Reflective practice

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).

Schön, Donald A. (1983). The reflective practitioner: how professionals think in action. New York: Basic Books. ISBN978-0465068746. OCLC8709452.

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.

Ziebart, C., & MacDermid, J. C. (2019). Reflective Practice in Physical Therapy: A Scoping Review. Physical Therapy, 99(8), 1056+.

Thinking about thinking…

For a long time I thought everyone thought about what they think about, how they think about it, and what their thinking concluded – now I know that some people never do this and live on simply following the rules (and probably having a fun and relaxed time of it!).  I, on the other hand, have always spent time at the end of the day thinking about my thoughts and what they mean and how I come up with them.  The technical term for this is ‘metacognition’, or ‘thinking about thinking’, and it’s a strategy that can be really useful in cognitive therapy as well as pain management – and even more useful in your professional work as a therapist.

I started writing this post after reading this from the Skeptical Methodologist… in it The Skeptical Methodologist points out that although ‘…the scientific method as we know it from the enlightenment is a sound way to find truth about our world, we must always remember that the evidence we produce from any one experiment is only as good as the assumptions that went into it.’

What this means, is that if we don’t include our assumptions in any experimental method, we won’t be able to seriously critique our findings – our findings may only hold true in certain circumstances.  This doesn’t detract from the truth of those findings in those circumstances, but it does mean that we can’t generalise without risking making errors.  For more about this, read Ben Goldman’s article on How Myths Are Made.

If we’re unaware of our assumptions we may never look at our findings in the light of them – and this error is one I’m especially concerned about when I see exclusive reliance on  ‘self reflection’ and peer review of practice.

After all, if we have learned our professional skills from others within the profession, and even our professional peers haven’t had a broad or general knowledge of other approaches to treatment (or even to science), then we’re unlikely to know the assumptions that we hold. Sometimes it takes an ‘outsider’ or an interaction with another model or approach to help us look at what we assume is a ‘given’.  This can be challenging and sometimes disheartening – but can aid us in generating new and different ways of viewing our practice.  Think of general systems theory which came originally from engineering and has now influenced almost all the sciences including biology, chemistry, physics, sociology, psychology and health care!

Wikipedia states that: ‘Metacognition refers to a level of thinking that involves active control over the process of thinking that is used in learning situations. Planning the way to approach a learning task, monitoring comprehension, and evaluating the progress towards the completion of a task: these are skills that are metacognitive in their nature. Similarly, maintaining motivation to see a task to completion is also a metacognitive skill. The ability to become aware of distracting stimuli – both internal and external – and sustain effort over time also involves metacognitive or executive functions.’

Metacognitive monitoring and metacognitive control of emotional states have been suggested as a way for people with mood disorders and other behavioural disorders to take control of their illness.  The suggestion is that the person monitors his/her emotional state, applies a label to it, compares it to what they would really like to feel, and then takes action to make the current emotional state become closer to the goal state.  Another approach is to become aware of the thoughts – label them, recognise the emotions – then choose what actions to take that will ensure what is important (eg a value) is done.  This is one of the underlying strategies of ACT.

So, what does metacognition look like?

For me, it means forever asking questions about ‘why’.  Why do I take notice of this and this and this?  Why does that strategy work here but not here?  It means I become aware of my thoughts – then I can check my beliefs, and the foundations of those beliefs, test them for helpfulness (and accuracy!).   I can match those thoughs against whether they are helping me achieve what I want in my life, and often whether they’re even accurate.

In pain management, it can mean helping patients identify their thoughts – and especially, their anxious worrying or ruminating.  Metacognitive theory suggests that this approach developes into ‘cognitive attentional syndrome’ where the thinking actually focuses attention on emotional content and distracts from active coping.   ‘This pattern consists of worry, rumination, fixation of attention on threat, and coping behaviours that the person believes are helpful but many of which backfire and keep emotional problems going.’ Treating these problems using metacognitive therapy involves ‘helping patients develop new ways of controlling their attention, new ways of relating to negative thoughts and beliefs, and by modifying metacognitive beliefs that give rise to unhelpful thinking patterns.’ Sound familiar?

In other words, if we can help people become aware of what they’re thinking and that it’s unhelpful and probably based on unaccurate beliefs (and distinct from who they are), and we’re able to engage them in activities that are much more interesting and involving, they’ll be able to reorient themselves into a life they want to live.

But before we start employing metacognitive therapy in pain management, how about spending about 10 minutes after doing an assessment or a treatment – and thinking about your thinking?  What goes through your mind while you’re working with that person?  What are your assumptions?  Check out whether you’re assuming things on the basis of gender, age, ethnicity, occupation, even diagnosis.  You might be surprised at what you find out.

Don’t forget, I post most days during the week, love coments (even when they don’t agree with me!) and will reply!  If you want to come back, just bookmark – or you can subscribe using the RSS feed link at the top of the page. Hope you have a good week!

Research and practise – relevant?

This week I want to focus on research.  A couple of events brought this up for me:

I spent some time with Margaret Morrell, professional supervisor and trainer in supervision on Friday.  She raised the thought with me that many practitioners (from any field) don’t routinely question what they do and why. Her view is that supervision provides a forum for this to happen – so that people can continue to develop as a professional, and to routinely bring criticism and questioning into their practice to be the very best they can be.  I was a bit stunned when she said this – I can’t remember a time when I didn’t routinely question what I do, how I do it, why I do it and want to be challenged, but it seems that there are those therapists who simply follow the ‘rules’ and act more as technicians than professionals.

This is a real problem for patients who don’t know the practice style of the health professional they are seeing – how do they know if the therapist they are seeing is simply doing what he or she has always done, or whether their practice is routinely informed by recent research developments?

The second event to raise this issue with me was via the SomaSimple forum where someone pointed out that there are people who question their profession over and again, and there are people who are satisfied with doing what they’ve always done.  There are people who can’t answer the question ‘why does it work’ – and worse than that – they don’t care.  And this means our therapy can’t move past holding onto ‘comforters’ or things that seem reassuring even when they may not stand up to the cold hard light of day.  I wrote about this recently when talking about occupational therapy and the ‘myth’ of ‘activity is good’.   It may be that the belief that activity is good is demonstrated empirically to be sound, but until then it’s simply a belief.

By coincidence, I received a contents list from the journal ‘Rehabilitation Psychology’ which has a complete issue on Methodological Advances and Issues in Rehabilitation Psychology.  While this issue is mainly about psychology in rehabilitation, it has so much application to rehabilitation in general, I think it’s worth exploring.
Here’s the abstract from the editorial from the journal:

Scientific research plays an important role in advancing the knowledge base of rehabilitation psychology. Research contributes to theory building and provides the foundation for empirically supported rehabilitation psychology practices, and model-based diversity-sensitive evidence-based interventions help persons with disabilities to become fully integrated into the society. Objective: In this article, the guest editors present their rationale for developing this special issue on methodological advances in rehabilitation psychology. Conclusions: They suggest that rehabilitation psychology research needs to be theory driven using rigorous research designs, strategies, and techniques and describe their selection of articles designed to highlight some exciting new developments in rehabilitation psychology research and to stimulate thinking and facilitate discussion about incorporating these new techniques in theory-driven research programs.

You know, that doesn’t sound so very different from arguments about using research in any field of human endeavour.  Perhaps it’s tainted a little by the drive to have a theory-driven approach, using rigorous research designs – I mean, where is the place for human judgement and expert opinion??!  (sly reference to this post where I reported that psychometric data predicts more accurately than clinician opinion…)

Is research relevant to practise?  Well yes, of course – if you ask me.  Sadly, some others in my field of pain management might say ‘yes, but’… .

I mean it does take time to read the literature.  It does mean holding a lot of information in your head and comparing your current practice with what the literature is coming up with.  It does mean critiquing research to establish whether it has application beyond its study scope.  It means working out irrelevant from relevant information, it means never taking something at face value, it means being prepared to change practice from what was learned as ‘truth’ all those years ago in training.  It can mean being unpopular when it becomes important to disagree with people who are vocal or ‘senior’ or happy to do what is palliative and doesn’t challenge patients.  It is such hard work!!

Ask yourself today: have I reviewed the treatment of a patient recently?  Have I checked in with the latest evidence for or against the model I use in my practice? Do I use a model, or do I ‘follow the rules’ as a technician might?

More on research and practise – and some practical stuff too – tomorrow!


Supervision has both a good reputation and a not so good – for me it’s been a mixed blessing because I have rarely had effective supervision from an occupational therapist (with the exception of my current occupational therapy supervisor!), and in fact the majority of my clinical supervision has been from psychologists.

I’ve posted much more about supervision in the Occupational Therapists Only section of my blog – there are some specific issues for occupational therapists that I want to grapple with – but here are some general thoughts on how supervision works for me, both as a supervisee and a supervisor.

Supervison for me entails someone else to challenge my thinking – I know I have cognitive biases that I am not aware of (we all do), and I need someone to challenge me in case I’m working an assumption that I’m not aware of.

Supervision also involves the process of talking which can help with formulating the information that is flying around in my head. By selecting and and putting together pieces of information to transmit my thoughts, I am actively processing in a different way from when I’m documenting assessment findings, or therapy process. The talking part involves me clarifying by using the clinical model that helps to explain what I’m seeing.

Supervision for me isn’t typically about me talking about my personal responses to a given clinical situation (as in, how do I feel about the therapy with this person, how am I coping). That aspect is something I prefer to deal with abstractly using music, dance, art, photography. I’m not sure that talking about how frustrated I am with someone, or how disappointed I am with someone does anything for me apart from encourage me to invest expectations in the person – when it’s their choice as to what they want to do next.

Supervision can be a form of therapist control. I’ve experienced this in the past where a therapist used supervision as an opportunity to rein in and dictate therapy practice, and discourage exploring issues. ‘Do it this way’ was the motto, with little encouragement to reflect, and most importantly for me, no evidence that ‘this way’ was any more effective than any other way.

Hawkins and Shohet, quoted by Smith, M. K. (1996, 2005) ‘The functions of supervision’, the encyclopedia of informal education, Last update: December 28, 2007, suggests the following foci for supervision.

The primary foci of supervision (after Hawkins and Shohet 1989)


To provide a regular space for the supervisees to reflect upon the content and process of their work Educational


To develop understanding and skills within the work Educational


To receive information and another perspective concerning one’s work Educational/Supportive


To receive both content and process feedback Educational/Supportive


To be validated and supported both as a person and as a worker Supportive


To ensure that as a person and as a worker one is not left to carry unnecessarily difficulties, problems and projections alone Supportive


To have space to explore and express personal distress, restimulation, transference or counter-transference that may be brought up by the work Administrative


To plan and utilize their personal and professional resources better Administrative


To be pro-active rather than re-active Administrative


To ensure quality of work Administrative/Supportive

Clinical supervision is seen as a sub-set of ‘educational’ supervision. I think it might be important that the three components of supervision are openly discussed and for some people, to have different supervisors for each component. It’s tough being open and honest with someone as a supervisor who may also be responsible for assessing performance and pay!

When I’m providing supervision, I really try to use the motivational model to help the therapist decide on:

(1) his or her values (what is important in his or her practice)

(2) various options and the consequences of those options

(3) how to reconcile ambivalence about making a choice as to which option is most aligned with his or her values as a therapist

This process requires extensive use of active listening skills, particularly levels of reflective listening. A potential area of conflict could be me trying to impose my own therapy values onto the person I’m supervising. I want to avoid this, because I believe it’s important for therapists to develop trust in their own internal radar.

I also provide loads of information leads. Sometimes supervision is simply about technical information.

Above all, supervision with me is confidential. I treat supervision as just another therapeutic session, subject to the same ethics as any other therapy. That is, I don’t expect to share content without the permission of the person. The only exception I make is the same exception I make clinically – personal safety and the safety of others.

For me, clinical supervision is all about the person being supervised. What he or she needs and wants from supervision is paramount. If ‘control’ is what supervision is about, it’s not really supervision, it’s management.

A couple of references for you:
This one is from Mark Smith who is part of infed. This site has a good number of thought-provoking articles on life-long education. Well worth a look.

The ERIC digest has an older article Models of Clinical Supervision that explores a number of different models for supervision.

Victoria’s Mental Health Services has a good pdf document Clinical Supervision Guidelines as well as information in that link. Great to download the guidelines if you’re thinking of developing your own thoughts on the issues.

And the final one is a paper about ethics and supervision, suggesting that if Guidelines for Supervision are in their infancy, so too are ethics in supervision.