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Levels of ego development and reasoning about counselling in adults 2005

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L E V E L S OF EGO D E V E L O P M E N T A N D REASONING A B O U T COUNSELLING IN A D U L T S by M A R Y K A T H L E E N GOW B.A. Hon., Dalhousie University, 1991 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF M A S T E R OF ARTS in THE F A C U L T Y OF G R A D U A T E STUDIES (Counselling Psychology) THE UNIVERSITY OF BRITISH C O L U M B I A October, 2005 © Mary Kathleen Gow, 2005 11 Abstract This study investigated the relationship between levels of ego development and reasoning about counselling in adults. To date, ego development research has not made a clear distinction between "psychotherapy" and "counselling," nor has it included many "non-client" participants. Fifty adults living in non-urban areas in the Lower Mainland of British Columbia completed The Washington University Sentence Completion Test (WUSCT - a measure of ego development) and the Reasoning about Counselling (RAC) questionnaire. Thirty participants had no previous experience with counselling. A mixed methods design, employing both quantitative and qualitative analyses, revealed a significant relationship between ego development and reasoning about counselling across all domains in the total sample. When the sample was divided into two groups, those with and without previous experience in counselling, a significant relationship between the two variables was found in three out of the four domains. Qualitative findings illustrate the relationship between levels of ego development and reasoning about counselling from a more personal perspective. Findings from this study indicate that utilizing the ego development model to inform the practice of counselling psychology enables counsellors to better understand their adult clients' frame of reference and so choose treatment interventions that are the most appropriate. I l l Table of Contents Abstract i i Table of Contents i i i List of Tables v List of Figures vi I. Introduction 1 The Context of the Study Within the Research Literature 1 The Counselling Process 1 Developmental Conceptualization 4 Levels of Ego Development and Psychological/Psychiatric Treatment 6 Rationale 9 Purpose'of the Study 10 Research Questions 10 II. Literature Review 12 Loevinger's Construct of Ego Development 12 What is "Ego?" 13 How Does the Ego Develop? 14 Measuring Ego Development 19 Ego Development and Mental Health 25 Ego Development and Expectations of Counselling 28 Counselling Outcomes 28 Therapeutic Expectations 30 Summary 34 III. Method 36 Mixed Methods Research 36 Recruitment of Participants 37 Measures 38 The Washington University Sentence Completion Test (WUSCT) 38 The Reasoning About Counselling Questionnaire (RAC) 40 Demographic Data 41 Data Collection 41 Preparation of the Data 42 Generating Additional Categories for the R A C Scoring Manual 43 Training the Independent Raters 46 Data Analysis 47 Demographic Data 47 WUSCT data 47 R A C data -49 IV. Results 52 Descriptive Statistics of the Demographic Variables 52 Stages of Ego Development 55 Ego Development and Reasoning About Counselling 57 R A C Responses Ordered by Ego Development Level 58 iv V. Discussion 64 Quantitative Findings: Level of Ego Development and Reasoning About Counselling: Total Sample and Participants with Counselling Experience...64 Quantitative Findings: Level of Ego Development and Reasoning About Counselling: Participants with No Counselling Experience 68 Qualitative Findings: Variability of Reasoning About Counselling According to Ego Development Level 70 Implications for Counselling Practice 72 Limitations of Study 76 Implications for Future Research 79 References 83 Appendices Appendix A : WUSCT Short Form 81 96 Appendix B: Reasoning about Counselling (RAC) Questionnaire 98 Appendix C: Demographic Questionnaire 100 Appendix D: Request for Permission to Recruit Participants 102 Appendix E: Letter of Permission to Conduct Study at Coast Garibaldi Health.. 106 Appendix F: Notice Soliciting Volunteers 108 Appendix G: Statement by Front Desk Staff. 110 Appendix H : Explanatory Letter 112 Appendix I: Email to Dr. Young-Eisendrath 115 Appendix J: Email from Dr. Carol Foltz 117 Appendix K: R A C Scoring Manual 119 Appendix L: R A C Raters' Practice Exercises 126 Appendix M : Levels of Ego Development and Reasoning About Counselling Levels According to Gender 131 Appendix N : R A C Responses Ordered by Ego Development Level 133 V L is t of Tables Table 1: Sample Demographics 54 Table 2: Stages o f Ego Development: Current Study V s . Two Population Studies 57 Table 3: Correlations Between Ego Stage and Reasoning About Counselling Item Scores 58 Table 4: Levels o f Ego Development According to Gender 132 Table 5: Reasoning About Counselling Levels According to Gender 132 List of Figures Figure 1: Distribution of Ego Development Levels in Total Sample 1 I. Introduction This study was based on the premise that viewing adult clients from within a developmental context enhances a counsellor's knowledge of their clients' world. Counsellors are encouraged to work with clients using evidence-based practices, yet often lack wisdom about how to interact with clients in ways that are consistent with the client's ways of viewing his or her world. Research has shown that there is a significant relationship between different stages of adult development and how adults reason about psychotherapy and psychiatric services (Dill & Noam, 1990; Loevinger, 1980; Manners, Durkin, & Nesdale, 2004; Noam, 1992; Noam & Dil l , 1996; Pieretti, 1996; Rowan, 2004). The purpose of this study is to consider whether this relationship exists among individuals who are seeking counselling services (as opposed to psychotherapy or psychiatric services) and among individuals who have never attended counselling. I explored this question by measuring individual developmental levels and reasoning about counselling in a relatively rural, adult population in southern British Columbia. This focus was driven by the notion that i f adults' attitudes and reasoning about psychotherapy are associated with their level of development, as the research suggests, adults at different levels of development will also express developmentally distinct attitudes towards counselling. The Context of the Study within the Research Literature The Counselling Process Twelve years ago, a book was published called We've Had a Hundred Years of Psychotherapy and the World is Getting Worse (Hillman & Ventura, 1993). The title of this book is a potentially daunting declaration for counsellors who work long days strengthened by the notion that they are being of some assistance to their clients. Some 2 studies indicate that as many as 50 percent of clients do not return after their initial visit to counselling (Piper et al., 1999; Sue & Sue, 1990). It seems unlikely that these clients are "being cured" overnight. Is the practice of counselling psychology indeed as bleak as it may seem? Certainly clients continue to access services, and waiting lists continue to grow. Perhaps these clients will only attend one session. Perhaps they will attend counselling for many years. Either way, daily, humans enter into the client-counsellor relationship with the hope and belief that it is a useful and meaningful pursuit. The dictionary defines counselling as "the job or process of listening to someone and giving them advice about their problems" (McKean, 2005, p. 220). A dictionary definition is offered here (rather than a more formal definition from a counselling text) to illustrate the breadth of the term. Indeed the practice of counselling seems as widespread as its definition. Feltham and Dryden (1993) emphasize that counselling skills are used by nurses, general practitioners, social workers, youth workers, teachers, and pastors as well as psychologists, psychotherapists and psychiatrists. Counselling services range from vocational and financial counselling to grief counselling, addictions counselling, trauma counselling, and spiritual guidance. These services are delivered through one-to- one contact, in groups, with couples and families, over the telephone and internet, and through various written materials such as self-help manuals. Even within the more formal practice of counselling psychology, counsellors differ greatly in how they approach their work with their clients. Some take an expert stance, indeed seeing themselves as givers of advice; others take a more collaborative position with their clients. Some counsellors prefer to practice short-term, "brief therapy, while others prefer to work with clients for a number of years. Counsellors 3 may draw on subjective, "local knowledge" of their clients. This includes understanding the client's interpretation of the problematic situation, and watching the client closely for clues about their "lived experience." Counsellors may also draw on more "expert knowledge," as they consider, from a more objective standpoint, how various aspects of the client's life (e.g. age, gender, marital status, family history, and medical history) may be impacting the current problematic situation. Depending on the theoretical framework from which the counsellor operates, he or she will rely, in differing degrees, on these "local" and "expert" sources of information. Similarly, clients come to counselling seeking help with some sort of problem, yet they often have very different ideas about the role of the counsellor and the purpose of counselling. Some clients expect counsellors to "tell them what to do" from their "expert" role, other clients expect counsellors to encourage self-exploration, and may resent being "told what to do." Still other clients are in the unfortunate position of entering counselling against their will , and may have little expectation of success or motivation towards change. Given these broad practices and preferences, it is not surprising that "counselling" may sometimes be experienced as far from helpful. While the goals of counselling are often discussed by both client and counsellor, clients are rarely asked about their own "theory of change" or for their beliefs about the role of a counsellor (Duncan & Miller, 2000; Eisenthal, Emery, Lazare, & Udin, 1979; Hubble, Duncan, & Miller, 1999; Lazare, Cohen, Jacobson, Williams, Mignone, & Zisook, 1972). Similarly, counsellors, typically working from within one therapeutic orientation, may, without knowing, choose treatment plans and interventions that make little sense to a client's frame of reference (Noam & Di l l , 1991). 4 The present study will contribute to research that investigates how referring to a "developmental" framework may assist counsellors in meeting the needs of their clients more appropriately. Understanding clients from within a developmental context enables clinicians to choose treatment interventions which are integrated with the clients' particular ways of viewing his or her world. The following section introduces one such developmental framework, Jane Loevinger's (1976) theory of ego development, and discusses how the concept relates to aspects of mental health. Developmental Conceptualization Theorists in the field of developmental psychology are particularly interested in how individuals change across the life span (Erikson, 1959; Fowler, 1981; Gilligan, 1982; Kegan, 1994; Kohlberg, 1969; Moffitt, 1993; Piaget, 1952). Distinct stages of growth are recognized and measured using a variety of different constructs such as intelligence, psychosocial interaction, and morality. More recently, the construct of "ego" has also been used to describe development across the life span. (Loevinger, 1976; Noam, 1993.) As an alternative to the Freudian way of thinking about the self in terms of the id, the ego and the superego, Jane Loevinger's (1976) theory of ego development is based on H. S. Sullivan's (1953) concept of the self-system. The "ego" is manifested in an individual's particular motivations, in his/her processes of integrating information, and in his/her overall frame of reference. Loeveinger states that people have recognizable patterns of common "frames of references" which are distinct and measurable. These patterns are representative of different developmental stages of ego functioning. Within Loevinger's model there are nine stages of ego development. Although these stages are distinct, they are measured along a continuous dimension (Loevinger, 5 1998). Each stage encompasses and supersedes the one before - beginning with the most basic, impulsive, least reflective, early stages of ego functioning known as the "Impulsive" stage, and evolving to the most complex and reflective, highest stage of ego functioning called the "Integrated" stage. Similar to Piaget's (1952) psychosocial stages, Erikson's (1959) generational crises, and Kohlberg's (1969) stages of morality, as an individual gets older, he or she has the potential for moving towards higher levels of ego development. Age, however, is not generally a predictor of ego stage. Individuals who are the same chronological age may be at different ego stages. Researchers in the mental health field (Noam & Di l l , 1991; Noam & Houlihan, 1990; Noam, Recklitis, & Paget, 1991; Recklitis & Noam, 1999) have noticed a connection between ego development and aspects of "mental health." For example, Noam (1998) states, ". . .ego development is, in part, a sequence of mental health capacities; the mental health dimensions are interwoven into the fabric of what the ego is and the direction in which it develops" (p. 272). Noam perceives movement from the lower stages of ego development, where one acts impulsively and defensively, to the middle stages of ego development where one seeks a sense of self by identifying with others, as not only a leap in developmental stage, but also as a step towards more positive mental health. Similarly, movement from seeking a sense of self through identifying with others, to developing an autonomous yet integrated view of self, can be viewed equally as a step in mental health ability and as movement from the middle to upper levels of ego development. This idea suggests that development of the ego is synonymous with improved, or "mature," mental health. Loevinger (1976) claims, however, that ego development and mental health are two separate constructs with no overlap. She argues that people with high levels of ego 6 development can still face significant mental health challenges, and that individuals with lower ego development levels can possess many mental health strengths. How ego development relates to issues of mental health remains a primary area of investigation in ego development research. Levels of Ego Development and Psychological/Psychiatric Treatment Some light has been shed on the relationship between ego development and mental health by research that investigates the ego development levels of clients presenting for psychiatric and psychological treatment at hospitals, community agencies and private clinics (Borst & Noam, 1993; Dil l & Noam, 1990; Evans, Brody, & Noam, 2001; Gold, 1980; Hauser, Borman, Jacobson, Powers &Noam, 1991; Noam, Recklitis, & Paget, 1991; Teusch, 1988; Vincent, Castillo, & Rierdon, 1996; Vincent & Vincent, 1979; Waugh & McCaulley, 1974; Young-Eisendrath & Foltz, 1998). Findings indicate that certain psychological symptoms have been found to exist at certain levels of ego development. For example, individuals who score at lower levels of ego development typically are more likely to initiate assaults, accidents, and suicide attempts (Browning, 1986). Symptoms of anxiety, psychotocism and somatization are more common in individuals at the lower levels of ego development (Wilber, Rounsaville, & Sugarman, 1982). Research has also shown that higher ego development levels are associated with greater openness to experience (McCrae & Costa, 1980) and to greater psychological mindedness, absence of repression, and dispositional creativity and intuitiveness (Vaillant & McCullough, 1987). Additional research has investigated the treatment requests of individuals seeking psychiatric and psychotherapeutic services (Noam & Di l l , 1991; Young-Eisendrath & Foltz, 1996). It was found that individuals who score at the lower levels of ego 7 development respond better to, and request more frequently, services that are very directive in nature. Alternatively, individuals who score at the higher levels of ego development request more collaborative, insightful forms of therapy. One study investigated the relationship between ego development level and "reasoning about psychotherapy" and included a non-clinical sample of graduate level university students. Young-Eisendrath and Foltz (1998) assessed the ego development level of 115 adults in total, 64 from educational settings and 51 from clinical settings. Their sample included 85 females and 30 males ranging in age from 16 to 77 years. Participants were asked to fill out Loevinger's (1976) Washington University Sentence Completion Test (see "Measuring Ego Development" p. 18) as well as the Reasoning about Psychotherapy (RAP) (Young-Eisendrath & Foltz, 1998) questionnaire. The RAP asks individuals questions such as "What does a psychotherapist do?" "Do you think therapy can change people? If yes, how? If no, why not?" Participants in Young- Eizendrath and Foltz's study scored across all nine stages of ego development. In the patient group, the researchers found a significant relationship between ego development stage and reasoning about psychotherapy across all items. In the student group, a significant relationship between ego development stage and reasoning about psychotherapy existed in two of the four items on the RAP questionnaire. Some major themes emerged from this study: individuals at the lower levels of ego development in this study preferred therapy in which the therapist provided concrete services such as advice giving and direct help. Individuals at these levels viewed the therapist as responsible for choosing direct, "hands on" interventions which help the client. Participants at the middle stages of ego development were primarily interested in talking about their problems and feelings. Focusing on problem solving versus self- 8 discovery seemed to be the key to successful therapy for individuals at these stages. At the higher stages of ego development, individuals in this study were more likely to seek therapy which allowed a great deal of self-exploration. Individuals at these stages tended to take much of the responsibility in the therapeutic relationship, seeing the therapist as more of a facilitator, or partner in the journey, rather than the leader, or director. This study indicated that individuals at different stages of ego development seem to have distinctly different, measurable, and predictable preferences and attitudes about psychotherapy and the process of change. These results support similar research in this area (Lazare et a l , 1972; Lazare & Eisenthal, 1977; Noam & Dil l , 1991). To date, ego development research in the field of mental health has excluded a focus on the relationship between levels of ego development and adult reasoning about counselling per se. Much of the literature describes a distinction between psychotherapy and counselling (Feltham, 1995; Lees, 1999; Palmer & McMahon, 1997; Woolfe, 1997; Worden, 1991). Some researchers suggest that psychotherapy can be seen to focus on intervention, treatment, and reconstruction, while counselling is viewed as more enabling and facilitating (Clarkson, 1994). Others see psychotherapy as dealing with the unconscious world of the client, while counselling focuses more on the "here and now" (Woolfe, 1997). Delvin (2004) believes that the general public finds "counselling" a more understandable and less frightening term than "psychotherapy." Ego development research has focused primarily on individuals who are seeking clinical treatment rather than on laypersons who may be more familiar with the term "counselling." Young- Eisendrath and Foltz's (1998) study used a non-clinical sample, yet they were all graduate level university students. This study therefore seeks to contribute to the literature in two ways; by investigating the relationship between adult levels of ego 9 development and reasoning about counselling (from both a qualitative and a quantitative perspective); and by including laypersons in the sample who have had no prior experience with counselling. Rationale It seems that most mental health practitioners ultimately strive to meet their patients' and clients' needs as respectfully and as accurately as possible. Yet there remain individuals who are labeled as "resistant" or "unmotivated to change." Could some of these individuals be "motivated" by a counselling approach that considers how one's attitudes towards counselling may be related to one's individual frame of reference? "If the self is indeed a set of attitudes, beliefs, images, and actions, [as Loevinger suggests] then different selves should imply different narratives of psychotherapy, its purposes and interventions" (Young-Eisendrath & Foltz, 1998, p. 318). In turn, i f there is indeed a relationship between level of ego development and attitudes towards psychotherapy, it seems logical that these differences would also be reflected in individual attitudes towards mental health counselling. The ego development perspective provides a potentially useful framework for informing the practice of counselling psychology. It reminds clinicians that a client's way of viewing his/her world is not always reflected in the client's chronological age. It raises questions about the effectiveness of working with each client in exactly the same manner. It acknowledges that individuals can have very different opinions about the ways in which counselling is effective, and it suggests that these opinions may be loosely predicted by understanding a person's "developmental" frame of reference. 10 Purpose of the Study "Therapists, both beginning and experienced, may recognize that a client's self should be respected in terms of the particular meaning it carries - such as gender, class, and ethnic meanings. Few therapists, however, recognize the possibility that there is an extensive developmental context that may underlie both the client's self and her or his fundamental beliefs about psychotherapy." (Young-Eisendrath & Foltz, 1998, p. 316). Perhaps, the most "successful" counsellors recognize and consider their clients' underlying assumptions about various treatment approaches, and respond accordingly. Life presents us with a unique challenge and opportunity to reveal our true selves - as Freud said, to love and to work. But one would hope, also, to dream and to manifest in ourselves that which, at times, seems unimaginable. Some clients may be striving for what Maslow (1962) referred to as "self-actualization." At the same time, other clients may be happy with learning how to control their impulsive and hostile behaviour. Neither pursuit is more admirable than the other, and both deserve the utmost respect and attention of the counsellor. Considering how levels of ego development may distinctly relate to reasoning about counselling potentially widens the opportunity for successful counselling outcomes. By referring to a developmental framework, counsellors are provided with a "road map" - another tool to help meet the needs of each client most appropriately, and so enhance the quality of the counsellor-client relationship. Research Questions Three research questions guided this study. The first was, is there a relationship between levels of ego development and adults' reasoning about counselling? This question sought to investigate the extent to which these variables are related. Previous research has been conducted in the fields of psychiatry and psychotherapy. The second 11 question was, does this relationship exist among people who are not seeking counselling services and who have had no prior experience with counselling? By including laypersons in the sample, a broader picture of the relationship between the two variables is possible. Thirdly, are there noticeable patterns and attitudes reflected in the responses provided by the participants when the data are organized according to ego development levels? This question sought to gain a more subjective view of how reasoning about counselling is related to adult levels of ego development. 12 II. Literature Review This chapter begins by tracing the origins of Loevinger's concept of ego development, outlining Loevinger's definition of ego, and describing the sequential stages of ego development. A review of the literature surrounding the measurement of ego development includes a discussion of the discriminant and incremental validity of Loevinger's (1976) measurement of ego development, the Washington University Sentence Completion Test (WUSCT). Research in the field of ego development and mental health is reviewed with particular attention focused on typical symptom patterns and behaviours that occur at different levels of ego development. The literature surrounding the particular relationship between ego development and mental health treatment requests is also discussed. The chapter ends with a description of how the current study contributes to the research literature. Loevinger's Construct of Ego Development "Personality theories often lack an appreciation of development, and developmental theories often lack an appreciation of individual differences. Jane Loevinger's work on ego development bridges the gap between these two domains." (Westenberg, Blasi, & Cohn,1998, p. 12). In the words of Loevinger (1976), "individual differences in character have interested men for centuries. Interest in how character is formed in childhood and youth is also ancient. But to see those two phenomena as manifestations of a single developmental continuum is a modern twist. That insight is the i origin of ego development as a formal discipline" (p.3). Hy and Loevinger (1996) refer to ego development as the "master trait" (p. ix) - a "hidden hand" to intelligence. Like intelligence, ego level "appears to be a major 13 determinant in measurable individual differences." This section discusses Loevinger's conception of the ego, how the ego develops, and how it is measured empirically. What is ego? Contrary to psychoanalytic thought, ego, for Loevinger, is not merely a collection of functions, or instinctual drives. Rather, ego is the process of how these functions are synthesized. Ego is one function encompassing personality, individuality, and overall attitudes towards life and self. The ego can be understood as a "self-theory" (Harre, 1989). Similar to the notion of an internalized life story, the ego can be compared to a theory that we have about ourselves; an integrative "narrative" that permits our self- recognition and provides life with meaning (Young-Eisendrath & Foltz, 1998, McAdams, 1998). Loevinger (1976) herself described the ego as a holistic construct subsuming other developmental domains such as stages of moral development (Kohlberg, 1969, 1981; Piaget, 1932), stages of interpersonal understanding (Selmen, 1980) and developmental sequences of intellectual or worldview conceptualizations (Perry, 1970). Loevinger (1976,1998) suggested that ego development represents the integration of four "inextricably interwoven" personality characteristics: cognitive style (conceptual complexity and cognitive development); interpersonal style (attitudes towards interpersonal relationships and other people); conscious preoccupations (the principal focus of conscious thinking and behaviour - e.g., the extent to which one conforms to social rules) and character development (moral development). Research investigating this claim (Novy et al., 1994) supports Loevinger's conception of the ego as a broad construct that encompasses a range of personality characteristics. 14 Critics of developmental theory suggest that it is difficult to differentiate between the construct of ego development, and general intelligence, or cognitive development (Sanders, Lubinski, & Persson Benbow, 1995). This assertion will be discussed in more detail in the section "Measuring Ego Development" below. Generally research has shown that there is a clear distinction between the structural development of cognition, and structural development of the self, or ego. How does the ego develop? Different theorists have slightly different ideas about how the ego develops. Ego development has been described as both a gradual evolutionary process, as well as a series of distinct stages. H . S. Sullivan (1953) might explain it as a process of keeping the self-system free from anxiety. Observations which are discordant with one's frame of reference are anxiety producing. New meanings (which are concordant with one's observations) are contemplated in order to avoid this anxiety. As new meanings are created and integrated into one's "self-system," so the ego develops. Developmental psychologist Robert Kegan (1994) described the process of moving from one developmental level to another as a voyage into the unknown; "The early voyagers, from their perspective, risked their very lives when they sailed near to what they regarded as the edge of the universe. Neither the world as they know it nor their very way of knowing it would be the same after the voyage as before it. Likewise, a change in our order of consciousness is not just a change in the figures of our attention, it is a change in the very ground from which we attend. The extraordinary voyage that sets out to discover a new part of the world ends up being a voyage to a new way of understanding what the world is" (p. 266). 15 Stages of development can be viewed as "paradigms of meaning" based on people's actual narratives of themselves and others around them (Loevinger, 1998). Manners and Durkin (2001) explain Loevinger's concept of a developing ego as "the progressive redefinition or reorganization of the self in relation to the social and physical environment.. .Each sequential stage represents a restructuring of the self-system toward greater self and interpersonal awareness, conceptual complexity, flexibility, personal autonomy, and responsibility" (p. 542). Similarly Westenberg, Blasi, and Cohn (1998) note, "Because ego development concerns what is central to the person as person, moving from one stage to the next could be [viewed as] more like a personal conversion..." (p. 25). The particular progressive sequence in which movement occurs from one stage to the next is referred to in the literature as "sequentiality." For stage developmental theories such as Loevinger's, establishing the sequentialitiy of the stages is of utmost importance. Sequential changes come about as a result of the "internal logic" of the developmental continuum, not by external factors (Manners & Durkin, 2001). A closer examination of the sequentiality of Loevinger's ego development stages follows a brief description of each stage. Descriptions are offered in the first person to aid in comprehension, and are solely derived from Hy and Loevinger's (1996) own descriptions. The first stage: The ego begins with the differentiation of the self from others, but at birth, babies do not have this ability. The first stage, also known as the presocial stage, is then considered more of a theoretical stage (Young-Eisendrath, 1982). This stage cannot be measured using the WUSCT because it is pre-verbal. At this stage I am focused on the gratification of my immediate needs. I am strongly attached to my mother. As I learn to speak, I will learn to differentiate myself from others. 16 E2 -Impulsive Stage: At this stage I am demanding and impulsive as I continue to establish a separate identity. I understand others in black and white terms - good people give me things, mean people do not. I am very present-centered. I do not understand rules, and make little sense of causation. I am curbed by rewards and punishments and restraints, but I perceive punishment as retaliatory. I cannot tell the difference between feeling bad physically and feeling bad emotionally. E3 Self-Protective Stage: At this stage I begin to have the ability to control my impulses. I understand rules, but the main rule is don't get caught! I am quite wary of interpersonal relationships and I tend to blame others when I get into trouble. Many people describe me as "opportunistic" and "hedonistic" -1 like immediate gratification, and don't really have any long term goals, or ideals that I live by. I tend to see life as a "zero-sum game." If I am an adolescent or an adult at this stage, I may be considered an "operator" or in extreme cases, a sociopath. E4 Conformist Stage: At this stage I am a person who is much more group-oriented than egocentric. I identify myself with my peers and the people who are in positions of authority, like my parents, teachers, or boss. I am preoccupied with being accepted socially, with material things and with my appearance. People often describe me as "conventional" because I believe "there is a right way and a wrong way, and it is the same for everyone all the time, or at least for broad classes of people described in demographic terms" (Hy & Loevinger, 1996, p. 5). I do not really recognize individual differences - 1 tend to judge people by their external behaviours rather than their intentions, for example, " A l l teenagers are rowdy and that's why he is rowdy." I tend to see outsiders as "weird" or "stupid." 17 E5 Self-Aware Stage: By this stage I have learned that it is actually impossible for anyone (self included) to conform perfectly to stereotypical roles, and I now believe that everyone is entitled to his or her own opinion. I perceive my interpersonal relationships as feeling-oriented, not just action-oriented. I can make a distinction between "who I ought to be" and "who I am." I begin to understand myself as distinct from the group, and I have more ability to conceptualize my "inner life." I begin talking about my goals and plans somewhat concretely. I am also more open to multiple possibilities, rather than upholding absolute rules and statements. E6 Conscientious Stage: At this stage I am a person who has solid long-term goals and who works towards them. I have ideals, and I am a reflective person. I understand that life presents us with choices on a daily basis, as well as in the long run. I have greater conceptual complexity than people at lower levels of ego development, in the sense that I separate "morality" from conventional rules and preferences. Even though I may still conform to rules, the rules themselves are not as important as the motives and consequences surrounding the rules. For example, I do not feel guilty about breaking the rules, but I do feel guilty about hurting another person. By this stage I have learned to engage in self-criticism, and evaluate my long-term goals in terms of my own values - "I approve or disapprove of a given conduct not just because my family or my schoolmates or the authorities do, but because that is what I personally feel." (Hy & Loevinger, 1996, p.6). Appropriateness and priorities are taken into account when deciding between right and wrong. I value achievement, and see work as a means of achieving the standards one has set for him/herself. I also tend to think more about the social problems. Sometimes I feel too much responsibility for others. 18 E7 Individualistic Stage: At this stage I am more tolerant still of individual differences and I become more and more distant from role identities. I am more focused on my subjective experience rather than objective reality. I differentiate between my inner and outer self. I am more aware of my own internal conflicts and have to work hard at becoming more tolerant and accepting of myself. Emotional dependence concerns me, and I view relationships with other people as somewhat antagonistic. They often get in the way of me accomplishing my goals. I continue to struggle with the pursuit of personal freedom and interpersonal responsibility. I am learning how to tolerate the inevitability of inner conflict, to transcend polarities, and to recognize paradox with humour. E8 Autonomous Stage: At this stage I recognize others' need for autonomy. I understand and believe that people need to make their own mistakes and find their own way in life. This even extends to my children. I have stopped feeling responsible for others, and have stopped the excessive striving characteristic of lower ego stages. I see the multifaceted nature of real situations and people versus perceiving things as morally right or wrong. I recognize the conflict between needs and desires, without trying to solve it - this is part of the human condition. I recognize parody and have a high tolerance for ambiguity. I no longer strive for achievement, rather for self-fulfillment, and self-actualization. E9 Integrated Stage: At this stage I am among less than one per cent of the population of America. I am what Maslow referred to as a "self-actualized" person - someone who is growth-motivated, seeking to understand his or her intrinsic nature, and seeking to achieve integration, or "synergy" within the self (Masow, 1962). At this stage I am able to fully reconcile inner conflicts and integrate paradoxes. The complexities that I, at one time, was only just aware of, that I then gained an acceptance of, I now understand. People describe me as "wise," and "broadly empathic." 19 The most convincing evidence of the sequentiality of Loevinger's stages is found in longitudinal studies. Redmore and Loevinger (1979) conducted a large-scale study of adolescents representing a wide cross section of ethnic background, socio- economic status, and level of education. A l l participants whose re-test interval was greater than one and a half years were shown to have a statistically significant increase in ego development scores upon re-test. More recently, Westenberg and Gjerde (1999) analyzed data from 97 males and females whose level of ego development was measured at ages 14 and 23 years. Both genders showed a significant increase in ego development scores over the nine year period. The average growth was one and a half ego development stages. The sequentiality of Loevinger's stages has been challenged by research that has shown some individuals to decrease in ego stage over time (Adams & Fitch, 1982; Loevinger et al.,1985; Redmore, 1983). Researchers hypothesized that for those participants who perceived their environment as threatening, a regression to less complex, more secure ways of functioning would occur. However, formal research into the causes of such regression has not been performed to date. The construct of ego development can be more fully comprehended by examining its measurement, a discussion of which follows. Measuring Ego Development In 1968 Loevinger devised the "Washington University Sentence Completion Test" (WUSCT) to empirically measure her construct of ego development. The WUSCT asks the individual to complete 36 sentence stems such as "When I am nervous, I..." and "When a child won't join in group activities..." Responses to the sentence stems are 20 scored, and averaged. The total score indicates the individual's current level of ego development. Much of Loevinger's (1976) conception of the ego and its development was formulated through examination of empirical data generated in the form of responses to these sentence stems, rather than from theory per se. This section discusses the uses of projective tests in general, as well as the discriminant (conceptual) and incremental validity of the Washington University Sentence Completion Test in particular. Projective tests have been described as a "relatively unstructured task, that is, a task that permits almost an unlimited variety of possible responses. In order to allow free play to the individual's fantasy, only brief, general instructions are provided" (Anastasi & Urbina, 1996, p. 411). Some of the more popular projective tests include the famous Rorschach inkblot test, the Thematic Apperception Test (TAT), and human figure drawings. Yet there has been growing controversy over the use of these projective techniques for psychological assessment (Grove & Barden, 1999; Joiner, Schmidt, & Barnett, 1996; Lilienfeld, Wood, & Garb, 2000; Sharkey & Ritzier, 1985). For example, use of the Rorschach, which asks participants to describe what they see in a series of ten inkblots, may lead to the overperception of psychopathology (Garb, Wood, Lilienfeld, & Nezworski, 2002). Clinicians who use the TAT have been known to overdiagnose psychological disturbance (Lilienfeld, Wood, & Garb, 2001). Research indicates that test results from the Draw-a-Person: Screening Procedure for Emotional Disturbance (DAP: SPED; Naglieri, McNeish, & Bardos, 1991) often bear no significant relationship to personality or to mental illness (Motta, Little, & Tobin, 1993; Thomas & Jolley, 1998). "Although the Rorschach, TAT, and human figure drawings are the most commonly used projective techniques, the WUSCT is arguably the most extensively 21 validated one" says Lilienfield and his colleagues (2002, p. 461). Over the last 30 years, the WUSCT has been used in over 300 studies and translated into at least 11 languages (Westenberg, Blasi, & Cohn, 1998). Substantial empirical support for the conceptual soundness of the theory and its measurement continues to accumulate (Lilienfeld et. al, 2000; Manners & Durkin, 2001). A review of the literature on the discriminant validity of the WUSCT follows. As discussed above, three central tenets of ego development theory have been largely supported in the literature: the unitary nature of the ego, the four interwoven aspects of the ego (character development, cognitive style, interpersonal style and conscious preoccupations), and the sequentiality of the stages. Also discussed above, critics of ego development theory have questioned the discriminant validity of the WUSCT stating that ego development is simply a measure of intelligence. A recent study (Cohn & Westenberg, 2004) published in the Journal of Personality and Social Psychology does not support this assertion. Cohn and Westenberg (2004) conducted a meta-analysis of 42 studies with a total of 5,648 participants. The researchers recovered 52 independent correlations between ego level (measured by the WUSCT) and intelligence. The weighted average correlations ranged from .20 to .34 depending on the intellectual ability assessed (e.g. verbal test, achievement test). For each type of intelligence test, weighted correlations between ego level and intelligence test scores were computed. For example, the weighted average correlation between ego level and measures of verbal intelligence was .32. The weighted average correlation between ego level and measures of knowledge and achievement were .20. Adjusting for measurement error had minimal impact on these values. These small 22 correlations suggest little overlap between the two underlying constructs, and so provide further evidence for the discriminant validity of the WUSCT. The nature of the relationship between ego level and individual differences in verbal abilities (verbosity, word fluency, vocabulary) has also been the focus of investigations into the discriminant validity of the WUSCT. Loevinger herself was particularly interested in this area of research. In one sample of 204 women, Loevinger and Wessler (1970) found a median correlation of .31 between level of ego development and number of words used in WUSCT responses. In another sample of 543 women, the median correlation was .35. Again these moderate correlations suggest that while ego development may be somewhat related to verbal ability, the WUSCT does not simply measure verbal ability. Discriminant validity of the WUSCT has also been investigated by addressing the relation between ego development and socio-economic status (SES). Redmore and Loevinger (1979) conducted a study using a large and diverse sample of adolescents from four different schools. Overall, there was a significantly positive correlation between ego stage and SES. Yet two of the four schools showed no relation between the two variables. In a more recent study conducted by Browning (1987), SES was moderately correlated with ego stage across gender and age. Snarey and Lydens (1990) investigated whether the relationship between SES and ego development is consistent across all environments. These researchers speculated that since SES is predominantly measured by education and occupation, work environment and work complexity would naturally confound this relationship. They hypothesized that in a work environment that promotes psychological development (such as a kibbutz community founded on principles of participatory democracy and economic equality), 23 education and occupation may not be related to ego development. They tested their hypothesis by comparing three samples of participants on ego development, SES, and work complexity. Snarey and Lyndon's (1990) hypothesis was confirmed - ego development was not significantly correlated with occupation and education among workers in the kibbutz, but was significantly correlated with these variables among individuals who lived and worked in urban areas. The researchers conclude that SES is not strictly related to ego development, and that sociopolitical factors (such as the equitable distribution of occupation in the kibbutz) are also relevant to ego development measurement' Some research has investigated the relationship between levels of ego development and gender (Cohn, 1991; Hauser & Safyer, 1994; Streich & Swensen, 1985; Truluck & Courtenay, 2002). Studies suggest that gender differences in ego development are moderately large during adolescence, with females scoring higher (Cohn, 1991). These differences decline significantly among college aged men and women (Streich & Swensen, 1985), and disappear entirely among older adults (Truluck & Courtenay, 2002). These findings suggest that ego development may be a variable distributed relatively equivalently across different adult age groups. The incremental validity of a measurement is known as "the extent to which the measurement adds to the predictive validity already provided by other measures" (Gleitman, Fridlund, & Reisberg, 2003, p. 623) or the extent to which the test adds to what is already known. Some speculate that "contemporary measures of 'moral reasoning' and 'ego development' probably add little to the prediction of meaningful psychological phenomena over conventional general ability measures" (Lubinski & Humphreys, 1997, p. 191). Certainly few relevant studies have been published that 24 address the incremental validity of the WUSCT. Yet the existing literature seems to support the predictions generated by ego development theory. For example, Hart and Hilton (1988) investigated the relationship between ego development level and patterns of contraceptive use among female adolescents. These researchers found that the degree of consistency in the use of contraception was predicted by participant's ego development level. Similarly, Cohn and Westenberg's (2004) meta-analysis of 42 studies (discussed above) tested the incremental validity of the WUSCT by statistically removing the influence of intelligence from ego level scores. Sixteen studies were located which examined a range of issues such as the relationship between ego level and aggressive behaviour, risk reasoning, openness to experience, and maternal sensitivity. Ninety-four percent of these tests of association showed a significant relationship between ego level and the criterion variables. For example, Loevinger's theory predicts that impulse control increases in strength as individuals progress through the lower stages. Research revealed that ego level scores are negatively correlated with disruptiveness (Luthar, 1991) and positively related to impulse regulation (Browning, 1986) and complexity of risk judgments (Cohn, 1984). Loevinger's model predicts that as an individual matures, his or her egocentric orientation is replaced with an increasing capacity for perspective taking. Studies revealed a positive relation between ego level and tolerance (Helson & Roberts, 1994), nurturant parenting (Jacobson, Jacobson, & Frye, 1991), and community volunteer status (Morros, Pushkar, & Reis, 1998). Aggressiveness and delinquency were negatively correlated with ego level (Browning, 1986; Frank & Quinlan, 1976). Loevinger's theory also predicts that individuals at the Conformist (E4) and Self-Aware (E5) stages are concerned with social status and social approval. Once again, Cohn and Westenberg's 25 (2004) meta-analysis, after controlling for intelligence, revealed that individuals at the conformist level showed a greater likelihood to experience shame (Einstein & Lanning, 1998) as well as an increased fear of negative social evaluation (Westenberg, Sieblink, Warmenhoven, & Treffers, 1999). A considerable amount of research on the validity of ego development theory has taken place over the last 30 years. The review of the literature suggests that such research largely supports the validity of ego development theory and its measurement. Despite these findings, important gaps still remain in the literature. For example, more research is needed to clarify the different rates that people progress through ego development stages, as well as when and why some people experience ego stage regression. The next section, addresses how the construct of ego development relates to aspects of mental health. Ego Development and Mental Health Research that has examined the ego development level of individuals presenting for psychiatric and psychotherapeutic treatment has shown a systematic relationship between developmental level and typical symptom patterns (Noam et al., 1984; Noam & Dil l , 1991; Noam & Houlihan, 1990; Recklitis & Noam, 1999; Vincent & Castillo, 1984; Vincent & Vincent, 1979). Noam et al. (1984) collected a sample of 57 boys and 57 girls, aged 12 to 16, who were inpatients at a major psychiatric teaching hospital in Boston. The participants represented a wide range of mental health diagnoses including neuroses, psychoses, and character disorders. Participants completed the WUSCT while their mothers completed the Achenbach Child Behavior Checklist. Only 21.1 percent of the 114 adolescents had reached the conformist level (E4) or above. A l l but five scales of the Achenbach syndromes were correlated significantly with ego development. The following scales produced significant moderate and substantial 26 negative correlations: "Somatic Complaints," "Aggressive Delinquent," "Anxious- Obsessive," "Depressive-Withdrawal," "Immature," and "Hyperactive." Significant negative correlations were also found for the broad-band syndromes ("externalizing" and "internalizing"). The researchers also noted that the conformist adolescents (highest ego level in the sample) were consistently high on guilt and depression. They called for the use of adolescent samples consisting of higher levels of ego development, as well as the use of adult samples, to clarify the relationship between "internalizing symptoms" and levels of ego development. Additional research suggests that maturation of developmental capacities does not always lead to better adjustment. In a study of adolescent suicidally, it was found that some adolescents became more vulnerable to suicidal ideations and behaviour with increasing ego development (Borst, Noam, & Bartok, 1991). Although suicidality is prevalent among adolescents at the lower ego development levels, it usually coexists with internalizing problems and disorders (Borst & Noam, 1993). Adolescents in the middle stages of ego development are more prone to self-rejection, and more likely to see intrapsychic and interpersonal problems within themselves than individuals at the lower levels (Borst & Noam, 1993, Noam & Houlihan, 1990). In this light, the "mature" tendency not to externalize and blame others, as is typical of individuals at the lower levels of ego development, could pose a risk factor in a vulnerable individual or population, leading to an increase of depression and suicidality. This research questions Loevinger's assertion that higher stages of ego development are more adaptive. As Noam states, " A person may use more advanced intellectual and social capacities to develop a consistent theory of self, but one that is based on self-hate and self-rejection" (p. 47,1993). Noam reminds the reader that 27 particularly among clinical populations, ego "maturity" may be in stark contrast to the "holistic integration" that typically describes Loevinger's highest levels of ego development. Scoring at a higher level stage does not always mean that a balance, integration, and holism have been achieved. Noam and Dill 's (1996) research with adult psychiatric outpatients tested the hypothesis that individuals at higher stages of ego development are "shielded" from the need for psychiatric treatment. Noam and Di l l predicted that their sample, consisting of 86 adult psychiatric outpatients, 46 percent of whom had an Axis II diagnosis, would contain at least a few individuals who scored at the higher levels of ego development. Participants were asked to complete the WUSCT and the Symptom Checklist, or SCL- 90-R (Derogatis et al. 1976), a 90-item self-report inventory of current psychiatric symptoms. Patients in the sample ranged from the second least mature stage of ego development to the second most mature stage (E3-E8). Twenty-five percent of the sample scored at level E6 - Conscientious level, or higher. The modal stage for both men and women in this sample was E5 - Self-A ware. There was no tendency in this sample of psychiatric patients for ego stages to be lower than is found for non-patients of similar age. The sample represented a normative adult outpatient group in terms of global symptom severity and in terms of specific symptoms of the SCL -90. Correlations between the WUSCT scores and the SCL-90-R Global Severity Index and symptom dimension scores were negative for both men and women. This finding indicates that among this sample, symptomatology on every dimension tended to decrease as ego development increased. 28 The above literature highlights the importance of considering the relation of ego development to certain mental health issues. Generally, research indicates that as ego development increases so does one's ability to face and overcome personal mental health challenges (Noam & Di l l , 1996). Interestingly, research supports the assertion that certain mental health challenges are related to particular levels of ego development (Borst et al., 1991; Di l l & Noam, 1990; Noam et al., 1984). Research also demonstrates that people at higher levels of ego development can face significant mental health challenges (Borst & Noam, 1993; Noam & Di l l , 1996; Noam & Houlihan, 1990). The following section extends the review of ego development and mental health literature by focusing on counselling outcomes, and how ego development specifically relates to expectations of counselling. Ego Development and Expectations of Counselling Counselling Outcomes Much of the literature suggests that different therapeutic treatment modalities achieve largely similar results (Albon & Jones, 1988; Hellerstein, Rosenthal, & Pinsker, 1998; Lambert & Bergin, 1994; Miller, Duncan, & Hubble, 1997; Wampold, 1997). Leading outcome researcher Michael Lambert (1994) states, "Research carried out with the intent of contrasting two or more bona fide treatments shows surprisingly small differences between the outcomes for patients who undergo a treatment that is fully intended to be therapeutic" (p. 158). In fact, Lambert (1994) found that 40 percent of the variance in outcome is due to the client, and factors in the client's life, rather than from specific techniques or interventions that the therapist performs. Okiishi, Lambert, Nielson, and Ogles (2003) focus on neither treatments, nor the client as the unit of analysis in their research. These researchers note that some therapists 29 are much better than others at facilitating change in their clients. They state, "research about effective treatments generally assumes that the individual therapist is a relatively unimportant part of the outcome equations, rather than the central figure that facilitates patient improvement" (p.362). Results from Okiishi et al.'s (2003) study including 56 therapists and 1779 clients indicated that none of the four therapist variables (level of training, type of training, gender, or primary theoretical orientation) influenced patient outcomes. This supports the suggestion that it is the individual therapists, not the use of specific techniques, who are responsible for variation in client outcomes. Despite similar levels of symptomatology at intake, it was found that clients differed significantly on the rate of change depending on which therapist they were working with. Calling for more research that focuses on 'empirically supported therapists,' the researchers emphasize the importance of continued monitoring of how client progress may be a function of the individual provider. Despite one's personal beliefs about whether it is the therapist, the treatment, or the client that generates change, the trend toward evidence-based practice within mental health counselling is worldwide. Policy makers and practitioners alike emphasize the importance of using current research to inform therapeutic practice. Psychological associations across the globe list "best practices" for the treatment of various mental health problems, based on the most recent research available. Indeed, the premise that the practice of mental health counselling should be informed by the best available evidence is both logical and timely. Yet some practitioners continue to question the relevance of applying research conducted in the "sterile" environment of the laboratory to the more unpredictable environment of their counselling offices. Some treatments might be extremely effective, but are likely to fall short when clients perceive them as 30 unrealistically demanding, for example. The challenge for the clinician, then, revolves around determining which technique(s) or approach(s) are appropriate for individual clients at particular stages in their lives. Much research has demonstrated the value of engaging clients in conversations about exactly what type of therapeutic services they expect (Cruz & Pincus, 2002; Di l l & Noam, 1990; Duncan & Miller, 2000; Eisenthal & Lazare, 1972; Eisenthal et al, 1979; Frank, Eisenthal, & Lazare, 1978; Hubble, Duncan & Miller, 1999; Byon, Chan, Thomas, 1999; Lazare et al, 1972; Noble, Douglas & Newman, 1999; Rokke, 1999). These studies support the claim that therapeutic outcome is influenced in part by the extent to which the therapist meets the clients' expectations of counselling. The next section focuses specifically on clients' therapeutic expectations and levels of ego development. Therapeutic Expectations Research investigating how ego development level is related to therapeutic preferences and expectations has been limited. Generally, individuals at lower levels of ego development expect therapy to be directive and largely therapist-driven. Individuals with higher levels of ego development expect therapy to be more client-driven, and more introspective (Dill & Noam, 1990; Noam & Dil l , 1996, Young-Eisendrath & Foltz, 1998). Noam and Di l l (1996) examined the ego development levels and treatment requests of 102 patients presenting for treatment at the Adult Outpatient Clinic at McLean Hospital, the largest psychiatric facility of Harvard Medical School. The researchers were curious, in part, i f level of ego development was related to patients' treatment needs. Understanding that individuals who function at lower levels of ego development are typically concrete, non-reflective, and focused on immediate 31 gratification, the researchers hypothesized that these individuals would request treatment that offered concrete, immediate intervention. Similarly, individuals functioning at the higher levels of ego development who are typically complex, self- reflective and focused on self-development, were hypothesized to prefer insight-oriented treatment, or treatment which was more conducive to self-exploration. Participants were administered the WUSCT and the Patient Request Form (Lazare et al., 1972). The modal stage of ego development for men and women was E5, the Self - Aware stage. As hypothesized, treatment preferences did vary with ego maturity. "Psychodynamic insight" was significantly more likely to be requested by patients at higher levels of ego development than by other patients. "Triage/referral," "reality contact," and "social intervention" were significantly more likely to be requested by patients at lower levels of ego development. The researchers highlight the importance of considering patients' (or clients') cognitive and interpersonal capacities when choosing treatment plans and interventions. Knowledge of a client's ego development level may help predict, to a certain extent, the types of preferred treatment. For example, based on ego development theory, individuals functioning at E5, the Self-Aware level, are likely to request a variety of treatment modalities. Individuals at this level have gained the capacity to be objective, and self-reflective, yet also expect a relatively concrete and support-giving relationship with their therapists. This contrasts with a more autonomous perspective at the higher ego levels, where individuals prefer a more collaborative relationship with their therapists. Similarly, individuals at the lower ego development levels, who typically lack self-awareness, and tend to locate conflicts outside the self, prefer a therapeutic alliance that provides support and direct help with social skills (D'Andrea & Daniels, 1992; Dil l & Noam, 1990; Loevinger, 1980; Noam & Di l l , 1996). 32 Several researchers report using the concept of ego development to aid their clinical practice with adolescents and adults (Bjorklund, 2000; Bruce, 1984; D ' Andrea & Daniels, 1992; Manners, Durkin, & Nesdale, 2004; Pieretti, 1996; Rowan, 2004; Swensen, 1980; Young-Eisendrath, 1982). These studies have noted that certain types of therapeutic approaches and interventions are better suited for clients functioning at different ego development levels. For example, for individuals functioning at E2, the Impulsive stage, behavioural therapy, modeling and social skills/self-management training proved to be effective interventions (Bruce, 1984). At the Self-Protective stage, E3, clients were better suited to Reality Therapy and behaviour modification. Researchers found that using Gestalt Therapy interventions that encourage vivid expression of thoughts and feelings, were very helpful for clients who scored at E6 - the Conscientious stage. Similarly, the Existential Therapy approach that involved discussions about inner conflict, self-understanding, and self-actualization was particularly helpful for clients who scored at E8 the Autonomous stage (Manners, Durkin, & Nesdale, 2004). The distinction between the practice of psychotherapy and the practice of counselling has been highlighted in the mainstream mental health literature, yet this distinction remains a gap in the field of ego development research. Traditionally "psychotherapy" has been the term used in medical settings such as psychiatric units and out-patient clinics (Blake, 2004). Indeed, much of the ego development research has been conducted in these settings (Borst & Noam, 1993; Borst, Noam, & Bartok, 1991; Di l l & Noam, 1990; Noam & Di l l , 1991; Noam & Houlihan, 1990). Yet some practitioners believe that "psychotherapy" represents a much deeper, more fundamental process of change, reserved for the more disturbed clients - a process that is quite distinct from counselling (Palmer & McMahon, 1997; Worden, 1991). Psychotherapy is seen to focus 33 on the unconscious, while counselling focuses on the "here and now" (Woolfe, 1997). Psychotherapy is perceived as treating "personality" problems, while counselling treats reality-oriented problems (Arbuckle, 1967). Psychotherapy is seen as a long process, while counselling is considered to be relatively brief (Clarkson, 1994). Counselling practice typically encompasses a broader network of services than the practice of psychotherapy (McLeod 2001). Kirkwood (2000) surveyed the application of both "formal counselling" and "counselling skills" in an island community in Scotland. He found that in one year, 2.15 percent of the population had received formal counselling, while 23.1 per cent had received help through the use of counselling skills by an advice worker, social worker, or health professional. This study highlights the fact that, particularly in non-urban areas, the term "counselling" refers to mental health services provided at schools, colleges, churches, and workplaces, as well as to those provided at health clinics and community agencies. This study seeks to expand the ego development and mental health research by focusing on the relationship between adult levels of ego development and adult reasoning about counselling. Fifty adults living in non-urban areas in Southwestern B C participated in the study, 30 of whom had no prior experience with counselling. Participants completed the WUSCT (Short Form) to measure ego development (Appendix A), and the Reasoning about Counselling (RAC) questionnaire (Appendix B). The R A C is a questionnaire adapted from Young-Eisendrath and Foltz's (1998) RAP questionnaire. It asks individuals four open-ended questions about their expectations of, and attitudes towards, counselling. The distributions of ego development levels within the sample are presented. Variables such as age, gender, level of education, income, ethnic origin, and experience with counselling are noted. Formal correlations are drawn between the 34 variables, level of ego development and reasoning about counselling. Distinctions are drawn between participants who have had experience in counselling and those who have not. Verbatim responses to the four R A C protocol items (e.g. "What is counselling?" and "What does a counsellor do?") are presented ordered by developmental level. Noam (1992) states, "Many times we stress our patients with an interpretation that far exceeds their capacity to self-observe" (p. 690). The application of ego development theory to the practice of counselling psychology challenges the clinician to acknowledge a client's personal strengths and resources, and to support the client's expectations about counselling and the process of change. By identifying the client's underlying developmental frame of reference, counsellors are more likely to recognize the potential limitations of their most favoured therapeutic tools and instead, provide their clients with interventions that meet the needs of the client directly. Systematically planning, implementing, and evaluating interventions that match the client's frame of reference may heighten the probability for successful therapeutic encounters. Summary This chapter has reviewed a diverse range of studies addressing Loevinger's construct of ego development and how the construct relates to mental health symptomatology and expectations of counselling. The findings generally support the validity of Loevinger's ego development theory and its measurement, although certain aspects of the theory require further investigation. The literature has shown that generally, while individuals at higher levels of ego development are not free from mental health challenges, they are better able to face and overcome these challenges. Further investigation into the relationship between particular mental health vulnerabilities and 35 different ego development stages is required. The literature also supports the notion that an individual's expectations of psychotherapy can be related to his or her level of ego development. Several studies suggest that the construct of ego development can be useful when formulating treatment plans and interventions for mental health clients. This study extends the research literature by investigating the relationship between ego development levels and adult reasoning about counselling. The relationship between these variables will be examined qualitatively and quantitatively by answering the questions; is there a relationship between adult levels of ego development and adults' reasoning about counselling? Does this relationship exist among people who have had no prior experience with counselling? And are there noticeable patterns and attitudes reflected in the participants' responses when the data are organized according to ego development levels? It is expected that results from this study support previous research which suggests that individuals at different stages of ego development have different attitudes towards the therapeutic process. i 36 III. Method This study investigates the hypothesis that a relationship exists between an individual's reasoning about counselling and his or her level of ego development. This chapter begins by reviewing the "mixed methods" research design used in this study. The recruitment of participants is described. The two measures used in this study, the Washington University Sentence Completion Test (Loevinger, 1976), and the Reasoning About Counselling Questionnaire (adapted from Young-Eisendrath & Foltz, 1998), are reviewed. Methods of collecting, preparing, and analyzing the data are described. Mixed Methods Research Traditionally, correlational studies investigating the relationship between two variables are associated with the quantitative approach to research. A "mixed methods" research design has been used for this study. Mixed methods procedures use both quantitative and qualitative methods of gathering and presenting data in a single study. There are different types of mixed methodology strategies largely differentiated by whether the quantitative and qualitative data are collected at one phase, or at separate phases throughout the study. This study employs a "concurrent nested strategy" (Creswell, 2003). This model collects both types of data in one phase. The term "nested" refers to the primary use of one source of data (qualitative or quantitative), within which the other method is "nested." Often the nested method addresses a different question from the dominant method, giving the researcher a broader perspective from which to analyze results (Tashakkori & Teddlie, 1998). This study uses qualitative data to enrich the understanding of a primarily quantitative study. The primary focus of the study is to examine the relationship between ego development and reasoning about counselling. The secondary focus of the study is to 37 provide the reader with rich, subjective descriptions of people's attitudes towards counselling at each level of ego development. By integrating two forms of data in the analysis and interpretation phases of the research, the reader will gain a more comprehensive understanding of how ego development may be related to reasoning about counselling. Recruitment of Participants Participants for this study were volunteers recruited from three government health units in the Vancouver Coastal region of British Columbia. The offices are located in Squamish, Whistler, and Pemberton. These health units provide a variety of services including audiology, mental health counselling, planned parenthood, and environmental consultation. In Whistler and Pemberton the health offices use the same waiting room as the local doctors' offices. Permission to recruit participants was solicited from Vancouver Coastal Health Authority (Appendix D) and subsequently granted (see Appendix E). Participants were not limited to people accessing services directly from the health units. Participants included people waiting for appointments at nearby doctors' offices, as well as some staff of the health units. Notices soliciting volunteers for the study were displayed on the front desks of the health units (see Appendix F). Questionnaire packages were also on the desks. As people checked in for their appointments they were invited to join the study (see Appendix G - "Statement by front desk staff). Potential participants were instructed to take a questionnaire package and read the explanatory letter (Appendix H). Participants had to be 19 years of age or older, and were assured that their privacy would be protected by not putting their name anywhere on the questionnaires. Participants were instructed to return 38 the questionnaires in the sealed envelope to the health unit desk, or alternatively, they were given a label and stamps to mail the questionnaire to the researcher at the Department of Educational and Counselling Psychology, and Special Education at the University of British Columbia. On 10 occasions the researcher joined the staff in the health units for the purposes of recruiting participants. Participants were recruited over a four month period, from August 17, 2004 until December 23, 2004. The study was closed after four months, with a total of 50 participants. (For a detailed description of the sample, please see the "Results" section (pp. 52 - 55). Measures The Washington University Sentence Completion Test (WUSCT) The WUSCT is a semi-projective measure which asks individuals to complete the stems of 36 sentences (Loevinger & Wessler, 1970). The test generates two scores representing the test-taker's level of ego development. The first score is the "item sum score" or ISS. Responses to each item on the test are individually assigned a score from two to nine (representing each level of ego development) according to a standardized scoring protocol. Scores are added together to produce the ISS. This score is most often used in correlation studies (Dill & Noam, 1990) and is used in this study. The second score is the ogive "total protocol rating" or TPR. This is an overall stage score that the rater assigns after he or she has looked at the whole test protocol, not just the individual items. The TPR is typically used in descriptive studies. It is also used in this study. For an extensive discussion of the discriminant and incremental validity of the WUSCT please see Chapter II, pages 21 to 24. In this study the Short Form of the WUSCT Form 81 is used to measure ego 39 development (Appendix A). Given that participants were volunteering their time, and were asked to fill out two questionnaires, the Short Form was chosen due to the reduced amount of time required to complete the measurement. When using the Short Form of the WUSCT, researchers can choose between using the first half and the second half of the full 3 6-item measurement. The Short Form consisting of the first 18 items was chosen for this study due to its slightly stronger internal consistency (see below) (Novy, Blumentritt, Nelson, & Gaa, 1997). In addition, the first 18 items of the WUSCT are identical for women and men, facilitating distribution of the measurement. (Of the last 18 items on the WUSCT, six items differ in the use of the pronoun "he/she" or noun "woman/man" necessitating different forms for males and females). Studies investigating the psychometric comparability of the two halves of the WUSCT generally support parallelism. Novy et al. (1997) performed a study with 85 adult outpatients from a pain center in the southern United States. The 36-item WUSCT Form 81 (Hy & Loevinger, 1989) was administered to participants as part of a pre- treatment assessment battery. Two trained raters scored the WUSCT protocols using the item-sum scoring method. Individual responses were scored and added together to calculate scores on each half of the WUSCT. Interrater agreement based on independent ratings was .95 (Pearson's correlation). The means and standard deviations for the item-sum scores on the two halves of the WUSCT were 94.67 and 11.61, and 97.51 and 8.42, respectively (Novy et al., 1997). Coefficient alpha for the first and second halves were .82 and .76 respectively. The correlations of the first and second half item sum scores with the 3 6-item sum scores were .94 and .87 respectively. These results suggest that the two halves of the WUSCT have highly similar psychometric properties and may be used interchangeably. 40 The Reasoning about Counselling Questionnaire ( R A O The R A C asks individuals four open-ended questions about their attitudes towards counselling; "What is counselling?"; "What does a counsellor do?"; "What does a client do?"; and "Do you think counselling can change people? If yes, how? If no, why not?" The R A C also asks individuals whether they are currently attending or have ever attended counselling, and i f they have ever worked as a professional counsellor (see Appendix B). The R A C is based on the Reasoning about Psychotherapy (RAP) questionnaire designed by Young-Eisendrath and Foltz (1998). The R A C differs from the RAP by replacing the word "psychotherapist" with the word "counsellor". There are six possible response categories to the four items on the questionnaire. "Although the content varies across RAP [RAC] questions, each set of six categories is based on an underlying developmental sequence ordered from less to more complex, from concrete to abstract from less to more agency and personal responsibility, and from conceptions of psychotherapy that are linear or unidimentional to ones that are relational" (Young- Eisendrath & Foltz, 1998, p. 320). For example, the six categories for the R A C item, "What Does a Counsellor Do?" are: 1. Concrete provision; 2. Support and problem- solving; 3. Emphasis on counsellor's skills; 4. Counselling as a special relationship; 5. Emphasis on the client's agency and insight; and 6. Complex (Young-Eisendrath & Foltz, 1998). For each of the four item responses the participant is given a score from one to six. Scores are summed across each of the four R A C items for a total score. Young-Eisendrath and Foltz (1998) state the scoring manual for the RAP was composed and validated based on theoretical principles, as well as on data from a previous study. "Using moral, ego, and interpersonal development as a theoretical backdrop" (p. 320) the authors initially recorded five theoretical levels of "reasoning 41 about psychotherapy." These are "Concrete help," "Problem solving," "Expressing feelings," Processing feelings," and "Interpersonal discovery." These five levels were converted into relevant categories of response for each of the four RAP items. Young- Eisendrath and Foltz's (1998) pilot study was then conducted with 52 participants. Two raters scored the RAP protocols. The researchers amended their original categories based on the pilot subjects' actual responses. The final RAP manual consisted of six possible response categories for each question, as opposed to the previous five possible categories. The authors do not say specifically how or why they added an extra category after completing the pilot study. Two fresh raters scored the pilot subjects with 70 to 80 percent agreement. In order to focus specifically on subjects' reasoning about counselling, it seemed reasonable to replace the RAP term "psychotherapy" with "counselling," and the term "psychotherapist" with "counsellor" for the current study. Unfortunately, repeated attempts to contact Dr. Polly Young-Eisendrath for permission to do so have been unsuccessful (please see Appendix I, email dated February 29, 2004). This term therefore, was replaced without formal consent from the original author of the measurement. Demographic Data The third portion of the questionnaire package asked basic demographic questions including age, gender, marital status, level of education, household income and ethnic origin (see Appendix C). Data Collection One hundred and five questionnaire packages were handed out. Forty seven 42 participants completed the questionnaires while waiting for their appointments, or dropped off their questionnaires at the desk at a later date. Five questionnaire packages were received by mail. One questionnaire package was unusable as it was completed by a professional counsellor. One questionnaire package was unusable as it was submitted after the study was closed. Locked boxes were located at each of the health unit desks for the purposes of storing the completed questionnaire packages. These boxes were emptied monthly in Squamish, and weekly in Whistler and Pemberton. Twenty one sets of stamps and labels were handed out in total. Preparation of the Data The data for this study consisted of responses to the 18 WUSCT sentence stems, responses to the four R A C questions, and responses to standard demographic questions. Completed questionnaire packages were collected from the health units by the researcher and were also received by mail. Each package was assigned a number from one to fifty, and a location indicating whether the participant completed it (or dropped it off) in Squamish, Whistler, or Pemberton. The WUSCT data were prepared as they were collected (i.e. over a four and a half month period). Data from the WUSCT was divided according to Item responses. For example, responses to Item # 1, "When a child will not join in group activities..." were entered on one Excel spreadsheet. Responses to the second item, "Raising a family..." were entered on another spreadsheet, and so on. The R A C data were prepared after scoring the WUSCT and immediately prior to giving it to the independent raters to score. The R A C data were divided by the researcher in a similar fashion as the WUSCT data. Responses to the first R A C item "What is 43 counselling" were assembled in a word file. The responses to the second item, "What does a counsellor do?" were assembled and saved in a separate file and so on. The demographic data was prepared after scoring the WUSCT and preparing the R A C data. Demographic data for each participant was entered into the student version (10.0) of SPSS. Data was grouped according to age, gender, marital status, level of education, level of income, previous and/or current experience with counselling, and ethnic origin. Generating Additional Categories for the R A C Scoring Manual As mentioned above, repeated attempts to correspond with Dr. Young-Eisendrath were unsuccessful. Although the researcher finally received correspondence from Carol Foltz, Dr. Foltz was unable to locate Young-Eisendrath's scoring manual used in their study (see correspondence, Appendix J). It became necessary for the researcher to develop her own categories for three of the four R A C items, based on the original scoring manual for RAP Item number two (which is included in Young-Eisendrath and Foltz's [1998] published study.) This process of developing the item categories began by studying the theory behind the construction of the initial categories, and by closely looking at the division between the categories in RAP Item number two. The scoring manual for Item number two includes verbatim responses from participants at each level of reasoning about psychotherapy. In addition, Young-Eisendrath and Foltz's (1998) study included verbatim responses to the RAP items from participants at each level of ego development. These responses were used as examples to describe the current R A C categories. While there are clear differences between the concrete answers (level one) and the 44 complex answers (level six), initially it was difficult to determine on what basis, for example, a level four RAP response is considered lower than a level five RAP response. It was helpful to consider the five theoretical categories that Young-Eisendrath and Foltz had originally determined, from which the final RAP categories were generated - "Concrete help" "problem solving" "expressing feelings" "processing feelings" and "interpersonal discovery." Once again, these categories are "based on an underlying developmental sequence ordered form less to more complex, from concrete to abstract, from less to more agency and personal responsibility, and from conceptions of psychotherapy that are more linear or unidimentional to ones that are relational" (Young- Eisendrath & Foltz, 1998, p. 320). From the researcher's perspective, it seemed that the first four categories used in the RAP scoring manual for Item number two, match the first four theoretical categories that the researchers began with. For example, "Concrete provision" matches "concrete help," "support and problem solving" matches "problem solving," "emphasis on therapist's skills" matches "expressing feelings," and "counselling as a special relationship" matches "processing feelings." The fifth theoretical category "interpersonal discovery" seems to match RAP level six "Complex". If this is the case, level five (emphasis on client's agency and insight) was the new category added after Young- Eisendrath and Foltz's (1998) pilot study. In this light, the distinctions between the categories seem somewhat clearer. For example, while a level four response acknowledges that counselling is a special relationship where feelings are processed, where one can explore and understand self, the emphasis is still on the therapist to make this happen. It does not acknowledge that this 45 process is largely the responsibility of the client (level five response). A level five response acknowledges that a client must be motivated and committed to change and open to identifying patterns of behaviour. The counsellor is seen as someone who initiates and guides this process, as well as someone who "knows enough to pull out when the client is moving on her or his own" (Young-Eisendrath, 1998 p. 325). Level six goes one step further by talking more about the self and interpersonal discovery ("life journey"), emotional growth, personal development, and living in a more gratifying ways ("new ways of being and doing.") After reading Young-Eisendrath and Foltz's (1998) theory, and studying their data, it seemed logical to use the same category divisions as Young-Eisendrath used for Item number two for each of the three remaining R A C items. (These categories are "Concrete provision," "support and problem solving," "emphasis on therapist's skills," "psychotherapy as a special relationship," "emphasis on client's agency and insight," and "complex.") This decision was made because the titles of these categories seem to best reflect the developmental sequence upon which they are ordered. The final R A C scoring manual was sent to the thesis supervisor who confirmed that it represented a reasonable reflection of the theory. The process of generating categories for the three R A C items enabled the researcher to delve more closely into the theory behind Young-Eisendrath and Foltz's (1998) RAP categories. Young-Eisendrath and Foltz state that the initial categories were based at least partially on ego development theory (in addition to moral and interpersonal development theory). Despite the fact that these researchers used empirical data to verify these theoretical categories, their system of categorizing RAP levels remains based on the 46 ego development theoretical system. It is to be expected, then, that levels of ego development and levels of reasoning about counselling, are correlated. The qualitative portion of this study (see description below) yields somewhat more insightful information about participants' reasoning about counselling. Training the Independent Raters Two independent raters scored the R A C questionnaire. Each rater had a minimum Master's level education, and had experience with coding and scoring research data. Also, each rater worked as a counsellor, and so is familiar with the field of counselling. The raters were given the scoring manual consisting of the R A C category descriptions as well as examples of actual responses in each category taken from Young- Eisendrath and Foltz's (1998) data (Appendix K). The five theoretical categories used by Young-Eisendrath and Foltz to construct the original RAP categories were also given to the raters (i.e. "concrete help," "problem solving," "expressing feelings," "processing feelings," and "interpersonal discovery") to explain some of the theory behind the division in categories. The raters were instructed to look at reasoning rather than specific terms as they rated the responses. For responses that contained a combination of statements rated at different levels, the raters were instructed to rate the response according to the highest level. The raters were given the opportunity to ask any questions pertaining to the scoring manual, the reasoning behind the division in categories, or any part of the scoring process. Each rater of the R A C questionnaires was required to complete 10 practice exercises for each of the four items (40 in total) (Appendix L). The degree of proficiency expected from the raters on the practice exercise was 85 percent. Interrater agreement 47 based on independent ratings by the two raters was 0.9813 as calculated by Intra-class correlation coefficient. With such a high correlation, the two raters' measurements for the practice exercises are said to be in perfect agreement. Data Analysis Demographic Data The demographic variables of the sample were categorized according to gender, age, marital status, income, education, and minority classification. The sample was further grouped into two categories; participants with previous counselling experience, and participants with no previous counselling experience. Descriptive statistics were generated for these variables using the student version (10.0) of SPSS. WUSCT data The WUSCT was scored according to the guidelines outlined in the self-teaching scoring manual published by Hy and Loevinger in 1996. The researcher began by reading the scoring manual and completing the practice exercises for items 1 through 18. The practice exercises were completed over a one-month period beginning in September, 2004. For each item, a score of at least 85 percent on the practice exercises was achieved. Research indicates that i f the practice exercises are completed successfully, as they were in this study, inexperienced raters gain roughly the same proficiency as experienced raters (Hy & Loevinger, 1996). Partially due to the unanticipated length of time required to recruit participants, the researcher began scoring the WUSCT item responses for the first 32 protocols immediately following the completion of the practice exercises. As mentioned above, the researcher divided the data according to item number, creating 18 item response lists. 48 Thirty-two responses to item number one were scored, 32 to item number two were scored, and so on. After each of the 18 items of the WUSCT (Short Form) were scored for the first 32 protocols, the researcher sent the results to her thesis supervisor (Dr. Richard Young) who has some experience with scoring the WUSCT. The researcher asked her supervisor to check the ratings she had assigned the responses, paying particular attention to the responses with question marks beside them. Question marks indicated that the researcher had particular difficulty assigning a rating to that response. Discrepancies between the supervisor's ratings and the researcher's ratings with question marks were resolved by discussion. The final 18 WUSCT protocols were scored according to the same procedures outlined above (responses added to the item response lists and scored individually, then sent to supervisor for confirmation). Nine hundred items were scored in total (18 items on 50 protocols). As per the directions in Hy and Loevinger's (1996) scoring manual, after scoring the WUSCT responses grouped together by item, the researcher then read each of the 50 total protocols and assigned an impressionistic Total Protocol Rating (TPR) to each protocol. The impressionistic TPR is the researcher's impression of the ego development level of the protocol's author. A frequency distribution of the item scores (scored out of context) was then made, as well as a cumulative frequency distribution (ogive), for each protocol. Using the ogive rules listed in Hy and Loevinger's (1996) scoring manual, an ogive TPR was assigned to each protocol. For each of the 50 protocols the impressionistic TPR matched the ogive TPR, and so this value was recorded as the final 49 TPR score. TPR scores are typically used in descriptive analysis of data (Hy & Loevinger, 1996). At this stage, the Item Sum Sore (or ISS) was also calculated, by adding together the 18 item scores for each protocol. The Item Sum Score is used in correlative data analysis and is simply a total of the 18 individual item scores. The TPR scores were used to calculate the distribution of ego development levels within the sample shown in the form of a frequency table and a histogram. The TPR scores were also used to sort R A C responses according to ego development level, for the qualitative portion of the study. Item Sum Scores are used for correlation analysis to study the relationship between the variables level of ego development and reasoning about counseling. R A C data As discussed above, the R A C questionnaire was scored by two independent raters. For each item on the R A C , subjects received a score from one to six. Like the WUSCT, items were scored out of context by creating four item response lists (one for each item on the RAC) . After all of the individual items were scored, total scores were calculated for each protocol by adding together and averaging the individual item scores. Reliability analysis of the R A C scores from the two raters was conducted using the total R A C scores, as well as using each of the four R A C item scores. Interrater agreement was very high, indicating almost perfect agreement between the two raters' measurements of R A C scores. (RAC total scores: alpha=0.9426; R A C item 1: alpha= .9135; R A C item 2: alpha=.9727; R A C item 3: alpha=.9346; R A C item 4: alpha=.9734). Both the total R A C scores and the individual item scores were also used for correlation analysis with the WUSCT ISS scores. 50 The open-ended nature of the items on the R A C questionnaire yielded data that was also analyzed qualitatively. Qualitative analyses were conducted to determine i f there were noticeable differences in participants' reasoning about counselling when the data were organized according to ego development level. As the current study was primarily quantitative in design, the use of specialized procedures for analyzing qualitative data (such as grounded theory or phenomenological strategies) was not appropriate. The researcher, then, had a variety of choices about how to approach the qualitative data. For some qualitative researchers, the temptation may be to start at line one of the data and to draw out observations as he or she proceeds. However, observations formed in this manner can be ad hoc and commonsensical (Silverman, 2000). Particularly when the aim of the analysis is to investigate the attitudes of certain groups of participants, analyzing single statements and responses can be misleading. For the purposes of this study, the generic steps towards qualitative data analysis as outlined by Creswell (2003) were employed. The first step was to group the R A C protocols according to ego development level. (The WUSCT total protocol ratings (TPR scores) were used to determine level of ego development). The second step was to read the R A C protocols. A l l of the R A C protocols written by individuals at each level of ego development were read together, beginning with the protocols at the lowest stages and progressing to the highest. After reading the protocols, the researcher reflected on the general feeling of the responses given by participants at each ego stage. She questioned the extent to which the responses paralleled Hy and Loevinger's (1996) descriptions of individuals at each level of ego development. 51 The data was then further examined, or recoded, according to the separate R A C items. For example, within each category of ego development level, four additional categories were generated by grouping together the responses to each of the four R A C items. Assembling the data in this way facilitated the exposure of a variety of themes represented in the R A C responses. Responses, or sections of responses, that suggested similar meanings were highlighted. Finally, the findings of the analysis were conveyed by means of a narrative passage. The purpose of classifying the responses in this narrative fashion is to familiarize the reader with a more subjective perspective of how people reason about counselling at each stage of development. Many verbatim statements are included in the narrative, as well as a description of the overriding themes at each level of ego development. A complete list of R A C responses is included in Appendix N . 52 IV. Results This study investigated the hypothesis that a relationship exists between an individual's reasoning about counselling and his or her level of ego development. In order to better understand the sample, the presentation of the results begins with the descriptive statistics of the demographic variables of the sample. The current study adds to the literature by including individuals with no prior experience in counselling, therefore analyses are conducted separately for this group. The sample is then described in terms of level of ego development. Average ego development levels are similar to those of the general population. Correlational analyses between the Ego Development scores and the Reasoning About Counselling scores are presented that support the hypothesis that these two variables are related. These two variables are also shown to be related among individuals in this sample with no previous counselling experience. Finally, responses to the R A C questionnaire are summarized, ordered by ego development level. R A C responses support the hypothesis that reasoning about counselling varies according to level of ego development. Descriptive Statistics of the Demographic Variables The sample included 50 participants ranging in age from 19 to 71, with an average age of 39.84 (SD=12.38). Approximately half of the sample were females (n=24) and half were males. Two participants reported they were transgendered. Thirty-eight percent (n=19) were single, and 38 percent were married or living in common-law relationships. The majority of the sample had an annual household income of below $60, 000 (n=27, 54 %). Education levels varied, with 38 percent (n=19) of the sample at the high school level or below, and 36 percent with a Bachelor's, Master's, Professional, or 53 Doctorate degree (n=18). Eighty-four percent of the sample was Caucasian. As shown in Table 1, two thirds of the sample had no prior or current experience with counselling. This group differentiated from those individuals with previous counselling experience on one variable in particular. Those with no previous counselling experience had higher income levels (mean=2.75 (SD 1.42)) than participants who had previous counselling experience (mean=2.15 (SD 1.31). These results are not consistent with research that suggests that individuals with higher socioeconomic status attend counselling more frequently (Browning, 1987). Interestingly, six individuals did not report their level of income. None of these individuals had previous experience with counselling. Similarly, neither the individuals who excluded their level of education, nor the individual who excluded her ethnic origin, had previous counselling experience. These results suggest a relationship between previous counselling experience and willingness to share the more private details of one's life. 54 Table 1 Sample Demographics Number of participants (%) Variable Previous Couns. No Prev. Couns. Total Gender Male 10(50%) 14 (46.7%) 24 (48%) Female 10(50%) 14(46.7%) 24 (48%) Transgendered 0 2 (6.7%) 2 (4%) Age 30 or below 4 (20%) 7 (23.3%) 11 (22%) 31-40 9 (45%) 10(33.3%) 19 (38%) 41-50 4 (20%) 7 (23.3%) 11(22%) Above 50 3 (15%) 6 (20%) 9(18%) Marital Status Single 9 (45%) 10 (33.3%) 19 (38%) Married/Cmn. Law 6 (30%) 13 (43.3%) 19 (38%) Separated/Div./Wid. 5 (25%) 7 (23.3%) 12 (24%) Income Below $35, 000 8 (40%) 5(16.7%) 13 (26%) $35, 001-$59, 999 6 (30%) 8 (26.7%) 14 (28%) $60, 000-$84, 999 3 (15%) 3 (10%) 6 (12%) $85, 000-$ 120,000 1 (5%) 4(13.3%) 5 (10%) Above $120, 000 2 (10%) 4(13.3%) 6 (12%) No info 0 6 (20%) 6 (12%) Education High school or below 7 (35%) 12 (40%) 19(38%) Some college, no degree 7 (35%) 6 (20%) 13 (26%) Bachelor's degree 5 (25%) 7 (23.3%) 12 (24%) Mast./Prof./Doc. degree 1 (5%) 3(9.9%) 4 (8%) No info 0 2 (6.7%) 2 (4%) Minority Classification Yes 1 (5%) 6 (20%) 7 (14%) No 19 (95%) 23 (76.7%) 42 (84%) No info 0 1 1 (2%) n 20 30 50 55 Stages of Ego Development Results from this study are consistent with research that shows the modal stage of ego development in the general population of adults to be E5, the Self-A ware stage (Browning, 1987; Holt, 1980; Noam & Di l l , 1996). The total sample had an average level of ego development of 5.32 (SD 1.33). Ego development levels among individuals with no counselling experience were slightly lower than those who had attended counselling, but not significantly different (5.30 (SD 1.29) vs. 5.35 (SD 1.42)). No participants in this sample scored at level E2 - the Impulsive stage or at level E9 - the Integrated stage. Again, this is consistent with research that suggests that these more extreme groups are underrepresented in the general population (Adams & Fitch, 1982; D'Andrea & Daniels, 1992). Figure 1 presents the distribution of ego development levels within the total sample, using the Total Protocol Rating (TPR) scores from the WUSCT. For the distribution of ego development levels according to gender please see Table 4, p. 132. 56 3.0 4.0 5.0 6.0 7.0 8.0 WUSCT Total Protocol Rating Figure 1. Distribution of ego development levels in total sample Few studies researching ego development and mental health have identified counselling experience as a separate variable for investigation. Table 2 compares the current sample with two different studies in terms of the frequency distributions of participants at eight different ego development levels. As can be seen in Table 2, the current study contains a much more even distribution of ego development levels among individuals without previous counselling experience. For example, in Young-Eisendrath & Foltz's (1998) sample of students, no individuals scored at ego level 3 - the Self- Protective stage, or lower, and almost half (47%) of the students scored at ego level six - the Conscientious stage. In the current study, 10% of individuals with no previous counselling experience scored below level E3, and only 30 percent scored at the 57 Conscientious stage. The fact that this study's sample was collected neither from explicitly mental health settings nor educational settings, may have contributed to the more even distribution of ego development levels. Table 2 Stages of Ego Development: Current Study Vs. Two Population Studies Ego Stage (TPR) Noam & Young-Eisendrath Current study Dill (1996) & Foltz (1996) Patients Patients Students Prev. Coun. No Prev. Coun E2 - Impulsive 0% 8% 0% 0% 0% E3 - Self-Protective 2% 6% 0% 10% 10% E4 - Conformist 10% 22% 5% 20% 16.7% E5 - Self-Aware 58% 24% 19% 25% 26.7% E6 - Conscientious 20% 30% 47% 20% 30.1% E7 - Individualistic 7% 8% 25% 20% 13.3% E8 - Autonomous 2% 4% 1% 5% 3.3% E9 - Integrated 1% 0% 3% 0% 0% n 102 51 64 20 30 Ego Development and Reasoning About Counselling Correlation analyses between the Ego Development and the R A C scores were carried out using Spearman's rank correlation. This type of correlation is usually used for ordered, categorical data and, in this study, it is more reliable than Pearson's correlation. Table 3 lists the correlations between ego stage and R A C item scores for the total sample, as well as for individuals with and without previous experience in counselling. There is a significant relationship between ego development and reasoning about counselling across all domains for the total sample (p<.001). Among individuals with previous counselling experience, ego development and 58 reasoning about counselling are significantly related on three out of the four R A C items. R A C item two, "What does a counsellor do?" was not significantly related to ego development for these individuals. Among individuals with no previous counselling experience, ego development and reasoning about counselling are also significantly related on three out of the four items. R A C item four, "Do you think counselling can change people? If yes, how? If no, why not?" was not significantly related to ego development for these individuals. Table 3 Correlations Between Ego Stage and Reasoning About Counselling Item Scores Ego Stage Prev. Couns. No Prev. Couns. Total (N=20) (N=30) (N=50) RAC1 .462* .428* .422** RAC2 .383 .556** .485** RAC3 .556* .464** .472** RAC4 .655** .254 .432** R A C total .659** .505** .571** Note. RAC1 refers to the item. What is counselling? RAC2 refers to the item. What does a counsellor do? RAC3 refers to the item, What does a client do? RAC4 refers to the item, Do you think counselling can change people? If yes, how? If no, why not? V<.oi. **̂ <.ooi j R A C Responses ordered by Ego Development Level After analyzing the formal relationship between level of ego development and reasoning about counselling, it is important to note the informal attitudes and themes expressed in the R A C responses across the six different ego development levels represented in the sample. As the reader is presented with subjective descriptions of 59 individuals at each ego development level, he or she may gain a more complete picture of how individual reasoning about counselling seems to relate to ego development level. In summarizing the responses here, it is noted whether a particular response came from a person with counselling experience (C) or from someone with no counselling experience (NC). For the complete list of R A C responses ordered by ego development level, please see Appendix N . E3 - Self-protective Stage (N=5) Responses collected at this stage displayed a vigilance about controlling one's environment and one's self. There was a sense of fear of being deceived. For example, counselling was described as being told "what to think and what to feel (NC)," and only for those who are "troubled (NC)" and "need help (C)." The counselling process was seen as largely therapist driven. Counsellors were expected to be "unbiased (C)," to "listen (NC)," and to give direction. One participant described the counsellor as "sit[ting] on the couch and zon[ing] out (NC)." This type of impulsive and somewhat hostile response is not unusual at this level of ego development (Hy & Loevinger, 1996). Blame was often externalized. Clients "talk about their problems (C)," and "vortex and bitch about their problems (NC)." Can counselling change people? Generally the answer was yes - "yes, everyone needs someone to talk too [sic] (NC)," "Yes, for the better (NC)." One participant with counselling experience stated, "It may or may not help, but it will change people (C)." E4 - Conformist Stage (N=9) Individuals at this stage continued to describe counselling as "talking (C)," and "getting advice (C)." Clients were seen as unhappy people ("if you are going to counselling you can't be happy (NC)"), who are expected to listen to their counsellors. Counsellors were described as."professionals (C)" who 60 "charge you money (C)," "listen, and tell you what you have said (C)," and "make you feel better (C)." There still existed a sense of counselling acting on, rather than with, the client. Conventional and cliched responses such as, "If you don't let it out to someone it will bug you forever (C)," and "see[ing] the big picture of life (NC)," occured more frequently at this ego level than at the Self-Protective stage. Can counselling change people? Most participants answered "Yes" - by giving clients the opportunity to be heard, and by "see[ing] things objectively (NC)." E5 - Self-Aware stage (N=13) At this stage, participants began to speak about change in terms of relationship and self-discovery. Counselling was described as "sharing & discussing ideas & troubles with another (NC)," and as "an exchange of opinions & ideas (NC)" rather than strictly listening to advice. Participants began speaking more concretely about their goals and plans, and there was less onus on the counsellor to direct change. Counselling is described as "a process...to make effective changes (C)," an opportunity to "better yourself (NC)" and for the purposes of seeing "how many happenings in our life affect our behaviour (C)." Counsellors were seen as facilitating this process of awareness and goal achievement by "teaching] you how to empower yourself (C)" and by "helping view things in a different perspective (NC)." Clients were described as having more responsibility in the counseling process and are expected to "learn about themselves (NC)." Does counselling change people? The first overtly negative responses to this question appeared at this ego stage; "No because it doesn't really tell you anything different (C);" "No, but I think it can give people direction and a lot of focus (NC)." The particular nature of the counselling relationship was emphasized more at this level - counselling can change people " i f the counsellor and 61 the client are compatible (C)" or " i f the counsellor treats each client with every special need or attitude they may bring (NC) . " These statements are illustrative of the more complex and independent frame of reference that begins to emerge at this ego level. E6 - Conscientious stage (N=13) Participants at this level appeared reflective, goal-oriented, and more open to multiple possibilities than individuals at lower levels of ego development. Absolute responses were replaced with more contingent statements and comparisons. Some responses even seemed contradictory, such as the simple answer to the question "Does counselling change people?" - "Yes & no (NC) . " In answer to the question "What is counselling?" some typical answers were, "Al lowing people to talk about what bothers them & assist them to find their own answers (NC) , " "...an opportunity to have your voice heard. It is a chance to explore your feelings and behaviours in a safe environment (C)," and "...getting thoughts & ideas to concerns and issues you may not have thought of...providing alternatives (NC) . " Counsellors were expected to be "neutral (C)" and "non-judgmental (NC) , " to "listen, open up dialogue/ provide perspective, (C)" to "accept a person for what they are [sic] (NC) , " and "to support your personal growth (C)." What does a client do? "Works hard (NC) , " "hopefully comes with an open mind (C)," "[is] autonomous in the solution ( N C ) , " and does "their best to empower themselves (C)." Generally counselling was seen as changing people, but there are many qualifiers; " i f the client seeks help with honesty and openness (C) ," " i f the counselling is good (all isn't) (C)," " i f someone wil l ingly goes (NC) , " "[if] the client... connects] with the counselor (NC) . " The extent to which counselling changes people seemed to depend most on the client's level of willingness and commitment to change - "there has to be a willingness and a desire to change (C) ," "[clients] must be open minded and willing to see themselves in a different light (NC)," "the person [must] genuinely want to make some changes (C)." The notion that the client is largely responsible for counselling outcomes continued to emerge at the higher levels of ego development. E7 - Individualistic stage (N=8) Participants at this ego level demonstrated more complex conceptions, their responses often consisting of combinations of responses singly rated at lower levels. Ideas that would appear as polar opposites to individuals at lower ego levels seemed easily reconciled by participants at this level. Responses illustrated more of a focus on self-acceptance and the subjective experience. For example, counselling was described as "finding reasons, solutions, being comfortable and accepting what you feel (C)," as "self acceptance," as a "wonderful, positive, supportive tool (C)," and as "an important service that all individuals should partake in (NC)" rather than just for people who are unhappy. What do counsellors do? They "help to build stepping stones towards enlightenment and contentment (NC)" and "work in unison with the client (C)." They "listen & guide and [do] not judge (NC)." They "listen with compassion...help[ing] us to feel safe to communicate our stories (C)." Clients are expected to "work with the counsellor (NC)" but also to "keep the good and discard the rest (C)" - to decide for themselves, be self-directed, and "take responsibility for their actions (C)." A l l participants at this ego stage agreed that counselling can change people. The client's willingness to change, "the right counsellor - client pairing (NC)," and the quality of the counselling ("some of it is a whole lot of B.S. (NC)") remain factors which seem related to counselling outcome. Interestingly, for one respondent, the client's level 63 of intelligence related to counselling outcome - counselling was seen as changing "those who are intelligent enough to seek answers..." E8 - Autonomous stage (N=2) Although only two participants scored at this level of ego development, it was evident that these individuals are unique, genuine, objective, and non-judgmental. They appear to have a high tolerance for ambiguity and to recognize paradox with humour. Their responses had a poetic twist. Counselling was described as "a means of helping us to realize that we are but human, reflecting back on us that it is ok & normal to make mistakes but not ok to keep repeating them (C)." Counsellors were described as a "fellow traveler (NC)" and as "a filter of sorts (C)." Clients can do "anything & everything (NC)" but were still held responsible for "realiz[ing] that it is he/she who has the keys to unlock their own anxieties! (C)" Does counselling change people? Yes. "...the road is long & very, very hard but it can & does happen (C)." The counselling process was seen as one of many "paths (NC)," spawning the "realization that we all possess the virtues necessary to unlock the mysteries of our own pain (C)." The existential notion that life is a "full circle (NC)" - that we end where we begin, was suggested. 64 V. Discussion Loevinger's (1976) construct of ego development suggests fruitful applications to research within the field of counselling psychology. This study has focused, in particular, on the relationship between levels of ego development and adults' reasoning about counselling. This research was conducted with individuals who have had prior experience in counselling, as well as with "non-client" participants. Findings from this study support the hypothesis that level of ego development is significantly related to reasoning about counselling in adults. This relationship is shown to exist among adults both with and without previous counselling experience. A qualitative examination of the findings also reveals a relationship between level of ego development and reasoning about counselling. This chapter begins by noting how the results of this study contribute to the existing body of ego development literature. The findings are discussed in relation to the three primary areas of investigation guiding this study; the relationship between adult levels of ego development and reasoning about counselling; the relationship between adult levels of ego development and reasoning about counselling among participants with no previous experience in counselling; and the variability of reasoning about counselling according to ego development level. The limitations of the study are highlighted. Implications for counselling practice and for future research are discussed. Quantitative Findings: Level of Ego Development and Reasoning about Counselling: Total Sample and Participants with Counselling Experience The variables "level of ego development" and "reasoning about counselling" were found to be positively correlated using Spearman's rank correlations for categorical data. 65 Correlations were performed using the total RAC scores, as well as the individual RAC item scores. In the total sample, a significant relationship was shown among the variables across all domains. The strength of the correlations was moderate, with the variables sharing 33 % of the total variance. These results suggest that other variables may be primary factors contributing to the relationship between ego development and reasoning about counselling. Regression analysis with these data could determine which other variables are related. Generally, these findings are not surprising, as the system used to categorize RAC data is partially based on Loevinger's theory of ego development. Yet some specific demographic features of the sample may have contributed to these data. For example, much of the ego development research has tended to include more females than males (Borst & Noam, 1993; Noam & Dill, 1996). Young-Eisendrath and Foltz's (1998) sample of students included 54 females and Only 10 males. The current study included an even number of male and female participants in the sample, guaranteeing a lack of gender bias. Similarly, there were an equal number of single participants, as there were married or living in common law relationships. It is difficult to speculate what may have contributed to such even distributions in these categories, Another demographic feature was the broad age range in the sample (19-71 years). The age range among individuals with no previous counselling experience was slightly smaller (25 to 70 years). These demographics are similar to Young-Eisendrath and Foltz's (1998) sample which included a "patient" group, ages 16 to 77, and a "student" group, ages 23 to 70. Noam and Dill's (1996) study investigating levels of ego development and treatment preferences among patients also used a sample ranging in age 66 from 19 to 71. Much of the ego development research has used samples with narrower age ranges (Browning, 1986; Borst & Noam, 1993; Gold, 1980; McCrae & Costa, 1980). Samples with narrow age ranges often contain a small degree of variability. In fact, even in Noam and Dill 's (1996) study, 58 percent of their sample scored at E5 - the Self- Aware stage. Similarly, Young-Eisendrath and Foltz's (1998) sample of students included no participants below E4 - the Conformist stage, and 47 percent of the sample scored at E6 - the Conscientious stage. The wide age range in the current sample however, generated a relatively even distribution of ego development levels discussed below. A broad distribution of ego development levels allows for the generation of more accurate correlations with other variables. In the current study, the distribution of participants among the six levels of ego development levels represented in the sample resembled a bell-curve. The average level of ego development was E5, the Self-Aware stage, which is the modal stage of ego development for North Americans (Browning, 1987; Holt, 1980; Noam & Di l l , 1996; Westenberg, Blasi, & Cohn, 1998). When the sample was divided into participants with and without counselling experience, the distribution of participants among the six ego stages remained relatively equal. One explanation for these results is the potentially "average" composition of the participants used in this study. Participants were not collected from particularly specialized settings (such as universities and hospitals) and so were perhaps more representative of the population at large. Despite the broad representation of ego development levels, no participants in the current sample scored at the lowest or the highest levels of ego development (E2 - the Impulsive stage, or E9 - the Integrated stage). These results are not surprising for a 67 number of reasons. Ego development literature shows only a very small majority of the North American population at these levels of ego development (Browning, 1987; Noam & Di l l , 1991). Using the Short Form of the WUSCT, consisting of 18 items versus 36, narrows the chances of participants scoring at the outer stages (Novy et al., 1997). This sample did not include adolescents, a population potentially more likely to score at the lowest level of ego development (Browning, 1986; Evans, Brody, & Noam, 2001; Gold, 1980). With a small sample size of 50, the chances of including voluntary participants at these outer lying levels of ego development are even further reduced. Among those participants with previous counselling experience, there was a significant correlation between ego development level and reasoning about counselling on all but one item on the R A C questionnaire. Responses to the question, "What does a counsellor do?" were not significantly correlated with ego development level for participants with previous counselling experience. It is the researcher's belief that these variables are not correlated in this sample because there is a wide degree of variability in the participants' perceptions of what counsellors do. The term "counsellor" describes a broader range of individuals than the term "psychotherapist" (McLeod, 2001). Counsellors are often perceived as generalists whereas psychotherapists are seen as working with a more distinct population (Palmer & McMahon, 1997; Woolfe, 1997; Worden, 1991). As Kirkwood's (2000) research in a small island community in Scotland shows, with a limited number of referral options, "counselling skills" may be used by a variety of different workers in non-urban settings. (In Kirkwood's study, 23 percent of the sample had received informal counselling services, while only 2 percent had received formal counselling services). It is reasonable 68 to speculate that participants in this study with previous counselling experience may have accessed such "informal" counselling services, thus broadening their interpretation of what counsellors actually do. Quantitative Findings: Level of Ego Development and Reasoning about Counselling: Participants with No Counselling Experience Among those participants with no previous counselling experience, there was once again a significant relationship between ego development level and reasoning about counselling on all but one of the items on the R A C questionnaire. Responses to the question "Does counselling change people?" were not significantly related to ego development level. These results are consistent with Young-Eisendrath and Foltz's (1998) findings. In their group of students, the correlation coefficient between ego stage and RAP item four ("Does psychotherapy change people? If yes, how? If no, why not?") was only .04. These authors speculated that the small degree of variability of ego development level in their student group accounted for these results. The current sample, however, includes a wide degree of variability in this category. It appears that in this sample, beliefs about how and why counselling may or may not change people are related more to counselling experience than to level of ego development (although this has not been statistically investigated). Indeed, a weak relationship between ego development level and counselling outcomes is understandable among a population who has never attended counselling. It is reasonable to speculate that those participants with no previous counselling experience have refrained from seeking counselling services, in part, due to their generally negative beliefs about the counselling process. Indeed research supports the idea that willingness to seek counselling services is 69 related to fundamental beliefs about the counselling process (Duncan & Miller, 2000; Byon, Chan, & Thomas, 1999; Tinsley, Brown, De St. Aubin, & Lucek, 1984; Noam & Dil l , 1996). Research suggests that individuals with a higher socioeconomic status (as measured by income and level of education) typically attend therapy more frequently (Browning, 1987; Frank, Eisenthal, & Lazare, 1978). Interestingly, in the current sample, the participants with no previous counselling experience had a higher income, with 27 percent of this group recording a household income of $85, 000 or higher. Similarly, participants with no previous counselling experience recorded slightly higher levels of education, with 10 percent of the sample recording post-baccelaurate levels of education (versus 5 percent of participants with counselling experience). One possible explanation for these data is that seeking counselling services may be more stigmatized among this wealthier, more educated, non-urban, population. These potentially "high profile" citizens may be reluctant to access counselling services in smaller communities where confidentiality can be harder to maintain (Bourke et al., 2004; Helbok, 2003; Warner et al., 2005). Additionally, while individuals with higher socioeconomic status have been shown to attend therapy more frequently, many of these individuals may prefer to receive counselling services from "psychotherapists" versus "counsellors." The lack of availability of "psychotherapeutic" services in non-urban areas and the inconvenience of traveling long distances to attain this type of treatment may contribute to this group's lack of participation in counselling. In the current study, six participants did not disclose their level of household income, and two participants did not disclose their level of education. One individual did 70 not disclose her cultural background. Interestingly, none of these individuals report previous experience with counselling. These data suggest that for this sample, those individuals with counselling experience were more likely to reveal the more-personal details of their lives. Perhaps for these individuals, access to counselling is more related to factors such as openness and candidness, than to factors such as education and income. Qualitative Findings: Variability of Reasoning About Counselling According to Ego Development Level A closer investigation of the relationship between levels of ego development and reasoning about counselling was conducted by viewing the verbatim responses to the R A C questionnaires ordered by ego development level. The literature suggests that people at lower levels of ego development perceive counselling as largely therapist driven (D'Andrea & Daniels, 1992; Dil l & Noam, 1990; Loevinger, 1980; Noam & Di l l , 1996; Young-Eisendrath & Foltz, 1998). As ego development level increases, individuals take more responsibility for the counselling process. Results from this study supported this tendency. Although there was some overlap in the R A C responses when ordered by ego development level, some major themes emerged. Individuals at the lower levels of ego development appeared guarded, and often responded with hostile and sarcastic remarks. The counselling process was perceived as largely directed by the counsellor. This result supports previous research suggesting that individuals at this ego stage prefer to take a more passive role in the counselling process (Noam & Dil l , 1996; Young-Eisendrath & Foltz, 1998). Participants at the conformist level (E4) were the most difficult to distinguish from the other ego development levels, although the typical cliched responses 71 were evident at this level. This result is consistent with Young-Eisendrath and Foltz's (1998) research, as well as with Hy and Loevinger's (1996) assertion that "the conformist person, by definition, is the least distinctive type" (p. 12). At the Self- Aware stage (E5), participants appeared open to multiple possibilities and to seeing alternatives in situations that people at lower levels construe as "black and white." At this stage, people believe that each individual is entitled to his or her own opinion (Hy & Loevinger, 1996). Participants at the Self-A ware stage in this study voiced their opinions by being the first to suggest that counselling may not change people, or may only change people i f certain conditions apply. This stance is clearly a change from the guardedness and conformity seen at the earlier stages. At the sixth level of ego development, the Conscientious stage, themes of self- discovery and responsibility for personal growth started to become more evident within the sample. These findings support ego development research that describes individuals at this stage as goal-oriented, reflective, and flexible in their outlook (Loevinger et. al, 1985; Young-Eisendrath & Foltz, 1998). Counselling was viewed as an opportunity for personal empowerment, with the client largely responsible for the change process. At E7, the Individualistic stage, participants in this sample appeared characteristically concerned with issues of self-acceptance. Counselling was described as the process of becoming more comfortable with oneself, and as an activity from which all individuals could benefit. These results support Noam and Dill 's (1996) findings that individuals at higher levels of ego development are more likely than others to request treatment that involves introspection. Finally, although the current sample included only two participants at the eighth level of ego development, these individuals demonstrated genuineness, humour, 72 and a belief in the process of "self-actualization." Counsellors were viewed as "fellow travellers," and the counselling process as one which takes much time and dedication on the part of the client. These characteristics are described by Hy and Loevinger (1996) as typical traits of individuals at the highest levels of ego development. Young-Eisendrath and Foltz (1998) also found these tendencies among their participants at the higher stages of ego development. In the face of existing research which identifies a relationship between adult levels of ego development and "treatment preferences" (Noam & Di l l , 1996) and "reasoning about psychotherapy" (Young-Eisendrath & Foltz, 1998), results from the current study which identify a relationship between adult levels of ego development and "reasoning about counselling" are not surprising. To see this relationship "spelled out" in the responses to the R A C questionnaires was nevertheless intriguing for the researcher. Naturally the easiest distinctions were made at either end of the ego development continuum. Although there are some exceptions, generally responses made by individuals at the higher stages of ego development seemed longer. Although ego development level and verbosity have been shown to be unrelated, further investigation into the relationship between verbosity and reasoning about counselling might yield informative results. There were no apparent distinctions between the responses made by those individuals with previous counselling experience and individuals with no previous counselling experience. Implications for Counselling Practice These findings raise questions about how to integrate Loevinger's theory into daily counselling practice. For example, from a developmental perspective, clients at the Self-Protective stage of ego development (E3) may be best served by interventions which 73 focus on developing conforming values and a sense of belonging to a group. While encouraging such behaviours may not be typical of most counsellors, it can be argued that without such treatment the person may be unable to progress beyond this Self- Protective stage to the next stage - the Conformist stage. One may question whether the aim of counselling is to challenge clients to develop to the next highest ego stage. On one hand, facilitating clients' development to more advanced ego stages might enable a greater number of clients to experience the advantages associated with advanced ego stage functioning. Yet an equally important objective of counselling may be to help the client to live successfully at the stage of ego development at which they currently function. As Swenson (1980) notes, "one may be a 'happy' and 'successful' conformist, or an 'unhappy' and 'unsuccessful' conformist" (p. 387). In this light, it is noteworthy that research continues to show how few people progress to the advanced stages of ego development (Bjorklund, 2000; Manners, Durkin, & Nesdale, 2004; Noam & Di l l , 1996; Westenberg, Blasi, & Cohn, 1998). The average ego development level for adults is E5, the Self-Aware stage, a stage involving very basic self and interpersonal awareness. Research has shown that individuals at this modal stage still perceive the counsellor as largely directive and responsible for the counselling process and outcome (Noam & Dil l , 1996; Young-Eisendrath & Foltz, 1998). Encouraging these clients to assume most of the responsibility for counselling process and outcome (as do individuals at advanced ego stages) is not appropriate. Counsellors who primarily focus on advancing their clients' levels of ego development, rather than on working from within the client's current frame of reference, could be holding their 74 y clients responsible for achieving goals that they are simply developmentally incapable of attaining. Ivey (1986) explores this question of promoting advanced levels of development in his book, Developmental Therapy. The underlying principles of Developmental Therapy stem from Piaget's theories of cognitive development. The Piagetian categories of sensori-motor, concrete operations, formal operations, and post-formal (referred to by Ivey as dialectic/systemic) are used to describe the developmental levels of the client. Ivey maintains that adolescents and adults cycle through these stages again and again, and that clients may present at any one of these cognitive developmental levels. The first stage of the counselling process therefore is to identify the client's predominant developmental level. Then the counsellor chooses whether to focus on expanding development "horizontally" or "vertically." Horizontal development includes developing the client's range of resources within his or her existing developmental level. For example, concrete individuals can be helped to develop more concrete descriptions of the issue(s) that brought them to counselling. Vertical development includes challenging the client to view his or her world from the next highest level of cognitive functioning. For example, concrete individuals can be helped to see maladaptive patterns they are repeating (formal operations). While Ivey insists that vertical development is not effective until the client maintains a solid foundation at his or her predominant developmental level, the ultimate goal of counselling is to produce movement across the several levels of development. Ivey's model provides counsellors with tangible suggestions for facilitating developmental change with each client. 75 While most counsellors have been trained to practice within one paradigm using a single framework from which to choose their interventions, the trend is increasing towards more evidence based practice. That is, clinicians are now encouraged to consult not only their own theoretical beliefs about change, but also to consult the research about which interventions work best with specific populations. Referring to a developmental context, such as Ivey's and Loevinger's, encourages the clinician to develop a framework in which several counselling theories or interventions might be utilized, depending on the circumstances of the particular client. For example, in the current study, individuals at the lower levels of ego development displayed a fear of deception, and tendencies towards impulsivity and externalizing blame. One may speculate, based on previous research (Manners, Durkin, & Nesdale, 2004) that behaviour modification and Reality Therapy might be useful interventions to address these tendencies. Similarly, individuals at the middle stages of ego development in this study were focussed on self-discovery and empowerment. Client centered counselling, interpersonal counselling, and solution- focused counselling are all appropriate interventions to support clients at these levels (Bruce, 1984; D'Andrea & Daniels, 1992; Swenson, 1980). Individuals at the higher stages of ego development were open to multiple possibilities and focused on self- actualization. Gestalt counselling and Existential counselling might be used to meet the needs of these clients. Ethical practice in nearly every social science involves the continued integration of theory, assessment, and practice. Loevinger's model of ego development provides counsellors with a potentially fundamental tool that links developmental theory with counselling practice. This systematic, practical framework helps counsellors to identify 76 and meet their clients' most basic needs and so enhances the likelihood of counsellors building effective relationships and enjoying positive outcomes with their clients. Of course one of the criticisms of developmental stage theories is that people tend to fluctuate between stages at any one time. Perhaps "lower order" needs do not always have to be met before "higher-order" needs. Empirical evidence that supports differential treatment based on certain client personality variables is limited at best. More research needs to be conducted to determine the value of using developmentally based interventions with clients. Limitations of the Study Prior to discussing future research directions it is appropriate to acknowledge the limitations of this study. One limitation is the small sample size of 50. Originally 100 participants were expected to volunteer for this study. The study was closed due to lack of further interest after four and a half months. Many of the participants who were observed completing the questionnaires reported that the questionnaires "were hard" and "made you think." Participants varied in the amount of time taken to complete the questionnaires, the majority taking about 30 minutes. The perceived "difficulty" of the questionnaires, as well as the amount of time required to complete them may have been deterrents for those participants who did not return their questionnaire packages. The sample was not homogeneous according to cultural differences, and was therefore not representable of any one population. The sample was primarily Caucasian (84 percent) which is not surprising given that the data was collected in typically "white," non-urban, neighbourhoods. However, it was expected that more Aboriginal peoples would be represented in the sample. Aboriginal peoples from four outlying reserves 77 access the services at the health units where the questionnaires were distributed. One explanation for the under-representation of this group could be a dislike of pencil and paper questionnaires (Russell et al., 2005). The lack of studies including large minority groups continues to be a gap in ego development research. The sample was limited to adults 19 years of age and older. Including children and youth in the sample would increase the variability in ego development levels and provide additional data for qualitative analysis. This would pose additional logistical challenges, however, such as the need to obtain consent from parents, and the need to use different versions of the WUSCT (for children and youth) which are less reliable and valid. The optimal way to administer the WUSCT is to have the test administrator present. In this study, front desk persons were instructed to give noncommittal answers to any questions participants had about completing the WUSCT - for example, "Finish the sentence any way you wish," or "There are no right or wrong answers." However, participants were not closely observed as they completed the questionnaires. Nor was the researcher present at all times to ensure that participants did not converse about their answers with each other. In addition, some participants completed the questionnaires after they had left the health offices. A test administered in this way holds the danger of subjects asking their friends, "How do you think I should answer this?" Some responses to questionnaire items, therefore, may not be totally reflective of the individual participants. (Most of the questionnaire packages were filled out by individuals who were alone at the health units thus reducing the likelihood that participants consulted with each other, or their friends). 78 The study is limited by the 18-item form of the WUSCT, a measurement potentially less accurate at locating subjects at the extremes of the ego development continuum. Furthermore, the WUSCT was scored by the researcher with the assistance of her supervisor who had prior experience with the method. The WUSCT is traditionally scored by two raters, both of whom have completed the practice exercises outlined in Hy and Loevinger's (1996) scoring manual. Repeated attempts to find additional experienced raters willing to score the WUSCT protocols were unsuccessful. Similarly, the researcher also experienced difficulties in accessing the RAP scoring manual used by Young-Eisendrath and Foltz (1998). As a result, the six possible response categories for three of the four R A C items were constructed by the researcher. Although these response categories were composed according to Young-Eisendrath and Foltz's (1998) theoretical principles and data, the categories were not validated by data from any previous research. Using a more widely available and validated measurement of reasoning about counselling (such as Tinsley et al.'s (1980) Expectations About Counseling questionnaire) would contribute to the robustness of this study (although it would be difficult to engage individuals with no history, or intention, of seeking counselling services in this type of research). The R A C questionnaire made no specification of the kind of counselling services participants had accessed or were accessing. The setting in which the questionnaires were distributed offered mental health oriented counselling, nevertheless, participants' responses may refer to more informal counselling services such as vocational or financial counselling. Finally, this study examines the relationship between levels of ego development 79 and reasoning about counselling. There are no treatment groups and no randomization. Therefore no causal relationship between these two variables can be drawn. The volunteer sampling procedure decreases the generalizability of findings. The adults who participated in this study, therefore, should not be considered representative of adults in general. It is hoped however, that this study may contribute to the growing body of knowledge addressing ego development levels and the practice of counselling psychology. Comparing the findings of this study with other related research allows the researcher to make larger claims about the data analysis. Implications for Future Research This study is important because it provides data supporting the assertion that people's reasoning about counselling is related to their level of ego development. Future research using experimental designs would allow researchers to investigate if, in fact, certain treatment modalities work more effectively for clients at specific levels of ego development. Not only the choice of therapy method, but also the total mode of address to the client should be investigated in relation to level of ego development. This includes examining the influence of the counsellor's level of ego development on the counsellor- client interaction. Also, the specific counseling requests of individuals at each level of ego development should continue to be researched, to further understand the relationship between ego development stage and counselling expectations. More research is also needed to determine how aspects of mental health and the construct of ego development are related. For example, i f certain levels of ego development are correlated with specific mental health vulnerabilities, clients and counsellors alike may gain a more complete understanding, perhaps even a more 80 empathic perspective, of the particular challenges clients are facing at specific times in their lives. Data has shown that people at higher levels of ego development are more open to, and attend counselling more regularly. Continued research needs to focus on whether the counselling process in fact advances ego development level. Baseline and post- intervention data could be collected to examine how ego development is occurring throughout the counselling process. Studies should also continue to use longitudinal measures to assess ego functioning, particularly in those individuals who are currently seeking and/or who have sought counselling in the past. Longitudinal studies may help to identify reasons for variable rates of ego development, as well as when and why people regress in ego level. Longitudinal developmental designs with a treatment outcome perspective could explore whether client's ego development is related to changes in symptomatology and vise versa. Finally, research has shown that many cultural factors can influence a client's behaviour and attitudes towards counselling. Further investigation into how Loevinger's (1976) construct of ego development applies to people of various ethnic origins is required. Investigating how counsellors' levels of ego development influence their multicultural competency is also important. Generally, every human seeks to avoid suffering, and to learn from his or her life experiences. Also, every human has his or her own particular "frame of reference" or way of viewing the world. Most adults have had the experience of reflecting on their own "selves" and of recognizing profound shifts in their own ways of making meaning and interpreting experiences throughout their lifetime. Is this capacity indicative of an 81 underlying developmental continuum? Perhaps. Why does it matter? Noam (1992) states, "Love and work as markers of health do not suffice once we take a fundamental developmental perspective. For they are adaptational outcomes that potentially misdiagnose as healthy those who produce and produce without ever experiencing the basic creativity and deeper vitality inherent in lifelong development" (p. 690). It remains debatable whether adults truly move beyond what Piaget (1952) referred to as "formal operations." Similarly, it is questionable whether aspects of one's personality change fundamentally after early adulthood. Nevertheless, the ability to reflect on one's life, to attempt a more objective view of one's self for the purposes of better adapting to one's environment, is inherently human. In this respect, change is inevitable. Loevinger's theory of ego development provides a useful framework for understanding our clients' frames of reference. Some clients come to counselling weathering massive changes in their lives. Other clients perhaps hope to change just one small thing in their life. Regardless, such times present the individual with the opportunity to discover his or her personal potential. This discovery is manifested by observable shifts in the way individuals give meaning to their lives. The concept of ego development encourages counsellors to consider more closely the self-defining narratives of their clients. A more accurate understanding of a client's world enables the counsellor to meet a client's needs more directly, and more ethically, and so enhance the counselling experience. After a hundred years of psychotherapy, the time is ripe for bridging theory with practice. Perhaps it is not realistic to expect counsellors to begin assessing their clients 82 using the WUSCT. It is realistic however, for counsellors to consider the notion of practicing in an "outcome informed" manner, and to assume responsibility for failed therapeutic alliances where responsibility is due. If ego development encompasses what is central to the person as person (Westenberg, Blasi, & Cohn, 1998), the concept seems useful for a practice which revolves around helping people make sense of their world. 83 References Adams, G. R., & Fitch, S. A . (1982). 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Cohn (Eds.), Personality development: Theoretical, empirical, and clinical investigations of Loevinger' s conception of ego development (pp. 315-330). Malwah, NJ: Lawrence Erlbaum Associates. 96 Appendix A SENTENCE COMPLETION TEST (SHORT FORM 81) Date Inst r u c t i o n s : Complete the following sentences. 1. When a c h i l d w i l l not j o i n i n group a c t i v i t i e s 2. Raising a family 3. When I am c r i t i c i z e d 4. A man's j ob 5. Being with other people 6. The thing I l i k e about myself i s 7. My mother and I 8. What gets me int o trouble i s 9. Education 10. When people are helpless 11. Women are lucky because 12. A good father 13. A g i r l has a r i g h t to 14. When they talked about sex, I 15. A wife should 16. I f e e l sorry 17. A man f e e l s good when 18. Rules are Word 6 Version: June 25, 2004 98 Appendix B 99 REASONING ABOUT COUNSELLING QUESTIONNAIRE Please t e l l me what you think about counselling by answering the following questions. What i s counselling? What does a counsellor do? What does a c l i e n t do? Do you think counselling can change people? I f yes, how? If no, why not? Have you ever been to, or do you currently attend counselling? yes no Do you currently, or have you ever worked as a counsellor? yes no Thank you f o r p a r t i c i p a t i n g i n t h i s study. Word 6 Version: June 25, 2004 page 1 of 1 100 Appendix C 101 This page asks a few basic demographic questions. Please answer only those questions which you feel comfortable answering. W h a t w a s y o u r a g e o n y o u r l as t b i r t h d a y ? W h a t is y o u r g e n d e r ? M a l e F e m a l e T r a n s g e n d e r e d A r e y o u c u r r e n t l y . . . M a r r i e d D i v o r c e d C o m m o n L a w ( l i v ing w i t h W i d o w e d p a r t n e r ) S e p a r a t e d S i n g l e ( n e v e r m a r r i e d ) W h a t is t h e h i g h e s t d e g r e e o r l e v e l o f e d u c a t i o n tha t y o u h a v e c o m p l e t e d ? L e s s t h a n h i g h s c h o o l B a c h e l o r ' s d e g r e e S o m e h i g h s c h o o l , n o d i p l o m a M a s t e r ' s d e g r e e G r a d u a t e d f r o m h i g h s c h o o l D i p l o m a P r o f e s s i o n a l d e g r e e ( for e x a m p l e : o r E q u i v a l e n t ( G E D ) M D , D D S , L L B , J D ) S o m e c o l l e g e , n o d e g r e e D o c t o r a t e d e g r e e T h e n e x t q u e s t i o n is a b o u t t h e to ta l i n c o m e o f Y O U R H O U S E H O L D f o r t h e P A S T 12 M O N T H S . P l e a s e i n c l u d e y o u r i n c o m e P L U S t h e i n c o m e o f a l l m e m b e r s l i v ing in y o u r h o u s e h o l d . P l e a s e c o u n t i n c o m e B E F O R E T A X E S , i n c l u d i n g i n c o m e f r o m a l l s o u r c e s . W a s y o u r to ta l H O U S E H O L D i n c o m e in t h e p a s t 12 m o n t h s . . . b e l o w $ 3 5 , 0 0 0 $ 8 5 , 0 0 0 to $ 1 2 0 , 0 0 0 $ 3 5 , 0 0 0 to $ 5 9 , 9 9 9 a b o v e $ 1 2 0 , 0 0 0 $ 6 0 , 0 0 0 to $ 8 4 , 9 9 9 d o n ' t k n o w P l e a s e c h e c k o n e o r m o r e c a t e g o r i e s b e l o w to i n d i c a t e w h a t e t h n i c o r i g i n y o u c o n s i d e r y o u r s e l f to b e . _White Other Asian Black, African American, or Negro Pacific Islander _Aboriginal/First Nations Chinese _Asian Indian Other ethnic origin Japanese T h a n k y o u a g a i n f o r p a r t i c i p a t i n g in t h i s s t u d y . Word 6 Version: June 25, 2004 102 Appendix D T H E U N I V E R S I T Y O F B R I T I S H C O L U M B I A 103 LETTER TO AGENCIES Main Office Tel: (604) 822-8229 Fax: (604) 822-3302 Program Areas Special Education School Psychology Measurement, Evaluation & Research Methodology Human Learning, Development, & Instruction Counselling Psychology Tel: (604) 822-5259 Fax: (604) 822-2328 Department of Educational and Counselling Psychology, and Special Education Faculty of Education 2125 Main Mall Vancouver, B.C. Canada V6T 1Z4 July 9, 2004 Stephen Holliday, Ph.D., R. Psych. Director, Sea to Sky Mental Health Vancouver Coastal Health Authority Box 220, 1140 Hunter Place Squamish, B C V 0 N 3 G 0 Dear Dr. Holliday, Thank you again for taking the time to consider aiding me with my research. Attached is the cover letter that describes the project and its purpose. Also attached are the two questionnaires I wil l be using in the study, the Washington University Sentence Completion Test (WUSCT - Short Form 81) and the Reasoning about Counselling (RAC) questionnaire. As individuals check in for their appointments they wil l be asked by your front desk staff i f they would like to participate in the study. (Attached is the statement your staff will be asked to make to people visiting the health centre.)There wil l also be a poster displayed in a laminated frame at the front desk, inviting people to join the study. Curious individuals wil l be given a package containing: • the cover letter • the WUSCT (Short Form 81) • the R A C questionnaire • a page of demographic questions • an envelope addressed to U B C , Dept. of Educational and Counselling Psychology, and Special Education. As you wil l note, participants are instructed to complete the questionnaires and return them to the front desk in the sealed envelope. If participants prefer to mail their questionnaires, they may obtain a stamp from the front desk. A "locked box" will be provided for the purposes of holding those envelopes returned to the desk. I will collect the envelopes from the locked box in your office weekly. Word 6 Version: June 25, 2004 page 1 of2 106 Appendix E 108 Appendix F i Research conducted by the University of British Columbia, Department of Educational and Counselling Psychology, and Special Education. 110 Appendix G Ill STATEMENT BY FRONT DESK STAFF People approaching the front desk of the Coast Garibaldi Health offices in Squamish, Whistler, and Pemberton, will be asked, "Would you like to participate in a study about counselling? Front desk staff will point to the laminated frame displaying the project poster. They will then say, "An explanation of the study is included in the package." If participants have specific questions about how to answer the questionnaires, front desk staff will say, "Please answer the questions to the best of your ability." or they may say, "Finish the sentence any way you wish." or they may say, "There are no right or wrong answers." If these answers do not satisfy the participant, front desk staff will say, "Please contact the contact person listed on the cover letter." 112 r Appendix H 114 Study Procedures: You wil l be asked to fill out two short questionnaires. The first questionnaire asks you to complete eighteen sentence stems. The second questionnaire asks you five questions about counselling and the counselling process. You do not need to have ever been in counselling to answer these questions. You wil l also be asked some basic demographic questions such as age, marital status, and level of education. Take as much time as you need to answer the questions. The approximate total time required is ten to fifteen minutes. Please do not place your name on the questionnaires. Return the questionnaires in the sealed envelope provided to the desk where they were distributed. If you prefer to mail your responses, please obtain a postage stamp from the desk where the questionnaires were distributed. Conf ident ia l i ty : If you complete the questionnaires, it wil l be assumed that consent has been given to participate in this project. Please remember that your identity wil l be unknown, provided you do not put your name anywhere on the questionnaires. The sealed envelope containing your responses wil l be put directly in to a locked box kept at the desk where you obtained the questionnaires. This box will be emptied weekly by the Co- Investigator of the study. Only the Principal Investigator and the Co-Investigator wil l have access to this raw data. If you have any inquiries concerning the procedures of this study specifically, please phone the contact person listed above. Should you have any concerns about your rights or treatment as a research participant you may contact the Research Subject Information Line in the U B C Office of Research Services at the University of British Columbia at 604 822-8598. You have the right to decline to enter, or to withdraw from this study at any time without consequences to your treatment and/or medical care. Thank you for your interest, and especially for your time, in participating in this project. Word 6 Version: June 25, 2004 page 2 of2 115 Appendix I 117 \ Appendix J 119 Appendix K 120 Scoring Manual for R A C Items 1,3,4 Scoring Manual for R A C Item # 1 "What is Counselling?" 1. Concrete provision: Getting advice from a doctor, getting medication, seeing a specialist or no response (e.g. don't know). "analiss" "a doctor - a doctor who helps people" "to tell the truth, I really have no idea" 2. Support and problem solving: Talking about problems, listening to someone, helping people. Counsellor is perceived as the agent of change. "a listener and questioner" "discussion with another person" "dealing with emotional problems of people" 3. Emphasis on counsellor's skills: The counsellor has special interpersonal skills (listening, supporting, interpreting) that help the client change. The counsellor acts as a change agent or catalyst which motivates the client to change. The individual has no understanding of discovery or insight. "an interpersonal process in which the client is helped to change his thoughts, feelings, and behaviour" "a shared process of problem solving, the client offering the content, the therapist providing the tools" 4. Counselling as a special relationship: The counsellor provides a special kind of relationship or environment to discover, explore, and know self. " a means of helping a person or persons to understand him/herself better and to improve his or her relationship via the transference relationship" "a process whereby someone wanting to change asks for another's assistance in that process" "psychotherapy helps you to understand yourself better and helps place emotion in better perspective" " a relationship through which people learn to recognize and accept all their feelings and to act on them in a spontaneous, but not impulsive, socially acceptable way" 5. Emphasis on client's agency & insight: The counsellor guides the process in which client becomes responsible, independent, or integrated 121 "an opportunity for individuals to learn about themselves and to use this understanding to change their way of thinking and responding to life situations" "a process in which a person comes to know the self better, accept one's strengths and weaknesses; deal with the cause(s) of psychological imbalance and deal with faulty relationships to improve them" "a process whereby the client learns to identify his/her patterns of behaviour and their psychological origins; and explores possible options for change with the therapist" difference between level 4 and 5 - the relationship with and interventions used by the therapist leads to understanding - at level 5 this understanding is viewed as impetus for growth - understanding which leads to further action. 6. Complex: Complex elaboration of knowledge, skills, and process leading to client's growth and self-discovery "a human relationship played out with particular rules designed to enable emotional growth on the part of the client or patient (probably resulting secondarily in the growth of the therapist) "an interpersonal process whereby a person is helped to an increased awareness of his/her feelings, thoughts, and behaviour. Through this process the therapist helps the individual begin to change in ways that are growth-producing and will eventuate in an increased ability to deal with all aspects of living in a more gratifying way" "a body of knowledge and a method of facilitating change. If done well, it's a kind of shamanism" "a process which takes time. It involves learning how a person contributes to his/her own difficulties and helping that person to see alternatives. Changes are really quite small and often involve accepting conflict and using old demons to one's advantage" 122 Scoring Manual for R A C Item # 3 What does a client do? 1. Concrete: "I don't know - maybe answer questions" "come for help" "takes their medicine" "not for me" 2. Seeks support and/or solving of problem/ trying to find solutions: "discussion with another person" "dealing with emotional problems of people" 3. Emphasis on counsellor's skills: (Individual has no understanding of discovery or insight - the counsellor is viewed as the agent of action) "listens to his doctor, and does what he asks them to do" "hopefully relate to the therapist to help se l f "he or she should participate wholeheartedly in each session" "expose painful parts of him/herself - allow therapist to expose motivations for behaviour" 4. Couselling as a special relationship: Special relationship or environment to discover, explore & know self. Joint process. "Talk! Try to understand himself, be honest with the counselor" "works a great deal and i f willing - listens a lot to help him or herself "explores his or her life with the therapist" "creates with the therapist an emotional relationship which allows him to re- experience and change" 5 . Emphasis on client's agency & insight: Client is/becomes responsible, independent, or integrated. Insight is present. "the client/patient does most of the work. He/she is responsible for all the actual 'change' that takes place. The patient must self-examine, determine what is valid for him/her, and take steps to change or modify behaviour" "the client must be motivated and committed to change. The client must feel free to share his feelings and thoughts and learn to look at them less defensively" "is with the therapist as fully as possible, accepts the emotional connection, is committed to change, and takes in and works on the therapist's interventions" 123 "the therapist's questions and responses are to be carefully considered; outside the therapist's office, the client should think about what transpired during the session, and try to apply it to his/her own life" "accept their involvement in their life" "takes responsibility for learning how to change" "should be active in counselling" 6. Complex: Complex elaboration of seeking help, valuing counsellor's skills as well as own process. Emphasis on client's growth and self-discovery. "the client works toward an increased understanding of the realities of himself or his life, both in the context of his interaction with the therapist and in his reflection and daily life experience outside the actual therapy sessions" "the exact same thing as the therapist, but without the skill that comes with studying theories and methods, and without the same enthusiasm for uncertainty" 124 Scoring Manual for R A C Item # 4 Do you think counseling can change people? If yes, how? If no, why not? 1. Change through concrete provision: Client is passive "change takes place when he talks to you & with treatments" "yes, by helping them" "yes & no - nonchalant" 2. Change through support & solving of problems "Yes, get you to talk about yourself, and find ways for you to solve some of your problems" "no, I don't think after a certain age that you can actually change, however, you can be helped to handle a situation and accept things" "I hope so" "yes, I haven't found out yet" 3. Change through counsellor's skills: Counselling is viewed as acting on the client. Counsellor's skills motivate/ help the client to change. Individual has no understanding of discovery or insight. " much of therapy is education which leads to shifts in attitudes & behaviour" "through support and education the client tries new behaviours and new ways of thinking" "at least change their feelings about themselves and by understanding more, he/she can approach things differently" "it can help people understand what they are and then i f they are not happy they are better equipped to change to what they would rather be" "it is largely a process of building not only self-esteem, but the necessary intrapsychic structure to regulate the self-esteem" 4. Special relationship is vehicle for change "the vehicle for change is the relationship between the therapist & patient. The unique experience impacts on the patient and brings about change." "a combination of timing, fairy dust, cognitive change, working through transference issues, experiencing difference" 5. Change through client's agency & insight "through the efforts of the client, or patient, and this is only in small stages" "through a thorough understanding of one's own actions and their consequences" 125 "when the client or patient is open enough to be truly understood or appropriately 'guided,' and is willing to independently and persistently work to effect chosen changes" "the change takes place gradually as the client tries on new feelings and behaviour for size - with the encouragement and support of the therapist - and working through these new behaviours with significant others who may offer resistence to the client's change. The bottom line is the client's decision to allow change to take place" 6. Complex "Yes, the change takes place through new self-knowledge and commitment to grow into new ways of being and doing" "yes & no, it depends on how you interpret change. If you mean basic altering of the personality structure, then I doubt it - i f it means developing another (higher?) level of making meaning, then yes" 126 Appendix L 127 Practice Exercises for R A C Items 1-4 Practice Exercises for R A C Item # 1 What is Counselling? 1. listening to someone 2. an aid to be used in bettering yourself 3. seeing a specialist 4. a journey embarked upon by two people (where at time it may be difficult to tell who is the leader and who is the follower) resulting in beginning where you started, yet somehow it's different 5. a chance for individuals to learn and grow 6. counseling is a program where you talk to a trained outsider. With their tools, change is easier. 7. not sure 8. talking to someone who is neutral in your life 9. a special relationship where the client learns to identify reasons for their behaviour 10. assisting people with personal and family problems Answers 1. 2 2. 5 3. 1 4. 6 5. 5 6. 3 7. 1 8. 3 9. 4 10.2 128 Practice Exercises for R A C Item #2 What does a counselor do? 1. listens to the client, reflects back to him/her, points out patterns, summarizes, relates 2. a neutral person who would discuss & try to help solve problems that a person could not deal with alone 3. allows the client to come to insights that lead to change that improves the client's quality of life 4. they ask you questions 5. essentially, the therapist and client go on an exploration together, and integrate their findings through their interaction 6. helps client feel better about himself 7. unknown 8. offers a holding environment - a safe, predictable, trusting setting in which the client can explore his feelings and options. This is done by being consistent & receptive 9. gives you advice 10. role is that of objective observer. He/she attempts to have the patient reevaluate their position from a perspective they have not considered. He/she helps the patient see underlying currents, themes in the patient's actions. Answers 1. 3 2. 2 3. 5 4. 1 5. 6 6. 2 7. 1 8. 4 9. 1 129 Practice Exercises for R A C Item # 3 What does a client do? 1. talk about their problems 2. trust the therapist enough to truly explore his/her life with them 3. attend each session 4. think about counseling during the week, not just in the therapist's office 5. bitches 6. be honest with the counselor, finally, in hopes of truly understanding, or at least accepting oneself 7. listen to the counselor, and do what he/she tells them to do 8. seek closure 9. seek closure with the help of an outsider, understanding that true closure begins with all the dirty work - why not have a little company... 10. works hard Answers 1. 2 2. 4 3. 1 4. 5 5. 1 6. 4 7. 3 8. 2 9. 6 130 Practice Exercises for R A C Item # 4 Do you think counseling can change people? If yes, how? If no, why not? 1. Yes, i f the counselor and client are compatible, change is definitely possible 2. Yes, it helps people to overcome their issues/resolve their problems 3. Yes and no, most of it is crap 4. I guess i f someone really wants to change, it is possible. 5. For profound change to occur, much hard work needs to be done. Perhaps this can be achieved through the counseling process. In my experience, counselling doesn't always change people for the better 6. No, but it does provide the opportunity to have someone listen to you, and everyone could use that 7. having the opportunity to be human, with someone as forgiving as a counselor, extends into daily life 8. Yes, i f someone is willing to go to counseling, they can change. But they must be willing to take responsibility too, and to be open to new perspectives 9. No, but counseling teaches people new ways of thinking and behaving 10. yes, by allowing issues to be identified Answers 1. 4 2. 2 3. 1 4. 5 5. 6 6. 3 7. 4 8. 5 9. 3 131 Appendix M 132 Table 4 Levels of Ego Development According to Gender Ego Stage (TPR) Men Women Transgendered E2 - Impulsive 0 0 0 E3 - Self-Protective 2 (8.3%) 2 (8.3%) 1 E4 - Conformist 6 (25%) 3 (12.5%) 0 E5 - Self-Aware 7 (29.2%) 5 (20.8%) 1 E6 - Conscientious 5 (20.8%) 8 (33.3%) 0 E7 - Individualistic 2 (8.3%) 6 (25%) 0 E8 - Autonomous 2 (8.3%) 0 0 E9 - Integrated 0 0 0 n 24 24 2 Table 5 Reasoning About Counselling Levels According to Gender R A C (total score) Men Women Transgendered 1 - Concrete Provision 2 (8.3%) 0 0 2 - Support and Problem Solving 7(29.2%) 9(37.5%) 2(100%) 3 - Counsellor's skills 11(45.8%) 8(33.3%) 0 4 - Special Relationship 3(12.5%) 6(25%) 0 5 - Client's agency/insight 1(4%) 1(4%) 0 6-Complex 0 0 0 n 24 24 2 133 Appendix N 134 R A C Responses Ordered by Ego Development Level Ego Development Level 3: Self- Protective Stage (n=5) E3 Responses to R A C Question # 1 What is counselling? 1. A way of sorting out life situations to make them understood (C) 7. Helping people with life (NC) 19. When someone tells you what to think and what to feel (NC) 21. Listening to someone (NC) 38. It's for people who need to talk about their problems in order to be happy living their lives (C) E3 Responses to Question # 2 What does a counselor do? 1. asks questions in a way that a person can solve a crisis or understand life (C) 7. That's an open question (NC) 19. Sit on the couch and zones out (NC) 21. Listen and suggest (NC) 38. A counsellor listens and creates avenues, through discussion to assist troubled people find the answers to their issues (C) E3 Responses to Question #3 What does a client do? 1. A client will tell the counsellor things that they are having problems with (C) 7. Spends a lot of money, in hopes of a little advice, or maybe just needs someone to talk to/ (hence a friend) (NC) 19. Vortexes and bitches about their problems (NC) 21. Talk (NC) 38. A client comes needing help, but not necessarily willing to be assisted (C) E3 Responses to Question # 4 Do you think counseling can change people? If yes, how? If no, why not? 1. It may or may not help, but it will change people (C) 7. Yes, everyone needs someone to talk too [sic] (NC) 19. Yes, for the better - It helps them overcome their problems (NC) 21. Only i f they want it to (NC) 38. Counselling can help anyone. A l l people need to talk about their issues. A n unbiased, educated ear can help all individuals lead happier lives (C) 135 Ego Development Level 4: Conformist Stage (n=9) E4 Responses to R A C Question # 1 What is counselling? 2. Talking about problems (C) 8. Assisting others through discussion of life issues (NC) 22. To try to help someone mentally adjust to the life they have created for them selves by bad decisions & predicaments or other bad cards life has dealt (NC) 29. Unknown (NC) 33. Listening and guidance (C) 34. It is so you can talk to someone about things that bother you deep inside (C) 40. It is a session where you get advice or another point of view from a professional regarding your problem (C) 42. Where individuals need help, it is something that can help them deal with what is needed for a better way of life (NC) 47. Taking money under false pretence (NC) E4 Responses to R A C Question # 2 What does a counsellor do? 2. talking with their client (C) 8. Helps others by listening and helping to resolve issues through discussion (NC) 22.1 don't know but I would think they would help people adjust or readjust their lifestyle to become a happier person. Because if you are going to counselling you can't be happy (NC) 29. unknown (NC) 33. Listen and tell you what you have said to show you what you already know (C) 34.1 think they try to help resolve what bothers you, and make you feel better about yourself (C) 40. Listens to you and asks questions (C) 42. Listens and trys to deal with the situation as best they can to their knowledgement [sic] (NC) 47. Not much - listens (NC) E4 Responses to R A C Question # 3 What does a client do? 2. Talking about his problems (C) 8. Talk about their lives & problems (NC) 22. (NC) 29. unknown (NC) 33. give yourself closure (C) 136 34. see's [sic] a counsellor or provides his or her time with someone who charges you $ 40. Talks about their problems (C) 42. Explains what ever the situation may be and listens to the counsellor for advice (NC) 47. Pays (NC) E4 Responses to R A C Question # 4 Do you think counselling can change people? If yes, how? If no, why not? 2. Yes, it should help people dealing with their problems and then they maybe can go on with something else (C) 8. Yes. By discussing your issues with someone who is not directly involved will help to see things objectively (NC) 22. Yes. A lot of people have blinders & can't really see the big picture of life. They would need counselling " i f the counsellor is good to help them adjust (NC) 29. Unknown (NC) 33.1 think so. If you don't let it out to someone it will bug you forever. You need to talk to people, sometimes (C) 34. Yes, because they listen to you (C) 40. Yes, I believe counseling can change people by showing them that their [sic] are alternative ways to deal with most issues in life (C) 42. It could be yes or no depending of the individuals personality and their way of life, the way they were brought up by their parents and also the area ex. city, country (NC) 47. only if they listen (NC) Ego Development Level 5: Self-A ware Stage (n= 13) E5 Responses to R A C Question # 1 What is counselling? 6. It is a process whereby someone who has problems (of any kind) can seek out help to make effective changes in their lives in positive ways (C) 11. Helps a person understand their emotions, ideas. Identifies how many happenings in our life affect our behaviour (C) 15. Counselling is a place where people go to hear what people already know but in different words (C) 16. Non-judgemental. - getting help from a professional when you feel you can't deal or work through your problems or feelings (C) 137 17. Sharing & discussing ideas & troubles [with] another in hopes to give better direction/peace of mind (NC) 20. Talking & listening to people about their problems & stresses & life (NC) 25. A n aide to be used in bettering yourself (NC) 26. According to the dictionary, counselling is an exchange of opinions & ideas or advice or guidance from a knowledgeable person and I agree with that (NC) 32. Is a process whereby a person who has training or particular life experience assists another in resolving a problem(s) (C) 35. Someone who listens to someone else problems [sic] (NC) 36. Talking and listening (NC) 44. Talking to a qualified individual about something (NC) 49. a way of guiding someone who may have confused or unhappy thoughts with the intent of balancing them without pressure or prejudice (NC) E5 Responses to R A C Question # 2 What does a counsellor do? 6. Listen and help people through difficult times (C) 11. See above, (helps a person understand their emotions, ideas. Identifies how many happenings in our life affect our behaviour) help us deal with the task. Provide support, coping tools. Make us aware of reasons for behaviour in the first place (C) 15. Tell people exactly what they already know (C) 16. Talk you through things, coping mechanisms, change patterns (negative ones), listen, encourage, teach you how to empower yourself, and also be straightforward & honest (C) 17. Help [with] process of finding answers/ solutions. Help view things in different perspective (NC) 20. Listen & give advice. Recommend suggestions and alert the police (NC) 25. Help people understand (NC) 26. A counsellor listens, first, then helps the client to understand & verbalize his or her problems dealing with the ups and downs & difficulties in life. Then, hopefully the counsellor will be able to help the client to make a plan for his or her life so she can get on with it (NC) 32. A counsellor assists a client in the resolution of his (her) problem by making use of his (her) training or experience (C) 35. Solves the problem, and listens (NC) 36. Listen (NC) 44. Listen, support, give feedback & facilitate "healing" (NC) 49. refer above (a way of guiding someone who may have confused or unhappy thoughts with the intent of balancing them without pressure or prejudice) (NC) E5 Responses to R A C Question # 3 What does a client do? 138 6. Seeks out help from a professional when situations in their lives get to a point that they don't know how to change them(C) 11. Participate, practice, (C) 15. Tell their problems (C) 16. Admit things, realize your not a bad person, acceptance, learn about your past - how it effects your present/ future (C) 17. Work together [with] counsellor's guidance - see above (sharing & discussing ideas & troubles [with] another ...) (NC) 20. Vent and complain about counseling (NC) 25. try to understand (NC) 26. brings to the counsellor all the things that are making it difficult for him/her to get along with other people, perform at work - etc. and with the counsellors help tries to figure out why and what to do about it (NC) 32. a client (hopefully) brings a positive attitude and a will to resolve his (her) problem(s) to this process (C) 35. helps with the problem (NC) 36. pays, hopefully for a good reason (NC) 44. Talk, divulge, &, in doing so, hopefully learn about self (NC) 49. with any degree of effort he/she seeks help through an unbiased trained person (NC) E5 Responses to R A C Question # 4 Do you think counselling can change people? If yes, how? If no, why not? 6.1 think counselling can and does help people that have a real want to change. There are, no doubt, situations where a persons problems are so deeply seeded that it manifests into a complete unwillingness to be helped (C) 11. Yes, many people unaware of external influences, or other factors that affect their quality of life./ I'm sure there are many more reasons, I just haven't experienced them (C) 15. No because it doesn't really tell you anything different (C) 16. Yes (I think it should be mandatory - once a year for every Canadian over 16!) people would feel so much better talking to a professional about their feelings and any problems can be dealt with or at least worked on (C) 17. could - help understand/ view new perspective. Help better communication skills (NC) 20. No, but I think it can give people direction and a lot of focus (NC) 25. Yes - By having outside influence, a person can look oneself more objectively [sic](NC) 26. Perhaps some but not all. Sometimes we just have to live with the hand we are dealt and a good counsellor can guide you through the rough spots and teach you how to handle most of them (NC) 32. Yes if the counsellor and the client are compatible and the client has [the] attitude and the will to do so (C) 139 35. Yes, because they listen to you (NC) 36. Yes, you need someone to talk to (NC) 44. People do not "change" as much as learn about themselves & become aware of how the world works & how he/she can react to the world around (NC) 49.1 think it can help i f each client works together with the counselor and if the counselor treats each client with every special need or attitude they may bring (NC) Ego Development Level 6: Conscientious Stage (n=13) E6 Responses to R A C Question # 1 What is counselling? 3. Counselling is a program that can assist people in dealing with personal and family problems (C) 4. It's helping people cope with life. Most people can benefit from a little help now and then (C) 9. Provide venue for important discussion of people's problems (C) 12. Allowing people to talk about what bothers them & assist them to find their own answers (NC) 13. Counselling is a medium whereby a person requires help in their personal & professional life and needs the advice of a professional educated and impartial to help them achieve that goal (NC) 14. Counselling is an opportunity to have your voice heard. It is a chance to explore your feelings and behaviours in a safe environment (C) 23. Counselling is a chance to discuss your feelings with someone who listens and helps guide your thoughts (NC) 27. It is when you sit down with a trained professional in the field and discuss your life and what's going on in it (NC) 31. A place to speak & listen to get a better grasp on your problems (NC) 35. Counselling is the act of listening and providing clarity to anyone seeking it.(NC) 41. You pay for 1 hour and hope that she or he can help you in this point in your life can help you change or understand what is happing [sic] at this point of your life (NC) 45. Getting thoughts & ideas to concerns and issues you may not have thought of.. .providing alternatives (NC) 48. It is listening and respecting the person who seeks it (NC) E6 Responses to R A C Question # 2 What does a counsellor do? 3. Listen. Provide a sounding board for a client who needs to talk through a problem 140 with someone who is neutral. Assist the client to develop new strategies when dealing with his/her problems (C) 4. Objectively assesses the situation, offers analysis of the situation and offers suggestions for action and insight into the problem (C) 9. Listen, open up dialogue/ provide perspective (NC) 12. See above (allowing people to talk about what bothers them & assist them to find their own answers) (NC) 13. A counsellor helps a person with whatever problems they are unable to deal with themselves. They provide a perspective that allows a client to work through their particular problem (NC) 14. Assist you in organizing your feelings in a safe & healthy manner. To support your personal growth (C) 23. A counsellor is or should be someone who accepts a person for what they are and can make the client feel he is worth something (NC) 27. A counsellor listens to what you tell them and tries to help in solving or at least helping you understand your problems, fears, worries etc. (NC) 31. Listens & provides advice but not answers (NC) 35. Listens tentatively, asks questions, when necessary provides answers, is there for comfort when the person feels alone; and also holds a neutral ground in order to be viewed as non-judgemental (NC) 41. To how many day's a week you go/ The counsellor listens to what is happing [sic] at this point in your life (NC) 45. One who provides the above (thoughts & ideas to concerns and issues you may not have thought of...) - provides the option (NC) 48. Listen's [sic] to hear not to respond (NC) E6 Responses to R A C Question # 3 What does a client do? 3. Approach sessions with honesty and openness. Show a willingness to listen to and apply suggestions that are given (C) 4. Hopefully comes with an open mind, is given valid insight and uses the suggestions to make a few changes (C) 9. Diagnoses problems, issues which weigh on their minds.. .and (C) 12. Try to open up as best they can (NC) 13. A client provides information on the situation that they need help dealing with. They also work on the advice given so that they can be autonomous [sic] in the solution (NC) 14. Their best to empower themselves to make the changes they want for themselves in their lives (C) 23. a client attends counselling sessions and hopefully after some sessions can start to understand and accept the problems or reasons he/she is there for (NC) 27. a client discusses whatever they want with a counsellor and the counsellor listens to them and gives positive feedback (NC) 31. works hard to resolve his/her problems (NC) 141 35. be side show up. I would have to say trust this neutral person and accept that they are there for you. the client must be open and honest without worrying about consiquences [sic] of things said (NC) 41. In she or he/ own words try's [sic] to tell what is bugging them (NC) 45. Should take the info from the counsellor - consider the info. Weigh the options - and make the desisions [sic] (NC) 48. Talk's [sic] about their feelings (NC) E6 Responses to R A C Question # 4 Do you think counselling can change people? If yes, how? If no, why not? 3. Yes - i f the client seeks help with honesty and openness. There has to be a willingness and a desire to change (C) 4. Yes - i f the counselling is good (all isn't) and the person genuinely wants to make some changes. I see someone making minor adjustments rather than major basic value changes (C) 9. Yes, helps them find their own way through their issues (C) 12. No - it does not change them it may assist them in looking at themselves from a different angle (NC) 13. Sure. I think that i f someone willingly goes to a counsellor they are open to change. Of course they must be open minded and be willing to see themselves in a different light than how they have perceived themselves (NC) 14. No, counselling offers the opportunity to make change and an exploration of the avenues for personal change (C) 23. Y e s & n o ( N C ) 27. Yes, because everyone could definitely use someone to talk to and have them listen. It's positive and with positive things comes positive results (NC) 31. Yes by allowing problems to be identified and pathways to resolving them to be identified (NC) 35.1 think that the right counselor can change people. I think in all relationships people are compatible. This could be true for counselor client relationships. I think the client needs to connect with the counselor (NC) 41. Yes! There are some people in their life have be lost they seek help in hope that that person can slowly straton out there arrow [sic] (NC) 45. If it helps them make a decision or come to a realization when they need it most (NC) 48. Yes. A good counselor can help you sort out how you really feel (NC) 142 Ego Development Level 7: Individualistic Stage (n=8) E7 Responses to R A C Question # 1 What is counselling? 10. Counselling is conversation with an objective trained professional where the individual has an opportunity to express his or her fears, frustrations, anxieties, desires, goals in a discreet & confidential setting (NC) 18. Get a second opinion by a specialist. Someone who's neutral in your life (C) 24. Gives guidance to those who are struggling or have some kind of mental/social impairment or just need help/ someone to ask questions of (NC) 28. An important service that all individuals should partake in, whether from a professional or a close friend to improve mental health (NC) 30. A n opportunity to discuss issues affecting your life with a professional (NC) 39. Having the opportunity to openly talk to a qualified professional. Discussing life, its challenges and dilemmas we might be facing. Finding reasons, solutions, being comfortable and accepting what you feel having someone helping you to strive to be happy (C) 43. Counselling can be a wonderful, positive, supportive tool that ables us to live a better quality life. Also educate's [sic] us on life skills, which sometimes we are never taught healthy coping skills or listening skills & self acceptance (C) 46. Counselling is the direction a person or a trained professional will do to help you see the errors of your ways, actually guide you and bring out your best qualities (C) E7 Responses to R A C Question # 2 What does a counsellor do? 10. Listen & guide. Does not judge (N) 18. Get you to talk about your life/ listen/ give advices/ make you realize.. .(C) 24. Talk-open up communication/ diagnose mental illnesses - get medical help & referrals i f needed (NC) 28. Support people and help them work through their problems. Assess potential solutions and help to build stepping stones towards enlightenment and contentment (NC) 30. Listen. Offer strategies to deal with what's bothering you (NC) 39. Empathy. Listens, is patient, is open, tactful and is removed from the challenges you may be facing. Seeks to make you feel comfortable and recognize what you feel. Works in unison [with] the client to overcome problems and find their smile again (C) 43. A good counsellor listens with compassion, understanding. Helps us to feel safe to communicate our stories. Then helps teach us ways to cope in a healthy manner, & love ourselves & others. Helps us to set healthy boundaries (C) 143 46. Listens, develops hypothesis, guides and instructs (C) E7 Responses to R A C Question # 3 What does a client do? 10. Confess (NC) 18. Trust the counsellor/ asking for help (C) 24. hopefully listens to advice and acts accordingly (NC) 28. try to work with the counsellor to get to the root of the problem and suggest sound approaches to healing (NC) 30. talk & listen & learn. Try to implement new strategies to deal with issues they're struggling with (NC) 39. Discusses openly what they feel./ They need to want assistance from a counsellor to make chances in their lives (C) 43. Expresses our stories & myths we grow up with. Explains our emotions & fears. Trust's [sic] the counsellor with our stories (C) 46. Listens, collects information, keeps the good & discards the rest (C) E7 Responses to R A C Question # 4 Do you think counselling can change people? If yes, how? If no, why not? 10. Yes, I think that the right counsellor - client pairing can result in some self- direction that can be positive (NC) 18. Yes!/ Make them see life a different way (C) 24. Yes & no - some of it is a whole lot of B.S. (NC) 28. Yes, I believe that no individual can work through any issue without some input from the outside (NC) 30. Yes. If people really want to change, and have the right tools to do so - it's absolutely possible. The mind is an incredibly powerful thing (NC) 39. Yes. Sometimes people lack the ability to be objective or really "see" situations, their reasons or solutions. Sometimes it takes another to collate the thoughts and feelings in your head and direct them in a path that is positive (C) 43. Yes I believe counseling can change people i f the person wants to change & take responsibility for their actions. I have witnessed both scenarios with a lot of people. Some people have embraced the change & thrived from the experience. I believe counseling to be very proactive (C) 46. Yes, for those who are intelligent enough to seek answers to better improve their personality (C) 144 Ego Development Level 8: Autonomous Stage (n=2) E8 Responses to R A C Question # 1 What is counselling? 5. The elimination of a path not previously seen (NC) 50. it is a means of helping us to realize that we are but human, reflecting back on us that it is ok & normal to make mistakes but not ok to keep repeating them (C) E8 Responses to R A C Question # 2 What does a counsellor do? 5. Try & act like a guide or a fellow traveler, at least (NC) 50. they help us to reflect on our life experiences and filter out wrong perceptions that we have allowed to stay with us a counselor is a filter of sorts (C) E8 Responses to R A C Question # 3 What does a client do? 5. Anything & everything (NC) 50. a client listens initially, then one who really listens fully realizes that it is he/she who has the keys to unlock their own anxieties! (C) E8 Responses to R A C Question #4 Do you think counselling can change people? If yes, how? If no, why not? 5. Ya . - same answer as the first question (the elimination of a path not previously seen)./ - Ha ha full circle. - (NC) 50. Yes! Through the realization that we all possess the virtues necessary to unlock the mysteries of our own pain, the road is long & very, very hard but it can & it does happen (C)

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