NATIONAL INSTITUTE OF MENTAL HEALTH

FOREWORD

The Seymour Vestermark Memorial Award was established in 1969 by the National Institute of Mental Health and the American Psychiatric Association to honor the late Dr. Vestermark. A pioneer in the field of professional mental health training, Dr. Vestermark served as Chief of the NIMH Training Branch from 1948 to 1958. The memorial awards have been presented annually to individuals who have made notable contributions to undergraduate and postgraduate medical education and to the continuing education of physicians and behavioral scientists.

The 1975 award, presented at the APA annual meeting on May 14, 1976, honors Dr. Raquel E. Cohen, Associate Professor at Harvard Medical School and Senior Associate in Psychiatry at the Judge Baker Guidance Center in Boston, Massachusetts.

Dr. Cohen has been a major force in developing educational programs to instruct mental health professionals over the past 15 years. As part of the NIMH-sponsored team of mental health professionals who assisted in the disaster situation after an earthquake traumatized the inhabitants of Managua, Nicaragua, she helped shape a program of crisis intervention techniques for use in disaster relief.

We, at NIMH, share Dr. Cohen's enthusiasm in using self-observation and self-assessment to test the applicability of known principles to novel experiences and unfamiliar types of professional work. As she points out, advanced technology may be capable of opening new horizons for mental health practitioners, but self-observing systems are still the basic means of gathering the data we need to develop new methods of intervention and more effective service programs.

Bertram S. Brown, M.D., Director

National Institute of Mental Health

The Functions of Experimental Participatory Experiences In the Learning-Teaching Process

Raquel E. Cohen, M.D., M.P.H. Senior Associate in Psychiatry
Judge Baker Guidance Center
Associate Professor Harvard Medical School

The award of the Vestermark Prize has been a provocative honor in that it has stimulated some profound thinking about the learning and teaching activities which are an integral part of my professional life. It has prompted me to try to distill from professional past experience, from understanding of educational process, and from a variety of clinical and academic documentation, a cogent and insightful statement about the approach I have evolved in 15yearsof community work. Thus, I hope to clarify how experimental material and observations have been translated into knowledge which, in turn, serves as content for teaching.

This paper will reflect efforts to analyze retrospectively attempts to refine impressions of the substantive nature of community mental health work in order to organize a body of knowledge. It has required me to look systematically at various professional situations in which I found myself, to elicit from them the objectives which were sought, and to trace the formulation and development of guidelines for action. In this discussion, I will try to describe the multilevel process of participating with others in specific professional encounters and in new forms of endeavor, while at the same time raise the types of questions which occurred largely outside of traditional or classical mental health settings.

The basic attitudinal stances that appear to underlie my community activities can be described as the use of experimental participatory interactions to further knowledge of mental health phenomenology and the need to try new methods of intervention because the known and familiar ones did not achieve the needed results. Accompanying these were constant self-awareness of feelings, self-observation regarding methodologies, as well as awareness and observation of outer social phenomenology. It was necessary to integrate and to attempt to synthesize both inner and outer experiences in an ongoing conceptual building process. This integrative process was carried out through learning and teaching activities with colleagues and students who exerted a constant support for inquiry and discovery. The question to be addressed is whether or not this type of procedure, used in conjunction with other research findings, is scientifically valid in constructing a theoretical professional knowledge base.

Is it possible to develop innovative approaches that provide adequate mechanisms to acquire data both qualitative and quantitative—to build frames of reference and to guide our interventions while we pursue more traditional scientific studies? Or should we wait? How can we correlate these methods, and can we, practically, integrate components of each in our programs? I would like to propose that direct participatory activities and interactions with individuals in new and unfamiliar areas of work carry with them an inherent opportunity to develop useful concepts that can be generalized and learned within a natural-historical developmental context. These concepts can become reinforced and solidified—not rigidified—and experimentally presented through the teaching reflective process where they will continue to be tested by students and skeptically sifted by our colleagues.

We can capitalize on the opportunity which presents itself in the practice of psychiatry, since we as individuals are the "participatory instruments" in our work. But we need to add a fourth dimension to our awareness (1) of self, (2) of others, and (3) of the interactions between ourselves and others. The fourth dimension incorporates all of these processes and adds conceptualizations of the meaning of the interactions within a group of reference points, which eventually become integrated into the learning-teaching content. These new added patterns of ideology are developed to enhance further knowledge of psychiatric phenomenology.

Although current technology such as videotape can open new horizons and activities, the self-observing systems and subjective recollections of everyday episodes still remain an important contribution through which we can continue to gather valid data. As we ourselves accumulate a group of observations about ourselves and our interactions with others, and as we utilize objective material, recording the phenomenology of the interaction of others with us, we can perceive salient points and areas of dynamic significance.

What delineates single specific areas out of the multiple types of activities in which we are engaged, and how do we organize the specific variables so that we can bring these elements of new knowledge into the realm of already accepted values in our profession? What mechanisms are invoked to promote a change from a set of observations to an investment and belief in their value, leading ultimately to their inclusion into our professional concepts and teaching theories? I will try to answer some of these questions by using concepts from the field of behavioral and human sciences, coupled with my own experiences in moving to new and unfamiliar types of professional work.

I have found the theoretical constructs of Piaget, Rappaport, and others helpful to guide me along and to clarify the learning process in new settings and experiences. From both psychological and developmental studies, it appears that the mind has an innate need to exercise an ordering and knowledge-generating capacity so that it can develop concepts which are essential to learning. These drives to learn seem to be based on a principle of oscillation between equilibrium and disequilibrium states based on factual acceptance of new observations which stimulate the sensory apparatus. That is, when a new fact enters the conceptual mind, a disequilibrium state occurs until this new fact has found its place within the individual's belief system. The mind deals with a new piece of cognitive evidence by energizing a group of processes which sort out ways of fitting in the new fact and organizing its components along "logical and believable constructs." Coupled to this theoretical understanding of a mental process is our recognition of the principle of reward and pleasure which highlights the activity of conditioned learning, whether positive or negative. In a mind that is reaching out to new stimuli, this conditioning potential governs driving forces which respond by continuously rearranging solutions to fit acceptable frames of reference. Thus, a feeling of reward is experienced when "things make sense."

Let me now interpret more concretely my analysis of past experiences and learning-teaching activities. Certain sequential principles have emerged which I will enumerate below. Then, I will describe some of my activities in order to illuminate the processes by which I became aware of and identified the sequences:

(1) Experiential and participatory interactions which start the process followed by reactions and feelings produced by the situation

(2) The awareness that the patterning of phenomenology observed repeats itself and appears as variations of the same theme in multiple combinations

(3) The continuous drive to organize seemingly unrelated types of experiences that later on show some similarities

(4) The potential for linking these reappearing patterns which allow us to make inferences

(5) The discovery that self-observation in these new settings promotes approaches which are aimed at developing some rationale to sustain the continuous attempts at problem solving

(6) The search for descriptive words to conceptualize the phenomenology and the development of a terminology that integrates concepts into psychiatric theories and practice;

("interface team," to link levels of mental health programs; "ego auxiliary technique to help abusive parents")

(7) Learning-teaching activities as a polishing and crystallizing process for new ideas in the effort to incorporate data into psychiatric frames of reference.

These sequential concepts evolved through activities and experiences that occurred in four different settings during the last 10 years. In the first, I was director of a new community mental health center located in a section of Boston where the population was composed of middle and low socioeconomic groups, where services were sorely needed for multi-disorganized families, and where existing social systems were overwhelmed by the requirements of the community. The purpose of this mental health program was to offer clinical mental health services and to develop consulting and collaborative programs with other human services. My second experience was working in a large urban school aided by a team of mental health professionals; the focus was on participating and collaborating with educators to develop approaches to deal with the mental health needs of children with special educational difficulties. The third experience was heading a team of bicultural and bilingual mental health professionals sponsored by NIMH to assist in the post-disaster situation caused by an earthquake in Managua, Nicaragua. We were asked to provide mental health services to individuals traumatized by the earthquake. Also, as part of this project, we developed educational programs to instruct mental health professionals in some of the crisis intervention techniques we were practicing. In addition, we were given an opportunity to offer suggestions to government leaders who were in the process of designing a mental health program for Nicaragua. The fourth experience is presently going on; I am heading a team of multidisciplinary professionals to assist social service agencies in six New England States in the development of service programs for child abuse and child neglect.

These experiences all presented the following similar conditions to me:

(1) A lack of familiarity

(2) A need for a new role and new self-expectations

(3) Multiple and unrealistic levels of expectations from others about the process and objectives of our work and

(4) A lack of control and certainty about most issues, in contrast to the known and reliable settings of the training centers where I had obtained my basic professional training. In this problematical context the need was clear to develop a cohesive approach to defining the types of activities to be undertaken and to establishing directions, goals, and desired outcomes. The opportunity to participate in a teaching setting further reinforced the motivation to continually conceptualize these processes, the underlying principles that guided them, and the rationale for new activities. The daily experience of sharing information with my colleagues, students, and staff furnished the fourth dimension of ideological consolidation.

Before I specifically describe my understanding of the participatory learning process, I would like to sketch a profile of the general characteristics of practitioners in our field. Most of us in the discipline of psychiatry have developed a sense of role and function that makes for a composite professional stance, derived from a combination of our personality development and an attitudinal approach to our professional behavior, which in turn is integrated with our personal goals and work perspectives.

As professionals we attempt to modify our own attitudes and needs in order to develop objectivity. We are embarked on a continuous search for self-understanding upon which we can draw in responding to a given situation. We generally select a theoretical principle which allows us to operate with a sense of mastery and direction that is harmonious with our experience, our technical training, and our philosophical understanding of mental health and mental illness. Each of us has found useful specific models with frames of reference which lead us to choose certain methods of noticing, observing, and collecting relevant data and which provide patterns to guide us in selecting methods of intervention, with differing levels of hope for success.

Our guiding principles are also determined by the type of professional relationship we find ourselves in and generally they are based on some standardized, pre-programmed goal-directed theories. The way we conceptualize our activities and our responsibilities has a relationship to some preferred school of thought, which has brought a body of knowledge to aid us in organizing the phenomenology that we see around us.

As we interact professionally in unfamiliar settings provided by chance and historical circumstance, we try to understand what is happening by using perceptual selectivity of social behavior variables whether acted or shared in speech. The conceptual understanding and experiencing of the multi-levels of phenomenology, both internally in ourselves and externally in our surroundings, require that we develop a capability to grasp the meaning, quality of functioning, and the interrelationships among a great number of variables. It is useful to regularly exercise discerning judgment about the importance of the issues presented, to evaluate them carefully in the light of our theoretical constructs, and to adopt material that we consider significant and discard what we consider extraneous or unimportant. Can we learn to live comfortably with fragmented, compartmentalized, continually changing perceptions of only a part of our environment, captained by our sensory apparatus and our ability to invest emotionally in a set of interactions? We can acknowledge that these perceptions are influenced by unconscious forces that mold and orient our judgment, often leading us through faulty and mistaken paths. We try to yield flexibly to situations that contain so many levels of complexity that we can only grope for "hunches," "gut feelings," and "chance possibility." Not all of our activities are necessarily guided by sensations of this type, but these perceptions can be weighed along with intellectual and objective studies and reports of information developed by many other individuals which may shed light on unfamiliar material and provide us with small islands of knowledge.

I began my professional work in the community with a heritage of experiences, concepts, knowledge, and skills acquired through basic training in classical adult and child psychiatry. This traditional background influenced my value system and created and structured my frame of reference. It supplied the foundation on which I could build concepts arising from new experiences. The learning methodology I employed seems, on the one hand, to recapitulate the process theorized by Piaget; on the other, to involve, through a feedback exchange, the accretion of increments of knowledge lending sense and direction to my efforts.

I have found Piaget's theory especially useful in clarifying the requisite steps when confronting an unknown situation. I proceed developmentally, first by incorporating concrete observations; then, by seeking connections and links between phenomenological occurrences, I am able gradually to devise concepts. Specifically, I make connections along certain sequential-logical lines, pre-programmed by the theories in psychiatry that I am familiar with and believe in. This mastery sets the stage for problem solving by developing the capacity to scan the many options and find possibilities for explanations and solutions.

The next step is the utilization of an experientially enriched thinking ability to generate abstractions, hypotheses, and theories. This permits me to make sense out of the resemblances and common attributes among experiences and enables me to make inferences or build metaphors. As Piaget indicates, when the awareness is presented with new data which need to be accommodated within certain constructs, the mind has to reorder the theoretical principles to embrace them. It monitors among the many explanations, the many solutions, and selects the most reasonable and harmonious piece in relation to previously held beliefs. The feedback methodology addresses itself to a continuous need to correct a sense of knowledge and to redirect behavior when new items of valid and invested information enter the awareness. Individual pieces of new knowledge, depending on their importance and the intensity of needed correction, find an accommodation by a series of mental steps which test and reshape beliefs.

An example of this occurred as I began to interact with educators in formulating plans for children who were having difficulty in learning and adapting to school programs; it became evident that conceptual and philosophical barriers existed between our professions. I perceived these barriers intellectually and also became aware of behavior that puzzled me and could not be explained in terms of my usual understanding of professional performance. Slowly I perceived that it was not that we had different interests or that the educators were operating out of benign neglect or indifference, but that the issue concerned sincerely held beliefs about how one helps a child. After developing a sense of the emerging pattern and becoming convinced of the sincerity and effectiveness of teachers who chose paths different from the mental health approach that I was accustomed to, I realized that, in order to collaborate, a facilitating process had to be instituted beforehand. It is out of these activities and beliefs that I developed the "co-professional collaborative" approaches that I have introduced in some of my writings and teachings.

The following questions are puzzling to me: Assuming that in the natural course of mental activity the mind tends to form concepts by a process of abstract thinking, how did my observations and experiences get programmed so that I would select and pick up certain components of events, abstract from those components key issues, and organize a group of ideas and concepts? How were these observations singled out, tagged as important, and abstracted so that they could be incorporated into my psychiatric know-how where they were deemed usable and valuable enough to share with others? What were the elements of interactions that I felt were significant enough to warrant enlarging my professional concepts and to spur the revision, refining, reforming, and assimilation of ideas to add new pieces of information to already accepted tenets? How did I proceed to remake beliefs acquired in the past in order to accommodate new information? And why did I want to displace or change concepts acquired through previous experience and training, so that they could be absorbed into new constructs and could alter either mildly or radically a firm belief?

My participatory activities in the unfamiliar surroundings where my professional endeavors took me were not neatly planned or developed "to study and do research." But they opened up opportunities to apply already known principles to novel situations. My characteristic method of working seemed to be a free floating scanning approach designed to register the familiar and expectable phenomenology, but also to alert me to the unfamiliar, unexpected and unusual transactional interactions and self-reactions (as in counter transference).

I was conscious of the tendency to use old and tried methods for different new situations and needed to find methods to modify this habitual modality of reacting. As when working in the clinic, I used the same psychological instruments to amplify the modality of accepting non-understood signals during my observations; the scanning focus followed a certain arousal of attention and labeled it "important." These general psychiatric modes of observing and recording were enhanced by knowledge gained from the social and political sciences which allowed me to understand and explain phenomenology within the social context of behavior and provided a broader than merely clinical base for making inferences. The fact that new knowledge (both theoretical and practical) entered my awareness propelled me to find new answers.

I trained myself to suspend making rapid, "reasonable," or professionally guided (dynamic) closure. As my experience increased, I tried to be "open ended" to sensory input, both internal and external, and attempted to refrain from organizing at a conscious level what was new. That is, I proceeded, using my usual professional approach, but being aware that this constituted a "launching pad" to propel me into further unknown territory.

Let me illustrate by describing another experience. As part of our educational activities in Managua, we were invited to speak to a group of senior physicians who had had to suddenly evacuate their offices and homes and go to a nearby small hospital to offer their professional services to victims of the earthquake. They had asked me to talk about crisis theory and crisis intervention so that they might be able to use some of these techniques in their daily activities. I traveled to the hospital and met with a group of about 20 men who were curious although somewhat skeptical about the ideas of this foreign American team. I started my remarks by developing the conceptual basis for crisis with some explanations of the feelings that accompany loss, and, as I was speaking, I began to feel a sense of depression and noticed that my audience was becoming more and more uncomfortable. Suddenly, one of the doctors got up from his chair and rushed out crying, with strong sobbing noises; this had the effect of stimulating questions around issues of sadness and anger at consequences of loss. The rest of the meeting was devoted entirely to this piece of content, changing dramatically from what was supposed to be an educational exercise to a painful, extremely emotional and open sharing of the tragedy of losing overnight a wealth of accumulated personal and professional belongings. Not only had the doctors physically lost their offices and homes, but all their patients had scattered out of the city, so that their source of income had completely disappeared, with no clue as to when it would reemerge.

I proceeded to listen and to support the outpouring of feelings but found myself confused as to how to deal with a group whose expectations had matched mine in anticipating that this would be a professional, educational activity. I wondered if I had used the wrong techniques, what I had missed in terms of setting up the appropriate situation for learning, and how I could deal with this degree of feelings in one session since I would not see the group again. As I tried to incorporate all these observations and feelings into some conceptual frame and also to achieve an understanding of what had happened, it became apparent to me that I was seeing the phenomenology of suppressed mourning. I sensed that the reactions of these physicians—confirmed by the reactions of others later on—indicated that they had been denied the opportunity and time to mourn. They had had to immediately devote their professional services to the citizens of Managua. It also became evident that they had no setting where some of the mourning might be expressed and where support systems were available.

The question was how to deal with this situation among colleagues who needed to have a built-in set of defenses to be able to function on a professional basis and, in terms of self-identity ego ideal, to avoid breaking down and losing face before other colleagues. As I addressed other groups, responding to their demands to learn more about intervention with post-disaster victims, I had many opportunities to see variations on the theme of incredible denial concerning the effects of the earthquake on the professional, coupled with revelations of intense rage and murderous feelings which were not perceived as part of the expression of loss or sadness. Through trial and error and utilizing my own knowledge about different types of group processes, I was able to develop a balanced approach that enabled me to talk to colleagues and help them express emotions that were appropriate for mourning, while carefully stressing the objectivity that would allow them to link some of their feelings to the situation, but not to give full range to their total intensity. I also offered to see individuals who wanted to speak with me personally. Little by little this was accepted and I found that my daily activities included many private meetings with colleagues who would remain after a group session to converse with me alone. It was in this setting that a deeper and fuller range of emotions was shared. It is out of this experience that I added a recommendation both to NIMH and to national planning for disaster-assistance groups. I suggested that it was necessary to send support professionals from outside the area to assist the professionals who had sustained personal losses and were manning the rescue operations.

Out of all these experiences my conceptual understanding of what happens in unfamiliar professional work encounters is as follows: As stimuli get stored in our "mini-computer," we assemble banks of discrete new pieces of information and hold onto them without interpreting them according to previously selected, rooted, and consistent formulas. Then the opportunity exists to experiment with alternative ways of organizing and interpreting our perceptions, which, in turn, opens the path to alternative and perhaps more advantageous hypotheses. Still, we need to take into account and accept the boundary constraint of both the professional role (as self-interpreted by the individual) and the professional setting of the interaction. These are key factors in the accumulation of inputs and strongly influence the attentive selectivity of psychiatrically invested coded messages. What allows us to synthesize the large number of variables into simpler codes for brain storage is the professional readiness to organize and link events in a particular predetermined way.

My own efforts to understand, to master, and to label the continuous perception of events that took place in a variety of new settings eventually began to produce comprehensible patterns, and a sense of comfort developed. Through time and experience, a new phenomenology of patterns accrued and gradually became reinforced in my belief system by reverberating against similar and already highly invested internal concepts. The process of trying to understand outside occurrences made me increasingly aware of the major or minor changes in different variables that with time and repetition became more intelligible. This clustering effect appeared to reveal central themes that became formalized and integrated as their numbers increased and as their usefulness and validity were confirmed by the success of my interventions and by feedback from my students and colleagues.

If there was some confusion about the quality and meaning of material, it still held enough content to give me a sense of familiarity; my general knowledge was enhanced, and new facets were added to my understanding. For instance, an important change occurred in my school mental health consultation activities when a new law was instituted in Massachusetts mandating the public schools to educate all children between the ages of 4 and 21 who have special learning needs. Before I had felt that I was a "mental health sales person," always trying to incorporate mental health principles into educational activities as a "good ingredient" in the lives of children. Now I could rely on the force of the new educational law for children with special needs to back all the activities that integrated mental health and education. My internal self-awareness of role and function, as well as the expectations with which I was met in the schools, rapidly changed. This produced a confusing and unprecedented situation in an area where, after many years, I had developed specific patterns of interactions and where I had been aware of ambivalent and doubting approaches by others. As they searched for help, I was mobilized into the expectations of school personnel as an ally and facilitator for the "outside law" that was mandating educators to do things that were unfamiliar to them. They were not only looking for a consultant and a collaborator, but also needed expertise in the whole area of technical assistance to be able to fulfill mandated activities. This was a new role for me, with more assertive components and more immediacy to problem solving and responsibility. It opened up new opportunities for human interaction, coupled with new self-expectations and expectations from others that influenced a spectrum of relationships. Slowly, this world also came into focus and the new skills, attitudinal components of the role, self-expectations and expectations from others began to fuse into composite patterns with increasing degrees of familiarity and comfort.

My hunches, beliefs, and comfort with experimentations in regard to particular interactions and procedures led me to enter into several novel areas of collaboration. This, in turn, generated still more opportunities for integrating learning and acquiring new knowledge of interactions which reinforced previously held but vaguely defined beliefs. The process of slowly moving onward through conceptual steps and open-ended beliefs built up the interactive modality in a continuum of learning which permitted me to develop intermediary theoretical formulations toward the final resolution of ideas. Along with these intellectual pursuits, it was necessary to strengthen my ability to bear the anxiety of not having a clear understanding of the meaning of the wide variety of activities whose relationships to the procedures and outcomes were obscure. As I began to deal more effectively with this insecurity, I was able to observe new situations more acutely. Eventually, I recognized that there had to be periods of activity which would appear ambiguous, muddled, and disorganized, and which would eventually order and clarify themselves and find their links to a conceptual or theoretical base. This understanding is extremely helpful in alleviating the doubts and uncertainties of working in new and unfamiliar areas. When my confusion was high, I had a guiding principle, "when uncertainty and doubt are strong, don't take chances until clearer patterns emerge—the objective was to gather further information to clarify the pattern before action can be taken."

This principle was demonstrated rather forcefully to me when I began working with social workers in the area of protective services within the public welfare system. My usual consultant role as a supportive and resourceful colleague was seen as somewhat helpful but not what the workers needed. As I observed the patterns of utilization of this function, it became evident that it was not meeting the priorities of the workers. Their needs were at a different level of urgency and seriousness compared to the needs of other systems in using mental health consulting services. The variables of the life and death of a child who is beaten and killed and the responsibility mandated by the law produced a situation where consultation and resource were not sufficient. What was needed was assertive, clear direction on how to resolve problems that would minimize the risk factors in the life of the child. I had to develop different approaches, bring in material from child and adult psychiatry in a different format, and participate at a more intimate and collaborative level than I had done previously in my mental health consultation activities. I had to participate as a clinician used to dealing with life-threatening potentials and advise on definite patterns of activity to control the danger. These necessitated a rearrangement of my ov/n internal identification and expectations and a deliberate development of new skills, which I developed in an evolutionary approach.

Summary

The uncertainties of working in a new setting and of trying to develop conceptual order out of new data impose constraints on the ability of the professional to feel comfortable and to respond rapidly to new ideas and feelings. These constraints are directly related to the scope of the professional's own sensory apparatus and the conceptual boundaries of his/her professional mind-set.

Flexibility and open-ended beliefs are necessary, as is a willingness to concentrate on small areas of understood activities and to move gradually to broader conceptual themes. Testing these against known theoretical backgrounds offers a process through which data can be organized and a belief value system developed which then can be incorporated into further learning experience. This material, in turn, can be formulated into teaching content. The encounter between phenomenology, unknown and unsystematically presented by fortuitous historical circumstances, and professional activities provides an opportunity to organize new ideas and concepts in the concept of multiple self-experiences.

Insight can occur when, in the professional's attempts to deal with data that do not fit readily into theoretical categories, a variety of questions arise that promote findings of some rational explanation for the phenomenology and lead us to develop new content that enhances our learning and teaching potentials.