Draft in preparation
Paper 6:The implications of the reflective practioner model and post-modern thinking for clinical training
Joe Kiff, Dudley South PCT and Delia Cushway, Universities of Coventry and Warwick Doctorate in Clinical Psychology
Introduction
Previous papers in this series have raised a number of issues about clinical psychology that have implications for clinical training. In this paper we wish to explore these areas and to discuss some possible solutions.
Possible implications
- It is important that academics socially construct the profession more clearly. The business of helping people with psychological problems through psychological means is a knowledge-based activity. Part of this knowledge comes though scientific enquiry but there are other forms of knowledge that experienced and competent psychologists draw on and we need to formally develop the skills to acquire and develop these. As part of this reframing courses perhaps need to provide a clearer intellectual context for what they offer. The implication of this series of papers is that more attention needs to be paid to epistemology and the role of science within this. There needs to be a clearer critical analysis of the limitations of science on the one hand and clear coordinated teaching about developments in post-modern thought on the other.
- At the moment it could be argued that the teaching of critical psychology, gender and racism awareness, practice ethics, issues of power, the role of the personal in our work etc is conducted on a piecemeal basis without any philosophical underpinnings that would tie them together into an important coherent basis for practice.
- With a pluralist epistemology in place we can then address the questions surrounding what sort of psychologist are we trying to produce. What is an appropriate ‘professional’ stance to the business of of helping people with psychological problems? To what degree are we trying to turn out a standardised product at the end of the course, people with the same views and values? What weight should we give to current naïve demands in the NHS for evidence-based treatments?
- Selection. What sort of people do we want to select for training? What mix of idealist, rationals, guardians and artisans? Should courses seek to train people across this spectrum or should they specialise and market themselves more clearly to people of certain types. Offering a more academic, scientist practitioner based training to suit guardians and rationalists or a more practical reflective based model attractive to the idealists? How do we attract more men and people from ethnic minorities into training?
- With pluralist views legitimated trainees need to be provided with a framework for understanding themselves psychologically. The study of individual differences and personality has been long neglected on training courses, but without this input how can they conceptualise the interplay between their own psychology and their preferred ways of working? - Which is at the heart of the reflective practitioner model. In these papers we have relied on Myers Briggs type models, very much as a starting point, and there is clearly work to be done in making Big 5 approaches relevant. As an aside the question of therapy for trainees takes on a fresh relevance. The rationale for such sessions is not so much the need for them to deal with their own pathology and problems, though this might be necessary, but rather to provide a confidential space within which they can explore the clinical implications of their own temperament, character and learning history.
- A problem that exists at the moment is training attracts many people who are ‘intuitive feelers’ who come to feel that their personhood is denied in the process of training. With the current emphasis on a rational, technical approach people often feel alienated from their course. More needs to be done to legitimate their personal approach to the work. In occupational psychologist circles such people are seen as well suited to the task of helping people psychologically but they are not well served by the content of most courses.
- Their needs to be a clearer understanding that many people bring many aspects of their personality with them into training which can be helpful in their journey to become a clinician. For example sound social skills, an ability to interpret the behaviour, feelings and thoughts of others. There is a feeling among some of us that training actually deskills and devalues our intuition and our sensitivity rather than supporting its development and growth. This leads to the need for courses to not only provide academic experiences that feeds information into people but also experiences that facilitates personal growth, harnessing and building on the existing strengths of trainees.
- In many ways courses are a metaphor for therapy. Their style suits particular people trying to achieve particular ends. A limited academic, scientist-practioner approach to training will suit left brain dominant rationales but can be unnecessarily problematic for others. Conversely a more experiential course will perhaps favour others. Course organisers will need to be aware of balancing these approaches, providing support and context to the people who find it problematic. This model emphasises the socialisation role that courses provide and it is important that courses are cognisant and respectful of the various ways of being a psychologist in the real world.
- As a related question for courses to address: how, given that people are not infinitely plastic, does the academic teaching interact with trainees existing personality and values and attitudes to produce and contribute to their development clinically and professionally? What does this say about the real world difficulties of bringing about change? This is perhaps an interesting area for further research.
- One large advantage of exploring issues around individual differences in training is that it should lead to a clearer understanding of the difficulties of minorities on courses. With few men and people from ethnic backgrounds coming into training validating and supporting them needs thought and sensitivity.
- Courses need to address the characteristics of both internal and external lecturers to ensure the there is balanced professional input. At the moment courses typically lay claim to providing teaching form a broad range of models but in practise trainees complain that the always seem to end up being fed the CBT line, presumably because this is easier to package and teach. Lecturing is probably easiest for concrete thinking extroverts, who of course bring their own biases.
- Of course to is important that clinicians from the reflective practitioner camp make themselves available to lecture and supervise. Up to now some of have felt what we do is not what courses want people to know about; or that to package up the contradictions and uncertainties inherent in this way of working is not easy in either role.
- There needs to be a similar monitoring of the pool of supervisors, with a better attempt to match supervisors to trainees, particularly in the first year. Once elective placements become available this is less of an issue. With the new recommendations for training the longer foundation placement could prove particularly irksome if trainees are inappropriately placed. From long-term observation in personal awareness and training groups it is clear that most placement failures arise from personality clashes between supervisors and trainees. Differences in assumptive worlds, poor management of power relations on both sides, etc play far more of a part than clinical ineptitude.
- This means that course should facilitate early discussion with trainees about the values and theoretical and professional aspirations. Of course many people are not able to articulate these readily early on and many are generally open to a range of experiences. But it may be appropriate for courses to be aware of these issues and to reflect upon them sensitively with trainees.
- This then puts down a challenge to clinicians and the knowledge industry to make far more use of critical theory and the reflective practioner model to explore clinical work in a fresh creative way. What are people’s actual views in training, after training, as supervisors in the real world? What are client’s views of their ongoing experience of being in therapy in the real world of the NHS?
- In part these developments can only go forward with the cooperation of the BPS who set the accreditation criteria for courses. Obviously the curriculum is packed already and being more inclusive in term of educational content will not be easy. Thought will need to be given as to how to preserve the right balance of inputs.
- As I write this and talk to people about their reservations about clinical psychology and training I become increasingly concerned about the inappropriate use of power, by both supervisors and clinical colleagues. There is a fine line between clinical confrontation and coercion, between putting an alternative view of the world that might be useful to another, and the attempt to indoctrinate and impose an alternative view because it is in the others best interest. Course should perhaps address the issue of power more thoroughly than they do.
Conclusion
It is clear that the acknowledgement and integration of a pluralist post-modern analysis into training, with its strengthening and underpinning of the reflective practitioner paradigm poses a number of challenges to course organisers. However such a move legitimates and values the personal differences of trainees, which should reduce the stress of training for some. It should also lead to the production of more flexible and reflective practitioners better able to provide services to our diverse communities.
References
Address Dr Joe Kiff, c/o Psychology Dept, Cross Street Health Centre, Cross St., Dudley, DY1 1RN. ; joe.kiff@dudley.nhs.uk Delia Cushway,
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