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Reflective writing: a tool to support continuous learning and improved effectiveness in implementation facilitators

Tanya t. olmos-ochoa.

1 HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System – Sepulveda, 16111 Plummer Street (152), North Hills, CA 91343 USA

Karissa M. Fenwick

David a. ganz.

2 David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA USA

Neetu Chawla

3 Department of Health Policy and Management, Fielding School of Public Health, University of California at Los Angeles, Los Angeles, CA USA

Lauren S. Penney

4 Elizabeth Dole Center of Excellence for Veteran and Caregiver Research, South Texas Veterans Health Care System, San Antonio, TX USA

5 Departments of Medicine and Psychiatry, University of Texas Health Science Center at San Antonio, San Antonio, TX USA

Jenny M. Barnard

Isomi m. miake-lye, alison b. hamilton.

6 Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA USA

Erin P. Finley

Associated data.

Consents associated with primary data collection for clinician/staff participants in CTAC did not include permission to share data in publicly available repositories. De-identified administrative datasets may be eligible for future data sharing once national VA guidance on request and distribution processes are provided (in process). Final datasets will be maintained locally until enterprise-level resources become available for long-term storage and access.

Implementation facilitators support the adoption of evidence-based practices and other improvement efforts in complex healthcare settings. Facilitators are trained to develop essential facilitation skills and facilitator effectiveness is typically evaluated post-implementation, but little is known about how facilitators apply and adapt didactic knowledge after training, or how learning and refining experiential knowledge occurs during the facilitation process. We propose the use of reflective writing as a tool to document and support facilitator learning and facilitator effectiveness.

Using an instrumental case study of the Coordination Toolkit and Coaching (CTAC) project, we explore the use of reflective writing by facilitators to support their learning and effectiveness. Six primary care clinics participated in weekly hour-long facilitation calls over a 12-month period to implement quality improvement projects related to care coordination. Two facilitators completed templated reflections after each facilitation call for their assigned sites, totaling 269 reflections. We used the declarative-procedural-reflective model, which defines the process of skill development in clinical practice, to qualitatively analyze the reflections. Two independent coders used content analysis principles to code text that captured facilitators’ observations, evaluations, interpretations, and communication. Descriptive statistics were used to analyze reflections by facilitator and by code within and across reflections.

CTAC facilitators primarily used the reflections to summarize the calls (observation), assess the facilitation process and the tasks and activities they used (evaluation), document their thoughts about how to improve their own effectiveness (interpretation), and describe their communication with implementing teams. Ninety-one percent of reflections included observations, 42% interpretation, 41% evaluation, and 44% facilitator communication. In total, we coded 677 segments of text within reflections: 39% represented observation, 20% interpretation, 18% evaluation, and 23% facilitator communication.

Conclusions

The process of reflective writing allowed the CTAC facilitators the time and structure to evaluate their facilitation and to think critically about how to adjust their facilitation in response to their observations and interpretations. Reflective writing is a feasible and acceptable tool to support and document facilitator learning and effectiveness.

Trial registration

The project was registered with ClinicalTrials.gov ( {"type":"clinical-trial","attrs":{"text":"NCT03063294","term_id":"NCT03063294"}} NCT03063294 ) on February 24, 2017.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-021-00203-z.

Contributions to the literature

• Implementation facilitators are highly skilled individuals who enable change and support improvement in complex healthcare settings. Although the skills and training required for effective facilitation have been evaluated previously, few studies have explored how to support facilitator learning and effectiveness during facilitation.
• Clinicians and other professionals use reflective writing to improve and refine their skills through observing, interpreting, and evaluating their practice. Reflective writing by facilitators may support facilitator learning, while also documenting the facilitation process in close to real time and providing additional context to evaluate facilitator effectiveness and implementation outcomes.

Implementation facilitation is an evidence-based implementation strategy used by healthcare organizations and health services researchers to support the adoption of evidence-based practices and to enable quality improvement (QI) [ 1 , 2 ]. Facilitation, which often requires high-intensity interactions with healthcare staff to be successful [ 1 ], can be challenging work that entails attending to both the technical (e.g., QI methods) and relational (e.g., interpersonal dynamics) needs of the implementing staff [ 3 , 4 ]. The skills needed by facilitators to effectively support implementation and QI efforts are well documented [ 5 – 8 ]. Less is known about whether and how the experience of facilitation impacts facilitator learning and effectiveness during the facilitation process [ 3 , 9 ].

Reflection, “the process of intentionally focusing one’s attention on a particular content; observing and clarifying this focus; and using other knowledge and cognitive process to make meaningful links,” [ 10 ] has been used to enable learning within clinical and other professions [ 11 , 12 ]. The declarative-procedural-reflective (DPR) model used in clinical psychology offers a comprehensive framework illustrating how reflection acts as the “engine” for learning [ 13 ], and describes the process of skill development, from didactic learning to its application and refinement in practice. Learners can engage in reflection about their interactions with clients, patients, or colleagues in the context of structured activities like supervision, consultation, and reflective writing [ 10 , 13 ].

Reflective writing is defined as the practice of writing descriptively and analytically about experiences and interactions, including personal reactions and interpretations [ 13 ]. The use of reflective writing is a long-standing tradition across a variety of professions. In management, personal and unstructured reflective writing by managers can promote analysis, synthesis, and critical thinking [ 11 ]. In psychotherapy training, reflective writing can deepen skill in evidence-based practices [ 10 ]. In medical training, reflective writing through structured rubrics and creative writing exercises can improve patient care skills and provider wellbeing [ 14 , 15 ].

Early evidence suggests that reflection, such as through reflective writing, may promote the development of expertise, reduce stress, prevent burnout, and increase the effectiveness in clinicians [ 16 , 17 ]. Despite being distinct practices, both clinical work and implementation facilitation hinge on the application of conceptual skills and knowledge within the context of a structured interpersonal relationship. Therefore, we propose that the benefits of reflective writing seen in other fields, including skill acquisition, may also extend to implementation facilitation. Recent studies have examined how facilitators acquire and retain knowledge from trainings and how key skills are transferred from expert to novice facilitators [ 17 , 18 ]. Underexplored is how facilitators adapt and refine their facilitation during the facilitation process and how facilitator effectiveness can be supported and sustained. Documentation of the facilitation process from the facilitator’s perspective may provide a more nuanced understanding of facilitator efforts to learn and adapt their facilitation skills and inform strategies to support and evaluate facilitator effectiveness. In this paper, we use an instrumental case study of the Coordination Toolkit and Coaching (CTAC) project in the Veterans Health Administration (VA) to describe the use of reflective writing by implementation facilitators.

CTAC initiative outcomes

CTAC was a QI initiative funded by the VA to improve patients’ experience of care coordination in primary care [ 18 – 20 ]. A cluster-randomized design was used to recruit matched pairs of VA primary care clinics assigned to either an active (distance-based facilitation plus online toolkit access) or a passive (online toolkit access only) strategy. Clinics selected locally initiated projects to address their care coordination concerns. Facilitation played a key role in helping clinic sites organize their projects to assure clinic-wide implementation, which helped improve intra-clinic communication and created hands-on experiences enabling broader QI skill development for participating staff. In contrast, clinic teams with no facilitator experienced more variable project uptake and skill development was limited to project-specific knowledge [ 21 ].

Study design

To describe the use of reflective writing by CTAC facilitators and to better contextualize our evaluation findings, we used an instrumental case study design, which focuses more on the issue being researched (use of reflective writing) than on the case from which the issue is analyzed (CTAC) [ 22 – 25 ]. Data were generated by two CTAC facilitators employed to deliver the intervention; both were novice facilitators with doctoral training in health services who had reviewed a facilitation training manual developed for CTAC and shadowed a more experienced facilitator for at least 6 months prior to facilitation of CTAC sites. Each CTAC facilitator was assigned as the primary facilitator for three clinics and was responsible for hosting weekly hour-long facilitation calls with each site over a 12-month project period ( n = 269 calls across six clinics).

At the start of facilitation, the two CTAC facilitators debriefed verbally with each other about what transpired on the initial facilitation calls; these debriefings proved helpful in thinking about the facilitation process. As a result, the two facilitators began to document and reflect on their facilitation process more consistently, with the goal of improving their facilitation over time. Facilitators logged these reflections using a simple template developed in consultation with the CTAC team, which contained prompts about the facilitation call’s date, duration, participants, an open-ended summary of what transpired on the call, and descriptions of facilitation challenges and success experienced on the call. Figure ​ Figure1 1 provides an example of a completed facilitation reflection. Thus, in addition to hosting facilitation calls and completing site-related facilitation tasks (e.g., introducing QI methods), CTAC facilitators also completed brief (<5 min) written reflections after each facilitation call [ 26 ].

Example of CTAC facilitator reflection

Conceptual framework

We used the DPR model to guide our coding and analysis of facilitator reflections [ 10 , 13 ]. In the DPR model, skill development and learning occur via three cognitive systems. The declarative system consists of conceptual, technical, and interpersonal knowledge gained from didactic training and study. In the procedural system, declarative knowledge is put into practice during communications with clients. Finally, the reflective system analyzes past, current, or future clinical experiences; compares them with stored information; identifies plans of action; and either maintains or changes stored information as a result of the analysis [ 13 ]. Thus, “information is imported into the reflective system from the declarative and procedural systems for analysis and evaluation, prior to re-export back to these systems with plans for action, change, or retention of the status quo.” [ 13 ]. Reflection is defined as “a metacognitive skill, which encompasses the observation , interpretation , and evaluation of one’s own thoughts, emotions and actions, and their outcomes.” [ 10 ]. Reflection through observation, interpretation, and evaluation requires focused attention on a problem, reconstruction and observation of a situation, elaboration, self-questioning, problem-solving, and imagining of alternatives [ 10 ] during and after clinical encounters. Through reflection, individuals can derive perceptual learning, or learning from a “mental representation” of events “to facilitate new understandings” that are then reinforced or debunked when applied in practice to generate new learning [ 13 ].

Data analysis

We conducted a retrospective qualitative analysis of CTAC facilitators’ use of reflective writing during implementation. To operationalize the DPR model’s reflective system in our analysis, we generated three top-level codes representative of the reflection process: observation, evaluation, and interpretation. We defined observation as text in the facilitators’ reflections that was descriptive, contextual, and a neutral account of what transpired on the facilitation calls. The evaluation code was used to identify text that provided a general valence of the facilitation call (e.g., productive, challenging) and/or the facilitators’ self-perceived effectiveness, such as through descriptions of whether their facilitation methods were successful/unsuccessful. The interpretation code represented facilitators’ analyses of why events transpired as they did, along with the facilitators’ theories about how to refine their facilitation as a result of their analyses, which suggests perceptual learning or efforts to learn. Facilitators also provided examples of implementation tasks and activities that enabled them to support clinic sites (e.g., discussions related to the project timeline, providing QI methods support). We created an additional code, facilitator communication , to capture these tasks and activities and organize them into sub-categories in our results.

Two independent coders iteratively generated a codebook and used content analysis principles to code facilitator reflections in ATLAS.ti (version 8, GmbH, Berlin), resolving discrepancies in code application through weekly discussions to reach consensus [ 27 , 28 ]. Codes were applied to complete sentences and spanned multiple sentences as needed to capture each theme occurrence. Within reflections, each code could be used more than once to capture multiple occurrences of observation, evaluation, interpretation, and facilitator communication. Following coding, the coders identified general themes and presented them to the broader CTAC team (principal investigator, project manager, project evaluator, CTAC facilitators) for discussion and further refinement [ 29 , 30 ]. We used descriptive statistics to analyze reflections by facilitator and by code across sites.

CTAC facilitators’ use of reflective writing varied within and between facilitators, by length (word count), number of reflections completed per site (mean = 45), and processes logged (observation, interpretation, and evaluation, facilitator communication) (Table ​ (Table1). 1 ). These processes were not mutually exclusive, and reflections often contained all four.

Code occurrence by reflections and coded text segments

Content of facilitator reflections

The content of facilitator reflections (Fig. ​ (Fig.2) 2 ) typically started with observations that provided useful context for the facilitators’ evaluations and interpretations of the facilitation call. Observations primarily summarized the call, including descriptions of call attendance, project progress and updates, decisions made, and team dynamics. Evaluations generally focused on the perceived valence of the call (e.g., productive, challenging), facilitators’ assessment of the effectiveness of facilitation strategies used to address project goals, and the affective (e.g., mental, emotional) impact of the facilitation process on the facilitator.

Exemplary quotes of reflective processes in facilitator reflections. Abbreviations: AMSA Advanced Medical Support Assistant, HAS Health Administration Service

Text coded as interpretation revealed the most about the facilitators’ perceptual learning and efforts to learn by documenting adaptations facilitators tested and made to their facilitation during each facilitation call. In their interpretations, facilitators reflected about their facilitation successes and challenges, including factors related to team dynamics, resistance to change, lack of participation or engagement, and project progress. Facilitators also wrote about future strategies to overcome challenges and enable success by weighing possible next steps in their facilitation. In their reflections about the facilitation process, facilitators considered the clinic environment and its impact on project progress, the implementation site’s response to QI methods and tools, and the site’s enthusiasm and engagement vis-à-vis project progress.

Descriptions of facilitators’ communication with the implementation team (Fig. ​ (Fig.3) 3 ) often occurred alongside examples of reflective interpretation and evaluation, suggesting that communication style was a frequent source of reflection, adaptation, and learning for facilitators. Facilitators communicated with sites about managing the project timeline and adjusting project expectations and suggested alternatives to elements that did not work or were outside the scope of the project. They also offered QI and implementation resources to facilitate project progress and the completion of project deliverables. Generating and maintaining enthusiasm and engagement for the project made up a significant part of the facilitators’ communication-related reflections, including maintaining momentum, encouraging attendance and verbal participation on calls, and fostering effective team communication. Facilitators also communicated with teams to create buy-in for data collection, manage team dynamics, navigate project setbacks, guide effective communication with leadership and other key stakeholders, and discuss project sustainability and spread. Additional file 1 contains exemplary quotes.

Exemplary quotes of facilitator communication in facilitator reflections. Abbreviations: AMSA Advanced Medical Support Assistant, HAS Health Administration Service, SMART Specific, Measurable, Achievable, Relevant, and Time-Bound

The process of reflection through writing allowed CTAC facilitators the time and structure to evaluate their role, to adjust their facilitation in response to their observations and interpretations, and to process the affective impact of facilitation. Reflections included observations of what transpired on the facilitation calls, evaluations of the facilitation process including facilitators’ self-perceived effectiveness, interpretations of the facilitation process including facilitators’ perceptual learning and efforts to learn, and descriptions of the facilitators’ communication.

To our knowledge, this study is the first to explore the use of reflective writing by facilitators during implementation. Existing facilitation studies report on facilitators’ characteristics and skills and on activities used by facilitators during facilitation [ 6 – 8 ]. However, few studies have reported on facilitators’ experiences of the facilitation process [ 9 , 31 , 32 ]. Reflective writing may help to capture examples of facilitator learning and self-perceived effectiveness by documenting facilitators’ application of basic didactic knowledge, perceptual learning, and the incremental development of facilitation expertise [ 15 ]. Reflective writing also enabled facilitators to continuously evaluate their facilitation process, identify areas for improvement, and support their learning and effectiveness. Reflecting via writing produced a record of facilitation activities that facilitators could later consult to recall facilitation activities and discussions. It is unclear whether reflective writing offered other unique benefits compared to alternative forms of reflection (e.g., supervision/mentoring, recordings); more work is needed to compare the potential impact of different forms of reflection on facilitator learning. Based on results, we developed and refined a sample reflective writing template with prompts designed to encourage facilitators to reflect on and document their facilitation efforts (Additional file 2 ).

Written reflections also provided the CTAC team and external evaluators with context to better understand the mixed-methods outcomes of the CTAC initiative [ 33 ]. For example, external evaluators reviewed the written reflections to better understand how implementing teams addressed critical junctures in the implementation process (e.g., failure/obstacles to implementation) from the facilitators’ perspectives. The reflections were helpful in providing additional context to explain trial results, assessing fidelity and adaptations to the facilitation process, documenting facilitators’ perspectives on successes and challenges to implementation, and aiding facilitator recall during weekly updates to the CTAC team. Our findings align with others suggesting that regular check-ins during implementation may improve documentation of and engagement in implementation activities [ 34 ]. Additional research is needed to assess the potential of facilitator reflections as a novel data source to evaluate facilitation and implementation outcomes.

There were several study limitations that should be considered. The CTAC reflective writing template was open-ended and relatively brief, potentially limiting the extent to which facilitators described thoughts and activities. Nonetheless, these data were rich in detail and offered insight into how facilitators reflect when given minimal prompting. CTAC facilitators were novice facilitators who chose to complete reflections; we were therefore unable to assess whether and how facilitators with different levels of training or expertise may use reflective writing differently. Furthermore, data were limited to reflections from only two facilitators, the total employed for the project. Nonetheless, the high facilitation intensity (weekly, 1-h calls over 12 months) and multiple study sites in this project resulted in a large number of written reflections that captured variations in content within and across reflections and facilitators. CTAC facilitation took place in the context of a funded QI project, and facilitators had protected time to complete their reflections (<5 min each to complete). Facilitators with higher caseloads and/or a lack of protected time may have more difficulty completing reflective writing. Finally, we did not empirically measure the relationship between reflective writing and facilitator outcomes, although the two facilitators in this study anecdotally reported that reflective writing improved their wellbeing and practice. Additional work assessing the use of templated reflections with larger facilitator samples and varying levels of facilitator expertise may address some of these limitations. Work to explore reflective writing across different facilitation settings, and in both internal and external facilitation contexts, is also needed.

Two facilitators, given protected time, found reflective writing to be a feasible and acceptable tool that enabled them to document their observations, interpretations, evaluations, and communication during the facilitation process. Reflective writing provided facilitators a means by which to attend to opportunities for learning and improving their effectiveness as facilitators, while also providing an important source of real-time qualitative data on implementation progress and activities. Reflective writing by facilitators may also have potential for informing the broader study of fidelity to and outcomes in implementation facilitation.

Acknowledgements

We want to acknowledge and thank Lisa Rubenstein for co-conceiving CTAC and Debbie Delevan for the administrative support she provided on the project. We thank Polly H. Noël, Danielle E. Rose, Alissa Simon, and Susan E. Stockdale for their valuable contributions to the CTAC project.

Source of support

This material is based upon work supported by the Department of Veterans Affairs, Quality Enhancement Research Initiative through a grant to the Care Coordination QUERI Program (QUE 15-276). The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the US government.

Abbreviations

Authors’ contributions.

DAG (principal investigator) conceived the project, acquired funding, and contributed to the manuscript. TTO and KF led the development of the manuscript, and EPF contributed to the manuscript and provided guidance regarding framing and theory. LP, NC, IM, and ABH contributed to and reviewed the manuscript. JB coordinated the project and contributed to the manuscript. All authors read and approved the final manuscript. None of the coauthors has competing interests.

This project was funded by the Veterans Affairs, Quality Enhancement Research Initiative (QUERI) through a grant to the Care Coordination QUERI Program (QUE 15-276). The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the US government.

Availability of data and materials

Declarations.

This project was supported by the VA Quality Enhancement Research Initiative (QUERI). VA Central Office and the IRB at VA Greater Los Angeles Healthcare System designated and approved the project as non-research. Process data collected by the facilitators were collected as part of the quality improvement project and do not identify individual participants in the project. As non-research, participants were not formally consented, but they were also not mandated to participate and could opt out from participating. Their consent was implied through their participation in the project.

No individual person’s data in any form are included in this manuscript.

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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A Reflective on Clinical Psychology

Table of contents, the power of theoretical foundations, a glimpse into clinical practice, the therapeutic relationship: catalyst for change, self-reflection: an ongoing practice, conclusion: navigating the human experience.

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• Jan 9, 2021

My Reflections on My Journey to Clinical Psychology

My first day in a clinical role will live with me forever. I had been studying psychology for 3 years at this point & had all of these ideas in my mind about what a career in clinical psychology would like on the ground. I turned up armed with all these psychological theories & models, ready to apply them to make people ‘better’ & the world a better place. I had my pen & my notebook ready. I’d seen how therapy was done on the TV. I ‘knew’ what therapy should like. So naïve.

My first role was as a community neuropsychological support worker. I was supervised by psychology & occupational therapy colleagues to deliver brief mood assessments & interventions (CBT-based) & neuropsychological rehabilitation tasks. The first thing that struck me was how low & unmotivated the patients were, especially in contrast to my mood, which was ecstatic to have acquired such a great post & motivated to get going & put all I had learned into practice! The biopsychosocial picture of neuropsychological deficits & rehabilitation had largely been neglected in our teaching at university. We had been taught ‘this is the neurological deficit & this is how you treat it’, which seemed straightforward enough to me. Low mood, anxiety (as well as the environment, competing multi-disciplinary approaches & spouses) seemed to complicate this picture completely! I learned very quickly to contain my own thoughts & feelings to be congruent & aligned with the patient, & I learned to adopt holistic formulations of presenting issues!

The second thing that struck me, & probably one of my most important realisations of my career to this day, was how understandable & reasonable each person’s distress was. Here they are, at the start of their much longed for retirement, ready to finally travel the world, & now they find themselves wheelchair bound, speech-impaired & unsafe to be left alone due to severe anterograde amnesia. There was nothing irrational or faulty about their thinking or their distress. Suddenly all the models I had been taught (primarily traditional Cognitive Behavioural Therapy, psychodynamic & biological models) did not seem to fit the clinical picture.

The same realisations hit me over & over again in my next clinical roles in inpatient & outpatient mental health services. Patient after patient, the notes all read the same- ‘patient has a history of sexual abuse, parental neglect & maltreatment’ followed by a list longer than my sons list to Santa of different diagnoses; paranoid schizophrenia, bipolar disorder, schizotypal personality disorder, depression, borderline personality disorder, anti-social personality disorder. Further, the over representation of those from BAME communities, lower socio-economic groups & oppressed & marginalised groups was startling.

Again, at university we were taught about the ‘signs & symptoms of mental illness’. We were taught about a list of diagnoses & disorders. This made sense sat at a desk in the library or in a lecture hall. The professor made a compelling argument. And then I entered a clinical setting. The word ‘disorder’ just did not sit well with me at all. If a person has been abused by those they should feel safest with their whole life, then would it not make sense that they would constantly feel anxious, fearful & ‘paranoid’ of others intentions? This did not sound disordered to me at all; in fact this his sounded like a very useful, adaptive & effective function of the brain.

Working across physical & mental health settings, another prominent realisation was that the environment in which we live could very much help or hinder health & wellbeing. Our capitalist, individualistic & Christian society places such an emphasis on productivity, being a ‘good & productive citizen’, & on individual achievement at the expense of co-production & cooperation that we become disconnected from what we actually need to maintain our health. The very things that we need to maintain our emotional & physical health - physical activity, secure social connections & time in nature, which all produce serotonin, dopamine & oxytocin (the brains feel good chemicals)- are they very things such a society takes us away from. And ironically, this type of society takes us towards all the things that contribute to physical & mental ill health- a sedentary lifestyle, competitiveness, lack of safety & security in accessing resources (exams, schooling, job uncertainties), lack of connection with others, lowered opportunities to develop secure attachment with parents & lack of opportunity to connect with nature. Capitalist societies encourage a focus on status & accomplishment in terms of monetary & material success, convincing us this is what we need to be well & ‘happy, when ironically this focus deprives us of the things that we actually need.

Further, the structural & material inequalities facing many patients were obvious. Over crowding, unsafe neighbourhoods, victimisation of marginalised groups, lack of access to resources such as safe & secure housing, food, schooling etc were all clearly contributing factors when undertaking wellbeing assessments. However these factors were scarcely addressed in interventions, if addressed at all.

Throughout the services in which I worked, the dominant narratives reflected that of a British society- narratives that include the biomedical model of distress, ideas about distress & suffering being abnormal, ideas about being a productive citizen, ideas about parenting & the model family etc. It became apparent to me over & over again that these dominant narratives did not fit for the vast number of patients we saw. This was particularly the case with ‘revolving door patients’, which made me question- maybe, just maybe, it’s the treatment approach that’s the problem- not the patient.

These realisations started me on a journey that would shape my understandings of distress & ultimately my clinical practice throughout my career.

My ‘relevant experience’ path to clinical psychology, like so many others, reflects a varied journey. I worked in various clinical & research roles across a range of clinical & academic settings; as a research assistant at university & for the local NHS trust, as a health care assistant in forensic & mental health inpatient services, a support worker in learning disability services & community mental health services, as an assistant psychologist in pain management & physical health settings.

These roles enabled me to develop various transferable skills that were relevant to the broader role of the clinical psychologist such as how to build effective & constructive working relationships with the multi-disciplinary team, leadership & project management skills, data entry, management & analysis skills, flexible communication skills & report writing & note-keeping skills. They also enabled me to start developing crucial clinical skills such as containment, de-escalation & crisis management skills, the ability to ‘sit-with’ discomfort, self-awareness & self-management skills, brief therapeutic intervention skills & an appreciation of the role of the all important therapeutic relationship.

Many of my learning experiences that shape my current thinking & the clinical psychologist I am today were gained from these roles. I developed an understanding of different services, service pathways & the role of other health professionals within the multi-disciplinary team & the role of the clinical psychologist within such services. Most importantly, thy influenced my understandings of distress & the way I practice clinically. I came to appreciate the evolutionary & functional role of thoughts & emotions as well as the importance of systemic & wider ecological analysis, assessment & intervention in understanding these inner experiences. As a result I endeavour to avoid locating distress in the individual, always contextualising distress within the socio-political context. When offering intervention, whether with staff or patients, I always strive to explore top-down interventions as well as bottom-up ones, ensuring I do not become a maintaining factor in harmful social practices. This may include lobbying at government level, challenging unhelpful or unfair or unjust policies this may be informing policy development or addressing service structures. It may also include challenging unhelpful dominant social narratives such as austerity or biomedical understandings of distress.

Another key moment in my formation as a psychologist was undertaking training in Acceptance & Commitment Therapy (ACT). Not only did this model help me to make sense of my early career realisations & to frame them in a psychological model for clinical purposes, it also offered me a profound explanation in terms of how I made sense of my personal career journey when applying for clinical psychology training.

I, along with the patients, family & colleagues that I work with, live in a society that views happiness as the norm & anything that deviates outside of this as abnormal. The concept of unpleasant inner experiences such as distressing thoughts, feelings & physical sensations being inherent to our survival & a normal & understandable response to our experiences fit with my evolutionary psychology beliefs. Understanding thoughts & feelings not as something to change or challenge, but as a friendly ally scanning our environment for potential danger & threats, trying to keep us safe helped me to start changing my relationship to the more difficult thoughts I experienced. It also helped me support patients to learn to view their thoughts regarding their unchangeable situation such as a pain condition, diabetes or stroke in such a way, reducing the impact of these thoughts on their actions & their wellbeing. Learning to view inner experiences in this way, & viewing thoughts as just a thought, can be an empowering & liberating experience enabling us to choose which ones to listen to & which ones to let go.

The added dimension of values-based living within ACT also helped me at a time when I was feeling particularly hopeless & despondent with my career. I had applied several times for the clinical psychology doctorate & despite having many interviews I was just not able to acquire a place. I noted that the thoughts my mind was generating were very critical & reflected catastrophizing & all or nothing thinking styles. I constantly had thoughts such as ‘I am not good enough’, ‘I will never achieve a place’ & ‘if I don’t get a place then I was failure’.

Like so many others I had placed clinical psychology training on a pedestal & had become overwhelmed by all-or-nothing thoughts… I noted that I was so focused on the goal of attaining a place on clinical training that I had lost sight of the here and now, and all the amazing work I was already undertaking & achieving; key note speaker at a highly reputable conference, published papers, pioneering service development & offering psychological intervention… Actions I was already undertaking connected with my values such as to promote psychological thinking in others, to develop high quality psychologically-informed services, to help & support others. I started to reconnect with what was important to me, what gave me & my career purpose, what gave me satisfaction & joy in my daily life.

Connecting with these values instead of my goals & learning to live aligned to them was the first step to changing my attitude towards clinical psychology training. The second step was practicing mindfulness & thought defusion. Again, my thoughts were taking my focus to the future & to the ‘what if…’ scenarios are minds are set up to create in anticipation of potential danger. ‘What is I never gain a place on training…’ ‘What if I can’t think of answer to the interview questions…’ ‘What if my anxiety overwhelms me again…’ Each time I attached to & fused with these thoughts my anxiety increased & my connection with the present moment & all my current values-based actions weakened.

I started to move away from back & white / all or nothing thoughts. I started to see the grey areas. I stopped living in my head, fused & automatically believing the thoughts my mind generated- the stories about my experience. Instead I started to live connected to my actual experience, as lived through my direct senses with the world. I connected with my daily actions in the workplace linked to my values, the achievements I had already accomplished, the values-based actions I was already undertaking. Living in the here & now, connected to my values, rather than my goals, enabled me to feel enriched & reconnected with my purpose. Of course I continued to set goals along the way including obtaining a place on clinical psychology training, but removing my focus from these goals & gently shifting it on to my values reduced the sense of pressure & stress I felt, whilst enhanced my wellbeing on a daily basis.

So my closing words of wisdom to all aspiring psychologists are to resist fusing & buying into every social narrative you encounter & every thought you have regarding your career choice, to use every experience as a learning opportunity & to connect with your personal & career values. Live everyday in the moment, taking valued actions, & if you do set yourself goals, hold your focus loosely on these! And always contextualise experience.

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Reflecting on my internship experience as a Psychology Research Assistant

• Post author By coen_sharon
• Post date April 5, 2017

By Gona Mustafa, Psychology graduate

As my internship comes to an end, I find it hard to believe that 13 weeks have flown by so fast. When I first received an email from Tim Ward (Work Experience Consultant from the University of Salford’s Career Development and Employability Team) offering me a 13 week internship experience in psychology, I was really unsure of what to expect. As exciting as “ become a graduate associate in Psychology and gain vital work based experience towards a graduate role ” sounded, I was not sure about doing it. It was a full time job, something that I did not see myself doing straight after graduation, particularly as I had to manage it alongside family commitments. On the other hand, I felt truly lucky and I thought this was a once in lifetime chance to work alongside such professional and knowledgeable individuals.  It was an opportunity to interact with people who have expertise in what they do, to learn and gain valuable real-world experience in the field of my degree, and to use what I had learned over the last three years in a professional setting.

It turned out that taking on the internship was the best decision I have ever made. I was invited to a pre internship session along with other interns, where we were told about what to expect during the internship. We were also asked to write down three goals that we’d like to achieve by the end of the internship; my goals were to:

• Build self-confidence.
• Gain practical work experience in the fields of psychology.
• Familiarise myself with professional working environment.

In the first week, despite feeling slightly anxious, Gemma made me feel really welcome and provided me with a list of tasks to get me started. I started by doing some literature searches on the research, which I thoroughly enjoyed and it helped me enrich my knowledge about the subject.  The following weeks I had the opportunity to carry out a number of different tasks such as researching, reading and summarising research articles, writing an introduction, coding and double coding videos. I also designed an experimental condition, tried out different equipment and video cameras to use during the experiment which involved handling sensitive and confidential data.  In addition, carrying out the activities above allowed me to use the skills I had learned during my degree as well as learning new skills such as transcribing and double coding data.

Gemma supported me in learning how to deal with setbacks in the workplace in an effective manner and view them as an opportunity to explore and broaden my knowledge about the topic. In addition, as part of the internship we had the opportunity to take part in regular professional training from the university’s professional service and careers and employability development teams which I found extremely beneficial. We also had access to career coaching at the end of our internship, which was designed to help us deal with any issues academic, personal or professional that is limiting our ability to gain graduate level role.

My experience as an intern has been a big learning process. I’m certainly glad that I took the opportunity – not only have I learned much more than I could have ever expected, it has also prepared me for the real world. I have managed to achieve most of my goals and gained many transferable skills such as time management, balancing work and family life, solving problems and dealing well with unexpected situations.  In addition, I have much more confidence in my abilities, met so many inspiring people, and learned more about possible career paths.

I’m extremely grateful for this experience and amazed by what I have achieved in a short period of time. I can’t thank my line manager Dr Gemma Taylor and the University of Salford’s Career Development and Employability Team enough, especially Tim Ward, for giving me such amazing and enriching experience.