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First published 2008 ISBN: 978 0 443 10139 7 British Library Cataloguing in Publication Data Acatalogue record for this book is available from the British Library Library of Congress Cataloging in Publication Data Acatalog record for this book is available from the Library of Congress Note Neither the Publisher nor the Authors assume any responsibility for any loss or injury and/or damage to persons or property arising out of or related to any use of the material contained in this book. It is the responsibility of the treating practitioner, relying on independent expertise and knowledge of the patient, to determine the best treatment and method of application for the patient. The Publisher The Publisher’s policy is to use paper manufactured from sustainable forests Printed in China vii Foreword In this accessible, thought-provoking book, Sally French and John Swain encourage qualified and student therapists (and other health profes- sionals) to think deeply about the needs and aspirations of the disabled people with whom they work. They explore the recurring challenges that people experience when living with long-term illness, physical impairment, mental health problems or learning difficulties. Unusually, they report on the experiences both of disabled service providers as well as service users. Their discussion reveals the skills and resources that disabled people bring to health care, as well as highlighting the ways in which difficulties arise from unexamined oppressive social systems and attitudes. The book traces historical changes in the professions of physiotherapy and occupational therapy, and the wider social and political forces that influenced how disabled people were treated in the twentieth century. Through reading first-person accounts, readers glimpse lives that were blighted by harsh institutional regimes, and by unpleasant medical ther- apies imposed without consultation. If not kept out of sight, disabled people all too often found themselves being made physically ‘accept- able’, even when this acceptability required painful operations, or clumsy prosthetic limbs. Whilst offering a critical perspective, the authors do not hector or blame health professionals for current inade- quacies of practice. Instead, readers are invited to identify for themselves the current taken-for-granted assumptions that operate in health care and rehabilitation. The authors discuss the pervasive influence of the biomedical model and its premise that disabled people need ‘cure’ or ‘normalization’ in order to live satisfactory lives, as well as the power imbalances in the healthcare system which continue to silence or distort the voice of service users. The authors present the social model of disability with great clarity, helping readers to understand the barriers that disabled people face in viii FOREWORD participating fully in everyday life, and maintaining meaningful roles and occupations. Through encountering models of critical reflection, guided activities, as well as research that vividly presents the voices of disabled people, readers will find themselves confronting the complex- ities of current ‘buzzwords’ such as empowerment, independence and partnership. The authors seek to make the field of disability studies accessible for health professionals and relevant to practice, through providing vari- ous reflective activities. Greater accessibility is clearly needed. This subject, whilst gathering momentum within academia, appears to have had only marginal impact to date on professional education and per- spectives. For example, recent research showing that children with cerebral palsy have as good a quality of life as their peers has been met with surprise by parents, as well as by health professionals. Such reac- tions perhaps reveal how deeply ingrained is the association between impairment and tragedy within our culture. Readers are likely to find themselves increasingly aware of the many structural barriers to change within health and social care (and within the wider society) that diminish disabled people’s choices and quality of life. Yet the book also carries positive messages that individual thera- pists can create meaningful change, even within a context of limited time and resources. We learn about what is currently positive within health care and rehabilitation, from the viewpoints of disabled people. These accounts show that person-centred practice is highly valued, and that therapists’ communication and relationship-building skills are as important to rehabilitation outcomes as their technical expertise. Some of the communication skills are not difficult to acquire, such as asking service users what they need to build a satisfying lifestyle rather than telling them what they need. Yet therapists’ existing status and assump- tions about their roles create barriers to genuine partnership working. The book carefully avoids empty exhortations but offers engaging activ- ities to help the reader develop not only a better intellectual understand- ing of disability but useful strategies for working in alliance with clients. Healthcare and rehabilitation professionals are increasingly expected to use evidence to guide practice. Unfortunately, the evidence which is judged to be most valid tends to be positivistic in nature, overly influ- enced by the biomedical model of disability, and focused solely upon measurable functional outcomes. The authors show that taken-for- granted ‘tragedy’ perspectives on disability are also incorporated within many current research tools and methods. One of the chapters in this book offers a refreshing alternative perspective by offering evidence Foreword ix derived from participatory research methods in which disabled people themselves initiate and control the research. The findings of such stud- ies provide many insights into disabled people’s needs, aspirations and preferences. The book is also helpful for introducing student and qualified thera- pists to the range of resources that are (or should be) available for dis- abled people, including Independent/Integrated Living Centres which have a user-controlled ethos, thereby avoiding the usual barriers of status and power in traditional services. In brief, this is a book which offers therapists, and other health professionals, the opportunity to learn about the social and political dimensions of disability and health care, to question existing roles and practice, and to work in more appropriate ways with, rather than on, disabled people. Frances Reynolds 1 1 Chapter What is critical reflection? CHAPTER CONTENTS Questions, questions, A broader context 10 questioning questions 1 How to use this book 16 Reflective practice 3 We are not beginning this book as might be expected, by examining the meaning of key terms like disability and impairment. Nor are we leap- ing into the more usual subject matter of disability studies such as preju- dice, inaccessibility and disablist language. We begin, instead, by exploring the possibilities for the engagement of professionals with dis- ability studies, the possibilities for developing professional practice, and the processes of change. We hope that it will be clear by the end of this introductory chapter why this is our starting point. QUESTIONS, QUESTIONS, QUESTIONING QUESTIONS You need a notebook, journal or workbook to document your thinking and responses as you read and consider the ideas discussed in this book. Those of you familiar with distance learning, for example with the Open University, may feel comfortable with this approach. This can, however, feel at the best unnecessary (bits to skip) and at the worst threatening (with implications that your thinking and practice are not good enough). We could begin with why you bought, borrowed or stole this book (and who you stole it from!). This is our shared starting point: what are you looking for and how do you wish to use this book? And perhaps the most threatening question – why? We shall end this chapter by considering how you might use this book, but to get there 2 UNDERSTANDING DISABILITY we shall begin by engaging you in the questioning approach. You will consider the first of many questions in the following activity. Activity 1.1 WHAT IS GOOD PRACTICE? Make a few notes to summarize your thoughts on the meaning of ‘good practice’. Did you find this an easy question to answer? As you might expect in a chapter entitled ‘What is critical reflection?’, we hope that you did not. The following discussion considers some of the embedded questions inherent in the question, ‘What is good practice?’ Good practice can be determined and defined within the knowledge base – in recent par- lance this is referred to as evidence-based practice. It is good practice because research has shown, for instance, that one form of therapy is better than another. Second, good practice is grounded in the informed intuition, creativity and art of the experienced practitioner. Third, good practice is defined in the evaluation of practice. This can be in the evaluation of process and/or product. In terms of process, notions of good practice can be and are expressed, perhaps derogatively, by ‘buzz words’, such as partnership, empowerment and client-centred practice. In terms of product, good practice may be defined in terms of meeting the needs, hopes and expectations of clients, and indeed practitioners. Within these ways of conceiving good practice there are embedded issues relating to how it is defined and who defines it. The question of ‘how’ relates to science, research and the knowledge base of good prac- tice. If good practice is based on scientific evidence, one line of ques- tioning addresses the quality of the evidence – how valid and reliable is it? This is a much disputed and debated arena. Jupp (2006:250), for instance, suggests quantitative methods of research do not pay atten- tion to social meanings and the ways in which we construct our social world. Qualitative research, based for instance on case studies or the lives and experiences of individuals, provides ground for critical reflec- tion but also raises questions concerning whether the findings can be generalized when considering practice: can good practice be based on the examination of a few cases, particularly when the research cannot be replicated? What is critical reflection? 3 As noted above, research-based evidence is not the only knowledge base for practice. Practitioners’ knowledge of what constitutes good practice is also founded in practice itself. The idea of reflective prac- tice is grounded in the development of ‘practice in action’. This can include ideas of intuition, creativity and problem-solving thinking by practitioners. Finally, reverberating throughout is the question of whodefines good practice? This takes us into the realm of political questions and of power relations between the different participants. Such differences in the power to define what is good practice can even be embedded in the terms used to refer to the participants. On one side there are patients, clients, customers, service users, carers and so on, each term connoting a particular relationship between disabled people and service providers. It works in the other direction too of course. Terms such as professional, service provider, care, cure, intervention and even ‘practice’ have poli- tical connotations. Consider the term ‘professional’, for instance, and its implications for relationships including expertise, the rightful power to define needs, to intervene and to allocate resources. ‘Stakeholder’ is another current and widely used term that covers all those with an inter- est in defining good practice – policy makers at national, regional and local levels, academics and researchers, practitioners, service managers, informal carers and disabled people themselves. The term can, however, gloss over real differences in views from different standpoints and obscure possible conflicts. What is ‘at stake’ depends on the standpoint of stakeholders and there are inequalities between stakeholders in their power to define and determine what is good practice. In answering the question ‘What is good practice?’ we have attempted to demonstrate that questions beget questions that it will take us the rest of this book to address. We shall turn first to the development of practice by practitioners, exploring the notion of reflective practice. REFLECTIVE PRACTICE There is now a plethora of literature for health professionals that takes a broadly reflective practice approach, though there are differences among the specific models used. There is also an abundance of courses, both pre-service and in-service, that wholly or partly embrace reflective practice. We shall look first at the basic principles of reflective practice and where these ideas come from. We shall then ask for your opinion on the strength of this approach. Finally we will use a research-based 4 UNDERSTANDING DISABILITY example to consider possible limitations. We will begin by looking at a definition of reflective practice. Gould (1996:1) writes: There is considerable empirical evidence, based on research into a variety of occupations, suggesting that expertise does not derive from the application of rules or procedures applied deductively from positivist research. Instead, it is argued that practice wisdom rests upon highly developed intuition which can be difficult to articulate but can be demonstrated in practice. An understanding of professional knowledge as developed by practi- tioners themselves, through and within their practice and their system- atic analysis of practice, is central to the origins of the notion of reflective practice. These ideas have been developed in different ways and in a variety of contexts. Ghaye & Lillyman (2000), for instance, have pro- duced a series of books on reflection for healthcare professionals. They offer a framework of 12 principles of reflection with particular emphasis on the first three (Ghaye & Lillyman 2000:121): 1. Reflective practice is about you and your work. 2. Reflective practice is about learning from experience. 3. Reflective practice is about valuing what we do and why we do it. The ‘father’ of these developments is generally acknowledged to be Donald Schön (1983, 1987). In his view (1983:50): both ordinary people and professional practitioners often think about what they are doing, sometimes even while doing it … It is this entire process of reflection-in-action which is central to the ‘art’ by which practitioners deal well with situations of uncertainty, instability, uniqueness and value conflict. He also stated that (1983:61): Practitioners do reflect on their knowledge-in-practice. Sometimes in the relative tranquillity of a post-mortem, they think back on a project they have undertaken, a situation they have lived through, and they explore the understandings they have brought to their handling of the case. Schön’s work has been widely adopted, and adapted, in professional training and development. So let us get to the crux of this issue and look at a framework for reflect- ive practice presented by Rolfe et al (2001). Their book is a users’ guide for nurses and the helping professions. They first distinguish between ‘macro’ and ‘micro’ models of reflective practice. Macro models address the underlying philosophy of reflection and possible stages in developing What is critical reflection? 5 thinking and action. One example of the work they draw on is that of Kim (1999) whose model goes through three phases: 1. Descriptive phase – the practitioner taking a particular situation, event or encounter and asking what happened. 2. Reflective phase – the practitioner asking ‘What did I make of this?’ 3. Critical/emancipatory phase – the practitioner moving the question- ing forward to the implications for acting, thinking and feeling differently. At the micro level, models address ways in which reflection is con- ducted and facilitated within each of these phases. This will become clearer in Box 1.1 which summarizes this framework for reflective prac- tice, incorporating both the macro and the micro. Box 1.1 A framework for reflective practice Descriptive phase ● What is the problem? ● What was my role in the situation? ● What was I trying to achieve? ● What actions did I take? ● What was the response of others? ● What were the consequences? ● What feelings did it invoke in the client? ● What feelings did it invoke in me? ● What was good/bad about the experience? Reflective phase ● So what does this tell me? ● So what was going through my mind as I acted? ● So what did I base my actions on? ● So what other knowledge can I bring to the situation? ● So what could I have done to make it better? ● So what is my new understanding of the situation? ● So what broader issues arise from the situation? Critical/emancipatory phase ● Now what do I need to do in order to stop being stuck? ● Now what broader issues need to be considered if this action is to be successful? ● Now what might be the consequences of this action? (Derived from Rolfe et al 2001:34–39) 6 UNDERSTANDING DISABILITY Activity 1.2 REFLECTING ON PRACTICE The best way to evaluate a reflective approach to the development of practice is to try it out for yourself. Using the questions in the framework for reflective practice (Box 1.1), reflect on a situation you have experienced or a particular problem you have encountered as a practitioner or a student. Reflect on your practice by writing notes in response to each of the questions. Do not worry if some of the questions seem irrelevant to the particular situation you are considering. Whether or not you were able to carry out the first part of this activity, make a list of what you consider to be the strengths of the reflective practice approach. (Derived from Ghaye 2000:70–72) Ghaye (2000) provides a list of the claims of reflective practice that may be useful to compare with your list of strengths. In doing so he uses the plural term ‘reflective practices’ to emphasize that it covers a number of different approaches rather than just one. There are four claims: 1. Reflective practices improve the quality of care we give. 2. Reflective practices enhance individual and collective professional development. 3. Reflective practices change the power relationship between academics and practitioners by broadening who generates and controls know- ledge for safe and competent health care. 4. Reflective practices improve the clinical environment. Within this claim it is suggested that practitioners need to recognize and be critical of organizational structures that condition and shape profes- sional practice. Reflective practices also help to build a better world: here it is sug- gested that reflective practices connect with hopes, intentions and strug- gles for more just, democratic, compassionate, caring and dignified healthcare systems. Ghaye & Lillyman also provide a list of the qualities of reflective practice which concentrate more on the personal benefits from the practitioners’ viewpoint (2000:36): ● Authenticity: coming to know our authentic self through meaningful relationships with others in our healthcare team and organization.