A COUNSELLING INTERNSHIP AT THE PSYCHOLOGY DEPARTMENT OF THE
JANEWAY CHILDHEALTH CENTRE WITH
A STUDY OF THE GROUP THERAPY NEEDSOF PARENTS OFCHI LDRENWIT H IMPULSIVE AND/OR AGGRESSIVE BEHAVIORAL PROBLEMS
BY
CATHERINE J.TREMBLETT, B.Ed. (El e ml , B.Sp.Ed
A report submitted to the School of GraduateStudies Inpartial fulfilmentof the requirements for the degree of
Masterof Education
Faculty of Education MemorialUniversity of Newfoundland
December, 1995
St.Jbhn's Newfoundland
1+1
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~~b~~~~uereucree Qirec li(lndes acquisitionset des servicesbibiiOgl8phiques 395.roeWell.-.gIQll OlliIWs{OnIa"oj K1ACW'+I
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This rBport is dedicatedto my father,CalvinGreen, whoalways hadfaith in me.
i i ABST RA CT
This is a report of an Educa tiona l Psychology int e r n shi p at t.he JanewayChildHealthCentre. The in t e r n s hip wa sconductedfr o m Jul y 31,toOctober 27, 1995.
Thefirstse c tio n presentsa decnLf ed repce t of the goa ls and the activitiesundertakenby the internto meet thesegoals. The second section reports on <I developmental project stud y i ng the group needs of parents ofchild r e n with impulsi veand/o raggressive behaviour problems . This proj ect inc l u d e d a re v i ew of the literatur e , the development of aque s t i o nnair e , theint e r vi e wi ngof e parents of children with impuls ive and aggressive behaviour problems, a dis c ussion of reepcneee to th e int e r v i ew and re comme nda t i o ns for therapists planni.ng to developparent groups forparents of childrenwithimpuls i veand/or aggressivebehaviour.
TABLEOFCONTENTS
DEDICATION .
ABSTRACf i i
ACKNOWLEOOEMENTS v
LIST OFTABLES vi
INTERNSHIP REPORT
1. Ra tio na lefor Int e rns hi p .
11. Set t ing .
A. Developmen t a l Psychology Ser vic e . B. ClinicalEva luati onand Treat.ment Service s . C. BehavioralTherapyService ....•....•... ... . . .
D. SocialEmo t ional Servic e .
Ill. Dur a t ion... ... ... . ... .... ... ... .. ...•. .. . IV. Supervi s ion ... . . .. ... .. .. . .. .. ... .... ... . . . 10
V. Goa ls... ... . ... ...• ... ... . ... ... .. 13 VI. Activ i ties Undertake ntoMe.:t the Goals.... . ... ... . IB A. Teachi ng Rounds. ... ... .. .... .. . ... ... .. . . .... 19
B. caseConfe rences 23
C. Clinic s ... .. . ... .. ... ... .... ... . . ... . ... 24 D. Educ ati onal and Informat ionalExperie nces 28 E. Pro f essionalReadi ngand Di s c uss ion 31 F. As s e ssment and Tr ea t men t.pr e pa ra tio n 31 G. Obs e rv i ng Ind i v idua l Ther apy Approaches. ... . ... .. . 32 H. FamilyTherapy .... ... ... .. ... ... ... 33 I. Administrati onandScoring ofTe st s 38
J. GroupCouns e llingSkill s 38
K. Developmental aeeearcb-aesecProject 39
L. Administration -10
M. supervision 41
N. Record Keeping ·12
O. Conclusion 42
P. ADevelopmental Project Studyingthe Group Therapy Ne e d s ofPa r e nt s of Childr en wit h Impu Ls Lveand/or
AggressiveBehaviora l Problems .... 44
1. Rationale and Purpose 44
2. Lite r at ure Review . 3. Ques tionnaire 4. Sample ...•.
5. Met ho d o l ogy .
6. Analys is ... ...•. ... . . ... •. .. •..•. . 7. Resul ts
8. Discussion.... .•.. 9. Recommendations ..
... 45 52 5'
54 55 60 65 Vil. References ..• :•... . . . • .
APPENDIC ES... . .. .... ... .• . . ..
.... . ... • •... . . . 68 . ....•• •. .•....• ••. •. 72 A: MUN, Faculty of Education Eth i c sCommitt e eApprova l . 72 B: Janewa y , Human In v e s t i ga t i on s Committee Approval... . 73' c: Janeway , Psychol og yDepa r tment, We e kly Report . . 74 D: List of Rea di ngsComp l etedDuri ng Interns hi p ...•• 75 E: Fami lyAs se s s ment Device .. . ... • .. ...•. . ... . . .... F: Questi o nna i r e .• •. ..• .••.. . .• ••.. ... .•... . ..
80 81 G: Consent ForRe f e r r al .. . ..•. ... . •....•.. . .•••... ... .. 86
ACICNOWLEDG EMENTS
I would like to thank Dr. Linda Moxley·Haege rt, my field superv isor . for pro vidingme wit han internshipsitesecondto none in Newfoundland as a learni ng oppo rtun i ty for a Maste r of Educational Psyc ho l ogy inter n pl a nn i ng to work as a schoo l guidance counse llor. In par ticular, Iwould lik e to ack nowl edg ehe rhighly skilled, direct , focusedmanner of supe r v i s ion.
Dr. Lee Klasstar ted as myprofess or , becam e my supervisor, men t o r and friend. I twas unde r thedi re c t i on of Dr.Kla s that I coo r d ina t ed -A Hand Up", a suppor t service program forMemo rial Un i vers i ty studen tswi th le a rn i ng disab i li t i e s . Thr oug ho u t th a t year and the year s uptothe pr e s e nt Dr. Kl asalwaysdemo n s t rated confidence in my abilitieo and jud ge men t s. For hi s profess ional i s m,unders ta nding, wisdom, andkindn ess I wil l always be gra te f u l.
Specia l tha nks to my fami l y for their encoura ge ment and uncondit iona l support,especial lymy husband Cr a i g , our daug hte r s Victoria andSarah, and mymothe r Ei leen Gree n.
Tab le Title
Lis t of Ta bles
Page Type andFreq u e ncyof Activ i t i e s Unde r t a ken at 19 the Jan e wa y by th e InterntoFurther Dev e lo p Knowledge andSki lls
Type and Frequency of Ac tivi t ies Unde rta ke nby J4 the Intern to DevelopKnowl edge ,Gai n Experi ence andBuildSkill s in Famil yTherapy
In tentions ofAt tendanceat a Paren t Gro up for 55 Pare n t s ofChildren withImpuls i ve and/or
AggressiveBehaviour Proble ms
Types, Fr e qu e nc y andLocati onof Child r e n'S 55 ProblemBehav i ours as Ratedby Parent s ofChildre n with Impu l s iveand/ o r Agg r es s ive Behavio u r Problems WhatHappen s When Probl emBe ha v iours Oc c u r inSchoo l 56 as Ratedby Parentsof Childre n withImpulsive and/
or Aggres siveaenevLc ur Pr o bl ems
Di s c i p line at Home as Rated by Parentsof Children 56 with Impulsive and/ orAggressiveBehaviou r Pr ob l ems Types of Behaviour Te ch niq u e s of WhichPa r e n ts 57 are Aware and Which ParentsHave TriedwithTheir Childrenwho Have Impu lsive and/or Aggressive Behav iourProb lems
SuccesswithBehavi ourTec hniquesTried andthe 57 Willingness toTry New Techni quesas Ratedby Parents of Childrenwith Impulsiveand/ or Aggressive Behavi our Pro b l e ms
Behavioursfor WhichParen t s of Impulsiveand/ or 58 Aggr ess ive Ch il d re nFeel The y Need Behavioral Techniques
10
11
12
What Parent sof Childrenwith Impu ls iveand / or Aggressive Behavi ourPro blems wouldLike a Parent Group toOf f e r Them
How Parents of Children wi thImpu l siv e and/or Aggressive Problems Feel They WouldBenefit by participa tingin a Paren tGroup Paren ts' WillingnesstoPar ticip a tein a Parent Group for Parents of Child r e n withImp u l si ve and/orAggressive BehaviourProblems
58
59
59
INTERNSHIP REPO RT Rational eFor Internship
To graduate, students in the Master'sDegree Program in Educ a tio na l puychcLcqy at Memorial Uni ve r s ity are provided wi tha cho iceof degr ee comp let:'.o n re quirements : the y maydo eithera thesis, projector aninternship. Or i g i na l l y , this studentopted for thethe s i s route. However , upon reflection on the ga i n s already achieved fr o m working on a partially completed the s i s (f or which literaturehad been reviewedand one year of work was completedas Program Coordinator for "A HandUp~ , a suppo r t services programfor MemorialUniversit;:' stud ents withlearning disabilities) the student felt tha t suffic ien t awareness and knowledge of and experience with learning disabilities had alreadybeen obtained. The writer de t e r mi n e d that engagingin an internshipwo u l d provide a more valuable and pertinent learning experience and would significantlyadd to her current counsellingawareness and skills. The internshipwoul d provi de an enhancement and/or de ve l o pment of skills in individual and group counselling, familytherapy, assessment ,and consultationand liaison, all of whic h are direct lyrelatedandtr a n s f era b l e toher curre nt pos it ion School Guidance Counsel lor/Educational Therapist. The Ja neway Child Health Centre (he re aft e r, re ferre dto asthe Janeway) was chosen as theint e r ns h i p site.
The inter n is presently emp loyed in the dual rol e of School GuidanceCounsel lor/Educational The r a p ist in twourba n schools, wo r ki ngwi t h children with va r i eddifficul ties whi c h oftenresult in referralsmade to the Jane way. Referralsto the Janeway are now sent to a cent r alized intake cc- o rdtnatoz for various services, and may be ma de for assessment or enrolment in ongoing programs. These pr og ra ms may invo l ve pe rsonne l fr o m the foll owi ng departments or services:
Psyc hology, ps yc h i a t ry, Audiology. the ThomasAnde r s o n Centre, and the Learning Be ha viour Clinic. (These havebeen the ones most commonl y utilized by the school systems .)
The intern had enjoyed her work as a School Guid a nc e Counsellor/Educational Therapistand take n gr e at pride init.
She had set high sta ndards to maintain and felt that the in t e r n s h i p would increa s e her knowledge and awareness of services prov i de d bythe Jane way, the communityand elsewhere, aswel l as strengthenandbroaden her counselli ng skills. The int e r n s hip would build on existi ng skills and develop new ones, thus enablingthe intern to provide better services upon re t urnto her dua l ro le job.
Acounselling int e r ns h i p is required to be a th irt e e n week, full-timepl a c e me ntat an approvedsetting. Supervis ion is provid e d by two pers o n s , a fi e ld supe rviso r at the internship site anda uni ve r s i t y supervisor. Edu c ation and guida nce services e ze fields of grea t chang e. Inc reas i ng demands for wo r k i ng with a vari e ty of pro bl e m situations,
scenarios, and attitudes mean that. professionals must continuouslyenhance existing skills and develop new skills vttaf to providing the best possible services.
Setting
The following criteria, stated in the Department of Educational Psychology Paper on the Internship Programme (1975), were considered in the selection of the internship setting.
1. Thequality of professional supervision. 2. The quality of learning opportunitiesand
experiences.
3. The relevancy to and usefulness of such experiences in the actual setting in which the intern ultimately expects to work.
4. The availability of time from full-time involvement of the intern fora minimum of thirteen consecutive weeks.
5. Availability of a qualified field supervisor on- site.
6. Ready access to the university supervisor. (p . 2) The Department of Educational Psychology Paper on the Internship Programme (1975) states "The intern should work wit.h a variety of clients appropriate to her eventual employment under conditions that protect the interest of the counselee as well as contribute to the competence of the
inte:rnn (p. 2). The stud e nt ha s alre ady ac h i e ved employment and will be returningto a setting wh i c h is highly related to and often dependent on the serv icesoffered.by the Janeway.
Ethical re gu l a t i o ns protect the interes tof the counselee. It is also import a n t to recognize that the Janeway provided placement, supervi s ionand clientelefor the intern. These clientele supposedly benefited fromthe int er a c tio n with and servicesprovidedby the intern. The Janewayalso benefited by haVing the intern as a full-time staff person. In addition , the internresearchedand developedre commend a t i o ns onthenat u r ean d type of needsof parentswith childrenwith impulsive and/or aggressive behaviora l problems; it is intendedthat such datawi ll be used bytheJa n e way tode ve l o p group therapy programsfo r these parents.
The Program Description Guide (De c ember, 1994) ofThe Jane way Psychology Department describes the following services :
Deyel opm e n t alPBYCh o 1 oa". Serv ic e
Developmental psychology is the branchof science which is concerned wi t h the orig in and change in physical, mental and social functioning that occurs through the life span.
On occasion, a young child doesno t progress along the expected pathway of development or he/she does no t progress at th e ex pe c ted rate of development. These observed changes in either the ra t e or pattern of
development progression may be due to either genet.ic and/or congeni tal fa C" t o r s. The::aimof the Deve lopmental Service in Psychology at the oeneway is to assess the presentdevelopmentalstatus of young Lnf crrt s or chi l dre n who aresuspected of exh ibitinga slower rateof developme n t or apatte r n of development that is different than might be expected. Upo n diagnosiscof a significa nt delay, appropriate stimulationactivities ca n be formula tedwithth e aim tore d uc e or dela yor cha ng ethe existing patternof behaviour and counsellingwiththe fa milymay be implemented at thisti me . Counsellingmay be in the form of parent groups, famil ythe r ap y, behaviourmod ific at ion programs,orcons ul t at i o nwi t h the preschoo lsora var ie tyof otherways. Most referrals for this program in i'sychologywill come through the childnevefo pmenc Program.
Aswe l l , at this mome n t inti me thisservice wil l app Ly totho s e pr eschool children whowou l dfa l l under neuropsychology, wh i c h is the branch of psychology concernedwi t h the studyof br ain-behaviouror relationshi p. Clinica l psychologists in this area generallyas s e s s adaptive abilities. The prima ry purpose of ne u ropsyc ho l ogywould be topr ov i de a comprehensive description of a child's ability and to relate this information to brainfunction, when thi s inform ation is us e dtohc~ppl an programs fo l. the home.
Referrals for preschool neuropsychologyar e appropriate in the fol lowingcircumstances:
Where there is knownor suspected neuropathology (e p i l e ps y, head injury, CNS infections, congenital neur-canarcmicet malfunct ions ) .
b. Where there has been a rece nt marked alterationin performance persona lity , or othe r aspects of adaptive functioning sugge s ti ng poss ible CNS involvement.
Congenital syndromesassociatedwith psychological or behaviour ou t c ome s (Le , PKU,Wi l l i amtS Syndrome, Turner'sSyndrome ).
Cl i nicalEy al u a t i gnan d Tre a t men t Se ryic es Thisservice is responsiblefor general evaluation and program planning for children S- 16 years of age.
~h i seva:'uatio nm",y be in t.erms of int e l lige n c e,school achievement, language skills, visua l-spatial motor skills, personality factors, adaptive behaviours and organizational capacities. Based on theresu l t s of the assessment, specific re comme nda t ion s arema de toschool and home.
Children agedS-16may be experiencingsome signif icantproblemin adapt ionacademically, sociallyor both.
It is only appropriate to refer a child for a psychoeducationalassessmentincaseswhe r e:
The childhas hadan assessmen tanda secondopinion is felt necessary (a retest intervalof atle a s t 6 months is re q ue ste d) .
b. whenassessment is necessaryas pre-operat ive and poat - opera tiveevalua tionor pre and post-therapy.
BcbniourTh era py $eryic;e
Behaviour therapy involves primarilythe application of learning principles to everyday problems. It is assumed that most of the actions pe o pl e per fo rm are learned andthatle arn i ng principlesca nbe effectivein cha ng i ng wha t people do. Research has shown that behaviour therapyhas provenapplications in child and adolescentdisorders. Using behaviour thera p y methods, the psyc ho logistsets speci f ictrea tme n tgoals wh ichare intended to expand the parents ' and/or ch i l d ' s skillsand abilities .
Treatment can include individua l wo r k wi t h the children, and almost always pa r entcounsel ling.
Typical areasof service fr ombehaviour the r apyare;' Chro n i c behavioralor medical con di t i o n s Non - c o mp l ianc e to medical procedures Eating disturbanc es
Except iona l chil dren Pain management Toil e t training Encopresis
Enuresis
Socialskills tr aining Sleep disturbances management Stress management
Behaviou r problems in hospital or at home Consultationto hospital staff and corrununi t yagencies In order tore f erto Be ha v i o ur Therapythere mus t be areasonablebasis toassume thatthepr e se nt ingpr oble nl$
havea behavior a l compo nen tor, alternat ive ly, there is a need , as part of the multi-d i s ci pline invest i ga t ion , to examin e poss i b le behavioral contri butions to complex sympto matology .
In terms of outpa tients, the fe asibili t yof using local re s ou r c e s should be examinedinal l cases.
srn:hl Emption.lslrvic _
This service would include psychodiagnostic asse s s men t, consultation, therapy and counsel li ng for chil dre n and adolesce nts pr e s e nt i ng wi th social, per s o na lity and eeotIo neI prob lemsand for thefami li e s of thesechildren. Suchproblems wouldinclude rea c t i o ns to par e nta l sepa rat i on and di vorce , be r e avement, depres sion , soci a l ski ll s difficu l ti e s, family dysfunc t i o n , anxie t y coping withchroni c disease, po st traumatic stressand ge nd e r iden t ity is s ue s.
Thefo rm of thera pymaybe individua l psychotherapy or family thera py. Some child gro ups current ly are
Social Skills Groups , La rge Psy cho thera py Group Ie, RelaxationGroup rc. In other cases the proble m with succ essin the ra py is muchmore simple in that the family and/orclientdoes not have the kn owledge tocopewith a certaincondition. Unde r thos e conditions these families should be referredto educationa l counselling .
Three fo r ms of pare nt groups are current ly being organizedin psycho logy , whi ch include:
1. Group for single parentsof hardto co nt r ol children.
2. T. ,lining grou p for pare nts of chi ldre n di a gnosed with At tentionDef ici t Hyperact ivityDisorder.
3. Chil dMana gemen t SkillTraining Program. (p.1- 41
Dura t i on
The inte r nshi pcommenced on Mond a y July31, 1995and continued for thi r t e e n consecutiveweeks, ending on Octobe r 28, 1995. For fi ve days a we e k the student worked at the inte rnshipsetting. One day aweek wasorigina lly designa t e d towo r k onceaearchan d complete reports for theJan e wa y, but due to the activities scheduled and learn i ng opportuniti es ava i l a ble , the intern deemed it morevaluableto be onsite for the fu ll fivedayseac hweek .
10 supervi sion
All proposed activitiesfor the in t e r nshi p were submitted to Memorial University'sFacultyof Education Ethica Commit t e e and the Janeway Child Health Centre Ruma n Inv e s tigat i o n Committee and 'Wer e gr antedapproval. Cop i e s ofthelettersof approval of both Memoria l university 'sFacultyof Educa tion Eth i c s Committee and th e Ja new ay Chi ldHeal thCentre Hu ma n Inves tiga tionsCommitteeare providedin Ap pe nd i c e s AandB re s pe c t i ve ly . Or.Lee Kl a awa s the academi csupervisorfrom the Faculty of E:ducati on (Divisionof EducationalPsycho logy) at Memorialuniversity. PeriodicallyDr.Klasand theintern met and consultedto monitor the intern'sprog ress. Dr. Linda Mo xley - Haegert,DirectorofPsyc hologyat the Jane way , wasthe fi e l d superviso r. Three joint meeting sat the beginning, mid po i nt an d theendof the internship we r e hel d withthe in t e rn . Dr.Klas and Dr. Moxley - Ha e gert present.
Dr.Li ndaMoxle y- Ha eg ert wasthe field supe rvisorand the personwithwhom the inte rn wo r k e dmo st closely. Dr. Moxl ey- Ha ege r t and the in te rn met for one schedul ed ho ur wee kl y to review the inter n 's prog ress and address concerns. In ad d it i o n , the in t e r n me t wi th Dr. Mo Xle y - Ha e ge r t , when necessa ry, at. unschedu led times. The int ern al so had the opportunit y to work withthr e e other full-time psycho l og i sts and fiv epa rt-time ps ych ol ogi st s . The ps yc holog y staff' s cl inica l respons i b ili t ies, as st ated in The Pr ogram DescriptionGuide tnecemcer, 1994}, ar eas follows:
11
L.Moxley-lIaegert • Director
Family Program, Prescho ol and Ado lescentProgram Dia be t i cTe a m
OncologyCrisis Inte rventi on Neu rol ogyTeam
FamilyThe rapyreferra ls Pre schoolReferrals Ou t pa t i e nt referral s
Social Skillsand Parenting Group
S. Manoc ha
Preschool and SchoolAge Pr og rams cys tic Fibros isClini c AsthmaticClinic
ps yc hia try Referrals fromDr.Bowering
Ref e r r a l s for childrenwith AttentionDeficitDiso r de r s Outpatient Referral s
ADD Parent Groups
SocialSkills and Parenting Group
s.Downey
LearningBe ha viour and AdolescentPrograms Learning /BehaviourClinic
DownIBand DysmorphicClinic Psy c hi a t ry referrals fromDr.Wh i t e Referralsfor Sleep Disorders , Anxiety,
Pai nand AngerManagement OutpatientReferrals BurnTreatmentManagement
Chroni c Pain Treatment (t o be developed) Prevent ionEducation
J.Lee
Co-ordi n a to r of Pres c hool, Fa milyand Adoles cent Programs Communica t ion /Development Cl i n i c
Out Pa t i e nt Referrals BehaviourTherapy Services Social Emotional Services
PsychiatryReferrals from Dr.St.John AdolescentSurvivorsof Sexual Abuse ADD Paren t Group /Soc ia l skills
A. Wareham
Psychiatry Program
Day Treatment and Psychiatry In-patient Referrals
H.Dalziel
Intake Co-ordinator, Family Program Community Mental Health Referrals
Co-ordinatorof programs from the Thomas Anderson Centre
L. McDonal d
NeuropsychologyReferrals CommunityMental Health Referrals
D. Coa dy
Brief rnee rvenef.cnrst , Co-ordinatorChild Abuse Program Child Protection - 1/2 time
social Emotional Therapy - 1/2 time N.Ornbolt:
Psychiatry community School Age Referrals Community Mental Health School Age Referrals c.Clanc y
Pre-school Program
Community Mental Health Referrals C.Arlett:
Community Mental Health Referrals Co-ordinator of School Age Programs
As can be seen, the psychologists provide a very comprehensive set of services and work clos ely together on a number of their responsibilities. This has been an excellent integrative model for the intern to learn under.
Goal.
The Departme nt of Educationa l Psyc hology Pape r on th e Internshi p Programme (1975) sta t e s thegoalsrequi red ofthe inte rnsh i p in meetingdepar tm en t a l re gul at i ons andst andar ds. The s e goalsar e as fol lows:
1. For the deve lopmentof competenc iesfo reachtrainee based on her needs , pre vious experie nces , and future vocat ional plans.
2. For practi calexperiencesthat willbri ng in t ofocus thetheore t i c a l training rec e ive dduri ngthe formal part of the progr am .
3. Fo r pra ct ical exp e r i ence s that will enabl e the trai nee and thedepartment toevaluatethet.raineeIs abili t y toeffectivelywork in hischose n fiel d . 4. oppor tu nit i e s for the trai nee to evaluat e her
pers onalbehaviour modal i t ies and work toward making any ne cessarychanges.
5. For feedback from the int ernship set ting to th e departmentregarding st r e n g th s andweaknesses of its st uden t s so that program improv e me nts ca n be implemented .
6. Forth e development ofresearchandproblem -solv ing skills appropriate to the needsof thestu d e nt and thesett ing , cons i d e r i ng thenat u r e of her placement and hervocational plans. (p. 2)
TheDe pa r t me nt algoal s me et thenee d s of various interns
14 in varied settings. These goals give an overview and a framework upon which to build. In addition, the intern had goals, both general and specific,which relatedparticularly to her setting and the practical exp eri en c e s to whic h she hoped tobeex p ose d andinwh i c h she hoped to be involved.
The intern 'stwogeneral goalswe r e :
1. Through observation , interaction . fa c i li t a t i o n, co- leading, leading, supervis ionand discussionto improve her currentcounsellingskillsan dbehavioralman agement te c hni ques and. as we l l, to gain newknowledge, counselling skills and behavioral management techniques.
2. Upon completion of the internship , the intern will provide the.Jane waywithresearch baaed information and recommendat ionson programdeve lopment perta ini ngto the needsof parentsof childre nwith impul s i ve and/or aggressiv ebehaviourproblems. Th e s e data and recommendationswill thenbe usedby the Janewa ysta ffin the development of a prog r a m of pa rentgrouptherapy fo r parentsof children wi t himpu l s i v e and/or aggressive behaviour pr obl e ms.
The int ern hadten specific goalswhichwe r e based on the goals of thedepa r t me n t ,wi t h the underlying the me s of herown two genera l goals. These specific goals we r e as follows : 1. To develop anawarenessand unde rs tand ingof the
philosoph yand theoreticalba s i s fromwhich the Janeway
15 operates.
2. To become familiarwiththe roleof the psychologist in the Janeway , more Rpecifi cally the fun c t ion of the psyc holo g i s t s in the Thomas Andersen Cent r e, Learning BehaviourClinic , Psychologyand Psychiatry departments. 3. To gain knowledge of various psychotherapies from a
numberof psych ologistsin this medical setting. 4. To be c o me awareof the fullth e r ape u t i c process, from
in take. to th e r apy, tote r mina t ion.
5. To become familia r withthe servicesand operationsof theTho mas Andersen Centre, Lear ningBehaviourClinic and the Psychology and Psychiatrydepartmentsand to find out how they are inter-related, the functionof each andhow theywork together. To become full y aware of howthe ne w referral systemwor ks .
6. To de v elop knowledge of and skills in family therapy techniques. This knowledge and skill will be developed through reading, discussionwi th field andacademic supervisors. observation, co-therapy, providing therapy and directed supervision during and after therapy sessions.
7. To enhance group counselling skil ls. A variety of groups at a variety ofage level s arerun at theJaneway. Gr oup counsel l ing skills will be enhanced through reading, discussion wit hot he r personnel andps y c hol ogis t s who are conducting groups, observation . co-leading. and the
"
research project component.
a. To enha nce individual psychotherapy and counse l ling skills.Thi swi l lbe achievedbyreadin g ,discussion wit h variousps y cho l o g i s t sreg a r d inga varietyofapp r oa c he s . and observationand supervision duri ngthe actualproc e s s of therap y.
9. To conduc t a research component. To research and study th e grou p therapyneedsof pa rentswithchildre n exhibit ing impulsiveand/o r agg r e s s i v e be havio ra l prob lems. Thisgoal wi ll be addressed throughthe followingprocesses:
Beco mingfamiliarwi t h parentand childgroup programsoffered at the Janewa y.
b. Thoroughl yreviewing the literatur e on the natu reand typ e s of needsshown/ repo rtedby pare ntsof childrenwit h impulsive and aggres sive behaviour an d impulsive and on techniquesofaggressivebehavi o ur man age ment;
reviewing the lite rat u re on gro up thera py approachesand programs for these parents.
Obta ini nga list of potential pa r e n t part icipantsto interviewfromthe Janewayby approachingJanew aytherapis ts to explain the nature of the interv iew andaskingeach ther a p is tto contact his/ her ownclientswho fit the intern's criteria .
17 d. Devisinga parent questionna i reto follow when
interviewingparents .
Intervie win gsevera lparents wi t hchildren exhi biting impulsiveand/or aggressive behavio ur pr obl e ms to di s c ove r wha t they feel they woul d like to bepr o vided ina pa r e nt gro u p.
f. Analy zing information and data gained fr om the parent interv iews an d questionnai r es. g. Baaedon a review of the currentparentgroup
counsellingprogramsconductedatth e Jane way, theli terat u r e review andthedat a gat he red from inte r views and ques tionnaires, ident ify the needs of parents with child ren with impulsive and/or aggress ive behav i o ur prob lems.
h. Leave theJa newa y child He a l t h Cent re wit h a re po rt doc ument ing th e parent need s for pa r ents of children wi t h aggre s s i ve and impul sive behaviour pro blems , along with recommendationsfor devel o pi nga group the rapy prog r a m.
10. To avail of the opportunit ies to atte nd informa tion sessions, wor kshops , clinics,con fere ncesor ee t e- confe rences on any topic relev a nt to the inte rnIs prof e ss ionalgrowt h.
re
Activ it i•• UndertakenTo MeetTheGoal . The intern is ve ry pleased to re port that she dideeeu all of he r statedgoals and even some addi t i onalgoals which werenot fo rma llyexpressed. Thes e goals wereme t. thro u ghthe varietyof act i vitieswhic hare shown inTable l .
Th e internwa sre qu i r ed tore c ordall activitiesandthe amountof time spe ntat each activity,the sa measisrequired of al l psychologis ts at the Janeway.The log was submitted weekl yto the Psyc hologyDepa rtmentsecreta r y,whoca lculated the variousstatistics. Thesestatisticalanalysesprovide theDirector with valu a b l ein f or ma t i o non the fun c tio n ing of ps ychologist s ind i vidu a lly and as a Department . A copy of theweekl y lo gispro videdin Append ixC.
Table1list s the act i vities and frequency of activ ities , mea s ure din hours, that thein t e rn actuallycarriedOI·~at the Janewa y. These hours were mainly accumulated during the thirt e en week place men t.but someadditi onal ho u r s wereadded atthe end of the thirteenconsecut iveweeks and onweekends throughout the in ternship . Some compone n t s of theac t i vi t y
"a eeee a ne nt; and treatment pr epara ti on- were possible to accomp lish off-site, but all other activi ties wer e done direct lyon site.
Afurt herdescription of each of theac t ivities in Table 1 follows.
"
Table 1
Type and FrequencyafAc:!=iyitiesUndertaken at the .Ianewayby theIntern to furtherDeyelop Knqwledgeand Skills
Frequency
Activity (Ho u r a)
Teaching Rounds 26.25
Case Conferences 5.75
Clinice 32.SO
Educational and Informational Experiences 63.50 Prof e s s i ona l Reading andDi s c u s sio n N/A Assessment and Treatment Preparation 133.SO ObservingVa r i o u s Individual Therapy Approaches 3.25
Family Therapy 52.SO
Administration and Scoring Tests 5.00
Group Counsellingskills a.75
Research 34.00
Administration 34.00
Su p e r vis i o n 15.00
Records 6S.00
Teachi ngRgun d o
The intern attended both teaching rounds and case conferences at the hospital in the Department of Child &
Adolescent Psychiatry. Teachi ng rounds and case conferences present inpatients of the psychiatric ward of the hospital.
The Policy and Procedure Ma nu a l (1 99 4) of the Janeway PsychiatryDepartment states the following policy regarding
admissionfor these patients:
Admission to the inpatient unit may be undertaken following outpa t.ient assessment for further assessment or treatment if the followingcriteria are met: 1. The young person has not reached sixteen.
Occasionallyolder patients may be admitted at t.he discretionof the attending physician.
2. If a bed is available. The wa r d has a maximum capacity of 13. but the func tionalcapacity may be less.
3. The child/adolescent is believedto suffer from a psychiatric di.sorde.r which requires further assessment or acute treatment.
In extraordinary cases ir.p a t i e nt admission may proceed outpatient assessment - usually for geographical re a s o ns . (p , 2)
Patientswi t h the following diagnoses reside on Ward 1C- Psychiatry: Attention Deficit Disorder; Attention Deficit Disorder with DevelopmentalDe l a y ; Attention Deficit Disorder
\'1ith Conduct Disorder; Major Depression; Bipolar Disorder (Ma n i c l ; Bipolar Depression(Mi xe d State); Separation Anxiety;
Conduct Disorder; Adjustment Disorder with Depression; Adjustmentwith Dis o r d e r of Conduct; Post Traumatic Stress Disorder; Schizophrenia; Anorexia Nervosa; Bulimia; Autism;
Pervasive Developmental Disorder; Developmental Delay (Mild);
Developmental Delay (Moderate); DevelopmentalDelay (Se ve r e) ;
21 Alc ohol Abuse; Drug Abuse; 'rcure ee ee Syndrome, Learning Disability (Dysle xia); Learning Disability (Oys c a l c uli a)I Lea r n i ng Disability (Ot he r ); Speech& LanguageDisorder ; an d Ob s e s s i v e comp ul sive Disorder (Ori en t at ion Handbook, 199 3). Apatien t may receiveone or moreof thesediagnoses .
Teaching rounds were conducted weekly on Thurs day mornings startingat 8:3 0and usuallycontinuingunt i l12:00 p.m. All professionalswork ing with the patient attended.
including psychiatrists , residents in ps ychiatry, psychologi s t s , social workere, nurses , te a c he r s (from the Janewa ySchool). anddiet ici ans . Re s i dents presented a case his toryof each inpat i e nt on the psychiatry ward. This was a very thorough presentation, which include d thefollo wing for each patient: mode of referral ; informants; the presenting problem; current physi cal and emotio nal state; medical history; pers on al history: premorbid personality; family history ; descr ipt i ve formulation ; anddi a gn os i s (Or i e n t a tion Handbook 1993, p.1-3) .
At the first teaching round s after a ne wadmitt an c e , a newpat i entwas presented ina very thoroug h ma nn e r. Each following wee kthepa tie ntwas presentedon mo re of an up da t e basi s. Each pro fession al worki ngwiththechil d present ed any per tine nt information hel d on the patient and, where appropriate , prov i ded inpu t into de ve lopinga planoftherapy for the patie n t. Al l prof e s s ionals pr ov i ded inpu t on eac h case. eveni f the ywe r e notwo r kingdi r e ct l y with thepatient
22 or the pa tien t was not on their caseload . The intern occa siona llyasked about how a school could help or what she could do to help a pa t ient in apar ticu larscen ario . Each we e k the r e was an update and monitoring of ongoingservices for each pat ie n t and a dec i si on was made for continuation pl a ns.
The Teac h ing Rounds presen t e d a golden learning opportu nity fo r the intern; they additionally provided perm i ss ion to see and talk wi t h children wi th ve rtoue ps yc h i a t r icandothe r pro blems , insteadof just reading about them. It enabled the in te rn to unde rstan dthe child from admi s sion throug h to dis charge and all the therap y and servi ce s included in tha t pr o c e s s. It hi ghlig h ted the sympto ms the childr en were exp e r iencin g and demo ns tratedthe di f fe rences in symp t omsincompariso nto another with the same dia g nos is.
In many cas e s, graduate candidates in Educa t i o n a l psy c hology donot have the op p ortu nitytowork di rectlywith children \.,ri thsuc hpsychi atr ic disorders. The yarelimi t ed to read i n g. Re a di ng is good, and pr ov i d es much knowledge on psych iatric disorde r s , but actua ll y comi ng fac ectccEacewith the chi ldren and obs e r ving thei r beh a viour is a much more inclusiv e le a r ni n g experie nc e . Guid a nce couns el lors wo rk i ng in the scho o l system ha v e child r e n wi th such disord ers in the i r schools . The expe r ience of Tea c h ing Rounds was invalua b leto theinte rn .
2]
Cas e Conferenc es
Case conf e r e nc e s were held three times per month on wednesday mornings, usually from 9:30to 11:00. Theinte r n attended three case conferences. All profes sionalsproviding servi c estoth e patien t attend thecase conference. Parents, fo s t e r parents, other approp riate relatives, social workers from out s i d e the hospital (with child protection services, financ ial assistance, etc . ), school board personnel and/ or school personnelmay also attend. Any person that wil l be pr o v i d i ng services forthe patientisusuall y in attendance.
The resident in psychiatry presents. The outline followedby the residentinpresentingatca s e conferences, statedin the Orie ntationHandbook (1993) , is as follows:
1. Names of those present andtheir position 2. Brief history in 2-3 lines
3. Investiga tions in hospita l 4. Psychological testing
5. Course inhospital: toinclude : behaviou r on the ward, at school, onou t i n g s, etc.rpaz-ent.aL interactions,etc.
6. Treatme nt: mede., progress , interve ntions, etc. 7. Plan s : discharge, follow-up, meds.
8. Copy: toreferri n g physicianand/orschoo l authorities and/or Department of Social Services , whenevernecessary.
Case conferences are the follow up plan of services fo r a patient who is being discharg ed. By at tending case confe re nces the in t er n confirme d and re new e d her belief in
24 ne t work i n g on the par t of all pers ons working with prov id ingservices for a child and being aware of the entire picture of thatchild' sli f e. Suchnetworki ng ensure s tha t peop le knowwho is res ponsiblefor whatservicesand helpsto avoidduplicat ion cf or gapsinservices.
The Chil dD~velopment Programme is a department of the Janewa y . This depar tment iscomposed ofvari ous prof e s s ional s and linked with ot.he r depa r t men ts wi t h i n the hosp it a l and serv ice s withinthe pro v ince . TheChild De ve l op mentProgr a mme (March, 1989) of th e Janewa y Child Developmen t Programme Departmenteeaeeer
The Child DevelopmentProg ra mme is an int er di sci plin a r y service staffed by developmental physicians, nu rse coordinator. socia l workers, psychologist, and clerical staff. Closeinterdepartme ntal links are maintainedwith other hospital departmen ts , suc h as Speech-Language Pathology, Neurology. Au d i ology , Genetics,etc. In t er age nc yli n k s are maint a ined with PublicHealthNursing across theprovince, Di r e c t Home Services Progr am, Provincia l Perin a t a l Pro gra mme an dChil d r e n' s Rehabilitat ionProg ram, to na me but a fe w. (p. 1)
This depar tm ent provides ser v ices to th e hospi tal and co mmun i t y throu gh fiv e clini c s : Communicat i o n/D e ve l o pme n t Clinic, Cl e ft Pala t e and Cr aniofacia l Cl inic, Down's and Dysmorphi c Syndromes Clinic, Le arn i ng/Be h av io u r Cl i nic and
FamilyClin i c. The chil dDeve l opmentProgramme (Marc h, 1989) of the JanewayChildDevelopment ProgramDepartment stat es :
Thi spr og r amme pr ovide sse rv i ce to the hospit a l andth e community in various ways. Inp a t i e nt hosp i t a l cons u l t a t i on are done on de velo pme nt a l issues spanni ng th e rangeof ch i l d hoo d. Programme staff also serve as con s ul t a nt s onchilddevelopmen t is sues throughout the hospital . Otherdirectse rviceis prov idedthro ugh the five cl i n ic s of the program me. All referrals come thro ugh our intake procedure and ar e sl o tt e d to the va r i o u s clinics as appropr iate . (p. 1)
The intern attended the Learning /Behaviour Clin ic regUlarly on Wednesday afternoons from1:00 to 4:30 . She attended the Communicat ion/Deve lopment Clinic for one patien t ca s e . The Le"arni ng/Be hav i o ur Clin icis fromwhere the intern , as a school guidance co unsellor , had received mo s t of her correspondenceand hadthemo s t contact with at theJa n e wa y.
Manychildrenare refe rredtotheLearning / Behaviour Clini cby their parents, school guidance co unsellors or educational psycholog ists . The intern wanted to gaina thorough working knowledge of the Learning/B ehaviour Clinic for future re f err al s and consul tat ions with the Learning/Behaviour Clinic. A perk for the in t e rn, besides learning how the clin i c operates, is having met and worked with the team members; th i s should facilitate even better communication with the clinic inthefu t ur e.
26 The internstartedas an ob s e r v e r and progressed todo follow up visits on he r own at th e Learning/Behav i our Clin i c . She attendedsessionswith different me mb e r s of the team, including pediatric ians, social wo rker, special servic es teacher and the psychologist. A varietyofca s e s andco n c ern s were seen, including learning disabilities and attention deficit disorders of various types. Chi l d r e n's environme n ts were compa redand theirab il itieswer e asseaeed in each of these environments. Th r e e environmentswhich usually wer'e monitore d wer ehome, sc hoo l and peer groups. Th e informa ti on providedabouta childin each of these environments , coupled wit hassessmentresults, is vital in the diagnos i ngprocess. Followingis the purpose of theLe arn i ng/Be ha v i o u r Clinic.as stated in the Policyand ProcedureManual (19 9 4 ) , De p a rtme n t of Child DevelopmentPr o g r a mme :
The Learning/BehaviourClinicwill act to provideschool- age chi ld r e n withap p r o p r i ate assessment and/or management for difficult ies re l a ted to academic and behaviora l fu nc t i o n i ng. Such difficultiesmay be evident in the classroom environment or may persistat home. Focusof the Learning/Be haviour willbe on understanding and managementof learning and behaviourdifficulties .
(p. 1)
Although most of the school correspondenc e is withth e Le a r n i ng/Be ha vio u r Clinic, man y childrenwi t hde v e l o pme n t al de l a y s are also referredtothe Janewayby parents. Th e Child
27 Developmen t.Program (March, 196 9 ) of the Jane...ayDe p a r t me n t of Child Developmentstates:
The Communication/ Deve lopment Clinicis the oldest and largest clinic, having begunin 1968. I tserveschildren zero to six years of age with developmental delay, speech -languageconcerns,hearing impairment.and various other develo pmental disabilities. tp,1)
Inthe la s t three yearsthereseems to be more children in schools exhibiting pervasive developmental delay symptomatology . Th e intern wantedto gainmore knowledgein the process of diagnos is, signs, symptomatology and the support services necessary fo r these children. Theinterndid get the opportunit y to observe and attend one case. The identifiedchild Axhibited a developmental concern and the familywa s seen asa smallgroup bythepediatrician, so c i al wor ke r,ped i.atr'Lcdan residentand the psychology int e r n . The family wa s al s o seen by a psychologis t and speech-language pathologist. The groupmeetingcontinued for onehour and a half. Af t erthe family meeting, there wa s a meeting of al l' prof essiona l s involvedwit h the child , inc lUdingre portsby other profe ssional s who could not attend. A thoro ug h discussionledto a decis ionregarding diagn,"sis, afo l l ow - up plan of services nec e s s a ry , and how the s e serviceacouldbe provided . The orig inal small 'iT-OUP of profess ionals , includi ng the inter n , met againwith the family to present the ir fi ndi ngsanddis cu s s any concerns or ques tionsthat the
2.
family commun i cated. The development a l concern inthis cas e was aqueried per v asive deve lopmen tal del ay, and a diagnosi s was withheldpending progress in fu r the r de v elopment of th e child; therewasno necessity for a diagnosisat that time.
Educa tion alandInfOrmatio nal Ex p o r i e n CeD
The inter n had formal meetings with all of the psychologists onstaffto discuss theirrol e s and the specific componentsof theirposi tions. Thi s.coup ledwithobservation and wo r k i ng on teams with the psychologists, provided the internwithspecific sonthe rolesof th e s epe y o hol oqLa t a fr o m different pers p e ctive s.
Discussio nwith psyc h i a t r i st s , reside nt s inps y c h ia t ry, pe dia t ric ians, socia l worke r s , teache rs . physio thera p is t, nurses, aud iol ogis ts, technicians oper at ingvar ious equipmen t and do i ng various pr oc ed ures , and se c r e t ari al staff all provided the intern wi t h va l u a b l e information on therapy , institut ionalproceduresand thephil o s ophy of the Janeway.
Al t hou gh te a ch i ng rounds and case confe r e nces were al readyadd res s ed, it is important to notetha t they alsowe re highlyedu catio naland info rmat i ve. Prac ticallyall of the acti v i t i e s of the inte rnshipwe r e fo r educational pur p o s e s, but this sect ion is prov i ded to hi ghligh t th e sp e ci a l edu cationa l oppo r t un i ties whi ch were not rou t ine , suc h as attenda nc e at rou nd s , and donot app rop r i atel y fit under other top i c s.
Hosp italorient a tion provided awider perspec t ive cn th e
29
total ope r a t i o noftheJa n e way . Many schoolchi l dr e n haveto stay at the Ja ne wa y for various psychiatric and medical It is effectivei f the scho o l guidance counsellor ca n speak tochildrenabout th e Ja n e wa y pr i or to ad mitt a n c e and after discharge, upon their return to school. This provides a real connection for the child, whenth e guidance counsellor can knowingly speak of specific aspects of the hospital whi c h the child may have encountered or may be encountering. I t prov idesa stronger basis upo n which cc build rapport and a trustingrelationship .
The in t e r n met wit h the Director, the psychologist and the teacher of theChild r en ' s RehabilitationCentre. Again, many school childrenava i l of the services provided at the Children's Rehabilitation centre . The school guidance co un s e l l o r has co r r e s pon de nc e with the staff there, who provide servicesto children in the schools. It was goodto actually see and talk with these people and gain a better understanding of th e services they are providingto school children,
Any school guida nc e counsellorIs in t e r ns hip at the Janeway wou l d no t be complete without a tour and thorough understandingofhowthe Janewayschool operates. The intern met with the school principal, visited the school sit e s and met with theteac hers ofpsychiatrypatients, These teachers ma yo r may not see the patie nt in a school sett ing. This school setting iEI notthe same as for a studentin a regular
30 sch o ol cla s sroom, but it did provide an opport u n ity to ma ny of the abili ties of thest u d e nt s. Students are often provided bedside t.e achf.nq . These teachers are a va lua ble co n t a ct for guidancecounsellorswho wish to gaininformation regardinga childadmitted to the Janeway.
The in t ernalsoattended se ve r al presentation s. One was at Memorial University, sponsored by the Psychology Department,by Dr.LindaSi e g a l on the "Mythsand Real ities of Le a r n ingDi s a b i l i tie s" . Sev eral presentations we r e made at;
the PsychologyDepartment of theJa ne wa y. Paul Ludlowof the Department of Soc ial Services presented an intensive in tervent i onprogramfo radolescentswhichhe is coordinating.
Dr.Elizabeth Woods,of the DivisionofAdole s c ent /Young Adult Medicine Chi l d r e n ' s Hospital, Boston, presented
"In terviewingand Confidentiality for AdolescentPat ients" at the Psychology Department. She also met for an informal discussion of psychiatrycasesat th e psychi~tryde pa r t me n t . The intern wa s pleased tohe able to at tendand he a rDr. Woods these two times on two different topics. She ha d much experience and educationto pass on in a clear and easy to understand and follow manner. The in t e r n also attended a meeting of all psycho logists in the St. Jo hn ' s health ca r e system. It wa s very interesting to hear thei r conce rns and th e possible changes for psychologistsworking in St.John's. The internaccompanieda child,with parental consent, to the AUdiologyDepartment for severalaudiology tests. This is
31 a department where the school guidance counsellor may need to refer a student for hearing and language related testing. The audiologist, Tim Lushington, explained each test and gave the intern a great deal of information about his work, the types of tests administered, and the information gained on a child from a visit to the Audiology Department forte s t i ng.
Prgfesd QDolRead ingand DiBpu ssi on
The intern did a great deal of professional reading prior to the commencement of and during the internship. Much reading was done on family therapy, which was one area on which the intern focused. Much reading was also done on parent training, anger and aggression and programming for parents and their children with impulse and aggressive behaviour problems. Appendix 0 provides a list of readings completed during the internship.
Throughout the internshipthe internhad opportunityfor informal discussions on a variety of topics and counselling issues with both psychologists and social workers. These informaldiscussions duringlunc h or in a more relaxed setting than in administrative meetings provided the intern with the opportunity to ask questions and gain opinions more freely.
A"eB,m,nt,and Treot:m,nt, preparation
Assessment and treatment time included a variety of activities, the main activity being preparation for therapy sessions. There was time spent with the team in preparation for family therapy or time alone reading on the particular
32 focus of a family'sproblems or issues . Ti mewa s then taken to review a case and itsis s ue s and to de c i de on a plan for the nextsession.
This also includedtimespent gettin gfamiliar wi t hte s t s vhd ch were necessary to administerand getting the appropriate co ns e nt fo rms ready for th e r a py. There are different consent fe z -me for the differentrequests ma deof client s. Some of these for ms include: conse nt for video-taping , co ns en t for audio-taping, consent for obs e r va t i o n by an inte r n, co ns e nt;
for ob s e r va t i o n throug h the one-wa y mirror , consent to consult, consent for referral and conse nt to release information. It also included any calls whi c h were made regardingclien ts, forexampleca l l s to schoolsand doctors . Sometimesafter a session, either withthe teamor asan individual,a'note reiterating the focal pointspresentedin the therapysession would be composedand mailed out to the client or family. This.notewould be co mpo s e d du:: ing the assessmentand treatment preparationtime.
Observing IndiyidualTherapy Apprgachep
Theint ern's gradua te cou r s e s in educational psychology and he r workexperience ha s provided her wi t h muchknowledge and experience in individual counselling . However, the inter n did arrang e to observepsychologists in ind i v i d ua l the r apy;
the intern observed ind i v i d ua l counselling by psycho logist ScottDowney at the Learning/BehaviourClinicand two sessions of brief the r ap ywi t hps yc ho l og i s t Doreen Coady. The sessions
)3 included adolescents presenting with phobia s and suicidal tendencies. Theint e r n also observed one-half sessionof play therapywit hpsychologist Chr isClancy.
The se experience sgave th eint.ernthe opportunityto see hNIdif fere n t the r apis ts wo rk. Their phil osophy, techn i q ue s and le ve l s of ex p erience al l influ ence d their styles of counse lling. The inte rn als o had an opportun ity to ob s erve otherpsycholog ists 'andsocial wo rk ersIcounsellingstyles in the familyprogr ammeandsingle -sesaion the rapy . It is aIwaya helpful toob s e rv e others' cou n sellingstyle s andtec h n i qu es. Oppo rtunit y f<:')r suc hob serva tion do not oft e n occur in the school aetting, whe re the re is us ua l l y onl y one guidance counsellor in each school .
Familv 'herapy
Avarietyof ac tiv i t ies inwhich the int e rnpart ic ipated providedth eopportu ni t yto develop knowl e dg e,ga inexpe rie nc e and build sk ills in family thera py. The se act i v ities and thei r frequency repre s en ted in hours ar e pr e s en tedinTable2. The int ern had ve rylimitedknowledgeandexpe r iencein fami l y ther ap y an d felt she neede d to start 'flith the bas ic histor i c a l dev e lopment of fami l y therap y andpro ceedthroug h to the currentphilos ophi e s andthe r a p i e s in use. The boo k familyTherapyis the text use d at Memo rial Universit y for the cour s e in family the r a py, It is cur r ent , systematicall y organi z ed , well written and pr o v i dedan excellentint r odu ct i on tofam ilytherapy,
34 Dr.Moxley-Ha e ge rt has taughtthe family therapycours e atMemor ial andused the text herself. Shewas very famil ia r withthete xt, whi c hprovedus eful in discussionand refe rence to specIficconce r ns theinter npres e n t ed. Ta ble 2
Type and Fremlenc y of Ac t iy i ti e sUn der ta k enbytheInt er n to oevelOPKn owl e dg e Gal n Exp e r i e nc e andBlIildSki l lS in EamJl y
-=
Ac t i v i ty
Reading and Discussion withDr.Mox ley- Haegert of the Text Boo k Family Sys t em Th e rapy (Becvar&Be c v ar, 19931 Obs e rve dSi ngleSession Family Therapy Observed Famil y Thera py - onewaymir ro r Co-the r ap i st withDr.Moxley-Haegert pr ima ryTherapistSu pervise d by Dr. Mox! e y -Haeger t
Admini s tr at i on.a nd Scor i n gof Famil y Ass ess men t Devic e
Re a d Articl es onFamilyThera pY
Frequen cy (Ho urs)
3.0 0
6.50 20 .15 15.15
NfA
NfA
The psycholog ist s in the familytherapy prog ramme read article s and di scus s ed ho w toprov i de single-s ess io n the rapy.
The int e rn als otoo kpart intheseexercises antI obs e r ve das the psycholog i s t s offe r e d single-s e s s i ontherapyfor thefi r s t ti me totwo families.In single -s es sio ntherapy, the families we r e informedwhen they were first cont ac ted thatthey woul d be recei vingsingl e-sessiontherapy and to hav e inmind the is su e s they wouldlik eto deal wit h. They were told that they
35 cou l d remainon the waiting li st forfamily therapyeven if they participated in the single-se ssion therapy. Two therapists metwiththe family, whiletheother members of the te a m viewed the sess i o n in another room on a te l e visio n One of the peopleviewing the family was appointed the spokesperson. The family met with the two therapists, then went out to the waiting room while the spokesperson went in and talked withthe therapist to pass on in s i gh t s which he/shehad picked up and some possible issues to focus on.
particularly strengths. The family returned, and the therapists informed the familyof the information passedon by the spokesperson.
The family program staff also met as a team to see special families that had been specifically ide nt if i e d for the team approach. The intern observed and was a part of the reflecting teamfor five family sessions. The family was seen by two therapists and the team vdewed the family either through aone-wa y mirror or on a televisionscreen in another room. The reflecting team used two thF.!rapiesmostfr e qu e n t ly, that of Michael White and Just Therapy. The Michael White approach no t e s the positives and focuses on the clients ' ability to externalize the problem in the family as the session progresses . Just Therapy is a reflective approach whichloo ks closely at the webs of meaningin a familysuch as gender, culture, economy and social aspects. The family would work with the therapists forapproximately one hour and
36 then tak e a break, goingout tothewa i t ing room. There we r e several differen t ways in which the teamin teracted withthe family at thispoint. Somet imesthree teammembers we n t into the room with the family presentand discussedtheir thought s on the pr oc e s s andhowthe familywas funct ioning. The family list e ne d quie tlywhile the teamddacuaaed theirpe rspec ti ves for appro xim a t e ly fifteen minutes, andthenwere provided an opportu n i t yto give feedback or askquest ionsof the team.
Sometimes. the therapists spoke direc tlytothe teamand we nt;
backafter the break andpa s s e d on th e information that the teamhadgi v e n. Sometimes a written message fro m the teamwas mailedto the family the nextday.
Altho ug h the intern was co-t herapis t with Dr. Mo xley - HaE.ger t, sheinitiallyhadli mi t e d interactionsinthe session and mainly observe d, de ve loping an underst a nding of the pr oces s of family the r apy, wh i ch is ver y differ e nt fr om individual therapy. Individual therapyconcentra tesonone pe r s o n and wha t he/she is communi cat ingin the rapy. Fami ly thera py foc use s on th eprocessof the family and howit is or is not me et ingthe family' sneeds , rat he r than on oneper son's pers pe ctive . This was ave ry newfr a meworkfor the internto unde rs t a ndand gain expe ri ence in using.
Reading, discus sion and the vi e wing of fa mily thera py using the team appr oa c h also pr o vid ed the inter nwith the opportunity to get into the mode and framework of family the rapy. Af te r only a few sessionsof co- therapy , the in t ern
'7
was ab le toengage in the rap y withthe family. After each se s s i on, Dr.Moxley-Haegertdiscussedhowtheinternperformed and th e te c hn iqu e s used in the session.
The inter n had two families wit h whom she co n d uct e d therapysessions as theprimarytherapis t. With th e firs t family, Dr. MOx.ley-Haegert was in attendance fo r the firs t session . Or.Moxley·Haege r t then felt thatthe int e rn was compete nt enoug h to see fami l ies on he r own so all othe r sess ions with these fa milie s we r e held by the int e r n on ly.
Bo th familie s we r enew ca s e s toth e psyc holog y Department. The int ern had the oppo r tuni t y tostar t with afa mily , pr ov ide the r a p y and discharge the fa mily. This exp e r i ence wa s conside re d the mos t valuable of the entire in t e rnshi p. The inte rntookall ofthe knowled ge and experience gai nedand had the opportunit y to provide family therapy for twofa mi lie s from the sta rt on to discharge. Regul a r uptiating and consul t a tionwas held with Dr.Moxley-Haeger t regardi ng these fa mi l i es.
The Famil yAsses s ment De vice is anassesamenttool that isre gularl yusedinthe family programme; a copyis pro vide d in Appendix E. Thi s device is give n to pare nts and any perso n s over twelveyears of age in the family. The Family Assessmen t Dev ice is a questionnaire composed of questions ebout allaspe c tsof family lifeincl udi ng: prob lem solving;
commun i c a tion; ro l e s; affective respons i veness ; affecti v e
38 lnvo1vement; behavio urcon troland general familyfun c tio n i ng. The intern administered and ce ore d se v en Family Assessment:
Devices.
Ma n y articlesandboo k s on family therapy were read to build a knowl e d g e background, develop a framework, promote understanding, gainaphilo s oph y and develop skills necessary to providefam! ly therapy. Thereadingscompleted duringth i s internshipare listedin Appendix D.
Adminiat.ntioDInd sporingof Tegh
The intern admi n istered and scor ed seven Family Assessment Devices, twoConn er s'Rating scales and one Becks' DepressionIn v en t or y . TwoVineland Adaptive BehaviourScales wer escoredbut. no t administered. The intern foundit quite useful using the s e assessment tools. She was familiar wi th the Conners' pz-Lcr-totheint e r n s hi p , but the others were new instrumentsto the intern.
The intern also reviewed many ot he r assessment in s t r ume n t s available at both the psychology Department and theThomas Andersonsite. Therewa s alsodiscussionwith the psychologists concerningthe varietyof assessmentinstrumen ts available andtheir use.
Grgllp CgltpulHnq ski1Jg
Many groups ar econve nedin the Psychiat.ryDe par t mentfo r inpatient.s. The intern att.ended and partici pated we e kl y ina group composedof allof t.he childrenon the psychiat.ry ward.
39 The purpose of the group was to provide the patients with the opportunity to di scuss any co nc e r n s the y had about the psychiatric ward and how it operates. The groupstartedeach session with a "check in" on how everyone was feeling and
"che c ke d out" wi t h a happy thought .
By attending and participating in the group the inter n had the opportunity to experience the dynamicsof thegroup process. Anothervaluable gai n ofat t e ndi ng the group was that it permitted the in t er n to become familiar with thi;
patients so that when they were presented at teachingrounds and case conferences ths intern could place a face and certain behaviours with a case for better identification and understanding.
The developmental projectco mpon e n t of this internship also studied group work, the dynamics of a group and what people expect or wouldlike to gain from a group. Readingon differenttypes and pr oc e s s e s of groups was also done by the intern.
Also, the intern sat in on meetings at the Psychology Department with psychologists and social workers who were planning and leading groups.
ney.lopmonta1RflBBarcb~B&SedPro1egt
Time was provided in the internship to complete a developmenta l research-based project. The research was proposedto the Human Investigations Committee and the Faculty of Education Ethics Committeefor approval. Therapists at the
40 Janeway we re pr e sent ed wi th in formation regarding th e rese a r ch. I tdid take a reasonable amount oftimeto disc uss and explainthe researc h to thetherapi flt:.s and to remindth e m to contact the i r cl i e nts. Once conse n t for referra l was received, the intern cont a c t ed the wi ll i ng parent s an d sc he d u le d an inte r view time . Paren ts occasi o nally miss e d appointmentsand had to bere schedu l ed . The intervi ews las t e d fro m forty-f i ve minutes toone hour.
Thes e act i v i tie s comprise the 34hou r s spenton ceeearch reported on Ta b l e 1. The analysis and result s were all comple t e d after the internshipwas comp leted . The parent int e rviews were not completedunt i l th e final week of the internship. Referrals were lateco min g inand thein t e rn was ve r y busy with other act ivities. making it di f f i c ul t to scheduleappoi ntment s . One interview was doneinthe parent's home, as i t was more conve n ient for he r. The proje ct is further de t a ile d ina later sectionof this report.
"Mini gtrat!.QD
Each week the in t e rn attended staff meetings inthe Ps yc h ology Departmentand site meetings at the Thomas Anderson site. where her office waslo c a t ed . The Janewayas a whole is undergoin g tremendous chang e. Origi nally , the Psychology De pa r t men t andtheThomas Anderson Centre existed as separate entities . Now, thes e two sites arecombined , but there is st i l lsomeconfusion, becausemany of the peoplethat worked in the Thomas Anderso nsite are social workers. This is th e
41 rationale for thetwomeet ings. On l ypsych ol ogi stsatte ndthe staff meetings. Bothpsychologistsandsocialworkers working at the siteatt end the site meetings.
Each programhas a tea mof membe r san d th e s e teamsha v e meetings. The intern attended one te a m meeting for each program, primarily to ga i n an id e a of the systems of the administrat:.i on and how long the waitlist s are for each program. Thein t e rn also attended a joi n t di s c ipline mental health meeti ng , which inc l u d e d al l of the professionalt¥
working in mental health at the Janeway.
Other administrative tasks incl uded the booking of therapy rooms, setting up of vi d eo eq ui pment , recording informat ion in the weeklylog and calling familieson thewa it list toconfirm i f they dost i l lwished
Supervision
The 15 hoursof supervision shown in Table1 re fl e c t supervision time with the on-site supervisor, Dr. Lind a Moxley-Ilaegert. Thein t e r nmet requ.Lar'Lyat 2:00p.m. foron e hou r eachweekwi t hDr. Moxley-Ilaegert, andmoreoft e n when necessary. The intern entered each meet ingwith a list of conc erns whichshepresented and Dr . Moxley-Haegertprovided responsesto the concer nsand discussedth e int e rn ' s work and progress. Specificdiscussion concerning skil ls, approaches andtherapysessi onswas usually done prior to orimme d i a t e l y after atherapy session.
Academic supe rv i s i onwas al so conducted byDr. Lee Klas.
"
He me t on three occas ions withboth theint e rn andDr.Mo x ley - Haege rt. These me eting s were pri or to sta rting the
in t e rns hip, at. themi d point of theinte rnsh ip andat theend
of the in t ernship. Dr.Klasalsomet wi t ht.he int ern alone an d had severa l tel e phone conversa tions wi th the intern throughout the inter n ship.
Re c o r d Keepi ng
The int er n kep t her own set of notes on eve r y therapy session in whi c h she tookany part . The s e not e swe r e usefu l thr o ugho ut the interns hipand were alldest ro y e d at the end of the placement. Othe r recordke e p i ng included reportwriting and documentat i on. Reports were wr i t ten fo r the family th e rapy sessi onsand t.heacti vitie s attheLea rni ng/Beha v iour Cl in i c.
Co nc l uslon
The chose n internship sit e, The Janeway Child Health Centr e, provided a grea t lea r n ing an d ski ll dev e lopment oppor tun i t y. Foremost, it prov ided ac c essto psychology ina med ical set t ing. It provi ded acce s s to a variety of psychologists and psychot hera py approaches . It gave the internan ins ide look int o thepro g r ams and services pro v i ded by the Janeway; certa inly , auch insightsare inval uableto a school guidancecoun s ellor. whore gula rl y ma k e s referralsto that setting.
43 Dr. Linda Moxle y· Ha egert is a highly qualified and experie nced famil y therapist, and there are several othe r re g i s t ere d psychologists in the unit. Un for t unatel y, the Janeway receives so many referrals th a t th e r e are wa i t i ng lists for children , adolesce nts, adultsand famili e s awaiting services. This was a positive factor forth e intern , because i t mean t that the Janewaypsychological service s we r e in demand and are under constant development. The setting provided a goodat mos phe r e for an internwho was tryingto en ha n c e skil ls and gain new knowle d ge and expertise in counse l ling andthe r ap y .
44 A Developmenta l ProjectStuc:l.y i ngtheGr o u p Therapy N••d. of
Parent. ofCh ildr e n with IlIlPu l . :l,veand/orAggre••lvi Beha viourPrabl . ..
Rat ion aleand Purpou,
A research and/or developmentalprojeet is one of the requiredcomponentsof anint e rnsh i pinthe Master'sDegree in EducationalPsychologyatMemorial Uni versityof Newfoundla nd. The pr o j e c t shou ld pr o v i de boththe internshi p site andthe inte r n withvaluab leuse ful informa tion an d ins ight s. At the Janeway, therapy services addre s s i ng a variety ofis s u es and conc e r ns are offere d to LndfvIdueka and famili e s by psychologistsand social wor ke rs ,all fromvarie dbackground s of interes t and expertise . Therapyse rv i c e sforchildre n and adolescents with impulsive and/ or aggressive behaviour diff i cu lti e s make up a la r ge pe rce nt a ge of the population receivingor requestingservices;these serv i ces areoffered through the pre-school, school-age, adolescent, family, psychiatry and learningbehaviourprograms.
Alongwith individual and family therapy, group therapy has been uti li z ed to mee t the needs of larg e gro ups with ide nt ified common needs. Thesegroupsar e offered regula rly ona ne e ds basis. Due to the high incidenceof children with impUl s iveand/or aggressive behav i ourdifficulc ieathereis a gre a t nee dfor the rapyservicesfor bothchildr enandpar e nt s. These parents hav evari ed needs for approaches, strategie s ,
