Clinical PsychologyClinical Psychology is circulated to all members of the Division monthly. It is designed to serve as a discussion forum for any issues of relevance to clinical psychologists

ClinicalPsychology

Issue 27 July 2003

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Reflective Practice

SPECIAL ISSUE:

Editorial Collective: Lorraine Bell, Jonathan Calder, Lesley Cohen, Simon Gelsthorpe, Laura Golding,Garfield Harmon, Helen Jones, Craig Newnes, Mark Rapley and Arlene Vetere.

Clinical Psychology is circulated to all members of the Division monthly. It is designed to serve as adiscussion forum for any issues of relevance to clinical psychologists. The editorial collective welcomes briefarticles, reports of events, correspondence, book reviews and announcements.

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11

Clinical PsychologyIssue 27 — July 2003

Edited by Delia Cushway & Amanda Gatherer

Correspondence 2

ArticlesReflecting on reflectionDelia Cushway & Amanda Gatherer 6

Redressing the balance: the place, history and future of reflective practice in trainingTony Lavender 11

Reflection: a blind spot in psychology?James Bennett-Levy 16

Personal professional development in clinical psychology training:surveying reflective practiceBruce Gillmer & Remy Marckus 20

Attending to the patient within usSimon O’Loughlin 24

Bubbles in a pond. Reflections in clinical practiceCatherine Paula 27

Making Reflective Practice real: problems and solutions in the South WestJacqui Stedmon, Annie Mitchell, Lucy Johnstone & Sue Staite 30

Lift the box lid: reflective writing for professional developmentGillie Bolton 34

Lift the box lid: reflective practice writing, an exampleHelen Drucquer 39

ColumnistsThe Alternative PageNigel Mills 42

Self-helpFelix Q. 45

✉ CBT and powerGillian Proctor’s article (CP25) on howCognitive-Behavioural Therapists can misusetheir power under the guise of collaboration withthe client is a much-needed warning to practi-tioners of CBT. Her statement, ‘Collaboration isthought to have been achieved when the clientagrees with and complies with the therapist’sworld view’ is an exact description of the processwhich psychiatrists have always used in decidingwhether or not a patient has insight.

The misuse of ‘insight’ inflicted great damageon the profession of psychiatry from which it hasyet to recover. Patients were well aware that psy-chiatrists were misusing their power. Do CBTpractitioners wish to damage their own profes-sion in this way?

Dorothy RoweGarden Flat, 40 Highbury Grove, London N5 2AG

Challenges to the current dominance ofCognitive-Behavioural Therapy in the NHS arefew and far between. Gillian Procter’s articlebrought a refreshing change, though seemed alittle biased in her review of the evidence. Themain tenets of her article were that CBT occu-pies an entirely positivist stance, ignores the dy-namics of the therapeutic relationship, andsubsequently is more a therapy of compliancethan collaboration. Whilst such criticisms mightbe true of novice therapists, experienced practi-tioners and academics have long written aboutthe importance of these issues.

Proctor asserts that CBT ignores ‘social struc-tural positions and material realities of oppressionand power’. A recent paper on case formulation,written by academics some would regard asCognitive Behavioural ‘fundamentalists’, empha-sised the need to focus on the individual withintheir social context (Tarrier & Calam, 2002). PaulGilbert, the president of the British Associationof Behavioural and Cognitive Psychotherapy,emphasises the importance of power and socialroles in his evolutionary theory of depression(Gilbert, 1992). Moreover, rather than viewingCBT therapists as ‘objective observers’ in therapy,

as suggested by Proctor, Gilbert encourages theuse of the therapeutic relationship to affect change.Similar methods have been emphasised by otherCBT therapists (e.g. Young, 1999).

Proctor, quite rightly, emphasises the impor-tance of culture in the therapeutic relationshipand the danger of normalisation, in a worldwhere normal means male. However, she ap-pears unaware of the efforts of CBT therapists torespond carefully to the diverse needs of theirclients. Padesky and Greenberger’s (1995) MindOver Mood includes in the accompanying thera-pist’s guide a chapter on ‘Individualising mindover mood’. This gives numerous examples ofhow culture can influence therapy at multiplelevels. Indeed, she highlights the fact that the pre-dominant schema of Anglo-American therapists isone of autonomy and achievement. She contraststhis with people of Asian origin who are morelikely to hold schema that are focused on pleasingothers. CBT therapists clearly recognise that real-ities are constructed and culturally bound.

The central tenet of Proctor’s article is that CBT ismore about compliance than collaboration. The titleof Christine Padesky’s (1993) keynote address‘Changing minds or guiding discovery’ aptly sum-marises this entire debate. Developing the skill ofSocratic questioning to a level where both clientand therapist are working in collaboration is a trulydifficult task. Novice therapists, myself included,can fall into a trap of mechanically delivering tech-niques without careful thought for the collaborativerelationship. It is not the founders of CBT who areto be blamed for this, but the therapists themselves.The proliferation of 10-day CBT courses in the NHSfurther compounds this situation. Professionals areprovided with a limited range of CBT techniquesand are given little opportunity to consider the is-sues Proctor so rightfully highlights. Her article fin-ishes with despair at the thought of CBT beingdelivered ‘wholeheartedly to every client’. Had thisbeen the case, she might have not gained such a badimpression of CBT in the first place.

Rory AllottEastglade Centre, 1 Eastglade Crescent, SheffieldS12 4QN

2

Correspondence

ReferencesGilbert, P. (1992) Depression: Evolution of powerless-ness. Hove: Lawerence Erlbaum.

Padesky, C (1993). Socratic questioning: changingminds or guiding discovery? Keynote address deliveredat the European Congress of Behavioural andCognitive Therapies, London, September 24.

Padesky, C. A. & Greenberger, D. (1995). Clinician’sGuide to Mind Over Mood. New York: Guilford Press.

Tarrier, N,. & Calam, R. (2002). New developments incognitive-behavioural case formulation. Epidemiological,systemic and social context: an integrative approach.Behavioural and Cognitive Psychotherapy, 30(3),311-328.

Young, J. E. (1999). Cognitive therapy for personalitydisorders: A schema-focused approach. Florida:Professional Resource Press.

✉ More self-help literature…I would like to contribute to the ongoing discus-sion about the value of fiction in informing clini-cal psychologists. More specifically, I would liketo question what the literature so far discussed re-flects about our profession as it seems as thoughwe are looking at some pretty predictablesources. Whilst I am as keen on Philip Pullman asanyone else, though we should not overlook theprecursor that is Ursula Le Guin’s Earthsea tril-ogy, I find the attention given to the reactionaryhigh church Tory tosh of Tolkein rather alarming.As clinical psychologists, we can do better thansuch ‘epic Pooh’, to quote the writer and criticMichael Moorcock. Indeed, Moorcock’s ownworks provide some illuminating parallels to ourpredicament as clinical psychologists. I am think-ing here of his series of fantasy stories about Elricof Melniboné. Elric, the ‘sailor on the seas of fate’,is the sickly and reluctant heir to the throne ofthe city-state of Melniboné. He has huge respon-sibilities thrust upon him by history and circum-stances and yet is controlled by those he seeks toserve and, most terrifyingly of all, by the very signof his office – his own sword, the sentient BloodDrinker which seeks glory and power in its ownright. In Elric’s world, there is no recourse to thecomforts of the mystical and the spiritual, forthese are mere illusions as he comes to learn thatthe apparently opposing gods of Law and Chaosare (a)morally equivalent, only interested in hu-mans as pawns in their own machinations.

Throughout his travails, Elric pursues an impossi-ble personal ideal, the quest to find his long-lostsister who may then reign along side him in anew golden age. He stumbles through adventureand misadventure in a myriad of different envi-ronments, some friendly others hostile, unsure ofhis alliances and allegiances, but always trying tolive up to his own high ethical and moral codes.Needless to say, Elric is prone to depression, cyn-icism and despair. Sounds familiar?

Moorcock himself has intimated that his fan-tasy is not reactionary romanticism or idealist es-capism, but contains a strong strand of hard-edgedsocial and psychological commentary on life in areactionary world allegedly ruled by invisibleforces that we are told we cannot control, and aclear line can be drawn between his work andMervyn Peake’s similarly allegorical Gormenghasttrilogy. Perhaps the main reason for my own in-difference to Tolkein is a generational one.Moorcock wrote these stories in the late 1960sthrough to the mid-1980s and I consider thatthey reflect a post-hippie call to a social and po-litical self-awareness and action that I think is par-ticularly relevant to our work as psychologists.

Dr Dougal Julian HareResearch Tutor, University of Manchester

✉ But where’s the horse?Harper & Moss (CP25) choose to use theConcise Oxford Dictionary as a primary sourceto reformulate ‘Formulation. Whilst the COD(1990) does indeed define ‘formulate’ as mean-ing to express reductionistically in a formula andto set forth systematically, the second and ar-guably more germane meaning is to ‘expressclearly and precisely’ (p. 463). It is this oddly elu-sive quality that is the hallmark of a good formu-lation.

Formulations in their modular obfuscation ofnaive reality can be barren of truth, but the con-verse (poesis and metaphorical claptrap) all toooften reminds me of the comments by the exiledSouth African poet Roy Campbell who remarked,on a deep and metaphorically complex verseabout an equine encounter, ‘he’s got the bit andsnaffle right, but where’s the bloody horse?’

Bruce GillmerAcademic Tutor, Doctorate in ClinicalPsychology, University of Newcastle

Clinical Psychology 27 – July 2003

3

✉ Psychology and technology – amarriage made in Heaven?

With the age of technology upon us, we havehad to find creative ways of keeping informationsafe. There have been demands for electronicrecords with increasing amounts of informationabout patients to be read by an increasing num-ber of people. For these reasons, I usually cringewhen I hear of new technological innovations,fearing even less privacy. However, I recentlyhad my prejudices challenged when reading anarticle in Openmind (121, May/June). A serviceuser described how less privacy and more tech-nology could be beneficial. He and his partneruse instant messaging (MSN, a form of instant e-mailing) to make sure that he eats properly anddoes not self-harm when alone in the house. Alsowhen going outside he uses a global positioningsystem (GPS) to mark places he visits regularly,providing electronic reassurance that he won’tget lost. He would like the next step to involvelinking GPS to his palmtop so that his partnercan see where he is, which would give him theconfidence to travel further from home.Previously I had only thought of these electronicadvances restricting liberty, forcing us into theage of ‘big brother’, having never consideredthat they may also enhance it. Perhaps we couldre-direct the drive for technology from informa-tion sharing and recording to empowering peo-ple in their communities.

Helen MyattCoventry and Warwick Course

✉ Assessing local needsAlison Murray’s letter on recommended staffinglevels (CP20) expressed concern about the fig-ures contained in the new guidance documenton workforce planning (the briefing paperGuidance on Clinical Psychology WorkforcePlanning – DCP information leaflet no. 6).Having read the guidance, Dr Murray will beaware that the Service Development SubCommittee that produced the guidance be-lieves that a single set of recommended figuresis very difficult to produce, justify or use per-suasively. The main thrust of the guidance is topropose an approach based on assessing localneeds and building local alliances. The earliersurvey showed that this approach was consid-

ered by a clear majority of clinical psychologiststo be more helpful than a recommended num-bers approach. However, we were aware thatsome people do still find recommended staffinglevels helpful, and that is why the available fig-ures were included in the guidance. In themeantime, the SIGs and Faculties are workingto produce updated recommended levels, andthese will be made available as soon as possible.

Roger PaxtonNewcastle, North Tyneside andNorthumberland Mental Health NHS Trust

Christine D’NettoMilton Keynes Primary Care NHS Trust

✉ It all ADS upI would like to respond to Phil Richardson’s ob-servations (CP25) on Autumnal DissociativeSyndrome (ADS), in which he notes how assis-tant psychologists suddenly go through a changeas the annual beauty contest organised by theClearing House Corporartion in Leeds ap-proaches.

As a personal sufferer of Autumnal DissociativeSyndrome (ADS) I’d firstly like to thank Phil forbringing this sidelined condition into the open.I’ve had the condition for two years now, and I’mquickly realising the best course of treatment isdisassociation from other victims, particularly inthe peak affliction periods around Decembertime. This is a difficult thing to do, as well-wish-ers (supervisors and other ADS sufferers with noinsight into their own condition) often recom-mend and assertively push for attendance at theADS self-help groups (or assistant groups to givethem their generic name). These groups don’twork on the same basis as say, AlcoholicsAnonymous. They work more like a doctors’waiting room: you go in with a bad toe, and comeout with a bout of ’flu. What is masked as ‘advice’and the ‘golden ticket to training’ is really noth-ing but a subversive plot to make you the same asevery other attendee. Any idea that hasn’t beenheard before, or used in a previously successfulapplication form, is quickly scuppered andfrowned upon. If you fail to mention clinical gov-ernance, scientist-practitioner models, evidence-based practice, empathy, MAS report, reflectivepractice, at least seven times each in your appli-cation form, you are banished as a heretic.

Correspondence

4

‘But wait,’ I said foolishly at the last self-helpgroup. ‘If I’m truly a scientist-practitioner, whyam I still pursuing an obviously falsifiable hy-pothesis?’ i.e. why am I taking advice from peo-ple who also haven’t got on the course (forlonger), who just take snippets from successfulapplication forms, who in turn probably got onthe course because they lived next door to thehospital? Why haven’t I adjusted my practice tofit the evidence? It’s all well and good spoutingthis stuff in your application form, but the evi-dence is all to the contrary: we’re all still flog-ging the same dead horse with the samebroken stick. We’re a homogenous can ofworms. Got a 2:1? Check. Got experience?Check. Got good references? Check. Action:Pick a worm out at random.

I don’t attend the groups anymore, which isboth rewarding (they go over the same old use-

less stuff time and time again), but yet anxietyprovoking (maybe they do hold the goldenticket, and I’ll be left in the dark with my stupidideas). These groups do create high dependency.

So what do you think? How to bypass thecringe filters without appearing either to havenot learned anything, not care, or have a narcis-sistic personality disorder. I might try to bite thebullet next year, and put something like: I havethree years’ experience. I have learnt stuff. Ihave become increasingly more cynical. I haveall the relevant academic criteria. I don’t have asevere personality disorder. If you want to see ifI’m socially skilled and interesting, give me abloody interview.

Or maybe I’ll lose my bottle and follow the rest.

Dave DawsonCynical ADS sufferer (recovering), Assistant Psychologist, Lincolnshire Health Trust


5

European Society for Traumatic StressStudies Regional Conference

Thursday 9th & Friday 10th October 2003;City Hall, Cardiff

Workshop topics covered include: long term aftercare following major traumaticevents, group treatment for PTSD, medicolegal issues, EMDR as a treatmentmethod, prolonged CBT for PTSD, providing for children following a majortraumatic event, behavioural reactivation for trauma survivors.

Speakers include: Professor Berthold Gersons, Kersten Bergh Johanneson,Professor Andreas Maercker, Professor Dean Ajdukovic, Joe Curran, Oscar Daly,Jonathan Bisson.

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Reflecting on reflection
Delia Cushway and Amanda Gatherer, Universities of Coventryand Warwick Doctorate in Clinical Psychology
This Special Issue includes a collection of articles presented at, or developed following, a dayworkshop held in September 2002 entitled ‘What is Reflective Practice within ClinicalPsychology?’ The aims of this workshop, which was organized by the Coventry and WarwickClinical Psychology Doctoral training course (in conjunction with the West Midlands DCP), were:

i. to review the use of reflection within clinical practice;

ii. to discuss the development of reflective practice through training and supervision; and

iii. to develop an understanding of the use of creative writing to enhance self-reflection andpersonal growth.

Throughout this Special Issue a number ofthemes will emerge regarding ReflectivePractice. These include questions around

how to define Reflective Practice; suggestionsaround how best to teach it; and the dilemmassurrounding how to assess professionals’ use ofit. These are challenges that are particularlysalient to professional therapist training courses,and our efforts at addressing these issues withinthe Coventry and Warwick Universities ClinicalPsychology Doctorate course will be reviewed.

How to define Reflective Practice?There is a risk that the term Reflective Practicemay lose its significance either because ofoveruse and consequent disregard or confusionover its true meaning. Difficulties abound indefining a concept that is in many ways intangi-ble and immeasurable, an ‘atheoretical con-struct’ (Gillmer & Marckus, this issue), ‘abehavioural scientist’s nightmare – almost im-possible to define tightly, and well-nigh uncon-trollable’ (Bennett-Levy, this issue).

A literal definition may be created from review-ing the terms ‘reflection’ and ‘practice’. For ex-ample, Chambers Dictionary (1993) defines‘reflection’ as ‘the action of the mind by which itis conscious of its own operations; attentive con-sideration; contemplation’. ‘Practice’ is defined as‘repeated performance as a means of acquiring askill; the process of carrying something out, suchas a profession or playing a musical instrument’.

Reflective Practice is discussed and reviewed

6

frequently within literature relating to education.Indeed, the term was initially utilised within thecontext of professional practice by DonaldSchön (1983, 1986) who introduced the con-cepts of ‘Reflection in action’, and ‘Reflection onaction’ in his writing about The ReflectivePractitioner within the teaching profession.Schön’s work is reviewed later in this issue byTony Lavender in his paper ‘The place, historyand future of Reflective Practice in clinical psy-chology’ and by Stedmon et al. (2003, this issue).

Other education-based references to ReflectivePractice within this literature include the follow-ing definition: ‘Reflective Practice is a mode thatintegrates or links thought and action with re-flection. It involves thinking about and criticallyanalysing one’s actions with the goal of improv-ing one’s professional practice’ (Imel, 1992).

There have been few attempts to defineReflective Practice within health and social care.A number of writers use metaphor to conveytheir understanding of the concept (Bolton,2001; Gardner, 2001). For example, Gillie Bolton(2001) refers to the ‘mind the gap’ messageheard often on the London Underground in hersuggestion that ‘Reflective Practice can enable a


Reflective Practice

SPECIAL ISSUE:


“mindfulness of the gap” – an awareness of andwillingness to tackle border issues’.

Gillmer and Marckus (this issue), in their re-view of clinical psychology training, use the term‘personal and professional development’ (PPD)to refer to ‘that part of the curriculum that is ded-icated to developing in trainees a capability tocritically and systematically reflect on the work-self interface’. Stedmon et al. (this issue) providetwo broad meanings of the term ‘reflection’within clinical practice: ‘personal self-awareness’and ‘learning by doing’. This paper also presentsthe concept of ‘reflecting on reflections’, andproposes that this process ‘forms the basis of acontinuous cycle of critical evaluation of one’spractice’.

How to teach Reflective Practice?Whilst a definition may remain elusive, the im-portance of reflection in enhancing professionalpractice is acknowledged by writers within severalprofessional fields (Schön, 1983; Salmon, 1988;Skovholt et al., 1997; Bolton 2001; Gardner, 2001).That it is a difficult area to teach and to assess isalso emphasized within a number of texts(Gardner, 2001; Perry & Cooper, 2001).

Once again it was writers in the field of educa-tion who initially emphasized the importance ofreflection in the learning of skills and knowledge.The work of Donald Schön (1983, 1986), in par-ticular, links with theories of learning espoused byDewey, Lewin and Piaget, each of whom arguedthat ‘learning is dependent upon the integrationof experience with reflection and of theory withpractice’ (Imel, 2001). Although each arguedthat experience is the basis for learning, theyalso maintained that learning cannot take placewithout reflection; that reflection is the essentialpart of the learning process because it results inmaking sense of or extracting meaning from theexperience.

The cultivation of the capacity to reflect in ac-tion (while doing something) and on action (afteryou have done it) has become an important featureof professional training programmes in many dis-ciplines. Schön (1986) also identifies the importantrole of the mentor within this process, arguing that‘real reflective practice needs another person asmentor or professional supervisor, who can ask ap-propriate questions to ensure that the reflection

goes somewhere, and does not get bogged downin self-justification, self-indulgence or self-pity!’

A number of writers refer to the ‘artistry’ ofprofessional practice. For example, Schön (1983)identifies the elusive nature of Reflective Prac-tice, and the subsequent challenge in teaching itto others in the following discussion:

for example, when we want to teach somebody

else to do what we know how to do. I don’t know

about your experience as teachers, but mine is –

the thing I find hardest in the world to do is to

teach a student what I know how to do best. For

example, to see interesting patterns in data, which

I know how to do, I cannot teach my students to

do, or I have to work very hard, or I ask myself,

‘What is it that I’m really doing when I do this?’

And I find I’m asking myself a surprising question:

I don’t know the answer to it. In order to get the

answer I have to actually think about what I do,

and observe myself doing it. My theories about it

don’t work very well.

Schön (1983) identifies the challenge to allprofessional training schools as the challenge ofeducating for artistry: ‘helping people becomemore competent in the indeterminate zones ofpractice, at carrying out processes of reflection-in-action, and reflection on reflection-in-action.And helping them to co-ordinate that artistrywith applied science’.

the experience of the students in any reflective

practicum is that they must plunge into the doing,

and try to educate themselves before they know

what it is they’re trying to learn. The teachers

cannot tell them.

Within the field of social care, Gardner (2001)refers to the ‘art’ of social work and refers tolearning being most effective if the pupil en-gages in learning in a personal way, rather thanlearning being impersonal and objective. She iden-tifies the challenge within social work trainingas ‘how to create an atmosphere in which stu-dents can develop and integrate the knowledge,skills, self-awareness and values that they willneed as workers’ and recognised a need for stu-dents to experience the intuitive process ofworking with people’s problems in addition to

7

Cushway & Gatherer

learning about more empirically-based knowledge.The challenge within the field of psychological

and clinical therapies seems to be a similar one,in which the requirement to teach and to assessscientific knowledge and clinical practice maydominate the curriculum, and yet the ‘artistry’ isalso to be acquired. Indeed, the term ‘artisticpractitioner’ waas referred to by Craig Newnesin his presentation to the conference uponwhich this Special Issue is based.

A number of the papers within this SpecialIssue emphasise the importance of ReflectivePractice in the implementation of psychologicaltherapies (for example, Bennett-Levy, O’Loughlin,Paula). Approaches to teaching Reflective Prac-tice within clinical psychology training are alsoreviewed later in this paper and in later paperswithin this issue (Gillmer & Marckus, Stedmon et al.)

Various approaches to the teaching ofReflective Practice in relation both to educationand clinical therapies have been reported withinthe literature. For example, Perry and Cooper(2001) discuss the use of metaphor as an educativetool for reflection. They report on the strengthsand limitations of the use of metaphor, and pro-vide examples of specific metaphors that havebeen created by teachers to illustrate and explaintheir personal experiences and images withintheir work. The authors suggest that metaphorsprovide a context within which to make sense ofthe world, bring about a richer understanding ofa concept and identify something that has pre-viously been unnamed, and as such provide away of learning something new about the way inwhich we perceive and relate to the worldaround us. Perry and Cooper report on a study inwhich teachers were asked to create metaphorsas a means of reflecting on their practice, whichwere then reviewed and interpreted to clearlyidentify the sense of personal meaning and learn-ing that could be derived from the experience. Itwas concluded that:

The use of metaphor provides a productive way

of reflecting on our professional lives and

practices in that it allows us to explore these

lives and practices from a diversity of perspectives

and over time. Thus use of metaphor encourages

this process of reflection to be ongoing and

purposeful.

8

Bolton (2001) identifies Reflective Practice as acreative art, and draws on literature and on theuse of stories to develop our understanding of,and our ability to utilize, reflection in our profes-sional practice. Bolton also emphasizes the elu-sive nature of reflective practice – ‘the more youlook, the less you see’ – and identifies some ofthe traps inherent within the practice of profes-sional reflection. The papers by Gillie Bolton andHelen Drucquer later in this issue develop andexpand on these ideas.

Others suggest a more direct and strategy-ledapproach to the development of ReflectivePractice, such as through the application of aprocess of enquiry that involves questioningwhat, why, and how one does things and askingwhat, why, and how others do things; by seekingalternatives and keeping an open mind; by ask-ing “what if...?”, hypothesizing; and by seeking,identifying, and resolving problems (Ross, 1990).

Teaching Reflective Practice onclinical psychology training coursesGillmer and Marckus (this issue) surveyed theteaching of Reflective Practice in clinical psy-chology training within the context of personalprofessional development. This paper, and thatby Stedmon et al. in this issue, acknowledge therecent British Psychological Society requirementfor clinical psychologists to be trained as compe-tent reflective scientist-practitioners, and re-views aspects of the various curricula that areaimed at developing reflective practice alongsideother aspects of personal and professionaldevelopment.

Stedmon et al. report that ‘about half of thecourses in the [clinical psychology] ClearingHouse Handbook advertise themselves as sub-scribing to a reflective model’. The authors thenreview the approach to training in reflective prac-tice within the South West training courses.They identify the need for teaching methods tobe varied, including both group and individuallearning environments, and have developed aworking group that represents all three SouthWest courses together with local providers, todevelop and implement a strategy for RP training.

Tony Lavender’s paper in this issue identifiesfour processes involved in Reflective Practice(reflection in action, reflection on action, reflec-


tion about impact on others, and reflection aboutself) and suggests how skills within each of thesemay be developed within clinical psychologytraining.

How to assess Reflective Practice skillswithin clinical psychology training?There are as many difficulties in assessingReflective Practice skills as there are in definingand teaching it. The ability to reflect upon one’sown practice requires self-awareness, honestyand insight into one’s values and attitudes, andan understanding of what it is that one is tryingto achieve. To then utilize such reflection in thedevelopment of one’s clinical practice requiresflexibility, adaptability and a willingness to ac-cept that the work one is doing may benefitfrom this process.

Gillmer and Marckus (this issue), in their re-view of personal and professional developmentwithin clinical psychology training, identify vari-ous and imaginative methods of assessment, in-cluding essay, assignment, reflective journal,portfolio and group work.

Teaching and assessment of ReflectivePractice on the Coventry and Warwickdoctorate training courseOne of the aims for us in putting on this confer-ence day on Reflective Practice was to stimulateus in our thinking and help us to develop furtherin this area. There is probably nothing very in-novative at present in the way that we ‘teach’reflective practice, if indeed it can be taught,but we do attempt to encourage reflective prac-tice in a variety of ways. Our teaching methodsare varied and include academic teaching, practi-cal skills teaching, often with the help of role-playand video, integrating theory and practice smallgroup discussions and supervision, as well as var-ious forms of experiential learning.

Personal development is regarded as an ex-tremely important aspect of the learning experi-ence and trainees attend a mandatory personaldevelopment group, which is held weekly forthe first two years of the course. The group isrun by an outside facilitator and provides anopportunity for trainees to explore and reflecton issues related to their own personal develop-ment. The group is seen as important in enhanc-

ing self-awareness, encouraging reflection, andunderpinning the therapeutic use of self in thera-peutic work.

Most assessments are specifically designed toencourage reflection and include a role-playedskills exercise which is videotaped and reflectedupon, a process analysis report on a transcriptof an individual therapeutic session, and a set ofvignettes illustrating professional or ethicaldilemmas in clinical practice. Each piece ofassessed work includes a reflective componentand the marking criteria include ‘evidence ofthinking reflectively about the work’. Traineesare expected to keep a reflective journal fromwhich they have to submit a journal report ineach of the first two years. Each year traineesalso appraise their personal and professional de-velopment using semi-structured forms. These arecommented upon by a peer and then discussedwith the trainee’s appraisal tutor. At the end ofthe course trainees present a professional port-folio, which includes a reflective account of theirdevelopment during the three years of training.

There is a debate about whether reflective workshould be formally assessed or not. We believethat some work cannot be formally assessed, forexample trainees are required to attend thegroup, but are not formally assessed on this.However, on clinical training courses, there is aheavy emphasis on assessed work, and there canbe a tendency for work that is not assessed to beseen by trainees as less important or less valued.For this reason, as well as because we believe thatit is possible to judge how someone is develop-ing as a reflective practitioner, we are attemptingto develop criteria by which we can assess theability to reflect, at least in written form. Thus thereflective journal is confidential to the trainee,but the journal reports that trainees produce aremarked pass or fail like other assessed work.Trainees are asked to consider questions like:What did you think or feel about the issue? Whatdid you learn? What was particularly significantfor you? How will you apply what you havelearnt to your clinical practice? How have yourbeliefs been affected? What do you think workedwell? What would you do differently in the fu-ture? What felt difficult or challenging? How willyou use feedback to inform future practice?Some marking criteria that we have found useful

9

Cushway & Gatherer

are evidence of openness, awareness of one’sown skills and needs, evidence of incorporatingpeer feedback constructively, evidence of re-flecting on the learning experience, evidence ofalternative ways of viewing experiences, abilityto analyse critical incidents, experiences, thoughtsand beliefs, evidence of own views about per-sonal and professional development and evidenceof attempts to make theory-practice links.

ConclusionIrrespective of its benefit to good clinical prac-tice, or perhaps in recognition of it, the BritishPsychological Society Committee on Training inClinical Psychology has brought the training andassessment of reflective practice into the arenaof core clinical competencies. Clinical doctoratetraining courses must now address issues relat-ing to the teaching and assessment of reflectivepractice as part of essential accreditation criteria.We hope the articles that follow will at least as-sist in that process.

ReferencesBolton, G. (2001). Reflective practice: Writing andprofessional development. London: Sage.

Chambers Dictionary (1993). Edinburgh: ChambersHarrap Publishers Ltd.

10

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Gardner, F. (2001). Social work students and self-awareness: how does it happen? Reflective Practice, 2(1).

Imel, S. (1992). Reflective practice in adult education.ERIC Digest,122 (ED346319).

Perry, C. & Cooper, M. (2001). Metaphors are goodmirrors: reflecting on change for teacher educators.Reflective Practice, 2(1).

Ross, D. D. (1990). Programmatic structures for thepreparation of reflective teachers. In R. T. Clift, W. R.Houston & M. C. Pugach (Eds.) Encouraging reflectivepractice in education. New York: Teachers CollegePress.

Salmon, P. (1988). Psychology for teachers: An alter-native approach. London: Hutchinson Education.

Schön, D. (1983). The reflective practitioner. NewYork: Basic Books.

Schön, D. (1986). Educating the reflective practitioner.Oxford: Jossey Bass.

Skovholt, T. M., Ronnestad, M. H., & Jennings, L.(1997). The search for expertise in counseling, psy-chotherapy and professional psychology. EducationalPsychology Review, 9, 361-369.

AddressClinical Psychology Programme, CoventryUniversity, School of Health and Social Services,Priory Street, Coventry CV1 5.

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Redressing the balance: the place,history and future of reflectivepractice in clinical training
Tony Lavender, Course Director, Salomons
This paper attempts to address three questions:

i. Why is reflective practice important inclinical training?

ii. Why has clinical psychology neglectedreflective practice?

iii. What is reflective practice and how mightit be integrated in clinical training andcontinuing professional development?

Why is reflective practice important?It is perhaps helpful to consider the alternative.What would it be like to be an unreflective prac-titioner and, if you were, what would that meanfor your practice, and do you think anybodywould want to see you?

Donald Schön’s two major works, TheReflective Practitioner (Schön, 1983) andEducating the Reflective Practitioner (Schön,1987) are of particular relevance. The second bookopens with:

In the varied topography of professional practice,

there is a high, hard ground overlooking a swamp.

On the high ground, manageable problems lend

themselves to solution through the application of

research-based theory and technique. In the

swampy lowland, messy, confusing problems defy

technical solution. The irony of this situation is that

the problems of the high ground tend to be relatively

unimportant to individuals or society at large,

however great their technical interest may be,

while in the swamp lie the problems of greatest

human concern. The practitioner must choose. Shall

he remain on the high ground where he can solve

relatively unimportant problems according to

prevailing standards of rigor, or shall he descend to

the swamp of important problems? (Schön, 1987: 3)

In these books Schön explores the limitationsof a purely scientific approach, or in his words‘the Model of Technical Rationality’, to practice.He attempts to develop ways of working and ed-ucating professionals in the indeterminateswampy areas of professional practice. His thesisis that most professions in their early stages of de-velopment, in attempting to establish a re-spectable standing in society, lay claim to aknowledge base supported by positivist science.However, if a profession is to reach maturity,there must be a recognition that practice contin-uously exposes the limits of science, and waysneed to be developed to help professional practi-tioners deal with the uncertainties and complexi-ties of the reality of practice. This is why thedevelopment of reflective practice is so impor-tant, because it helps us to deal with the swamp.

Why has clinical psychology neglectedreflective practice?There are undoubtedly many reasons but in thisbrief paper it is interesting to take a historical per-spective and look at the roots of the profession.The pattern of professional development described by Schön has been evident in clinicalpsychology (Hall, Lavender & Llewelyn, in press).

The first course started at the Institute ofPsychiatry in 1947 and in order to help the de-


Reflective Practice

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11

Lavender

velopment of the course Eysenck (1949) wenton a six-month tour of the States (University ofPennsylvania) to learn from their experience ofdeveloping clinical psychology. The conclusionshe reached are of interest when contrasted withthe American Psychological Association (APA)conclusions at that time. Pilgrim and Treacher(1992) have made similar observations.

Eysenck’s (1949) paper showed what an exclu-sively ‘scientific approach’ was being advocatedfor the development of clinical psychology in theUK. He contrasted the UK and APA perspectivesin the paper. Eysenck explained:

It was the view of the APA in 1948 that clinical

psychology … had great opportunities to meet

‘unmet social needs’ for more and better mental

hygiene services, including research. The task

before clinical psychologists lies in adopting such

policies in their training institutions that are best

calculated to provide services that can demonstrate

social usefulness (p.173).

In contrast he proposed for the UK model:

Psychology can not go where social need requires

… science must follow more germane arguments

than the possibly erroneous conception of social

need (p.173).

The consequence of this argument was to ex-clude therapy from the activities of clinical psy-chologists. As the APA stated:

the need for clinical psychologists with a

combination of applied and theoretical knowledge

in three major areas: diagnosis, therapy and research

(p.173).

Eysenck in his reply made a number of impor-tant points which were to have a significant effecton the initial developments in training:

Clinical psychology should not involve a training in

therapy, ‘therapy is something essentially alien’.

Clinical psychology demands competence in

diagnosis and/or research (p.173).

It is important to remember that the majortherapy practiced in a widespread way across

12

post-war America was psychoanalysis, and as iswell known, Eysenck had strong views about the‘unscientific’ nature of this enterprise.

So where did this leave space for reflectivepractice?

Eysenck’s paper (1949) made it clear that at leastone type of self-reflection was not appropriate.He again contrasted his own position with theAPA, which advocated that:

some kind of intense self-evaluation and that

whenever possible that should be psychoanalysis

(p.174).

Eysenck was at his most strident in his response:

It is proposed that the young and relatively

defenseless student be imbued with the ‘premature

crystallizations of spurious orthodoxy’ which

constitute Freudianism through the ‘transferences

and counter-transferences’ developing during this

training. Here, indeed, we have a fine soil on

which to plant the seeds of objective,

methodologically sound, impartial, and

scientifically acceptable research (p. 174).

These views heavily influenced the content ofthe early courses and appeared to set UK clinicalpsychology on a path that learned little from theAmerican experience. This path, followed bymost other professions, welded clinical psychol-ogy to the mast of a positivist approach to sci-ence, which meant that finding other ways of‘knowing about the world’ were rather put onthe back burner. These dilemmas and their rip-ples are evident in many of the current clinicalprogrammes and professional debates.

This is not to argue that ‘science’ and rigorousdevelopment of theory and research is not im-portant, but if that is all we think there is, thenwe will delude ourselves. We should be wary ofmyopic views of what constitutes evidence.Clinical psychology has shown its ability to em-brace new developments in theory and practice.Thus from the initial embracing of learning the-ory and its application in behaviour therapy inthe late 1950s and 1960s, this has extended tocognitive theory, systemic theory and social con-structionist conceptual frameworks. And the in-terest in humanistic and psychoanalytic theory


has remained alive since the early life of clinicalpsychology in the UK. It is however importantnot to assume that any one of these provides acomplete explanation for reality. They are approx-imations to reality, ways of understanding, thatare more or less helpful in unique contexts, or inthe swamps.

What is reflective practice and howmight it be inegrated into clinicaltraining and CPDSo given this view about the importance of reflec-tive practice what does it involve and how canwe promote the processes of reflective practicein clinical training? It is perhaps useful to identifyfour processes involved in reflective practice:

■ reflection in action;

■ reflection on action;

■ reflection about impact on others;

■ reflection about self (awareness and develop-ment).

There is overlap between these processes butthere seems some pragmatic justification for sep-arating them.

Reflection in actionSchön (1987) discusses a process which he con-siders as being present but often unacknowl-edged in all best professional practice. He callsthis ‘reflection in action’. ‘Reflection in action’refers to the process where, while you are act-ing, you reflect (cognitively and emotionally)about what you are doing and what you shoulddo next. This type of reflection is often precipi-tated by confrontations with the unexpected orwhen theory prescribed action hits its limits.Essentially it is the rapid analysis of the specificsof the context using our immediately availabletheories, and our constructions about the world(i.e. our deep subjectivity) that enable us to de-cide what to do. There are some parallels withthe notion of metacognition (thinking aboutthinking), and also with Patrick Casement’s(1985) notions of developing ‘a supervisorwithin’. Schön (1987) argues that it is the ability

to reflect critically in those moments where weencounter complexity and unfamiliarity, that is avital component of professional practice.

Our ability to do this can be reflected on afterpractice (see next section) but we must return topractice to see whether our post hoc reflectionshave improved our ability to think ‘in practice’.Schön also points to a number of methods thatwe might use to improve our reflective capacity.These methods include ‘real world’ and ‘simu-lated’ workshops.

■ Real world workshopsReal world situations can be used when you areasked to remember, or plan in the future, to payspecial attention to your thinking and feelingsabout dealing with unfamiliar situations. For ex-ample: I was asked to see a person who hadtried to kill himself and was seemingly not ableto talk to any of the staff in the hostel where Iworked. After agreeing to come and see me – atthe last minute he said he would, as long as Isaw him in his room. This situation promptedmany thoughts and feelings, about whether Ishould persuade him to come down, whatwould be the meaning of that decision for him,for me, for the staff group and other residents.Noting and recording those internal processeswhether alone or in supervision can help yourskill at undertaking and evaluating the decisionmaking process.

■ Simulated workshopsSituations like the ‘real scenarios’ (dealing with sur-prises) can be simulated in teaching and super-vision, through role plays, where participants areasked to note and record their thoughts and feel-ings in those moments leading to their decision.For example, presenting unfamiliar situationsduring clinical role plays and getting individuals orsmall groups (facilitated or not) to examine theprocesses of thinking and feeling during thosemoments, can prove constructive, and developpeople’s skill in ‘reflecting in action.’

Reflection on actionSchön also describes ‘Reflection on Action’ – thisobviously occurs after an event and can happenin a variety of ways. Many of these involve famil-iar processes and include:

13

Lavender

■ With others in supervision (individual orgroup: peer or expert). This is where the super-visor helps the supervisee to reflect aboutwhat has been done, what theory is relevant,or whether the situation takes the supervisorbeyond existing theory, as well as generat-ing plans about what to do. In these learn-ing contexts, Kolb’s (1974) learning cyclecan be helpful to think about the reflectiveprocess.

■ Alone. This can take a variety of forms:– listening to and observing tapes (audio

and visual);– thinking;– writing (notes, prose, poetry, memo writing);– drawing (diagrams or pictures)

Reflection about impact on othersA useful category of reflection involves ‘reflectionabout your impact on others’. We exist for muchof the time in interpersonal contexts to which webring our histories, meanings and ways of relatingwhich have impacts on others (other clients, fel-low team members, colleagues or organizations).If we are to promote reflective practice, individu-als need to find ways of reflecting about their im-pact on these others. In particular, feedback inthe form of the reflections of others about our im-pact on them, seems vital to the development ofour awareness. This is particularly significant inthe context of the NHS where the importance ofteams and other colleagues is vital to the work(Onyett, 1999). The ability of others to hold up amirror and show us what our psychological re-flections look like, is perhaps something we uti-lize too little. Some ways to help us reflect aboutour impact on others include:

■ Feedback from others. Systematically gatheringthis feedback from others can help in super-visory and appraisal processes (known as 360degree feedback) to deepen understanding andreflection. This usually involves collecting data(written or oral) from a variety of sources(clients, trainees, other psychologists, col-leagues from other disciplines).

■ Group tasks or task free groups. Such groupscan involve both ‘real’ and ‘simulated’ situa-

14

tions and it is useful if there are observers toprovide a non-participating perspective.Feedback from participants and observersabout particular individual’s interpersonal be-haviour can aid the reflective process.

■ Team assessment tasks, which requireindividuals to seek feedback about their im-pact and to write reflective accounts of theseexperiences.

■ Outdoor development exercises to examineperformance in a team and the role individualsadopt in teams as well as their interpersonalbehaviour. Sometimes challenges (even ifminor, e.g. to put up a tent rather than whitewater rafting) can bring out the kind of diffi-culties people experience in stressful worksituations.

■ Completing questionnaires, measures. Somepersonality measures (Myers Briggs, Millon,etc.) can provide interesting perspectives onyour preferred style with others. This may helpyou identify areas that are likely to be difficultto manage and areas that will play to yourstrengths.

■ Video observations. Watching videos of work-ing with others, be it in therapeutic, team orother group contexts, again can prove usefulin reflecting about your impact on others.

This list is intended to provide some prelimi-nary ideas about what might aid the process ofreflection on your impact on others

Reflections about SelfSelf-reflection and development should not be anoptional activity for clinical psychologists, giventhe expectations we place on others to develop.The methods by which we achieve this shouldhowever be more optional – different methodssuit different people. The processes to aid re-flection that have already been described canfeed into this developmental process. Given theearly history of clinical psychology it does seemnecessary to answer the question, why is this im-portant?

There seems to be a very simple reason.


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Psychological problems exist on continua; theydo not break down into categorical systems.Formulation, not diagnosis, is at the heart of thework of clinical psychologists. Whatever psycho-logical model you subscribe to, what is clear is thatwe all have vulnerabilities from our pasts, and wewill encounter social contexts that may exposethose vulnerabilities. None of us is immune topsychological problems. Having an awareness ofthose vulnerabilities, and the social contexts thatmay expose them, is important in deepening ourrespect and understanding for our clients’ diffi-culties. And it prevents us from assuming that weare categorically different from those that wesee, and in helping us develop ways of address-ing and coping with our vulnerabilities.

So what methods help development of thisawareness and growth?

■ Therapy. Yes it can help psychologists (whaton earth would we be saying if we think itcould not).

■ Reflection processes. All the reflection meth-ods previously described can be used tofeed the process of increasing our aware-ness of self and provide opportunities forgrowth;

■ Development at work. Our work withclients and colleagues, particularly workingthrough ‘stuck’ issues (Leiper and Kemp,2002) can improve awareness and lead todevelopment;

■ Development at home – relationships withpartners, family members and friends. Thesenaturally occurring encounters are often un-derestimated as awareness enhancing experi-ences and certainly can lead to change anddevelopment.

ConclusionIn this brief paper an attempt has been made tostate why reflective practice seems important, whyhistorically it has been problematic but is nowemerging in clinical training, and finally to providesome methods that might help reflective practice.There is a growing recognition (Galloway et al.,2003) that there is a need to balance our long-

standing position as scientific practitioners withan understanding and use of the processes of re-flective practice.

ReferencesCasement, P. (1985). On learning from the patient.London: Tavistock.

Eyensenck, H. J. (1949). Training in clinical psychol-ogy: an English point of view. American Psychologist,4, 173-176.

Galloway, A., Webster, R., Howey, L., & Robertson, W.(2003). Reflection and development: an integral partof clinical training. Clinical Psychology, 21, 27-30.

Hall, J., Lavender, A., & Llewelyn, S. (in press). A his-tory of clinical psychology in Britain: Setting anagenda. History and Philosophy of Psychology.

Kolb, D. A. (1984). Experiential learning. New Jersey:Prentice-Hall.

Leiper, R., & Kemp, R. (2001) Working through set-backs in psychotherapy. London: Sage.

Onyett, S. (1999). Community Mental Health Teamworking as a socially valued exercise. Journal ofMental Health, 8, 3, 245-251.

Pilgrim, D. & Treacher, A. (1992). Clinical psychologyobserved. london: Routledge.

Schön, D. A. (1983). The reflective practioner.London: Basic Books.

Schön, D. A. (1987). Educating the reflective prac-tioner. Oxford: Jossey Bass.

AddressSolomons, Broomhill Drive, Southborough,Tunbridge Wells, Kent

15

Reflection: a blind spot inpsychology?
James Bennett-Levy,Warneford Hospital, Oxford
Reflection hasn’t just had a poor press inpsychology. Over the past 60 or so years,it has had almost no press at all. If you ex-

amine a typical introductory psychology textbook,you won’t find the word ‘reflection’ in the index.

Yet this was not always the way. The conceptof reflection flourished in the days of WilliamJames and Sigmund Freud. 2500 years earlier,Buddha had identified self-reflection as the keyto self-understanding.

In the last century, it was the growth of be-haviourism and experimental psychology, whichseems to have sent reflection into exile. Theproblem was that (i) reflection is a purely inter-nal process, and (ii) is out of reach of the exper-imenter’s best attempts to bring it underexperimental control.

It appears in lots of forms and guises – we canreflect on past, present or future; on ourselves,on others, on the world; we can reflect on ourexperiences; we can reflect on our reflections onour experiences; we can reflect on our reflec-tions on our reflections on our experiences andso on ad infinitum. In short, reflection is a be-havioural scientist’s nightmare – almost impossibleto define tightly, and well nigh uncontrollable.

Reflection and the development oftherapist expertiseThese unruly features might suggest that reflectionis highly deserving of its enforced exile. How-ever, when those of us working in psychologyfrom a scientist-practitioner perspective stop toexamine our professional practice, an awkwardquestion arises: we spend our therapy hours,supervision hours and teaching time askingclients, trainees, clinicians – and, when we havetime, ourselves – to reflect. Why? On what empiri-cal grounds? Is there anything in the psychologyresearch literature which suggests the value ofreflection? The answer is very little.

16

My initial interest in the process of reflectionwas stimulated by personal experience of usingreflective processes during my training as a cog-nitive therapist. Later, I read the observations ofBeck (1995), Padesky (1996), and others, sug-gesting personal experience of cognitive therapy(CT) techniques was one of the best ways tolearn about CT. For instance, Padesky (1996:288) wrote: ‘To fully understand the process ofthe therapy, there is no substitute for using cog-nitive therapy methods on oneself.’

At the time, I was designing a university-basedCT training course. So a personal experientialcomponent was included, which came to beknown as self-practice/self-reflection (SP/SR). InSP/SR, trainees practise CT techniques on them-selves, either on their own or with a ‘co-thera-pist’. Following self-practice sessions, traineesreflect in writing on their experiences. Writtenreflections are central to their learning process,enabling them to look in depth at the implica-tions for themselves, for their clients and for cog-nitive theory. SP/SR is not designed to bepersonal therapy; its primary function is as a fo-cused training technique (Bennett-Levy, 2003).

Outcomes of SP/SRFrom the start, research into the impact of SP/SRwas undertaken collaboratively with the trainees.Our initial aim was to map the outcomes of SP/SR:how did it impact on trainee skills and knowledge?Later, we became interested in understandingwhat learning mechanisms could account for itsapparent effectiveness.

The outcomes research is reported in Bennett-


Reflective Practice

SPECIAL ISSUE:


Levy (2001, 2003). In brief, we found that SP/SRhad a self-reported impact at three levels – con-ceptual, practical and attitudinal:

1. Therapeutic understandings: for instancetrainees describe enhanced understanding ofthe role of therapist and change processes(see Bennett-Levy et al., 2001, for more pre-cise details).

2. Therapist Skills (Bennett-Levy et al., 2003): forinstance therapists report that they are betterat communicating the conceptual frameworkof CT, and establish a stronger therapeuticbond.

3. Therapist Self-concept (Bennett-Levy et al.,2001): for instance trainees report that theyhave greater belief in CT, having experiencedsome of its effects internally, and havegreater self-confidence as a therapist.

Process of SP/SRFrom a process perspective, trainees were report-ing a ‘deeper sense of knowing’ CT practices asa result of SP/SR. They were suggesting learningwas ‘deeper’ when comparing SP/SR to othertraining techniques such as didactic learning, orrole-plays with simulated clients. To give an ex-ample, one trainee commented:

Although I already knew that emotions are a result

of our interpretations of events, this situation gave

me a good example of that from my own

experience. So rather than just ‘knowing’ about

this phenomenon I ‘realised’ it – the difference

between understanding the concept at a head level

and gaining an unquestionable, full-bodied

experience of understanding.

Qualitative analysis of trainee observationsabout the learning process indicated that thedeeper sense of knowing is arrived at throughtwo quite different modes of information pro-cessing: what we termed Experiencing from theClient’s Perspective, which is equivalent to SP(self-practice), and Reflecting on Experience,which is equivalent to SR. In study interviewsand written reflections, participants were askedto describe these two processes, and the ele-

ments of them which were most important inachieving change. They described the processesquite differently.

The important elements of Experiencing fromthe Client’s Perspective were (1) its personal andemotional nature; (2) its doing/experiencingquality; and (3) the unique perspective affordedby being in the client’s chair. For instance, re-garding its emotional nature, a typical responsewas that of one participant who noted that ‘itwas striking to realise that nearly all of the exer-cises forced one to access feelings and memoriesfrom deeper layers than if one was just thinkingon an everyday level’.

On the other hand, the important elements ofReflecting on Experience involved (1) internalcognitive strategies such as persistent self-ques-tioning and following trains of thought; and (2)facilitative environmental supports, such as writ-ing and group reflections. The effect of thesestrategies and supports was to externalise andobjectify experience from a detached analyticperspective – a very different processing modeto the emotional, subjective, experiential natureof Experiencing from the Client’s Perspective.For instance, one trainee noted ‘SR takes me out-side the process of just doing it and makes methink about what I am doing and why I am doingit’. In the language of cognitive science, reflec-tion was providing a metacognitive perspectiveon trainees’ internal processes.

The experiential and reflective processes ap-peared to contribute separately and additively tothe deeper sense of knowing. Self-reflection wastherefore central to the subjectively experiencedbenefits of therapists undertaking SP/SR onthemselves as part of their training.

Accounting for the impact of SP/SRWhat theories from experimental psychology couldaccount for the apparent impact of SP/SR? At astretch, the literature could provide some expla-nation for why the personal, experiential com-ponent of SP/SR was perceived as so valuable.Experimental research indicates that superior re-call is obtained from self-referential materials,from emotional materials, and from materialswhich are enacted (Baddeley, 1997). Hence, it isreasonable to suppose that experiential learningis better retained in memory.

17

Bennett-Levy

But what about reflection, which partici-pants say is so important? As noted above, ex-perimental psychology has rather little to sayon the subject. In contrast, the adult educationliterature over the past 20 years has persis-tently emphasized the importance of reflection(Kemmis & McTaggart, 2000; Kolb, 1984;Schön, 1983). It is only now that practitionerdisciplines such as education, medicine, nurs-ing and psychology are focusing on processesof training that we can recognise that experi-mental psychology has had a blind spot for oneof the principal modes by which human beingslearn and understand things for themselves andabout themselves.

Reflection and the development ofwisdomOther research on therapist development hasalso indicated the key role played by reflection.In particular, studies by Skovholt and colleagueshave suggested that continuous professional re-flection is what distinguishes expert therapistsfrom average therapists: ‘A therapist and a coun-sellor can have 20 years of experience or oneyear of experience 20 times. What makes the dif-ference? A key component is reflection’(Skovholt, Rønnestad & Jennings, 1997: 365).Furthermore, social psychological research hasshown that the process of self-reflection is cen-tral, not only to the development of clinical wis-dom, but of life wisdom more generally(Staudinger, 1999).

And what about our clients? Reflective pro-cesses appear to be fundamental to our clients’progress in therapy. In all types of therapy, ther-apists ask clients to reflect on recent and past ex-periences; to re-evaluate; and to draw newconclusions. Some schools of therapy continueto use the term ‘reflection’ to describe theseprocesses, while others (e.g. cognitive therapy)use terms such as testing, problem solving, eval-uation, and cognitive restructuring, to describeelements of the process.

Reflection: a central mechanism inhuman learning Regardless of the precise terms used, the key pointis that, for humans, reflection is a central processfor learning about the world and ourselves. The

18

capacity to mentally represent past, present orfuture events, and to reanalyse, re-evaluate, andfind new meanings in them at one day, five years,or 50 years distance from the original event, isone of the cognitive skills that almost certainlydistinguishes us from the rest of the animalworld (Wheeler, Stuss & Tulving, 1997).

Experimental psychology has given us a varietyof learning theories: for instance, classical condi-tioning, S-R conditioning and social learning theory.But by sending reflection into exile, it has over-looked arguably the most important mechanismby which humans learn from their own experi-ence: self-reflection.

In summary, it is argued that reflection is theblind spot of psychology. A long overdue task isto build psychological models of the reflectiveprocess, to identify when and how reflection ismost useful and for what outcomes, and to de-termine the key learning mechanisms. We also needto distinguish between reflection, which has beenconstrued as a positive quality in this article, andprocesses which at first acquaintance appearsimilar, but seem to involve very different modesof processing – rumination, self-absorption, andnegative self-focus. The latter have all been iden-tified with negative affective states in the researchliterature (e.g. Sakamoto, 2000).

As psychologists, we need to come to gripswith, nurture and promote reflection, and to dothe necessary research. Reflection needs to takeits place alongside classical and operant condi-tioning in chapters on human learning in intro-ductory psychology textbooks. In a rapidlychanging world, the opportunities for reflec-tion are fast diminishing. Yet if reflection is theprimary means through which humans acquirewisdom and expertise, a sophisticated psychol-ogy of reflection has never been more neededthan now.

ReferencesBaddeley (1997). Human memory. Hove: PsychologyPress.

Bennett-Levy, J. (2003). Navel gazing or valuable train-ing strategy? Self-practice of therapy techniques, self-reflection, and the development of therapist expertise.In J. Henry (ed.), Proceedings of the First EuropeanPositive Psychology conference. Leicester: EPS/BPS.

Bennett-Levy, J., Lee, N., Travers, K., Pohlman, S., &


Hamernik, E. (2003). Cognitive therapy from the in-side: Enhancing therapist skills through practisingwhat we preach. Behavioural and Cognitive Psycho-therapy, 31, 143-158.

Bennett-Levy, J., Turner, F., Beaty, T., Smith, M.,Paterson, B., & Farmer, S. (2001). The value of self-practice of cognitive therapy techniques and self-reflec-tion in the training of cognitive therapists. Behaviouraland Cognitive Psychotherapy, 29, 203-220.

Kemmis, S., & McTaggart, R. (2000). Participatoryaction research. In N. K. Denzin & Y. S. Lincoln (Eds.)Handbook of qualitative research (second edition).Thousand Oaks, CA.: Sage.

Kolb, D. (1984). Experiential learning: Experience asthe source of learning and development. EnglewoodCliffs, NJ: Prentice Hall.

Sakamoto, S. (2000). Self-focus and depression: the three-phase model. Behavioural and Cognitive Psycho-therapy, 28, 45-61.

BRITISH PSYC

Division ofFacul

200

Title : New Developments in the PsycVenue: Harry Massey Lecture Theatre

University College London, 25Dates: September 8th – 9th 2003

Poster presentations are invi

The conference will address new developmand alcohol use and misuse. Poster presubstance misuse, addiction and psychology

Structured abstracts (up to 250 words) shstudy, its methodology and findings in the Authors’ in Addiction. Conference organiseacceptance.

If you wish to have a poster presentation aDr Paul Davis, Consultant Clinical Psy

Department of Psychology, 108 HaE- mail paul.e.d

Schön, D. A. (1983). The reflective practitioner. NewYork: Basic Books.

Skovholt, T. M., Rønnestad, M. H., & Jennings, L.(1997). The search for expertise in counseling,psychotherapy, and professional psychology.Educational Psychology Review, 9, 361-369

Staudinger, U. (1999). Social cognition and a psycho-logical approach to an art of life. In T. M. Hess & F.Blanchard-Fields (Eds.) Social Cognition and Aging.New York: Academic Press.

Wheeler, M. A., Stuss, D. T., & Tulving, E. (1997).Towards a theory of episodic memory: the frontallobes and autonoetic consciousness. PsychologicalBulletin, 121, 331-354.

AddressOxford Cognitive Therapy Centre, Department ofClinical Psychology, Warneford Hospital, Headington,Oxford OX3 7JX; [email protected]

19

HOLOGICAL SOCIETY

Clinical Psychology ty of Addictions 3 CONFERENCE

hology of Addiction

Gordon Street, London WC1

ted for the above conference.

ents in psychological perspectives of drugsentations are invited on any aspect of. Any addiction subject will be considered.

ould describe briefly the purpose of thesame format as listed in the ‘Guidance tors will make the final decision regarding

t this conference please forward a copy tochologist, University College London,mpstead Road, London NW1 2LS. [email protected]

Personal professional developmentin clinical psychology training:surveying reflective practice
Bruce Gillmer and Remy Marckus, University Of Newcastle
During the summer of 2001 seventeencourses were represented at a reflectiveworkshop conducted by Trish Hagan in

an attempt to examine and foster personal andprofessional development (PPD) in clinical psy-chology training (Hagen, 2001). These profes-sional trainers readily acknowledged a needyignorance in grappling with this familiar yet slip-pery construct. Though programmes had putrecognisably similar facilitative and supportivePPD structures in place, these varied consider-ably in their aims and in any unifying process. Itwas unclear whether these structures (or scaf-folds) were explicitly embraced within a coher-ent philosophy, or represented idiosyncraticmeans of achieving perceived aims, castingabout in largely vain attempts to meet diversepastoral, developmental, ethical, and conceptualneeds. Similarly, these attempts did not convinc-ingly distinguish genuine training needs from un-requited trainee wants.

On one thing there was unanimity: PPDspawns dilemmas. Although it has high empha-sis, it remains somehow extracurricular. PPDprovides structures for trainee support, yet it de-mands space for uncertainty. Whilst personaland professional lives are distinctive, it is non-sensical to separate the personal from the pro-fessional individual. PPD is central to the notionof the reflective practitioner, but remains pe-ripheral to the real training issues, which lie inthe domain of scientist practitioner. In order tobe a competency, PPD must have clear out-comes with properties that can be evaluated;but PPD is about formative process more thancontent and, for it to be summatively evaluatedas an outcomes-based construct, is reductionis-tic. Such tensions are not merely semantic butare the grist to the mill of ideologically opposed

20

staff members, and of trainees and their courses.Five core themes were generated at Trish Hagan’s

provocative two-day workshop:

■ Legitimising the personal in the professional.The integration of our personal and profes-sional lives is a struggle. Without a recogni-tion and appreciation of individual trainees’professional lives, there will always be asense of some ideal and abstract professionalself that will necessarily be elusive.Acknowledging this process as an essentiallypersonal professional development is a cru-cial first step. The second will require a pro-fessional acceptance that ‘the personal’ is alegitimate area in which to locate a core com-petency.

■ It is through the process of PPD, characterisedas a reflective competency, that each trainee be-comes a competent reflective scientist practi-tioner.

■ PPD requires a corporate embrace of a clearphilosophy that must be disseminated to andembraced by the wider teacher-supervisorcohort. This relates both to the public acknowl-edgement and the professional modelling ofthe inherent dilemmas and contradictions inconsidering personal and professional selves.

■ The diversity of individual PPD journeysneeds to be recognised and accommodated.


Reflective Practice

SPECIAL ISSUE:


■ PPD necessarily invites a deconstruction ofself during training, which is in direct con-flict with the super-competent image demandedof trainee applicants.

Effectively the workshop concurred that PPD is aprocess requiring curricular legitimacy in the train-ing of competent reflective scientist practitioners(Hagan, 2001). What remained decidedly cloudywas the nature of these kinds of competenciesand hence how to articulate and evaluate them.

It is necessary to distinguish what PPD is fromits evolving aims and outcomes. PPD is a processwith properties that traditionally and historicallyfacilitated largely supportive scaffolds (likementors); a process now espousing more develop-mental elements, inter alia to develop compe-tency in a reflective attitude to practice (BPS,2001). The problem of not distinguishing betweencurriculum constructs, processes, and materials,and their purposes only worsens as this messyand essentially formative curriculum module istossed into the (evaluative) competency stakes.Based on the experience of the workshop, thereflections provided by the participants, and theemerging conceptualisation it was decided tosurvey the clinical psychology programmesacross the UK in order to clarify more preciselyhow courses were actually attempting to imple-ment PPD, whether they defined it – as a corecompetency – how it was evaluated, and the var-ious scaffolds that were in place.

To guide this survey, all references in the 2001Clearing House Handbook and AlternativeHandbook were perused and all references toPPD were extracted. This information was sum-marised in a tabular arrangement, anonymisedfor training programme and sent to 24 trainingcourses, inviting them to participate in a projectto try to conceptualise PPD as a competency-based curriculum component. Comments wereinvited and courses were particularly requestedto examine and amend their identified tabulatedentry to an accurate representation of their ap-proach to PPD. We also requested copies ofcourse handbooks relevant to PPD.

Several months, reminders, exhortations, andclarifying telephone calls later and 17 courses(71 per cent response) had agreed to participate.All had submitted extracts from their handbooks,

clarified entries and, through this iterativeprocess, had contributed a considerable volumeof material. Given the inadequacy of our ownPPD programme in terms of definition, con-struct, core competency, and evaluation, the ap-parent reluctance of courses to provideinformation on PPD was unsurprising.

Table 1 represents a necessarily reductionisticattempt to depict PPD as it is constructed as acurriculum component across the responding UKClinical Psychology training programmes.

Just over half of the responding courses de-fined PPD. The majority of these understood PPDto be concerned with self-awareness and theeffect of individual history and training on pro-fessional development. As a secondary issue PPDprovided support and facilitated coping. Onlyone course specifically defined PPD as a focus onthe reflective scientist practitioner in training.

A similar number of courses portrayed PPD asproviding a core competency in their pro-grammes. Only six (35 per cent of respondents)of these nine, however, were also courses thathad a clear definition of PPD. This subgroup(type A – the good) all then went on to specifyaims, outcomes, and evaluation of their PPD pro-gramme. The attributes of the type A cluster areset out below. The remaining three of the groupthat provided a clear definition of PPD, but didnot have PPD as a core competency (type B – thebad), also tended not to specify aims, outcomes,or evaluations. Type C (the ugly) comprises theremainder of the courses surveyed (eight),which did not provide a clear definition of PPDyet, paradoxically, they variously included PPDas an undefined core competency and may ormay not include aims, outcomes, and evaluationswithin their PPD programme (most of us).

The core competency sought in PPD as a train-ing construct is universally aimed at enhancingself-reflection in professional and academic life.In short, as one course put it, the ‘cultivation ofa reflective stance’. The reflective scientist prac-titioner model dominates. Evaluation is undertakenby only seven of the responding courses. Self-di-rected learning, the use of a reflective journal, anda reflective practice assignment are examples.

Group work is one of the favoured mediumsfor PPD but it is unclear what issues are ad-dressed within group work. The reflective prac-

21

Gillmer & Marckus

titioner model dominates but purposes vary.Outcome and evaluation were hard to discern inany of the programmes. Where group work isundertaken it is usually mandatory.

The great majority of respondents use thefamiliar scaffolds of a peer group buddy system,a personal course tutor, and a non-coursementor. The aims of these particular roles areoften obscure and interchangeable. This may welllead to a similar lack of clarity among trainees

22

about who to turn to for particular needs: anissue central to a recent survey (Brooks et al.,2002) where realistic expectations was found tobe strongly predictive of trainee coping. The per-sonal course tutor role muddied personal andacademic support, with potential conflict betweenevaluative and supportive roles. That old nettle,personal therapy, is grasped by only four coursesand then is subsidised or funded. Those that donot offer personal therapy were explicit about it;

Table 1. Clinical training PPD programmes (n=17)

PPD Curriculum Components Yes No Salient Comments

Courses providing a definition of PPD 9 8 Self-awareness = 5

Effect of history, training on

professional development = 3

Provide support/facilitate coping = 2

Reflective scientist practitioner = 1

Courses specifying PPD as a core

competency (*Type A)

Specified aims

Specified outcomes

Specified evaluation

9

(6*)

8

7

8

9

10

Self-reflection and insight = 3

Self-development to fulfil

professsional role = 2

Integration of self, research and

practice = 2

Self-exploration = 1

Self-monitoring = 1

Cultivation of a reflective stance = 1

Courses providing groupwork

Mandatory attendance

Specified outcomes

Specidied evaluation

7

5

2

1

10

12

15

16

Reflective practitioner model = 5

Integrating theory and practice = 2

Support = 2

Occasional and diverse group

activities = 2

Personal awareness stressed as

mode of support = 1

Courses providing a buddy system

Specified aims

14

8

3

9

Practical informal support = 4

Orientation = 3

Skills sharing = 3

Personal course tutor

Specified aims

16

12

1

5

Personal and academic support,

advice = 6

Reviews, monitors = 6

Appraises, evaluates = 4

Non-evaluative = 2

Personal therapy

Subsidy or funding

3

3

14

14

No outcome evaluation

PPD under active review 6 11


a clear divide. Thankfully, about a third of the re-sponding courses have PPD under active review.Whether the remaining 11 (and the seven non-respondent) courses are similarly concerned isunclear.

Characteristics of Type-A PPD curricula:

■ PPD is clearly defined;

■ it is a systematic opportunity to develop pro-fessional self-awareness;

■ competency is developed in understanding theinteractions between self, others and work;

■ as a core competency in PPD, the trainee culti-vates a reflective attitude in a personal assimi-lation of theory and practice;

■ PPD occupies a clearly demarcated pro-gramme within the curriculum.

Outcomes are in specified domains reflectingidentifiable competencies:■ knowledge of the reflective model;

■ proper use of supervision;

■ demonstrable self-awareness (self-care/targetsetting);

Assessment is imaginative and diverse:■ essay;

■ assignment;

■ reflective journal;

■ portfolio;

■ group work.

These Type A programmes provide a clear leadfor PPD, which is consistent with the outcome ofthe Hagan (2001) workshop:

■ the personal domain is legitimised;

■ as a process of developing reflective process;

■ with an explicit rationale and philosophy;

■ recognising diverse pathways;

■ inviting structured self-examination.

In summary, PPD is that part of the curricu-lum that is dedicated to developing in trainees acapability to reflect critically and systematicallyon the work-self interface. This process is di-rected towards fostering personal awarenessand resilience.

PPD has been operationalised but remains an es-sentially atheoretical construct. The roles within thevarious scaffolds that maintain the process maygive rise to confusion. Whilst activities such asgroupwork are used, their purpose remains ob-scure. Little evaluation is undertaken and evidencefor good practice is slim. Assessment remains con-tentious. Nonetheless, an opportunity has arisenfor PPD to become a unifying rather than divisiveconstruct; as a trainee-led personal assimilationof declarative theory and procedural practice.

AcknowledgementsTrish Hagan’s workshop provided much of theimpetus for this project. We have borrowed freelyfrom the emanating material and summaries. Weare particularly grateful to the participating coursesthat have given us all a clear lead in this oftennebulous part of our work.

ReferencesBritish Psychological Society (2001). Criteria for theaccreditation of postgraduate training programmesin clinical psychology. Leicester: BPS.

Brooks, J., Holttum, S., & Lavender, A. (2002).Personality style, psychological adaptation and expec-tations of trainee clinical psychologists. ClinicalPsychology and Psychotherapy, 9, 253-270.

Hagan, P. (2001) Fostering personal and professionaldevelopment in clinical psychology training: ways andmeans. Workshop presented at Group for Trainers inClinical Psychology Conference, 9-11 July 2001,Oxford.

AddressDoctorate in Clinical Psychology, Ridley Building,University of Newcastle, Newcastle-upon-Tyne NE1 7RU;[email protected]

23

Attending to the patient within us
Simon O’Loughlin,Worcestershire Mental Health Partnership NHS Trust
Reflective practice is key to the meaningfulnessof therapeutic endeavour. It enables us tomake sense of things at different levels. In thispaper, I will stress the need in clinical work tounderstand contexts (of those who seek ourhelp, of ourselves, and of settings), processissues and contaminations (personal,dynamic and technical).

I will argue here that the most importantfeatures of the effective reflective practitionermay be free-floating thoughtfulness, a balanceof robustness and sensitivity, and a capacityfor providing, what I have termed, a ‘titratedintimacy’ in which psychological proximityand distance are finely managed.

Reflection in this paper should perhapsstart with the title and with a self-decla-ration of my own principal interest – the

application of psychoanalytic thinking in messyeveryday NHS work. The use in the title of theword ‘patient’ (much eschewed by our profes-sion) is deliberately chosen to describe some-one in pain presenting for attention. Tounderstand the patient before us, our task is tosomehow internalise for detailed scrutiny boththeir way of being and their problems. To at-tend effectively, we have to be aware also ofour own ‘patienthood’. And finally, as an unin-tended extrapolation, it may often be morehelpful in clinical practice to be patient ratherthan do things.

The encounterIn our work with patients, it is important to startby defining what the encounter is, to be freshlyaware of settings, to ask why each individualwants to be a patient, and, as essentially, why wewant to be a therapist. We may indeed check onwhether we are seeing a patient (implying pri-macy of dis-order) or client (primacy of contrac-tual arrangement). We need to be aware of the

24

impact of therapeutic style, and be clear aboutwhether or not we wish to attend to process is-sues, particularly those that potentially mitigatetherapeutic progress.

Psychopathology versus behaviourThe scientist-practitioner model has been de-scribed as the application of academic skills toclients whose problems are seen in relativisticterms and treated by doing things. In contrast, apsychoanalytic model would favour a model ofinternal disorder in which the patient is helpedby thoughtfulness about their problems emanat-ing from experience (Mollon, 1989). The reflec-tive practitioner feels intuitively nearer thesubjectivity of the latter than the objectivity ofthe former, yet needs to retain a balance that alsoacknowledges the implications of clinical con-tracts, prioritising interventions and theoreticalrationale.

Why patients come to see usThe notion of change is fundamental to clinicalpsychology, and patients may come to see us tohelp them change what they do or think orfeel. They may be seeking a cure, or more real-istic headway. They may want to dischargepain, discomfort or anxiety. They may be seek-ing insight, or perhaps to be less confused – oragain, if still confused, to have the experienceof being understood by another. They maywant answers, or perhaps better questionsabout their lives. They may be seeking the ex-perience of finding a point of contact, beingheld, a personally relevant titrated intimacy.And then again, they may come to us not tochange, using anxiety or hostility to reinforcethe status quo.


Reflective Practice

SPECIAL ISSUE:


Why we do what we doThe reflective practitioner will preface consider-ation of the above with a consideration of theirown motivations. There will be an awareness ofthe psychopathology of the helping professions,in which our own disorder is kept at bay by hav-ing non-patient status, and also the ways inwhich we achieve vicarious healing through ourpatients' struggles. Our own strengths and weak-nesses are always relevant, including patientgroups we like or dislike.

How do we hear our patients?We need an awareness of what patients want tocommunicate, but also of what they may be tryingnot to communicate, of incongruities. We needto be aware of both what we want to hear andwhat we do not want to hear. And to be clearabout the issue the patient wants to focus on andhow we reconcile this with what we want tofocus on.

ContextsOur reflectivity is shaped by our professionalstance as clinical psychologists, including train-ing, differing theoretical models and technicalskills. Our personal style, personal issues and fac-tors such as gender, age and race will modulateour capacity as a filter of information. We need toacknowledge systemic issues, such as structure oflocal services and NHS developments, and widerpolitical, cultural, societal and ethical factors.

Reflective practitioner qualitiesWe need to understand the implications of treat-ments, whether these be directive or psycho-educational, or supportive, or challenging andperhaps interpretative. We need an awareness ofstructure and context, and how these relate toissues of containment and intimacy. Titratingthe psychological space between therapist andpatient requires a deft touch, and is ever morechallenging with more difficult patients for whomconstant adjustment may be required within asingle session.

Being sensitive and attuned to patients must bematched by robustness that is neither domineer-ing or rigid but avoids being tentative. We needto understand the concept of reworking ratherthan simplistic (and so often infuriating) reflect-

ing back. Being daring or taking risks may feelreckless or unscientific, but when well-judged mayhave a hugely creative impact on our patients.

This raises the issue of self-disclosure. Implicitself-disclosure is unavoidable in the way we inter-act, dress and take care of clinical settings. How-ever, explicit self-disclosure is the consciousvolunteering of information about the therapistthat would otherwise be unknown. Some clinicianssee this as an empathic act, and would argue thisas theoretically sound, but I feel it is almost in-variably an acting out by the clinician.

Process issuesThose who work interpretatively may use trans-ference and countertransference, projection andprojective identification, to enhance or to be thevery vehicle of reflective practice. Others mayuse a more general self-awareness creatively.

Part identification with our patients is a pre-requisite for effective understanding. Patientsrightly value therapeutic coherence, but compe-tent reflective practice also means therapeuticflexibility in which changes in presentation can beaccommodated and ‘rules’ occasionally broken.Awareness of potential within patients needs tobe balanced with limitations in personal resources,and we need to be aware too of our own limita-tions as therapists.

Problems and contaminationsProblems can occur when accurate part identifi-cation with patients is extrapolated to aninaccurate general identification; just as mis-identification leads to misunderstandings, over-identifications can lead to merging. Reflecting onour own countertransference feelings can behelpful in understanding therapeutic malfunction.

There are issues of attraction, specialness andsexualised interaction, often subtlety acted out byan increased therapist intimacy or extension ofsessions – or by intellectualisation, even voyeurism.Admiration invariably leads to some form of col-lusion or cosiness, while heroic interventions – thehallmark of the novice – can lead to therapeuticblindness and displacement of conflict.

There are also issues of dislike or distaste, whichcan lead to guilt-mediated perseveration with asterile encounter, rationalisations or covert attacksunder the guise of ‘being helpful’.

25

O’Loughlin

Sadness or shared pain can lead to impotence,while our anxiety can propel us into unthinkingactivity. Feelings of clinginess may lead to dis-tancing, while seductive interaction may lead toconfusions or narcissistic focus on ourselves.Passivity can make us feel irritated and anger leadto retaliation or self-justification. These are justsome examples, but they underline the need tobe aware of our potential for acting out, bothglobally and in specific situations that have apersonal resonance.

Most clinicians have occasional dreams aboutcertain patients. These may enhance our reflec-tion by guiding us towards our unconscious fan-tasies. These may be sexualised, but more likelyto be persecutory.

Handling our own strugglesClinicians inevitably gain insights into their ownstruggles vicariously through work with patients,and, provided there is clear differentiation, eachmay gain.

The majority of us look outside the clinical set-ting for external reflection through formal indi-

26

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vidual or group supervision – and some wouldargue for personal therapy as potentially themost informative route of all.

SummaryAccurate and ongoing reflection on our clinicalpractice – and of the motivations of both our-selves and our patients – are essential in effectivepsychological work. Key factors are motilethoughtfulness and managing intimacy. Life is astruggle not just for our patients but also for clin-icians, and being aware of our issues – and doingsomething creatively about them – may make usmore available for those we seek to help.

ReferenceMollon, P. (1989). Anxiety, supervision and a space forthinking: some narcissistic perils for clinical psycholo-gists in learning psychotherapy. British Journal ofMedical Psychology, 62, 113-122.

ReferenceKidderminster General Hospital Clinical PsychologyDepartment, Bewdley Road, Kidderminster DY11 6RJ.

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Bubbles in a pond. Reflections inclinical practice
Catherine Paula, Birmingham Children’s Hospital NHS Trust
What follows is an account of myrelationship with reflection, as I see it at this point in my career. I hope that inreading this, others will be encouraged topause and consider their own relationshipwith this somewhat elusive character.

On arrival at the conference, I was sur-prised to find I appeared to be one of theonly A Grade psychologists present. The

main body of delegates seemed to be made up ofheads of clinical training courses, B grades,trainees and assistant psychologists. Since I firstheard of reflective practice during my training Ihad assumed that this was something qualifiedpsychologists knew about. However, over coffeeI discovered that some of the more experiencedpsychologists were attending ‘to find out what re-flective practice is’. It struck me then, how di-verse clinical psychologists are as a group ofprofessionals. I think it is safe to say, that despiteour best efforts, no two clinical psychologistshave the same training, and once qualified ca-reers and experience continue to diverge.

Taking this one step further, social construc-tionists argue that we all form our own picture ofan event according to our past and present ex-periences (Steier, 1991). Thus, in relation to re-flection, we all arrived at the conference withvery different experiences. Looking back, it isdifficult to map my own experiences with re-flective practice. However, I think a summary ofmy career path into clinical psychology may beuseful to give readers some idea of the contextfrom which I am approaching this article.

The pastI think that probably my formal teaching in re-flective practice began with my first assistantpost. This was in adult mental health in a securehospital. I spent a fair amount of my time workingwith a psychotherapist, and received psycho-

dynamic supervision on a weekly basis. Super-vision was mainly spent reflecting on the themesof a session and considering my emotional re-sponses. Although I found this excruciating attimes, there is no doubt that this type of super-vision got me thinking at much more of aprocess level than did the supervision I receivedfrom the clinical psychologists within the de-partment. I went from this post, onto clinicalpsychology training.

As a trainee, I was more focused on the con-tent of my clinical sessions, than the process. Mymain goals in supervision were to establish aplan of what to do in the next session, to in-crease my knowledge about the area of diffi-culty, and to manage my anxiety. I knew thatprocess issues were important, but my prioritywas certainly content. With all the demands oftraining, and constantly finding myself dealingwith new situations, I held on tight to facts andevidence. Now, two years out of training, manyof the difficulties I see in sessions are familiar tome. My own anxieties have reduced and thus Ihave more time and space to reflect on process.How then, does reflection fit into my day to daylife as a psychologist?

The presentI work in a community child psychology service,predominantly at a tier two level. I run clinics ina number of different health centres and approx-imately half my week is allocated clinical time.The remainder of my week is taken up with ad-ministration, liaison, attending meetings, givingand receiving supervision, and continued profes-


Reflective Practice

SPECIAL ISSUE:

27

Paula

sional development activities. For me, reflectionis mostly one of those unpredictable activities,like informal supervision, or stumbling across areally helpful idea. It is not on my list of ‘thingsto do’ and yet it seems to happen quite a lot. Ofcourse, there are some structured activities thatare likely to promote reflection such as supervi-sion and individual performance reviews butmore often than not, I realise I’m reflecting on acase, long after I’ve started reflecting. In fact, attimes, I think I do not realise that I have been re-flecting until it comes to an end.

I don’t find reflection easy to do ‘on de-mand’. Telling myself to reflect on a session, ismore likely to make my mind go blank, than re-sult in any kind of thoughtfulness. Reflectionseems to be one of those things that happensbest by itself. Rather like breathing, it becomesharder to do when you think about it. In situa-tions where I try to make myself reflect, for ex-ample when asked how I found a particularinteraction, I tend to come up with a stream ofwhat feels like pre-prepared material or stan-dard lines. It seems difficult to have true re-flections under pressure, although perhaps thischanges with experience.

Having said this, I have found that certain ac-tivities promote the likelihood of true reflection.For example, writing up a session, without anyparticular time pressures, can result in me find-ing myself staring at the wall, and bringing thethreads of a session together into a really usefulformulation or insight. Of course, I can only re-ally say that it feels useful to me. Whether or notthe family or a colleague would see it this way isanother matter. Driving between clinics is an-other ‘reflection promoting’ activity, as is watch-ing a videotape of one of my sessions. Similarly,allowing myself a few minutes at the start of asession to read through the case notes often re-sults in the flow of reflection.

Rereading this, I can see that a commontheme across these ‘reflection promoting’ activ-ities is time. Reflection itself doesn’t seem totake long, but a certain pause between activitiesis needed for a reflective bubble to rise to thesurface. In many ways, a bubble seems a goodanalogy. There is something intangible about areflection. It is created by a coming together ofdifferent elements, somewhere deep. The re-

28

flective bubble rises, gathering speed and vol-ume as it goes, and enters my awareness as itnears or breaks the surface. Once on the sur-face, ideas and insight ripple out across thewater. As the ripples fade, the reflection be-comes part of the new picture and can seem rel-atively unimportant, or is easily forgotten.

What, then, are the elements that make up thereflective bubble? To me, the process of reflectingseems to be emotional as well as cognitive. It is thecoming together of what I felt during a session,what I was thinking and what was happening, thatleads to a new perspective, understanding or in-sight. Being able to bring together these differentmemories of a session, or even a moment, re-quires both emotional and cognitive space, and anopenness to reflection. Perhaps it is the emotionalcontent of a reflection that makes reflectionsomewhat unpredictable, and means ‘on demand’reflection can be difficult.

Some reflections seem to be more cognitive innature and some more emotional. Reflections ofa more cognitive nature are easier to timetable.For instance, wondering why it is that a family isnot doing things that they agreed to during thesession, is something I may decide to considerduring supervision. However, the realisation thatthis is what is happening, is much less predictable.Perhaps this is the difference between the bubbleand the ripple? The more cognitive type reflec-tions seem to me, to be easier to access.

Reflections that are more emotional in contentseem much less predictable. For these reflec-tions, both a temporal and emotional pause maybe a necessary part of the setting. In a busy clin-ical setting this can be hard to find, however,semi-automatic activities such as driving be-tween clinics and making a drink, seem to pro-vide these ingredients. These are the times whenI’m most likely to finish reflecting before I realiseI have started. Perhaps I should stop viewingthese activities as breaks, or a waste of valuabletime, and be grateful for the reflective opportu-nities they bring.

Whilst writing this article, I have struggledwith the definition of ‘reflective practice’, andknowing what to include under this title andwhat to leave out. ‘Emotional’ reflections seemto be getting close to some kind of processing ofa session, rather like one might process an event


in one’s life. It’s the processing of a session partof reflection, simply a way of integrating an ex-perience into our lives, or both?

And the futureI came away from the conference feeling that Icould learn so much more from reflecting than Ido. In day-to-day working, reflection often getssqueezed out. However, I am no longer contentwith the idea that reflection is unscheduled andhave therefore set myself the following aims:

Reflection during my own supervision stillseems to come second to content more oftenthan I would like. I am trying to address this intwo ways. First, I have arranged to spend one su-pervision session a month exploring reflectivetechniques. This may include watching a tape ofa session with my supervisor, transcribing a ses-sion, and experimenting with different models ofsupervision. Second, I wrote up a difficult meet-ing with a family à la Bolton (1999) and foundthis process felt rather like self-supervision. In re-reading what I wrote, I gave myself a new per-spective on the session, in the same way aswatching myself on video does. I want to domore of this, and to some extent, the writing ofthis article has been just this.

At present most of my reflections occur out-side clinical sessions. I want to spend more timereflecting during the session. In practice, I thinkthis means engaging families in reflecting on ourwork together. By engaging families in the dis-cussion, maybe I can create the emotional andcognitive space needed for reflecting together.

I currently supervise an assistant, and am soonto start supervising trainees. What I can do toencourage reflection in supervisees is occupy-

DIVISION OF CLINICAL PSYCHOLOGY CA vacancy has arisen for a new member of the Continuing

concerned with how to monitor members’ CPD activities an

supports the Division Conference Committee and liaises with

Continuing Professional Development of Psychologists.

The Subcommittee meets four times a year, twice by teleconfer

London Office of the Society. If you have experience of organi

CPD within the profession the Committee would like to hear fr

Further information and Statement of Interest forms can be ob

via Gwen Ward at the Society office (telephone 0116 252 951

Statement of Interest forms should be returned to Lesley Dexte

ing me at the moment. The question of how totrain clinical psychologists to be reflective prac-titioners was raised during the conference. As isprobably predictable, as a group of psycholo-gists we seemed more able to identify the obsta-cles than the solutions. However, it seems tome, that many of our colleagues in related disci-plines, are ahead of clinical psychologists intheir use of reflective practice. Clinical psychol-ogists are a relatively heterogeneous group oftherapists and it is quite possible to be a clinicalpsychologist and not do much reflection at all.However, I think it would be very difficult to bea psychodynamic therapist or a systemic practi-tioner, and not reflect. During my first year as aqualified psychologist, I completed an introduc-tory course in systemic therapy. Each weekbegan with reflections on our learning from theprevious week. At times, this felt like death byreflection; however, I am fairly certain, that noone completed the course without an improve-ment in their ability to reflect. Perhaps I ambeing naive, but the process of reflection seemssuch an integral part of some models of work-ing, surely we can learn from these disciplines,rather than reinvent the wheel?

ReferencesBolton, G. (1999). The therapeutic potential of creativewriting: writing myself. London: Jessica Kingsley.

Steier, F. (1991). Introduction: research as self-reflexiv-ity, self-reflexivity as social process. In F. Steier (Ed.)Research and reflexivity. London: Sage.

Address66 Anchorage Road, Sutton Coldfield, West Midlands B742PG; [email protected].

29

ontinuing Professional Development Subcommittee Professional Development (CPD) Subcommittee, which is

d encourage a better understanding of supervision. It also

the Society Standing Subcommittee on the Co-ordination of

ence and twice by face-to-face meetings usually held at the

sing CPD events and wish to further the development of

om you.

tained from Committee Chair Zenobia Nadirshaw

7 direct line).

r, DCP Administrator.

Making Reflective Practice real:problems and solutions in theSouth West
Jacqui Stedmon,Academic Director Plymouth Clinical PsychologyTraining Course, Annie Mitchell, Clinical Director Exeter ClinicalPsychology Training Course, Lucy Johnstone,Academic TutorBristol Clinical Psychology Training Course, and Sue Staite, ClinicalLead for Psychology, Bristol South and West PCT
The Committee on Training in ClinicalPsychology has recently endorsed the re-flective practitioner model within the new

accreditation criteria for Postgraduate TrainingProgrammes in Clinical Psychology. The re-quired learning outcomes for trainees currentlyinclude the ability to demonstrate self-awarenessand to work as a reflective practitioner as well asto think critically, reflectively and evaluatively.The challenge therefore is to articulate our un-derstanding of what constitutes reflective prac-tice so that it can be operationalised to serve as abasis for teaching, assessment and clinical prac-tice throughout training.

What do we mean by reflectivepractice?Traditional didactic teaching and content-basedassessments lend themselves to the scientist-practitioner model, where the goal of establish-ing an evidence-base that can be used todetermine practice is paramount. However,Schön’s (1983) influential observations of ‘re-flective practice’ addressed the gap between es-poused theory and the moment-by-momentdecisions that characterise skilled practice acrossa variety of different professions. He argued thatwhile scientific theory may be necessary, or atleast useful, to inform practice, it is certainly notsufficient. In particular he noted the inadequacyof scientific theory to inform three ‘zones of in-determinate practice’; those characterised byuniqueness and unexpectedness and those giv-

30

ing rise to value conflicts. Arguably these excep-tions are more likely to be the rule in clinical set-tings where the psychologist is attuning to aunique individual facing extra-ordinary problemsin a social context open to highly subjectivevalue judgements. However there is safety in cer-tainty and clinical psychology has understand-ably shown some reluctance to move away fromits safe base in the scientific model. Newnes etal. (2000) suggest that it is the sign of a matureprofession to examine what it does with a criti-cal eye. The reflective paradigm gives us an op-portunity to do this.

If we are to subscribe to a unified reflective sci-entist-practitioner model we need to understandthe scientific and reflective positions as comple-mentary. There is a richness to be gained fromaccepting the rigour of science alongside the cre-ativity or ‘artistry’ of reflective practice, to useSchön’s phrase. The reflective practice (RP)model recognises the importance of giving equalvalue to the different sources of knowledge thatwe utilise in clinical practice. However, it is im-portant to recognise that whereas the scientificparadigm offers a method for discovering truths,the reflective position may be best construed asa metatheoretical framework for evaluating the


Reflective Practice

SPECIAL ISSUE:


status of these so-called truths. Thus, reflectivepractice leads us to take a critical and evaluativeposition in relation to our understanding of thepractice of clinical psychology and to the per-ceived wisdoms of our profession.

In practice, reflection can have two broadmeanings that are really quite different. It canrefer to the personal use of self-awarenessabout what we bring to and take from the ther-apeutic relationship in terms of our life experi-ences, our own social contexts and previousrelationships. In other words, it is the subjec-tive and experiential aspect of participating intherapy. Reflection can also be used to describepractice-based learning or ‘learning by doing’;that is, the recognition that a skilled practi-tioner acquires a procedural knowledge baseover time gained through experience. Otherhealth professions endorse the view that reflec-tive practice leads ultimately to creativity, flexi-bility and intuitively based practice where one’srepertoire of experiences as a clinician pro-vides an internalised knowledge base thatserves as a moment by moment guide to action(see, for example, Winter & Munn-Giddings,2001; Kember et al., 2001).

Both these definitions of reflective practicerefer to aspects of our knowledge base – de-rived partly from self-reflection and partly fromreflecting on practical experience. HoweverBleakley (1999) has argued that this narrowsubset of reflective practice is fundamentally in-trospective and is limited by drawing only fromthe personal. Reflective practice in this sensetherefore tends to be treated as if it were a psy-chological process free from cultural, linguisticand historical contexts. Bleakley proposes thatwe need to go one step further if we are to lo-cate our practice within wider social contexts.Essentially, he argues for ‘a shift from descrip-tive reflectivity to critical reflexivity, where thelatter theorises (problematises and relatavises)action as it happens.’ (p.328). The reflectivepractitioner must also reflect on reflections. Itis this notion of processing and reprocessingexperience and relating it to broader theoreti-cal perspectives that constitutes a metatheoret-ical framework which forms the basis of acontinuous cycle of critical evaluation of one’spractice.

Reflective practice: the South West modelOver the last 18 months, a small working partywith representatives from three programmes inthe South West (Exeter, Plymouth and Bristol)and from the local providers has been meeting todefine and implement our own understanding ofRP. The reflective component in the new Bristolprogramme was in fact initiated by local psychol-ogy providers who wrote the service specifica-tion for the course, and this close collaborationhas continued to shape the development of thereflective approach across the South West, bothin terms of teaching and supervision.

While accepting and valuing each pro-gramme’s individual flavour, our overall aim is toencourage and foster critical reflexivity in thebroadest sense. All three programmes make theirphilosophy explicit from the start by spelling outthe guiding theoretical frameworks in their re-spective handbooks and talking through the im-plications in the first weeks of training. Theedited version below is taken from one hand-book but is very similar to the other two:

While emphasising the importance of evidence-based

practice, we also recognise some of the limitations

and critiques of a pure scientist-practitioner model.

We seek to encourage trainees to:

– develop and draw on a broad range of evidence

and skills in their work. This particularly applies

to clinical practice, where empirical evidence

may be lacking and practitioners need to respond

creatively and flexibly in real-life situations.

– develop an awareness of their own feelings and

processes, and the part that they as a person,

with their own individual history, background,

experiences and values, play in all aspects of the work

of a psychologist. This implies a continual process of

personal development occurring in parallel with, and

contributing to, clinical, academic and research skills.

– take a constructively questioning approach to

all aspects of theory and practice. This will

include an awareness of the influence of social,

historical and cultural factors in constructing

the role and knowledge-base of clinical

psychologists and related professions.

31

Stedmon, Mitchell, Johnstone & Staite

Putting RP into practiceThe courses have integrated RP into their train-ing in a variety of ways, some shared, some pio-neered in one place only. It is particularlyimportant to co-ordinate our thinking about RPgiven that the region’s placements and supervi-sors are shared by all three programmes.

■ All the courses draw on the Hawkins andShohet model of supervision (Hawkins &Shohet, 2000) which draws on the psycho-dynamic tradition of making sense of uncon-scious personal and contextual processes, andis promoted via workshops and preplacementmeetings. Competence in reflection is a keycomponent of the region’s shared placementassessment form. We have jointly run success-ful workshops for local supervisors called‘Facilitating RP’ to explore the recent devel-opments in training outlined here and to pro-mote the role of reflective practice in thesupervisory process as part of an ongoingCPD programme.

■ All the courses require trainees to keep a re-flective diary throughout the three years. Thisis a journal in which they record, reflect on,question and make connections between allaspects of their training and personal devel-opment through the course. Although the ac-tual content remains private, the journal formsthe basis of a reflective essay in the third year(Bristol), the appraisal process (Exeter) andthe programme of reflective tutorials(Plymouth).

■ All three courses set aside teaching time forsessions on RP. In Bristol, this consists of ahalf day every three months in which to lookat both personal and professional issues, withthe aid of reading and relevant exercises.Plymouth also provides formal discussion timearound guided reading and reflective exercisesdesigned to model and encourage reflectiveprocessing. At Exeter a seminar series on re-flexive practice is convened by a medical ed-ucator (Alan Bleakley) who takes a criticaltheoretical stance and facilitates debate under-pinned by trainees’ experiences as individu-als and as inter-professional team members.

32

■ Evidence of reflective thinking (for example,the inclusion of a section covering thoughtsand feelings raised by the work, and criticalthinking about the wider context of the as-signment) is one of the criteria on most of thecoursework.

Individual programme initiatives include:

■ Plymouth: the use of a reflecting team ap-proach to explore the developing relationshipbetween the course team and trainees. Thecourse team takes regular opportunities to re-flect in open forum upon and about their ex-periences as trainers and their relationshipwith the trainee cohort. Trainees are invitedto share their reflections in turn so that a cul-ture of reflective dialogue is both encouragedand modelled in the staff–trainee relation-ship. In addition, each trainee is allocated toa small ‘reflective tutorial group’ facilitatedby a member of the course team, which pro-vides an opportunity to share personally chal-lenging material safely in a process thatpotentially mirrors their future role in profes-sional team work.

■ Bristol: we are evaluating a scheme that al-lows trainees to have up to 10 sessions ofpaid personal therapy to be taken at any timeduring the three years. This is optional, buthas so far proved very popular.

■ Exeter: we offer trainees the opportunity toform a reflective group with an external facili-tator (Mitchell, 1995). For the last few yearsthe groups have been facilitated by a skilledart therapist, drawing on the Winnicott notionthat learning is most creative when itemerges through play (Winnicott, 1971).

ConclusionAt present, about half the courses in the ClearingHouse Handbook advertise themselves as sub-scribing to a reflective model or some variationof this. Clinical psychology is in the middle of aparadigm shift, and one that seems to be wel-comed by the majority of trainees and super-visors. Nevertheless, if it is to be something morethan a fashionable phrase, we need to think very


carefully about what we mean by RP and howthis is actually going to influence our trainingand our practice. There is more work to be donein clarifying what we hope to achieve throughRP, its problems and drawbacks, and how wemay overcome barriers to working in this way. Ithas been an exciting and rewarding process dis-cussing and implementing this in the SouthWest. We continue to learn from each other, andhope that this summary stimulates ideas in awider audience as well.

ReferencesBleakley, A. (1999). From reflective practice to holis-tic reflectivity. Studies in Higher Education, 24(3),315-330

Hawkins, P. & Shohet, R. (2000). Supervision in thehelping professions (second edition). Milton Keynes:Open University Press.

Kennedy, P. & Llewelyn, S. (2001). Does the future be-

The Coventry and Warwick C

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One academic year from OctobPart time – one day a week

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For enquiries and appCatherine Beattie, phone: 02476 8883

long to the scientist-practitioner? The Psychologist14(2), 74-78

Mitchell, A. (1995). Personal support for clinical psy-chology trainees: the experience of a facilitated sup-port group. Clinical Psychology Forum, 76, 20-22.

Newnes, C., Hagan, T. & Cox, R. (2000). Fosteringcritical reflection in psychological practice. ClinicalPsychology Forum, 139, 21-24.


Winnicott, D. W. (1971). Playing and reality. London:Tavistock.

Winter, R., & Munn-Giddings, C. (2001) A Handbook forAction Research in Health and Social Care. London:Routledge.

AddressDoctor of Clinical Psychology, Department ofPsychology, University of Plymouth, Drake’sCircus, Plymouth PL4 8AA.

33

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Lift the box lid: reflective writingfor professional development
Gillie Bolton, University College, London
Reflective practice is key to the meaningfulness,effectiveness and personal and professionalsatisfaction of the therapeutic endeavour.Expressive and explorative writing offers a swift, dynamic, and challenging route toreflective practice. This paper draws upon my experience running groups for therapists,counsellors, clinical psychologists and otherclinicians. The processes of writing, andmaking reflective use of that writing, are examined

Areflective practitioner examines her prac-tice, and her approach to her practice,using the full range of her critical, affective,

spiritual, practical and knowledge-based faculties.Using reflective practice writing effectively iseven better than driving with all-round vision.Big shiny rear and wing mirrors, a well washedwindscreen and rear window are all working foryou to enable all-round vision. You can angle therear view mirror to see the children on the rearseat when you stop at traffic lights, or towardsyour face to take the eyelash out of your owneye. But using writing within reflective practiceadds an extra dimension – that of being able toapprehend what another road user might do be-fore they do it, and what your own instinctivereaction is likely to be.

Reflective practiceReflection upon action was a process identifiedby Schön (1983): a process of deeply consideringevents afterwards in order effectively to enhancepractice. Critical reflection upon situations of un-familiarity and complexity is a vital componentof professional practice. It can enable:

■ sensitive, fruitful review of ‘forgotten’ areasof practice;

34

■ critical study of personal decision-makingprocesses;

■ constructive awareness of colleagial relation-ships;

■ analysis of hesitations, skill, and knowledgegaps;

■ relief of stress by facing problematic orpainful episodes;

■ identification of learning needs;

■ dissemination of experience and expertise tocolleagues;

■ increased confidence in professional practice.

The reflective practice process described hereis an open questioning approach, one which willraise questions rather than simple answers. Aprerequisite is the willingness to lay one’s ownpractice and understandings open to question: awillingness to ‘risk abandoning previous “truths”and sit with not knowing’ (Gerber, 1994: 290).Reflection upon practice, like therapy, holds nosimple answers. For it to be effective, the reflec-tive practitioner needs to be open to uncertainty:

The goal of education, if we are to survive, is the

facilitation of change and learning, The only person

who is educated is the person who has learned

how to learn: the person who has learned how to

adapt and change; the person who has realised that


Reflective Practice

SPECIAL ISSUE:


no knowledge is secure, that only the process of

seeking knowledge gives a basis for security.

Changingness, a reliance on process rather than on

static knowledge is the only thing that makes any

sense as a goal for education in the modern world

(Rogers, 1969: 152).

Reflective practice has been much writtenabout. Many diagrams and stages have been iden-tified in an effort to help the practitioner to re-flect (e.g. van Manen (1995) reporting Dewey’s 5steps, Morrison’s 4 stage process developedfrom Habermas, Tripp’s lists (1995), Johns devel-opment of Carper’s 4 ways of knowing (1995),Kolb’s learning cycle (1984), and Mezirow’s lev-els (1981, 1991)).

Reflection is a natural process; it needs to becarefully facilitated and supported. Programmedmethods, however, can be disrespectful of thepractitioner, and can result in mere box tickingor rote exercise-doing. In a properly facilitatedforum, where effective processes are used, ex-perienced practitioners and students naturallyreach deep levels, work their way round andround cycles, and up steps, and could tick off allitems in a list if it was not a waste of time to doso. If practitioners are respected, treated withunconditional positive regard (Rogers, 1969) bysupervisor or facilitator, and guided towards lis-tening to, and rewriting their own stories, and ofcourse within them the stories of their clients,they will reflect effectively and fruitfully.

The reflective writing processCreative writing processes, used within reflectivepractice, enable practitioners to express whateverneeds expressing graphically, clearly, concisely andreadily. They also enable in depth exploration ofareas of experience to which it might otherwisebe difficult to gain access. Accounts are written,drawing upon the experience of practitioners;these can occasionally skim the surface of expe-riences, offering little insight, but then the groupor supervisor can sensitively support the writer togo back to the writing and extend and develop it.

This silent reflective writing process, in whichthe writer is communicating initially solely withthemselves, is perhaps similar to the developmentof an internal supervisor, recommended byCasement (1990).

The initial creative process of writing is anaesthetic synthetic one rather than being logicaland analytic. This is the ‘artistry’ Schön said reflec-tion upon practice required. Reflective practicewriting is not a process of thinking reflectivelyabout issues within practice, and then using writ-ing to record those thoughts, but of consciouslynot thinking, while allowing the writing hand toexpress and explore that which needs express-ing and exploring. It is more akin to image mak-ing in painting or drawing, than to intellectualthought. The writer allows an incident to replayitself on to the page, allowing their feelings andthoughts to emerge in the process.

The only way of expressing emotion in the formof art is by finding an ‘objective correlative’; inother words, a set of objects, a situation, a chainof events which shall be the formula of that par-ticular emotion; such that when the external facts,which must terminate in sensory experience, aregiven, the emotion is immediately evoked (Eliot,1960: 20)

Writing is useful for stress management, help-ing to avoid burnout and lowered performance:

Writing is a disinhibition strategy, as it anchors

people to a safe present while they re-experience a

past event, providing optimum distance possibilities

and hence cathartic reset (Evison, 2001: 256).

This initial writing stage is followed by a morecognitive process of reading and redrafting thewriting: to make sure it covers as much range aspossible. Reflective practice writers can effectivelycanvas what they did, thought, and felt. Theythen read the writing aloud to peers in a trusted,carefully facilitated forum. Once more the audi-ence are using artistry in their response.

Rose Flint, an art therapist and poet, uses poetrywriting in her reflective practice:

It not only gives me a deeper insight into the

patient’s experience but it provides me with space

where I can let go of any projection that I have

picked up that does not belong to me. It helps me

to separate from the often disturbing content of a

session and it enables my search for meaning to go

deeper, as I understand more of that which affected

me in the session. The making of a poem or picture

clarifies the counter-transference (Flint, 2002: vi).

35

Bolton

A group of clinical psychologists commentedhow time efficient the process is, and that: uncon-scious links are made conscious on the page. Theyalso found it physically exhausting and very affec-tive as well as effective. They were very surprisedby what they wrote about, and found it indulgent –i.e. they were anxious whether they should befocusing upon themselves.

The reflective practice writer needs to be ableto embrace that uncertainty which is central to alleffective therapeutic and educational processes.People have no idea before they start what theyare going to write – like Bilbo putting one foot infront of the other when he set out, not knowingwhere his adventure would lead. I have often beenasked how can I introduce people to such a dan-gerous process: what if material comes up withwhich the writer is unable to cope? ‘It could belike opening a can of worms’. Well, how do wedare step out of our front door in the morning,when life is so dangerous or face deeply troubledclients with the potential to set off all sorts ofcounter-transferences? We have to have faith inour own strength and capabilities. If we workwith clients we have to have the courage totackle any issues which bother us, or which holdus up in our explorations with them. Is this in-dulgent?

One therapist wrote about a childhood bereave-ment which had clearly had a massive impactupon his life. The writing was clear, limpid, fullof meaning and depth. Every therapist has be-reaved clients; coming to terms with one’s ownlosses is essential to being able to support andhelp others (see also Bolton, 2001: 17-19 ). Thehearing of others’ writing can feel like a privilegedand deeply informative window onto the experi-ence of others, and set off fruitful trains of think-ing into one’s own experience, as well as beinguseful to the writer.

Reflective practice writing: otherexperiencesBennett-Levy et al. found that trainee cognitivetherapists reported a ‘deeper sense of knowing’of CT (cognitive therapy) practices as a result ofa form of reflective practice using writing. Theprocess involves ‘self-practice, and self-reflection(SP/SR)’, in which ‘trainees practice CT techniqueson themselves (SP), either from workbooks on

36

their own, or they do ‘co-therapy’ with a trainingpartner. Then they reflect in writing on the ses-sions (SR), looking at the implications for them-selves, for their clients, and for cognitive theory’(Bennett-Levy et al., in press). ‘The written re-flections are, in my view, crucial to the process,enabling trainees to look in depth at the implica-tions for themselves, for their clients, and forcognitive theory’ (Bennett-Levy, 2003).

A further study with experienced psychologistsand cognitive therapists was ‘designed to assessthe experience and impact of SP/SR on practi-tioner development’ (Bennett-Levy et al., 2002).They found that: ‘CT practitioners report an en-hancement of their therapeutic skills in specificareas … SP/SR participants appear to develop amore “lived theory” of CT and a more elaborated“theory of the client”, and “theory of the thera-pist” (Bennett-Levy et al., 2003). Bennett-Levyquotes Skovholt, who has undertaken consider-able research into therapist development, as say-ing: ‘A therapist and a counsellor can havetwenty years of experience or one year of expe-rience twenty times. What makes the difference?A key component is reflection’ (Skovholt et al.,1997: 365).

Davidson (1999) reports using a reflectivewriting approach to support and develop hispractice within an eating disorders unit:

Through reflection and writing, we can struggle toget a conceptual grip on the situation. With aleap of faith we can open ourselves to honestlyexperiencing what is going on in our relation-ships. Even if the resultant understanding andexperience is partial, it should yield a point ofleverage where something that we can do is re-vealed. And if it transpires what we do does nothave the desired result, then at least we have newinformation with which to enhance our experi-ence and aid further reflection (Davidson, 1999).

Gerber (1994, 1996) has used writing to helphim to understand and come to terms with hispsychotherapeutic work with South-East Asianrefugee patients.

Reflective journals are often used. Best (1996:298) stresses the value of a journal, ‘as a processof integration,’ for containment and therapeuticspace; it is a safe place to put experiences andemotions, however, bad. These can then be re-


viewed more safely at a later date: the materialwill have remained the same on the page in theinterval, but the writer will have moved on andbe able to reassess the situation, their feelingsand thoughts about it. She also calls it a playspace: ‘space to explore and confirm’.

Writing in its first stages is private, unlikespeaking to a supervisor; this privacy enables thewriter to reach reflective depths. Davidson com-ments how, on introducing colleagues to reflectivewriting, people ‘say how it helped their writingto know it was acceptable to write in forms oftheir own creation, and as a way of expressingtheir experience. The norm seems more often afeeling of intimidation at the prospect of using aforeign tool with stuffy rules’ (Davidson, 1999).

ConclusionReflection is essential for effective practice. Aclinician needs to be able to recreate a situation(whether clinical, or an event with colleagues, orone which does not at first sight seem to relateto the professional). A purely critical, rational,analytic approach will only access some of theexperiences which need to be examined, andwill only examine part of them. This is becausethe more tricky areas of our experience, thosewhich are perhaps the most troubling, or themost difficult for us to sort out, are hidden fromour immediate critical, rational analyticprocesses.

This parallels the experience of our clients.They need the help of therapists or psychologiststo reflect upon their experience in order to un-derstand it and relate more effectively and hap-pily to themselves and the world. They mightalso indeed need the help of the arts such as inart or writing therapy. Clinicians also need helpto reflect upon their experience; this can be of-fered by supervisors and peers. Expressive andexplorative writing is a time efficient, cheap andeffective method which can be accessed at anytime (further information on how, who, when,where and with whom in Bolton, 2001). Allied tosupervision or carefully facilitated group work,reflective practice writing offers the key tomeaningful, effective and satisfying therapeuticendeavour. Its use both in training and as ongo-ing professional development will transform av-erage therapists into expert therapists.

ReferencesBennett-Levy, J. (in press). Cognitive therapy fromthe inside: enhancing therapist skills through prac-tising what we preach. Behavioural and CognitivePsychotherapy.

Bennett-Levy, J. (2002). Navel gazing or valuabletraining strategy: self-practice of therapy techniques,self-reflection, and the development of therapist exper-tise. In J. Henry (Ed.) Proceedings of the FirstEuropean Positive Psychology Conference.Leicester: British Psychological Society.

Bennett-Levy, J. (2003). The value of self-practiceof cognitive therapy techniques and self-reflection inthe training of cognitive therapists. Behaviouraland Cognitive Psychotherapy, 29, 203-220.

Best, D. (1996). On the experience of keeping a ther-apeutic journal while training. TherapeuticCommunities, 17(4), 293-301.

Bolton, G. (2001). Reflective practice writing forprofessional development. London: Sage.

Casement, P. (1990). Further learning from the pa-tient. London: Tavistock Routledge.

Davidson, B. (1999). Writing as a tool of reflectivepractice. Group Analysis, 32(1), 109-124.

Eliot, T. S. (1960). The sacred wood: Essays on po-etry and criticism. London: Methuen.

Evison, R. (2001). Helping individuals manage emo-tional responses. In R. Payne & C. Cooper (Eds.)Emotions at work: theory, research, and applica-tions in management. Chichester: Wiley.

Flint, R. (2002). Fragile space: therapeutic relation-ship and the word. Writing in Education, 26, ii-viii.

Gerber, L. (1994). Psychotherapy with southeastAsian refugees: implications for treatment of westernpatients. American Journal of Psychotherapy,48(2), 280-293.

Gerber, L. (1996). We must hear each other’s cry:lessons from Pol Pot survivors. In C. Strozier & F.Flynn (Eds.) Genocide, war and human survival.New York: Rowman & Littlefield.

Johns, C. (1995). Framing learning through reflec-tion within Carper’s fundamental ways of knowingin nursing. Journal of Advanced Nursing, 22, 222-234.

Kolb, D. A. (1984). Experiential learning. London:Prentice Hall.

Mezirow, J. (1981). A critical theory of adult learningand education. Adult Education, 32(1), 3-24.

Mezirow, J. (1991). Transformative dimensions ofadult learning. San Francisco: Jossey Bass.

37

Bolton

van Manen, M. (1995). On the epistemology of reflectivepractice. Teachers and Teaching: Theory and prac-tice, 1(1), 33-49.

Morrison, K. (1996). Developing reflective practice inhigher degree students through a learning journal.Studies in Higher Education, 21(3), 317-331.

O’Loughlin, S. (2003). Attending to the patient withinus. Clinical Psychology, this issue.

Rogers, C. (1969). Freedom to learn: A view of whateducation might become. Columbus: Charles E.Merrill.

38

BRITISH PSYCDivision o

Quality and Eff

Vacancies have arisen on the Quality and Effectiwho are interested in contributing to the develop

profession for the delivery of quality health care needs of the individual.

Terms of reference of the Committee are:◆ educating and advising the profession on the

quality practice;◆ establishing guidelines for quality client-centr◆ identifying and disseminating innovative exam◆ working with other professions and organisati

multidisciplinary quality initiatives;◆ commissioning and managing projects on imp◆ stimulating activities relating to audit clinical

within the profession.

The Committee has recently undertaken the task for NHS Research and Development arising fromSteering Group for the BPS Centre for Outcomes

Further information can be obtained from John HWard at the Society office who will also supply Stelephone 0116 252 9517 (direct line).

Statement of Interest forms should be returned to


Skovholt, T. M., Ronnestad, M. H. & Jennings, L.(1997). The search for expertise in counselling, psy-chotherapy and professional psychology. EducationalPsychology Review, 9, 361-369.

Tripp, D. (1995). Critical incidents in teaching.London: Routledge.

[email protected]

HOLOGICAL SOCIETYf Clinical Psychology

ectiveness Subcommittee

veness Subcommittee (QUEST) for peoplement of clinical psychology as a leading edgeservices that are based on research and the

development and implementation of audit and

ed care and professional practice;ples of good practice;

ons in developing and implementing

ortant aspects of quality care and practice; effectiveness and Research and Development

of responding to the new funding arrangements the Culyer report. The Committee is also the, Research and Effectiveness (CORE).

all, Chair of the Committee, through Gwentatement of Interest forms to interested people,

Lesley Dexter at the BPS Offices.


Lift the box lid: reflective practice writing, an exampleHelen Drucquer


Reflective Practice

SPECIAL ISSUE:

Evidence-based medicine has nearly managedto deal a further blow to the sixth sense,perhaps one of the most vital tools in the

therapeutic armoury.Consider the following. Patricia is extremely

phobic of dolls, especially those with hair. Itmatters because she has three children under sixand they are not allowed to have dolls, play withdolls or have friends in the house who may bringdolls. She’s also not too keen on allowing herhusband, a tolerant chap, into bed with her andhe has taken refuge at his brother’s. It’s spreadeverywhere, like a virus; she’s phobic of goingout alone, on a bus. She doesn’t like the phone

or the door bell or Meadowhall; well – nothing issafe, really. The best evidence points to a cogni-tive behavioural approach and a referral hadbeen made previously.

And indeed, the first therapy worked. Dolls hadbeen allowed in the house; ones without hair,anyway. The husband was allowed home. Sothrilled was he that he booked a weekend away,her and the kids and himself. Toys, slots, chips.The chance to get back together, have fun. Offthey went.

This was just too much for the phobias. Theyscowled and prowled. Locked out! Denied! Theytried to keep her home but no, she’d learned to

Helen Drucquer is a therapist in a general practice health centre. She belongs to one of Gillie Bolton’sprimary care reflective practice writing for professional development groups.

Nine primary care practitioners (most of the others are GPs) attend the group to which Helen be-longs, once a month. They each bring and read to the group a piece of writing – a story, poem, or re-flective passage – which expresses and explores an area of current concern. A discussion followseach piece of writing: supportively drawing out whatever issues seem to be relevant to the writer.These might involve particular patients, relationships with colleagues, relationships with higher au-thorities, or more personal issues with a bearing upon clinical practice. The group members offertheir own ideas, making connections to other areas of experience, in an intense and lively discussion.As well as knowledge and skills, they are also not afraid to touch upon feelings, spiritual values, andpersonal territories where appropriate.

Group members then return to their work with fresh insight, supportive advice from colleagues, asense they are not the only ones struggling with certain issues, and, perhaps most importantly, deeperlevels of understanding and wider perceptions with which to practice. The ways in which these af-fect practice are then brought back to the group to be discussed and reflected upon further. This isa process of reflection being a way of working life, rather than an exercise undertaken for a course.

Members of the group have said that the process offers help with the often unfinished, and seem-ingly unsustainable nature of their work. They also appreciate its creativity as a form of explorationand expression. This kind of writing takes them by surprise: it tells them what it wants to be and do,and it tells them what areas of their experience they will explore. One group member said: thingscome out because the story lets them out. Another, who had just discovered poetry writing, said: Ilike poetry because I can’t make it do what I want. It has to do what it wants. And another: this writ-ing enabled me to find what I had never lost but didn’t know

Gillie Bolton

39

Drucquer

think them down. She plucked the positive thoughtfrom under the fridge magnet as the kids scram-bled into the car. The phobias slid into the boot.All day long they rattled at the windows of thechalet, until at three a.m., she flung open the tophalf of the door and welcomed in her familiars,her foes. Within half an hour, they had all beenbundled back on the road, kids crying and sleep-ing, husband hurt, bemused, resigned. ‘Oh darkfamiliar foes! Take me home, take me back downdown into that hard mouthed embrace thatmakes me special, wicked and damned.’

This was the referral to me. ‘Dear H., NewPatient. Came to Drop-in with a belly ache. Toldme she had a fear of dolls and that she wouldn'tsleep with her husband who’s at brother’s. Shehas had cognitive behaviour therapy. I have afunny feeling about the dolls. Love, Dr. M’ (Drop-in is an old fashioned, non-evidence based methodof running a surgery, highly popular with patients,who can turn up without appointment, at a pre-determined time (at our surgery it is betweennine and ten). They don’t seem to mind the wait;on the contrary, several people have told me thatthey enjoy its soothing rhythm.

Drop-in! That shamanistic event which is inop-erable without the sixth sense. Please don’t askabout it. Like a fawn which you glimpse in theforest, it will spring away once it feels your pres-ence. M. and I rely on our trust in the animal.Likewise, I creep up on the phobias; imagine whatwould have happened if Patricia had spottedthem climbing into the boot of that car? Theywould have found ever more devious ways tofind their way to the target. Please. Don’t ask mefor evidence.

The notes continue the trance state communi-cation of drop-in. Following a late night visitwhen a different doctor decided not to admit –(yes, her mental state is serious!), I note that elo-quent +++ of the Lloyd George shorthand.‘Panicky +++. Tearful +++.’ (Lloyd George’s arethe brown envelopes stuffed with hospital let-ters and sheets of handwritten practitionernotes, blue for girls and red for boys. They arewonderful snapshots of a person’s life.)

Now I pick up the strange baton where intu-ition and pressure from referrers collide after Ireceive the following note. ‘Dear H. Re Patricia S.What’s happening with your waiting list? Do we

40

hang on? It’s always to drop-in. See notes. Love, M.’So we skip the waiting list, for no other reason thanold fashioned sixth sense. No evidence. Thanks.

Two insults to the wisdom of phobia have en-sured its reinforcement. If you are taken into bedby uncle at the age of three and taught to usehands, thighs and mouth until the time comes toaccept penetration when you’re bigger and if tokeep you quiet a present of a doll is tucked intothe crook of your arm for the duration, then per-haps you will learn to hate that mini-receiver ofwhispered hurts, guilt and shame. As the man’slock of hair falls into your face, you grip thedoll's hair and tug it as if to hurt him back. If atfirst the doll comforted and repaired, later itmocked you, because you had grown big enoughto be hurt and penetrated; then rejected whenthat dirty blood came at puberty in favour of ayounger whiter flesh. The doll remained impas-sive, unruffled except for the hair which youplucked, secretly, with revenge. ‘Oh may thehair too be unmoved, like the hair on the dollmother gave me for Christmas. I never took itout of its box. Look here’s the photo to prove it.’

And she shows me a photo of herself, a littlegirl with the same staring eyes she has today,holding the doll box up to the camera as if tobear witness to what has occurred in the forbid-den room of her being.

Second insult. This phobia has wisdom, re-member. She does not just dislike physicality, butshe thoroughly rejects a decent man. How can weunderstand this? After the first, abusive, marriage –an easygoing, hardworking chap has taken onthe older two as his own. This is how it is. It issafe. Safe at last to hate, reject, control. To becelibate, to be inward, to be afraid, to say no. Todo nothing. To be still. And to worship cleanli-ness, next not only to godliness but to an un-touched doll in a box.

Can you tell me if trust is evidence-based?Intuition? Sixth sense? And who is to say how farthe lid of the box should be lifted and how farthose silent, impassive secrets should be keptforever in the shadows.

Patricia and I are not going to tell you.

Reflective postscriptStrangely enough, the focus of this piece of writ-ing was not the patient, but a sense of fierce loy-


alty which was burning in me at the time aroundthe topic of the wisdom of intuition in the ther-apeutic setting. What’s more, it was more on be-half of my close medical colleagues, beset asthey are by protocols, evidence-based medicine,appointment-only systems and so on. I lovedrop-in, as do patients, because although it is soexhausting, difficult to research, infuriating forstatistic mongers and of course not always med-ically effective, it nonetheless forces us all tokeep the sixth sense honed and our intuitiveskills honoured.

Another burning passion of mine suddenlyemerges unbidden in the last two paragraphs –what I call the ‘mind your own business’ factor.Frankly, I don’t want to explain it now as I have

Do you want to know how the Division Co

Join the Finance and Membership Subcom

There is currently a vacancy for one member on thiswith two face-to-face meetings in Leicester and fourone and a half hours.

Membership matters take up about 25% of the meeti

The terms of reference of the Subcommittee are:◆ To advise the Division Committee on matters

and in particular:– To monitor Division finances, includi

expenses, and to advise the Division Cpublication expenses.

– To scrutinise membership applicationdetermine elections to membership.

– To advise the Division Committee on

◆ To take such appropriate executive action ondelegated to the subcommittee from time to t– To monitor the finances and constitut– To liaise with the office of the Societ

documentation, the operation of the ru– To advise the Council of the Society

subscriptions,

Further information can be obtained from Jill Tyrer,Treasurer, through Gwen Ward at the Society officeforms, telephone 0116 252 9517 (direct line).

Statement of Interest forms should be returned to Le

yet to do my ‘reflective writing’ homeworkabout it. It’s to do with what needs to remainhidden, unresearched, mysterious and is akin there-fore to the sixth sense and the fawn in the forest.Actually, the fact that the focus is not the patientparadoxically frees up the writing about her. Thephobias become entities in their own right, theycome alive and my imagining of them has a muchlonger rein. Chronology and continuation take aback seat and as for outcome – it becomes laugh-ably irrelevant. (I feel obliged to add, somewhatdefensively, that this did not in fact turn out tobe a long-term case.)

[email protected]

41

mmittee spends your subscription fee?

mittee and find out.

Subcommittee, which meets six times a year evening teleconferences lasting about

ng time with financial matters using up the rest.

relating to finance and membership,

ng office costs, committee and working partyommittee on fees, budgets, subventions and

s and, on behalf of the Division Committee, to

the election of honorary members.

matters of finance and membership as may beime, and in particular:ions of Branches and Special Interest Groups.y in matters of finance, membership, Divisionles and AGM arrangements.

on the suspension of members in arrears of

Chair of the Committee and DCP Honorary who will also supply Statement of Interest

sley Dexter, DCP Administrator.

There is increasing evidence of a link betweenexcess mercury and deteriorations in cognitivefunctioning. Spencer (2000), in a review of theliterature, notes that many studies have foundhigh levels of mercury in people withAlzheimer’s disease.

What are the major sources of mercury expo-sure? Fish is one (but then how to get those es-sential fatty acids? Life is difficult…) and thenthere are those amalgam dental fillings. If yourclient has a mouth full of black fillings and is com-plaining of cognitive difficulties it could be onehypothesis that they might like to test. The issueof mercury toxicity from amalgam fillings is a con-tentious one; naturally, as there are huge vestedinterests involved. There are millions of potentiallaw suits and many companies and professionalsinvolved, not to mention the NHS for whom therewould be major financial implications, and thereis likely to be considerable resistance to a full in-vestigation of this issue. Nonetheless, evidence isaccumulating and is sufficient to result in Swedenbanning amalgam fillings and Germany to prohibtheir use in pregnant women and toddlers.Dentists meanwhile have been shown to havemercury urine levels over four times that of con-trol subjects and are significantly more likely tohave kidney and memory disturbance and im-paired psychomotor performance (Ritchie, 2002).

Implications for practiceIn the UK an ever-increasing number of dentistshave decided not to use mercury and are remov-ing amalgam fillings in a safe, protected way.(Contact: British Society for Mercury-freeDentistry, 1 Welbeck House, 62 Welbeck Street,London W1M 7HB; 0207 486 3127.) This is anissue on which your clients will have to make uptheir own minds and I would not recommendthat you send them all along to the nearest mer-

cury-free dentist. But you may like to direct themtowards some reading material and allow them tomake their own decision. The Dental Handbookprovides a well-referenced overview of the area(published by What Doctors Don’t Tell You,Satellite House, 2 Salisbury Road, London SW194EZ; 020 8944 9555; www.wddty.co.uk).

AluminiumIn parts of the world where there are high con-centrations of aluminium in the soil and waterthere are also high rates of neurological diseasesuch as Alzheimer’s disease and Parkinson’s(Rondeau, 2000). This link has also been shownin the UK. The brains of people who have died ofAlzheimer’s have also shown high concentrationsof aluminium. Patients receiving renal dialysisbegan to show signs of dementia until it wasfound that the dialysis fluid had a high level of alu-minum. Once the aluminium was removed cog-nitive functioning improved (Bennet, 1998).There is now a general recognition that aluminiumis not good for the brain, and, if the source of ex-cess aluminium is stopped, cognitive deterioration,(if caused by the aluminium) may be reversed.

Implications for practiceAluminium in drinking water can be removed bysome domestic water filters. Sales of aluminiumcooking utensils have plummeted, but it couldbe that your client still has some left from the‘old days’. You may like to point out the evi-dence to them and let them decide whether toinvest in some nice solid iron stuff (and in sodoing increase the iron content of their food andreduce their risk of depression due to anaemia,as well as reducing their intake of aluminium).

ReferencesBennet, T. (1998). Alzheimer’s disease and other con-fusional states. London: Optima.Ritchie, K. A. (2002). Health and neuropsychological func-tioning of dentists exposed to mercury. Occupationaland Environmental Medicine, 59(5), 287-93.Rondeau, V. (2000). Relation between aluminium con-centrations in drinking water and Alzheimer’s disease.American Journal of Epidemiology, 152(1), 59-66.Spencer, A. J. (2000). Dental amalgam and mercury indentistry. Australian Dental Journal, 45(4), 224-34.

[email protected]

42

The AlterAlternativenative PageA bimonthly look by Nigel Mills at some ofthe issues and therapies which cancomplement a psychological perspective

Mercury and aluminium:neurotoxins?


43

Dr Nigel Roberts, Head of Psychology Services,West Cumbria Health Authority, West CumberlandHospital, Whitehaven, Cumbria CA28 8JG; tel.01946 523653, fax 01946 523546

South Birmingham Psychology Service, 208Monyhull Hall Road, Kings Norton, BirminghamB30 2QJ; tel. 0121 678 3400, fax 0121 678 3401

Dr Peggy Easton, Consultant Clinical Psychologist,Psychology Department, Chichester Priority CareServices NHS Trust, 9 College Lane, Chichester,West Sussex PO19 4PQ; tel. 01243 787970 ext.4344, fax 01243 815306

Dr Richard Corney, Head of Clinical PsychologyServices, Psychology Department, Royal AlexandraHospital, Rhyl, Clwyd LL18 3AS; tel. 01745 343188ext. 3222

Ann Pim, PA to District Clinical Psychologist andDirector of Clinical Services, Greybury House,Bridge Sreet, Walsall WS1 1EP; tel. 01922 858515/858450

Morris Nitsun, Head of Psychology, Psychotherapyand Counselling Services, Redbridge Health CareTrust, Goodmayes Hospital, Barley Lane, Ilford,Essex IG3 8XJ; tel. 0181 970 8434, fax 0181 9705779

Ingolf Gudjonsson, Clinical Psychology Advisor,Adult Psychology Service, Doncaster RoyalInfirmary, Armthorpe Road, Doncaster DN2 5LT;tel. 01302 366666 ext. 3214

Peter Watson, Head of Psychological Services,Combe House, George Eliot Hospital, CollegeStreet, Nuneaton, Warwickshire CV10 7DJ; tel.01203 350111; fax 01203 353744

Lindsay Royan, North East London Mental HealthTrust, The Petersfield Centre, Petersfield Avenue,Harold Hill, Romford, Essex RM3 9PB; tel. 01708796464, fax 01708 796475

Juliana C. Macleod, Clinical Psychology ServicesManager, Pluscarden Clinic, Dr Gray’s Hospital,Elgin IV30 1SN; tel. 01343 543131 ext. 77499

Ilona Kruppa, Lead Psychologist, Mental HealthDirectorate, Rampton Hospital Authority, Retford,Nottinghamshire DN22 0PD; tel. 01777 247312

Gail Scothern, Head of Psychology Service for OlderPeople, Directorate of Psychiatry for the Elderly,Towers Hospital, Gipsy Lane, Leicester LE5 0TD;tel. 0116 246 0460 ext. 2662

Ron Tulloch, Director of Psychology and ClinicalDevelopment, The Coach House, Stockton HallPsychiatric Hospital, Stockton on the Forest, YorkYO3 9UN

Keith Homfray, Head of Psychology Services,Department of Clinical Psychology, 314-316Oldham Road, Royton, Oldham OL2 5AS; tel. 0161624 0420 ext. 5350

Pam Durrant, Head of Clinical Psychology Services,North Devon Hospital, Raleigh Park, Barnstaple,Devon EX31 4JV; tel. 01271 322442/322789

Martin Willmott, Lead Psychologist, WorcestershreMental Health Partnership NHS Trust, SmallwoodHouse, Church Green West, Redditch,Worcestershire B97 4BD; tel. 01527 488637

Keith Piper, Head of Clinical Psychology Services,Queen Elizabeth Hospital, Gayton Road, King’sLynn, Norfolk PR30 4ET; tel. 01553 613848, fax01553 613863

Deirdre MacIntyre, Principal Clinical Psychologist,Child Psychology Service, Eastern Health Board, KillChild and Family Centre, Co. Kildare, Ireland; tel.00 353 45 877731, fax 00 353 45 877512

Brian Stanley, Head of Psychology Services LearningDisabilities, Pollits House, Westwood Hospital,Cooper Lane, Bradford, West Yorkshire BD6 3NL

Carole Bosanko, Head of Psychology Department,East Cheshire NHS Trust, Macclesfield DistrictGeneral Hospital, West Park Site, Victoria Road,Macclesfield, Cheshire SK10 3BL; tel. 01625663547, fax 01625 663546

Christine Richards, Head of Forensic Psychology,John Howard Centre, 2 Crozier Terrace, Hackney,London E9 6AT; tel. 0181 919 8354

Dr Pauline McGill, Head of Psychological HealthCare, Barnsley Community and Priority ServicesNHS Trust, 11/12 Keresforth Close, off Broadway,Barnsley S70 6RS; tel. 01226 777914, fax 01226287604

Mobility of clinical psychologistsThe following clinical psychology departments have indicated that they are willing to be approached with enquiries about vacancies which may arise over the next year.

Cathy Thomas, Consultant Psychologist, St John’sHouse Hospital, St John’s House, Lion Road,Palgrave, Diss, Norfolk 1P22 1BA; tel. 01379643334; e-mail [email protected]

Padhraic Dolan, Head of District, ClinicalPsychology Department, Level 2, StrathmoreHouse, Brouster Gate, East Kilbride G74 1LF; tel.01355 249470

David McMahon, Head of Clinical Psychology, EastMidland Centre for Forensic Mental Health, ArnoldLodge, Cordelia Close, Leicester LE5 0LE; tel. 0116225 6040, fax 0116 225 6127

John Rowe, Learning Disabilities Service, City andHackney Community NHS Trust, St LeonardsHospital, Nuttall Street, London N1 5LZ; tel. 0207301 3086

Mary Leavy, Head of Clinical Psychology Service,Parkwood, East Park Drive, Blackpool FY3 9HG; tel.01253 306261, fax 01253 306264

Katherine Carpenter, Head of Department, OxfordDepartment of Clinical Neuropsychology, RussellCairns Unit, The Radcliffe Infirmary, Oxford OX26HE; tel. 01865 224264, fax 01865 727297, [email protected]

Tim Cate, Head of Psychological Health Service, StLuke’s Hospital, Marton Rd, Middlesbrough TS4 3AF

Dr Sally Furnish, Head of Psychology Services,Mersey Care NHS Trust, Mill Lane, RathboneHospital, Liverpool L9 7JP; tel. 0151 2503021/3035, fax 0151 220 4291, [email protected]

Andrew Rapley, Head of Child Psychology, Chelseaand Westminster Hospital, 369 Fulham Road,London SW10 9NH; tel. 020 8746 8972

Simon Jakes, MacArthur Metal Health Service, 6Browne Street, Campbelltown, New South Wales2560, Australia; e-mail [email protected]

Jan Aksnes, Acting Head of Clinical Psychology,Argyll and Bute Hospital, Lochgilphead; tel. 01546604904, fax 01546 604915

Kath Bland, Head of Psychology Services, South Tyne-side District Hospital, Harton Lane, South ShieldsNE34 0PL; tel. 0191 202 4060, fax 0191 202 4098

Teresa O’Mahony, Senior Clinical Psychologist,Hibernian Building, 13-14 Main Street, Skibbereen,Co. Cork, Ireland; tel. 00 353 28 40580, fax 00 35328 23172, e-mail [email protected]

Siri Wooster, Consultant Clinical Psychologist,CAMHS (East Herts), Hoddesdon Health Centre,High Street, Hoddesdon, Hertfordshire EN11 8BE;tel. 01707 365054 or 01992 465042

Ivan Burchess, Consultant Clinical Psychologist,Head of Clinical and Counselling PsychologyServices, 101-103 Bond House, St John’s Square,Wolverhampton WV2 4AX; tel. 01902 445715, fax01902 445491, e-mail: [email protected]

David Spellman, Consultant Clinical Psychologist,Pennine House, Burnley General Hospital, CastertonAve, Burnley BB10 2PQ; tel. 01282 474760

Mrs Rebecca J. Davies, Consultnat ClinicalPsychologist, Head of Teeswide CAMHSPsychology, Newberry Centre, West Lane Hospital,Aclam Road, Middlesbrough TS5 4EE

Thembi Sibisi, Head of Psychology, Bell House, LeGrand Bouet, St Peter Port, Guernsey GY1 2SB; tel.01481 701441; fax 01481 711108; [email protected]

To place or remove an entry, please write toJonathan Calder, The British PsychologicalSociety, 48 Princess Road East, Leicester LE1 7DR;fax 0116 247 0787; e-mail: [email protected]

Mobility of Clinical Psychologists

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THE MAY DAVIDSON AWARD2003

It is once again time to think of nominationsfor this award, made to a Clinical Psychologistwho has had made an outstandingcontribution to the development of clinicalpsychology within the first ten years of theirwork (i.e. graduated 1992) through clinicalresearch or other professional work.

Their work should be innovative and of anorder sufficient for the contribution to bebecome widely recognised as an importantdevelopment in British Clinical Psychology.

Any member of the Division may make anomination. Indicate what work merits theaward and enclosing a copy of the nominee’s CV.

Further information can be obtained fromLesley Dexter, DCP Administrator, on 0116252 9903. Nominations should reach her atthe Society’s offices by Friday 5 September.

Karen EhlertHonorary Secretary

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May 20Off to library. Odd looks from staff. Must be theSARS mask. Alison says it makes me look likesomeone from ER. Said I could even be goodlooking in one. Borrowed Which? Guide toManaging Stress and Worry: The Root of AllEvil. Reassuring chapter on famous worriers.Bridget Jones and Hamlet head the list, fol-lowed by the Apostle Paul and Jane Austen. Notexactly gratifying to find that Coleridge was ad-dicted to Opium, Mozart died depraved,Nijinski went mad and Poe was an alcoholic.Last example is Princess Di. Felt more anxiousand turned to the Which? guide. Chapter 5 is onmental illness. Even a section on ECT. Says it’seffective and generally safe. Apparently its saferthan antidepressants. Seems a bit much formanaging worry and stress but will ask clinpsych about it.

May 23Pub with Nigel. Told him about Worry. N saidthat Bridget Jones had every right to worry. Shewas, without a shadow of doubt, the most stupidwoman he had ever come across. Quoted fromWorry: ‘The appeal of her character may lie in

the fact that everyone can identify with her.’ Nincredulous. Said she had no bloody appeal andwent to bar.

May 28Asked clin psych what she thought of BridgetJones. Said she thought it really funny and couldeasily relate to her character. Beginning to seeclin psych in different light. Asked her if she everworried about relationships. Said, ‘Of course, butwhat about you…?’

May 31Camping with Tim and Alison. Lovely day.Brought along copy of Everyday Bites andStings and loads of sun-screen. Slapping it on.

May 31 (later)Nice triage nurse said she had never seen an al-lergic reaction to sun block before but mine wasunderstandable. Thought I’d fallen into a vat ofBrylcreem when I first came in. Turns out thatexcessive use of sun block mimics that scene inGoldfinger and the skin can’t breathe. Back toAlison who found it all terribly funny. Spent halfthe afternoon telling her mates via the mobile.Tim said he can’t wait for the photos to be de-veloped.

June 9Sauna with Nigel and Graham. N told G about fa-mous worriers. G said that he thought BridgetJones was a delight. Could really relate to her andfelt just as desperate sometimes about his ownawkwardness. Suggested he should meet mytherapist (for a date).

Felix Q.

A ROYAL SOCIETY OF MEDICINE COURSE SUPPORTED BYTHE OFFICIAL SOLICITOR TO THE SUPREME COURT ANDTHE NUFFIELD FOUNDATION

Child Psychiatry and the Law – expert witnesscourse for child mental health professionalsMONDAY-TUESDAY 7-8 JULY 2003

A two-day course being held at The Royal Society of Medicine,1 Wimpole Street, London, W1G 0AETEN CPD credits

Topics covered include:• The Law pertaining to children:• The role of Psychiatrist/Mental health professional• Assessment of Children• Good enough versus dysfunctional parenting: Assessing parenting risk• Adults psychiatry and the Children Act• Case history report preparation• Reviewing prepared reports• Preparing a report• Giving evidence• Role play mock court

Course elementsChildren Act: Essential principles; urgent child protection; parental rights andresponsibilities; protecting children within the family; alternative care; residency;special conditions; parents, guardians, relatives; fostering with family,grandparents, strangers; adoption; paternity; mother’s rights as separate fromfatherThe courts: Magistrates; High Courts; County Courts; criminal prosecutionsRules of evidence: expert and professional evidenceConfidentiality: reports on clinical patients; reports for lawyers; medico-legalassessmentsChildcare: child abuse; handicapped parents; mentally ill parents; abusingparentsAssessment: what to assess; how to assessPreparing a reportGiving evidenceTheory and how to use it: attachment theory; transcultural issues; child abuse;effects of parental illness; predicting long term outcome; adoption and fostering

The course is designed for Child and Adolescent Psychiatrists (Consultantsand Specialist Registrars) and Clinical Psychologists working with children

PLEASE SEND ME A BOOKING FORM FOR THE ‘CHILDPSYCHIATRY AND THE LAW’ COURSENAME _____________________________________________

ADDRESS ______________________________________________Please return to Sharan Gallagher, Academic Conference Department, Royal Society of Medicine, 1 Wimpole Street, London W1G 0AE. www.rsm.ac.uk

FAX: 0207 290 2977 or email: [email protected]

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BPS/DCPHIV & SEXUAL HEALTH FACULTY

RACE & CULTURE SPECIAL INTEREST GROUP

ConferenceWORKING WITH REFUGEES/ASYLUM SEEKERS

The morning will comprise of presentations & a panel discussion on:� Legal & Mental Health Aspects-Stuart Turner� The Cultural Meaning Of Rape – Ann Douglas� Political Aspects – Nimisha Patel� Systemic Issues In Working With Refugees & Asylum Seekers

– Renos Papadopoulos

In the afternoon there will be a choice of three workshops on:� Working With Interpreters – Rachael Tribe� Working With Traumatised Refugees – Traumatic Stress Clinic� Clinical Issues – Aruna Mahtani

The HIV & Sexual Health Faculty AGM will follow for members.

Date: Friday, 5th December 2003

Time: 9.30 am – 5.00 pm

Venue: The Resource Centre, 356 Holloway Road, London, N7 6PATel: 0207 700-0100(Nearest Tube: Holloway Road)

Cost: Students/Affiliates/Assistants: £30.00Members of Race & Culture SIG/ £60.00

Sexual Health/HIV Faculty/DCP:Non-Members: £75.00

For further information, contact Liz Shaw on: 0208 442-6464��………………………………………………………………………………………………………………

I WILL be attending the conference. I enclose a cheque made payable to the“HIV & Sexual Health SIG” (invoices not available) for (please circle):

Student £30.00Member £60.00 (please state what member of & no. if appropriate

……………………………………………………..…)Non-Member £75.00

Please send the cheque and this tear off slip to: Liz Shaw, St.Ann’s Sexual Health Centre,St.Ann’s Hospital, St.Ann’s Rd, London N15 3TH

KIIIInnnnssssttttiiiittttuuuutttteeee ooooffff

PPPPssssyyyycccchhhhiiiiaaaattttrrrryyyy

aaaatttt TTTThhhheeee MMMMaaaauuuuddddsssslllleeeeyyyy

Clinical and Research Refresher Course onPsychological Science and Mental Health Issues

Thursday 27th & Friday 28th November 2003 at the Institute of Psychiatry

This course, organised by the Department of Psychology, will provide participants with a comprehensiveupdate on empirically grounded developments in the psychological understanding and management of arange of problems. In addition, some presentations will present the latest thinking on key psychologicaltopics which are becoming increasingly influential in the development of psychological neuroscience.Presentations will be offered by leading experts in their field who will not only provide an overview of thestate of the art but will also provide up to the minute reference sources.

There will be a range of topics covered in the two days including the following:Psychosis – understanding and treatment, Bipolar Disorder, Mindfulness, Forensic, Genetics, AnxietyDisorders, Post Traumatic Stress Disorder, Neuropsychology, Virtual Reality, Children, families and CBT,Health Anxiety and Substance Misuse.

Speakers will include Professor Derek Bolton, Dr. Richard Brown, Professor David M. Clark, Mr. Padmal deSilva, Professor Judy Dunn, Professor Anke Ehlers, Dr. Ivan Eisler, Dr. Daniel Freeman, Professor PhilippaGarety, Dr. Laura Goldstein, Professor Jeffrey Gray, Professor Gisli Gudjonsson, Professor DavidHemsley, Professor Sheilagh Hodgins, Professor Elizabeth Kuipers, Dr. Veena Kumari, Dr. Dominic Lam,Professor Robin Morris, Dr. Sean Perrin, Dr. Emmanuelle Peters, Professor Robert Plomin, Professor PaulSalkovskis, Dr. Patrick Smith, Dr. Shamil Wanigarane, Dr. Ed Watkins, Professor John Weinman,Professor Mark Williams and Professor Til Wykes

This course is likely to be of interest to all those interested in psychological issues in the understanding andtreatment of mental health problems. This would include clinical psychologists, psychiatrists, psychiatricnurses, mental health researchers, therapists and others interested in mental health problems.

Bookings received before 30th September - £230 for two day courseBookings received after 30th September - £250 for two day course

Soni Mutschelknauss Lesley Anderson_ 0207 848 5033 _ 0207 848 5038_ [email protected] _ [email protected]_ Department of Psychology _ Department of Psychology

Box P077 Box P077Institute of Psychiatry Institute of PsychiatryDe Crespigny Park De Crespigny ParkLondon SE5 8AF London SE5 8AF

ING’SCollege

LONDONK

Costs and booking:

For further information or to request a booking form, please contact:

Or visit www.iop.kcl.ac.uk/quick/november.shtml

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© The British Psychological Society 2003ISSN 1473-8279

Documents

Clinical PsychologyClinical Psychology is circulated to all members of the Division monthly. It is designed to serve as a discussion forum for any issues of relevance to clinical psychologists