Paper 2:The Reflective Practioner model
Joe Kiff, Dudley South PCT
With the growing emphasis on the treatment of people with complex, moderate to severe problems it is little wonder that clinical psychology is undergoing a paradigm shift (Stedman et al, 2003). The problem of such treatments lies as much in the management of emotional phenomena that undermine either the therapist’s or the patient’s ability to maintain a useful therapeutic encounter as in the intellectual analysis of learning histories and cognitive strategies.
In this paper I want to briefly review this emerging paradigm in clinical psychology –that of the reflective practitioner- which seems to speak to these challenges, and to examine its relevance to the issue of complexity in clinical work.
The reflective practitioner paradigm
This paradigm was recently thoroughly reviewed in a special issue 27 of ‘Clinical Psychology’ in July 2003. Broadly there is a growing acceptance in the profession that there is a limit to the direct applicability of scientific knowledge to complex professional problems. This is organisationally acknowledged by the new criteria for training clinical psychologists which requires that they are taught how to reflect on their practice in an effort to be aware how the three aspects of:
i. their intrapersonal world (personality, values, learning history) ii. their interpersonal relationship with their patients. iii. wider social forces (institutional pressures from managers etc.)
contribute to clinical decision making. These forces can override or lead to modifications in established research based clinical protocols with both good and bad consequences. Practitioners need to be constantly monitoring their performance to reduce the tendency to error under these pressures and to learn appropriately when things go well.
The logic of these developments is that clinical performance is enhanced through the appropriate involvement of self-knowledge and a flexible response to the clinical situation on the part of the therapist.
If we look at various examples of complexities in clinical practice we can see how relevant this new latitude is:
The complexity of peoples problems
On first meeting a new client we often have the knotty problem of identifying the problem to be worked on. As Schon (1983) in his excellent book “The Reflective Practitioner” points out:
"In real world practice, problems do not present themselves to the practitioner as givens. They must be constructed from the materials of problematic situations which are puzzling, troubling and uncertain."
Most often now we are faced with many problems created and maintained by a number of factors. If there ever were isolated, individual phobias they seem to be in short supply now. Even if we reduce the level of complexity by identifying a lesser number of underlying cognitive schemas there are still considerable choices to be made. This is an immediate hurdle to implementing any straightforward research based programme. We must then fall back on intuition, experience, negotiation, and pattern recognition, onto a subtler basis on which to ground our practice. It is at this point the three sets of forces can come into play and must be weighed. For example:
- If my personality is such that I do not like complexity and confusion - do I try and resolve the tension by constructing the problem into something more simple and manageable.
- If I have had eating problems myself and I overidentify with my anorexic patient - do I try to resolve my uncertainty by focusing on self esteem issues that I had found useful myself?
- If we have long waiting lists and are limited to 16 sessions – do I decide to focus on just one, less central aspect of the problem, in order to achieve at least something.
Complexity of the patient’s account
From the ‘smile’ model one can see that the more complex the presenting picture, the more likely the person will have an emotionally difficult story to tell. Sometimes they understand that their symptoms arise out of their lives and the launch into extended convoluted accounts of their difficulties. Sometimes their story is too embarrassing and painful and they are reluctant to disclose. So how do we manage this? For example:
- If my time management is poor and I have been rushing around all day and feeling the pressure to do more – do I get impatient and try and cut a garrulous patient short.
- If my patient is telling her story to win my sympathy - do I allow myself to be emotionally touched and take a more sympathetic stance than I might normally take?
- If I have found professional identity in an approach that theoretically assumes that the life history of a person is not that important to the progress of therapy – do I try to focus the discussion on practical issues in the present rather than explore the context further?
The complexity of the patients relationship with us
Often the relationship between a therapist and a patient takes on a deeper resonance than the straightforward understanding of these roles would suggest.
- If in my normal life I navigate my relationships with the opposite sex with mild flirting and seduction – is this something I take pains to eradicate from my professional persona or do I allow it to leak back in when I am encouraging a social skills client to try to go out?
- If my child client looks to me to be the authority figure that they lack in their life – do I get drawn into being more directive and paternalistic than usual?
- Having recently read Garret & Davis (1998) and their study indicating the level of sexual interaction between clients and therapists do I change my practice and become emotionally colder and strictly businesslike in my work?
Complexity of our understanding their story
What is said is not always what is heard. What is meant is not always what is understood.
- If I have good pattern recognition skills – are the repetitive patterns I see in my clients relationship with her father and her husband real, or am I reading too much into it?
- If my patient tells me a very distressing life history but without emotion – do I understand that obviously it has not been too upsetting for them, or do I generate the emotion from within myself and assume that their lack of feeling is due to a strategy of pain avoidance on their part?
- When my elderly patient tells me about their fear and humiliation at being homosexual 60 years ago – can I really know what it was like, living in more liberal times?
The complexity of generating and following a treatment plan
For those of us working at level two (Mowbray,1989) producing treatment plans and following them through makes life relatively straightforward compared to those of us doing level three work. But modern psychologists are trained in a number of models usually cognitive behavioural, psychodynamic and humanistic counselling and most of us are trying, necessarily, to work at the more complex level. Whether we deliver the different approaches appropriately as single models or as part of an individual integrative approach there is often a dilemma as to which technique and theory to deploy with any particular patient at any particular time. For example:
- If I have a fluid and creative mind, do I see possibilities of intervening at different levels simultaneously and become frequently confused by the array of choices, often chopping and changing between approaches?
- If my client says they do not want to discuss the childhood sexual abuse but wants to concentrate on going on escalators – do I go along with this request, and if not am I acting on my growing dislike of her naïve presentation, persecuting her with questions about her past?
- Having been persuaded by managers to use a stepped approach to care - do I intervene at the simplest level first and work my way to deeper levels if necessary, even when it seems clear that this is likely to be a waste of time?
It seems to me that there is a continuum along which reflection can take place and our position depends upon our models of clinical psychology and our own personalities. We might illustrate this with reference to two extreme positions along this continuum; two distinct versions of the reflective practitioner model:
The Weak Version
For example, suppose that I work in the child speciality and take the view that I am there to treat symptoms. I have worked for many years and successfully treated many bedwetters through the routine administration of star charts. In my model of clinical psychology there is no need to pay too much attention to context, feelings, the learning history or the child’s story. Perhaps I am not the sort of person that finds it easy to reflect on life in this way. What does reflective practice mean to me? Perhaps it means essentially reviewing technical aspects of my performance: could I have introduced the approach more clearly to a particular child? Perhaps I would look at concrete aspects of the setting conditions to see if this might have produced a more efficient/effective performance. For example, I should have remembered to close the curtains in front of the one-way screen to stop children being distracted. In this version the emphasis is on the facilitation of rational thought. The areas relevant for reflection are limited by assumptions made on personal and professional grounds.
The Strong Version
Suppose I am another sort of therapist working in the same area, treating bedwetting. But for me feelings are primary, context is all, and the learning history and the child’s story is my guide. For me reflective practice has far wider implications. What is the relationship between bedwetting and the parents impending divorce? How is my reaction coloured by my own experience of my parents divorce, by my feelings of empathy with the child? How can I give the child confidence to tell their story? How can I listen appropriately and professionally?
Beyond the routine implementation of a technical skill, the human difference between therapists is how do you find a way to say the right thing, in the right way at the right time. There is no formula for this and it is a deep skill that comes out of who we have become as clinicians. It is an integrated performance that draws on many aspects of ourselves at any one point: our personal model of the world and of relationships, our own histories, our training, our knowledge, our professional theories, our clinical experience, the relationships in the room. All these come to bear and we continuously have to spontaneously speak out of this background in a way that is helpful to others. In my experience (and the experience of many colleagues), we come to realise that these processes are happening all the time in many subtle ways with most of the clients we engage with. This understanding then leads to the need to reflect actively and regularly on all levels of our performance in order to monitor and understand how to use and ameliorate the effects of such forces.
With the reflective genie out of the bottle it is likely that the strong version may come to be seen to underpin clinical excellence and that the weak version will be seen as too clinically restrictive. Reflectivity is about taking context into account. The difficulty with being more aware of context is that this brings uncertainty. Most of the reflective questions considered above have no definitive answer that can be culled from the literature; one is left to decide on the basis of clinical judgement as best one can. As a reflective practitioner one has to tolerate not knowing. Adrift from our positivistic certainties we now need a fresh philosophical stance to support us in our work.
From this analysis of the reflective practitioner model it seems to me that there is the possibility of establishing a viable alternative view to the old scientist practitioner model. In the next paper I wish to place this reflexive way of thinking in the wider context of recent developments in the philosophy of knowledge and science which underpin the post-modern revolution in thought which has yet to make a coherent impact in mainstream clinical psychology.
- Garrett, T. & Davis, J. (1998) The prevalence of sexual contact between British clinical psychologists and their patients. Clinical Psychology and Psychotherapy, 5, 253–256.
- Mowbray, D. (1989). Review of Clinical Psychology Services. MAS. Cheltenham
- Stedman J., Mitchell A., Johnstone L., Staite S., (2003) Making Reflective Practice real: problems and solutions in the South West. Clinical Psychology, 30-33
Address Dr Joe Kiff, c/o Psychology Dept, Cross Street Health Centre, Cross St., Dudley, DY1 1RN. ; firstname.lastname@example.org
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