In occupational therapy and some other health professions, reflective practice is a vital part of professional clinical activity. In others – not so much. And the term reflective practice has a heap of assumptions attached to it, so it may mean different things to different people.
I thought I’d unpack a bit about reflective practice today because I think it needs to be part of working with people experiencing pain. It helps us get out of our own mindset (when it’s done well), and opens a space for questioning what we do and why we do it – and as you probably all know, questioning is part of who I am!
According to Wikipedia (NO! Not an academic source – but kinda handy in this instance) “Reflective practice is the ability to reflect on one’s actions so as to take a critical stance or attitude towards one’s own practice and that of one’s peers, engaging in a process of continuous adaptation and learning” (Schon, D, 1983). In other words, we take an action then step back from what we’ve done to critically appraise it. The appraisal might be simply asking “what worked, what didn’t work, what would I do differently?” or it might be a more complex process in which someone else helps us to ask these questions or compare what we’ve done against a theory or another way of working.
I will admit that I hold some skepticism about how well we do reflective practice (the “we” being us human beings in general). This is because we’re incredibly prone to cognitive errors such as anchoring, commission and omission biases, framing effects, availability bias, vested interest bias and groupthink (see Scott, et al., 2017). The sneaky thing about these biases is that they’re implicit: that is, we often are oblivious that we do them. To combat them we need to take deliberate steps, and most of us haven’t been taught how to do this. Even when we have another person to work with as a prompt, we can get caught up in biases and fail to be critical about what we think of as “normal”.
Lilienfeld & Basterfield (2020) agree with me, pointing out that reflective practice theory and practice doesn’t draw on an understanding of the difficulties using introspection to become aware of biases (because we’re not aware of these intrinsic biases), that self-assessment often omits areas in which we either feel highly confident or we’re afraid we don’t know and don’t want to admit we’re struggling, and that we often don’t learn from experience. Ooops.
Yet, there’s enough evidence to show that by employing reflective practice, people can develop meta-cognitive skills in which they check their own assumptions, identify gaps in their knowledge, seek new information to fill those gaps, then try that knowledge out in practice (Ziebart & MacDermid, 2019).
BUT how do we do it, and does it make for better outcomes for the people we hope we help?
Lilienfeld and Basterfield (2020) offer some ideas – and caution us not to accept clinician satisfaction with the process of reflective practice with evidence of effectiveness. They propose drawing on research understanding debiasing: things like “consider the opposite” or “consider the alternative” as deliberate questions clinicians can ask themselves. Asking clinicians “how might I test out an alternative hunch?” could be a useful approach. Suggesting clinicians and their supervisors/mentors take an “outsider perspective” to step back from their decision-making as ‘disinterested third-party observers’ might help break through our tendency to overlook habitual practices just because they’re familiar (and perhaps help us remain willing to be vulnerable and compassionate towards ourselves instead of defensive).
I suspect clinicians working in pain management could do well with an ongoing relationship with a supervisor. Not someone who holds themselves as the “font of all wisdom”, not a “mentor” who feels responsible for shaping therapists into something new, but more as a mirror lens on practice. A neutral but supportive partner who can ask questions like “I wonder if we could use this [novel theory] to explore what’s going on” or “what if we thought about this [opposite theory] for a while to see what we learn”.
In situations where we are utterly certain of a causal relationship between X and Y, and where this leads to treatment A being the only viable option, we possibly only need to reflect on whether we’ve done the right diagnostics. In pain coaching/rehabilitation/management we have little certainty, far less to guide us, and a person experiencing pain. This person is often in a very vulnerable position where they trust us to do the right thing by them. If we fail them by being too certain we’re right without being challenged, we can do them an enormous disservice.
Lilienfeld, S. O., & Basterfield, C. (2020). Reflective practice in clinical psychology: Reflections from basic psychological science. Clinical Psychology: Science and Practice, 27(4). https://doi.org/10.1111/cpsp.12352
Scott, I. A., Soon, J., Elshaug, A. G., & Lindner, R. (2017, May 15). Countering cognitive biases in minimising low value care. Medical Journal of Australia, 206(9), 407-411. https://doi.org/10.5694/mja16.00999
Ziebart, C., & MacDermid, J. C. (2019). Reflective Practice in Physical Therapy: A Scoping Review. Physical Therapy, 99(8), 1056+.