Introduction and literature review
Counselling outcome research emphasizes that regardless of techniques used, the person of the counsellor and the counselling relationship contribute significantly to outcomes (Lambert & Barley, Reference Lambert and Barley2001). Hence the more self-aware and interpersonally effective the counsellor can be the more they are able to effect change in others. Similarly recent training research in cognitive therapy has focused on personal development contributing to interpersonal effectiveness as an important component in ultimately enhancing therapeutic expertise (Bennett-Levy & Thwaites, Reference Bennett-Levy, Thwaites, Gilbert and Leahy2007a) To this end, it is important that counselling education promotes and supports personal development in students.
Despite this acknowledged importance of personal development in assisting students to become professional practitioners (Schön, Reference Schön1983; Irving & Williams, Reference Irving and Williams1995), there has been limited research available to guide educators in making this aspect of teaching effective (Bennett-Levy, Reference Bennett-Levy2006). Furthermore, students’ perspectives are missing from counselling education research (Bennetts, Reference Bennetts2003). Gathering student perspectives may enable trainers to better understand student learning and how students experience the personal development process.
Bennett-Levy has found that self-practice of cognitive therapy techniques and self-reflection can offer a valuable aspect in training cognitive therapists (Bennett-Levy et al. Reference Bennett-Levy, Turner, Beaty, Snith, Patterson and Farmer2001). Laireter & Willutzki (Reference Laireter, Willutzki, Geller, Norcross and Orlinsky2005) strongly recommend self-practice and self-reflection as essential training strategies. Writing as a part of students’ self-practice process, can assist personal and professional development (Bolton, Reference Bolton2005).
Writing case studies is a commonly used teaching strategy in counselling education and other teaching disciplines (Ramsden, Reference Ramsden1992; Wasserman, Reference Wasserman1993). Case studies offer an understanding of people in contexts, support the application of theory to practice and develop case conceptualization skills (Prieto & Scheel, Reference Prieto and Scheel2002). These conceptual skills are essential for understanding clients’ needs. There is limited research on the value of using case study or self-case study when educating counsellors. Krieshok & Pelsma (Reference Krieshok and Pelsma2002) found self-case study to be useful for vocational psychology students in the application of theory to themselves in real-life situations, deepening understanding of theory and being able to generalize skills to their vocational counselling clients. The authors of the study were interested in cognitive therapy students’ experiences of self-case study.
Objectives
The study objectives were to explore cognitive therapy students’ perspectives on the use of self-case study related to their learning and personal development. This would allow a deeper understanding of student experience and the potential use of self-case study in cognitive therapy education.
Method
Participants
Participants were seven undergraduate students (six women, one man) completing introductory training in cognitive therapy as part of a Bachelor of Alcohol and Drug Studies or General Counselling programmes. In New Zealand, as in the UK, short courses in cognitive therapy training are increasingly being offered to a variety of mental health professionals (Myles & Milne, Reference Myles and Milne2004). Five participants were graduates and the remainder were completing training.
Ethical issues
An ongoing ethical concern for counselling education is the expectation that students use and share personal experiences while developing skills. This dual relationship requires trust from students and integrity from tutors who are also assessors.
The qualitative interviews were conducted 1–3 years post-self-case study as the researcher could only interview students following completion of the teaching relationship. Participation in this study was voluntary.
Ethical approval was granted by the research committee at the Auckland University of Technology.
Case study format in education context
In the Bachelor programmes cognitive therapy training is scheduled in the second year of counselling education. The introductory cognitive therapy training involved 70 hours of face-to-face teaching over 15 weeks including 30 hours of self-practice of techniques. Teaching emphasizes participatory and experiential learning. Students submit a taped cognitive therapy demonstration and case study for final assessment. Students have the choice of presenting a client or self-case study. They are instructed to choose a ‘manageable’ problem behaviour and to consult with their tutor if necessary.
The self-case study option involves an in depth exploration of a student's own problem behaviour ‘as if [they] were onlookers’ (Bolton, Reference Bolton2005, p. 7). This involves the student developing an assessment and treatment plan. The assignment requires students to complete and record the following tasks. First, provide a life review summarizing development, context and problem impact, then apply learning theory explaining what factors maintain the problem behaviour. The next task is to hypothesize what needs the problem behaviour is attempting to meet (Glasser, Reference Glasser1998). Students then completed a brief multimodal assessment (Lazarus, Reference Lazarus1989) including goals with relevant interventions and finally wrote a cognitive conceptualization (Beck, Reference Beck1995).
The self-case study was assessed on the application of cognitive theory to practice and specifically not on the personal content.
Procedure
Participants were recruited through a mail-out in 2007 sent to 46 students who had completed the cognitive therapy training between 2004 and 2006.
Narrative enquiry was chosen as a suitable research methodology related to the purpose of this qualitative research and the dual relationship of researcher and researched. The narrative interview method involves researchers positioning themselves as a reporter interviewing an expert on their experience (Josselson, Reference Josselson and Clandinin2007). Unstructured individual interviews opened thus: ‘I am interested in your story of what it was like to learn cognitive therapy and to write a self-case study. Start anywhere you wish from when you began the course or as you completed the course or as you were writing the self-case study.’
An adapted analytical tool by Lieblich et al. (Reference Lieblich, Tuval-Mashiach and Zilber1998) was used to analyse interview narratives for both content and form. This allowed exploration of experience and individual differences between participants. Themes were compared and contrasted between participants. This article will focus solely on themes, related to participants’ experience of completing a self-case study.
Results
Participants chose problems such as procrastination, comfort eating, perfectionism, and social anxiety. The following themes emerged from the analysis: understanding the problem, the tutor relationship, the writing process, personal development, childhood trauma, empathy, and integration of cognitive therapy skills.
The themes are presented and illustrated with verbatim participant reports. Pseudonyms have been used for participants.
Understanding the problem
Participants experienced the self-assessment task as very useful for illuminating the impact of the problems.
Mary described the limitations of anxiety:
Doing that study not only showed me my problem but showed me how big it all was. Every time I wanted to . . . [speak] . . . literally shaking and um sweating.
For some, this beginning self-awareness was unsettling.
Jayne describes this experience:
It was . . . an eerie experience, mm. . . . Yeah . . . , I hadn't even thought about it, that this [case study] was the catalyst until now, mm . . . it is very confronting.
Participants described this deepened self-understanding as personally challenging. They gained insights to their use of unhelpful coping mechanisms, e.g. alcohol and drug use, avoidance, and work addictions.
The tutor relationship
Five participants emphasized trust and safety as important qualities in the tutor relationship supporting the self-development process.
Mauri said:
especially the things that I wrote down that were quite um, personal . . . and I was happy to actually go to that level of depth because of the person [tutor] that was reading it and if I didn't know . . . and trust [that tutor] . . . as much as I did . . . , I wouldn't have shared as much.
Rachael wrestled with the decision to self-disclose.
It was . . . quite hard because I thought ‘Well I am putting all of my personal information into my assignment and how much do I want to do that?’ . . . and I realized that there was more benefit in it than there was discomfort.
Rachael's dilemma is a salient reminder for counsellor educators to support and treat students with the same ethical standards of care as counselling clients.
The writing process
All participants reported development of self-awareness through the writing process.
Writing in the third person developed new perspectives.
Jayne: Seeing your story written out with so much thought . . . it had never really occurred to me to look at myself really with that much depth before.
As participants self-reflected, they gained insights leading to ‘deepened’ self-knowledge. Andy describes this process.
I have known about that before, like a long time and . . . read about it [having a perfectionist attitude] . . . but it didn't actually change until I . . . I looked over my case, as I was writing it and I thought ‘It is really, really you and this is why, it is you and this is how, it is you.’
Personal development
Many participants attributed ‘life changing’ personal transformation to completing a self-case study.
Mary offered her experience:
The highlight was doing my own case study and I am just so grateful that I did that, as the social anxiety was . . . growing. For me . . . it was the breakthrough and that's changed my life, . . . it has enabled me to work where I am, . . . to be in groups of people, um it has changed every part of my social self . . . and my children . . . it is enormous.
The depth of personal development included core belief change. Mauri describes this.
But internal happiness, . . . to actually believe in it is a different level of happiness. I identified the core belief, . . . and to actually to be able to challenge it . . . which changes the emotional reactions for me in lots of situations.
Childhood trauma
Three participants viewed writing a self-case study as a catalyst for both remembering and processing childhood trauma. Participants emphasized the need for safety within the tutor–student relationship in order to tell these stories. As Bolton says: ‘Artistic processes such as writing can . . . enable a harnessing of . . . memories which we do not know we remember (2005).
Jayne concluded that self-case study had illuminated the effects of childhood sexual abuse.
When you look at it, in the context of survival, love and belonging, . . . you can see how much it would affect, well it did affect me, . . . in so many different areas, . . . power, freedom . . . because you're analysing yourself.
For Mauri, helpful emotional processing was catalysed through the writing process:
I have reached that place of release I guess, letting go, letting go of that anxiety, that fear that I had carried all my life and um a huge relief, really a huge relief.
Although the structure of the self-case study is more scholarly than creative, research into expressive and explorative writing has shown significant health benefits (Pennebaker, Reference Pennebaker2000; Lepore & Smyth, Reference Lepore and Smyth2002).
Empathy
Participants developed more empathy for their counselling clients as a direct result of their own self-practice and self-development.
Rachael: It [self-case study] gave me . . . an understanding of what it is like for anyone that I am going to try it [cognitive therapy] on.
Nellie: Underneath all of this that motivates them to do this behaviour . . . through survival . . . maybe some core thing going on . . . it makes it easier to empathize with them.
Participants transferred their deepened conceptual understanding of their own behaviour to their clients’ behaviour.
Integration of cognitive therapy skills
Six out of seven participants described a sense of mastery with the skill of challenging unhelpful thinking. This sense of competence was shown by continued self-practice.
Jayne: I do use CBT a lot on myself, on my irrational thinking, often catching my thoughts out. ‘How useful is this to be thinking this?’
Participants described continued personal benefit from using: thought records; journal writing to track negative thinking; questioning themselves ‘What is the evidence?’ and testing rules for living. They attributed their success to the simplicity of the cognitive model and positive experiential learning.
Discussion
Self-case studies provide multi-dimensional learning opportunities
This small study has built on the self-experiential work of Laireter & Willutzki (Reference Laireter and Willutzki2003), Bennett-Levy and colleagues (Reference Bennett-Levy, Turner, Beaty, Snith, Patterson and Farmer2001) and Haarhoff & Stenhouse (Reference Haarhoff and Stenhouse2004) by introducing self-case study as a new form of self-practice. This study has added depth to the understanding of how students might benefit from this new self-practice element.
Participants emphasized the usefulness of the self-case study structure in providing personal experiential learning opportunities. It afforded a unique learning experience where the student was both author and the subject of the case study. Including the ‘self’ into case study adds opportunities for reflective writing and reflective reading which consolidates the learning (Bennett-Levy, Reference Bennett-Levy2006.
Participants described their involvement in conceptualizing, writing, re-reading and then self-reflecting as deepening both their self-awareness and their understanding of cognitive theory. This finding is also consistent with earlier research (Bennett-Levy, Reference Bennett-Levy2003; Laireter & Willutzki, Reference Laireter and Willutzki2003; Haarhoff & Stenhouse, Reference Haarhoff and Stenhouse2004)
This study differs from previous research on self-practice and self-reflection (Bennett-Levy et al. Reference Bennett-Levy, Turner, Beaty, Snith, Patterson and Farmer2001) as it has not differentiated between reflection on process and reflection on content nor included structured written reflections. This difference raises ethical considerations in training which are further discussed later.
Personal development heightened participant empathy for the counselling clients’ experience which substantiates earlier cognitive therapy training research (Bennett-Levy et al. Reference Bennett-Levy, Lee, Travers, Pohlman and Hamerni2003; Laireter & Willutzki, Reference Laireter and Willutzki2003; Bennett-Levy & Thwaites, Reference Bennett-Levy and Thwaites2007b).
Participants developed a sense of confidence with development of cognitive therapy skills which matches earlier research (Laireter & Willutzki, Reference Laireter and Willutzki2003) and a sense of competency enabling continued self-practice of cognitive therapy as in Myles & Milne's (Reference Myles and Milne2004) study. Most described transfer of skills to clients as in the paper by Krieshok & Pelsma (Reference Krieshok and Pelsma2002). Participants’ perception of competence was not measured.
The use of self-case study can mean valuable self-development
Self-case study acts as a catalyst to facilitate personal development. Trust in the student–tutor relationship was an important foundation supporting students to write a self-case study for assessment. Autobiographical self-case study writing is a powerful exercise. As Ricoeur (Reference Ricoeur, Doeser and Kray1986) wrote: ‘Self comes into being only in the process of telling a life story’ (p. 132).
Participants considered the application of several cognitive theoretical approaches (Lazarus, Reference Lazarus1989; Beck, Reference Beck1995; Glasser, Reference Glasser1998) helped them to develop self-awareness. Most participants described moments in this self-development process where new knowledge became internalized. Their words were ‘internalized’, ‘owned it, [knowledge] moved from a head level to more of an internal level’.
As noted by Marton & Saljo (Reference Marton and Saljo1976) knowledge has become knowing which is tacit knowing. This integration of knowledge has a transforming effect on the person. Three participants described core belief change which they attributed to developing an understanding of how the core belief originated and use of thought records. Change at core belief level usually requires 6–12 months of sustained practice (Beck et al. Reference Beck, Freeman and Davis2003).
Childhood sexual abuse raised by participants was an unexpected finding in this research. Krieshok & Pelsma (Reference Krieshok and Pelsma2002) similarly found their students chose to disclose greater personal depth than trainers anticipated. It is acknowledged that these participants were a particular group who had already completed significant personal growth both within counselling training and in personal counselling. This may have prepared them to both continue further personal development through cognitive therapy skills practice and to specifically address childhood trauma via their self-case studies. The holistic structure of the case study and the writing process appeared to assist in bringing childhood sexual abuse forward and facilitate helpful processing (Pearson, Reference Pearson1994; Pennebaker, Reference Pennebaker2000).
Overall, participants experienced self-case study as deeply challenging, liberating and personally transformative. They recommended that tutors remain aware of students’ potential need for support. This is consistent with previous research (Bennett-Levy et al. Reference Bennett-Levy, Turner, Beaty, Snith, Patterson and Farmer2001; Truell, Reference Truell2001).
Limitations of this study
This study had a limited response to the 46 invitations sent to potential participants. However, seven participants is considered an appropriate number for an in-depth exploratory qualitative study (Rice & Ezzy, Reference Rice and Ezzy2005). The reason 39 individuals declined participation requires speculation.
Possible causes for the low response rate may have been: the power imbalance in the student–tutor relationship, students being disinclined to reflect further on personal case study material, lack of interest given that 1–3 years had passed and prioritization of achieving qualification over participation in research activities.
The self-selection of participants is a significant limitation. While the participants were a purposive sample of ‘experts’ on their own experience (Rice & Ezzy, Reference Rice and Ezzy2005), they may have chosen to be involved in this study because of positive counselling training experiences or loyalty to their former tutor. This dual relationship of the researcher as former tutor requires discussion. Participants’ desire to please their former tutor may have influenced the reported experiences. It also can be argued that the prior teaching relationship was a strength, as trust developed across time enabled safety for participants in disclosing to greater depth.
Completion of this study 1–3 years after participants had completed self-case study is a significant limitation due to participants’ reliance on memory. Perhaps participants gave insufficient attention to other life influences for personal development.
The self-case study being written for assessment is a significant limitation. It is possible that students perceived that writing a self-case study may lead to a pass or enhance chances of a high grade. This remains an ethical issue in any project in which personal material may be disclosed in the context of an academic assessment. The use of voluntary unmarked self-case studies could mitigate this ethical issue.
This small study size (n = 7) could be expanded with a larger group of participants interviewed by a researcher other than their former tutor immediately after completing the self-case study. If the researcher did not have a dual role with the participants, more students might participate in the study and disclose their experiences more freely.
Implications for counselling and cognitive therapy education
This study suggests that counselling and cognitive therapy education should consider inclusion of self-case study into the curriculum as a means of fostering theoretical understanding, skill enhancement and personal development. Personal development assists professional development which prepares students to develop as effective counsellors and cognitive therapists (Bennett-Levy & Thwaites, Reference Bennett-Levy, Thwaites, Gilbert and Leahy2007a; Corey, Reference Corey and Brooks2009). Despite the primary academic focus of counselling training, educators must consider the demands of personal development and support students accordingly (Krieshok & Pelsma, Reference Krieshok and Pelsma2002). Childhood trauma may be an experience for a number of students who are mental health professionals (Elliott & Guy, Reference Elliott and Guy1993). If self-case study is utilized as a teaching strategy, students and tutors need to be prepared for this possibility.
Conclusions
Self-case study can be an innovative teaching strategy providing multi-dimensional learning opportunities for students encompassing understanding of cognitive theory skill development and valuable self-development.
Declaration of Interest
None.
Acknowledgements
The authors thank Beverley Haarhoff and Clare Hocking for helpful feedback on earlier drafts of this paper.
Learning objectives
(1) To gain understanding about the experience of a group of students who wrote self-case studies.
(2) To develop awareness of the potential of self-case study as an effective teaching strategy.
(3) To consider the potential of self case-study for mastering skill development and promoting self-development for students.
(4) To appreciate the value of narrative enquiry as a research approach which can facilitate an in-depth understanding of students’ experience of writing a self case-study.
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