive regard, congruence and empathy in a client–centered approach (Horvath, 2000;
Rogers, 1951,) the alliance between Danny and the researcher seemingly grew as the
treatment sessions unfolded. On several occasions the researcher inquired if Danny was
comfortable with the process, to which he responded affirmatively. Continued bonding
throughout the treatment phase consisted of Danny having enough trust in the therapeutic
alliance to fill out an anger diary (with assistance from his support staff) as discussion
ensued regarding his ability to manage his anger.
In maintaining the foundation of the WA, the experience of mediated learning
bears resemblance to this process. Without a strong alliance between counsellor and
client the intent of counselling may not be realized. Danny was able to recognize his
internalized anger and what it was that made him angry. The mediated learning
component consisted of the offering of strategies for self-reflection on the incidents of
anger and situations of poor coping, in an effort to assist Danny in learning what he
needed to do when the early signs of anger were presented. Hence, without a solid
alliance Danny may very well have dismissed the strategies. The intentionality of
offering strategies that included the drawing of diagrams, providing enough time for
information processing for eliciting responses, having a support staff on hand for recall
34
memory, reading items aloud to influence understandings, and repetition of suggestions,
as a means of teaching anger management and coping skills triggered a reciprocity of
interaction between Danny and myself. Furthermore, the characteristics associated with
the mediation of meaning and transcendence are equally interconnected with the working
alliance relationship.
Intentionality & Reciprocity
The MLE advocates for the individual to understand things clearly (Feuerstein,
Rand & Rynders, 1988). Thus, the mediational tools discussed above provided Danny
with the opportunity to establish a realistic understanding of what was being said and
asked of him. In addition, as much as the mediator “will intensify and repeat certain
aspects of an act to be completed” (Feuerstein, Rand & Rynders, 1988, p. 63) and
regardless of the times I encouraged Danny to take fifteen minutes each night to review
the strategies, and regardless of inquiring if the researcher was being a nag, Danny still
provided evidence of having completed the process of managing his anger and coping
ability through weekly submissions of incident reports and data sheets. Danny was also
forthcoming in recognizing areas in which he could have used some of the strategies. Of
equal significance was Danny’s ability to divulge his perceived improvement in
managing his anger and coping in a stressful situation. In sum, it appeared that mediated
learning did occur due to the poignant exchange of giving and receiving between client
and researcher.
Mediation of Meaning
While at times Danny admittedly had difficulty in maintaining motivation to
conduct his homework consisting of nightly fifteen-minute reviews of the strategy
35
pointed out in each session, our solid alliance overcame any resistance that could have
ensued. My projected attitude of encouragement, self-disclosure, flexibility and empathy,
and Danny’s sense of humor and social abilities were paramount in the affective
processes, in order to sustain motivation and the relationship. As Feuerstein, Rand &
Rynders (1988) indicate a significant component of mediated meaning is the emotional
connections between the mediator (myself) and the client (Danny). A good example of
this occurred when I inquired into whether or not my repetitiveness was bothering him.
Danny indicated that he would certainly let me know. I thanked him for his honesty.
Another component of the mediation of meaning outlined closer to the end of our
time together as counsellor and client involved the focus on the good things Danny was
able to accomplish from his learning to better manage his anger and ability to cope. It
was suggested that Danny share with me one accomplishment he felt proud of. He would
be able to reflect on that one situation and tell me how he handled it. He indicated that he
felt good about “learning the skills and putting them into practice” and that he was
“opening up more to staff.”
Transcendence
Transcendence “means ‘bridging’ the experience and lessons learned in the
current situation to new situations” (ICELP, retrieved June 30, 2003). When Danny
returned for a final session four weeks after the treatment phase ended, Danny was able to
articulate the following: (a) he is proud about solving problems before he has an
outburst, (b) he has used his breathing and relaxation strategies, (c) he has met people
half-way (compromise), (d) he has discussed issues with staff, and (e) his positive self-
talk has gotten better.
36
Through discussions with Danny and his support staff, his ability to self-regulate
his anger and ability to cope is rated at approximately 80% of the time compared to his
inability to self-regulate at the pre-treatment phase. Danny indicated that he
automatically takes time to calm down in his room after a verbal prompt “calm please.”
Incidents of relaxation are becoming automatic as he suggested that he does this
anywhere, and continues to use staff for assistance where needed.
The following table (Table 1) highlights Danny’s self reported ratings for
managing his anger and coping with difficult situations
Table 1
Self-Report Treatment Ratings for Ability to Manage Anger & Cope with Difficult
Situations
Treatment
Session
Rating for Anger (1 poor – 10 good) Rating for Ability to Cope (1 poor – 10 good)
#1 5 9
#2 7.5 8
#3 5 10
#4 5 5
#5 10 10
#6 8 10
#7 9 10
#8 8.5 9
#9 9 10
#10 9 10
#11 9 9
#12 10 8
Results & Summary
Pre-Test Data
Three test instruments were used in this case study, and a pretreatment interview
was conducted. The Symptoms Checklist-90-R, the Adaptive Behavior Assessment
System (ABAS) and the Working Alliance Inventory (WAI-S). These were used to
37
determine pretreatment baseline functioning with regard to daily living, current
symptomatology and strength of the working alliance relationship prior to treatment.
Symptoms CheckList-90-R Data
Pretest scores on all scales on the SCL-90-R including Somatization, Obsessive
Compulsivity, Interpersonal Sensitivity, Depression, Anxiety, Hostility, Phobic Anxiety,
Paranoid Ideation, and Psychosis were found to be clinically significant. In particular,
elevated items included interpersonal sensitivity (T>80), depression (T=73), anxiety
(T=74) and psychosis (T=74). In comparison to the average population the scores
indicate substantially higher than average symptomatology in the aforementioned areas.
Specifically, five items stood out from the others: interpersonal sensitivity, depression,
anxiety, psychosis and the global severity index (GSI) were above the 70th
percentile.
The only item rating lower than a T score of 50 was the phobic anxiety scale.
Interestingly, the hostility rating was at the 65th
percentile.
Symptoms of individual sensitivity, depression, anxiety and psychosis dominated
Danny’s profile indicating much higher levels of anxiousness, individual sensitivity,
depression and psychotic characteristics than the average person when considered at the
95th
percentile. Overall, this symptom profile would indicate that Danny was suffering a
very broad range of psychological symptoms that make significant contributions to his
poor ability to cope and deal with his anger.
Adaptive Behavior Assessment System Data
Three informants (parent, staff, Danny) responded to the ABAS. Danny
responded to the Adult Form, his mother responded to the Parent Form and his
Residential Support Worker responded to the Teacher Form. Standard scores were
38
evaluated within a 95 percent confidence interval to ensure a smaller margin of error
when reflecting Danny’s current functioning prior to treatment and to increase accuracy.
Based on Danny’s scores on the Adult Form, statistical significance was found in the area
of “Communication”, while a noted level of significance was found in the area of
“Functional Academics”. Subscale scores on the ABAS are standardized on a mean of
10 with a low score of one and a high score of 19. An individual presenting with a
standard score of 10 on a subscale would be considered to be functioning within a normal
range. Deviations from the mean score of 10 suggest strengths (in the case of higher
scores) or weaknesses (in the case of lower scores). Danny’s overall average subscale for
communication was 10, which suggests he communicates the same as the average person.
Danny’s Academics subscale score was 5, suggesting that Danny’s score was below the
mean, indicating that Danny would stand out lower than his peers in this domain. Thus,
the significant difference in the communication domain reveals the score is 5-10% of the
total population. This can be considered to be remarkable, as his communication did not
match his academic abilities. In general terms, Danny presents as high functioning by
virtue of his ability to communicate extremely well. However, his cognitive functioning
and ability to become completely independent is well below average for the general
population. Danny is functioning at a level that is expected of anyone else his age, but
not necessarily a candidate for further education. Danny scored himself higher in ability
than he is actually capable of: he considered himself more capable than others see him.
As a result, the appearance of higher functioning leads to a mismatch of interventions.
People and staff may assume Danny is better able to adapt than he actually is.
39
His residential staff assessed Danny as presenting comparatively well in his
ability to communicate, socialize with others and use his leisure time; but less capable in
independent living, self-care, self-regulation and employable work. In addition, Danny’s
mother assessed him as comparatively effective in communication, social skills,
community use, leisure and occupation, but less capable of independent living and
employment, and self-care and regulation. Essentially, all of the ABAS data suggested
that Danny appears to be higher functioning primarily because of his communicative
skills, but less capable of independent living.
Working Alliance Inventory
The principle researcher filled out the WAI-S Inventory–Clinician Form after the
second session with Danny. The WAI-S suggested that a positive working alliance had
been established over the pre-treatment phase. There was some confusion over Danny’s
understanding of what we had decided together to pursue in therapy, and staff assistance
was needed. Furthermore, my understanding of the problem areas, anger management
and inadequate coping, did not coincide with Danny’s ideas about his problem: Danny
knew and acknowledged his anger and coping difficulties, but did not appear to have
developed a clear understanding that the intervention would target these issues. Again,
staff assistance was necessary. Further clarification on the establishment of mutual goals
needed to be completed.
Danny filled out the WAI-S Inventory–Client Form after our second session. His
results suggested that we had established a positive working alliance, but he did not
believe that I had a good understanding of what he wanted in therapy. Danny was
unaware of the problem affecting others in his life. His residential support worker
40
needed to provide assistance to enhance his understandings: She provided assistance by
reading aloud the questions in the inventory.
Content Analysis (Qualitative) – Pre-Treatment Interview
The pre-treatment interview included Danny and his mother. A series of seven
questions (see Appendix A) were asked of Danny and his mother was also invited to
participate in answering questions and telling her story. The questions were semi-
structured to allow for their individual narratives to emerge. Many themes that arose
from this interview complimented the creation of the working alliance relationship with
both Danny’s mother and Danny himself. Cooperation and enthusiasm in having the
opportunity to “try something different” was an initial theme, as Danny and his mother
were excited about this new modality of treatment. There was however, initial
awkwardness when I needed to take a direct approach in repeating what our goals in
therapy had been decided on, in order to remind Danny that we were working on his
anger and coping skills. Ongoing reviews and reminders were part of the mediated
approach. Another theme that emerged early in the interview was the honesty and
willingness of Danny and his mother to share his past and other pertinent information
when I inquired about what gets him angry, how he got angry and what he had done in
the past to help himself not become angry and cope with difficult situations. A historical
narrative between Danny and his mother emerged that included a rich and accurate
account of his childhood up to his current situation. As a result, an increased comfort
level in sharing information with me was evident. As the interview came to an end, the
theme of acceptance and eagerness to work on the mutually established goals of therapy
emerged whereby Danny affirmed his commitment to working on his anger management
41
and coping skills. When I inquired into whether or not he felt nervous he responded “Not
at this point!” and whether or not he wanted to see me again next week he replied “OK,
Sure! Next week is fine.” All pre-test data was collected as baselines prior to the
commencement of the treatment (B phase) of the study.
Post-Test Data
The following are the results of post-testing four weeks after treatment
completion, using the same three assessment tools utilized four weeks after treatment.
Symptoms Check List -R-90
While most items on the SCL-90-R continued to represent clinical significance
after mediated treatment phase interventions, many items decreased somewhat in clinical
significance. Two items, somatization (T=37) and anxiety (T=46) were rated
significantly below the mean after treatment. Danny’s levels of anxiety were reduced to
the 47th
percentile from the pre-test rating at the 70th
percentile range. His level of
individual sensitivity (T=61) reduced from the pre-test rating within the 80th
percentile
(T=80) down to a post-test rating within 60th
percentile. Depression decreased from a
pre-test rating (T=73) within 73rd
percentile, down to a post-test rating at the 63rd
percentile (T=67). In addition, psychosis pre-test rating within 73rd
percentile (T=74)
reduced to a post-test rating within the 59th
percentile (T=58). These changes would
indicate significant changes from Danny’s pre-test profile, suggesting improvements in
Danny’s quality of life and potential to manage difficult situations and his anger.
Of equal importance was the increase in significance with hostility (T=73), phobic
anxiety (T=59) and paranoid delusion (T=70). Hostility increased from the 65th
percentile to the 74th
percentile, phobic anxiety increased from the 47th
percentile to the
42
58th
percentile range, and paranoid delusions increased from the 65th
percentile range to
the 71st percentile range. These increases in Danny’s item profile may indicate more in-
depth psychological difficulties not specifically dealt with in treatment.
To summarize, as a result of treatment through mediated learning. Danny’s
symptoms of anxiety and depression decreased substantially to a point just below the
mean or that of the average person--suggesting increased self-regulation, ability to cope
and handle anger. Danny’s overall symptomatology decreased substantially as outlined
in Figure 6, and Danny’s levels of adaptive living as outlined in Figure 7 indicate
significant increases in his ability to live semi-independently. This demonstrates the
viability of using both counselling and mediated learning techniques in assisting those
with dual-diagnosis. This study further demonstrates the importance of a solid working
alliance between counsellor, client and the support staff who may be required to provide
assistance out of session. Levels of hostility increased which may indicate undisclosed
resentments and other issues, not specifically dealt with during treatment
Adaptive Behavior Assessment System
The same informants (Danny and mother) with the exception of Danny’s original
residential worker completed the post-tests of the ABAS. During the treatment phase
Danny’s first residential support worker was replaced by another support worker,
resulting in this person filling out the Teacher Form instead. Again, standard scores were
evaluated within a 95 percent confidence interval to ensure a smaller margin of error
when reflecting Danny’s functioning post-treatment. Based on Danny’s scores on the
Adult Form, statistical significance was found in the areas of “Community Use”,
“Functional Academics,” “Health and Safety,” and “Self-Care.” This may indicate an
43
increase in his confidence level in these specified areas. Compared to his pre-test scores,
notable statistical significance was found in the area of Health and Safety. This may
suggest an elevated comfort level in his ability to monitor his behavior. In addition, these
areas of significance continue to indicate that Danny continues to score himself higher in
ability than his true capabilities dictate.
Danny’s new residential support worker assessed him as presenting well in the
areas of social interactions and use of his leisure time. “Communication” was assessed as
being the same from the pre-test assessment. In addition, the areas of self-direction,
functional academics, school living, health and safety, and social were all significantly
elevated. These elevations may further indicate increases in Danny’s confidence levels in
his daily living and ability to cope and monitor his behavior.
Danny’s mother assessed him as capable in the areas of communication,
community use, social and leisure, as outlined in the pre-test. However, notable increases
in statistical significance were in the areas of home living, functional academics, and
health and safety.
In sum, post-test ABAS data suggests that while Danny seems to have increased
his ability to self-regulate and cope better with his anger, he is still less than fully capable
of independent living.
Working Alliance Inventory
As principle researcher, I filled out the WAI Inventory–Clinician Form after our
last treatment session, after all data had been collected. The WAI suggested that a
positive working relationship prevailed throughout the treatment and post treatment
phases of this study. Danny had developed an appreciation and interest in developing a
44
clear understanding of the interventions targeted to assist him with his anger and coping
skills. His residential support worker played a paramount role in assisting Danny with
his interventions out of session. Danny was receptive and open to discussion throughout
phases of the study. He admitted that he disliked the homework expectations of the
treatment phase, but he understood that it assisted him with his anger management and
coping. My only concern post treatment is Danny’s commitment to practicing the skills
he has been taught in order to assist himself in self-regulation. Without staff diligence,
Danny may not follow through with regular practice independently.
Danny filled out the WAI Inventory-Client Form after our final treatment session.
His results suggested that we had indeed established and maintained a positive working
relationship throughout the study. His results indicated that we had cleared up any
misunderstandings that were evident during the pre-treatment phase, as he indicated that I
had established a better understanding of what he wanted to accomplish during our
counselling sessions. It seems that misunderstandings were clarified with assistance from
his support worker in order to facilitate his understanding of what he had agreed to in
therapy.
Content Analysis (Qualitative)–Post-Treatment Interview
The post treatment interview (See Appendix A) was conducted with Danny and
his residential support worker. A series of eight questions were asked of Danny, and his
support worker was also invited to participate in answering the questions. Like the pre-
treatment interview, the questions were semi-structured to allow for individual narratives
to emerge. Themes emerged from this interview that reflected the level of learning and
the experience of counselling that took place for Danny.
45
With some assistance from his support worker to aide in his recall, Danny
specified what he had learned throughout the treatment phase. He indicated that he now
knew how to do an anger diary, use positive self-talk even though this continued to be a
challenge for him, and he learned how to use the coping and relaxation techniques that
were introduced to him. By using these strategies Danny and his support worker
indicated he does not become as angry as he once did and that he reviewed the treatment
tools on a regular basis with the assistance of his support worker and other residential
staff. Talking to staff and sharing his frustrations seemed to help Danny in recognizing
when he was angry or beginning to become angry. He jokingly indicated that “I talk
[vent frustrations and problem solve], and she [support worker] puffs [her cigarette]!”
When sharing how he now copes with stressful situations he indicated that he has been
able to use the strategies to maintain his relationships with his roommates. He did say
that he continues to work on his ability to cope in situations that involve his fiancée.
Danny suggested that others who are experiencing anger and coping difficulties
would benefit from counselling and learning new strategies. He specifically suggested
that our sessions helped him to become more aware and “catch himself where there is a
problem”.
Of equal importance is the experience of counselling that Danny shared. He
suggested that what he liked most about counseling was the confidentiality and knowing
that he could come into the session and say anything he wanted without others knowing.
He enjoyed the open communication that took place. He did however, mention that he
did not particularly enjoy the homework, but he did indicate that the homework “did help
46
me in a lot of situations.” His support worker summed it up. She mentioned that “in the
long-run “ the counselling benefited Danny.
A-B-A Phase Results
A-Phase: Baseline Data (18 Months)
June 2002 - January 2004
0
1
2
3
4
5
6
7
8
9
10
Jun-02
Jul-02
Aug-02
Sep-02
Oct-02
Nov-02
Dec-02
Jan-03
Feb-03
Mar-03
Apr-03
May-03
Jun-03
Jul-03
Aug-03
Sep
-03
Oct-03
Nov-03
Dec-03
Jan-04
Months
Angry Outburst
Throwing/Kicking/Punching Wall
Uncooperative
Self Regulation
Figure 3. A Phase: Baseline Data
47
B-Phase: Treatment Data
(13 weeks)
(March - June 20th, 2004)
0
1
2
3
4
5
6
March April May June
Months 2004
Angry Outburst
Throwing/Kicking/Punching Wall
Uncooperative
Self Regulation
Figure 4. B Phase treatment data (13 weeks)
A-Phase: Post Treatment Chart
June 21-Aug 30th 2004
0
1
2
3
4
5
6
7
8
9
June 21 - 30 July August
Months 2004
Angry Outburst
Throwing/Kicking/Punching Wall
Uncooperative
Self Regulation
48
Figure 5. A Phase: post treatment data (chart).
SCL-90-R Data
Figure 6. SCL-90-R pre & post-test scores
49
Figure 7. ABAS pre & post-test scores.
Pre-tests of the SCL-90-R (figure 6), ABAS (figure 7), WAI-S was conducted one
week prior to the commencement of the B phase treatment. The baseline A phase (figure
3) was conducted over an 18 month time period prior to the commencement of this study.
B phase treatment data (figure 4) was collected during the 13 weeks of intervention. The
final A phase baseline (figure 5), post-tests of the SCL-90-R (figure 6) and ABAS (figure
7), and the WAI-S was conducted four weeks after the treatment (B phase) concluded.
Limitations
This project was conducted by the principle researcher. However, Danny’s
residential support staff, and to a lesser extent, residential staff she supervised, were
required to assist in the homework and data collection process. Given the high staffing
50
turnover rates for residential workers within the field of Community Rehabilitation,
consistency in following through with the homework strategies may have been
compromised. In addition, Danny’s motivation level in following through with
homework between sessions may have fluctuated based on whether staff remembered to
support Danny with his nightly fifteen-minute practice sessions. In other words, Danny’s
learning during out of session homework may not have been a true indication of his
learning potential.
A statistical analysis of the data for the SCL-90-R and the ABAS was conducted.
However, the single case design limited the options thus allowing an opportunity for a
larger study to be conducted in the future.
Conclusion
An exploratory, mixed method single case study of an adult male with dual
diagnosis (developmental disability and mental illness) has been presented to illustrate
the efficacy of counselling for this population, while integrating Feuerstein’s Mediated
Learning Experience within Horvath’s Working Alliance concept. Counselling was
introduced to decrease angry outbursts and poor coping ability.
Results indicate while there continues to be clinically significant symptomatology
as outlined in the SCL-90-R post-testing, there were substantial decreases in the primary
areas of anxiety, depression, individual sensitivity and psychosis. As a result of mediated
learning approaches and a strong working alliance, significant improvements in Danny’s
ability to cope with stressful situations and handle his anger resulted in an increased
ability to self-regulate.
51
Post-test ABAS data suggests that while Danny seems to have increased his
ability to self-regulate his anger and cope better, he is still less than fully capable of
independent living as increasing independence was not the intended target area of
treatment. The mediational treatment tools (See Appendix B) were effective on the
targeted areas of anger management and coping ability.
Results further suggest that we had cleared up any misunderstandings that were
evident during the pre-treatment phase: as he indicated that I had established a better
understanding of what he wanted to accomplish during our counselling sessions. It seems
that misunderstandings were clarified with assistance from his support worker in order to
facilitate his understanding of what he had agreed to in therapy.
The WAI suggested that a positive working relationship prevailed throughout the
treatment and post treatment phases of this study. Danny had developed an appreciation
and interest in clearly developing an understanding of the interventions targeted to assist
him with his anger and coping skills. His residential support worker played a paramount
role in assisting Danny with his interventions out of session. Danny was receptive and
open to discussion throughout the study’s phases. He admitted that he disliked the
homework expectations of the treatment phase, but he understood that it assisted him
with his anger management and coping. My concern post treatment is Danny’s
commitment to practicing the skills he has been taught in order to assist himself in self-
regulation. Without staff diligence, Danny may not follow through with regular practice
independently.
Furthermore, the WA integrated with the MLE prove to be a powerful
combination in treatment efficacy setting the stage for the human component of
52
counselling while maintaining a mediated instructional approach to skill development. It
would seem then that the MLE alone may not be as effective without a human element
outlined in the WA skills taxonomy.
Of equal importance is the experience of counselling that Danny shared. He
suggested that what he liked most about counselling was the confidentiality and knowing
that he could come into the session and say anything he wanted without others knowing.
He enjoyed the open communication that took place. He did however, mention that he
did not particularly enjoy the homework, but he did indicate that the homework “did help
me in a lot of situations.” His support worker summed it up. She mentioned that “in the
long-run “ it benefited Danny.
This exploratory study illustrated my personal theory and a rationale for further
research into assisting people with disabilities and mental health issues in reaching
personal potentials. A review of the literature focusing on the establishment of a working
alliance and mediated learning experience has been included. In doing so I have
provided an integration of these two most important forms of intervention, while
promoting the psychologist as the main ingredient to assisting people with disabling
conditions to reach their full potential and to live a quality of life that is empowering,
rewarding and respected by society.
This review of the literature and study suggests the need for ongoing research
regarding disabling conditions--disabling conditions that include a continuum from the
obvious physical and developmental disabilities to the “hidden disabilities” such as
mental illness, and cognitive deficits.
53
There is much for health care professionals to learn with respect to the
improvement of the lives of people with disabilities--from assisting children and adults to
become aware of their own unique potentials, to providing the environment and
relationship necessary for success to become a reality. There has been movement away
from the medical model to include a social model where people with disabilities are
regarded within a socio-ecological system where disability rights are improving and
efforts to accommodate the needs of the disabled are progressing.
The doors of disability research need to be opened wider to interventions and
therapies that can be investigated, tested and acknowledged through research and utilized
for this population. As a result, research into the intricacies of counselling and teaching
are needed to enhance the opportunities for persons with disabilities to achieve their
potential. I believe this study has demonstrated the feasibility of utilizing a mediated
learning approach within the human element of the working alliance for individuals with
dual diagnosis.
54
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Appendices
Appendix A
Pre-Post Treatment Interviews
Pre-Treatment Interview Questions
1. Tell me what you’re thinking before we begin the research?
2. What do you want to work on?
3. What have you done before to help yourself not get mad?
4. What has worked for you?
5. What is your diagnosis?
6. Are you feeling nervous?
7. If so, how can I help you’re nervousness?
8. Do you have any questions for me?
Post-Treatment Interview Questions
1. What have you learned from our time together?
2. Do you get angry as often as you used to?
3. How do you help yourself when you get angry
4. Have the strategies we have worked with helped you?
5. What over the past several weeks that you have learned, would be helpful for
other people in your situation?
6. What did you like most about counseling?
7. What did you not like about counseling?
8. Is there anything else you would like to say?
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Appendix B
Data Collection/Treatment Tools
1. Frequency of outbursts and self/control/coping data sheet
2. Self-talk Coping Skills Sheet
3. Visual Cue Cards
4. Anger Control Techniques
5. Time Out Techniques
6. Anger Diary
7. Incident Reports
8. Symptoms Check Listt-90-R
9. Adaptive Behavior Assessment System
10. Working Alliance Inventory
11. Scaling Questions (1-10)