Patti Hagarty, B.A., B.CR., M.C. (Psych) Provisional Psychologist
In my desire to add to the research literature on dual diagnosis I conducted 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 was 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 to assist individuals with developmental disability and mental illness to reach potential and increase quality of life.
The WA is the underlying foundation that promotes and sustains the mediated learning experience. 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 describe the characteristic 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, 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 mediated 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. The aim of this clinical exploration is to demonstrate to the research community that people with both developmental disabilities and mental health issues may be served and benefit from a counseling process that integrates mediated learning and the Working Alliance to enhance quality of life.
The therapeutic principles in counseling 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 individuals can benefit from the rewards life has to offer.
The Realm of Disability
Over the past 25 years disability has been compartmentalized through the application of various models. Recent 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 that are necessary to attain full autonomy" (p. 210). The medical model's roots are based on a concept 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 are based on the premise that the person deviates from the normal rather than having an ability to adapt to the environment (Finkelstein, 1991 cited in Quinn, 1998).
In order to enable individuals to fulfill their potential, I believe 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). 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 Working Alliance
The WA is a construct that is based on the strong therapeutic relationship between the 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, 1979; Hiebert, 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). 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 more fully achieve their human potential"(Hagarty, 2002).
Different types of client-therapist relationships exist: 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, 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.
Efficacy of the Working Alliance
There is evidence that supports the benefits and importance of the WA in promoting successful outcomes in counseling. 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). Horvath and Symonds (1991) indicated 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). The following chart (See Figure 1) represents the steps in creating and maintaining a Working Alliance.
Model of the Working Alliance
Based on Hiebert & Jerry, 2002
Mediated Learning Experience
The MLE builds a foundation for cognitive development and change through interpersonal and focused intervention (Falik, 2000). It is "a special quality of mediated interaction between the child or [adult] and environmental stimuli" achieved by the intervening of an "intentional adult between the stimuli of the environment and the child [or adult]" (Kozulin & Presseisen, 1995, 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. 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.
Counselor As Mediator
Essentially, the interpersonal contact between counselor 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 counselor becomes the mediating agent. The counselor 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
The MLE is the intervention that elicits change. It "transcends, connects, and deepens experience" (Feuerestein & 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). This process has a number of factors that can influence and/or be influenced by 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.
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 counselor a starting point in determining "what to focus on, when to focus, and in what ways to focus" (p. 5).
When taking into consideration the development of competence and feelings of competence, the process is largely facilitated and mediated by the counselor who positions him or herself between the client and the agreed upon task. In this manner the counselor assists the client in succeeding and encouraging a sense of accomplishment and competence (Feuerstein, Rand & Rynders, 1988). This results in increased realization of cognitive and behavioral potential, and elicits positive emotions of competence. This paper describes a clinical case study utilizing the WA and the MLE.
The participant was a 22 year old male in a group home with two other roommates. The circumstances that brought him into service were frequent angry outbursts and his inability to cope with environmental situations both in his residential setting and during home visits.
He was born with microcephaly that presented with symptoms of psychomotor retardation. As a youth he was physically active and participated in many activities. He was struck by a vehicle while sitting on his bike at a pedestrian cross-walk, severely damaging his left leg. After spending approximately a month in hospital his leg was saved, however, the result was a leg deformation that makes it difficult to walk.
As a child he had always had difficulty in handling his anger to a point where he had difficulty handling his anger and was frequently physically restrained until he calmed down. After his lengthy recovery from the car accident, his 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, appeared to have increased the intensity of these behaviors. He was 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 the client and his mother shared their stories and reactions to the multitude of circumstances that brought him into residential services
The client was invited to make a commitment to one counseling session a week for a period between 12 to 16 weeks. Specifically, he was invited to become fully involved in recognizing his style of anger, learning ability, and skills potential by becoming familiar with the intervention tools and participating in the development of strategies that were created for this skill development intervention. Pre and post-test interviews 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) were 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 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).
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 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.
All sessions were conducted at the researcher's office free from distractions. The client 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. The participant was also invited to engage in weekly sessions and homework for out of session skill practice. Homework was carried out with 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 them and conducting problem solving (via an 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 he 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. Homework could prove to be a useful prosthesis to counseling. 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 counseling intervention was experienced emotionally, cognitively and behaviorally.
Intentionality & Reciprocity
The MLE advocates for the individual to understand things clearly (Feuerstein, Rand & Rynders, 1988). Thus, the mediational tools provided the participant with the opportunity to establish a realistic understanding of what was being said and asked of him. In sum, it appeared that mediated learning did occur due to the poignant exchange between the participant and myself as principle researcher.
Mediation of Meaning
While at times the participant admittedly had difficulty in maintaining motivation to complete his homework, our solid alliance apparently prevented any significant resistance from developing. My projected attitude of encouragement, self-disclosure, flexibility and empathy, and his sense of humor and social abilities were paramount in the affective processes, in order to sustain motivation and the relationship. As Feuerstein, Rand, and Rynders (1988) indicate, a significant component of mediated meaning is the emotional connections between the mediator (myself) and the client.
Another component of the mediation of meaning involved the focus on the good things he was able to accomplish from his learning to better manage his anger and ability to cope. It was suggested that he share one weekly accomplishment he felt proud of. He would reflect on that one situation and tell me how he handled it. He stated he felt good about "learning the skills and putting them into practice" and that he was "opening up more to staff."
Transcendence "means 'bridging' the experience and lessons learned in the current situation to new situations" (ICELP, retrieved June 30, 2003). When the client returned for a final session four weeks after the treatment phase ended, he 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.
Through discussions with the client and his support staff, his ability to self-regulate his anger and ability to cope rated at approximately 80% of the time compared to his inability to self-regulate at the pre-treatment phase. Incidents of relaxation became automatic as he suggested that he engages this anywhere, and continues to use staff for assistance when needed.
Results & Summary
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). Symptoms of individual sensitivity, depression, anxiety and psychosis dominated his profile indicating much higher levels of anxiousness, individual sensitivity, depression and psychotic characteristics than the average person. Overall, this symptom profile would indicate that the client 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, and the participant) responded to the ABAS. The participant responded to the Adult Form, his mother responded to the Parent Form and his Residential Support Worker responded to the Teacher Form. Based on his 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". The overall average subscale for communication was 10, suggesting he communicates the same as the average person. The Academics subscale score was 5, below the mean, indicating that he was 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. He scored himself higher in ability than his actual capability: he considered himself more capable than others see him. As a result, the appearance of higher functioning leads to a mismatch of interventions in the past. Professionals may have assumed he was better able to adapt than he was capable of. The appearance of higher functioning likely led to a mismatch of interventions in the past due to professionals (and family members) assuming that he was more better able to adapt than he was in fact.
Working Alliance Inventory
As principle researcher, I filled out the WAI-S Inventory-Clinician Form after the second session with the participant. The WAI-S suggested that a positive working alliance had been established over the pre-treatment phase.
The client filled out the WAI-S Inventory-Client Form after our second session. Results indicated that we had established a positive working alliance, but he did not believe I had a good understanding of what he wanted in therapy. The participant was unaware of the problem affecting others in his life. His residential support worker needed to provide assistance to enhance his understandings: she provided assistance by reading aloud the questions in the inventory.
The following are the results of post-testing four weeks after treatment completion, using the same three assessment tools utilized four weeks prior to treatment
Symptoms Check List -90-R
While most items on the SCL-90-R continued to represent clinical significance after mediated treatment phase interventions, many items decreased in clinical significance. Two items, somatization (T=37) and anxiety (T=46) were rated significantly below the mean after treatment. Levels of anxiety were reduced to the 47th percentile from the pre-test rating at the 70th percentile range. Levels 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). The psychosis pre-test rating within 73rd percentile (T=74) reduced to a post-test rating within the 59th percentile (T=58). These changes indicate significant changes from the pre-test profile, suggesting improvements in quality of life and potential to manage difficult situations and his anger.
As a result of treatment through mediated learning, symptoms of anxiety and depression decreased substantially to a point just below the mean or equal to that of the average person--suggesting increased self-regulation, ability to cope and handle anger. Overall symptomatology decreased substantially and levels of adaptive living indicated significant increases in his ability to live semi-independently. This demonstrates the viability of using both counseling and mediated learning techniques in assisting individuals with dual-diagnosis.
Adaptive Behavior Assessment System
As for the pre-test, the participant and his mother completed the post-tests of the ABAS. During the treatment phase his first residential support worker was replaced by another support worker, resulting in the new worker filling out the Teacher Form. In sum, post-test ABAS data suggested that while he seemed to have increased his ability to self-regulate and cope better with his anger, he was 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. The client had developed an appreciation and interest in developing a 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 with his interventions out of session. The participant was receptive and open to discussion throughout phases of the study.
The WAI Inventory-Client Form was filled out after our final treatment session. 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 counseling sessions
Content Analysis (Qualitative)-Post-Treatment Interview
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 and family. He did say that he continues to work on his ability to cope in situations that involve his fiancée, and he added that others who are experiencing anger and coping difficulties would benefit from counseling and learning new strategies. He specifically suggested that our sessions helped him to become more aware and "catch himself where there is a problem."
The client's residential support staff were required to assist in the homework and data collection process. Given the high staffing turnover rates for residential group home workers, consistency in following through with the homework strategies may have been compromised. In addition, his motivation level in following through with homework between sessions may have fluctuated based on whether staff remembered to support him with his nightly fifteen-minute practice sessions. In other words, his learning during out of session homework may not have been a true indication of his learning potential.
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 counseling for this population, while integrating Feuerstein's Mediated Learning Experience within Horvath's Working Alliance concept. Counseling was introduced to decrease angry outbursts and poor coping ability.
Results indicated 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 the participant's ability to cope with stressful situations and handle his anger resulted in an increased ability to self-regulate. Furthermore, the WA integrated with the MLE proved to be a powerful combination in treatment efficacy setting the stage for the human component of counseling while maintaining a mediated instructional approach to skill development. It would seem that the MLE alone may not be as effective without the human element outlined in the WA skills taxonomy.
The doors of disability research need to be opened wider to interventions and therapies that can be investigated, tested and acknowledged through research. As a result, research into the intricacies of counseling and teaching are needed to enhance the opportunities for persons with dual diagnosis.
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For further information: Phagarty@wjsgroup.com.