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Counsellor supervision : a study of the metaphoric case drawing method of case presentation in a clinical… Stone, Daniel Joseph 1988

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COUNSELLOR SUPERVISION: A STUDY OF THE METAPHOR IC CASE DRAWING METHOD OF CASE PRESENTATION IN A CLINICAL SETTING by DANIEL J . STONE B.A. ( P s y c h o l o g y ) , Simon F r a s e r U n i v e r s i t y , 1983 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS i n THE FACULTY OF GRADUATE STUDIES (Department of C o u n s e l l i n g P s y c h o l o g y ) We a c c e p t t h i s t h e s i s as c o n f o r m i n g i t o t h e r e q u i r e d s t a n d i n g THE UNIVERSITY OF BRITISH COLUMBIA September, 1988 © Daniel J. Stone,-. 198.8 In p resen t ing this thesis in partial f u l f i lmen t o f t he r e q u i r e m e n t s fo r an advanced d e g r e e at t he Univers i ty o f British C o l u m b i a , 1 agree that t h e Library shall make it f ree ly available f o r re ference and s tudy . I fu r ther agree tha t pe rmiss ion fo r ex tens ive c o p y i n g o f th is thesis f o r scholar ly pu rposes may be g r a n t e d by t h e head o f m y d e p a r t m e n t o r by his o r her representat ives. It is u n d e r s t o o d that c o p y i n g o r pub l i ca t i on o f th is thesis fo r f inancial gain shall n o t b e a l l o w e d w i t h o u t m y w r i t t e n pe rm iss ion . D e p a r t m e n t The Univers i ty o f British C o l u m b i a Vancouver , Canada DE-6 (2/88) A b s t r a c t An e x p l o r a t o r y study was conducted to i n v e s t i g a t e the e f f i c a c y of the Metaphoric Case Drawing (MCD) method of case c o n c e p t u a l i z a t i o n i n the context of c o u n s e l l o r - t r a i n e e s u p e r v i s i o n . S u p e r v i s o r s and t r a i n e e s r e p o r t e d a s i g n i f i c a n t i n c r e a s e i n understanding i n f i v e core c o u n s e l l i n g areas: i n c r e a s e d understanding of the c l i e n t , the c o u n s e l l o r ' s r o l e , the c l i e n t - c o u n s e l l o r r e l a t i o n s h i p , c o u n s e l l i n g g o a l s , and case p r e s e n t a t i o n e f f e c t i v e n e s s . S t a t i s t i c a l and q u a l i t a t i v e data f u r t h e r c o n f i r m the e f f e c t i v e n e s s of the MCD method i n p r o v i d i n g a more t i m e - e f f i c i e n t means of case p r e s e n t a t i o n (compared with the t r a d i t i o n a l V e r b a l Case D e b r i e f i n g method). The MCD was found to be p a r t i c u l a r l y u s e f u l i n case p r e s e n t a t i o n s i n which the c l i n i c a l m a t e r i a l i n c l u d e d themes of d e p r e s s i o n , s u i c i d e , r e l a t i o n s h i p problems, and m a n i p u l a t i v e c l i e n t s . Based on the present e x p l o r a t o r y study, the MCD method p r o v i d e s a v i g o r o u s , s t i m u l a t i n g t o o l f o r the e f f e c t i v e s u p e r v i s i o n and t r a i n i n g of c o u n s e l l i n g students i n a c r i s i s i n t e r v e n t i o n and s u i c i d e p r e v e n t i o n s e t t i n g . i i Table Of Contents Page ABSTRACT i i LIST OF APPENDICES i v LIST OF TABLES V LIST OF FIGURES v i ACKNOWLEDGEMENTS v i i CHAPTER I INTRODUCTION . 1 CHAPTER II REVIEW OF LITERATURE 5 1. C o g n i t i v e R e p r e s e n t a t i o n , V e r b a l P r e s e n t a t i o n , and V i s u a l Imagery 5 2. Metaphoric T h i n k i n g 6 3. The Metaphoric Case Drawing Method 10 CHAPTER 111 METHOD 17 Sub j e c t s 17 T r a i n e r s 17 T r a i n i n g Procedure 18 Case P r e s e n t a t i o n Process 19 Ve r b a l Case D e b r i e f i n g 19 Metaphoric Case Drawing 20 Measures 22 Research Design 24 CHAPTER IV RESULTS 27 CHAPTER V DISCUSSION AND CONCLUSION 44 . . . i i l l Page REFERENCES 48 APPENDICES 54 A. Figures of Speech 54 B. Practicum Training Procedure, Objectives, and Training Materials 56 C. Verbal Case Debriefing Format 88 D. Verbal Case Debriefing Case Presentation Example 93 E. Metaphoric-Thinking Exercise: Case Drawing Preperation 95 F. Metaphoric Case Drawing Case Presentation Example 98 G. Evaluation Questionnaire 100 H. Summary of A l l Subject/Trainer Ratings (N=244) of A l l Counselling Sessions (N = 108) by Sub-Scale 106 I. Subjects Mean Ratings by Sub-Scale by Group Across A l l F i r s t Counselling Sessions (N = 70 ) 108 J. Metaphoric Case Drawing Interpretation Procedure: Trainer's Guide 127 i v L i s t of Tables Table Page 1. Evaluation Questionnaire Sub-Scales and Corresponding Items 23 2. Summary of A l l Subjects and Trainers Ratings (N=166) of A l l F i r s t Counselling Sessions (N = 70) by Sub-Scale 28 3. Summary of S i g n i f i c a n t Effects by Sub-Scale (F-Ratio) 31 4. Means and Standard Deviations by Debriefing Method (Ss, Trs, A l l F i r s t Cases) 32 5. Means and Standard Deviations by Debriefing Method by Group by Sub-Scale 33 6. Means and Standard Deviations by Subjects/ Trainers by Sub-Scale (N = 70) 34 7. Mean Time (in Minutes) and Standard Deviation per Case Debriefing by Condition 40 8. Presenting Problem by Category by Condition (VCD/MCD) 41 9. MCD Percentage Increase in Understanding Over Pre/Post VCD Combined Means by Sub-Scale- 43 v L i s t of F i g u r e s F i g u r e Page 1. M e t a p h o r i c Case Drawing of a K n i g h t W i t h "Banners D r o o p i n g " 13 2. D i s t r i b u t i o n and Onset of C o n d i t i o n (A/B/A) by Group.. 26 3. Summary of Means and S t a n d a r d D e v i a t i o n s f o r C o n d i t i o n s A/B/A by Sub-Scale 37 4. Means and S t a n d a r d D e v i a t i o n of Combined S u b - S c a l e Scores (Ss/Tr R a t i n g s ) For A l l F i r s t C o u n s e l l i n g S e s s i o n s (N=70) by Group A c r o s s S e s s i o n s 38 v i Acknowledgments A number of people have contributed d i r e c t l y to this thesis. F i r s t , I would l i k e to acknowledge my committee chairman Dr. Norman Amundson, and express my deep appreciation for his support, guidance, and numerous, unhurried discussions on the thesis subject matter. I also want to thank Dr. Robert Ley for his valuable discussions, assistance, and support. Thanks are due to Dr. Ishu Ishiyama for valuable c r i t i c i s m s and points-of view. This type of study would not be possible without the cooperation and good w i l l of a number of people. In this regard I would l i k e to express my sincere appreciation to the s t a f f and volunteers of the C r i s i s Intervention and Suicide Prevention Center For Greater Vancouver for making their f a c i l i t i e s available and for permission to conduct this study. I also want to thank the Simon Fraser University graduate students who participated in the research. They took the majority of the t r a i n i n g during this study late at night, after hours, and on weekends. F i n a l l y , my deep gratitude to my family, and e s p e c i a l l y to my wife, Dr. Jane Hpbson. She somehow managed to balance a demanding professional schedule while keeping the peace on the home front during my frequent absences. Without her unflinching support I would s t i l l be thinking about doing this study. v i i I INTRODUCTION A fundamental goal in counsellor supervision is the development by the student of clear, detailed, and integrative case conceptualizations of tra i n i n g and actual c l i n i c a l counselling sessions. Such conceptualizations both stimulate and animate post-case analyses which in turn are central for the a c q u i s i t i o n and adequate understanding of four core concepts in counsellor t r a i n i n g : f i r s t , relevant elements of the case may be i d e n t i f i e d and d i f f e r e n t i a t e d ; second, seemingly contradictory aspects of the counselling session can be reconciled; t h i r d , the process of change can be made to stand out in r e l i e f against the background of the acquired co u n s e l l o r - c l i e n t a l l i a n c e ; f i n a l l y , a v i v i d case conceptualization w i l l help both student and supervisor to analyze the case at the appropriate l e v e l of complexity, to develop p r a c t i c a l a l t e r n a t i v e treatment strategies, and to generate testable hypotheses for future cases which may have similar dynamic features. Similar goals have been discussed by such authors as Loganbill and Stoltenberg (1983), who pointed out the lack of adequate emphasis in tra i n i n g in case conceptualization, and stressed the importance of developing counsellor-trainee supervision techniques. Such supervision techniques must integrate "cognitive, behavioral, emotional, and interpersonal 1 aspects...which can be synthesized into a comprehensive understanding of the student's current understanding" (p. 235). Nucho (1983), emphasized the need for counselling students to adequately understand the core concepts of the therapeutic process. She suggested the use of imagery, drawing, and art in case conceptualization to f a c i l i t a t e deeper exploration and f a c i l i t a t i o n of various cognitive and emotional aspects of the therapeutic process. Stoltenberg (1981), Loganbill, Hardy & Delworth (1982), and Schon (1983), recognized the importance of reducing anxiety by teaching students an e f f e c t i v e case conceptualization system. Shcorr (1974) extensively reviewed the e f f i c a c y of u t i l i z i n g imagination and visual imagery for understanding and interpreting the therapeutic process. As Simon and Brewster (1983) reported many counselling trainees tend to lack s k i l l s for developing a coherent inner map for understanding c l i n i c a l cases and for presenting case debriefings. The f a c i l i t a t i o n of case conceptualization can take many forms. T r a d i t i o n a l case conceptualizations usually consist of an informal or sequential verbal discussion covering such topics as presenting, problem, relevant c l i e n t history, interpersonal s t y l e , personality dynamics, emotional and behavioral factors (Loganbill and Stoltenberg, 1983, p. 237). In addition, points covered may also include analysis of content and affect of the session, tempo/duration/intensity of 2 the session (Stone, 1985), and integration of cognitive, behavioral, emotional, b i o l o g i c a l and interpersonal aspects of the case (Lazarus, 1986). The verbal-cognitive method is central for a l l of these approaches to case conceptualization and bears the stamp of the "question-answer" Socratic method or the more d i a l e c t i c a l t r a d i t i o n of " t h e s i s - a n t i t h e s i s -synthesis." The process involves talking and analyzing-hopefully leading to new discoveries that can be applied as increased knowledge in future counselling sessions. Case conceptualization can proceed along various lines using v i s u a l imagery and metaphoric thinking. Ozick (1986) defined a metaphor as a " l i n g u i s t i c phenomenon of interest due to i t ' s impact and functions in the a c q u i s i t i o n of communication and knowledge" (p. 63). The metaphor serves as an excellent means of capturing the richness and d i v e r s i t y of the counselling experience (Haley, 1976; Schorr,1974; Rule, 1984). Amundson (1988), suggested that the usefulness of metaphors can be extended "by having counsellors make drawings of their metaphoric imagery and then use the drawings in case discussions with other counsellors" . (p. 391). Preliminary research by Amundson (1986) and Ishiyama (1988) has supported the e f f i c a c y of the metaphoric case drawing method of case conceptualization. The purpose of the present .study is to compare the metaphoric case drawing method with the t r a d i t i o n a l verbal 3 case debriefing method of case conceptualization. The context for the present study of counsellor-trainee supervision is a c r i s i s intervention and suicide prevention s e t t i n g . 4 II REVIEW OF LITERATURE Cognitive Representation, Verbal Presentation, and Visual  Imagery In a more general context, Kelly (1963) theorized that people make sense of the world by constructing cognitive representations which are then modified to f i t more closely with the r e a l i t y of their experience. As McKim (1972) has stated, drawings may be a potent means of expressing, and consequently modifying, such representations: Ideas are internal constructs of perception, imagination and thinking. Ex-press means to press out. Idea-sketching is a way to express v i s u a l ideas, to l i t e r a l l y press them out into tangible form (p. 116) Horowitz (1970) has found that such images possess sensory q u a l i t i e s . They are thereby distinguishable from mental a c t i v i t i e s that are purely verbal or abstract. Although images may be associated with any of the sensory modalities, i t is l i k e l y that "Visual imagery is the most common" (p. 17). The predisposition to construct representations of experience theorized by Kelly (1963), and the prevalence of visual imagery hypothesized by Horowitz (1970), Paivio (1972), Schorr (1974), and Tower (1983), provide a natural springboard for understanding the elemental and pervasive human i n c l i n a t i o n for u t i l i z i n g metaphoric thinking. 5 Schorr (1974) noted that "Man's imagination is as i n f i n i t e and elemental as the universe" (p. 1). Images form the fundamental component parts of visual and metaphoric thinking. Reviewing the ef f i c a c y of imagery compared with verbal reporting alone in counselling Paivio (1972) noted that any part of an image may be e l i c i t e d i n s t a n t l y without apparent loss of int e n s i t y . Schorr (1974) supported this point by stating that when being asked to report on an image, for example the image of entering a fam i l i a r room - i t is very easy to talk about any aspect of the room ( l e f t part, c e i l i n g , center, furniture arrangement, right side of the room) in any sequence - and to do so quite naturally and with c l a r i t y . Thus Schorr (1974) stated: A l l images synchronize and exchange upon the request of the person who is asking about them, whereas a poem or verbal report can be recited forward, but backward only with great d i f f i c u l t y . The image of White-House i s seen as a single image while Basic-Truth requires two separate sequences... One need only ask a person to remember the middle l i n e of a long poem, or to repeat the poem backwards to demonstrate t h i s . Imagery, on the other hand, can occur between and among many images synchronously (p. 14) Metaphoric Thinking In i t s simplest form metaphor represents an i m p l i c i t comparison between two unlike e n t i t i e s , as distinguished from simile - an e x p l i c i t comparison signalled by the words " l i k e " or "as." The d i s t i n c t i o n , however, is not simple. The metaphor makes a q u a l i t a t i v e leap from a simple comparison, to an i d e n t i f i c a t i o n or fusion of two objects, to make one new entity partaking of, yet surpassing, the c h a r a c t e r i s t i c s of both. The essence of metaphor is understanding and experiencing one kind of thing in terms of another. Sloane and Perelman (1980), stated that allegory and simile are considered extended metaphors that sustain and elaborate a basic analogy; a symbol, too, is an extended metaphor (see Appendix A for a review of the "Figures of Speech"). In the Golden Bough, Frazer (1954) demonstrated metaphoric thinking in primitive cultures. For example, pregnant women were often compared with r i c e or wheat in bloom (a s p e c i f i c a l l y a g r i c u l t u r a l metaphor). In the same way, growth, decay, and death were often depicted by various stages of crop cycles. Kent-Jones (1980), reported that primitive s o c i e t i e s were capable of this type of agriculture about 7000 B.C., and probably e a r l i e r . Thus, i t appears that metaphoric thinking, as a system of thought, predates the development of formal l o g i c in Antiquity. Metaphors are pervasive in everyday l i f e , not just in language use but in thought and action. Lakoff and Johnson (1980) provided l i n g u i s t i c and c u l t u r a l evidence that suggested our ordinary conceptual system, which informs and guides thought and action, is fundamentally metaphorical in 7 n a t u r e . Thus, f o r example, t h e c o n c e p t ARGUMENT and t h e c o n c e p t u a l metaphor ARGUMENT IS WAR may be n o t i c e d i n e v e r y d a y l a n g u a g e by a wide v a r i e t y of e x p r e s s i o n s : Your c l a i m s a r e i n d e f e n s i b l e ; he a t t a c k e d e v e r y weak p o i n t i n my argument; h i s c r i t i c i s m s were r i g h t on t a r g e t ; I d e m o l i s h e d h i s argument; I've won an argument w i t h him; he s h o t down a l l of my arguments (p. 4) In a d d i t i o n , m e t a p h o r s a r e commonly us e d t o r e p r e s e n t p r o x i m i t y ("A c l o s e c a l l , " "He h i t t h e b a l l a c o u n t r y m i l e " ) ; d i r e c t i o n a l i t y ("He's i n a t a i l - s p i n , " " C i r c l i n g l i k e a v u l t u r e , " I f e e l up," "I f e e l down," "He's on t o p of t h i n g s " ) , and a v a r i e t y of o t h e r d a y - t o - d a y r e l a t i o n s h i p s ("Economic d o w n t u r n , " " B u l l m a r k e t , " "Economic u p s w i n g , " " F o o t o f t h e bed, " "Time f l i e s , " " M o u n t a i n of work," "Mouth of t h e r i v e r , " "Crown of t h e t r e e , " and so o n ) . The s t r u c t u r e , f u n c t i o n , and r o l e of t h e metaphor, as w e l l as t h e mechanisms by w h i c h i t p r o d u c e s i t s e f f e c t s , have been t h e s u b j e c t of e x t e n s i v e i n t e r e s t and s t u d y f r o m A n t i q u i t y t o t h e p r e s e n t t i m e . Numerous s c h o l a r l y t r e a t i s e s t h r o u g h o u t t h e m i l l e n n i a have examined t h e p e r v a s i v e use of metaphor and i t s r o l e i n meaning, l a n g u a g e , and c u l t u r e ( e g . , i n t h e 4 t h C e n t u r y , B.C., A r i s t o t l e - i n P o e t i c s , C a t e g o r i e s , and R h e t o r i c ; 5 t h C e n t u r y , A.D., A u g u s t i n e - C o n f e s s i o n s ; 1 3 t h C e n t u r y , Thomas A q u i n a s - Summa T h e o l o g i c a ; 1 7 t h C e n t u r y , Hobbes - L e v i a t h a n ; 1 8 t h C e n t u r y , Kant - Judgement; G i b b o n -D e c l i n e and F a l l ; 1 9 t h C e n t u r y , James - P s y c h o l o g y ; 2 0 t h 8 Century, Freud - General Introduction). Several d i s t i n c t types of metaphors have been i d e n t i f i e d . Metaphors may be of the substitution type (Breal, 1964), in which case the likeness between two objects is more obviously l i t e r a l (eg., the "leg" of a t r i a n g l e ) . Substitution metaphors are considered to be limited to two basic functions: 1) they serve an ornamental function or s t y l i s t i c function in language use, for example "The eye of the needle," and 2), as Black (1962) pointed out, they were useful in coining new concepts, for example " n i g h t f a l l , " or "time f l i e s . " Another type of metaphor is the comparison metaphor. Comparison theory originates in the writings of A r i s t o t l e , mainly in Poetics and Rhetoric. A r i s t o t l e believed metaphors implied riddles and could be used e f f e c t i v e l y in casting a new shade of meaning on a topic. For example, "crimson-fingered," applied to a suspected murderer. A r i s t o t l e ' s main contribution to the study of metaphor was to a r t i c u l a t e the idea that metaphors are e s s e n t i a l l y comparisons between two objects of unlike nature which, nevertheless, have something in common, as in "My mind is a blank," (McKeon, 1947). A t h i r d type, the i n t e r a c t i o n a l metaphor, is more complex. Richards (1936), Black (1962), Wheelwright (1962), Haynes (1975), and Ortony, Reynolds and Arter (1978) have extensively reviewed the i n t e r a c t i o n a l metaphor and point out that an e f f i c a c i o u s metaphor of this type juxtaposes 9 c h a r a c t e r i s t i c s so as to create and y i e l d new aspects of meaning. That i s , " . . . p l a c i n g known c h a r a c t e r i s t i c s of Y against X may provide new insights, either about Y or about X or about a new t h i r d Z, an i r r e d u c i b l e synthesis by juxtaposition which is d i f f i c u l t to reduce to a simile or l i t e r a l language - the metaphor creates the s i m i l a r i t y rather than formulating s i m i l a r i t y previously e x i s t i n g . . . " (Haynes, 1975, p. 273). Jung (1971), puts i t s i m i l a r l y , but captures something of the mystery, power, and elusive nature of metaphor: An archetypal [primordial types; universal images] content expresses i t s e l f , f i r s t and foremost, in metaphors. If such a content should speak of the sun and i d e n t i f y i t with the l i o n , the king, the hoard of gold guarded by the dragon, or the power that makes for the l i f e and health of man, i t is neither the one thing nor the other, but the unknown t h i r d thing that finds more or less adequate expression in a l l these similes, yet - to the perpetual vexation of i n t e l l e c t - remains unknown and not to be f i t t e d to a formula (p. 157). It is this t h i r d type, the i n t e r a c t i o n a l metaphor, that is of p a r t i c u l a r concern for the present study. The Metaphoric Case Drawing Method In the counselling process, Ejve (1983), stated that the integration of the c l i e n t ' s thought, f e e l i n g , and functioning a b i l i t y (primary and secondary processes) forms the a b i l i t y to 10 experience "Resonance and ambiguity - metaphorical thinking" (p. 81).Schorr (1974), Haley (1976), Begg (1978), and Rule (1984), a l l asserted the overal l value of the metaphor as a f l e x i b l e means of increasing the f a c i l i t a t i v e use of mental imagery in therapy and for keeping both the c l i e n t and the counsellor "On target" (Rule, 1984, p. 71). The metaphors may, in turn, be expressed v i s u a l l y through case drawings. As D i l l e y (1971) observed, additional insight may be gained through "Symbolizing the elements of personal concern and by drawing them so that s p a t i a l relationships may be considered" (p. 39). Thus, drawn images are representations of the mental contents which in turn express the primary experience of the counselling session. McKim (1972), suggested that drawing "Not only helps to bring inner images into focus, i t also provides a record of the advancing thought system" (p. 10) . With regard to visual aids in counsellor t r a i n i n g , Nucho (1983), suggested that various forms of art - including use of visu a l imagery, drawing, and creating shapes or forms from clay, wire mesh, and so on, a l l a s s i s t the student counsellor " C l a r i f y key concepts of the therapeutic process, c l a r i f y concerns experienced in the course of professional education, build group trust and activate peer support" (p. 84). Matarazzo (1978), has indicated that the major emphasis of counsellor t r a i n i n g in recent years has been the teaching of clien t - c o u n s e l l o r r e l a t i o n s h i p - b u i l d i n g s k i l l s . Loganbill 11 and S t o l t e n g e r g (1983) s t a t e d t h a t " T r a i n i n g i n case c o n c e p t u a l i z a t i o n , c e n t r a l t o t h e c o u n s e l l i n g p r o c e s s , has not r e c e i v e d comparable emphasis" (p. 235). I t may be t h e n , t h a t the use of v i s u a l imagery i n the form of m e t a p h o r i c case drawings which r e p r e s e n t v a r i o u s a s p e c t s of the c l i e n t - c o u n s e l l o r endeavor, may be as u s e f u l i n case c o n c e p t u a l i z a t i o n as i n the c o u n s e l l i n g p r o c e s s i t s e l f . When, f o r example, the s t u d e n t p r e s e n t s a m e t a p h o r i c case drawing d e p i c t i n g a k n i g h t "With banners d r o o p i n g , " the elements of d e f e a t , f a i l u r e and even shame a r e v i v i d l y c a p t u r e d i n a manner much more r i c h than a v e r b a l statement t o the e f f e c t of " F e e l i n g l o u s y about the c o u n s e l l i n g s e s s i o n " ( F i g u r e 1, p. 1 3 ) . A d d i t i o n a l i n f o r m a t i o n about how the s t u d e n t ( K n i g h t ) sees h i s r o l e , how he sees the c l i e n t ( W i n d m i l l ) , about h i s e x p e c t a t i o n s , and about t h e n a t u r e of the c o u n s e l l i n g p r o c e s s i t s e l f comes t o bear more v i v i d l y by employing a m e t a p h o r i c case drawing of the e x p e r i e n c e . I t i s the use of v i s u a l imagery, produced i n the m e t a p h o r i c case d r a w i n g , t h a t s e r v e s as a u s e f u l framework, a n c h o r - p o i n t , and c r u c i b l e f o r thought and d i s c u s s i o n d u r i n g the c o u n s e l l i n g s u p e r v i s i o n s e s s i o n . By u t i l i z i n g a n o n - l i n e a r method t h r o u g h which t o r e p r e s e n t and a n a l y z e the c o u n s e l l i n g s e s s i o n , the s t u d e n t i s encouraged t o g e n e r a t e what Toulmin (1972) r e f e r r e d t o as an " E p i s t e m i c s e l f - p o r t r a i t " (p. 3) of the e v e n t , and t o i n t e g r a t e s e l f - k n o w l e d g e w i t h new 12 13 discoveries about the counselling process in general. This represents the convergence - i n the counselling process, of imagination and phenomenology. A structured use of metaphoric case drawing as a formal tra i n i n g device in counsellor supervision has received s u r p r i s i n g l y l i t t l e attention in the published l i t e r a t u r e . Nucho (1983) u t i l i z e d visual metaphors in t r a i n i n g counselling students and found the effects powerful for increasing insight, understanding case material, and improving attitudes towards fellow counselling students. Amundson (1986) and Ishiyama (1988) reported preliminary studies suggesting that the use of metaphoric case drawings in a t r a i n i n g context increased student awareness and understanding in four target domains: 1) knowledge of the counsellor; 2) knowledge of the c l i e n t ; 3) increased understanding of the c l i e n t - c o u n s e l l o r r e l a t i o n s h i p , and 4) increased understanding of the counselling goals. Amundson (1986) was the f i r s t to s p e c i f i c a l l y explore the re l a t i o n s h i p between case drawings and i t s effects on the case presentation process. Forty-six case drawings of counselling sessions were presented in the context of a graduate l e v e l counselling practicum at a community college. The method was evaluated according to the extent the drawings f a c i l i t a t e d greater understanding of the c l i e n t , the counsellor, the c l i e n t - c o u n s e l l o r r e l a t i o n s h i p , and the counselling goals 14 (seven a d d i t i o n a l d i m e n s i o n s were r a t e d which were e i t h e r s u b s e t s of the i n i t i a l f o u r q u e s t i o n s or q u e s t i o n s about the p e r c e i v e d v a l u e of t h i s t y p e of case p r e s e n t a t i o n p r o c e s s ) . F a v o r a b l e r e s u l t s were i n d i c a t e d on a l l d i m e n s i o n s . The r e s u l t s of t h i s s tudy suggested t h a t the case drawing method was g e n e r a l l y p e r c e i v e d as an a s s e t by both the s t u d e n t p r e s e n t i n g the case and those o b s e r v i n g the case p r e s e n t a t i o n . Amundson (1986) thus e x p l o r e d the use of case drawings as a c o u n s e l l o r t r a i n i n g t e c h n i q u e i n a s u p e r v i s i o n c o n t e x t . E x t e n d i n g Amundson's (1986) s t u d y , Ishiyama (1987, i n p r e s s ) , conducted a s t u d y comparing the metaphor-drawing w i t h c o g n i t i v e method of case c o n c e p t u a l i z a t i o n witrh b e g i n n i n g c o u n s e l l o r t r a i n e e s . T h i s s t u d y r e f l e c t e d the s t u d e n t s p r e f e r e n c e f o r the metaphor-drawing method over the c o g n i t i v e method on 12 of the 15 a r e a s of case p r o c e s s i n g ( i n c l u d i n g most of the dimensions from the Amundson (1986) s t u d y ) . Ishiyama's s t u d y (1988) i n t r o d u c e d an element of p r e c i s i o n and c o n c e p t u a l r i g o r i n t o the assessment of the e f f e c t s of a c a s e - d r a w i n g p r o c e d u r e on c o u n s e l l o r - t r a i n e e s u p e r v i s i o n by u t i l i z i n g a c o u n t e r - b a l a n c e d d e s i g n and s t a t i s t i c a l compar i sons. Purpose Of Study The purpose of the p r e s e n t s t u d y was t o expand and a m p l i f y the Amundson (1988) and Ishiyama (1988) s t u d i e s i n a 15 c l i n i c a l counselling s e t t i n g , and to introduce a number of additional concepts and controls. This study, then, investigated the value of the i n t e r a c t i o n a l metaphoric case drawing method for counsellor t r a i n i n g by. comparing the metaphoric case drawing method with the t r a d i t i o n a l verbal case conceptualization method. It was hypothesized that the Metaphoric Case Drawing (MCD) method would increase counsellor-trainee understanding in f i v e target domains (counsellor, c l i e n t , r elationship, goals, and e f f i c a c y of case debriefing method) thereby f a c i l i t a t i n g the clear conceptualization of the cases above and beyond that gained through the Verbal Case Debriefing (VCD) method alone. It was further hypothesized that transfer of t r a i n i n g would take place thereby f a c i l i t a t i n g increased understanding in a l l f i v e target domains in the f i n a l VCD sessions following the introduction of the MCD method. 16 I l l METHODOLOGY Subjects The subjects of the study were 2 female and 5 male graduate students from the C l i n i c a l Psychology Program at Simon Fraser University, Burnaby B.C. They were enrolled in a four month c l i n i c a l practicum at the C r i s i s Intervention and Suicide Prevention Centre for Greater Vancouver from September 18, 1986 to January 10, 1987. The practicum focused on the ac q u i s i t i o n of counselling s k i l l s in the context of in-person and telephone c r i s i s intervention and suicide prevention. 6 Ss were registered in the M.A. program; 1 S was registered in the Ph.D. program. The same S had relevant counselling background in short-term and c r i s i s intervention and case presentation. The remaining 6 Ss were engaging in c l i n i c a l c r i s i s intervention counselling and case presentation for the f i r s t time. The age range of the Ss was from 23 to 31 years (mean: 26.6 years). Trai ners Trainers consisted of 3 males and 2 females. The p r i n c i p l e trainer and practicum supervisor (a M.A. 17 candidate in counselling psychology) has 15 years background in c l i n i c a l c r i s i s intervention counselling and tr a i n i n g . Of the four additional t r a i n i n g s t a f f two had a B.A.; one had a teaching degree; one was a Ph.D. candidate in C l i n i c a l Psychology. The mean c r i s i s intervention t r a i n i n g experience for the trainers was 5.6 years. A l l had been involved in c l i n i c a l supervision for at least 3 years. The age range was from 27 to 40 years (mean age: 33.1 years) . Training Procedure Ss attended an i n i t i a l four week tr a i n i n g program at the C r i s i s Intervention and Suicide Prevention Centre which was designed to equip them with the necessary s k i l l s and resources prior to actual c l i e n t work. The broad objectives of this program were to f a m i l i a r i z e the Ss with c r i s i s intervention theory and practice and provide the Ss with ample opportunity to practice and rehearse a variety of counselling techniques. Practice problems were f a c i l i t a t e d in the context of r e a l i s t i c role-taking situations u t i l i z i n g the trainers and other Ss as " c l i e n t s . " Audio tapes and audio-visual playback of Ss practice counselling sessions were used to supervise, assess, and monitor the progress of the Ss. Appendix B provides detailed information on 18 practicum t r a i n i n g procedures, objectives, and tra i n i n g materials. Case Presentation (Debriefing) Process The case conceptualization process consisted of analyzing and assessing each practice case during the preliminary t r a i n i n g , and each actual counselling session during the post-training, experimental phase of the study. Two methods were used: A) Verbal Case Debriefing (VCD), and B) the Metaphoric Case Drawing (MCD) Method. Verbal Case Debriefing (Method A: Control Condition) The Verbal Case Debriefing (VCD) format (Stone, 1985), was designed to provide a framework for assessing and analyzing cou n s e l l o r - c l i e n t casework. This method consisted of a review and ov e r a l l summary of the case, including presenting problems, goals, and outcome. In addition, a pumber of client- c o u n s e l l o r dimensions were reviewed: motivation, content, a f f e c t , the counsellor r o l e , obstacles encountered during the session, and a review of the actual counselling techniques used during the session. The VCD was introduced as a one hour module during the f i r s t t r a i n i n g session of the four week preliminary t r a i n i n g program. A practice role-play counselling session 19 was conducted by the trainers and the VCD method was demonstrated following the practice session. Ss then participated in a practice role-play after which they u t i l i z e d the VCD. Following completion of the f i r s t session, roles were reversed and a new practice session was conducted followed by a VCD. Trainers supervised the Ss a c q u i s i t i o n of the VCD method. Following the one hour VCD t r a i n i n g module Ss were given a print summary of the procedure (Appendix C). The t r a i n i n g consisted of an informal process which encouraged comments, questions, and ideas from the Ss. The process promoted discourse of a th e o r e t i c a l and p r a c t i c a l nature, however, the* focus was always anchored on application within the c r i s i s intervention context. During the course of the post-training research period, following each actual counselling session and upon completion of the Verbal Case Debriefing, the Evaluation Questionnaire (see Appendix G) was completed by the S, the trainer (s), and any other Ss who may have been available to p a r t i c i p a t e in the entire debriefing. Questionnaires were then co l l e c t e d and f i l e d by a t r a i n e r . A VCD case presentation example may be found in Appendix D. Metaphoric Case Drawing (Method B: Experimental Condition) The Metaphoric Case Drawing (MCD) method was designed 20 to evoke metaphoric thinking about the counselling session and then have Ss translate the thought-metaphor into a representative case drawing. Ss had complete freedom to produce any type of representation they choose eg, abstract, symbol, combination words and picture, l i n e drawings, and so forth. Drawings were produced on either 8 1/2 X 11 paper or f l i p - c h a r t size paper. Multicolored f e l t pens, crayons, and an assortment of colored pencils were ava i l a b l e . Ss were given a one-hour t r a i n i n g session in order to f a m i l i a r i z e themselves with the case drawing process. The session was conducted the evening prior to the onset of each groups' f i r s t MCD session (see Figure 2, p.26). During the one hour session, a Metaphoric Thinking Exercise was presented (see Appendix E). This provided a consistent framework for each of the three groups and provided an opportunity for Ss to r e a l i z e they were not being assessed on their a r t i s t i c or aesthetic a b i l i t i e s . The MCD method was presented as primarily instrumental: a means to an end. The only rule for the MCD was that Ss must, in some manner, include a representation of four s p e c i f i c sub-scales of the f i v e under study: 1) the c l i e n t ; 2) the counsellor; 3) the rela t i o n s h i p , and 4 ) the counselling goals. A MCD case presentation example may be found in Appendix F. As with the Verbal Case Debriefings, upon completion 21 of the MCD debriefing the Evaluation Questionnaires were rated by the trainee, the trainer (s), and any other Ss who were able to p a r t i c i p a t e in the entire debriefing. The MCD's and the Questionnaires were then collected and f i l e d by a t r a i n e r . Measures Evaluation Questionnaire. A 39-item Evaluation Questionnaire was constructed (Appendix G) including 8 of the items used by Amundson (1986) indicated by an * on the Questionnaire in Table 1. The Evaluation Questionnaire was introduced to the Ss at the onset of the f i r s t actual c l i n i c a l counselling session after completion of the four week preliminary t r a i n i n g program. Ss rated the effects of the two case presentation methods on their understanding and awareness of each of f i v e main components of the counselling process: 1) the general and s p e c i f i c concerns of the c l i e n t ; 2) a l l aspects of the c l i e n t - c o u n s e l l o r relationship; 3) the trainee in the role of counsellor and as an individual outside the counselling ro l e ; 4) the counselling goals, and 5) the perceived value of the case presentation debriefing process. Table 1 (p. 23) shows the Evaluation Questionnaire broken down into the f i v e sub-scales mentioned above and 22 Table 1. Evaluation Questionnaire Sub-Scales And Corresponding Items Sub-Seale I . C l i e n t I I . C o u n s e l l o t I I I . R e l a t i o n s h i p 1. < 5. 6. 7 . 9. 10. 2. 13. 14 . 22 . 24. 25. 26. 27. 3. 15. 16. Q u e s t i o n The c l i e n t ? Were you a b l e to e l i c i t ( a c t s about the c l i e n t ? Here p r e s e n t i n g problem c l a r i f i e d ? Your u n d e r s t a n d i n g of the v a r i a b l e s e f f e c t i n g the c l i e n t ? Your u n d e r s t a n d i n g of the o b s t a c l e s the c l i e n t must r e s o l v e i n o r d e r to s o l v e the p r o b l e n ? The c l i e n t ' s n o t i v a t i o n ? The c l i e n t ' s d e s i r e d outcome? The c o u n s e l l o r ? Your own s t reng ths /weaknes se s i n t h i s c o u n s e l l i n g s i t u a t i o n ? Your r o l e in t h i s c o u n s e l l i n g s i t u a t i o n ? I f e l t p e r s o n a l l y i n v o l v e d i n t h i s case p r e s e n t a t i o n ? I g a i n e d I n s i g h t i n t o the case and the n a t u r e of the c l i e n t p r o b l e n ? I g a i n e d i n s i g h t i n t o my f e e l i n g s and va lues r e g a r d i n g h e l p i n g t h i s c l i e n t ? I g a i n e d i n s i g h t as to what happened r e g a r d i n g the h e l p i n g p r o c e s s ? I g a i n e d i n s i g h t as to how I f e e l about myse l f as a c o u n s e l l o r ? The c l i e n t - c o u n s e l l o r r e l a t i o n s h i p ? Changes i n the c l i e n t - c o u n s e l l o r r e l a t i o n s h i p over the s e s s i o n ? R e s i s t e n c e , r e l u c t a n c e , r e c e p t i v i t y to new i d e a s , change, or d i r e c t i o n ( in the c l i e n t - c o u n s e l l o r c o n t e x t ) ? Sub-Seale IV. Goals Items Prom the Amundson (1986) Study V. D e b r i e f i n g 4. ' 11. 12. 17. IB. 19. 28. 21. 28. 23. 29. 39. 31. 32. 33. 34. " 35. ' 36. ' 37. " 38. 39. Quest ion C o u n s e l l i n g Goal s? How the f o u r - s t a g e i n t e r v e n t i o n model a p p l i e d in t h i s s e s s i o n (acceptance , c o n f l i c t i d e n t i f i c a t i o n , a l t e r n a t i v e s t e r m i n a t i o n ) ? What occurred to f a c i l i t a t e or b lock stage t r a n s i t i o n s ? Perce ived s o l u t i o n e f f e c t i v e n e s s ? ( s p e c i f i c outcomes l i k e l y to occur i f a g iven course of a c t i o n were fo l lowed)? I m p l l e i t / e x p l i c i t u n d e r s t a n d i n g of what i s needed i n t h i s s i t u a t i o n in the c r i s i s I n t e r v e n t i o n c o n t e x t ? Degree of complex i ty of t h i s s e s s i o n ? How e f f e c t i v e was the s e s s i o n i n f a c i l i t a t i n g change or adjus tment? How e f f e c t i v e was the s e s s i o n i n reducing p s y c h o l o g i c a l p a i n ? Ins ight i n t o Improved h a n d l i n g of a s i m i l a r s i t u a t i o n i n the f u t u r e ? Other group members were a c t i v e l y Involved i n the process? I exper ienced emot ional s a t i s f a c t i o n from p r e s e n t i n g / o b s e r v i n g the case p r e s e n t a t i o n ? I have Improved my a b i l i t y to p r e s e n t and p a r t i c i p a t e in the case p r e s e n t a t i o n proces s? My o v e r a l l unders tand ing of the case has improved as a r e s u l t of the case p r e s e n t a t i o n ? My awareness of the c o u n s e l l i n g process i n g e n e r a l has i n c r e a s e d ? I c o n t r i b u t e d i d e a s , t h o u g h t s , and f e e l i n g s d u r i n g the d e b r i e f i n g ? The d e b r i e f i n g he lped e s t a b l i s h e d a c o u n s e l l i n g p lan? Served as a c o n c r e t e r e f e r e n c e p o i n t ? Helped focus the d i s c u s s i o n ? Served as a summary? Prov ided a d d i t i o n a l i n s i g h t ? Degree of o v e r a l l impact? the corresponding question sets for each sub-scale. A seven point Likert scale was used to rate a l l questions accompanied by the following descriptors: (1) "Not At A l l ; " (2) "A L i t t l e ; " (3) "Somewhat;" (4) "Moderately;" (5) "Quite;" (6) "Very Much;" (7) "Extremely." Higher scores indicated the acq u i s i t i o n of greater understanding and awareness. Qualitative Measures. Qualitative measures used included t r a i n e r s ' c l i n i c a l case notes, filmed audio-visual segments taken randomly from 15 case debriefings (7 VCD; 8 MCD), tran s c r i p t s from the filmed segments, and the drawings from a l l MCD case debriefings. These measures were used to shed l i g h t on the s t a t i s t i c a l findings and have been integrated into the Results and Discussion section of the study. Appendix J provides an extensive review of the MCD interpretation process from a counsellor supervision and c l i n i c a l c r i s i s intervention perspective. Six detailed case conceptualization examples are provided. Research Design A multiple baseline A/B/A design was used with Ss acting as their own controls (Wiersma, 1986). The control condition (A) consisted of the Verbal Case Debriefing 24 method. The experimental condition (B) consisted of the Metaphoric Case Drawing method (MCD). Figure 2 (p. 26) shows the d i s t r i b u t i o n and onset of conditions A/B/A by-group. A 2 X 3 X 3 (Ss/Tr; MCD onset; A/B/A) between-within Analysis of Variance was used to analyze the Evaluation Questionnaire data. Non-numerical q u a l i t a t i v e measures were examined and the several sources integrated into the analysis of the r e s u l t s . 25 Figure 2. Distribution and Onset of Condition (A/B/A) by Group. IV RESULTS Quantitative Data Analysis Item Analysis. Overall, 244 ratings were obtained on the 108 separate c l i n i c a l case study presentations (71% rated by 1 Trainer: N= 77 cases; 23.5% rated by 2 Trainers: N= 25 cases; 5.5% rated by 3 Trainers: N= 6 cases; Ss ratings: N= 108) . The 39 items constituting the Evaluation Questionnaire were subjected to an item analysis to investigate the p o s s i b i l i t y of heterogeneity within the data set across groups of subjects and t r a i n e r s . P a r a l l e l analyses were performed on a number of subsets. The results ( u t i l i z i n g the Hoyt Estimate of R e l i a b i l i t y and Cronbach's Alpha for Composite) were highly consistent. Consequently, only the results for a l l Ss, Trainers, and f i r s t counselling sessions across conditions A/B/A (presented in Table 2, p. 28) were used for the analysis reported below. (The results of the analyses of the remaining subsets [ a l l 108 cases] are presented in Appendix H). The scales were highly i n t e r n a l l y consistent, as may be seen from the Hoyt Estimates of R e l i a b i l i t y , which ranged from .85 to .98. Thus, the item analysis provides j u s t i f i c a t i o n for using the 5 scale scores and the t o t a l scale score. In addition, the following assumptions appear 27 Table 2. Summary Of All S s / Trainers Ratings (N=166) Of All 1st Counselling Sessions (N=70) by Sub-Scale Pearson Hoyt Estimate Corr. Scale X S.D. Of Reliability* High Low Max. ( S s / T r s ) Client 27.4 7.6 .92 46 9 49 .79** Counsellor 32.9 9.5 .95 53 15 56 .72** Relationship 12.0 3.5 .85 21 5 21 .69** Goals 38.7 10.1 .92 61 20 70 .69** Debriefing 44.9 13.7 .97 73 22 77 .73** Total 155.8 42.48 .98 246 78 273 .78** * Cronbachs Alpha for Composite = 0.93 ** p < 0.001 28 to be j u s t i f i e d : a) a l l 70 f i r s t counselling sessions are coherent [see Appendix I for students ratings by Sub-Scale by Groups across a l l 1st counselling sessions]; b) Ss and Trainers are equally consistent; c) Ss and Trainers are equally consistent when compared to a l l 108 counselling sessions in the study. The means, standard deviations and range of scores for each of the f i v e sub-scales, in addition to the t o t a l score, may be found in Table 2, which also contains the Pearson correlations between subjects' and t r a i n e r s ' scores for each of the six scales. As may be seen, the correlations ranged from 0.69 to 0.79, a l l of which were highly s t a t i s t i c a l l y s i g n i f i c a n t . Thus, between 48% and 63% of the v a r i a b i l i t y in scale scores was held in common by subjects and t r a i n e r s , ( i e . , subjects and trainers tended to score the same case debriefing in a similar manner). In the case of each of the f i v e scales, the mean score f e l l close to the " t h e o r e t i c a l " mean of one-half the maximum. The means were s l i g h t l y above this value in each case, with the exception of the Debriefing scale, for which the obtained mean was somewhat higher. Thus, i t may be concluded that the subjects and trainers tended not to respond "automatically" in a p o s i t i v e d i r e c t i o n ; nor did they uniformly rate the sessions as negative. That there is a wide range of scores may be concluded from consideration of the standard deviations, a l l of which approximated 29 one-seventh of the maximum possible score. Analysis of Variance. The results of the six 2 X 3 X 3 between-within analyses of variance are summarized in Table 3, p. 31). As is evident from Table 3, a l l six main effects for Debriefing Method were highly s i g n i f i c a n t l y d i f f e r e n t (p <.001). Of the remaining sources of variance, three scales achieved s i g n i f i c a n t differences for the Group by Debriefing Method interaction (BC); the counsellor scale was s i g n i f i c a n t l y d i f f e r e n t for the Group main eff e c t (B) , and the Debriefing scale (A) was s i g n i f i c a n t l y d i f f e r e n t for the subjects and t r a i n e r s . The means and standard deviation for the six scores may be found in Table 4, p. 32 (for the Debriefing methods) and Table 5, p. 33 (for the Groups by Debriefing methods). Table 6 (p. 34) contains the subjects and trainers means and standard deviations for each of the six scores. As can be seen from Table 4 i t is clear that the MCD had an impact on both subjects' and t r a i n e r s ' perceptions of the c l a r i t y with which the case was conceptualized. The s i g n i f i c a n t group by DM interactions (Table 3), plus the single s i g n i f i c a n t group ef f e c t (Table 3), could be interpreted to mean that the time of introduction of the MCD must be considered when formulating t r a i n i n g procedures. However, examination of Table 5, and keeping in mind the extremely small group si z e s , allows us to reject 30 Table 3. Summary Of Significant Effects by Scale (F-Ratio) Effect Scale C (Debriefing Method) 2,16 df BC (D.M. by Group) 4,18 df B (Group) 2,8 df A (S/T) 1,8 df Client 141.68** 3.099* N.S. N.S. Counsellor 125.90** N.S. 4.59* N.S. Relationship 189.27** 4.03* N.S. N.S. Goals 112.28** N.S. N.S. N.S. Debriefing 251.33** N.S. N.S. 8.17* Total 219.35** 3.08* N.S. N.S. N.S. Not significant; * p < 0.05; ** p < 0.001 31 Table 4. Means and S.D. by Debriefing Method (S s, T r s , A l l l s { cases)* VCD (Pre) A MCD B VCD (P A ost) Scale X / S.D. X / S.D. X / S.D. Client 23.5 2.4 36.6 3.0 23.4 3.7 Counsellor 29.0 3.2 45.1 3.3 27.0 5.9 Relationship 10.5 1.2 16.5 1.0 10.2 1.7 Goals 34.2 2.8 50.9 4.4 33.2 6.5 Debriefing 39.6 3.9 62.8 4.2 35.7 6.4 Total 137.0 11.5 212.0 14.3 129.5 22.4 * A l l scales are significantly different, (p < 0.001) 32 Table 5. Means and S.D. by Debriefing Method by Group by Scale Group 1 A 2 1 B 2 Client* Counsellor Relationship 1 Goals Debriefing Total* P < 23.5 21.1 25.2 (4.24) (4.80)(2.01) 28.1 26.4 31.3 (3.30) (3.74) (4.35) 10.4 9.4 11.3 (1.65) (2.83) (1.08) 34.8 31.7 35.5 (2.36) (2.65) (4.67) 41.3 36.5 41.1 (6.60) (7.42) (7.31) 138.2 125.1 144.3 (13.4) (15.9) (14.8) 0.05 35.2 37.8 38.7 (8.96) (2.36) (4.01) 42.8 45.8 46.2 (7.07)(5.53) (3.59) 16.3 17.0 16.4 (0.96)(0.94)(1.87) 49.3 52.1 51.3 (11.3) (8.01) (7.14) 61.7 63.1 83.4 (11.5) (4.71) (3.97) 205.3 215.8 213.9 (33.2) (17.2) (17.5) A 1 2 3 23.3 20.1 25.8 (5.13) (2.38)(5.28) 27.3 22.5 29.8 (5.48) (9.20) (4.05) 9.6 8.6 11.6 (0.88)(2.36)(1.37) 32.6 27.9 37.1 (4.60)(4.95)(3.63) 36.4 31.4 38.2 (7.60)(2.36)(4.59) 129.1 110.5 142.4 (20.1) (21.2) (12.1) 33 Table 6. Means And S.D by Subjects/Trainers by Sub-Scales (N= 70) Scale Subjects Trainers Client 28.1 (7.9) 27.6 (7.8) Counsellor 34.9 (9.5) 32.5 (9.7) Relationship 12.2 (3.7) 12.6 (3.5) Goals 40.1 (10.3) 38.8 (10.8) Debriefing* 48.2 (12.9) 44.0 (14.6) Total 163.5 (41.8) 155.5 (44.7) * p < 0.05 34 this interpretation and to conclude that the time of introduction does not have an impact on the effect of the MCD. Further, from Table 5, i t seems that i t is the post A VCD condition that is the source of s i g n i f i c a n t interactions. It appears that 'group 2 is lower on the post a VCD, and group 3 higher. In f a c t , group 2 had only 2 Ss, one of which was the only S with prior experience. The t r a n s c r i p t s , video-tapes, and t r a i n e r s ' notes of the VCD debriefing sessions with this S indicate that he was was not trying too hard, whereas in the MCD condition there is an obvious increase in interest and e f f o r t (as may be seen by the MCD means for group 2 for a l l sub-scales in Table 5). Thus, i t seems l i k e l y that the s i g n i f i c a n t BC interactions and the single s i g n i f i c a n t B main effect in Table 3 were due to sampling error rather than the time of onset, and that the error had a marked impact because of the low number of subjects in the study. Qualitative Data Analysis Transfer of Training E f f e c t s . In addition to the s t a t i s t i c a l findings and tiranscr i p t s , video-taped segments and Trainers' case notes were u t i l i z e d to assess the extent to'which student learning transferred from the experimental condition (MCD) to f i n a l Verbal Case Debriefing method. It was hypothesized that the VCD scores following the MCD 35 portion of the study would r e f l e c t a mean increase compared with the i n i t i a l VCD t r i a l . As may be seen at a glance from Figure 3 (p. 37) and Figure 4 (p. 38) there was a s l i g h t decrease for a l l three groups combined, in post-A scores across a l l sub-scales. Table 5 demonstrates only group #3 showed a post-A increase and only for sub-scales for the c l i e n t , r e l a t i o n s h i p , and counselling goals. The question of why Ss did not seem to uniformly transfer the increased understanding derived from the Metaphoric Case Drawing method to the sessions following the end of the MCD t r i a l s , was one of some in t e r e s t . The following statements (transcribed from the video segments) from two students helps to shed some l i g h t on this matter: The verbal debriefings following the drawing method were a sort of hybrid of both without complete control of either (Student #1) and ...Realization that what we thought a superior method [ f i r s t exposure to VCD] r e a l l y turned out to be about a 5 on a scale of 1 to 10 in comparison to the drawing system. Going back [ f i n a l VCD sessions] was disappointing. The drawings r e a l l y made i t clear just how much we didn't know (Student #4) Debriefing Session Duration: Other Training C l i n i c  Considerations. In addition to the highly s i g n i f i c a n t e f f e cts of the MCD method on the 5 sub scales as shown in Table 3 ( a l l p <.001), the MCD method also appears to decrease the ove r a l l length of time required to conduct a 36 250-1 Client Counsellor Rel'n Goals Debriefing Total Figure 3. Summary of Means and S.D. for Conditions A/B/A by Sub-Scales 3 7 T T 9 10 I OH —i 7 Group 3 (N=3) VCD MCD Mean ±SD i— 10 Session Figure 4 Means and S.D. Combined Sub-Scale Scores/S s T r Ratings For All 1 , l Counselling Sessions (N=70) by Group Across Sessions. ^ case presentation as summarized in Table 7 (p. 40). The mean time per debriefing for the VCD was 34.9 minutes per case (S.D.= 17.9) for the t o t a l cases in this condition (N= 69). The mean time per debriefing for the MCD condition was 28.0 minutes per case (S.D.= 13.5) for the t o t a l cases in this condition (N= 39). This represents a reduction in time of 19.7% per case in favor of the MCD method. In conjunction with length of time per debriefing, the question of the d i s t r i b u t i o n of the types of c l i e n t presenting problems by condition arises and Table 8 (p. 41) summarizes these observations. Thus, i t may be seen that about 75% of a l l MCD c l i e n t problems involved either suicide, depression, relationship c o n f l i c t , or chronic use/abuse of mental health services in general with no apparent intent to a c t u a l l y do anything about their s i t u a t i o n . Rudestram (1978) has termed such c l i e n t s as chronic or manipulative. Authors such as McGee (1974), and Shneidman (1976) have noted that these types of presenting problems represent some of the most d i f f i c u l t situations to handle in any type of counselling context, both from a point of view of s k i l l s required and demand made on counsellors emotional, physical, and mental resources. In a l l four categories the MCD shows a r e l a t i v e percentage increase over similar cases in the VCD condition. Thus, based on the present study, i t appears that the MCD method reduces 39 Table 7. Mean Time (In Minutes) And S.D. Per Case Debriefing By Condition Condition Time VCD 34.9 (17.9) MCD 28.0 (13.5) No. Of Cases 69 39 40 Table 8. Presenting Problem by Category by Condition (VCD/MCD) Condition Total # % VCD % MCD % Problem of cases Suicide 13 12.1% 5 7.2% 8 20.6% Depression 24 22.2% 15 21.7% 9 23.1% Relationship Conflict 16 14.8% 9 13.2% 7 17.9% Manipulative (chronic users 12 11.1% 7 10.1% 5 12.8% of service) Other 43 39.8% 33 47.8% 10 25.6% Total 108 69 39 41 average case debriefing time by about 20%, even in the context of " d i f f i c u l t to handle" c l i e n t material. In addition, a review of the MCD means in r e l a t i o n to the VCD (pre and post) means reveals an increase in understanding in v i r t u a l l y a l l sub-scales, ranging from 33% to about 40%, as may be seen in Table 9 (p. 43). It appears that the MCD method may be p a r t i c u l a r l y e f f e c t i v e in debriefings involving highly emotionally charged cases (suicide, depression, relationship c o n f l i c t ) and cases involving frequent extreme f r u s t r a t i o n and confusion (chronic or manipulative c l i e n t s ) . This speculation received support from the Trainers' case notes and the filmed debriefings where, as one student put i t "...drawings were consistent at reducing and c l a r i f y i n g confusion and p u l l i n g things together when we were under pressure [from d i f f i c u l t - t o - h a n d l e cases]." 42 Table 9. MCD Percentage Increase In Understanding Over Pre/Post VCD Combined Means By Sub-Scale VCD Means* MCD % Increased Scale (Pre/Post) Means Understanding Client 23.45 36.6 35.9% Counsellor 2B.0 45.1 37.9% Relationship 10.35 16.5 37.3% Goals 33.7 50.9 33.8% Debriefing 37.75 62.8 39.9% Total 133.2 212.0 37.1% * Average Of Pre/Post VCD Means 43 V DISCUSSION AND CONCLUSION The research results s t a t i s t i c a l l y support (p= < .001) the hypothesis that the MCD method would increase counsellor-trainee understanding on the f i v e target domains (counsellor, c l i e n t , r e l a t i o n s h i p , goals, and e f f i c a c y of debriefing method). The MCD method proved to be a concise, v i s u a l framework which played a p i v o t a l role in integrating trainees' thoughts, feelings, and experience. By systematic application of the MCD method prior experience, imagination, and forethought may be convincingly examined, synthesized and fused in the counselling supervision context. For the most part subjects and trainers have similar perceptions for both VCD and MCD, therefore problems with i n t e r - r a t e r r e l i a b i l i t y and marked differences between subjects and trainers do not appear to be a factor in the strong p o s i t i v e observed r e s u l t s . S i g n i f i c a n t differences were found in the ANOVA for subjects and trainers (Table 3, p. 31; Table 6, p. 34) for the Debriefing Sub-Scale. These differences seem to be a case of trainers h i s t o r i c a l l y rating students a l i t t l e lower than the students rate themselves. This point is based on the assumption that t r a i n e r s , by d e f i n i t i o n , usually have a more sophisticated, global, and well integrated understanding of the subject material than is available to the student. Thus, a lower overal l rating would be expected by instructors in 44 comparison to students' self-assessment. One finding that was surprising was the decrease in ratings as subjects moved from the MCD method to the f i n a l VCD sessions. Perhaps, as one student suggested, there was i n s u f f i c i e n t mastery of the MCD technique for transfer of tra i n i n g to occur. The question of mastery of basic s k i l l s as a necessary condition for transfer of tra i n i n g to occur f u l l y has been examined extensively by such authors as Humpherys (1951), Saupe (1977), Horner (1978), and Baer (1982). Without "control" of the basic counselling s k i l l s i t is not l i k e l y that transfer to a new context w i l l occur uniformly. It appears possible that exposure to three MCD sessions is simply not enough for the technique to transfer to the new context (the f i n a l VCD sessions). Another, and more simple, explanation was that Ss came into the practicum without any c r i s i s counselling framework (with the exception of one Group #2 student), where everything was new and any framework and structure for learning basic counselling s k i l l s was embraced. When the MCD method was introduced part way into the practicum students, for the most part, took a quantum jump in s k i l l l e v e l and degree of conceptual sophi s t i c a t i o n (see the case study analyses in Appendix J ) . At that point Ss were able to think comparatively about the two methods and when Ss were returned to the VCD method there was a " l e t down" e f f e c t . Thus, as one student put i t , the f i n a l sessions of the VCD method may have received 45 lower r a t i n g s as a f u n c t i o n of the " r e a l i z a t i o n of how much more there was to l e a r n about the c o u n s e l l i n g p r o c e s s " [as made evident by the MCD s e s s i o n s ] . F u r t h e r Research Questions. F u r t h e r q u a n t i t a t i v e and q u a l i t a t i v e r e s e a r c h i s warranted to determine the e x t e n t , u t i l i t y and best context f o r the MCD method (eg., the MCD method i s e f f i c a c i o u s i n the c r i s i s i n t e r v e n t i o n context - how w e l l would the MCD method perform i n a long-term, f a c e - t o - f a c e c o u n s e l l i n g context? What would be the extent of the value the MCD method would p r o v i d e experienced c o u n s e l l o r s as a s e l f - a s s e s s m e n t , self-knowledge t o o l which c o u l d be i n t e g r a t e d i n t o the busy schedule of working c l i n i c a l t h e r a p i s t s as a means of combating c l i n i c a l burnout, d e c r e a s i n g a sense of p r o f e s s i o n a l i s o l a t i o n , and meeting the need f o r c o n t i n u i n g p r o f e s s i o n a l e d u c a t i o n ? ) . A review of Appendix J i n d i c a t e s the MCD method may very w e l l operate as a mechanism f o r i n t e g r a t i n g primary (unconscious) and secondary (conscious) p r o c e s s e s . The MCD method may a l s o be an e f f e c t i v e way to correspond between r i g h t and l e f t b r a i n f u n c t i o n i n g . These are a l l t e s t a b l e q u e s t i o n s which seem re s e a r c h worthy and may have value i n c o n t r i b u t i n g to the knowledge base of c o u n s e l l i n g s u p e r v i s i o n methods. F u r t h e r i n v e s t i g a t i o n s of these q u e s t i o n s would prove f r u i t f u l i n p r o v i d i n g c l i n i c a l s t a f f with a d d i t i o n a l t i m e - e f f i c i e n t , i n t e g r a t i v e techniques f o r managing t h e i r own 46 case-work and providing both counselling with creative, e f f e c t i v e approaches to a counselling concerns. students and wide variety c l i ents of Limitations. This is an exploratory study. The small number of subjects (N = 7) imposes l i m i t a t i o n s on the g e n e r a l i z a b i l i t y of re s u l t s . There was no attempt, within the scope of the study, to assess the v a l i d i t y of the Evaluation Questionnaire. This also l i m i t s g e n e r a l i z a b i l i t y . The study was gross: more s p e c i f i c research on findings is required (eg., the MCD was only introduced and withdrawn once). The study would need to be replicated in order to control for experimenter bias (eg., include trainers who are "blind" to the VCD/MCD conditions). Conclusion. Notwithstanding the li m i t a t i o n s of the study, the Metaphoric Case Drawing method provides a powerful means of ins t r u c t i n g counselling students. Its p r i n c i p l e value l i e s in e f f i c a c i o u s l y applying a process (training) to a problem (increasing student understanding of core counselling issues). The MCD method also provides a reduction in t r a i n i n g time required (compared with the t r a d i t i o n a l Verbal Case Debriefing method). The MCD method is r e l a t i v e l y easy for trainers to learn and appears to confer an advantage to counselling students, e s p e c i a l l y in the c r i s i s intervention and suicide prevention supervision context. 47 REFERENCES Amundson, N. (1986). Case Drawing in Counsellor Supervision. Unpublished Paper. Vancouver: University of B r i t i s h Columbia. Amundson, N. (1988). The use of metaphor and drawings in case conceptualization. Journal of Counselling and  Development, Vol. 6_6, (8 ), 391-393 . Aquinas, T. (1980). Summa Theologica (Vol 19): Part 1. In Hutchins, R.M. (ed.). Great Books Of The Western World. Chicago: Encyclopaedia Britannica. A r i s t o t l e . (1980). Poetics (Vol 9): ch 21; Categories (Vol 8): ch 1; Rhetoric (Vol 9): ch 2. In Hutchins, R.M. (ed.). Great Books Of The Western World. Chicago: Encyclopaedia Britannica. Augustine. (1980). Confessions (Vol 18): bk v. In Hutchins, R.M. (ed.). Great Books Of The Western Wo_rld. Chicago: Encyclopaedia Britannica. Baer, D. (1982). Applied behavior analysis. In Terrence, G. T. Fraubs, C. (eds.). Contemporary Behavior Therapy, New York: Guilford Press. Barthes, R. (1981). Camera Lucida: Reflections On Photo-graphy. New York: H i l l and Wang. Begg, I. (1978). Imagery and verbal communication. Journal  of Mental Imagery, 2_: 165-186. Black, M. (1962). Models And Metaphors: Studies In Language  And Philosophy. New York: Cornell University Press. Bogen, J.F. and Bogen, G.M. (1969). The other side of the brain III. The Corpus Callosum and C r e a t i v i t y B u l l e t i n . Los Angeles: Neurological Society. Vol. 3j4 : 191-220 , 73-105. Breal, M. J. (1964). Semantics: Studies In The Science Of  Meaning. Trans: Mrs. H. Cust. New York: Dover Books. Broughton, R.S. (1981). Psi and the two halves of the brain. Journal of the Society for Psychical Research. Vol. 48: 765, 133-147. Caplan, G. (1964). P r i n c i p l e s of Preventive Psychiatry. New York: Basic Books. 48 D i l l e y , J. (1971). Adding a visu a l dimension to counselling. Personnel and Guidance Journal, 50: 39-42. Ehrenwald, J. (1984). Anatomy of Genius: S p l i t Brains and Global Minds. New York: Human Sciences Press, Inc. Ejve, B. (1983). Resonance and ambiguity-about metaphorical thinking. Scandinavian Psychoanalytic Review, _6: 81-96. Erikson, E.H. (1956). Growth and c r i s i s of the healthy personality. In Kluckhorn, C. and Murray, H (ed.). Personality in Nature, Society and Culture. New York; Alfred Knopf. Faberow, N. L. (1977). Suicide: Past, present, and perspective. Proceedings of The Seminars of Suicide  Research, Sweden: Yrjo Johnsson Foundation. Frazer, J.G. (1954). The Golden Bough: A Study In Magic  And Religion. London: Macmillan and Co. Ltd. Freud, S. (1980). General Introduction To Psycho-Analysis (Vol 54): 510b-c; 512d-513a. In Hutchins, R.M. (ed.). Great Books Of The Western World. Chicago: Encyclopaedia Britannica. Galin, D. and Ornstein, R. (1972). Lateral s p e c i a l i z a t i o n of cognitive mode: An EEG study. Psychophysiology, 412-418. Gibbon, E. (1980). Decline And F a l l Of The Roman Empire (Vol 40): 775c-d. In Hutchins, R.M. (ed.). Great Books Of  Western World. Chicago: Encyclopaedia Britannica. Golden, K. (1977). Suicide assessment: A s e l f - i n s t r u c t i o n a l  tape. An audio-visual presentation, 56 mins; University of Arkansas, Department of Psychiatry (available in the University of B r i t i s h Columbia audio-visual department, Department of Psychiatry). Goldstein, A., Sorcher, M. (1974). Changing Supervisor  Behavior. New York: Pergamon Press. Haley, J. (1976). Problem Solving Therapy. C a l i f o r n i a / San Francisco: Josey-Bass. Haynes, R. (1975). Metaphor as in t e r a c t i v e . Educational  Theory, 25: 272-277. H i l l , R. (1958). Generic features of families under stress. Social Casework, 39: 139-149. 49 Hobbes, T. (1980). Leviathan (Vol 23): Part 1. In Hutchins, R.M. (ed.). Great Books Of The Western World. Chicago: Encyclopaedia Britannica. Horner, R., Baer, D. (1978). Multiple-probe technique: A variation on the multiple baseline. Journal of Applied  Behavior Analysis, 11 (1): 189-196. Horowitz, M. J. (1970). Image Formation And Cognition. New York: Appleton-Century-Crofts. Humpherys, L. G. (1951). Transfer of training in general education. Journal of General Education, 5_: 210-216. Ishiyama, I. (1987). Metaphor Drawing in Case Concept-u a l i z a t i o n and Presentation: A Study of Educational Effects of Metaphor Drawing Upon Beginning Counsellor Trainees. Unpublished Manuscript. Vancouver: University of B r i t i s h Columbia. Ishiy a ma, I. (1988). A model of visual case processing using metaphors and drawings. Counsellor Education  and Supervision, in press. Jacobsen, G.F. (1968). Generic and individual approaches to c r i s i s intervention. American Journal of Public Health, 58: 338-343. James, W. (1980). Pr i n c i p l e s Of Psychology (Vol 53): 380a-381a; 689a-b. In Hutchins, R.M. (ed.). Great Books Of  The Western World. Chicago: Encyclopaedia Britannica. Jung, C. G. (1971). The archetypes and the c o l l e c t i v e unconscious. (Vol 9): Part 1. In 2nd. e d i t i o n , Bollingen Series, XX. The Collected Works Of C.G. Jung, Princeton University Press. Kant, E. (1980). Judgement (Vol 42): 547b-548c. In Hutchins, R.M. (ed.). Great Books Of The Western World. Chicago: Encylopaedia Britannica. Kelly, G.A. (1963). A Theory Of Personality. New York: W.W. Norton. Kent-Jones, D.W. (1980). Origin and development of cereals. In Adler, M. (ed.). Encyclopaedia Britannica. Chicago: (Vol 3): 1157-1172. Lakoff, G., Johnson, M. (1980). Metaphors We Live By. Chicago/London: University of Chicago Press. 50 Lazarus, A. A. (1971). Behavior Therapy And Beyond. New York: McGraw H i l l . Lazarus, A. A. (1976). Multimodal Therapy. New York: Spr i nger. Lindemann, E. (1944). Symptomatology and management of acute g r i e f . American Journal of Psychiatry, 101: 141-148. Loganbill, C., Hardy, E., Delworth, U. (1982). Supervision: A conceptual model. The Counselling Psychologist, 10: 3-42. Loganbill, C. , Stoltenberg, C. (1983). The case conceptual-i z a t i o n format: A tr a i n i n g device for practicum. Counsellor Education and Supervision, 22: 235-241. Luria, A.R. (1973). The Working Brain. New York: Basic Books. Matarazzo, R.G. (1978). Evaluating the t r a i n i n g of therapists. In G a r f i e l d , S.L., Bergin, A.E. (eds.). Handbook Of Psychotherapy And Behavior Change. New York: John Wiley & Sons. McGee, R. (1974). C r i s i s Intervention In The Community. Baltimore, London, Tokyo; Park Press. McKim, R.H. (1972). Experiences In Visual Thinking. Belmont C a l i f o r n i a : Brooks/Cole. Nucho, A.O. (1983). The use of visual imagery in t r a i n i n g professional helpers. In Schorr, J . , Sobel-Whittengton, Robbin, Canella, (eds.). Imagery, Vol. (3): 72-85. New York: Plenum Books. Ornstein, R. (1972). The Psychology of Consciousness. San Francisco: Freeman Press. Ortony, A., Reynolds, R. E., Arter, J. (1978). Metaphor: Theoretical and empirical research. Psychological  B u l l e t i n , 85: 919-943. Ozick, C. (1986). The moral necessity of metaphor. Harper's: May, 62-68. Paivio, A. (1972). Imagery and synchronic ideation. Abstract Guide: XXth International Congress of  Psychology. Tokyo, Japan. 127-128. 51 P e n f i e l d , W. (1975). The Mystery of the Mind. P r i n c e t o n , New J e r s e y : P r i n c e t o n U n i v e r s i t y P r e s s . ( Rapaport, L. (1962). The s t a t e of c r i s i s : Some t h e o r e t i c a l c o n s i d e r a t i o n s . S o c i a l S e r v i c e Review, 36: 211-217. Ri c h a r d s , I. A. (1936). The Philosophy Of R h e t o r i c . London: Oxford U n i v e r s i t y P r e s s . Ross, E.D. (1981). L o c a l i z a t i o n of l e s i o n s i n the r i g h t hemisphere a s s o c i a t e d with d i s o r d e r s of a f f e c t i v e language. The Aprosodies. In L o c a l i z a t i o n i n Neuro-psychology. Kertesz (Ed). Academic Press. Rudestram, K. E. (1978). The Challenge of The Chronic C l i e n t . Keynote Address, 2nd Annual Conference f o r C r i s i s I n t e r v e n t i o n Centres, U n i v e r s i t y of Toronto, June 15-18. Rule, W. R. (1984). Using the t a r g e t metaphor i n therapy. J o u r n a l of Mental Imagery, _3 : 67-72. Sachs, V. (1968). C r i s i s i n t e r v e n t i o n . P u b l i c Welfare, 26: 112-117. Saupe, J . L. (1961). Learning and the e v a l u a t i o n p r o c e s s . In D r e s s e l , P. L. (ed.). E v a l u a t i o n In Higher Education. Boston: Houghton-Miffin. Schon, D.A. (1983). The R e f l e c t i v e P r a c t i t i o n e r . New York: B a s i c Books. Schorr, J . (1974). Psychotherapy Through Imagery. New York: I n t e r c o n t i n e n t a l Medical Book C o r p o r a t i o n . Shneidman, E.S. (1976). A p s y c h o l o g i c a l theory of s u i c i d e . P s y c h i a t r i c Annals, 6_ (11): 51-66. S i f n e o s , P. E. (1980). M o t i v a t i o n f o r change. In Davenloo, H. (ed.). Short-Term Dynamic Psychotherapy. New York: Jason Aronson. Simon, R., Brewster, F. (1983). What i s t r a i n i n g ? The Family  Therapy Newsletter, _7 : 24-29. Sloane, T.O., Perlamn, C. (1980). R h e t o r i c . In A d l e r , M. (ed.). E ncyclopaedia B r i t a n n i c a (Vol 1_5) : 798-805, Chicago. Smith, L. (1978). A review of c r i s i s i n t e r v e n t i o n theory. S o c i a l Casework, J u l y : 396-405. 52 S p e r r y , R . ( 1 9 6 8 ) . H e m i s p h e r i c d i s c o n n e c t i o n and c o n s c i o u s e x p e r i e n c e s . A m e r i c a n P s y c h o l o g i s t . 7 2 3 - 7 3 3 . u n i t y i n V o l . 2 3 : S p e r r y , R . ( 1 9 8 2 ) . Some e f f e c t s o f d i s c o n n e c t i n g t h e c e r e b r a l h e m i s p h e r e s . S c i e n c e . V o l . 2 1 7 : 1 2 2 3 - 1 2 2 5 . S t o l t e n b e r g , C . ( 1 9 8 1 ) . A p p r o a c h i n g s u p e r v i s i o n f r o m a d e v -e l o p m e n t a l p e r s p e c t i v e : T h e c o u n s e l l o r - c o m p l e x i t y m o d e l . J o u r n a l o f C o u n s e l l i n g P s y c h o l o g y , 2 8 : 5 9 - 6 5 . S t o k e s , T . , B a e r , D . ( 1 9 7 7 ) . An i m p l i c i t t e c h n o l o g y o f g e n e r a l i z a t i o n . J o u r n a l o f A p p l i e d B e h a v i o r a l A n a l y s i s , 1_0 (2) : 3 4 9 - 3 6 7 . S t o n e , D . J . ( 1 9 8 5 ) . C r i s i s I n t e r v e n t i o n T r a i n e r ' s H a n d b o o k . U n p u b l i s h e d T r a i n i n g M a t e r i a l . V a n c o u v e r : B r i t i s h C o l u m b i a . S t o n e , D . J . ( 1 9 8 6 ) . M e t a p h o r i c - T h i n k i n g E x e r c i s e . U n p u b l i s h e d T r a i n i n g M a t e r i a l . V a n c o u v e r : B r i t i s h C o l u m b i a . S t o n e , D . J . ( 1 9 8 7 ) . M e t a p h o r i c C a s e D r a w i n g I n t e r p r e t a t i o n : T r a i n e r ' s G u i d e a n d C a s e S t u d y A n a l y s e s . U n p u b l i s h e d T r a i n i n g M a t e r i a l . V a n c o u v e r : B r i t i s h C o l u m b i a . T o u l m i n , S . ( 1 9 7 2 ) . Human U n d e r s t a n d i n g . P r i n c e t o n , New J e r s e y : P r i n c e t o n U n i v e r s i t y P r e s s . T o w e r , R . B . ( 1 9 8 3 ) . I m a g e r y m e a s u r e m e n t i n c l i n i c a l s e t t i n g s : M a t c h i n g t h e m e t h o d t o t h e q u e s t i o n . In S c h o r r , J . , S o b e l - W h i t t e n g t o n , R o b b i n , C a n e l l a , ( e d s . ) . I m a g e r y . V o l ( 1 ) : 7 9 - 9 2 . New Y o r k : P l e n u m B o o k s . W e i r s m a , W. ( 1 9 8 6 ) . R e s e a r c h M e t h o d s I n E d u c a t i o n . B o s t o n : A l l y n and B a c o c , I n c . W h e e l w r i g h t , P . E . ( 1 9 6 2 ) . M e t a p h o r And M e a n i n g . B l o o m i n g t o n : I n d i a n a U n i v e r s i t y P r e s s . 53 Appendix A F i g u r e s of Speech 54 Figures of Speech (Sloane and Perlman, 1980) 1. Metaphor A comparison between two ostensibly d i s s i m i l a r phenomena; an i m p l i c i t comparison between two unlike e n t i t i e s . A l l of the following are considered variations of, or extended forms of, a basic metaphor. 2. Simile An e x p l i c i t comparison signalled by the words " l i k e " or "as." 3. Allegory An extended metaphor, for example John Bunyon's Pilgrim's Progress, wherein man's method of earning Chr i s t i a n salvation is compared to a road on which he journeys, and the comparison is maintained to such an extent that i t becomes the central s t r u c t u r a l p r i n c i p l e of the entire work; an extended metaphor that sustains and elaborates a basic analogy. 4. Analogy (from the Greek ana logon, "according to ratio") A s i m i l a r i t y in proportional rel a t i o n s h i p s . Plato employed a functional analogy when he argued that the Idea of the Good makes knowledge possible in the i n t e l l i g i b l e world just as the sun makes vi s i o n possible in the perceptual world. Here a relationship not yet understood is analogous to one already f a m i l i a r . 5. Pe r s o n i f i c a t i o n A t t r i b u t i n g human q u a l i t i e s to a nonhuman being or object 6. Irony A discrepancy between a speaker's l i t e r a l statement and his attitude or intent 7. Hyperbole Overstatement or exaggeration 8. Metonymy and Understatement (Synecdoche) Substituting one word for another which i t suggests or to which i t is in some way related - as part to whole, for example " A l l hands on deck" 55 Appendix B P r a c t i c u m T r a i n i n g P r o c e d u r e , O b j e c t i v e s , and T r a i n i n g M a t e r i a l s 56 Training Procedure Ss attended a four-week t r a i n i n g program (26 hours) in c r i s i s intervention theory and practice u t i l i z i n g stage-specific c r i s i s intervention models ( i n i t i a l contact/acceptance, problem i d e n t i f i c a t i o n , a l t e r n a t i v e s , termination). Material covered included: an investigation of c r i s i s intervention p r i n c i p l e s ; analysis of c r i s i s states; c r i s i s intervention counselling modalities; c r i s i s management techniques (depression, suicide, traumatic incidents); an overview of the history and development of c r i s i s intervention, and contemporary handling strategies (Caplan, 1964; H i l l , 1958; Jacobson, S t r i c k l e r , Martin, & Morley, 1968; Lindemann, 1944; McGee, 1974; Rapaport, 1962; Sachs, 1968; Sifneos, 1980 ; Smith, 1978; Shneidman, 1976; Lazarus (1971/1976). The four-week t r a i n i n g program was structured as follows: Week 1- (8 hours): review of c r i s i s intervention p r i n c i p l e s , theory, issues ( c o n f i d e n t i a l i t y , types of si t u a t i o n s , mobilization of community resources); p r a c t i c a l application of theory (role-taking, rehearsal, using t y p i c a l situations as material; demonstrations by tr a i n e r s ; introduction of debriefing procedure; Week 2 and 3- (8 hours): two four-hour monitoring sessions (Ss observe actual c l i e n t sessions in progress); a l l monitored sessions debriefed with Ss, discussed and analyzed; Week 4- (10 hours): part of week in classroom ( s p e c i f i c situations presented to Ss who in turn alternated between the role of " c l i e n t " and "counsellor"); l a s t f i v e hours Ss worked with actual c l i e n t s under direct supervision of a tra i n e r ; debriefing process applied in a l l practice and actual counselling sessions. As part of the i n i t i a l t r a i n i n g Ss practiced interviewing s k i l l s using role-play and video-playback techniques. A l l Ss completed 12 structured role-play practice sessions (mean: 24 min. per session) and each session was followed by a case presentation given by the S (Mean: 19:36 min. per case presentation). Case presentations followed the debriefing format developed by Stone (1985) and outlined in Appendix C. Ss presented their case (based on the role-play practice material) while the other group members and one of the trainers observed. Following a br i e f presentation by the S questions and comments were encouraged in order to reduce and 57 c l a r i f y p o i n t s of c o n f u s i o n , i n t r o d u c e r e l e v a n t c o u n s e l l i n g themes, and add a number of p e r s p e c t i v e s to the presented m a t e r i a l . Video-playback m a t e r i a l was presented i n 30% of the p r a c t i c e s e s s i o n s as a means of a r b i t r a t i n g d i s p u t e d m a t e r i a l and p r o v i d i n g a reminder when events that occurred d u r i n g the p r a c t i c e s e s s i o n could not be v i v i d l y r e c a l l e d by the group. Ss were a l s o r e q u i r e d to observe a minimum of 4 a c t u a l c o u n s e l l i n g s e s s i o n s with one of the t r a i n e r s s e r v i n g as the c o u n s e l l o r . T h i s o b s e r v a t i o n a l l e a r n i n g served as a way to get the Ss one-step c l o s e r to the a c t u a l c o u n s e l l i n g c o n t e x t . I t a l s o served as a means f o r the Ss to i n t e g r a t e a v a r i e t y of the techniques and concepts that were covered i n the p r a c t i c e s e s s i o n s . Upon completion of the four week t r a i n i n g Ss were randomly assigned to one of 3 groups. Group #1 c o n s i s t e d of 2 females; group # 2 - 2 males; group # 3 - 3 males. Each of the three groups was assigned a 10 week c o u n s e l l i n g schedule (Figure 3) c o n s i s t i n g of a designated four-hour block per week du r i n g which Ss would be a v a i l a b l e to p r o v i d e telephone c r i s i s i n t e r v e n t i o n c o u n s e l l i n g . A l l c o u n s e l l i n g s e s s i o n s were s u p e r v i s e d by at l e a s t one t r a i n e r . 58 C r i s i s I n t e r v e n t i o n Program O b j e c t i v e s : The f o l l o w i n g program o b j e c t i v e s w i l l be met, over the next four weeks, using a combination of: t h e o r e t i c a l review, r e h e a r s a l and r o l e - t a k i n g ( i n c l u d i n g video p l a y - b a c k ) , o b s e r v a t i o n a l l e a r n i n g , p r i n t m a t e r i a l , c l a s s d i s c u s s i o n , and p r a c t i c u m s u p e r v i s i o n of c o u n s e l l o r - t r a i n e e c l i e n t case-work. 1) P a r t i c i p a n t s w i l l demonstrate the a b i l i t y to : i n a v a r i e t y of c r i s i s s i t u a t i o n s u t i l i z i n g a f o u r - s t a g e p a r a p r o f e s s i o n a l c r i s i s i n t e r v e n t i o n model. 2) The c o u n s e l l o r ' s r o l e w i l l be reviewed i n the context of the r e s p o n s i b i l i t i e s a s s o c i a t e d with c r i s i s i n t e r v e n t i o n and s u i c i d e p r e v e n t i o n c o u n s e l l i n g . 3 ) P a r t i c i p a n t s w i l l demonstrate an a b i l i t y to a c c u r a t e l y assess degree of s e v e r i t y of r i s k and generate i n t e r v e n t i o n s t r a t e g i e s f o r s u i c i d a l c l i e n t s . 4) A formal case d e b r i e f i n g method w i l l be i n t r o d u c e d and a p p l i e d throughout the e n t i r e practicum to ensure i n t e r v e n t i o n s are a p p r o p r i a t e , thorough, and i n t e g r a t i v e . a) b) c) i d e n t i f y assess i ntervene 59 C r i s i s I n t e r v e n t i o n Model * Stage I: Acceptance 1. r e f l e c t i o n of f e e l i n g s 2. congruency of a f f e c t / c o n t e n t 3 . demonstrated understanding of c l i e n t ' s f e e l i n g s t a t e Purpose: to e s t a b l i s h t r u s t , a sense of s a f e t y , and p e r m i s s i o n f o r the e x p r e s s i o n of thoughts and emotions Stage I I : C o n f l i c t I d e n t i f i c a t i o n 1. paraphrasing 2. open-ended q u e s t i o n s - "who, what, how, when..." 3 . probe response - combine open-ended q u e s t i o n s with paraphrasing (used f o r i s o l a t i n g and e x p l o r i n g s p e c i f i c content) Purpose: to reduce and c l a r i f y problem content; to s e p a r a t e immediate from long-term concerns Stage I I I : A l t e r n a t i v e s 1. i d e n t i f y p o s s i b l e a l t e r n a t i v e a c t i o n s to the s i t u a t i o n 2. review the p o s s i b l e consequences of contending a l t e r n a t i v e s 3 . review the c l i e n t ' s f e e l i n g s a s s o c i a t e d with each contending a l t e r n a t i v e Purpose: i d e n t i f y and separate urgent from non-urgent s t r e s s o r s ; develop a p p r o p r i a t e i n t e r v e n t i o n s ; ( i t may be u s e f u l to examine the worst p o s s i b l e outcome i f no i n t e r v e n t i o n were i n t r o d u c e d - t h i s may help rank order p r i o r i t i e s ) • M o d i f i e d from Smith (1978), Caplan (1964), and Rapaport (1962) 60 Stage IV: Termination 1. does the c l i e n t have an accurate, simple view of the problem s i t u a t i o n and alternate courses of action? 2. does the c l i e n t have an accurate perception of what steps are to be taken? (sequence); how these steps are to be implemented? what resources are required for e f f e c t i v e implementation? 3. does the c l i e n t have a back-up plan in the event of an obstacle or return to a c r i s i s state? Purpose: to end the session in an integrated manner allowing the c l i e n t to i n i t i a t e the action discussed and have a good understanding of what to do i f the c r i s i s state returns or erupts Goals of C r i s i s Intervention (Stone, 1985) There are Two primary goals: a) reduce psychological pain, and b) help the c l i e n t with the change or adjustment process. C r i s i s counselling is an attempt to f a c i l i t a t e hopefulness within c l i e n t s and to help c l i e n t s acquire a r e a l i s t i c sense of control over their present and future. C r i s i s Conceptualization It may be seen from the diagram on the following page, that as a person encounters a c r i s i s (or f l a s h p o i n t ) , and resources are mobilized unsuccessfully, the l e v e l of competence and confidence may begin to erode. As the l i n e decreases and the level of disorganization i n t e n s i f i e s , the person may experience helplessness, hopelessness, and- at some point i f resources are continually mobilized unsuccessfully- anxiety may become an a l l consuming f e e l i n g and command the w i l l . The right side of the diagram represents possible outcomes following intervention. Whether the outcome is better than the p r e - c r i s i s state, the same, or worse depends to a large extent on the q u a l i t y and timing of the intervention, the resources available in the community, and the w i l l (motivation) of the c l i e n t . The intervention strategy is to d i f f e r e n t i a t e between p r e - c r i s i s and current ( c r i s i s ) functioning (cognitive, emotional, physical, behavioral, interpersonal), and address the differences. The goal is to f a c i l i t a t e a) physical survival in the aftermath of the c r i s i s ; 61 Better Functioning Crisis Pre Crisis lerei Reduced Functioning Disorganize tion Crisis Conceptualization b) e x p r e s s i o n of f e e l i n g s a s s o c i a t e d with the c r i s i s ; c) c o g n i t i v e mastery of the e n t i r e e x p e r i e n c e , and d) b e h a v i o r a l and i n t e r p e r s o n a l adjustment, r e q u i r e d f o r present and f u t u r e l i v i n g . D e f i n i n g a C r i s i s A c r i s i s r e p r e s e n t s any s i t u a t i o n that can be p e r c e i v e d as a t h r e a t , a l o s s , or a c h a l l e n g e coupled with the f o l l o w i n g three f a c t o r s : a) a hazardous event; b) a t h r e a t to l i f e g o a l s , and c) an i n a b i l i t y to respond with adequate coping mechanisms (Rapaport, 1962). C r i s i s r e f e r s to the person's emotional response to the event r a t h e r to the event i t s e l f . Types of C r i s i s I. Developmental c r i s e s - b i r t h , c h i l d h o o d , adolescence, adulthood, o l d age, ( E r i k s o n , 1956). I I . A c c i d e n t a l c r i s e s - p e r i o d s of p s y c h o l o g i c a l and b e h a v i o r a l upset p r e c i p i t a t e d by l i f e hazards i n v o l v i n g s i g n i f i c a n t l o s s e s such as i l l n e s s , death, (Caplan, 1964). Traumatic i n c i d e n t s would f a l l i n t o t h i s category (a trauma would be d e s c r i b e d as an event that f a l l s o u t s i d e of the usual realm of human expe r i e n c e : being robbed or a s s a u l t e d , s e r i o u s a c c i d e n t , n a t u r a l d i s a s t e r s such as f l o o d s , earthquake, e t c , ) . I I I . C r i s e s that r e s u l t from r o l e change or other a l t e r a t i o n s i n i n t e r p e r s o n a l b e h a v i o r : unemployment, s e p a r a t i o n and d i v o r c e , marriage, job promotion, school g r a d u a t i o n , or the breakdown of p r e v i o u s l y w e l l f u n c t i o n i n g coping s t r a t e g i e s (Jacobson, et a l 1968). 63 Stage-Related Questions (Stone, 1985) The four stages of c r i s i s intervention are acceptance, c o n f l i c t i d e n t i f i c a t i o n , a l t e r n a t i v e s , and termination. Use of adequate question techniques are central to u t i l i z i n g the four-stage model e f f e c t i v e l y . The questions on the following pages are designed to as s i s t you in developing d i f f e r e n t aspects of the intervention process. Some of the questions are very simple and obvious, for example "How are you feeling?" Some are more subtle and complex, for example "Can you describe yourself a l i t t l e b i t as you were before the c r i s i s and compare i t with how you are now?" Each question is designed to enable you to accomplish something s p e c i f i c . In the f i r s t example (above) the question helps create a climate of openness, t r u s t , and demonstrated acceptance -elements necessary for a constructive beginning to the intervention. In the second example the question is used at a more advanced stage and is designed to accomplish something very d i f f e r e n t : to reduce and c l a r i f y confusion, to discover i f there is an actual difference between pre and post c r i s i s functioning, and i f there i s , to discover what the differences are so that appropriate resources may be suggested. Each intervention is d i f f e r e n t so the questions you use to di r e c t and manage the intervention w i l l vary widely. The following pages contain a brief series of intervention questions which have been proven e f f e c t i v e in practi c e . The questions are grouped according to stages I through IV of the c r i s i s intervention model. They are suggested as a guideline. Find those which su i t your st y l e best and add to the l i s t as you hear or think of questions that work well for you. I. Acceptance: (developing trust) Openi ng 1. How are you feeling? 2. Where would you l i k e to start? 3. What have you been thinking about since we last talked? 64 4. How have you been f e e l i n g s i n c e we l a s t t a l k e d ? 5. What were you t h i n k i n g about r i g h t before we s t a r t e d t a l k i n g ? 6. What would be most important to d i s c u s s ? 7. Give me one word that best d e s c r i b e s how you are f e e l i n g at t h i s moment. . . Now put that word i n t o a sentence. (This technique i s best f o r people who are having r e a l d i f f i c u l t y g e t t i n g s t a r t e d , or who are " t o n g u e - t i e d " ) . Problem 1. Describe the problem i n your own words. 2. What worries you most about the s i t u a t i o n ? 3. What would you c o n s i d e r the main o b s t a c l e ? 4. Give me a quick summary of the problem as you see i t . Descr i p t i o n 1. What was i t l i k e ? 2. Say more about t h a t . 3. What happened? Where? When? 4. Who were you with? 5. Describe how the s i t u a t i o n developed Percept ion 1. What meaning does the s i t u a t i o n have f o r you? 2. Say something about your p o i n t of view? 3. What do you thi n k ? 4. What's your best guess about what i s going on? 5. How do you thin k other key people see t h i s s i t u a t i o n ? Is that the same or d i f f e r e n t from the meaning the s i t u a t i o n has f o r you? Background 1. What l e d up to the event? 2. What have you t r i e d so f a r ? 3. Has a s i m i l a r s i t u a t i o n occurred before? If so, how d i d you handle i t then? 4. What do you u s u a l l y do when you f i n d y o u r s e l f i n a c o n f l i c t or d i s t r e s s s i t u a t i o n ? Example 1. Can you g i v e me an example? 65 2. Can y o u t h i n k o f an a n a l o g y o r m e t a p h o r t h a t w o u l d d e s c r i b e y o u r s i t u a t i o n ? ( i m a g e , add on T . V . , j o k e , w e l l - k n o w n f i g u r e f r o m l i t e r a t u r e , e t c . ) . E x t e n s i o n 1. S a y a l i t t l e more a b o u t t h a t . 2. A n y t h i n g e l s e ? 3 . What e l s e do I need t o know a b o u t t h i s s i t u a t i o n ? 4. What e l s e c a n you add t o t h a t ? C o n f l i c t I d e n t i f i c a t i o n : ( e x p l o r a t i o n ) A p p r a i s a l 1. How do y o u f e e l a b o u t i t ? 2 How d o e s i t l o o k t o y o u 3 What do y o u make o f i t ? 4 What do y o u t h i n k i s b e s t ? E x p l o r a t i o n 1. L e t ' s e x p l o r e t h a t some more 2. A r e t h e r e any more a n g l e s y o u c a n t h i n k o f ? 3 . How d o e s t h i s a f f e c t y o u ? 4. How do y o u f i t i n t o t h i s p i c t u r e ? C l a r i f i c a t i o n 1. Any a s p e c t s o f t h i s t h a t d o n ' t make s e n s e t o y o u ? 2. What seems t o c o n f u s e y o u ? 3 . C a n y o u e x p l a i n what y o u meant b y . . . ? 4. In what way? H y p o t h e s i z i n g 1. What w o u l d be y o u r i d e a o f a s a t i s f a c t o r y o u t c o m e t o t h i s s i t u a t i o n ? 2. How much c o n t r o l do y o u h a v e o v e r t h e o u t c o m e ? 3 . What f a c t o r s a r e o u t s i d e y o u r c o n t r o l ? 4. What w o u l d y o u a d v i s e a f r i e n d who came t o y o u w i t h a s i m i l a r p r o b l e m ? ( p e r s p e c t i v e o f d e t a c h e d o b j e c t i v i t y ) 5. S p e c u l a t e a l i t t l e on what c h o i c e s y o u h a v e ? 66 I I I . A l t e r n a t i v e s ; ( i n t e g r a t i o n and l i n k i n g ) I n t e g r a t i o n 1. 2. 3. 4. How do you e x p l a i n t h i s to y o u r s e l f ? What do you think i s best? How do you r e l a t e t h i s to your other ideas? How would you p u l l a l l t h i s together? Review 1. If you had choice i n t h i s s i t u a t i o n what would you do? 2. If the same s i t u a t i o n came up again how would you respond? 3. Review what meaning t h i s event has f o r you p e r s o n a l l y , p r o f e s s i o n a l l y ; what areas of f u n c t i o n i n g are hardest h i t ? (eg. p s y c h o l o g i c a l , emotional, c o g n i t i v e , p h y s i c a l , i nterpersona1) E v a l u a t i on 1. What do you t h i n k about the idea...? 2. According to your standards how does i t look? 3. How would you ev a l u a t e a l l t h i s ? 4. What are the p o s i t i v e aspects that we have di scussed? 5. What are the elements that are beyond your c o n t r o l ? A l t e r n a t i v e s 1. What are the p o s s i b i l i t i e s : i n t e r n a l / e x t e r n a l resources? 2. What i f t h i n g s don't work out the way you hope? 3. What are the p o s s i b l e f a l l - b a c k p o s i t i o n s ? 4. What w i l l you do when we f i n i s h our se s s i o n ? 5. What are your plans f o r the r e s t of today? t o n i g h t ? tomorrow? the up-coming weekend? R e l a t i o n 1. How do the ideas we d i s c u s s e d f i t with your other plans? 67 2. How does t h i s a f f e c t your work? 3. How does what we d i s c u s s e d s t a c k up w i t h your s e l f - p i c t u r e ? 4. What i s the r e l a t i o n s h i p between t h e s e t h i n g s ? P e r s p e c t i v e 1. What a r e your e v e n t u a l o b j e c t i v e s ? s h o r t - t e r m o b j e c t i v e s ? 2. What would you l i k e t o be d o i n g f i v e y e a r s from now? 3. What are your l o n g - r a n g e p r o s p e c t s ? What a c t i o n / r e s o u r c e s do you need to i n i t i a t e i n or d e r t o t a k e a f i r s t s t e p towards t h e s e o b j e c t i v e s ? IV. T e r m i n a t i o n : ( c o n c l u s i o n of i n t e r v e n t i o n and a c t i o n s t a g e ) P l a n n i n g 1. How do you propose t o improve the s i t u a t i o n ? 2. What do you want to do? 3. Do you have enough i n f o r m a t i o n t o make an inf o r m e d d e c i s i o n ? 4. How would you rank o r d e r the demands you need to respond t o from most t o l e a s t u r g e n t ? I n f o r m a t i o n 1. What i n f o r m a t i o n / r e s o u r c e s do you need b e f o r e you d e c i d e ? 2. What do you know about your s i t u a t i o n now? 3. How w i l l you f i n d out more about i t ? 4. What k i n d of image or p i c t u r e do you have r i g h t now? Imp l e m e n t a t i o n 1. What w i l l your f i r s t s t e p be? 2. How w i l l you t a c k l e t h i s ? 3. Does your proposed f i r s t s t e p meet your r a n k - o r d e r e d " u r g e n t " o b j e c t i v e s ? 4. Put down on a p i e c e of paper t h e one t h i n g you a r e a v o i d i n g most r i g h t now. Can we pursue t h a t f o r a minute? 68 Act ion 1. What do you want to do about i t ? 2. Where do you go from here? 3. Review your basic plan 4 . Review your s t a r t i n g point 5 . What is your strategy in the event you get stuck? Summary 1. How would you describe our session? 2. How would you describe our session to someone else? 3. How are you fe e l i n g right now? 69 C r i s i s Versus Long-Term Counselling (Faberow, 1977) I. Goals C r i s i s Long-Term Reconstitute Strong emotional support; cognitive mastery (may i n -clude i n t e l l e c t u a l i n s i g h t ) ; Establish sense of hope for future; resolution of der-i v a t i v e c o n f l i c t s Rehabi1i tate Emotional a f f e c t i v e mastery (cognitive-emotional integrated i ns ight) Restructuring of personality; Resolution of basic conf1i cts 11. C h a r a c t e r i s t i c s Temporal aspects Short-term (1-6 contacts) Pressure Pressure for quick resolution Information Minimal amount of information available P r e c i p i t a t i n g Event Usually a single event . Presenting Symptoms Disorganization, imm-ob i l a z a t i o n , chaos Telephone Used maximally III . Counselling Aspects Long-term (6 mos +) No pressure-1iesurly approach Optimal amount of info available Often no one event-build-up Discomfort, c u r i o s i -ty, generalized f e e l i n g of unhappi-ness, inadequecy Avoided, i f possible A c t i v i t y High Authority D i r e c t i v e , strongly supporti ve Others May involve as many others as possible M i n i ma 1 Does not lead, may or may not suggest May or may not-often a one-to-one relationship 70 Focus Sharp, i n c i s i v e , c l e a r l y e x c l u s i v e Resources Used and i n c l u d e d P l a n P l a n i s a c t i o n o r i e n t e d I n d e c i s i v e - not always p a r t i c u l a r l y c l e a r ; approach o f t e n s u b t l e and s u g g e s t i v e May or may not be used C o n t e m p l a t i v e l y o r -i e n t e d 7 1 Evaluating Motivation for Change (Sifneos, 1980) Look for or help develop the following when f a c i l i t a t i n g c l i e n t change: 1. C l i e n t ' s a b i l i t y to recognize d i f f i c u l t i e s are psychological in nature 2. Honesty in se l f - r e p o r t i n g 3. Willingness to pa r t i c i p a t e a c t i v e l y in discussion/action r e l a t i n g to the si t u a t i o n 4 . Introspection and c u r i o s i t y about the s e l f 5. Desire to change and not just expect symptom r e l i e f 6. R e a l i s t i c expectations of outcome 7. Willingness to make a reasonable and tangible s a c r i f i c e (must be p a r t i c i p a t i v e ) Change and Adjustment (Stone, 1985) Meaningful change occurs most often when the following factors are present: 1. A therapeutic a l l i a n c e is created (client-counsellor relationship) 2. What the counsellor does and says is of relevance to the c l i e n t (perceived task relevance) 3. C l i e n t motivation is v e r i f i a b l y high 4 . Resources must be available or found which w i l l enable the c l i e n t to follow through on appropriate suggestions Summary 1. Avoid getting caught in a premature analysis 2. Find out what meaning the presenting problem has for the c l i e n t 3. Make a guess or ask "What is most needed now?" 72 4. Think of the c l i e n t as an i n d i v i d u a l who i s unique but a l s o p a r t of a l a r g e r system or con t e x t . A review of the l a r g e r context may lead to a more thorough understanding of the p r e s e n t i n g problem and may r e v e a l p e r s o n a l or e x t e r n a l resources that the c l i e n t was not f u l l y aware o f . 5 . M a i n t a i n the r o l e of detached observer (an i n t e r e s t e d person who i s i n v o l v e d , s u p p o r t i v e , h e l p f u l - but one who avoids g e t t i n g caught i n the c l i e n t ' s i n t e r p e r s o n a l p o l i t i c s ) . 6. Remember, c r i s i s c o u n s e l l i n g i s an attempt to f a c i l i t a t e h opefulness w i t h i n c l i e n t s and to help them grasp a r e a l i s t i c sense of c o n t r o l over t h e i r d e s t i n y . 7 3 Depression And Suicide: Introduction The most recently published S t a t i s t i c s Canada Report (1985) indicates that suicide claimed 3259 l i v e s (2566 males, 693 females). It is generally agreed that for every completed suicide there are about 100 suicide attempts. For every attempt or completion there are at least 10 other people d i r e c t l y effected who could be considered survivors (friends, co-workers, family). Expressed as a rough formula (3259 X 100 X 10), there are over 3 m i l l i o n Canadians more or less d i r e c t l y effected by suicide each year. The following section is meant to a s s i s t practicum students for the task of i d e n t i f y i n g , assessing, and intervening in situations where s u i c i d a l elements are present. The goal is to provide strong support and supervision u n t i l the c l i e n t can be seen by the appropriate mental/medical health care professionals. It is important to remember that most s u i c i d a l people do not want to be dead: more accurately, they just want to stop l i v i n g in the manner that is causing so much pain. This d i s t i n c t i o n may be c r i t i c a l in helping the s u i c i d a l person r e a l i z e that there i s almost always hope and help. 74 Assessment of Severity of Depression 1) Look for p r e c i p i t a t i n g event 2) Duration, frequency, and intensity of current s i t u a t i o n : a) history of previous episodes; how handled? usual coping style? b) history of previous h o s p i t a l i z a t i o n ; consent form signed i f c l i e n t wants counsellor in the role of case management 3) B i o l o g i c a l Signs: a) easy f a t i g a b i l i t y b) disturbed sleep (usually less) c) disturbed appetite (usually less) d) weight change (usually less) e) v a r i a t i o n in mood (feel worse in A.M.) f) psychomotor disturbance (agitated or extremely lethargic) g) decreased sex drive 4) Psychological Signs: a) loss of interest in usual a c t i v i t i e s b) decreased g r a t i f i c a t i o n c) sad mood d) anxiety e) negative thinking (helpless, hopeless, worthless, etc) f) loss of a b i l i t y to concentrate or excessively dwelling on problem g) slowed thinking; constricted thinking 5) Social Signs: a) impaired performance b) withdrawl from people c) decreased free-time a c t i v i t y d) i r r i t a b i l i t y e) short-temper f) increased/decreased interpersonal c o n f l i c t s g) loss of sense of humour h) marked change from p r e - c r i s i s l e v e l of communications (usually a decrease in frequency and quality) 75 6) A f f e c t : C l i e n t ' s f e e l i n g state: notice body language, voice tone; note unfinished sentences 7) Level of Functioning: Has i t changed? (work, family, general responsibi-i t i e s , s o c i a l , educational, interpersonal, etc.); What l e v e l before crisis/depression?; appearance: poor grooming, disheveled? lack of concern may indicate deeper depression 8) Cogn i t i ons: Are d i s t o r t i o n s present? i f so to what extent and what kind? 9) Suicide Assessment: If appropriate (usually a good idea even i f only to rule out this area. See Suicide Assessment Format) 76 Techniques for Depressed Clients 1. Self-image improvement: a) p o s i t i v e imagery (client-generated) b) p o s i t i v e affirmation (written, spoken, displayed) 2 . Cognitive Restructuring: Emotions a) challenge apparent malcognitions b) challenge u n r e a l i s t i c goals/objectives c) search for p a r t i c u l a r thoughts that trigger or perpetuate depressed feelings a) i f c l i e n t repressing/suppressing encourage expression and v e n t i l a t i o n b) i f emotion is too overwhelming use d i s -tancing, fantasy, or simply acknowledge and agree to defer c) suggest c l i e n t keep a journal for written v e n t i l a t i o n , focusing f e e l i n g s , and d i f f -e rentiation of thoughts and feelings 4. Environmental Restructuring: a) can depressing factor be removed? b) can c l i e n t leave depressing environment? c) can c l i e n t cope more e f f e c t i v e l y with present environment? d) what support is available? ( s o c i a l , family, community, professional) 5. Values and Goals Act i vi t i es: a) c l a r i f y p r i o r i t i e s b) one day/one year exercise a) find out what is required and develop a c l i e n t - c o n t r a c t b) a s s i s t c l i e n t in creating daily/weekly schedule i f appropriate 77 7. S p i r i t u a l : (reason f o r e x i s t e n c e ; meaning i n l i f e ) 8. R e f e r r a l : a) e x p l o r e c l i e n t ' s f a i t h i n God, s o u l , or source of inner s t r e n g t h a) c o u n s e l l o r c o l l a b o r a t i o n and teamwork approach; c o n s u l t a t i o n with other mental/ medical h e a l t h care p r o f e s s i o n a l s 9. A c t i o n Steps: a) does the i n t e r v e n t i o n meet the immediate demands? does the i n t e r v e n t i o n safeguard a g a i n s t the worst p o s s i b l e outcome? b) i s the c l i e n t capable of e n a c t i n g the course of a c t i o n ? c) maintain phone a v a i l a b i l i t y ; monitor p r o g r e s s ; use case management technique with others i n v o l v e d (when a p p r o p r i a t e ) 78 Indicators of Suicide 1. Previous attempt(s) 2. I n a b i l i t y to communicate 3. Disorganization: confusion, delusions, ha l l u c i n a t i o n s , loss of contact with r e a l i t y , d i s o r i e n t a t i o n 4. Preoccupation with f i n a l arrangements; leave-taking behavi or 5. Severe or prolonged depression 6. Changes in personality or behavior 7. Accident proneness; misadventure 8. Disorganized or breakdown in family structure 9. Unwished-for aloneness; extended, unresolved loneliness 10. Poor i m p u l s i v i t y - r e f l e c t i v i t y control; poor judgement 11. Helplessness, hopelessness 12. Frustrated dependency 13. Loss of sense of control; frequent a n g e r , i r r i t a b i 1 i t y , h o s t i l i t y , violence, apathy 14. Sense of powerlessness (real or imagined) 79 Suicide Assessment Model (Golden, 1977) According to this model suicide potential is evaluated in the following six areas: 1. f e e l i n g tone 2. s u i c i d a l planning 3. related history 4. strengths 5. overal l assessment 6. d i s p o s i t i o n and treatment plan 1. Feeling Tone: a) pattern of communication- does the person respond to questions easily? does the person seem relieved to be talking about emotional problems? are traumatic incidents talked about blandly? is the person interested in the interview? i s the communication d i r e c t , relevant, rational? b) body language- is eye contact good? does the person appear to be agitated, tense,? 2. Suicide Plan a) l e t h a l i t y - i e . , a gun Vs. a bottle of a s p i r i n b) a v a i l a b i l i t y of means- i e . , access c) s p e c i f i c i t y of plan- i e . , a recently completed w i l l or a person giving away valued possessions Vs. an off-hand statement to the effect "I think I ' l l jump off the bridge somet ime." 3. History a) p r e c i p i t a t i n g c r i s i s - death in family, recent loss (job, r e l a t i o n s h i p , etc) b) mental status- how has the person handled s t r e s s f u l s ituations in the past? attempt to assess what the person is capable of doing vs. what he is ac t u a l l y doing; is the c l i e n t getting support ? (friends, family, co-workers, professional community); is the c l i e n t impulsive? what is the person's l e v e l for f r u s t r a t i o n tolerance? is the c l i e n t able to express negative feelings verbally or is there more of a tendency to act out? c) medical status- are there any 1ife-threatening i l l n e s s e s present? have any major su r g i c a l procedures been recommended for the immediate future (hysterectomy, heart, etc) ? 80 d) f i n a n c i a l status- what, i f any, f i n a n c i a l pressures are present now? future? 4. Strengths a) r e a l i s t i c plans for the future- i e . , job, family, educational b) feelings of pride and accomplishment- degree of pride in home, job, etc. c) s t a b i l i t y of l i f e s t y l e - degree of s a t i s f a c t i o n with present l i f e s t y l e ; p o s s i b i l i t y and scope for change d) other dimensions in this category might include verbal s k i l l s , insightfulness, the c l i e n t ' s interest in others, i n t e l l i g e n c e , l e v e l of a c t i v i t y , energy l e v e l , and so on 5. Overall Assessment Based on the previous four points is the ris k high, moderate, low, or no risk? 6. Disposition and Treatment Plan Based on your assessment should the c l i e n t be referred for counselling, receive strong, immediate support combined with counselling,; be referred for further professional assessment; followed by phone and put in contact with appropriate community resources; does the si t u a t i o n warrant the dispatch of an emergency service (ambulance, inhalator, emergency counselling team, e t c . ) ; what role can family members, friends, interested others play in the di s p o s i t i o n and resolution of the situation? 8 1 A Psychological Theory of Suicide (Shneidman, 1976) 1. General Self Destructiveness (Inimicality) Self-destructive "thrust" precipitated by: a) physical health b) rejection c) inner feelings of f a i l u r e d) pain 2. Disturbance (Perturbation) a) how disturbed, shook-up, mentally upset? b) ranges from t o t a l l y s i l e n t , withdrawn or hyperactive violence to equanimity and peace of mind c) negative emotional states: - p i t i f u l forlornness, deprivation, d i s t r e s s , and gri e f -blaming others, anger, hate, physical aggressiveness -self-blame, remorse, g u i l t , depression, need for punishment -affectlessness, withdrawal that includes disgust, bitterness, sardonic humor 3. Constriction ( i s o l a t i o n of the mind's content) a) increased c o n s t r i c t i o n of i n t e l l e c t u a l focus b) c o n s t r i c t i o n of memory or associations c) tunnel v i s i o n d) dichotomous thinking 4. Cessation a) death, stopping, eternal sleep (the f i n a l stopping of consciousness) b) the insight that "I can be out of i t . I can put an end to s u f f e r i n g ; I can solve this mess; I can get even" A Psychological Theory of Suicide: Definitions Like an explosion, an unexpected suicide i s thought of as a combination of three main ingredients (general self-destructiveness, disturbance, and constriction) and the presence of an i g n i t i n g spark (cessation). Shneidman (1976) uses dynamite as a model: a combination of n i t r o g l y c e r i n e , saltpeter, a carbonaceous material (charcoal). The explosion i s sparked by the application of heat. 82 General Self-Destructiveness The "thrust" could be a sudden, intense increase in psychological or physical pain that goes beyond the c l i e n t ' s a b i l i t y to cope (eg., a severe loss or strong r e j e c t i o n ) . It might also be a build-up of smaller events such as a penchant for complicating everything, "messing everything up," or continuous, unremitting arguing. Intervent i on 1. the s u i c i d a l person needs to understand that his sufferings are appreciated 2. acknowledgment, reassurance and support are combined with p r a c t i c a l help 3. p r a c t i c a l help in this type of s i t u a t i o n means coordinating a c t i v i t y ; staying with the c l i e n t ; getting the person's permission to c a l l a family member, fr i e n d , co-worker, physician-; plan strategy for getting the c l i e n t to a professional or agency where a thorough assessment and treatment plan can be i n i t i a t e d 4. the c r i s i s intervention role may take the form of a support role in consultation with other health care professionals, co-workers, and family 83 Goal S e t t i n g For C r i s i s I n t e r v e n t i o n (Stone, 1985) D e f i n i t i o n : a goal i s a b e h a v i o r a l accomplishment that c o n t r i b u t e s to managing a problem or some pa r t of i t . Goal S e t t i n g : C h a r a c t e r i s t i c s Goals have the f o l l o w i n g c h a r a c t e r i s t i c s : 1) c l e a r and s p e c i f i c 2) measurable and v e r i f i a b l e 3) r e a l i s t i c : i e . , i n r e l a t i o n to the i n d i v i d u a l s a b i l i t y , r e s o u r c e s , env-ironmental c o n d i t i o n s , c o s t s , e t c . 4) they must be adequate ( c o n t r i b u t e ) 5) congruent with person's values 6) set i n a reasonable time frame Goal S e t t i n g : Functions Goals serve 3 important f u n c t i o n s i n c r i s i s management 1) c l e a r l y d e f i n e d goals r e f l e c t a c t u a l i n d -i v i d u a l concerns and t h e r e f o r e p r o v i d e meaningful d i r e c t i o n i n managing c r i s e s ; 2) p r o v i d e a b a s i s f o r s e l e c t i n g and us i n g p a r t i c u l a r c r i s i s management/conflict r e -du c t i o n s t r a t e g i e s ; 3) p r o v i d e a framework f o r e v a l u a t i n g the outcome Procedure For S e l e c t i n g and D e f i n i n g Goals 1) review broad c r i s i s management goals with a f r i e n d , f a m i l y member, p h y s i c i a n , c o u n s e l l o r , e t c . 2) decide on s p e c i f i c goals or changes d e s i r e d 3) ex p l o r e the f e a s i b i l i t y of the s t a t e d goals 4) together i d e n t i f y and examine any r i s k s a s s o c i a t e d with the goals 5) d i s c u s s i n d e t a i l the p o s s i b l e advantages of the goals 6) based on the i n f o r m a t i o n above, make one of the f o l l o w i n g d e c i s i o n s : a) to co n t i n u e the c o u n s e l l i n g process (steps 1 through 5) b) r e c o n s i d e r 1 or more of the goals ( i e . , t i m i n g , r e s o u r c e s , c o s t s , impact on o t h e r s , e t c . ) c) proceed to step 7 84 7) d e f i n e g o a l s , subgoals, l e v e l of change and a c t i o n plan 8) a f t e r the goals have been set and d e f i n e d and the implementing s t r a t e g i e s have been s e l e c t e d , a formal or i n f o r m a l c o n t r a c t may be n e g o t i a t e d . The advantages of t h i s type of c o n t r a c t are: a) i n c r e a s e s the chances of r e s e a r c h i n g and a c t i v a t i n g a l l r e q u i r e d support (people, programs, dates, etc.) b) emphasizes the importance of a c t i v e p a r t i c i p a t i o n c) the c o n t r a c t i s the b a s i c l i n k between the s t r a t e g i e s s e l e c t e d and the c o n c r e t e c r i s i s management goals d) promotes commitment e) prepares the person m e n t a l l y and e m o t i o n a l l y f o r whatever a c t i o n w i l l f o l l o w f) promotes the stance that the person i s i n charge of events and b u i l d s a p o s i t i v e s e l f - i m a g e g) p r o v i d e s a focus f o r expending energy p u r p o s e f u l l y 9) generate balanced goals when p o s s i b l e : -phys i c a l -emotional - p s y c h o l o g i c a l - i n t e l l e c t u a l - s p i r i t u a l (meaning i n l i f e ) - c a r e e r - f i n a n c i a l - s o c i a l - f a m i l y -community This process a s s i s t s i n g e n e r a t i n g goals that address: (1) the c l i e n t ' s purpose/meaning i n l i f e , p e r s o n a l growth, r e l a t i o n s h i p with o t h e r s , c a r e e r , f i n a n c i a l g o a l s ; (2) goals that are focused on pure r e c r e a t i o n (but at l e a s t h a l f of these should c o s t very l i t t l e money); and (3) goals focused on p h y s i c a l e x e r c i s e . 85 10) No-Suicide Contracts: This is an emergency goal-setting strategy designed to get a c l i e n t past a " c r i t i c a l moment." The contract may be either (1) verbal; (2) written, or (3) some combination of both. The desired outcome is to obtain a promise from the c l i e n t not to engage in any form of li f e - t h r e a t e n i n g behavior for a fixed period of time (eg., overnight, over the weekend, e t c . ) . No-suicide contracts usually contain a check-in clause (phone c a l l in the evening and again in the morning, e t c . ) , and generally are in force u n t i l the c l i e n t meets again with the counsellor, physician, etc., in person: eg., "I w i l l take no dangerous or 1ife-threatening action from now u n t i l our meeting at 0800 Monday morning." Purpose 1) buy time 2) allow the " c r i t i c a l moment" to pass and reduce adverse effects that may result from c l i e n t impuls i vi ty 3) constructively challenges the c l i e n t ' s sense of hopelessness 4) provides a dramatic demonstration of concern and support on behalf of the counsellor Rationale 1) people tend to keep promises that are requested and given in "good f a i t h " 2) demonstrates the c l i e n t s t i l l has influence and some measure of control (the a b i l i t y to make a meaningful contract) which tends to reduce feelings of hopelessness 3) demonstrates strong support and concern at a time when a c l i e n t may f e e l emotionally deadened 4) helps distinguish between the idea of wanting to be dead versus not wanting to l i v e in so much pain- t h i s is a c r u c i a l d i s t i n c t i o n and, to some extent- the c l i e n t ' s response to thi s question helps set the goals for the intervention. 86 Problem Solving (Stone, 1985) 1) Identify and c l e a r l y state problem(s) 2) What are the c l i e n t s current b e l i e f s about the problem. What does the problem represent (mean) to the c l i e n t . What is at stake?; What is the c l i e n t ' s current method for handling the i d e n t i f i e d problem?; Clearly outline the current method of handling : some of the strategies for handling may be out of awareness but nevertheless within the c l i e n t ' s c a p a b i l i t i e s . Examine what is_ being done compared with what could be done. 3) At what point does the current method of handling the problem break down? Clearly outline when, how, why this might happen. 4) Generate alternate methods of handling (hypotheses) that the c l i e n t thinks might be more adequate: Hypotheses: #1 #2 #3 #4 #5 5) Test Hypotheses: a) rehearsal (role-play: formal/ informal) b) adjust, modify, refine c) try in real s i t u a t i o n 6) Review With Counsellor: a) what were the results? did i t work? b) restate the problem updating i t with the new information gained from step #5c c) carry through steps #2 through #6 u n t i l the s i t u a t i o n improves d) i f progress is not s a t i s f a c t o r y ask c l i e n t to consider introducing other resources (family, friends, agencies co-workers, professionals). 87 Appendix C V e r b a l Case D e b r i e f i n g Format 88 Debriefing Format (Stone, 1985) 1. Tempo, Duration, Intensity a) pace, cadence b) ov e r a l l length of time c) emotional and cognitive i n t e n s i t y 2. Situation Analysis (content-affect) a) what was your role? b) examine emotions: expressed, suggested, hidden c) examine content: what happened, how, why? what were the the di r e c t causes of the event? the ind i r e c t causes?; what were the h i s t o r i c a l circumstances? what were the effects of the behavior/event? can these be determined accurately?; what was the exact sequence of events? what would result i f the sequence was altered?; how is the event and i t s impact altered by a s h i f t in perspective?; what individual actions had the greatest s i g n i f i c a n c e in the chain of events? d) consider: -behavi or -cognition -emot i ons -the c l i e n t ' s meaning; the counsellor's interpretation -motivation 3. Closure/Integration a) what discoveries were made? b) what was not discussed? anything unfinished or unacknowledged? c) opportunity to c r i t i q u e any aspect of the debriefing process Debriefing Process Overview  Introduction The purpose of the debriefing procedure i s to allow for an exploration of what happened during the counselling session, how i t happened, and to a r t i c u l a t e and analyze the counsellor's r o l e . The perspective taken by the trainer in f a c i l i t a t i n g the debriefing is one of support where the counsellor's constructive e f f o r t s are reviewed in d e t a i l . S i m i l a r l y , areas requiring improvement are reviewed and discussed in the context of the clie n t - c o u n s e l l o r 89 i n t e r a c t i o n . The counsellor-trainee is r e a l l y the "expert" on the session and consequently w i l l begin the debriefing with a review of the case. The supervisor/trainer w i l l make whatever observations are appropriate and guide the debriefing through the following sequence: 1. Tempo, Duration ,Intensity a) Pace/Cadence: It is important to examine the tempo of various aspects of the session. Were some stages hurried and others protracted? Was enough time allowed for the i n i t i a l acceptance and development of trust? If not, outline the consequences. Did the c l i e n t sound and appear to be given enough time to explore her ideas and feelings? How was the counsellor's voice-tone and body language? Was i t appropriate for the type of session? b) Overall length of time: The o v e r a l l duration of the session i s one important aspect of determining effectiveness. A well paced 30 minute session is preferable to a 45 minute session containing too much r e p e t i t i o n , "yes, buts" etc. If the session seemed too long an examination of "who was in c o n t r o l " may be productive. Was the session more-or-less a 50/50 e f f o r t ? Did the c l i e n t interrupt the counsellor and vice versa? Did the counsellor attempt to "rescue" the c l i e n t : what were the effects of this? If the session seemed too b r i e f , did the counsellor rush certain stages of the session? which ones and how? (examples); Did the counsellor seem uncomfortable managing certain aspects of the session (content/affect/particular s i t u a t i o n s ? ) ; Discuss any discrepancies between the observer (trainer) and the counsellor, eg., did i t sound to the trainer l i k e the c l i e n t wanted to talk about certain things that the counsellor did not notice or acknowledge? Keep in mind the constraints of time-management in t h i s s e t t i n g : the C r i s i s Centre handles about 2500 counselling requests per month, that is over 80 per day. Take the time required, but sessions should be tight and well managed according to the r e a l i t y of the demand. Unnecessary time spent with c l i e n t s should be discouraged. 2. Situation Analysis: Affect/Content a) What was the counsellor's r o l e : How does the counsellor perceive his role? Did the c l i e n t want a l i s t e n e r ? more support? more d i r e c t i o n or exploration? was there a match or a mismatch between what 90 the counsellor did and what was a c t u a l l y required? It is important the counsellor have a v i v i d idea of what his role a c t u a l l y was in r e l a t i o n to what i t might have been given the requirements of the c l i e n t . Examine the effects of any discrepancies, pauses, h e s i t a t i o n , silences, and a l t e r a t i o n s in a f f e c t , or incongruent s h i f t s in content, theme, and f e e l i n g states. b) Examine emotions (expressed, suggested, hidden): The expression of emotion is an integral part of c r i s i s counselling. Many emotions are, however, not e a s i l y expressed or acknowledged. A d i s p a r i t y between thought and f e e l i n g state may result from unexpressed or unaccepted emotions (this could, of course, apply to either the c l i e n t or the counsellor). Were any such d i s p a r i t i e s noted or addressed during the counselling session? Was adequate time, encouragement, and permission given to allow the expression of important f e e l i n g states? Were open-ended questions and probing s k i l l s appropriately timed and applied? was paraphrasing u t i l i z e d to a s s i s t in the c l a r i f i c a t i o n and reduction of confusion? c) Examine content of the c o u n s e l l o r - c l i e n t i n t e r a c t i o n : (what happened? why? how?) Much of the c r i s i s counselling session i s directed by the questions and prompts of the counsellor. Given this assumption, what was the c l i e n t ' s response to the question pattern in general and certain questions in p a r t i c u l a r ? Did the counsellor's approach f a c i l i t a t e or s t r a i n the communication? did i t lead to c l a r i f i c a t i o n , i n s ight, or discovery? Was the counsellor's role in the session more appropriately one of attentive l i s t e n e r ? (thus rendering a question/probe pattern unnecessary or inappropriate). Was the counsellor more active or passive in the session? Was the l e v e l of a c t i v i t y appropriate given the requirements of the session? If there was a d i s p a r i t y in l e v e l of a c t i v i t y vs. requirement what might account for this? (provide s p e c i f i c behavioral examples and actual dialogue from trainer's notes). Note the effect of the development of the session on the counsellor and the c l i e n t . Was either bored, frustrated, h o s t i l e , i n d i f f e r e n t ? What might account for these observed effects? Who was in control of the content? What was the r a t i o of counsellor questions to c l i e n t responses? Was the counsellor confused or lost? If the c l i e n t required focussing what did the counsellor say or do to provide direction? 91 3. C l o s u r e / I n t e g r a t i o n C l o s u r e of the d e b r i e f i n g s e s s i o n should i n c l u d e an overview of new l e a r n i n g d u r i n g the d e b r i e f i n g p r o c e s s . The t r a i n e r should take p a r t i c u l a r note to ensure t h e r e i s a r e p r e s e n t a t i v e balance of what the c o u n s e l l o r d i d w e l l and what needs to be improved. Review how the present s e s s i o n f i n d i n g s c o u l d apply to cases i n the f u t u r e c o n t a i n i n g s i m i l a r dynamic f e a t u r e s . Has the c o u n s e l l o r mastered the b a s i c p r i n c i p l e s f e a t u r e d i n the present d e b r i e f i n g ? I f not, there i s no reason to expect t r a n s f e r of t r a i n i n g to occur i n other cases with s i m i l a r requirements (homework and follow-up may be a p p r o p r i a t e i f c e r t a i n p r i n c i p l e s have not been mastered). Has the d e b r i e f i n g process been a f a i r , c o n s t r u c t i v e , v a l u a b l e experience f o r the c o u n s e l l o r ? 92 Appendix D Verbal Case Debriefing Case Presentation Example 9 3 Control Condition (A: Verbal Case Debriefing) Following each counselling session Ss were asked to make their case presentation by verbally reviewing the following points (with the assistance of any notes they happened to take during the session): 1) The c l i e n t ' s main concerns were: (Example: "The c l i e n t was primarily concerned with her 'confused' marital s i t u a t i o n , p a r t i c u l a r i l y her husband's spending habits. Concern was also suggested about her husbands 'careless' attitude towards herself and the children. She was f e a r f u l of physical violence." 2) The way the c l i e n t responded to me was: (Example: "Guarded at f i r s t . Seemed more t r u s t f u l after we discussed her f e e l i n g s - somewhere around 15 minutes into the session." 3) My role in t h i s session was: (Example: "To reduce and c l a r i f y confusion. To try to present something tangible that would allow her to hold out r e a l i s t i c hope that she could manage the s i t u a t i o n . To give her p r a c t i c a l help in the form of community resources." 4) How I f e l t about myself as counsellor: (Example: "I f e l t in charge most of the session. When she started crying I f e l t a b i t panicky then angry-I think that may have come through. For some reason her tears reminded me of how my father used to manipulate my mother with tears when he was drunk. " 5) Counselling goals: (Example: "I think this was a f i r s t step for her. I think she may have been testing the service to see what kind of a response she would get. Based on our session I believe she w i l l contact some of the resources suggested, but she i s going to need a l o t more support and encouragement to face her husband with her fears." 6) What new discoveries did you make as result of your  presentation?: (Example: "The idea that my own past family d i s t r e s s (father's drinking) surfaced during the session was a complete shock to me. I think i f that happens again I w i l l have a better way to handle i t . " 94 Appendix E Metaphoric-Thinking Exercise: MCD Preparation 95 Metaphoric-Thinking Exercise (Stone, 1986) Example: Nouns Abstract Concepts -apple -penci1 -Churchi11 -wall -confess i on -camera -brush -tree -plant - b a l l -family -French Quarter - t h i r s t r i d i c u l e percept ion friendship evi 1 defeat basic truth humani ty psychological confusion prejudice revenge Purpose: The purpose of the exercise is to allow students an opportunity to develop new understanding of a topic by associating apparently incompatible ideas and cr e a t i v e l y finding meaningful s i m i l a r i t i e s and differences represented in the form of a metaphoric drawing. Materials: 8 1/2 X 11 paper, f e l t pens, crayons, pencils F a c i l i t a t o r ' s Guidelines 1. F a c i l i t a t o r requests that counsellor-trainees spontaneously verbalize any nouns that come to mind. Each student should try to generate two or three nouns. 2. F a c i l i t a t o r records nouns on a chalkboard or f l i p - c h a r t (should be f u l l y v i s i b l e to a l l group members). 3. F a c i l i t a t o r requests students to spontaneously verbalize any abstract concepts that come to mind. Each student should try to generate two or three concepts. 4. F a c i l i t a t o r records abstract concepts next to noun l i s t . 5. Noun and abstract concept l i s t s should be generated by students in "brainstorming" fashion (no interruptions, no discussion of words; the nouns and abstract concepts are the "raw material" and should be generated "off the top," without regard to order or apparent i n t e l l i g i b i l i t y ) . 96 6. Working i n d i v i d u a l l y , the f a c i l i t a t o r requests students choose any one noun on the l i s t , match i t to any one abstract concept on the l i s t , and generate their impression of the corresponding image in the form of a metaphoric case drawing. The task is to think c r e a t i v e l y about how seemingly disparate ideas may lead to new understanding. For example, one student chose the noun "apple" and the abstract concept "revenge." The task is to answer the question "In what way might an apple contain some of the elements that would describe the concept "revenge?" In this case the student's drawing showed the seeds of the apple contaminating the rest of the apple (the "seeds of discontent"). The skin (outside) of the apple was healthy looking, but the i n t e r i o r was diseased. 7. Following the production of the drawing (5 minutes) the f a c i l i t a t o r requests each student present their work and, informally, discuss i t s unique meaning. Interpretations are made by the student. Following the students presentation (5 minutes) observers may make observations, ask questions, and extend and expand the metaphor contained in the drawing. 8. This procedure is followed u n t i l a l l students have presented a metaphoric drawing. 97 Appendix F MCD Case Presentation Example 98 E x p e r i m e n t a l C o n d i t i o n (B: M e t a p h o r i c Case Drawing Method) The m e t a p h o r i c case drawings r e q u i r e d f o u r c r i t e r i a : Example: (Below i s an a c t u a l d r awing by s t u d e n t of a " C l i e n t D r i v e n t o the W a l l . " The c o m p u t e r i z e d i n s e t shows the the c l i e n t who l a c k s "eyes to see or arms t o r e a c h the rope") 1) the c l i e n t ' s main c o n c e r n s : (Example: "The c l i e n t f e l t i s o l a t e d , p o w e r l e s s , and s u i c i d a l . She f e l t l i k e she was s t r a n d e d h a l f - w a y up a c l i f f : a f r a i d t o go up (the unknown) and a f r a i d t o go down (the d e n i z e n s of the d e e p ) . " 2) something r e p r e s e n t i n g the c l i e n t - c o u n s e l l o r r e l a t i o n s h i p : (Example: "She r e l a t e d t o me w i t h a g r e a t d e a l of c a u t i o n . My main i m p r e s s i o n was t h a t she was embedded i n a s i t u a t i o n too f r e i g h t e n i n g f o r her t o t u r n around and f a c e . I t h i n k she g e n u i n e l y wanted h e l p but j u s t c o u l d not r e a c h out t o grab the rope. I r e a l l y c o u l d n ' t make c o n t a c t . " 3 ) how t h e c o u n s e l l o r saw h i s / h e r r o l e : (Example: " I saw m y s e l f as a l a s t r e s o r t - a s i t u a t i o n where a genuine r e s c u e was r e q u i r e d . G i v e n the 1 i f e - t h r e a t e n i n g theme of the s e s s i o n I don't t h i n k t h a t i s an o v e r s t a t e m e n t . I l i t e r a l l y f e l t l i k e I had t o p u l l her up or she would j u s t d i s a p p e a r . " 4) t h e c o u n s e l l i n g g o a l s (where the case i s g o i n g ) : (Example: "The c l i e n t needs an immediate c a r e s e t t i n g . She had t a k e n a l e t h a l compound and r e q u i r e d emergency m e d i c a l i n t e r v e n t i o n . A f o l l o w - u p team has been d i s p a t c h e d t o the h o s p i t a l t o h e l p w i t h the assessment. She w i l l p r o b a b l y be h o s p i t a l i z e d . " Metaphoric Case Drawing Of Client ^v*v;»<•^7JT' ^ v•• :*•**N•••'*' :•'•*•*"•*' , "Driven To The Wall" Q Q Appendix G E v a l u a t i o n Q u e s t i o n n a i r e 100 Evaluation Questionnaire 6 Rate your level of understanding of the following: 1) The c l i e n t : 1 2 3 4 5 6 7 2) The counsellor: 1 2 3 4 5 6 7 3) Client-counsellor r e l a t i o n s h i p : 1 2 3 4 5 6 7 4) Counselling goals: 1 2 3 4 5 6 7 5) Were you able to e l i c i t facts about the c l i e n t ? 1 2 3 4 5 6 7 6) Was the presenting problem(s) c l a r i f i e d ? 1 2 3 4 5 6 7 7) Your understanding of the variables a f f e c t i n g the c l i e n t ? 1 2 3 4 5 6 7 8) Your understanding of the obstacles the c l i e n t must resolve in order to solve the problem? 1 2 3 4 5 6 7 9) The c l i e n t ' s motivation? 1 2 3 4 5 6 7 10) The c l i e n t ' s desired outcomes or goals? 1 2 3 4 5 6 7 101 Evaluation Questionnaire 1 2 3 4 5 6 7 Rate your level of understanding of the following: 11) How the f o u r - s t a g e i n t e r v e n t i o n model a p p l i e d i n t h i s s e s s i o n (acceptance, c o n f l i c t i d e n t i f i c a t i o n , a l t e r n a t i v e s t e r m i n a t i o n ) ? 1 2 3 4 5 6 7 12) What occurred to f a c i l i t a t e or block stage t r a n s i t i o n s ? 1 2 3 4 5 6 7 13) Your own s t r e n g t h s and weaknesses i n t h i s c o u n s e l l i n g s i t u a t i o n ? 1 2 3 4 5 6 7 14) Your r o l e i n t h i s c o u n s e l l i n g s i t u a t i o n ? 1 2 3 4 5 6 7 15) Changes i n the c l i e n t - c o u n s e l l o r r e l a t i o n s h i p throughout the c o u n s e l l i n g s e s s i o n ? 1 2 3 4 5 6 7 16) R e s i s t a n c e , r e l u c t a n c e , r e c e p t i v i t y to new id e a s , change, or d i r e c t i o n ( i n the c l i e n t - c o u n s e l l o r c o n t e x t ) ? 1 2 3 4 5 6 7 17) P e r c e i v e d s o l u t i o n e f f e c t i v e n e s s ( s p e c i f i c outcomes l i k e l y to occur i f a giv e n course of a c t i o n were f o l l o w e d ) ? 1 2 3 4 5 6 7 18) I m p l i c i t / e x p l i c i t understanding of what i s needed i n t h i s s i t u a t i o n i n the c r i s i s i n t e r v e n t i o n context? 1 2 3 4 5 6 7 102 Evaluation Questionnaire 2 3 4 5 6 7 Rate your level of understanding of the following: 19) Degree of c o m p l e x i t y of t h i s s e s s i o n ? 1 2 3 4 5 6 7 20) How e f f e c t i v e was the s e s s i o n i n f a c i l i t a t i n g change or a d j u s t m e n t ? 1 2 3 4 5 6 7 21) How e f f e c t i v e was t h i s s e s s i o n i n r e d u c i n g p s y c h o l o g i c a l p a i n ? 1 2 3 4 5 6 7 22) I f e l t p e r s o n a l l y i n v o l v e d i n t h i s case p r e s e n t a t i o n ? 1 2 3 4 5 6 7 23) Other group members were a c t i v e l y i n v o l v e d i n the d e b r i e f i n g p r o c e s s ? 1 2 3 4 5 6 7 24) I g a i n e d i n s i g h t i n t o the case and the n a t u r e of the c l i e n t problem? 1 2 3 4 5 6 7 25) I g a i n e d i n s i g h t i n t o my own f e e l i n g s and v a l u e s r e g a r d i n g h e l p i n g t h i s c l i e n t ? 1 2 3 4 5 6 7 26) I g a i n e d i n s i g h t as t o what happened r e g a r d i n g the h e l p i n g p r o c e s s ? 1 2 3 4 5 6 7 103 Evaluation Questionnaire 2 3 4 5 6 7 Rate your level of understanding of the following: 27) I ga i n e d i n s i g h t as t o how I f e e l about m y s e l f as a c o u n s e l l o r ? 1 2 3 4 5 6 7 28) I ga i n e d i n s i g h t f o r improved h a n d l i n g of a s i m i l a r s i t u a t i o n t h e f u t u r e ? 1 2 3 4 5 6 7 29) I e x p e r i e n c e d e m o t i o n a l s a t i s f a c t i o n from p r e s e n t i n g / o b s e r v i n g t h e case p r e s e n t a t i o n ? 1 2 3 4 5 6 7 30) I have improved my a b i l i t y t o p r e s e n t and p a r t i c i p a t e i n the case p r e s e n t a t i o n p r o c e s s ? 1 2 3 4 5 6 7 31) My o v e r a l l u n d e r s t a n d i n g of the case has improved as a r e s u l t of the case p r e s e n t a t i o n ? 1 2 3 4 5 6 7 32) My awareness of the c o u n s e l l i n g p r o c e s s i n g e n e r a l has i n c r e a s e d ? 1 2 3 4 5 6 7 33) I c o n t r i b u t e d i d e a s , t h o u g h t s , and f e e l i n g s d u r i n g the d e b r i e f i n g ? 1 2 3 4 5 6 7 34) The d e b r i e f i n g h e l p e d e s t a b l i s h a c o u n s e l l i n g p l a n ? 1 2 3 4 5 6 7 104 Evaluation Questionnaire 6 Rate your level of understanding of the following: 35) The d e b r i e f i n g s e r v e d as a c o n c r e t e r e f e r e n c e p o i n t ? 1 2 3 4 5 6 36) The d e b r i e f i n g h e l p e d f o c u s the d i s c u s s i o n ? 1 2 3 4 5 " 6 37) The d e b r i e f i n g s e r v e d as a summary? 1 2 3 4 5 6 38) The d e b r i e f i n g p r o v i d e d a d d i t i o n a l i n s i g h t ? 1 2 3 4 5 6 39) Degree of o v e r a l l impact? 1 2 3 4 5 6 Other Comments would be welcome: 105 Appendix H Summary of A l l S u b j e c t / T r a i n e r R a t i n g s (N=244) of A l l C o u n s e l l i n g S e s s i o n s (N=108) by S u b - S c a l e s ' 106 Appendix H. Summary Of All S 3 / T r a i n e r s Ratings (N=244) Of All Counselling Sessions (N=108) by Sub-Scale Pearson Scale X S.D. Hoyt Estimate Of Reliability* High Low Max. Corr. ( S , / T r Client 28.0 7.5 .92 46 9 49 .78** Counsellor 33.6 9.4 .96 54 11 56 .72** Relationship 12.4 3.6 .86 21 3 21 .68** Goals 39.6 10.2 .93 61 17 70 .69** Debriefing 45.6 13.4 .97 73 22 77 .74** Total 159.2 41.9 .98 246 77 273 .79** * Cronbachs Alpha for Composite = 0.94 ** p < 0.001 107 Appendix I Subjects' Mean Ratings by Sub-Scale by Groups Across A l l 1st Counselling Sessions (N=70) 108 Ss Means For "Client" Sub-Scale Group 1 (N=2) o VCD • MCD 109 Ss Means For "Client" Sub-Scale Group 2 (N=2) o VCD • MCD 49n Sessions 1 1 0 Ss Means For "Client" Sub-Scale Group 3 (N=3) o VCD • MCD 49-1 111 Ss Means For "Counsellor" Sub-Scale Group 1 (N=2) o VCD • MCD 56-i Sessions Ss Means For "Counsellor" Sub-Scale Group 2 (N=2) o VCD • MCD 56-i Sessions Ss Means For "Counsellor" Sub-Scale Group 3 (N=3) o VCD • MCD 56n Sessions o VCD MCD Ss Means For "Rel'n" Sub-Scale Group 1 (N=2) Mean= 11.4 SD= 3.3 20 Casea 1 r 1 1 — 1 1 1 1— 1 1 1 1 1 0 1 2 3 4 5 6 .7 8 9 10 Sessions 115 Ss Means For "Rel'n" Sub-Scale Group 2 (N=2) o VCD MCD 21-18H 15H Sessions Ss Means For "Rel'n" Sub-Scale Group 3 (N=3) 117 L Ss Means For "Goals" Sub-Scale Group 1 (N=2) o VCD • MCD 70-1 118 Ss Means For "Goals" Sub-Scale Group 2 (N=2) o VCD • MCD Sessions Ss Means For "Goals" Sub-Scale Group 3 (N=3) o VCD • MCD 70-| Sessions 120 77-1 Ss Means For "Debriefing" Sub-Scale Group 1 (N=2) o VCD • MCD CO 66-55-44-33-22-11-0 0 i 2 3 4 5 6 Mean= 46.9 SD= 14.3 20 Cases 7 T 9 10 Sessions 121 77-. Ss Means For "Debriefing" Sub-Scale Group 2 (N=2) o VCD • MCD pa m a (0 a> 66-55-44-33-22-11-0 . ~~r~ 2 3 4 6 ~~r~ 7 Mean= 43.9 SD= 14.8 20 Cases 8 9 —i 10 Sessions 122 Ss Means For "Debriefing" Sub-Scale Group 3 (N=3) o VCD • MCD 77-, Sessions Ss Means For "Total" Sub-Scale Group 1 (N=2) VCD MCD ~r~ 2 ~T~ 3 4 6 Uean= 156.B SD= 42.7 20 Cases 7 8 9 -1 10 Sessions Ss Means For "Total" Sub-Scale Group 2 (N=2) o VCD • MCD 273-1 234H 195H Sessions Ss Means For "Total" Sub-Scale Group 3 (N=3) o VCD • MCD 273i Sessions Appendix J MCD I n t e r p r e t a t i o n Procedure: T r a i n e r ' s Guide and Case Study P r e s e n t a t i o n s 127 Metaphoric Case Drawing I n t e r p r e t a t i o n Procedure: T r a i n e r ' s  Guide (Stone, 1987) Much of the understanding e x t r a c t e d from the metaphoric case drawing i s s u b j e c t i v e i n nature: meanings are unique, i d i o s y n c r a t i c , and o f t e n symbolic. However, some g u i d e l i n e s are r e q u i r e d f o r u n i f o r m i t y of a p p l i c a t i o n , thoroughness, and c o n s i s t e n t i n t e g r a t i o n of m a t e r i a l from one case to the next. The f o l l o w i n g system has been developed u s i n g a v a r i a t i o n of Barthes (1981) method of a n a l y z i n g photographs- which depends on two p r i n c i p l e concepts d e r i v e d from the L a t i n terms: studium and punctum. Studium i s the o v e r a l l e f f e c t of the drawing; that which i s f a m i l i a r based on the observer's knowledge of the c u l t u r e ; Punctum i s some aspect of the drawing that p r i c k s , p i e r c e s , or punctures the observer's consciousness; t h i s concept i n L a t i n a l s o i m p l i e s a "cast of the d i c e , " - that i s , the punctum i s put i n by the student " o u t s i d e of awareness," u n c o n s c i o u s l y , by a c c i d e n t . The punctum i s always s t r i k i n g and o f t e n poignant. An example of studium and punctum may be seen i n F i g u r e B (page ): the o v e r a l l e f f e c t (studium) i s one of t e r r o r and pan i c on beha l f of the c l i e n t (on the h o r s e ) ; what s t r i k e s the observer most v i v i d l y (punctum) i s the c o u n s e l l o r (standing) who has the lower h a l f of h i s body p o i n t i n g one way, h i s trunk p o i n t i n g i n the o p p o s i t e d i r e c t i o n , and h i s head r e v e a l i n g h i s face and the back of h i s head s i m u l t a n e o u s l y . The student was completely unaware of h i s s e l f - r e p r e s e n t a t i o n u n t i l i t was p o i n t e d out i n the debr i ef i ng. Six dimensions have been developed to a s s i s t the t r a i n e r with the i n t e r p r e t a t i o n process of the MCD: These dimensions are d e f i n e d and case examples are pro v i d e d on the f o l l o w i n g pages. 1. 2. 4. 5. 6. 3 . general i n t e n t i o n (studium) i d e n t i f i c a t i o n of s u b - s c a l e elements ( c l i e n t , c o u n s e l l o r , c l i e n t - c o u n s e l l o r r e l a t i o n s h i p , goals) a c c i d e n t a l (unconscious) elements (punctum) p o s i t i o n / p r o p o r t i o n a l i t y MCD f u n c t i o n s i n c o r p o r a t i o n 128 I. General Intention (Studium) Emotional tone: a) the observer's immediate, uncensored response (eg, in Figure F i t may be defeat vs. triumph; in Figure B i t may be a sense of alarm vs. confidence) b) d i s p a r i t y of f e e l i n g vs. experience eg, in Figure A the observer gets a very precarious f e e l i n g about the counsellor's "footing" (domino- l e f t side of bridge), when, in f a c t , the t r a n s i t i o n (from the main counselling work to the termination of the session) was handled very smoothly by the student. This discrepancy represents a substantive debriefing issue. II. I d e n t i f i c a t i o n of Sub-Scale Elements Comprehending the drawing structure: Locate the: a) c l i e n t b) counsellor c) clien t - c o u n s e l l o r r e l a t i o n s h i p d) representation of counselling goals If these elements are vague or represented in the abstract, have the, student explain where they are represented in the drawi ng. I I I . Accidental (Unconscious) Elements (Punctum) Some aspect of the drawing that: a) pierces, punctuates, or cuts eg, in Figure F the windmill (client) blades at eight and eleven o'clock both appear to have been "lanced"; the blade at one o'clock appears disheveled; Did the Knight (counsellor) do that? did he "take a chunk out of (or "mess up") the c l i e n t " ? What meaning does the counsellor give t h i s aspect of the drawing? What is the evidence for these "chunks" based on the actual counselling session? 129 IV. Position/Proportionality Relationships between: a) objects or certain elements in the drawing eg, in Figure E the l e f t hand is "caught" in the Chinese finger puzzle, the right hand is not: why?; in Figure C the " b a l l and chain" on the c l i e n t appears to be r i s i n g rather than sinking: what meaning might that have to the student? b) deletions, omissions, excessive d e t a i l eg, in Figure A the landscape on the right side of the bridge (client) is much more f u l l y a r t i c u l a t e d than the l e f t side (counsellor): what might this mean? In Figure B the l e f t side of the drawing i s breaking-up: losing structure and continuity-what sig n i f i c a n c e does this have?; the counsellor's l e f t hand i s fixed and excessively r i g i d : what meaning for the student? how does the student's* i n t e r -pretation conform or diverge from the interpretation of the observer(s)? D i f f e r -entiate and account for the discrepancies V. Metaphoric Case Drawing Functions Does the drawing: a) inform- how? b) s i g n i f y - what? c) surprise? d) waken/arouse p a r t i c u l a r emotions/ideas? e) reveal- what? f) conceal- what? g) evade/ avoid? h) defer- eg, in Figure B the counsellor's scribbled out face masked a too-intense-to-face personal issue related to the c l i e n t ' s s i t u a t i o n (child abuse); some issues are better i d e n t i f i e d and deferred to a time in the future: the MCD allows t h i s i ntensity to be i d e n t i f i e d , acknowledged, and deferred in a non-threatening manner. 130 VI . I n c o r p o r a t i o n P r a c t i c a l and th e o r e t i c a l integration of material: a) markers or reference points: eg, the term "domino-step," from the Figure A debriefing came to s i g n i f y , or provide a short-hand method for conceptualizing various personal aspects of the termination process for one student: when he said "this l a s t session contained a 50% domino-step", a whole cluster of s p e c i f i c meanings were v i v i d l y conveyed in s t a n t l y - the student is ref e r r i n g to pa r t i c u l a r t h e o r e t i c a l and p r a c t i c a l problems encountered in a previous debrief-ing, but this time we can communicate these meanings completely in one-tenth the time and advance the learning with questions l i k e : "Break off the fragment that i s unlike the domino-step and talk about that." In thi s way unnecessary r e p e t i t i o n is avoided and new knowledge is rapidly integrated with past experience. In order to further c l a r i f y the interpretation process the following pages contain a summary analysis of the debriefing case notes for six MCD sessions (Figures A through F) . Figure A General Intention and I d e n t i f i c a t i o n of Sub-Scales: This drawing conveys a sense of completion for the c l i e n t who i s seen just over the bridge (on the right hand side) and fading by sequence into the future. The counsellor, by contrast, is . precariously balanced on the l e f t side of the bridge, just "stepping" onto the bridge. The tension is created by the v i o l a t i o n of the expectation that the c l i e n t and the counsellor w i l l make the t r a n s i t i o n (from substantive counselling concerns to the termination of the session) together- in unison, as expected by c r i s i s intervention theory. Position/Proportionality, Accidental Elements, and MCD  Functions: The student's meaning of himself as counsellor (domino on the l e f t ) was as follows: the face of the domino i s s p l i t in h a l f - the top four dots represented the four stages of the c r i s i s model- their presence indicated to the student that he "has a good th e o r e t i c a l understanding of the four 131 stages." The bottom of the domino shows three dots: the meaning the student gave this was "the three dots represent my actual a b i l i t y , in practice, to deliver three of the four stages. The one I can't do well is the fourth stage: termination." The student represents himself as taking a " f a l t e r i n g " step in the d i r e c t i o n of the session termination but sees himself "way behind the c l i e n t . " In f a c t , the trainer and one observer both pointed to a number of well executed termination tasks that the counsellor performed seemingly without e f f o r t , perhaps without r e a l i z i n g his effectiveness. This discrepancy between the counsellor's perception and the apparent "f a c t s " of the case represents a common student-counsellor d i s p a r i t y between self-perception and actual behavior, v i v i d l y conveyed by the student's experience as represented in the drawing. More s p e c i f i c a l l y , the counsellor has reversed the top and bottom half of the domino: his t h e o r e t i c a l grasp of the four stages i s three out of four; his p r a c t i c a l application of the four stages was four out of four in thi s case. The a r t i c u l a t i o n of the c l i e n t ' s side of the drawing (right side) is disproportionate to the d e t a i l contained in the counsellor's side ( l e f t s i d e ) . Observe the r a t i o of d e t a i l to a v a i l a b l e space: the horizontal lines in the lower half of the c l i e n t ' s side represent a tablet or notebook that the student l i t e r a l l y could "write a story on about the c l i e n t ; " the upper half of the right side captures something of the c l i e n t ' s confusion (scribbles) and, at the same time- and to the surprise of the counsellor, an accurate representation of the c l i e n t ' s forward momentum and path toward the future (by great measure as a result of the e f f o r t s of the counsellor to e f f e c t i v e l y reduce and c l a r i f y the c l i e n t ' s confusion). By contrast the l e f t side of the drawing (counsellor) is constrained, tentative, and undifferentiated. The footing of the bridge i s "close to the edge," the domino (counsellor) i s off balance and awkward appearing, and his own sense of himself (professional identity) underlying his position i s blank. Incorporation: the main lesson from this drawing was that the counsellor r e a l i z e d he could afford to trust his a b i l i t i e s more (based on the ove r a l l evidence of what he did- as ci t e d by the observers and confirmed by the counsellor); also, an awareness that, contrary to what he i n i t i a l l y thought, his a b i l i t y to give immediate application to the theory was, in fact , in advance of his conceptual grasp of the fine p r i n t of the theory (termination e s p e c i a l l y ) . This represents a di r e c t reversal of the students i n i t i a l assessment of his own performance (excellent on theory- not too good on application of theory). F i n a l l y , the image of this MCD- p a r t i c u l a r l y the domino's off-balance step onto the bridge, was used a number 132 of times i n f u t u r e s e s s i o n s as a mechanism f o r r a p i d l y r e c a l l i n g a l l of the above m a t e r i a l , as a measurement a g a i n s t which to assess other cases i n v o l v i n g t e r m i n a t i o n i s s u e s , as a re c o r d f o r measuring the students emerging p r o f e s s i o n a l i d e n t i t y , and as a de v i c e f o r mon i t o r i n g the congruence between h i s a c t u a l c o u n s e l l i n g behavior and h i s p e r c e p t i o n of h i s performance. F i g u r e B General I n t e n t i o n and I d e n t i f i c a t i o n of Sub-Scales: t h i s drawing communicates a r e a l sense of d e s p e r a t i o n on beha l f of both c l i e n t (on the horse) and the c o u n s e l l o r ( s t a n d i n g ) . The c l i e n t ' s i n t e r n a l resources "have d i s s o l v e d " (conveyed i n the drawing by the empty horse on the i n s i d e of the merry-go-round). The c o u n s e l l o r i s s t i f f ( p a r t i c u l a r l y h i s l e f t arm and hand), confused ( l e g s , trunk, and head a l l going i n d i f f e r e n t d i r e c t i o n s ) , yet he i s making a v a l i a n t e f f o r t to reach the c l i e n t - d e s p i t e h i s u n c e r t a i n t y . P o s i t i o n / P r o p o r t i o n a l i t y , A c c i d e n t a l Elements, and MCD  F u n c t i o n s : The student was s u r p r i s e d to r e a l i z e he drew h i s lower body, trunk, and head a l l f a c i n g d i f f e r e n t d i r e c t i o n s . An examination of t h i s r e v e a l e d a p a r t i c u l a r type of i n t e r p e r s o n a l d i s t o r t i o n ( i n t h i s case c o u n t e r t r a n s f e r e n c e ) based on the c l i e n t ' s p r e s e n t i n g problem ( c h i l d abuse i n c i d e n t ) and the c o u n s e l l o r ' s p e r s o n a l past h i s t o r y . The r e p r e s e n t a t i o n of the c l i e n t - " t w i s t e d every which way"-bet r a y s a s e r i o u s c o n f l i c t f o r the student i n h i s r o l e as " c o u n s e l l o r " - the convergence of u n f i n i s h e d p e r s o n a l b u s i n e s s vs. the r e s p o n s i b i l i t i e s inherent i n the c o u n s e l l i n g r o l e . As the drawing i n d i c a t e s , i f the c l i e n t grabs on to the c o u n s e l l o r the outcome w i l l be that the c o u n s e l l o r gets p u l l e d over backwards and dragged i n t o the machinery of the merry-go-round. This c o n f l i c t of r o l e s (person vs. c o u n s e l l o r ) i s common and, as i t u s u a l l y does, came up unexpectedly i n t h i s case. I t i s worth n o t i n g the c o u n s e l l o r ' s r e p r e s e n t a t i o n of both f a c i n g the c o n f l i c t and, at the same time evading i t (his f a ce i n i t i a l l y l o o k i n g at the c l i e n t then s c r i b b l e d o u t ) . The u n d e r l y i n g p e r s o n a l aspects of t h i s case -as they r e l a t e to the c o u n s e l l o r - were d e f e r r e d to a l a t e r time at the request of the student. I t was a l s o noted t h a t , to some ex t e n t - t h i s drawing r e p r e s e n t s two c l i e n t s . I t i s not s u r p r i s i n g that the student had great d i f f i c u l t y i n f i n i s h i n g the l e f t s i d e of the drawing: he r e p o r t e d a " s e r i o u s l o s s of focus as to where the c l i e n t was going," and by e x t e n s i o n , where was going i n r e s o l v i n g a s i m i l a r concern. I n c o r p o r a t i o n : the most dramatic l e s s o n from t h i s case p r e s e n t a t i o n was the p o t e n t i a l f o r "combustabi1ity" when the 133 counsellor's past, s e n s i t i v e , or incomplete experiences are evoked or provoked in the counselling session. This student learned something very important about the necessity of adequate personal examination as a requirement for e f f e c t i v e l y performing the counselling function. One other short-term eff e c t of this experience was that the student was very wary of engaging c l i e n t s on anything other than an i n t e l l e c t u a l l e v e l : t h i s imbalance was eventually corrected over the course of the practicum- largely as a result of the student's hard work and commitment. Figure C General Intention and I d e n t i f i c a t i o n of Sub-Scales: at f i r s t glance this drawing communicates somewhat happy-go-lucky, f e s t i v e tone. However, certain aspects of the drawing create a c o n f l i c t with a s t r i c t l y "party" d e f i n i t i o n : a) the person getting on the right side of the teete r - t o t t e r (counsellor) is doing so with an apparent sense of urgency; b) the person at the other end (client) appears anything but happy; c) the person in the middle ( c l i e n t ' s physician) i s present but seems not to be making a difference in "balancing" the s i t u a t i o n ; d) the two people jumping off the teete r - t o t t e r (family members) seem to be doing so oblivious of the consequence to the c l i e n t . This is seen as the p i v o t a l action in the drawing. Their action in "leaving" the s i t u a t i o n is what appears to p r e c i p i t a t e the c r i s i s for the c l i e n t . P o s ition/Proportionality, Accidental Elements, and MCD  Functions: The student's interpretation of this drawing was that the c l i e n t was being abandoned by his family and weighted down by the advice of the physician (ball-and-chain: Rx) whose point was that the c l i e n t (age 23) needed to learn how to get by in l i f e without his parents. The presenting problem was the c l i e n t ' s i n a b i l i t y to function s o c i a l l y and at work as a result of trying to take care of and r e h a b i l i t a t e two a l c o h o l i c parents who were, e s s e n t i a l l y , unconcerned about their l i f e - s t y l e . The motion lines indicate the student's sense of a present, immediate danger to the c l i e n t . The counsellor's role is to provide an immediate intervention that w i l l be strong enough to "right the balance quickly". The physician is seen as being in a position to re-balance the c l i e n t , but without s u f f i c i e n t force or weight to t i p the scales. The student is also concerned with being "stepped on" 134 by the physician as soon as he (the student-counsellor) applies s u f f i c i e n t weight to the s i t u a t i o n . What this drawing r e a l l y captures is the student's r e a l i z a t i o n that the physician i s r i g h t : the c l i e n t needs to learn something about the l i m i t a t i o n s of his r e s p o n s i b i l i t y to his parents. What is of interest is that the student drew the ball-and-chain so that i t is actually providing the c l i e n t with a counter-balance to his downward plunge: generally, something that heavy would f a l l at a greater rate of speed than the person. In t h i s case i t is r e a l l y "lightening up" the s i t u a t i o n . The point is that what the student thinks of as an anchor around the c l i e n t ' s leg is r e a l l y a central counselling goal for this intervention. An additional session with the c l i e n t a r t i c u l a t e d this point in such a way that the c l i e n t was able to l i s t e n to the point and accept i t in a way he couldn't from his physician. Incorporation: There was a tendency for the counsellor to side with the c l i e n t in c r i t i c i z i n g "doctors in general" with regard to the physician's assessment. There was a lapse of counsellor o b j e c t i v i t y : in f a c t , i t turned out the physician's assessment of the core of the unease was accurate. The learning for the student in t h i s s i t u a t i o n was to be cautious about developing the a l l i a n c e with the c l i e n t by siding against other professionals involved who might have a valuable point but lack something in their presentation: a problem of form vs. content. The "betrayal" in this MCD was, indeed, the c l i e n t f e e l i n g abandoned by his parents, but the counsellor also expressed a "betrayal" of the idea of detached o b j e c t i v i t y (considered to be part of the role of the counsellor) by siding too quickly with the c l i e n t against the physician. Figure D General Intention and I d e n t i f i c a t i o n of Sub Scales: The student had a great deal of d i f f i c u l t y attempting to represent this session with a MCD. After a half hour of wrestling to fi n d a way to metaphorically represent t h i s s i t u a t i o n the counsellor-trainee gave up. In an attempt to resolve the student's "block" a technique was used in an e f f o r t to bypass left-hemispheric interference (Broughton, 1978). The student was asked to count backwards (out loud) from 1000 by three's and four's while simultaneously generating a drawing with his l e f t hand (this was a right handed student). The general idea was to keep the l o g i c a l , r a t i o n a l , sequential left-hemisphere of the brain busy while allowing the i n t u i t i v e , imaginative, creative right-hemisphere temporary dominance. Figure D was the r e s u l t . 135 In t h i s drawing the counsellor (top triangle) had no idea what the c l i e n t (bottom triangle) was thinking or f e e l i n g . The counsellor portrays his role as "scattered" (going in a l l d i r e c t i o n s ) , somewhat purposeless, and unable to make contact with the c l i e n t (points of the triangles o f f - c e n t r e ) . The counsellor has no sense of the c l i e n t ' s internal or external l i f e , or of what is required for e f f e c t i v e intervention. Position/Proportionality, Accidental Elements, and MCD  Function: The c l i e n t ' s presenting problem in t h i s session involved some questions about handling acute depression in the context of a recent relationship s p l i t . The confusing element here was the c l i e n t ' s personal s t y l e : long pauses before responding, hesitant, very deliberate speech, monotone voice. The student realized during the debriefing that he took this pattern as a sign of his own shortcomings in the role of counsellor. The student's response was to lay down a barrage of questions: during the f i r s t ten minutes of the session the counsellor asked 43 questions- usually a sure indicator of a counsellor struggling for control. This aspect of the counsellor's behavior i s v i v i d l y captured in the MCD: a l l the a c t i v i t y is at the l e v e l of the counsellor; the appearance of the a c t i v i t y is disorganized. In t h i s MCD the c l i e n t appears more squarely and firmly on the ground than does the counsellor- a point which accurately r e f l e c t e d the opinion of the student and the observers during the debriefing. Incorporation: The learning in t h i s s i t u a t i o n was to allow (even f a c i l i t a t e ) c l i e n t generated pauses or silences (maybe the c l i e n t is thinking about an important point?); to delay a rigorous pursuit of content u n t i l the c l i e n t has a r t i c u l a t e d some themes; to delay pursuit of content u n t i l a counselling a l l i a n c e (trust, acceptance) has been established; and, as a counsellor, to be a l e r t to the r a t i o of questions asked vs c l i e n t responses (or, put d i f f e r e n t l y , the r a t i o of energy expended vs. p r o d u c t i v i t y ) . The "Passive C l i e n t " a c t u a l l y turns out to be an overzealous, somewhat confused counsellor-trainee attempting to provide s t r i c t l y " c r a n i a l " counselling by sheer "top-down" force. Making a d i r e c t point-to-point h i t with two triangles would be "one in a m i l l i o n " using the above counselling approach in this s i t u a t i o n . Figure E General Intention and I d e n t i f i c a t i o n of Sub-Scales: In t h i s drawing the counsellor's index fingers are caught in a Chinese finger puzzle ( c l i e n t ) . The motion lines indicate the a c t i v i t y i s centered around extracting the l e f t hand- which also seems to be more severely "caught." In fact, the right index finger appears to be unencumbered in the trap, which is loose f i t t i n g and f a i r l y comfortable appearing. 136 Position/Proportionality, Accidental Elements, and MCD  Function: The l i t e r a t u r e on brain hemerispherality indicates that in the right handed individual the l e f t side of the brain presides over l i n e a r , a n a l y t i c , i n t e l l e c t u a l functions. By contrast, the right side of the brain is considered to be the seat of i n t u i t i v e , emotional, " f e e l i n g " functions including symbolic, creative, and metaphoric generativity (Sperry, 1968/1982; Bogen, 1969; Ganlin and Ornstein, 1972; Ornstein, 1972; Luria, 1973; Penfield, 1975; Broughton, 1978; Ehrenwald, 1984). Using this model, a cursory analysis would indicate the student might be more comfortable i n t e l l e c t u a l i z i n g about the c l i e n t ' s presenting problem (suspected c h i l d abuser) than actually coming to grips with the subject emotionally. In f a c t , this is-what happened as the counsellor-trainee discussed her interpretation of the session: the right hand ( l e f t - b r a i n i n t e l l e c t ) accepting the content as a matter of fact while the l e f t hand (Right-brain s e n s i t i v i t y , emotionality) fought hard to "get free from something emotionally repulsive." (It should be noted that i t is not necessary to use this type of framework for analysis ( l e f t - r i g h t brain functions) though i t seems to work well in the context of visual imagery and metaphoric drawings. Incorporation: The learning in this debriefing had to do with the importance of objectively i d e n t i f y i n g d i s p a r i t i e s between the counsellor as she thinks and the counsellor as she feels towards the c l i e n t and his concerns. In this case to allow the counsellor to get free of the emotional "bind" she f e l t and to be able to u t i l i z e more of her feelings about the potential danger to encourage the c l i e n t to seek immediate assistance (no apparent abuse had occurred to date- the s i t u a t i o n was handled in the more cognitive mode of "what i f " - the r e s u l t was a session mediated by questions and answers with an unacknowledged emotional undercurrent that created noticeable tension but never was incorporated in the counselling process, eg, the counsellor could have asked "What are your fears about your si t u a t i o n ? " ; "Were you ever abused as a c h i l d " ? ; or simply, "How are you f e e l i n g right now as we discuss the notion of c h i l d abuse"?). Figure F General Intention and I d e n t i f i c a t i o n of Sub-Scales: The general f e e l i n g communicated by this drawing is one of perceived defeat by the Knight (counsellor): the drooping banners and sagging head of the horse (representing the f a i l u r e of the c r i s i s intervention model to "carry" the counsellor to an e f f e c t i v e outcome) are preceded by a 137 "tortured path back from the skirmish" (with the c l i e n t : the windmill). There is an o v e r a l l sense of f a i l u r e , yet something in the carriage of the Knight conveys a sense of strength and pride (posture, erect head, position of legs, the way he is holding the banner). Position/Proportionality, Accidental Elements and MCD  Functions: The windmill (client) shows b i t s missing from the blades at eight and eleven o'clock, and a somewhat disheveled looking blade at one o'clock. The main body of the m i l l (representing the counselling issues) is r e l a t i v e l y unarticulated: the counsellor had trouble defining the counselling goals as well as his s p e c i f i c r o l e . As may be observed most of the a c t i v i t y took place on the outside area of the windmill (external vs internal contact), and has the markings of "fray" or "battle" more than an "engagement of two people uni f i e d in their purpose and d i r e c t i o n . " The c l i e n t was described by the counsellor-trainee as "defended, guarded, and thorny," a description which was confirmed by the t r a i n e r . The d i f f i c u l t y in the session- well conveyed in the drawing, was that the counsellor never got past the c l i e n t ' s e x terior. The c l i e n t c r i t i c i z e d the counsellor's " a b i l i t y and experience" and the trainee never got beyond "jousting" with the c l i e n t to es t a b l i s h his authority (supremacy?). The convoluted "path" leading from the windmill represents the c l i e n t ' s g u i l t and even shame at having idealized this session in the form of having attempted to uphold the " c r e d i b i l i t y of counsellors everywhere." The student f e l t l e t down by the c r i s i s intervention model (horse) and f e l t he had made a good e f f o r t to follow the stages of the model but got nowhere with i t . The trainer concurred with the e f f o r t s of the student but f e l t the subtle "one-upmanship" was central throughout the session and tended to negate any "good counselling" on the part of the trainee. This session lasted forty minutes and, towards the end, the counsellor was able to find the "eye of the storm" for a few minutes to engage in a meaningful discussion with the c l i e n t regarding his presenting problem (professional engineer l a i d off after twenty-two years s e r v i c e ) . It was f e l t that the counsellor did a very e f f e c t i v e job at s e n s i t i v e l y handling the c l i e n t ' s strong emotions during the few moments he (client) allowed himself to become r e f l e c t i v e . The student later f e l t that aspect of the session was what allowed him to represent himself " t a l l in the saddle" in the drawing, even in the face of apparent defeat. Incorporation: The p r i n c i p l e learning was managing defensive, s a r c a s t i c c l i e n t s ; the r e a l i z a t i o n that there is an underlying 138 need; a v o i d i n g p e r s o n a l i z i n g and d e f e n s i v e l y r e a c t i n g to c l i e n t "barbs." There was a l s o what the student c a l l e d a "secondary r e a l i z a t i o n " : namely, that the c o u n s e l l i n g s e s s i o n i s not the p l a c e to "do b a t t l e " to p r o t e c t the s a n c t i t y of the i d e a l of the c o u n s e l l i n g endeavor: a moment of i n s i g h t on behalf of the student f o r which we were a l l very g r a t e f u l . 139 Figure A. MCD of the "Transition" 140 Figure B. MCD of the "Mer ry -Go-Round 141 1 4 2 143 Figure E. MCD of the "Chinese Finger Puzzle" 144 145 

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