Problem Based Learning Reflective Account Psychology Essay

The Problem Based Learning (PBL) exercise was entitled ‘The relationship to change.’ Each Case Discussion Group (CDG), consisting of 7 trainees, had to produce a presentation on this topic. Our CDG decided to look at the relationship of the media in changing attitudes towards mental health, with a focus on the Tripartite Model (Triandis, 1971) to explain attitude formation and Stages of Change Model (Prochaska and DiClemente, 1984, cited in Sarafino, 1998) to think about the process of change. I will reflect on the process of change since starting the PBL for both myself and the group, and how this is reflective of changes that occur in clinical practice, with consideration of these two models. The PBL exercise occurred before we started on placement; as such, there are areas that we did not consider or have time to cover; for example, the relationship of the mental health service and teams in changing attitudes towards mental health, both in the community and within services, and how attitudes about mental health influence therapy. I believe these may be important aspects to reflect upon here.

Though we were all of similar ages, we had one male in our group and a variety of different individual characteristics and experiences, although we all shared apprehensions about actually ‘doing’ the presentation. As the group sessions progressed, there were shifts in the extent of the contributions made by different group members. Initially, I remained relatively quiet and felt quite daunted by the process. As I felt more settled and gained more knowledge about the task in hand, I contributed to a far greater extent and felt able to put my point of view across. I believe as a group we were very respectful of one another’s needs and that this developed as we grew in confidence.

There was a general consensus of the title being very vague. I felt that there was a need amongst us to get something done and have something to work on, and we became very task-focused. Having watched the other groups’ presentations, I realised that we remained task-focused throughout the experience in comparison to other groups who largely reflected on their experiences. This may be reflected in therapeutic interventions whereby time constraints and limited sessions mean that we become more focused on the task at hand and neglect to reflect on the therapeutic process. On reflection, however, our group formed a strong bond at an early stage, perhaps drawn together by the safe environment we created to share ideas and anxieties and the shared goal of wanting to achieve, and this formed the basis of a positive experience of this learning task. As the group evolved and held trust in one another, we felt able to hold different opinions and constructively worked through these until a consensus was reached. This is something I feel we would not have achieved so successfully at the beginning due to a need to be liked and please one another and therefore feeling restrained and less willing to share a differing opinion. This may be reflected in clinical practice with clients who may initially feel less able to voice ideas or disagreements with our expressed understandings of their difficulties but are more able to do so as the relationship develops. This can be vital when thinking about formulation and highlights the need to reformulate with new information.

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Of the six formal sessions that we met together for our CDG, three were attended by our facilitator. This had an impact on the group dynamics; due to this being our first assignment and us being new trainees, there was an inherent need for us to seek reassurance that what we were doing was ‘right’ and to gain approval from the facilitator when she joined us. I was much quieter when she was present, through anxieties about being evaluated and I noticed as a group, we tended to be more restrained and tentative. Part of the role of a clinical psychologist may be to facilitate groups, both therapeutically and in other settings such as group supervision. The differences that arose in the sessions where we had a facilitator compared with those when we did not may also be reflected in other group settings. Whilst the power differential cannot be removed and the way in which people interact under different circumstances will vary, I have considered how important it is to try to make people feel as comfortable as they can in such settings, perhaps through sharing experiences and anxieties, where appropriate. This has certainly been a helpful part of my own supervision whereby my supervisor has shared her experiences and ‘mistakes’ and I have felt more empowered to talk about difficult situations I have faced. However, this is still an area that I need to become more comfortable with; accepting that it is neither required nor desirable to know everything or to get everything right.

As a group, we worked productively on the task in hand, setting homework tasks for each of us and to then share these with the group at the beginning of each meeting. This is highly reflective of a CBT framework whereby we were very directive and focused on achieving the goal of getting our presentation written. Through my clinical practice, I have seen how using CBT can ‘fit’ very well with what some clients want, in terms of them having identified the areas they want to change and wanting practical techniques and homework tasks to enable them to do this. However, there have been other clients I have worked with for whom I have been unsure that a CBT approach was best suited to their needs. One client in particular brought with him each week complex family difficulties. Working within a CBT focused team, I felt constrained to keep to a CBT approach but following supervision and a subsequent consultation with family therapy, alongside the CBT we addressed relational difficulties and this appeared to bring about change within his system that constituted a shift in his depression. Thinking about how we approached our PBL task, I wonder if we neglected a more holistic approach and in our focus on getting the task done, we missed opportunities to learn from the process and engage with the relationships that were forming and changing. In subsequent CDGs, we have reflected more upon how we have formed and developed as a group but it is perhaps an area we need to remain mindful of due to our apparent need to still remain more task-focused.

Models of change

Our group decided to look at two models relating to our chosen focus of ‘the relationship of the media in changing attitudes towards mental health.’ The stages of change model (Procheska and DiClemente, 1992) proposes five stages of change: pre-contemplation, contemplation, preparation, action and maintenance, with relapse also being a feature of the change process. In the service where I am on placement, people are required to be motivated to engage and change, and are thus usually at the contemplation or preparation stage. I was struck by the contrast of these clients and the clients I spent time with when working two shifts on an acute ward as part of my induction. Here, many of the clients were less aware of having difficulties or not wanting to make any changes. I reflected on how different therapy might be with clients at different stages and how different techniques may be employed, such as motivational interviewing, at earlier stages. However, I also considered for whom there was a ‘problem’ and whether if the client is not at risk to themselves or others and not in distress, should society’s representation of ‘normal’ mean that such clients are forced to change? In addition, it is important to consider what constitutes significant change. Through working with a client who checks obsessively, I have found that my expectations were different to hers and that she has achieved a reduction in checking that is sufficient for her. This enabled me to consider my own attitudes and beliefs about the distress people experience and how important it is to fully listen to clients and what their goals are.

We also looked at the Tripartite model which looks at attitudes and how these are influenced and changed. It suggests that attitudes are comprised of three parts, cognitions, affect and behaviour, and that attitudes can be changed by working on any one of these parts, for example through new information, direct experience or forced behaviour. I was very motivated to look at attitudes towards mental health since I feel there is still a lot of stigma attached to mental distress and was interested in the role that the media plays in both supporting and trying to address this, whilst also being aware that this can vary depending on other factors such as culture. I was surprised during my induction on the inpatient ward by the views held by some staff towards the clients whereby some clients were seen as their diagnosis, rather than as people, and were consequently infantilised and not treated as individuals. I found myself trying to get to know more about the clients than just their ‘diagnosis’ by engaging with them through activities, such as playing pool. The therapeutic relationship is a vital and influential component of therapy (Roth and Fonagy, 2005). It is interesting to think about how both the therapist’s and client’s attitudes towards mental health difficulties impact upon the therapeutic relationship. When working with clients in a therapeutic setting, I am now more mindful of seeing beyond their distress and thinking more holistically, as well as consideration of our attitudes towards the distress and drawing upon the resources and resilience clients have already. My experiences on the ward also enabled me to think more about staff and team attitudes in general. As the role of clinical psychologists changes and they take on more consultative and leadership roles, team dynamics will be an important factor to consider and thus changing attitudes may be an important factor to consider, through increased training and supervision.

Final Reflections

It has been interesting to reflect on the dynamics of our group. I feel that as a group we bonded very quickly and that this was significantly aided by a shared goal of getting our presentation done alongside a common theme of feeling quite anxious about getting it ‘right.’ Through the experience of shared learning, we were able to draw upon a wealth of experiences and construct a presentation that employed humour to get our message across in a format that felt safe and fun for us. This very much reflected our CDG meetings which employed humour but focused on the task at hand. It has also enabled me to think about my own use of humour and how I feel that this can be an important factor in clinical practice to aid the therapeutic alliance and to enable clients to alleviate some of their distress. As a group, I think that we moved from tentative explorations of ideas to being more empowered to express and manage differing opinions and achieving an agreed consensus following discussions. With hindsight, I believe we neglected to reflect sufficiently on the process of change for us as a group during the PBL task but that we are now more aware of our need to develop these skills further. Our presentation focused on attitude change towards mental health difficulties. I believe there is a large role for clinical psychologists, and mental health teams, to consider the attitudes we hold and to consider how we view different client groups, mental health difficulties and diversity. I believe that being aware of such attitudes is an important factor in acknowledging the need for change in some attitudes, alongside training and good supervision. I hope that as my own training and confidence develops, I will feel better equipped to be able to facilitate changes in such attitudes.