Reflective practice is an integral aspect of Clinical Psychology and is referenced by both the Psychological Society of Ireland and the British Psychological Society as a necessary element of training programmes for accreditation. This article represents a reflection on the beginning of clinical training and settling into the role of a trainee. It follows three main themes: the establishment of new working relationships; the process of learning how to sit with urges to always ‘do’ something with clients; the urge to ‘fix’ their difficulties for them; and therapeutic endings. The merits of reflective practice are explored in the context of personal and professional development.
Reflective practice is becoming an increasingly valued domain in Clinical Psychology – particularly in the area of clinical training1 and is referenced by both the Psychological Society of Ireland (PSI) and the British Psychological Society (BPS) as a necessary element of training programmes for accreditation2-3. Bolton4 describes how reflective practice can enable professionals to learn from experience about: themselves; their work; the way they relate to home and work, significant others and the wider society and culture. Moreover, the PSI 2(p4) states that courses ‘should ensure that trainees are cognisant of the importance of self- awareness and the need to appraise and reflect on their own practice’. There are many benefits to be reaped from practicing in this way.
Alarcon and Lyons5 postulate that engaging in reflective practice leads to an increase in job satisfaction and a decrease in work related stress for the practitioner. They also highlight that the practitioner can experience greater empathy between them and their clients as well as a greater unity and wholeness of experience in their work. Schon6 suggests that it helps professionals to make complex decisions in challenging situations without access to all existing information through a two part process: reflection-in-action (during the event) and reflection-on-action (after the event). He also states that it enables us to wonder at our own work, our world and indeed ourselves, because ‘problems do not present themselves to the practitioner as givens…he must make sense of an uncertain situation that initally makes no sense.6(p40)
This article explores my personal and professional development as a trainee clinical psychologist thus far. It focuses on the process of settling into the role of a trainee in my first placement (adult mental health), and the importance of clinical supervision in facilitating this. More specifically it will cover the establishment of new professional (supervisory) and personal development relationships, the process of learning how to sit with my urge to always ‘do’ something with clients and my desire to ‘fix’ their difficulties for them. It will also explore my first set of endings as a trainee, both with my clients and my supervisor.
A new set of relationships
As I took the next step in my journey to becoming a Clinical Psychologist I formed two new relationships, which became of great importance to both my professional and personal development. I began my first placement and so a new supervisory relationship. This brought with it a range of feelings. In honesty, although excited and eager to get started, I felt slightly overwhelmed and uncertain as to whether I possessed the competence to provide my clients with a service comparable to what they would receive if seen by a more senior clinician. Jenny Webb7 described such feelings accurately when discussing trainee’s experience of beginning new placements: “You may be assailed by a combination of heroic good intentions and feelings of ignorance and incompetence”7(p4) I also wondered whether I was as fit for the job as my fellow trainees and felt a desire to impress my supervisor with my up-to-date knowledge so that she would think of me as a ‘good trainee’. I identified with what I now know to be ‘imposter syndrome’.
I realized my feelings were not in isolation when I read Clance and Imes8 paper entitled ‘the imposter phenomenon in high achieving women: dynamics and therapeutic intervention’. I immediately recognised some of myself in the article, particularly my ability to dismiss high grades and achievements as lucky breaks. As I explored this further in supervision I became comforted in the knowledge that my enthusiasm and dedication for helping my clients, along with two hours of formal supervision a week, as well as class discussions, meant that my clients were actually receiving plenteous expertise and input. In keeping with this and grounding myself in knowing that I will have at least something to offer my clients, a line I read by Nancy McWilliams9(p47) stood out to me; ‘the uniqueness of every person makes it impossible ever to be fully prepared for the next client’.
At this time I also began my own personal development journey with a Psychotherapist with the aim of gaining a greater understanding of myself and also to experience therapeutic processes from the client’s seat. Some research findings also suggest that engaging in personal therapy can enhance reflective practice capacity for psychologists.10 My first session showed me how intimidating it is to sit across from a complete stranger with the expectation of sharing my inner most feelings with her. I felt the need to tell her on meeting that I was a Trainee Clinical Psychologist, to which she responded with little reaction. In the next session we spoke about this. Ashamedly I admitted that I had offered this information to highlight that I didn’t need to be there, but that I was present as a matter of exploration. Together we discussed the sense of stigma and shame I was alluding to at coming to therapy. It made me sit back and realize what courage my clients were already coming to me with in that they were brave enough to seek and admit they needed help with their distress.
I began to wonder if my feelings in starting with both a new supervisor and a therapist could be comparable to those of my new clients – overwhelmed, hesitant, unskilled and cautious of beginning a new relationship despite how attractively it was presented. This in itself was interesting to reflect on and I believe kept me mindful in my initial sessions with clients as to just how daunting this must be. I endeavored to keep a strong focus on building a therapeutic alliance with them so as to create a safe space from which to explore themselves and also as the therapeutic alliance is noted to be a significant factor in facilitating therapeutic change.11
As my capacity to share my thoughts, feelings and emotions grew in supervision, I began to notice the impact of this on my client work and how my capacity to offer the same trusting space for my clients grew too. Being allowed to set the agenda for the meeting anchored me in the supervisory relationship. It gave me a sense of empowerment and validation in that I knew the meeting was focused on my needs. This was something I tried to do with my clients. I hoped that giving them this opportunity would instill the same sense of confidence building in learning to get their needs met. I had one particular client who was observed to have difficulty each week in setting the agenda and thinking about what it was she wanted to discuss. When speaking in supervision it was noted that the clients upbringing was marked with disruptions to key attachment relationships such that she may have internalised a sense that her needs were not important or worthy of being met, including in therapy. Gray12 talks about the importance of acknowledging this potential in clients with a history of difficult early childhood experiences. This experience showed me the importance of recognizing that we as human beings function on many different levels other than verbal, and so sometimes what is not said in-session but may be conveyed through behaviours is important to consider when working with clients.
The need to ‘do’
Although I see myself as a somewhat natural reflector, often in supervision I found myself eager just to stick to the facts of ‘what had gone on in my week’. Reflecting now I feel this was most likely as I wanted to prove myself as a capable trainee and was conscious that I wanted my supervisor to know ‘just how much I had done this week!’. I was lucky to have caught myself doing this as it started to spill into my client work. In an effort to ensure that I completed by-the-book CBT with one of my clients, I found myself getting lost in the pragmatics of it, focusing on what we needed to get done in the session, what I had prepared for the session and so not being fully present for what she was bringing, as in a way, it didn’t fit into my schedule. I recall, when asked about the week just gone, referring in passing to the anniversary of a major loss. While not on the “agenda” for that session, it was only as a consequence of us given that issue real time and importance that we were able to discuss something of real importance to that client. Following the session I brought this to supervision and reflected on how I had almost let my need to ‘tick the CBT box’ surpass my client’s needs and which could have led to a rupture in our therapeutic relationship as well as him feeling invalidated. Moreover, certain research findings point out that ‘heroic’ client’s efforts and the personal attributes a therapist brings to the therapeutic relationship can have a greater effect on therapeutic outcome than any particular technique or therapeutic orientation.13
Another example of this came with a client where following the assessment process; I presented my detailed hypothesis of the nature of her difficulties discussed and their origin. The client didn’t particularly agree, however, with the formulation and we agreed to rework it together. We then contracted for therapy but quite soon after she disengaged. On reflection, I believe that my rush to present her with a complete and intelligent formulation meant that I missed the mark. Levy14 stated that this can be ‘a stance many therapists find difficult [a more cautious and less interpretive mode of formulation] because of their own neurotic needs to be brilliant and special in both their patients’ and their own eyes’ (p24). Perhaps more time spent reflecting on this at the time would have resulted in a different outcome for the client. Page, Stritzke, and McLean’s15 paper found that participants (psychologists) valued the role of reflection as part of the process of developing a formulation, especially when working with cases that they identified as challenging or perceived they were ‘stuck’ with. Supervision helped me see that assessment and formulation are continuing processes throughout therapy and meeting the client where they are at is by far the most important outcome. It helped me to become OK in just being with a client and not always focusing on the doing.
The need to ‘fix’
Mason16 described a position of ‘safe uncertainty’, meaning that a person feels able to tolerate not knowing exactly what to do with a client and engage in the creativity that is provided by this position. He suggests it comes with feeling contained by a positive supervisory relationship. Pica17 further elaborates on this concept and suggests that a certain amount of uncertainty is necessary in clinical training programmes as it forces the trainee to enhance their critical thinking skills through having to focus on how and why a client is saying something and not just what is said. For me, once the supervisory relationship became more established I then began to feel more at ease with thinking out loud and sharing my uncertainty with my supervisor, as opposed to needing to appear confident and competent at all times. Being given a ‘wondering’ stance in supervision, whereby my supervisor did not immediately provide me with the answers I was looking for, allowed me to do the same with my clients.
However, earlier in my placement I struggled more with uncertainty and felt a need to ‘fix’ my clients difficulties and provide them with the solutions to do so. This led to discussions in supervision about the meaning of progress and change to both client and therapist. Subsequently I explored with clients what change meant to them whether it was something aspired towards or something frightening, leaving behind the safety of their current position.
In my own personal development work, I spoke about my feelings of working with such clients and whether it was OK to feel frustrated. My therapist asked me two things – what change meant to me, and how I would respond if I were asked to try something new, yet difficult. This was interesting for me to reflect on in that change is something I certainly find difficult and have struggled with in the past. What is more, I realized that perhaps I would be quite compliant if asked to do something, wanting to please the other person. In thinking about this it made sense to me why I was frustrated with such clients – I was imposing my own beliefs on them. It highlighted to me that ‘we don’t see things as they are, we see them as we are.’18(p834) Entering into this thinking about my own ways of being allowed me to be more patient with my client in our following sessions. This outcome is echoed by research from Fisher, Chew and Leow19 which suggested that therapists who used personal reflection in their ability to understand themselves could attune more fully to their clients and their clients’ distress.
This experience showed me just how much my own personal beliefs can get in the way of the therapeutic relationship and also the importance of self reflection in maintaining a full presence for clients. This issue was highlighted by Bolton4 when discussing Smyth’s work when he stated that being able to bring the personal into the professional serves to strengthen and increase empathy between the client and the professional.
‘Endings’ – terminating the therapeutic relationship
As I approached the end date of my first placement I began the process of finishing up with my clients and ending our therapeutic relationships. Although I had only been in the service for a short time, some of my clients had made considerable progress, with one client reporting feeling extremely pleased on his progress when hearing on the reduction in his scores on the BDI-II. I had underestimated how hearing this information would affect him. So often we can take psychometric measures for our own use and overlook the impact for the clients in giving them feedback on the same. I too was amazed with this result, and felt a sense of accomplishment for myself in having helped him on this journey along with pride for my client that I had not expected to feel. When we parted ways that afternoon I knew I would remember this client and such a positive experience throughout my career.
The process of giving and receiving gifts at the end of therapy has also made me think at length about the significance of endings. For one client I had to return a gift, and worked hard on doing so in a way that was not invalidating of the gesture but rather recognizing the importance of what the client had brought to the therapy too. For another client I accepted the gift on the basis that it appropriately validated her wish to acknowledge the importance of the work that we had done together. A study by Brown and Transgrud20 found that when psychologists perceived that the gift being given as inexpensive, informed by cultural context, and presented with gratitude for good work at the end of psychotherapy, they were more likely to accept the gift.
Receiving these gifts made me reflect on my own personal experience of being given gifts in the past. As an only child, I received presents from most family members at birthdays and Christmases. They would usually insist that I open them in front of them and await my reaction. As a result my response would be to put on a show of delight, regardless of how I felt about the actual gift. I was always conscious not to offend them as they had gone to such effort. Receiving gifts from clients, although in a completely different context, activated my internal instinct to respond with the same script. These dilemmas are debated in the literature, albeit not too frequently. A study by Willingham and Boyle21 found that Clinical Psychologists on the whole viewed gifts as powerful objects that warranted acceptance. In this study accepting gifts was thought of as a culturally authenticated response, especially to ‘small’ gifts. These findings built on previous research by Knox and colleagues22 and Spandler and colleagues.23 However, some research, including Brown and Transgrud’s20 work, is based on case vignettes of what psychologists perceive they would do in a situation and so does not reflect real world results to a greater extent.
The feedback I received from my supervisor at the end of placement gave me faith for the future with regard to my own competence and confidence as a Clinical Psychologist. She stated in review that my ‘natural capacity to build therapeutic relationships’ was a real strength. This experience helped me to feel confident in my skills going forward in thinking that no matter what population of people I am working with, be it in an adult mental health, intellectual disability or older adult service, they will always just be people in distress and being able to form a strong therapeutic relationship with them will guide us in therapy.
Writing this article has afforded me the opportunity to pause and reflect on my experience of clinical training thus far, and my development as a Clinical Psychologist to date. Keeping a reflective journal has been important to me in taking regular time to synthesise and formulate my experiences as a developing clinician. It has been interesting to compare my experience of engaging in personal development / therapy work independent of the course, using this as a medium to reflect and the process of writing this piece. In my personal journal I feel I am able to write in an honest and open manner that may not flow as freely nor as easily when voicing my thoughts to a supervisor or colleague. The process of re-reading has also been an important one for me in seeing on paper my own growth as a trainee. Keeping a journal is a challenging task and one which I, unfortunately, can put at the end of my list when faced with a busy week of tasks.
In all, the value of reflective practice for me in clinical training so far is undoubted and has had an invaluable contribution to my professional development and self-care practice. Working with people who are in distress, or at times quite emotionally dysregulated, has real potential to impact one’s personal emotion and compassion resources. I feel that engaging in reflective practice through writing and through supervision is not only an invaluable tool in developing one’s understanding of the client’s world but also in ensuring a healthy recognition of the impact that therapeutic process can have on the therapist.
- Binks, C., Jones, F. W., & Knight, K. (2013). Facilitating reflective practice groups in clinical psychology training: A phenomenological study. Reflective Practice,14(3), 305–318.
- Psychological Society of Ireland (PSI). (2009). Guidelines for the assessment of postgraduate professional programmes in clinical psychology. Retrieved June 8th, 2017, from http://www.psihq.ie/page/file_dwn/5/accreditation-clinical-postgrad-application.pdf
- British Psychological Society (BPS). (2016). Standards for the accreditation of doctoral programmes in clinical psychology. Retrieved June 8th, 2017, from http://www.bps.org.uk/system/files/Public%20files/PaCT/Clinical%20Accreditation%202016_WEB.pdf
- Bolton, G. (2014). Reflective Practice: Writing and professional development. London: Sage.
- Alarcon, G. M., & Lyons, J. B. (2011). The relationship of engagement and job satisfaction in working samples. The Journal of Psychology, 145(5), 5463-480.
- Schön, D. F. (1983). The reflective practitioner. New York: Basic Books.
- Webb, J. (2014). A guide to psychological understanding of people with learning disabilities: Eight domains and three stories. East Sussex: Routledge.
- Clance, P. R., & Imes, S. A. (1978). The imposter phenomenon in high achieving women: Dynamics and therapeutic intervention. Psychotherapy: Theory, Research & Practice, 15(3), 241-247.
- McWilliams, N. (2004). Psychoanalytic Psychotherapy: A practitioners guide. New York: The Guildford Press
- Wigg, R., Cushway, D., & Neal, A.(2011). Personal therapy for therapists and trainees: A theory of reflective practice from a review of the literature. Reflective Practice: International and Multidisciplinary Perspective,12(3), 347–359
- Goldfried, M. R., & Davila, J. (2005). The role of relationship and technique in therapeutic change. Psychotherapy: Theory Research, Practice, Training,42, 421–430.
- Gray, A. (1994). An introduction to the therapeutic frame. London: Routledge.
- Duncan, B.L., Miller. S.D., & Sparks, J. (2004). The Heroic Client: A revolutionary way to improve effectiveness through client directed outcome informed therapy (revised ed.). San Francisco: Jossey-Bass.
- Levy, S. T. (2002). Principles of interpretation: Mastering clear and concise interventions in psychotherapy. U.S.A: Jason Aronson Inc.
- Page, A., Stritzke, W. G. K., & McLean, N. J. (2008). Toward science-informed supervision of clinical case formulation: A training model and supervision method. Australian Psychologist,43(2), 88–95.
- Mason, B. (1993). Towards positions of safe uncertainty. Human Systems,4(3–4), 189–200.
- Pica, M. (1998). The ambiguous nature of clinical training and its impact on the development of student clinicians. Psychotherapy: Theory, Research, Practice, Training,35, 361–365.
- Epstein, R.M. (1999). Mindful Practice. Journal of the American Medical Association, 28(2), 833-839.
- Fisher, P., Chew, K., & Leow, Y. J. (2015). Clinical psychologists’ use of reflection and reflective practice within clinical work. Reflective Practice, 16(6), 731-743.
- Brown, C., & Transgrud, H. B. (2008). Factors associated with acceptance and decline of client gift giving. Professional Psychology: Research and Practice, 39(5), 505-511.
- Willingham, B., & Boyle, M. (2011). ‘Not a neutral event’: Clinical psychologists’ experiences of gifts in therapeutic relationships. Psychology and Psychotherapy: Theory, Research and Practice, 84, 170-183.
- Knox, S., Hess, S. A., Williams, E. N., & Hill, C. E. (2003). ‘Here’s a little something for you’: How therapists respond to client gifts. Journal of Counseling Psychology, 50, 199–210.
- Spandler, H., Burman, E., Goldberg, B., Margison, F., & Amos, T. (2000). ‘A double-edged sword’: Understanding gifts in psychotherapy. European Journal of Psychotherapy, Counselling and Health, 3(1), 77–101.
BA Applied Psychology, MA Educational Neuroscience, Doctoral Student in Clinical Psychology, UCC