In this material you will find information on attitudes, clinical supervision and reflective practice. When working with the family your own attitudes and beliefs may be influential in how you interact with and support a family when mental distress emerges. Therefore it is important to be aware of your own personal beliefs and attitudes towards working with families.

Working with families in a high-quality manner demands that you to have reflective skills to understand what happens in the family while you are working with them. If you consider this from the systems theory viewpoint you will realize that you are now part of the system when working with a family. furthermore, from the Open Dialogue viewpoint, when you are working with the family you become part of the team. Clinical supervision is a process that helps you to reflect, consider and understand all of these issues with the guidance and support of an experienced supervisor.

After engaging with this material you are able to

  • Recognize and reflect on your own attitudes towards family work and ways of working with families
  • Describe the role of clinical supervision in supporting professional development where it is available.

The literature describes several characteristics which are beneficial in the caring relationship:

  • With reference to the list above, is there any other characteristics that you would add? Are there characteristics that you would remove? Provide justifications for your answers.

  • Think about each of the characteristics above, can you think of any examples where you have used these characteristics in your everyday practice?

  • Do you think that these skills are innate or can mental health professionals learn them from clinical practice? Give reasons for your answer.

The caring relationship can also be a means for the family member to be confirmed (Kasén, 2002). The importance of being confirmed has been described as “the greatest single factor ensuring mental development and stability” (Watzlawick, Baverlas & Jackson, 1967, p.84). A confirming relationship helps to develop skills and behaviors necessary to manage situations. Nurses can, through communication and dialogue, enter the world of mental health service users and their families in order to understand their distress. A person develops through a good relationship in which the service user or the family members are allowed to be as he/she feels at the moment. Numerous research findings have stressed the importance of a well-functioning relationship to create qualitative care (Benner, Tanner & Chesla, 1996). Such a relationship allows the person to recover and to be a part of, as well as co-operate in, the process, and to strive towards health (Watson, 1979).

Sometimes the thing that prevents working with families is attitudes, and evidence suggests that some mental health professionals have negative attitudes towards working with them. These negative perceptions emerge from the person's own personal history, lack of professional competence and sometimes a lack of education about working with families.

Openness to reflective thinking, readiness to think issues from an emotional intelligence viewpoint and learning from and about one's own attitudes provide a good starting point for professional growth. These are skills that are necessary in all areas of mental health provision and not just families. An example of negative attitudes towards working with families is evident in Wades (2006) study about caring for children with bipolar disorder. The parents in that study felt degraded and humiliated by health care staff when they sought help for their children. In addition they often felt that they were being blamed for their children’s behaviour, especially from school teachers. In another study, Ewertzon et al (2010) indicated that the majority of the family members in their study had experienced a negative approach from the professionals that they encountered which indicated a lack of confirmation and cooperation. On the other hand, staff members who were welcoming, kind and had an open attitude made the parents feel secure and were seen as indicators of good care. In data collected as part of the eMenthe project, several characteristics were seen as desirable attitudes and skills when working with families:

  • Strength-based thinking
  • Respectful attitude towards service users and families, seeing them as as co-workers in care
  • Willingness to enhance own professional growth
  • Professional awareness of ethical issues
  • Positive attitudes towards self-reflection

It is worthwhile also to stop how professionals might support stigmatization with their activities.

It is important to underline that family members are not a homogeneous group. For mental health practitioners, it is important to understand the motive for the family members actions and to identify their individual needs, therefore a working relationship with each member is essential (Goodwin & Happell, 2007). Mental health practitioners need to be encouraged to reflect on their interactions with families to ensure that they are non-judgmental, positive in their attitudes and facilitative.

Below are some questions for you to think about when you are working with the family:

  • In what way do you ask the service user when you want to contact his or her family?
  • Recall the kind of words that you use? In what situations might you want to ask to contact the family?
  • Pay attention to your verbal and non verbal communication: are you sitting, standing, smiling, looking busy or relaxed etc. * Stop and think: are you really willing to work with the family? Do you think of them as a resource and co-partner or as a burden?
  • If you hesitate, then it is even more important to think abut the previous issues. Your hesitation will be reflected in the answers you get from the service user and might even hinder your work with the family.
  • Think about your own childhood and your own family? Do you think that you background affects the way that you work with service users and their families?
  • What about you current family situation, does this influence your attitude towards working with families?

Reflecting on these types of questions is important, they help you to reflect and guide you in your professional career. Clinical supervision is also an important part of maintaining professional competence and will be discussed in the next section.

In this text we focus on clinical supervision in the context of working with families. Clinical supervision can be seen as a tool to enable professional growth, emotional intelligence, better quality of care for service users and families and also as a tool to help practitioners to support their own well-being and to avoid phenomena like compassion fatigue. However, clinical supervision is not a personal therapy but its focus is always linked to work and care provided by the practitioner.

What is clinical supervision?

  • Many different definitions of clinical supervision.
  • At its simplest, it is essentially a formal learning alliance whereby supervisee meets regularly with an experienced practitioner (the supervisor) to reflect on clinical and professional issues related to the supervisee’s ongoing clinical and professional learning and development.
  • It is a formal process.
  • It is not therapy.
  • It is not managerial monitoring or managerial admonishment
  • Personal support, learning and professional development at the core of clinical supervision.
  • Fits in with the concept of ‘Lifelong learning’.

What is the purpose of clinical supervision?

  • Enables practitioners to develop knowledge and competence, assume responsibility for their own practice and enhance consumer protection and the safety of care in complex clinical situations.
  • Developing best practice for service users, an invitation to be self monitoring and self accountable and an activity that continues throughout ones professional life (Cutcliffe et al, 2001)
  • To promote and protect the welfare of the of the client and the development of the supervisee (Carroll, 1996)
  • To protect people in care from nurses and to protect nurses from themselves (Barker, 1995).

Are their different models of clinical supervision?

  • There are numerous models described in the literature.
  • Protor’s (1986) model most widely used in nursing – outlines three tasks and categories of responsibility of the supervisee/supervisor relationship.

    1 Normative task (Managerial)

    2 Formative task (Educational)

    3 Restorative task (supportive)

  • There are also different formats of delivering clinical supervision; individual Clinical Supervision or group Supervision.

There is some further information on Proctors (1986) model of clinical supervision at the following link.

In some countries there are laws, regulations and recommendations governing the use of clinical supervision practices. In some countries it is a common practice, whereas in other countries it is not widely available. Make sure you know what the situation is in your country and in your work place. When working with families, clinical supervision is important, as you are working with and within many relationships at the same time.

In data we collected for the eMenthe project, clinical supervision was mentioned from two different perspectives: Firstly as a skill in Master's level education, (skills to use clinical supervision to support own professional growth) and as an attitude (willingness to enhance their own professional growth).

Given the descriptions of clinical supervision above, why do you think it is important for mental health professionals to engage in Clinical Supervsion?

Do you think there are any potential disadvantages or barriers to implementing clinical supervision?

Reflective questions

  1. What is the difference between clinical supervision and therapy?
  2. Looking at the different formats of clinical supervision (indivdiual or group), which one would you prefer and why?
  3. Thinking about your current area of practice, what issues do you think you would like to talk to your clinical supervisor about?
  4. Thinking about clinical supervision as part of your practice, what issues would encourage or discourage you from attending clinical supervision?

Over the last number of years nurses and other mental health care professionals have been encouraged to become more reflective and to engage in reflective practice. The intention of reflection is always to enable practitioners to tell their story of practice. By doing this they can identify, confront and resolve any contradictions between what they aim to achieve and what happened to the actual practice (Johns, 1995). This session will briefly look at the main features of reflective practice and introduce the reader to a reflective cycle.

What is reflective practice?

According to Sommerville and Keeling (2004 p 42)

'Reflection is the examination of personal thoughts and actions. For practitioners this means focusing on how they interact with their colleagues and with the environment to obtain a clearer picture of their own behaviour. It is therefore a process by which practitioners can better understand themselves in order to be able to build on existing strengths and take appropriate future action'

Johns (2002 p 9) provides another definition:

'I describe reflection as a window through which the practitioner can view and focus self within the context of her own lived experience in ways that enable her to confront, understand and work towards resolving the contradictions within … practice between what is desirable and actual practice'

Given the two definitions described above, what potential does reflective practice offer mental health nursing and other mental health professionals?

Schon describes 2 different types of reflection:

1. Reflection in action

  • Occurs during practice -on the spot experimenting
  • When the attentive practitioner watches, interacts and adjusts reactions and approaches through thinking in a focused way while working (Taylor, 2000:3)
  • Recognition of & thinking about a new experience while engaged with it
  • Practitioner can select and integrate actions from previous experience when addressing a practice problem

2. Reflection on action

  • Cognitive postmortem (Greenwood, 1993)
  • Retrospective analysis & interpretation of practice
  • Occurs after the action. Details are recalled through rich description and analysed through careful unpicking and reconstruction of all the aspects of the situation, to gain fresh insights and make amendments if necessary (Taylor, 2000:3)
  • Enables continuous development of knowledge, skills & future practice

Many authors advocate the use of structured reflection to aid learning. In this way, Stuart (2013) suggests that refection can be actively facilitated, planned and managed to enable the learner to extract meaning from experience. As Dewey (1933 p 35) an early advocate of reflection stated:

'While we cannot learn or be taught to think, we do have to learn how to think well, especially how to acquire the general habit of reflecting'

Many reflective cycles have been formulated to assist practitioners to engage in reflective practice. One of the most well known cycle is Gibbs Reflective cycle (Gibbs 1988). There is more information about Gibbs Reflective Cycle and how to use it at this link.

  • Spend some time thinking about an incident that happened in your practice, it can be something that went well or something that didn't go well. Use Gibbs reflective cycle to discuss the incident and write a brief report on each of the stages.
  • Thinking about activity 4, use Gibbs cycle again to work through your experiences of using a structured reflective cycle.
  • Watch the following short presentation about reflective practice from YouTube.

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