Introduction
There is renewed interest in developing and refining a reflective approach towards the training of cognitive behavioural therapists (Bennett-Levy et al., Reference Bennett-Levy, Turner, Beaty, Smith, Paterson and Farmer2001; Bennett-Levy, Reference Bennett-Levy2006). Self-Practice/Self-Reflection (SP/SR) is based on the premise that techniques in cognitive behavioural therapy (CBT) can be effectively learnt through trainees practising the techniques on themselves then reflecting on this practice (Bennett-Levy et al., Reference Bennett-Levy, Turner, Beaty, Smith, Paterson and Farmer2001; Bennett-Levy, Reference Bennett-Levy2006). Specific benefits have been reported to arise with SP/SR such as improving communication of the conceptual framework of CBT, increased attention to the therapeutic relationship, empathic attunement, therapist self-reflection and therapeutic flexibility (Bennett-Levy et al., Reference Bennett-Levy, Turner, Beaty, Smith, Paterson and Farmer2001).
However SP/SR is not unproblematic, with challenges associated with the self-reflection component. Central amongst these is the observation that setting time aside within courses for reflection does not necessarily result in trainees using such time to reflect (Boud and Walker, Reference Boud and Walker1998). Rather, to promote self-reflection, activities should be framed within the learning context of the course, to provide direction and be well planned and supported to ensure trainees are aware of the process and course requirements (Boud and Walker, Reference Boud and Walker1998).
Potentially the use of blogs, a freely accessible web-based communication tool, provides an ideal way to establish an appropriate and structured learning context to support reflective practice. Providing a personal learning space to enable trainees to interact around study topics has been central amongst several proposed uses of blogs within teaching and learning. Little has been reported concerning the use of blogs to support psychotherapy training. This is surprising given the emphasis such training places upon reflective practice (Schön, Reference Schön1983).
Using a focus group methodology, this small study seeks to examine the benefits and limitations of using reflective blogs to support a SP/SR approach towards CBT training.
Method
Participants
Participants were 19 (4 male, 15 female) health and allied health professionals with a mean of 18.8 years' experience. All had completed a postgraduate module in adjuvant CBT, and none had previous CBT training.
SP/SR course requirements
The module comprised five teaching days delivered 3 weeks apart to give trainees enough time to practise and reflect on the CBT techniques and then post these on the blog. A supervision day was then provided 2 months after the last teaching day, allowing trainees enough time to have further practised the techniques.
The first day provided trainees with an appreciation of the core assumptions underlying CBT, discuss cognitive models and the SP/SR supervision model. Throughout the following 4 days there was a strong emphasis upon skills development in five core CBT techniques: problem level formulation, guided discovery, cognitive restructuring, behavioural experiments, and activity scheduling. The approach to training was participative and experiential. Each day began with a 90-minute group supervision session based around the CBT technique previously covered. This was followed by introductions to the next CBT technique to help trainees gain an appreciation of the procedural aspects of the technique. Role play was not used as it was felt that SP/SR would provide a substitute for the learning of procedural skill.
Recording SP/SR reflections using structured blogs for each of the CBT techniques was a formal course requirement, although not part of module assessment. During the first teaching session trainees were given a copy of a seminal SP/SR paper (Bennett-Levy et al., Reference Bennett-Levy, Turner, Beaty, Smith, Paterson and Farmer2001) and asked to consider the paper to establish shared SP/SR ground rules for the following session. Trainees were informed that they were required to post at least one reflective blog for each of the CBT techniques learnt during the course. A deadline of a week prior to the following teaching session was set for all posts to enable the course tutor to synthesize reflections to inform the subsequent supervision session.
The reflective blog
Trainees were taught how to access and post a reflective blog during their second teaching session. Blogs were easily created using a standard blog tool included within the universities' electronic managed learning environment (Blackboard). A separate blog was established for each of the five CBT techniques covered during the course.
Trainees were not instructed in any form of reflection but asked to summarize what they had learnt about the respective CBT techniques, commenting in particular on what they found useful and difficult. The course leader [PF] posted to each blog on at least one occasion to motivate those who had already posted or encourage those still to post. As established during the setting of ground rules, blog postings included the name of the contributing trainee, but it was stressed that reflections should contain no confidential patient information.
Methodology
At the end of the module all trainees were invited and agreed to participate in a focus group to discuss their experience of using reflective blogs to support SP/SR. A focus group methodology was chosen, given its suitability to examine not only what people think but also the reasons as to why they think that way. Each focus group included an experienced facilitator and scribe, with questions based upon previous research into SP/SR (e.g. Bennett-Levy et al., Reference Bennett-Levy, Turner, Beaty, Smith, Paterson and Farmer2001) and into the use of blogs to support teaching and education (e.g. Williams and Jacobs, Reference Williams and Jacobs2004). To avoid potential bias the lead author and course teacher [PF] did not participate in the focus groups.
Analysis
Focus groups were audio-taped, with data gathered complemented by a practitioner-researcher self-study approach (Bennett-Levy et al., Reference Bennett-Levy, Turner, Beaty, Smith, Paterson and Farmer2001). Each audio-tape was transcribed verbatim, with subsequent organization and analysis supported with N5 software. A general inductive approach was adopted as the basis of the initial thematic analysis undertaken by the author [PF] and a researcher not associated with the project, with additional steps taken to ensure rigour (Pope, Ziebland and Mays, Reference Pope, Ziebland and Mays2000).
Results
Enhancing Self-Practice/Self-Reflection
Motivated Self-Practice/Self-Reflection. The requirement to post reflections on the blogs helped participants establish the value of practising CBT techniques on their own. This was mainly achieved by the blog providing participants with the ability to read others' reflections that highlighted the value of reflecting on practice.
Structured Self-Practice/Self Reflection. The use of blog posting deadlines ensured that participants actively engaged in SP/SR. Interestingly, participants indicated that the visibility of knowing who had posted to the blog served as encouragement to post reflections by the deadline. Presumably the lack of anonymity about who had not posted served to place participants under a certain amount of peer group pressure to conform to the SP/SR process.
Learning community
The reading and sharing of trainees reflective posts helped to establish a sense of support from within the teaching group and normalize the learning experience. Reading blog postings helped participants become aware that others were also experiencing similar difficulties learning the CBT techniques. The reflective blog also reinforced that learning was taking place; the chronological postings on the blog served as an historical reflective record that demonstrated increased understanding and competence with increased practice.
Enhancing the process of Self-Reflection
Several participants highlighted how the reflective postings of other trainees provided examples regarding the skill of reflection, enabling them to challenge and adapt their own reflective process. Additionally, the process came to be seen as an enjoyable learning experience, further enhancing a willingness to engage.
Improved course supervision
A review of the blog content was used to help set the agenda for the group supervision session provided at the beginning of each teaching day. This helped to inform the content of the supervision session whilst establishing a sense that the session was shared and relevant to all trainees.
Problems with the reflective blog
Skills teaching. The course was developed without the use of role play as it was felt that the SP/SR process would enable trainees to gain competence in the CBT techniques alone. Participants, however, felt that the need remained to have some opportunity to be watched using the CBT techniques to ensure they were being undertaken correctly, prior to engaging in SP/SR.
Technical problems. Several participants reported a range of technical difficulties accessing the blog, particularly with respect to knowledge in accessing web sites and using passwords. Additionally, in some cases participants were unable to access the blogs from work as trust security restrictions were placed upon website access.
Discussion
Results of this small study highlight ways in which SP/SR can be enhanced through the addition of reflective blogs. Several benefits were associated with increasing trainee engagement with the process and overcoming poor trainee participation (Boud and Walker, Reference Boud and Walker1998).
Including a requirement to post reflections on the blog potentially places SP/SR at the centre of the learning experience, due both to the availability of the posts by other trainees, and the synthesis of the posts to inform the group supervision sessions. Requiring posts to include the contributor's name promotes the idea that learning is not undertaken in isolation but as part of a learning community. This contributed not only to a sense of peer pressure to engage in the SP/SR process (Boud and Walker, Reference Boud and Walker1998) but also helped to normalize the learning experience by enabling trainees to realize that difficulties in learning techniques are often commonplace. These beliefs were aided by the availability of the chronological posting of reflections on the blog, which helped trainees appreciate that difficulties can be overcome through continued SP/SR.
SP/SR blogs also brought about improvements in the quality of the reflective skills. Whilst blog posts are initially quite diverse in style and content, it is common for a distinctive style of blog posting to emerge, given the ability to read previous entries (Williams and Jacobs, Reference Williams and Jacobs2004). The distinctive style became set by those reflective blog entries that were identified as being of the highest quality, and so setting the standard for other trainees' posts. Furthermore, the knowledge that all postings would be read and possibly scrutinized by others potentially forces trainees to confront their own opinions more comprehensively and consider how these would be reflected upon within their peer group (Williams and Jacobs, Reference Williams and Jacobs2004). This may promote a deeper level of reflection (Oravec, Reference Oravec2002) than would otherwise be produced were trainees merely required to reflect in their own time.
Alongside benefits, the study also points to two main limitations. SP/SR supported by reflective blogs should not be used in isolation from other training techniques, such as role-play. Rather it should be seen to complement such techniques as proposed within the DPR model of therapist skill development (Bennett-Levy, Reference Bennett-Levy2006). The other difficulty arose as a consequence of the use of computer-based technology to support the reflective blog. Clearly, consideration needs to be given towards supporting trainees who may be less familiar with such technologies. Appreciating which factors serve as barriers to the uptake of computerized CBT may inform ways to provide such support.
In conclusion, this study highlights the potential that utilizing reflective blogs to support SP/SR has in establishing an effective and flexible CBT training approach. With due consideration given to the identified limitations, the approach has the potential to increase training capacity at a time when demand for CBT training is high due to the roll out of Improving Access to Psychological Therapies. Indeed, several Psychological Wellbeing Practitioner training programmes have now adopted the SP/SR approach supported by reflective blogs.
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