Reflective activity and experiential learning

Ideas of ‘thinking about one's thoughts’ and ‘questioning one's knowledge’ existed in ancient philosophy, as in the traditions of Socrates and Confucius. The title of modern father of reflection in learning belongs to Dewey. He argued that the learner develops higher-order understanding and practice through ‘reflective activity’. He saw this as a conscious, purposeful activity of willing and open-minded intellects that attempt to match new experience with pre-existing ideas for interpretation and further action (Reference DeweyDewey 1933). Dewey contrasted reflection with lower-order processes, continuous ‘trial and error’ loops or capricious and instinctive ‘impulses’ based on tacit motives and assumptions that cannot be made explicit, justified or controlled. Students and practitioners may be seduced by the familiarity and effortlessness of habitual premises, rules of thumb or assumptions, as long as these remain effective, at least superficially. Reflective thinking instead can be unsettling, as it often arises when we experience mismatch between our expectations and results.

Dewey described reflective thinking as a number of distinct mental states, though not always in a strict succession:

1. • perplexity, caused by the failure of a habitual action or conjecture to produce the anticipated result

2. • intellectualisation, which is initiated by a critical survey of the situation and produces an understanding

3. • the creation of alternative hypotheses or solutions; hypothesis testing starts new reflection.

Recognising the influence of Reference KolbDewey, Kolb (1984) proposed a similar model of cyclical experiential learning where concrete experience is observed and described, reflection leads to abstraction and decontextualisation, and the product theory can be tested in future encounters with concrete experience (Fig. 1).

FIG 1 Kolb's theory of experiential learning (after Reference KolbKolb 1984).

Barriers to trainee reflective practice

Reflection is a natural property of the adult thinker when confronted by challenge. Given the thinking space, self-consciousness can question the efficacy, validity and value of ideas and actions (Reference MezirowMezirow 1981). However, in many courses reflective learning seems opportunistic and discretionary and can be disrupted or even prevented within established apprenticeship models by the limited ‘legitimate participation’ of new entrants (Reference Lave and WengerLave 1991). Induction into the community of psychiatric practice may restrict the depth and pace of participation. Medicine has a highly hierarchical structure and new learners often face a maze of rule-bound social associations with seniors and other disciplines. This gives the impression of hierarchy within reflective practice: higher-order reflections become permissible as status increases. Lack of central participation may discourage a natural tendency for reflective thinking; instead, rules and chunks of knowledge from the ‘old-timers’ are promoted as the initiating steps to acquire legitimacy in this community. Reflective experience is often supplanted by examinations and workplace-based assessments of measurable competence, and trainees are often preoccupied with what is expected of them (Reference Boud, Keogh and WalkerBoud 1985) rather than with their learning needs.

Integrating reflection into training and the workplace

If all of this is necessary for reasons of accountability or safety, vicarious experiences could be used for reflection (Box 2). When shadowing consultants, trainees' learning can be enhanced greatly if the consultants demonstrate critical reflection in decision-making, thus not only teaching through example, but also expanding the observations on which learners can base their own critical reflection. This requires an atmosphere of openness, equality and freedom of speech, which is not always available (Reference Grant, Kilminster and JollyGrant 2003). A receptive community of practice, where newcomers are treated with respect and are offered early concrete experience, would be a fertile ground for reflective learning.

Psychiatry is in a privileged position because of its protected time for supervision, but the ability of supervisors to assist reflective learning varies (Reference Kilminster and JollyKilminster 2000; Reference Grant, Kilminster and JollyGrant 2003; Reference LaunerLauner 2006). The most positive experience of supervision I had involved a dialectic analysis on events and cases. As Reference LaunerLauner (2006) proposes, storytelling, thinking aloud and questioning can reveal and challenge tacit theories, assumptions and attitudes in dealing with psychiatric cases. Bringing these to light permits scrutiny, reconstruction and testing in future action. Reference EngeströmEngeström (2001) also suggested ‘investigative’ learning cycles, where cognitive conflict created by the failure of usual approaches to produce meaning or solution prompts reflection. ‘Problems’ posed by supervisors need to be realistic, multifactorial situations (e.g. ethics and care planning challenges) that can be intellectualised and analysed reflectively, rather than decontextualised questions of fact.

It has been widely argued that reflective aids (e.g. templates prompting reflective questioning; critical incident reports; personal diaries; reflective writing) can contribute to transformative learning, particularly of values and attitudes (Reference GibbsGibbs 1988; Reference Boud and WalkerBoud 1990; Reference Rolfe, Freshwater and JasperRolfe 2001; Reference RodgersRodgers 2002; Reference Atkins and MurphyAtkins 2003; Reference BranchBranch 2005), and the Royal College of Psychiatrists (2010b) recommends that they be included in appraisal portfolios.Footnote † Social components of reflective learning are equally important (Reference Boud, Keogh and WalkerBoud 1985): peer-group meetings for problem-based learning or case discussion can accelerate participation and create micro-communities of reflective practice using, for example, action learning (Box 3) (Reference DilworthDilworth 1998). Finally, psychotherapy can play a role in the development of reflective psychiatrists, for example through Balint groups, group therapy and psychodynamic supervision (Reference Grant, Holmes and WatsonGrant 1993; Reference HopkinsHopkins 1994).

Activating transformative learning

Reflecting on this complexity, I developed a series of tutorials on diagnosis for students and trainees. These tutorials aim to activate ‘transformative learning’ based on discussions about psychiatric knowledge and practice and the multifaceted influence of society and culture. This can happen by asking questions fraught with value judgements and creating conditions for critical reflection (Box 4). When teaching, I try to act like a ‘coach’ (Reference SchönSchön 1987) who avoids giving ready answers. Working on the principle that adult students possess the abilities to reflect on such issues, the teacher is there to provide the right mixture of questioning, challenge and support and to create realistic situations in which these questions can be investigated, for example when working with patients and their care team, or during paper exercises using vignettes drawn from practice. Such a setting is especially useful in the analysis of narratives, emotions, values and attitudes, and can challenge stigma.

The reflective tutor should also observe and reflect on the direction of the learning activity by keeping track of events. In my tutorials I try to monitor nuances of the dialogue, non-verbal communication and participation, often inviting criticism and opposing opinions, or discovering gaps in my own knowledge. The literature refers to such challenges in teaching as ‘critical incidents’ (Box 5). These events may seem trivial, but they are useful material for reflection. Reference TrippTripp (1993) suggested that any incident or pattern in events can be rendered ‘critical’ when translated into a concise narrative and used as material for structured reflective analysis and modification of action. Such events tend to have in common some discomfort or disequilibrium (Reference Cunningham and CunninghamCunningham 2008).

The literature proposes various approaches to incident analysis. investigating dilemmas or ‘non-events’ (Reference TrippTripp 1993); asking the ‘why?’ question (Reference TrippTripp 1993); seeking alternative perspectives from students, colleagues or the literature (Reference BrookfieldBrookfield 1987); and adopting a stance of humility by acknowledging ignorance or failure as an opportunity for transformation (Reference MezirowMezirow 1981). Analysing group processes from within can also become a form of ‘social engineering’, where participants reflect on the components of the situation and the effects of various actions, with the purpose of modifying behaviours or finding solutions for teaching and learning challenges (Box 5) (Reference LewinLewin 1948; Reference StenhouseStenhouse 1975).

Artistry in professional practice

Reflection could be seen as a model for wider professional practice, from diagnosis and management planning to interaction with patients and colleagues. Reference SchönSchön (1983) proposed a new emphasis on reflection and artistry as an alternative to the traditional ‘technical rational’ paradigm for professional practice. His work was a product of the gradual realisation in the 1970s that the positivism and technology which had established the modern professions could not account for all human experience. Schön's ‘reflective practitioner’ was also a response to those ‘experts’ who shield their practice with an air of mystification, aiming to preserve status and autonomy in the face of challenging criticism, and to achieve the ‘cooperation’ of their clients. He also attempted to address the gulf that separated nomothetic academic research and idiographic frontline practice (Table 1).

TABLE 1 Two sides of professional practice

Real-life professional practice is characterised by artistry, often based on tacit knowledge, at the centre of which is a reflective loop that does not conform to the methods of academia. Nevertheless, this does not automatically achieve higher levels of criticality. Thus, in instrumental, problem-solving reflection the goal and the frame of reference are taken for granted and the effort is to reformulate theory and technique in order to reach the desired outcome. In contrast, complete learning involves meta-reflections that challenge the goal, motivation and explanatory model itself (Reference Argyris and SchönArgyris 1996), indicating the importance not only of finding the ‘right answers’ but also of asking the ‘right questions’.

The ‘theory in use’ model

In my experience, such an approach is particularly useful in setting psychiatry in its wider context and in acknowledging complexity and subjectivity, especially when communicating with patients and colleagues who have not been trained in the same way. When I formulate a case in order to inform care planning, I try to bear in mind that psychiatry has a long history of vicissitudes between conflicting paradigms, none of which can fully address the complexity of mental states. The discovery of drugs that were far superior to psychoanalysis in the treatment of psychosis is just the latest episode and founded psychiatry firmly in the technical rationality of bioscience – albeit, in common with most of medicine, technical rationality remains a partial explanatory model. As described earlier, diagnosis highlights not only the importance of professional skill but also its contextual frames of reference. In clinical practice, a tacit pattern recognition developed with experience gives rise to a hypothesis that is proved, rather than disproved (Reference PopperPopper 1968). Similarly, although basing treatment decisions on best available evidence is advocated, ‘knowledge’ produced by research is limited by generalisability/clinical relevance in inverted relation to rigour and objectivity. Although statistics might predict events in populations, they cannot reliably forecast individual cases because of the existence of the recognisable syndrome with virtually unlimited individual factors (Reference Sackett, Sackett, Haynes and TugwellSackett 1991). As a result, clinicians often draw evidence from the collection of ‘cases’ they have seen throughout their careers, which has little scientific robustness, but high validity for the individual.

This is an example of ‘theory in use’ (Reference Argyris and SchönArgyris 1996), an explanatory and action model that, although frequently employed, is rarely made explicit. In the extreme, such tacit theories, if they are applied uncritically as all-explaining, can restrict our perspective of patient suffering. In a psychiatrist, this can happen under the guise of a striving to be rational, unemotional and objective, while defining problems and desired outcomes unilaterally, usually in terms of symptoms and their control. Diagnosis and treatment plan may be based on inferences, and value judgements on states of mind, functioning and problems that are not thoroughly tested for their validity in a dialogue with the patient and other members of the team. When asked to communicate opinion, such a psychiatrist might talk directly about their conclusions without describing the underlying logic, or might refer to biochemical or psychodynamic explanations without considering alternative perspectives and narratives, including that of the patient. Miscommunication is often exaggerated further by existing or assumed deficits in the psychocognitive function of the disordered mind. The concepts of insight and capacity then become central in defensive professional relationships with challenging patients who ‘do not know what is best for them’.

The theory in use may not even be compatible with the declared explanatory theory. Often, espoused theories are adopted at early stages of training as an ideological vehicle necessary for legitimation in the eyes of the community of practice. At worst, decision-making might be based on little conscious reasoning beyond rules of thumb, habits, conjectures, values and emotions in combination with selective, uncritical reading of research.

Critical reflection: a challenge to ‘theory in use’

If, instead, critical reflection is integrated into education and facilitated in supervision, peer groups and multidisciplinary meetings, it can become part of the psychiatrist's arsenal for dealing with relationships, case formulations and healthcare provision and can counteract the ‘theory in use’ model of practice. For Reference SchönSchön (1983), reflectivity is the key to learning through experience and developing ‘unrestricted’ professionalism. Schon proposed that professionals tacitly use ‘reflection-in-action’: whenever facing complexity, uncertainty and cognitive conflict they formulate an explanatory theory unique to the case at hand that informs their immediate action. This continues after the event as ‘reflection-on-action’ during educational and supervisory activities. Theories and actions can be revisited, reformulated and applied in experimental conditions or real practice. The reflective psychiatrist will question their implicit knowledge, engage in a dialogue with colleagues and patients, validate their theories and assumptions and present them to open scrutiny, bringing closer espoused theories and theories in use (Table 1) (Reference SchönSchön 1983; Reference Argyris and SchönArgyris 1996).

Reflection is a constant, dynamic activity that transcends the single individual and has the potential to reform whole groups or organisations from within. Being a social function, it has a role in criticising group-established hermeneutic and practical frames of reference. I analyse here only the example of the medical model of illness, but there is vast scope for critical reflection in psychiatric practice, where so much more than biomedical work takes place. Stigmatisation of deviance, deprivation of liberty, treatment without consent, tension between the individual and the social good, to name but few, are domains of evaluation, ethics and interpretation, largely influenced by traditional and current dominant discourses. The testing of hypotheses using statistical methods is the most robust approach for bioscientific knowledge in psychiatry (e.g. in the development of pharmacological treatments). On the other hand, qualitative and reflective methods are necessary to critically review and develop mental health law, sociology, psychodynamics and service management

Lack of validation

Although theoretically robust, reflective practice has not been extensively validated in real-life applications. There are reasons to doubt its practical merits: reflection is arduous, even unsettling, compared with tacit, habitual modes of practice, and can be met with resistance. Research has raised the question that some students and professionals might have genuine difficulty in reflecting because of their individual cognitive and learning styles, albeit this remains a controversial issue (Reference KolbKolb 1984; Reference Merrill, Reiser and DempseyMerrill 2000; Reference Coffield, Moseley and HallCoffield 2004; Reference Paschler, McDaniel and RohrerPaschler 2010).

Lack of time

The relevance of having time to reflect was compellingly argued in the context of social work (Reference IxerIxer 1999); I draw parallels with psychiatry, where decisiveness is often necessary in situations that involve the risk of violence or self-harm. It is debatable whether ‘reflection-in-action’ can be employed so swiftly, or whether well-rehearsed skills are then at play; proper reflection seems to require some detachment and interruption of action not afforded by many real-life situations. Similarly, the vast breadth of the psychiatry syllabus can act as a strong argument against methods that require more time and exploration, albeit it could be counterargued that, in the long-run, reflection is more economic, because it counteracts strategic learning and equips doctors to deal with novel situations that factual knowledge cannot predict.

Need for technical rationality

Promoting critical reflection should not be equated with denial of the multiplicity of knowledge within psychiatry or construed as an antithesis to objectivity. The impressive advances in therapeutics we have witnessed over the past 30 years have to be credited to the biomedical side of psychiatry and, despite its limitations, it still offers hope of finding more causal links and practical treatments. Denying technical rationality and evidence-based practice is a dogmatism just as perverse as denying the uniqueness of the individual, their narratives and meaning. I stressed that the art in psychiatry lends gravitas to reflective practice, but we should keep in mind that psychiatry is also a branch of biological science that demands a foundation of objective knowledge to grow. Thinking back to Schön's reflective practitioner, patients surely dislike a detached expert who ignores subjective experience and never admits ignorance, but would feel equally disconcerted in the hands of a psychiatrist who has no answers to questions of fact.

Oppression and demoralisation in the name of reflection

Thinkers have argued that the quintessential function of critical reflection is to lay the grounds for emancipation. The liberation of reflection will require substantial change in the way apprenticeships channel the legitimate participation of juniors. We should be wary and challenge any potential for oppression in the name of reflection. Modern medical education stresses accountability, and stakeholders demand clearly defined and assessed outcomes. Since there is no consensual understanding or technical means of objectively assessing reflection, any attempt to include it in mandated outcomes should be regarded with suspicion (Reference IxerIxer 1999). Nevertheless, the recording of reflection is already advocated for use in appraisal and it might not be long before unreflective enthusiasts proceed to its inclusion in summative assessment schemes. Both extremes are hazardous: institutional communities can act oppressively either by restricting substantial reflectivity or, conversely, by perverse applications in systems of conformism management.

Hierarchy might equally prevent critical reflection in established professionals. As they find their niche of central participation and expand their responsibilities to include nurturing the development of juniors, it appears that, more confident of their status, they experience less of the cognitive conflict necessary for reflection and self-awareness. A feeling of failure, dissonance or disequilibrium is argued to be essentially positive as material for reflection (Reference Cunningham and CunninghamCunningham 2008), but it can have a demoralising by-product of constant self-doubt. It could equally be argued that professionalism requires a balance of restorative and maintenance functions, the identification and reward of the positive rather than constant emphasis on deficits. Striving for continuous improvement is itself a socially prevalent discourse and, as such, can be seen as a product of its time and place, not as an absolute good.

Critical reflection without outlet or end

Theory claims that the reflective individual is in a better position to identify situational shackles and challenge them accordingly. In most definitions, the value of reflection is seen in consequent praxis, usually implying change. Reference FreireFreire (1971) warned that reflection without outlets for praxis becomes meaningless ‘verbalism’. One has to wonder whether awareness of intractable situations is any better than ignorance. It is anyway doubtful that total intellectual emancipation is feasible or necessary. In the past, it was identified with ‘total’ theories with pretence to all the answers – ‘meta-narratives’ that postmodernism warned us not to trust (Reference LyotardLyotard 1984). Any thought, no matter how noble and ambitious in its horizons, is in essence always socially constructed, partial and context-bound. In this sense, reflection can never reach the promise of realisation on an epistemologically or ethically privileged plane. Meta-reflection can thus become an infinite process, a barrier to praxis, without which the profession's existence is meaningless. Reflection can also be a source of excessive anxiety and insecurity when it attempts the impossible feat of encompassing all of the alternative discourses that are continually proliferating in our era of ‘supercomplexity’ (Reference BarnettBarnett 2000).