Introduction
Over the past 20 years, a number of studies have suggested that a training technique known as Self-Practice/Self-Reflection (SP/SR) may be a valuable adjunct to ‘usual’ therapy training. This article will assume a basic knowledge of SP/SR as a training intervention but for further details and examples see Bennett-Levy et al. (Reference Bennett-Levy, Thwaites, Haarhoff and Perry2015), Farrell and Shaw (Reference Farrell and Shaw2018) and Kolts et al. (Reference Kolts, Bell, Bennett-Levy and Irons2018). In brief, SP/SR participants practise therapeutic techniques on themselves using appropriate personally salient material, and reflect on the implications of their experience for their clinical practice, for their knowledge of the specific psychotherapy model utilized, and for their understanding of themselves. The Self-Practice element of SP/SR covers different techniques or interventions utilized within the specific therapy model and these are applied to oneself. For example, in cognitive behavioural therapy (CBT)-based SP/SR, a participant may undertake a behavioural experiment to test an identified belief that ‘If I give a presentation without practising it three times then it will be a disaster and my incompetence will be revealed’ (Bennett-Levy et al., Reference Bennett-Levy, Thwaites, Haarhoff and Perry2015). In Schema Focused Therapy, a participant might complete an imagery exercise involving a childhood experience when the participant was left on their own; the participant might then try and identify what their needs were and how this may have contributed to the development of any Early Maladaptive Schema (Farrell and Shaw, Reference Farrell and Shaw2018). The participant would then reflect on the Self-Practice (SP) experience through written reflections (SR). Some of these reflections are typically chosen to be shared with the training group (often via a message board), so that members can reflect on the extent to which their experiences are similar or different from others.
SP/SR has been used in a range of delivery models, including co-therapy pairs (e.g. Bennett-Levy et al., Reference Bennett-Levy, Lee, Travers, Pohlman and Hamernik2003), manualized workbooks (e.g. Bennett-Levy et al., Reference Bennett-Levy, Turner, Beaty, Smith, Paterson and Farmer2001, Reference Bennett-Levy, Thwaites, Haarhoff and Perry2015; Davis et al., Reference Davis, Thwaites, Freeston and Bennett-Levy2015; Haarhoff et al., Reference Haarhoff, Gibson and Flett2011; Thwaites et al., Reference Thwaites, Bennett-Levy, Cairns, Lowrie, Robinson, Haarhoff, Lockhart and Perry2017), self-case studies (Fraser and Wilson, Reference Fraser and Wilson2010; Haarhoff and Stenhouse, Reference Haarhoff and Stenhouse2004) and reflective blogs (Farrand et al., Reference Farrand, Perry and Linsley2010). To date, the published research has largely focused on CBT-based SP/SR programmes (and using manualized workbooks) (Bennett-Levy, Reference Bennett-Levy2019; Bennett-Levy and Finlay-Jones, Reference Bennett-Levy and Finlay-Jones2018), although variants of SP/SR are starting to emerge in other therapies, e.g. acceptance and commitment therapy (Pakenham, Reference Pakenham2015). For this paper, we limit the scope to SP/SR rather than the wider category of ‘personal practice’ which might for instance include meditation-based programmes such as MBCT [see Bennett-Levy and Finlay-Jones (Reference Bennett-Levy and Finlay-Jones2018) for a full review of the main types of personal practice].
The identification and codification of best practice principles for SP/SR is timely, as manualized SP/SR workbooks based on different psychological therapies are starting to emerge (e.g. compassion-focused therapy, Kolts et al., Reference Kolts, Bell, Bennett-Levy and Irons2018; schema-focused therapy, Farrell and Shaw, Reference Farrell and Shaw2018). Studies to date have reported that SP/SR has a positive impact on conceptual, technical and interpersonal skills, as well as enhancing the important metacognitive capacity to self-reflect (Bennett-Levy et al., Reference Bennett-Levy, Turner, Beaty, Smith, Paterson and Farmer2001, Reference Bennett-Levy, Lee, Travers, Pohlman and Hamernik2003; Farrand et al., Reference Farrand, Perry and Linsley2010; Haarhoff et al., Reference Haarhoff, Gibson and Flett2011; Thwaites et al., Reference Thwaites, Bennett-Levy, Davis, Chaddock, Whittington and Grey2014). In particular, it has been suggested that SP/SR may have a primary impact on therapist interpersonal skills (Bennett-Levy et al., Reference Bennett-Levy, Lee, Travers, Pohlman and Hamernik2003) and enhance the integration of the interpersonal with technical and conceptual skills so that there is a more nuanced and fluent approach to therapy (Thwaites et al., Reference Thwaites, Bennett-Levy, Davis, Chaddock, Whittington and Grey2014). Participants report an increased understanding of the process of therapeutic change and potential barriers to this. The impact of SP/SR has been attributed to the ‘reflective bridge’ it makes between the ‘personal self’ and the ‘therapist self’ (Bennett-Levy, Reference Bennett-Levy2019; Bennett-Levy and Haarhoff, Reference Bennett-Levy, Haarhoff and Dimidjian2019), so that the experience of psychological therapy on the ‘personal self’ through SP/SR impacts on professional understandings and skills, and leads to a deeper sense of knowing the therapy ‘from the inside’ (Bennett-Levy et al., Reference Bennett-Levy, Turner, Beaty, Smith, Paterson and Farmer2001, Reference Bennett-Levy, Lee, Travers, Pohlman and Hamernik2003). Thus, in CBT for example SP/SR may have a particular role to play in therapist skill development, as ‘usual’ CBT therapy training tends to be stronger in the conceptual and technical domains than in the interpersonal or personal domains (Bennett-Levy, Reference Bennett-Levy2006; Bennett-Levy et al., Reference Bennett-Levy, McManus, Westling and Fennell2009a).
There is a growing literature that addresses the acceptability of SP/SR (Haarhoff et al., Reference Haarhoff, Thwaites and Bennett-Levy2015) and the types of experience, benefits and changes that may occur [see Gale and Schröder (Reference Gale and Schröder2014) for a meta-synthesis of qualitative studies]. The increasing interest in SP/SR across therapeutic modalities is presumably based on the fact that it occupies a clear niche in therapist development and the increasing evidence that it does produce change. However, as for psychotherapy, any intervention that is not inert and has the potential for benefit logically also has the potential for harm [see Castonguay et al. (Reference Castonguay, Boswell, Constantino, Goldfried and Hill2010) for a conceptual overview of types of harm from therapy]. For instance, self-reflective groups are generally believed to be beneficial in training, yet half of the participants in one study reported distress and a significant minority were not able to use this experience in a helpful way (Knight et al., Reference Knight, Sperlinger and Maltby2010). As efforts are made to increase the accessibility and the potency of SP/SR in order to maximize its benefits, so there is a concern to minimize harm of any type. If the aim is to enhance the therapist’s competence, understanding, satisfaction and resilience, even temporary disruptions of these should be avoided or minimized whenever possible, especially as most therapists in training are also providing therapy at the same time. However, although SP/SR has been researched in various contexts, and the results appear promising, a small minority of trainees exposed to any form of personal practice (e.g. personal therapy, meditation programmes) may experience distress (Bennett-Levy and Finlay-Jones, Reference Bennett-Levy and Finlay-Jones2018); this includes participants in SP/SR programmes (Bennett-Levy and Lee, Reference Bennett-Levy and Lee2014).
Several factors have been identified which may impact on engagement with SP/SR and experience of benefit. These include course structure and requirements, expectation of benefit, feelings of safety with the process, a positive or negative experience of the training group, and available personal resources (Bennett-Levy and Lee, Reference Bennett-Levy and Lee2014; Jenkins et al., Reference Jenkins, Waddington, Thomas and Hare2018). An important issue, therefore, is to minimize the potential distress for trainees.
A further point is that participants may undertake SP/SR at different stages of career development. Some participants may have had no experience of being a mental health practitioner; others have no experience of being a therapist; others may have been trained in one therapy modality, and are now learning another; and some SP/SR studies have been undertaken with therapists who are already highly experienced as therapists or supervisors (e.g. Davis et al., Reference Davis, Thwaites, Freeston and Bennett-Levy2015). At each of these stages of learning, the pre-existing schema or absence of schema as mental health practitioner, therapist or specialist therapist is likely to determine the ease or difficulty of assimilating SP/SR experience into existing schema, or accommodating to develop new schema. These schemas are also likely to determine the emotional reaction to SP/SR. For instance, for some trainees without previous mental health background, it might be immensely challenging to engage with personally challenging material while their identity as a therapist is still in a fragile and early stage of development. However, for those who have previous experience as mental health practitioners in other roles or traditions, training in a specific therapy modality may essentially be what has been described as ‘supplantive learning’ (see Atherton, Reference Atherton2013b), and there may be a need to ‘forget’ or at least ‘put to one side’ highly developed knowledge, skills and sense of self in the previous role while one learns something new (e.g. Robinson et al., Reference Robinson, Kellett, King and Keating2012). This may be particularly difficult if the participant feels that the new skills/roles are in some way imposed (Atherton, Reference Atherton1999), for example, when role or career progression only seems possible by training for a new role. Finally, for experienced therapists, deliberate engagement with ‘therapist self’ and ‘personal self’ schema during SP/SR (e.g. Davis, Reference Davis2018) may be experienced as either assimilation (increasingly nuanced and deeper sense of self) or in some cases as accommodation (a new sense of self) which may be accompanied by stronger emotional reactions.
The theoretical ideas underpinning SP/SR are contained within the Declarative-Procedural-Reflective (DPR) model proposed by Bennett-Levy (Reference Bennett-Levy2006): ‘Reflection is identified as central to therapist skill development and, accordingly, a pivotal role is given to a reflective system, which enables therapists to reflect and build on their conceptual (declarative) knowledge and procedural skills’ (p. 57). Thus SP/SR as an activity seeks to engage the reflective system to further develop and link together declarative knowledge and procedural skills. In particular, it is believed that the interpersonal aspects of therapy – perceptual skills such as attunement, therapist stance, interpersonal knowledge, and relational skills – can especially benefit from SP/SR. However, while the DPR model provides the essential guidance for SP/SR on what to do and why to do it, there is rather little evidence on ‘how’ to implement SP/SR programmes.
At this stage, the field is not ready for a systematic review of SP/SR implementation processes. Other frameworks are needed to inform how to do it (with whom, in what way, and under what circumstances). In the absence of SP/SR-specific evidence (Thwaites et al., Reference Thwaites, Bennett-Levy and Haarhoff2015a), we suggest that the broader adult learning and professional practice literature can provide a strong theoretical underpinning to the principles that should be used when developing or implementing an SP/SR programme.
Accordingly the purpose of this paper is to distil a set of principles that guide how SP/SR is designed, adapted and implemented. We have drawn these principles from (1) models of adult learning, professional development and practice; (2) the theoretical underpinnings of SP/SR; (3) our experience in developing and facilitating SP/SR programmes; and (4) our wider experience in training, supervision and therapist development.
Existing and emerging SP/SR programmes and workbooks are implicitly or explicitly built on many of these principles (indeed the principles have been in large part derived from reflection on developing, testing and rolling out SP/SR). However, SP/SR is currently being adapted, enhanced and rolled out in new settings and for new therapeutic modalities. Consequently, we believe it is important to distil these emerging principles and make them explicit so that wherever SP/SR is used, it can be delivered and accessed in a way that is: (a) relevant to the individual; (b) most likely to enhance participant learning and development in an optimal way; (c) least likely to cause significant emotional distress; and can be used for (d) practitioners of different levels of experience; (e) as part of or alongside training programmes, and (f) in contexts where the practitioners are not currently in training (Bennett-Levy et al., Reference Bennett-Levy, Thwaites, Haarhoff and Perry2015). All these principles require examination and empirical testing as SP/SR becomes more widely utilized as a training method.
Figure 1 illustrates the structure of this guidance and principles, plus the sources of information underpinning the framework.
Figure 1. Moving from wider literature and specific experience to guiding principles and practical implications.
Section 1: Principles for designing, adapting and developing an SP/SR programme
SP/SR is conceptualized as a way of supporting and enhancing practitioner development at different stages in a person’s career. As such, it follows a number of key developmental, educational and professional principles that can inform programme design, adaptation, and implementation will be addressed in the main body of this paper under three main headings:
(1) Process issues in SP/SR,
(2) Content of SP/SR,
(3) Structure of SP/SR.
Process issues in SP/SR
At a conceptual level, we believe that there are some central generic ideas about development and learning that inform SP/SR programmes.
The notion of the Zone of Proximal Development guides SP/SR design
Vygotsky’s (Reference Vygotsky1978) concept of the Zone of Proximal Development suggests that for effective learning to occur, there must be a match between the stages of development of the practitioner and the types of task and types of learning that are sought. In addition, with ‘scaffolding’ the individual can complete tasks (and learn how to do this unsupported) that would have been outside their knowledge or skill set when working alone without support. There are similar ideas in the coaching literature (e.g. Macaux, Reference Macaux2010). Whilst undertaking an SP/SR programme, the content and structure of the programme provides the guidance or scaffolding. If the challenge is too low, there is insufficient stimulation and arousal for learning to take place; if too high then the practitioner will be anxious or overwhelmed and so unable to learn. In the zone, the person is able to learn; scaffolding tries to ensure that the person remains in the zone and adjusts the zone. For example, a specific module of CBT-based SP/SR might focus on learning how to design and implement a behavioural experiment, something that the therapist has not done before and which might be outside their current skill set even if they have some declarative knowledge around this. The content of the module (e.g. additional declarative explanations about behavioural experiments, suggested process and examples of potential materials that could be used, experience of applying this process to oneself and associated review process) provide clear scaffolding that might allow the therapist to develop novel skills in an unfamiliar domain, something that might have been too far outside their current knowledge and skillset to successfully achieve this without scaffolding.
The starting point for a specific SP/SR programme requires careful consideration of the participant’s (or group of participants’) current level of competence and understanding. Based on this, in what areas and in what ways can participants develop? What is it that they need to learn at this point? How do they need to learn? Equally, what is their level of self-knowledge? What aspects of their ‘personal self’ or ‘therapist self’ can they develop (Bennett-Levy, Reference Bennett-Levy2019)? What do they need to learn about themselves at this point? How open/willing are they to learn it?
Understanding of change processes underpins the way that SP/SR is implemented
From a Piagetian standpoint, there is a need to be aware of both assimilation and accommodation processes (Piaget, Reference Piaget1948). Provided that the starting point for the material and the exercises is pitched at the right level, then relevant self-schema should be activated. By building demand progressively across a course of SP/SR, much of the new experience will be assimilated into the existing self-schema. These self-schemas will then become updated with new experience and become increasingly detailed and rich. However, there may be new experiences that cannot be assimilated and disequilibrium will occur. The disequilibrium may be experienced as uncomfortable, but accommodation will result through reorganization of the material and the emergence of richer or more complex self-schema. Assimilation and accommodation typically work together in children, but it has been argued accommodation may be more difficult as people age (Atherton, Reference Atherton2013a) and people may be more likely to fit experience to categories rather than develop new categories. Thus when accommodation does occur because the fit is no longer possible, it may be particularly uncomfortable. Atherton (Reference Atherton2013b) has also described the process in non-Piagetian terms as de-stabilization, disorientation and re-stabilization leading to a ‘learning trough’ before new skills emerge. Other may recognize this as de-skilling often described in professional training (e.g. Lombardo et al., Reference Lombardo, Milne and Proctor2009; Robinson et al., Reference Robinson, Kellett, King and Keating2012, Thwaites et al., Reference Thwaites, Cairns, Bennett-Levy, Johnston, Lowrie, Robinson, Turner, Haarhoff and Perry2015b). There are two implications for SP/SR programmes: firstly, occasional disequilibrium at key points is normal and to be expected so it can be normalized and structures and procedures to manage it are required. Secondly, at times it is likely that progress may be seen as linear, but at other times step changes may occur. These step changes may be preceded by or occur alongside dips in confidence and perceived competence as the disequilibrium or learning trough occurs.
Adult learning informs engagement in SP/SR
As adult learners, Knowles (Reference Knowles1990) argues that (compared with younger students in any educational or training programme), participants will be self-directed, more likely to engage in experiential tasks, more ready to learn about real-life problems, and more oriented to competency development. In line with these principles, SP/SR seeks to facilitate a degree of engagement that is appropriate to each participant by balancing invitations to elicit greater degrees of engagement with prompts to consider their readiness to do so. Consequently, which self-schema and the degree to which they are accessed and developed will vary from one participant to another – there is no single ‘right way’ to engage in SP/SR. Although by definition all SP/SR participants are adults, younger people or people at the start of their career or professional training may be less in an ‘adult learner’ perspective in the area of therapeutic practice and so any assumptions about the extent to which a given individual is an adult learner may need to be calibrated.
Reflection as the engine of lifelong learning as a therapist drives SP/SR
It has been argued that reflective practice is the key to continuing therapist development (Bennett-Levy et al., Reference Bennett-Levy, Thwaites, Chaddock, Davis, Stedmon and Dallos2009b). Bennett-Levy et al. (Reference Bennett-Levy, Thwaites, Chaddock, Davis, Stedmon and Dallos2009b) provide a working definition of reflection as ‘the process of intentionally focusing one’s attention on a particular content; observing and clarifying this focus; and using other knowledge and cognitive processes (such as self-questioning, logical analysis and problem solving) to make meaningful links’ (p. 121). Reflection may be understood as what turns experience into expertise as learning occurs from re-arrangement and integration of existing information into something that is more than the sum of the parts. It is believed that reflection is particularly useful in joining up and synthesizing different types of experience and knowledge. In more familiar terms this joining up is believed to be the difference between ‘twenty years of experience or one year of experience twenty times’ (Skovholt et al., Reference Skovholt, Ronnestad and Jennings1997, p. 365) when reflection has occurred and the person has linked ongoing experience to current knowledge structures and so further updated them leading to deeper levels of understanding. However, the context and activity in which reflection occurs is important as studies on reflective practice groups have shown that although they have various benefits they can cause distress (e.g. Knight et al., Reference Knight, Sperlinger and Maltby2010) and perhaps also harm. Furthermore, it may be unwise to assume that people know how to self-reflect or what to reflect on or that the quality of self-reflection will naturally increase (Niemi and Tiuraniemi, Reference Niemi and Tiuraniemi2010). In practice this skill may need to be actively developed (see Orchowski et al., Reference Orchowski, Evangelista and Probst2010). Recent SP/SR manuals have started to specifically include guidance on ‘how to reflect’ to try and establish common basic skills in this area (Bennett-Levy et al., Reference Bennett-Levy, Thwaites, Haarhoff and Perry2015).
Content of SP/SR
There are a number of important principles to guide the choice of SP/SR content and its sequencing.
SP/SR exercises need to be grounded in appropriate content
SP/SR is currently considered an adjunct to training and a means to continuing development rather as a primary training method. It is used to deepen understanding and develop new awareness about therapeutic strategies of which the participant already has some knowledge. Therefore the content and activities are chosen so that the practitioner already has a sufficient degree of familiarity and understanding. While the degree of challenge or ‘stretch’ can increase over time, both Vygotskian and Piagetian principles would suggest starting with the familiar. Thus, if used alongside a training programme, there should be sufficient time for the participant to understand the material and practice during training before it becomes content for SP/SR. Feedback on initial practice may also be important to ensure that the trainee has developed sufficient understanding and skill to ensure that what is practised during SP/SR is ‘good enough’ for further development, rather than further practice and reflection on the misunderstood. In addition, mechanisms may need to be in place to provide appropriately delivered corrective feedback if it becomes clear that a participant has misunderstood. In short, there is likely to be little benefit if during SP/SR trainees or therapists are practising and reflecting on the ‘wrong thing’ or in an unhelpful state of confusion or self-criticism without corrective mechanisms in place.
Once people have experience of SP/SR with familiar material, the ability to use SP/SR techniques with relatively unfamiliar or novel material will be much greater because they should understand the process. However, two issues remain: first, it is important to make sure that corrective feedback is accessible; second, the likelihood of deskilling or learning troughs has probably increased. Equally, for experienced practitioners it may also be important to provide summaries of key concepts or practices or provide links to appropriate materials or updates as it may have been a while since they developed their basic knowledge and skills and there may have been drift (e.g. Waller, Reference Waller2009) and/or the field may have moved on.
SP/SR needs to be grounded in context
As SP/SR seeks to develop skills and self-schema in interpersonal areas, so the content should provide the means to develop these with reference to specific characteristics of the therapist’s work context. For example, appropriate content could and perhaps at times should be explicitly grounded with reference to particular clinical problems and populations (e.g. client group, service, etc.). In addition, it has been argued that CBT therapists need to develop cultural competency (Friedberg et al., Reference Friedberg, Gorman and Beidel2009; Stone et al., Reference Stone, Beck, Hashempour and Thwaites2018) and SP/SR can be a useful intervention in developing awareness of one’s own cultural identity and potential implications of this for the delivery of therapy (Haarhoff and Thwaites, Reference Haarhoff, Thwaites, Haarhoff and Thwaites2016).With greater adaptation, programmes can include exercises specifically designed to lead to reflection on cultural, multicultural, religious or group-specific issues (e.g. asylum seekers, veterans) (e.g. Bennett-Levy et al., Reference Bennett-Levy, Thwaites, Haarhoff and Perry2015; Haarhoff and Thwaites, Reference Haarhoff, Thwaites, Haarhoff and Thwaites2016).
As therapists develop, it is likely that their roles will increase in range including supervision, consultancy, training, service development and leadership. More experienced therapists can use SP/SR to not only consider the implications for their therapy, but for the other roles that they occupy such as in supervision and training or in consultancy/expertise. This was a specific focus in Davis et al. (Reference Davis, Thwaites, Freeston and Bennett-Levy2015) where the experienced CBT therapists, most of whom were already supervisors, were asked specific reflective questions about the possible implications for their ‘supervisor self’. They rated various aspects of their practice in relation to their therapist role, but in retrospect the study could also have investigated the impact on self-ratings specifically regarding supervision skills.
SP/SR seeks to develop self-reflective knowledge and skills
Reflection and self-reflection are skills-based activities (Bennett-Levy et al., Reference Bennett-Levy, Thwaites, Chaddock, Davis, Stedmon and Dallos2009b). Trainees and practitioners will come to SP/SR with different levels of knowledge, skill and experience in reflection and self-reflection. Within a course of SP/SR it is expected that the ability of the practitioner to engage in self-reflection will usually increase over time. Earlier exercises should seek to develop an explicit awareness of self-reflection and facilitate reflective skill (e.g. knowing what content is most appropriate, how to best access relevant material, identifying and troubleshooting barriers to reflection) as without such focus, the depth and content of self-reflection may not change over time and reflection on interpersonal aspects may be under-represented compared with conceptual and technical elements (Niemi and Tiuraniemi, Reference Niemi and Tiuraniemi2010). The relative emphasis in early modules could therefore include content on ‘doing SP/SR’ and ‘learning from SP/SR’ in much the same way that early supervisory sessions with novice supervisees are often ‘about supervision’ as much as it is about the supervised cases. This is similar to ‘learning how to learn’ and levels of learning as described by Bateson (Reference Bateson1973). Later exercises can then draw upon this experience and address tasks that may increase in complexity and/or material that may increase in its degree of personal salience and challenge. A key aspect of this content is training participants to become aware of barriers to reflection (e.g. high emotion, too much information, boredom, complacency) and help them to identify triggers and actions which would enable them to engage the reflective system at these points (often when needed most). Reflective prompts can be used to help people to then use these skills while in therapy, supervision, etc. In this way reflection on action can develop into reflection in action (Schön, Reference Schön1983).
Structure of SP/SR
As for therapy and supervision, there are three levels of structure within SP/SR: within-session, across-session and the contexts or structures within which the activity is situated. Recognizing and attending to all of these is likely to maximize success and prevent, resolve and mitigate things that could potentially go wrong.
SP/SR programmes should facilitate process through within-session structure
The basic structure of exercises within SP/SR seeks to scaffold the participant in a predictable and increasingly familiar way. Thus all SP/SR exercises share the same basic features that can be applied to different content areas in different programmes, based on experiential learning principles (Kolb, Reference Kolb1984). SP/SR exercises are also framed by the concept of the reflective practitioner (Schön, Reference Schön1983). Exercises typically include a rationale, provision of information about the skill or technique, initial ‘calibration’ of the bottom of the Zone of Proximal Development, the exercise itself, and then scaffolding or prompts that encourage people to observe or notice, and then questions that abstract, link or synthesize. The linking and synthesizing are critical, for example in a CBT-based SP/SR programme: ‘What are the implications of your experience of doing the behavioural experiment for your clinical practice? How does it match with your understanding of CBT theory?’. Or in a schema-focused therapy-based SP/SR programme a participant might be asked to engage in a task identifying when their modes and schema are activated and then would be asked about the implication of this experience for their understanding of schema-focused therapy (Farrell and Shaw, Reference Farrell and Shaw2018). The scaffolding allows each person to extend the Zone of Proximal Development upward and find their own upper level by engaging them in reflection. The skills of reflection on experience and self-reflection become internalized through repetition.
SP/SR facilitates process through across-session linkage
While each SP/SR session can stand alone as discrete exercises, linking across sessions is assumed to be a key part of the process. At a conceptual level, repeated accessing, engagement, and updating of the same or related self-schemas with new material is most likely to have the maximal effect. This can be achieved when across several SP/SR modules, different types of experience and material are attended to, re-constructed and observed and then, if appropriately prompted, can be conceptualized and synthesized and the schema are updated (Piaget, Reference Piaget1948). One way to do this is to initiate and develop threads than run through the course of an SP/SR programme. These threads can include identifying particular skills to develop, beliefs about self that can be tracked, or themes such as application to particular aspects of one’s work. For example, some evaluations of CBT-based SP/SR have identified beliefs about the ‘personal self’ and about the ‘therapist self’ before the programme and then tracked them on a weekly basis (e.g. Davis, Reference Davis2008). While these beliefs have been used for programme evaluation, they also provide linkage and facilitate repeated engagement with the same personally relevant content on a week-to-week basis.
SP/SR should safeguard process through programme structures
Regardless of the context of SP/SR implementation, there are a range of structural considerations that are required to ensure safe and effective practice. There is no prescriptive set of conditions. Indeed this would be inconsistent with the principles outlined above and requirements will vary substantially dependent on a range of factors. However, consideration and clarity is needed about a number of issues including:
(1) Responsibility for the programme: where are the programme boundaries and/or links: who hosts it, what is its status within the host organization, is it affiliated with other organizations?
(2) Participants: trainee, autonomous practitioner, degree of experience as a therapist and responsibility in managing their professional development?
(3) Basis of participation: is it obligatory, expected but with opt out, encouraged, voluntary, self-initiated?
(4) Participation and academic assessment: is participation in the programme subject to assessment for an award? If so, how?
(5) Governance: who needs to know this is happening; who has oversight?
(6) Roles and relationships between participants and facilitator/organizer: what is the status of participants? Are there any power considerations and dual roles (supervisor, tutor, assessor, manager, etc.)? How will these be managed?
(7) Relationships between participants: are there dual roles (friends, work colleagues, etc.)? What are the boundaries?
(8) Information flow between participants: what information is shared with other participants? Is it anonymous? Do participants interact directly? Is it moderated? If so, by whom and on what basis?
(9) Information management: what information is shared? With whom (facilitators, directors, supervisors, etc.), in what form, who has access to it, what can/should be disclosed to whom and under what circumstances? How is it stored and for how long? Who is responsible for information management? Under what guidelines and codes of practice?
(10) Managing disequilibrium and unexpected consequences: what structures and procedures are in place to manage distress?
(11) Evaluation of programme: is the programme being evaluated? If so, by whom, for what purpose and how?
(12) Ending the programme: will communication with facilitator/host, sharing of reflections, responsibility for managing distress or other unintended or untoward effects finish immediately after the final structured activity within the programme? Will there be a follow-up? Can participants carry on sharing reflections, e.g. on a blog? If so, for how long?
(13) Information about the programme and consent: what information is provided to participants about these issues? Is a formal consent process necessary?
Given the range of issues above, and in line with best practice in therapy and supervision, there are a range of key tasks that are required for safe and effective SP/SR implementation. These include some form of pre-programme meeting where key information is shared and participants and organizers can develop a shared understanding and address any concerns or incorrect beliefs, a contract or set of agreements (the formality and detail of this will be determined by answers to the questions outlined above) and a robust review process at key points.
Section 2: Applications of the principles
In Table 1 we take each of the principles in turn, provide a brief summary of the key issue and provide some of the main implications for designing, adapting and implementing programmes. By respecting these principles and applying them in different contexts, SP/SR programmes will emerge in various forms. However, we also indicate how well-designed generic programmes aimed at a particular level of trainee or therapist could also be adapted to various degrees to work in particular settings. Thus, Table 1 provides guidance on how to develop stand-alone or novel programmes, but also how to adapt or implement programmes within specific settings and for specific purposes.
Table 1. Guiding principles, key ideas and implications for designing, adapting and implementing SP/SR programmes
Section 3: Further reflection on self-reflection and sharing
Before concluding, it is worth considering the implications of asking people to fully engage in self-reflection. Although not reviewed in detail here, there is a fairly extensive literature on the differences in people’s ability to self-reflect (Bennett-Levy and Thwaites, Reference Bennett-Levy, Thwaites, Gilbert and Leahy2007; Eva and Regehr, Reference Eva and Regehr2005; Kuiper and Pesut, Reference Kuiper and Pesut2004) the extent to which this skill set can be developed and how, the circumstances under which it is more likely to occur or not, the influence of mood on content, the impact of blind spots, the possibility of distress or destabilization, and ultimately its effectiveness [see Atherton (Reference Atherton2013c) for a lively discussion and bibliography]. Although self-reflection is thought to be enhanced by the presence of another or others (hence there is usually an element of shared reflections between participants in one form or another), there are some important implications for SP/SR programmes.
First, it is likely that some material may be inappropriate to share or that people will be unwilling to share in particular circumstances as is known to be the case in supervision (see Ladany et al., Reference Ladany, Hill, Corbett and Nutt1996). Shame in particular has been associated with non-disclosure (e.g. Yourman, Reference Yourman2003). Reflection on, and writing about, intensely personal material may be personally beneficial and there are also suggestions that re-reading self-reflections at a later point (re-reflection) is also beneficial (Sutton et al., Reference Sutton, Townend and Wright2007). For self-reflection to be effective the possible impact of self-censorship must be minimized so it does not become an exercise in impression management or other motivation for non-disclosure. Anecdotal evidence suggests that anxiety, fear of judgement or rejection, or self-consciousness or embarrassment can all be important issues for some participants and may impact on sharing. Therefore, attention to process in the early stages of sharing reflections is likely to be beneficial. SP/SR programme material can explicitly alert participants to these issues and so normalize them. The material can also draw attention to how these concerns can lead to possible self-censorship and then provide prompts in the early stages of the programme to explore these concerns and related behaviours.
Second, the ability to understand, link and manage the public-private and professional-personal boundaries is one of the competences expected from mental health professionals and is detailed in many training standards and guidelines (e.g. Royal College of Psychiatrists, 2013). This includes knowing when others could and should be informed. Therefore what is reflected-on, what is recorded by the person and what is shared and with whom it is shared must be explicitly and transparently managed.
Third, these issues are especially important when there is an aspect of assessment related to participation in an SP/SR programme (Sutton et al., Reference Sutton, Townend and Wright2007). Although these issues apply to participants at any stage in their career, they may be particularly relevant among younger participants and those of any age moving into unfamiliar roles with little previous training in professional settings or opportunity to develop self-reflective skills.
Based on these issues and some helpful sources (e.g. Atherton, Reference Atherton2013c; Orchowski et al. Reference Orchowski, Evangelista and Probst2010; Sutton et al., Reference Sutton, Townend and Wright2007) it is recommended that:
(1) A clear distinction is made between self-reflections for personal use when completing SP/SR (i.e. recorded as part of the reflective process) and the reflections chosen to be shared with fellow participants. Typically, we suggest a distinction between reflection on content, and reflection on process. In the private space, it is important to reflect on the content of one’s thoughts (‘I was feeling upset as my partner hadn’t phoned’), as well as on the process (e.g. ‘How useful were Socratic questions in building my awareness of alternative explanations and changing my mood?’). In the public space, we suggest that participants share their observations about the process rather than the content.
(2) It is made clear to all participants that they are not under obligation to share all of their self-reflections (although unwillingness to share any material may indicate that the person may not be ready to engage in SP/SR).
(3) A clear rationale is offered for why sharing of self-reflection material is recommended.
(4) Careful consideration is given to the time and conditions necessary to engage in self-reflection, the sharing of reflection, and the further reading and reflection on the shared reflections.
(5) Expectations of confidentiality are made clear to any sharing community.
(6) When material is shared online, that an appropriate and secure platform is used and all reasonable precautions are taken.
(7) Procedures are clearly communicated concerning the online storage, security and access; the possibility of removal of material once shared; procedures to close down, store and/or destroy shared material at the end of the programme; any additional uses, etc.
(8) Conformity with any relevant legislation or institutional policies. Consulting guidelines for Data Management Plans used in both clinical and research settings may be helpful as the issues overlap and these normally cover the issues in a high level of detail [see Drummond et al. (Reference Drummond, Cromarty and Battersby2015) and Jones (Reference Jones2011), respectively for overviews].
(9) When a reflective portfolio is assessed, the procedures of assessment are made clear, including how the assessment will be conducted, who will conduct the assessment, how material will be stored and for how long, who will have access, whether copies will be made, whether material will be retained, etc.
(10) People submitting material for assessment have the right to remove or redact certain sections of the portfolio.
(11) Guidance on these issues is provided to participants in writing.
(12) Participants can seek advice on these issues through an appropriate route which should be as separate as possible from those who will be involved in the assessment.
Conclusion
In the history of psychological therapies there have been clear tensions between innovation versus codification, between proprietary branding versus collectively held knowledge, and between building on what has worked before versus reinventing the wheel. We have tried to strike a middle ground in this article and sum up what we know so far (both from experience directly in running SP/SR programmes but also from related areas such as training and supervision) and make it available while at the same time using it to develop and enhance our own work in the field. There is now a degree of maturity in the field of reflective practice programmes in psychological therapies and for SP/SR in particular. The programmes that have been developed so far have gone through various iterations, have been tested in various settings and have been reflected on, and so what has emerged is not haphazard. The enthusiasm for SP/SR is very encouraging, but as we seek to increase its potency and enhance the benefits that we believe are there, we are mindful of the possibility of unintended harm. SP/SR programmes are being developed in a range of other therapeutic modalities (e.g. schema-focused therapy, Farrell and Shaw, Reference Farrell and Shaw2018; compassion-focused therapy, Kolts et al., Reference Kolts, Bell, Bennett-Levy and Irons2018) in addition to the CBT content of the previous programmes, therefore it is important that we have generic guiding principles rather than procedures that are based in specific forms of therapy.
Many of the principles described in this paper are embedded in SP/SR and similar experiential learning programmes that have been developed so far, but we have also considered some of the possibilities for further development that may go beyond current SP/SR practice. While we recognize that at times we may be in danger of stating the obvious, it may only seem obvious once it has been stated. The emerging principles in this paper are heuristic not prescriptive. We would hope they lead to careful implementation of existing programmes, thoughtful adaptation, ongoing innovation, and especially more evaluation and although currently the studies are lacking in this area (hence the approach taken in this paper). In time, a systematic review would be useful to capture evidence and best practice in this area.
Author ORCIDs
Richard Thwaites, 0000-0002-6104-7027, Mark H. Freeston, 0000-0002-8107-1219, James Bennett-Levy, 0000-0003-0998-116X
Acknowledgements
None.
Financial support
No financial support was provided for this paper.
Conflicts of interest
All three authors have received honoraria for training on this topic. Authors Bennett-Levy and Thwaites receive royalties for books on this topic.
Ethical statement
Ethical approval is not required for this paper as it does not involve data collection, it is a synthesis and position paper.
Key practice points
(1) While there are increasing numbers of SP/SR outcome studies, few aspects of the process, content and structure of SP/SR implementation have been empirically evaluated.
(2) With SP/SR programmes now being offered in different therapies, it seems an appropriate time to establish some key principles to guide the choice of process, content and structure of SP/SR programmes.
(3) We suggest that the adult learning and professional practice literature can provide a set of principles to guide the development and implementation of SP/SR programmes.
(4) These principles are articulated together with the implications for designing, adapting and implementing programmes.
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