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Working within the Zone of Proximal Development: Reflections of a developing CAT practitioner in learning disabilities

Frain, H., 2011. Working within the Zone of Proximal Development: Reflections of a developing CAT practitioner in learning disabilities. Reformulation, Winter, pp.6-9.

Introduction / outline

As a clinical psychologist working with people with learning disabilities I am conscious of the need to match therapeutic work to the level of ability of my client. This may be in terms of their cognitive abilities, what they are or are not able to understand at a verbal level, or their abilities to recognise and comprehend their emotions (and those of others). CAT emphasises the need to work within a client’s ‘zone of proximal development (ZPD)’ (Vygotsky, 1978) and provides a framework and tools with which to do so. In this paper I reflect on my first experience of using CAT as a trainee practitioner with a client with a learning disability and working within his ZPD (and my own).

The Zone of Proximal Development

Researching within the Soviet Union, Lev Vygotsky (1896-1934) had a diverse range of interests and was a prolific writer prior to his death aged 37. His work in cognitive and child development has been particularly influential both within the fields of psychology and education. Vygotsky’s work highlights the social nature of learning, suggesting that a child does not learn in isolation, he does so in relation to others. How he comes to understand the world and himself is heavily influenced by his parents, teachers, peers and the society he lives in. This emphasis on the reciprocal and interactive nature of learning has been influential in CAT’s understanding of the development of the self, of target problem procedures and also the therapeutic relationship.

Vygotsky’s developmental research indicated that learning takes place in two stages, firstly through interaction with another, secondly by internalising the learning and being able to repeat it on one’s own. Vygotsky (1978, p86), suggested the zone of proximal development is

Working within the Zone of Proximal Development

“the distance between the actual developmental level as determined by independent problem solving and the level of potential development as determined through problem solving under adult guidance, or in collaboration with more capable peers”.

Scaffolding and the ZPD

Wood, Bruner, and Ross (1976) developed this further and introduced the concept of ‘scaffolding’. This refers to the support offered by the more knowledgeable other and also to the ‘tools’ that are offered to them in order to continue their own learning.

Leiman and Stiles (2001) have described how psychotherapy involves a developmental sequence of assimilation during which a therapist assists a client to begin to recognise, reformulate, understand and revise problematic experiences. They suggest that ZPD represents the “place where clients move through the continuum of assimilation with the therapists help”.

Within effective CAT therapists are mindful of the client’s ZPD. The strong emphasis on collaboration means that attempts to work beyond the client’s ZPD are quickly recognised either in therapy or in supervision as the dissonance within the therapeutic relationship often leads to a reciprocal role enactment; for instance, the client experiences the therapist as controlling and bullying, feels bullied and submissive and withdraws into silence or doesn’t complete homework tasks.

Assessing Alex

Alex was referred by a consultant psychiatrist. He has Prada Willi Syndrome, which in his case has led to learning disabilities and hyperphagia – difficulties with controlling appetite. In some individuals it can lead to arrested sexual development. Alex lives in a specialist residential home for people with PWS where he is on a strict calorie controlled diet and access to the kitchen is restricted. During our initial assessment Alex described not feeling like a “real man” and connected this mainly to penis size (which was assessed by his G P as within the normal range) but he also described a pervading controlling to controlled reciprocal role.

I used an adapted version of the psychotherapy file with Alex. It did not particularly add anything new in terms of reformulatory material but it did provide a useful insight into Alex’s receptive language abilities and understanding. This aided my ability to ensure my language in sessions and the reformulation material remained in his Zone of Proximal Development.

The assessment phase gave me the opportunity to familiarise Alex with the CAT tools e.g. diagrams, by making them a part of the way we worked. I drew out the controlling to controlling role very early on, supplemented with stick figures to represent the concepts. Initially the controlling role focused on his family who had always told him what to do and had, during his childhood been physically abusive.

Reformulating in Alex’s ZPD

Reformulation letter

Using the client’s language the therapist begins to provide descriptions of difficult states or procedures and these are internalised and later used by the client in order to describe and understand their difficulties. Such understandings are deepened by the reformulation letter which provides a shared understanding of the development and maintenance of difficulties and outlines an agreed agenda for the continuing therapy. A standard prose reformulation letter was clearly not going to facilitate work within Alex’s ZPD. With encouragement from my supervision group I developed a booklet with one concept per page, using some of the existing prose, with a picture or diagram on the opposite page that captured the key concept. The booklet contained the following aspects;

Why Alex had engaged in therapy,
The development of his difficulties,
Continuing problems, namely feeling controlled or pampered by his family, his condition and sometimes staff and getting too close to people and getting hurt,
How we might work in therapy and how it might help.

The booklet described TPP’s as patterns, “what I think, what I feel and what I do” and described the following;

Letting my thoughts get me down
I worry that my penis is too small. I think I am not a ‘real man’. This makes me low. I stay in my room not feeling any better and feel bad about myself. I carry on worrying that my penis is too small.
Holding my feelings in
Either I hold my feelings in and don’t get the things I want or I explode and hurt people which causes trouble and makes me feel bad.
Feeling controlled
Other people often tell me what to do. I give in and do as they say but feel I am missing out. They are controlling me and make me feel like a baby. Other people don’t learn that I can make my own choices. They keep telling me what to do.

Sequential Diagrammatic Reformulation

The second aspect of reformulation, the Sequential Diagrammatic Reformulation (SDR), provides a semiotic shorthand for both client and therapist to describe and explore repeating patterns of behaviours and states. It becomes in itself a sign between therapist and client, with shared meaning for the client’s experiences, for instance they may begin to discuss the ‘green loop’ rather than the experience of social avoidance as a result of a critical to criticized reciprocal role. The SDR can be developed at the client’s pace, perhaps starting with a single state.

When Alex was familiar with the concepts in the reformulation booklet I brought to our session print outs of all the illustrative diagrams and pictures used in the reformulation booklet, two pairs of scissors, glue and a large sheet of paper with which to construct the SDR. Having explained what we were going to do I suggested we needed a starting point. Alex and I had just talked about difficulties with his parents on a recent home visit and he felt that ‘doing controlling’ was a very important issue. He cut out what had become the ‘controlling to baby’ role and stuck in on the paper. Over the next two sessions we continued to map out how feeling like a baby made him feel either sad or angry and the procedures that ensued.

I am aware that the cutting and sticking might seem a little ‘Blue Peter’, but I feel it was effective in three ways;

The pictures helped us develop a shared language, Alex could point to a picture on the map and say “I felt a bit ___” and I would understand what he meant.
It made the process of developing the SDR quite relaxed, neither of us felt under pressure to produce a perfect diagram and we were able to discuss his experiences as we constructed it.
It provided a useful way to keep the ‘controlling to controlled / baby’ role within our relationship in check. If I felt myself reaching for the scissors before we had agreed something I would pull back or occasionally Alex would tell me to “hold up” and we would discuss it further and agree who would do the cutting and sticking.

Whilst we identified more than one reciprocal role, Alex felt this one as the most important to him. It impacted on his feelings about himself as a “real man” and captured his relationships with his family, staff and peers. In order to remain within his ZPD and not overwhelm him with too many concepts we agreed to make the controlling to controlled role the main focus of the SDR and our subsequent work.

Recognition and Revision within Alex’s ZPD

Alex made good use of simple diaries that used the diagrams from the SDR. He was increasingly able to recognise the controlling to controlled role when enacted by others. A harder task was helping him consider when he might be in the controlling role. Through discussion he was able to recognise that certain behaviours from him led to certain responses in others, for instance if he procrastinated before going out staff would ask him if he was nearly ready, which he perceived as nagging. He was not able to consider self to other or self to self reciprocation any further.

Alex saw the controlling to controlled role being enacted frequently in his parents responses to him smoking, however he also decided that he was not ready to discuss this with them and decided to focus on making changes in his relationships with staff. Alex and I began to develop a booklet that would help staff support him to make some changes and also suggest changes that they could consider in order to help him. We used the diagrams from the reformulation booklet to think about changes Alex could make to help him and staff exit from the controlling pattern. For instance, being ready for appointments on time so staff wouldn’t have to ‘nag’. We then jointly discussed the booklet at a workshop for staff.

Ending

The second booklet we developed and shared with staff contained details of the patterns we had recognised, worked on and next steps, and as such formed part of what might normally be contained within a goodbye letter. I produced a second shorter letter that focused on our relationship. Within this I was keen to remind him how hard he had worked and also highlight the differences between our relationship and those he had with some members of staff. Alex, having been prepared over several weeks, had also produced a good bye letter, based on some heading suggestions I had given him. At the final session Alex described feeling more in control and ‘like a real man’.

Conclusions

For Alex there were potentially physical factors that were impacting on his relationship to his body and ultimately his self of being a “real man”. Whilst reassurance was given by the G P with regards to the size of his penis, Prada Willi Syndrome can impact on function and testosterone levels. Alex’s relationship with his body was an area that could have been given more emphasis within therapy, perhaps the minimal attention I paid to the issue reflects the limitations of my own ZPD at the time.

Working within a client’s ZPD is essential no matter what the client group. Given Alex’s learning disability extra consideration needs to be given to his abilities to understand and process verbal and emotional information.

I feel that four key factors helped me to work within Alex’s ZPD and make the work helpful for him;

Creating a validating therapeutic environment that acknowledged the importance of Alex’s concerns as he had not experienced this before. Possibly for the first time we labelled his difficult experiences and emotions which legitimised his concerns and gave him a way to talk about them.
Consistency – Using his words as far as possible we used the same phrases and expressions to describe his experiences and CAT concepts throughout our work. Again we used the same pictorial symbols throughout the work and these developed a strong shared meaning. Alex could describe a reciprocal role and target problem procedure simply by pointing to a series of pictures.
Providing clear and structured homework between sessions. Alex kept a diary of when he experienced one end of the key reciprocal role and was consistently able to recognise these.
Inviting his key worker in at the end of the session in order to share aspects of our work that Alex wanted them to know about. This meant that they developed their understanding of him and were able to help him use the tools, e.g. the SDR and the diaries therefore aiding his consolidation and between session learning.

Contact Details

Dr Helen Frain, Clinical Psychologist
Department of Learning Disabilities
Highbury Hospital, Highbury Rd, Nottingham NG6 9DR

Email: helen.frain@nottshc.nhs.uk

References

Leiman, M. & Stiles, W. B. (2001). Dialogical Sequence Analysis and the Zone of Proximal Development as conceptual enhancements to the assimilation model; The case of Jan revisited. Psychotherapy Research, 11 311-330.
Vygotsky, L.S. (1978). Mind and society: The development of higher psychological processes. (p86). Cambridge, MA: Harvard University Press.
Wood, D., Bruner, J., & Ross, G. (1976). The role of tutoring in problem solving. Journal of child psychology and psychiatry, 17, 89-100.
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Full Reference

Frain, H., 2011. Working within the Zone of Proximal Development: Reflections of a developing CAT practitioner in learning disabilities. Reformulation, Winter, pp.6-9.

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