Reflective Practice in Mental Health

Advanced Psychosocial Practice with Children, Adolescents and Adults

Martin Webber, Jack Nathan

• Publisher: Jessica Kingsley Publishers
• Year: 2010
• ISBN:
  9780857003966
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Reflective Practice in Mental Health is the authoritative, definitive guide to psycho-social theory and practice in mental health.

Featuring contributions from eminent experts, the book uses case studies to illustrate and address the complexities and dilemmas faced by practitioners involved in mental health care, and enables the reader to reflect on their understanding. Case studies from a variety of theoretical perspectives are included, covering psychodynamic theory, cognitive behavioural therapy, systemic family therapy, attachment therapy and therapeutic group-work. They also cover practice across a range of settings, including inpatient, community and children and family services.

This book will be a crucial and invaluable text for social work practitioners and social work students aiming to ensure the very best practice in mental health social work, and aims to be the seminal text for mental health psychosocial practice.

Part I

Context

Chapter 1

The Making of the Advanced Practitioner in Social Work

Jack Nathan

Introduction

This Chapter discusses the ways in which practitioners acquire advanced social work skills, a development given significant impetus by the Laming Report (2009) and the Select Committee’s Report, Training of Children and Families Social Workers (House of Commons Children, Schools and Families Committee 2009). There is now an unambiguous acknowledgement that, ‘obtaining a degree in social work must be only the starting point of career-long learning and development’ (House of Commons Children, Schools and Families Committee 2009, p.65).

Taking the lead from the Laming Report, the Select Committee goes on to assert the need for a practice-focused Master’s degree as a pathway to the development of the advanced practitioner. There are parallel developments taking place in the delivery of adult services. In The Roles and Tasks of Social Work in Adult Services (Department of Health 2009), the consultation document identifies the similarities in the roles and requirements of practitioners working with adults, emphasising the need for ongoing professional development within a career framework and culture that promotes evidence-based practice, as well as practice-based evidence.

These reports share a common central message. If social work is to leave behind its historical status as a ‘semi-profession’ (Etzioni 1969) and join the ranks of the law, medicine and psychology, then there needs to be a step change in the training framework so as to produce a social work profession predicated on the taken-for-granted assumption of advanced practice. This Chapter will outline the core elements that support the professional journey of a newly qualified social worker through to the making of the advanced practitioner.

What is an advanced practitioner?

In the early 1990s at the Institute of Psychiatry Alan Rushton (author of our foreword) and I began to define what constituted an ‘advanced practitioner’. Our definition was subsequently published in the Journal of Practice Teaching in Health and Social Work (Nathan 2002).

The work of Donald Schon (1987, 1992) was crucial in the evolution of these ideas through his conceptualisation of ‘the reflective practitioner’, which led to the innovation of the ‘training hierarchy’. By this was meant a form of continuing professional development in which the practitioner begins with a basic knowledge as a newly qualified social worker and with experience, supervision and post-graduate training evolves to being an advanced practitioner.

Schon (1987) conceptualised this progress by suggesting that after qualification a practitioner can be properly regarded as using what he calls ‘professional artistry’. At this point, after what is still only a three-year training programme, the newly qualified social worker (NQSW) will have trained in appropriate placements supported by the practitioner wisdom imparted by a competent practice supervisor. Buttressed by this support and having completed the degree programme, the practitioner will in theory be able to utilise a range of skills when confronted by what Schon (1992) refers to as situations characterised by ‘uncertainty, complexity and uniqueness’ (p.56) and I would add, at times, conflict. Schon views such practice as a more high-powered, esoteric form of competence that any reasonable lay individual may exercise in their everyday actions. His key point is that this form of practice competence does not depend on practitioners ‘being able to describe what [they] know how to do or even to entertain in conscious thought the knowledge [their] actions reveal’ (Schon 1987, p.22). In other words NQSWs demonstrate what has been called ‘a tacit knowledge’ (Nathan 2002).

At first glance this may seem an overly negative description of social work knowledge at point of qualification. In fact, sadly, it seems quite accurate. The Social Work Task Force (Department for Children, Schools and Families 2009), set up by the UK government to undertake a comprehensive review of front-line social work practice, gathered evidence that up to nearly six out of ten NQSWs in children’s services and one in four in adult services did not feel prepared for the demands of the job.

Given both the enormity and complexity of the task, it seems that Schon was perhaps over-estimating the newly qualified professional’s capacity to meet the challenges of the work. In fact this quite accurately tallies with our experience on our advanced level post-qualifying MSc programme at the Institute of Psychiatry. Practitioners with a wealth of experience, typically three to five years post qualification, apply to undertake our programme. During the interview they routinely give a coherent and fluent account of their workplace and offer rich material when asked to talk about a current case. What equally routinely happens when asked to give a reflective description, layering their work through the prisms provided by practice theories and/or any evidence base, is that many of these skilful improvisers become embarrassed and tongue-tied and struggle to do justice to the casework they have already demonstrated in their initial presentation.

To repeat, for this group of experienced practitioners, theirs is a ‘tacit knowledge’. In Schon’s (1987) terms their practice competence is predicated on a ‘knowing-in-action’ and/or a ‘reflection-in-action’ (see Figure 1.1 for a diagrammatic representation). According to Schon (1987), knowing-in-action reveals the practitioner’s capacity to be professionally spontaneous, skilfully responding to the requirements of the task at hand in their work with an angry client, for instance. What is key to this form of knowledge is that the worker does not necessarily have the reflective capacity to make explicit the underlying assumptions dictating their actions. Similarly, as a function of increasing casework experience, the practitioner can develop reflection-in-action, a form of professional artistry based on years of first-hand experience which enables the practitioner to improvise, to think on their feet. What we are beginning to understand is that for too long far too much has been expected of NQSWs who, it seems, would struggle to give even the kinds of casework accounts, however unreflective, that their more experienced colleagues are able to convey at interview. But even this group have had to ‘learn on the job’ and have in general not been provided the educational space to develop a practice worthy of the term ‘reflective’.

Schon (1987) summarised their current professional competence by claiming that ‘it is one thing to be able to reflect-in-action and quite another to be able to reflect on our reflection-in-action so as to produce a good verbal description of it’ (p.31). Our view is that it is only when this professional developmental point has been reached, that the reflective practitioner comes into being. Such a practitioner is no longer working from the realm of a tacit knowledge base or what one psychoanalyst appropriately termed ‘the unthought known’ (Bollas 1987). For the reflective practitioner, that which was previously non-conscious can now be thought about from within a range of practice paradigms and with a degree of research literacy. In other words, their work can be thought about and reflected upon from diverse perspectives (Schon 1987).

Figure 1.1 The reflective practitioner

We are now in a position to claim that what was previously a form of tacit knowledge can justifiably be termed explicit knowledge. This is often our experience at the end of the first year of the MSc programme when the practitioners present audio-taped case material at a viva examination. Anxiety-provoking as this experience often is, most students are able (in Schon’s words) to reflect on their practice reflections-in-action and to give an articulate, consciously thought through verbal narrative that is faithful to the work they have brought to the panel. They meet the requirements of what constitutes the reflective practitioner defined in the following terms:

A practitioner who has the capacity to translate the knowing-and reflecting-in-action from a tacit knowledge, based on learned intuition, into a form of practice knowledge that includes reflection on that practice, where that knowledge is explicit and articulated. What is termed explicit knowledge. (Nathan 2002, p.68)

It is important to clarify that a social worker armed with this complex, even sophisticated knowledge base, is not thereby able to claim omnipotent insight into all casework dynamics. Indeed the reflective practitioner may be more confident of that which remains unknown, especially in the realm of human emotional engagement. What the reflective practitioner can do, however, is work with a client at a primary interactive level based on knowing- and reflecting-in-action. Additionally, a reflective practitioner has a secondary reflective level that facilitates a capacity to explore other layers of the dynamic tensions inherent in work with highly disturbed or disturbing clients. This is illustrated by Case Study 1.1.

CASE STUDY 1.1 WORKING AS A REFLECTIVE PRACTITIONER

When I was an Approved Social Worker (in pre-Approved Mental Health Professional days) I undertook a Mental Health Act assessment of a woman with a history of violence whose mental health seemed to be deteriorating. The assessment took place at her home where the woman was screaming at the top of her voice for us to get out of her house, as she did not know why we (including two doctors) were all there. At a primary interactive level I attempted to explain in a rational manner that neighbours had been worried about her, especially after she had thrown a large fridge out of her first-floor window. The intention was to ‘explain’, using as many of the skills of spontaneity, partnership working and improvisation that I could muster. None of these seemed to make any difference as the woman quite rightly understood, however mentally disturbed she may have been, that we were threatening her literal as well as her emotional space.

As it was, it was only when I began to reflect on my own emotional experience at the secondary reflective level, using my counter-transference (see Chapter 6 for details about this concept), that I began to recognise that I was experiencing a profound sense of terror. At this point, I wondered to myself if this was how she was feeling. After all, strangers, mostly men, had forced their way into her house, leaving her powerless and out of control. I therefore suggested to her that she was terrified by our uninvited and frightening presence and suggested that we sat down. She was able to sit down and continue the interview in a much calmer manner. Although the outcome was that she was eventually placed on a section, I think the fact that her screaming had been heard, understood and put into words made a huge difference to the way in which the assessment was conducted. The police who were at hand in case violence erupted, did not need to be used. Alongside this woman’s conscious fury that was so clearly being given voice to, there was a less conscious communication, which was being registered at the secondary reflective level by me as terror, mirroring the client’s own internal emotional experience (see Figure 1.1 for a diagrammatic representation of these underlying dynamics).

What Case Study 1.1 highlights is that being a reflective practitioner is always a process. Any social worker’s initial response will begin at the primary interactive level, utilising the learned intuitive dexterity associated with knowing- and reflection-in-action that Schon identified through the use of spontaneity and improvisation. As in this case, in situations replete with uncertainty, complexity and potential conflict, this will not be sufficient. At the secondary reflective level, the reflective practitioner will usually be able to draw on a knowledge base that stems from their understanding of different forms of practice paradigms and research. With this particular client I turned to my grasp of psychoanalytic concepts such as projection and counter-transference (see Chapter 6) as it is implicit in our definition of the reflective practitioner that the social worker is a key instrument of knowledge, not an outsider to proceedings ‘delivering’ a service to the inert service user.

It is perhaps stating the obvious to suggest that in the deeply troubling human stories we are asked to bear witness to we are inevitably, and sometimes profoundly, drawn into their drama. At the scene of the sometimes intensely emotionally charged engagement with the client, the practitioner has to evolve a capacity to contain anxiety sufficiently to create a space, internally, to think. Casement (1985) referred to this quality as akin to having an ‘internal supervisor’. This form of internal supervision brings in its wake the possibility of thinking through difficulties instead of rushing to action. If I had only acted on my instincts, at the primary interactive level, I would have asked for police support and this could have escalated into a major violent incident. Of course, this is not to deny that there are occasions when this would be the app...

Table of contents

• Cover
• Of Related Interest
• Title Page
• Copyright
• Dedication
• Acknowledgements
• Contents
• List of Tables, Figures and Case Studies
• List of Abbreviations
• Series Editor’s Foreword
• Foreword
• Introduction
• Part I: Context
• Part II: Theoretical Perspectives
• Part III: Advanced Reflective Practice in Action
• Contributors
• Subject Index
• Author Index