The importance of reflexivity for aspiring psychologists

I recently had the arduous task of shortlisting 170+ applications for the apprentice Clinical Associate in Psychology (CAP) post, an NHS-based position which begins at band 5 whilst training, before then qualifying as a band 6 subject to passing the necessary course and clinical requirements. 

As we locked ourselves away for many days to shortlist, we noticed a common issue. We noticed that many applicants were not sharing their personal motivations for working in adult mental health beyond some stock phrases, or, how their lived experience might help and hinder clinical encounters with patients. 

Instead, many would over-emphasise their knowledge, qualifications and technical skills such as 'administering psychometrics', reminiscent of how a surgeon might describe their skills with a scalpel.

I would argue that it is vitally important that we do not draw these marked distinctions between the psychological principles that are 'administered' to patients and those that apply to ourselves. As Harry Stack Sullivan (1940) observed, 'We are all more simply human than otherwise' (p.283).

The over-emphasis on one's technical credentials is problematic for at least two reasons. Firstly, many applicants for apprenticeships are similarly qualified, so merely repeating one's CV is not always enough to be shortlisted. Secondly, the overemphasis on the technical neglects the influence of our subjective experience on our ability to care for others. 

As an interview panel, we are interested in the applicant's perceptions of the organisational realities of offering care within a publicly-funded healthcare provider, which had been degraded due to successive waves of austerity. Therefore, we hope that applicants would share some awareness of the interaction between the deprived material conditions, and the impact this has on the psyche. However, to our surprise, this was absent in many applications, as if reality was disavowed. My greatest surprise was not that the subjectivity of applicants was missing on a handful, but the vast majority.

I found myself wanting some kind of answer and so I looked to psychoanalysis to offer some thoughts on the absence of the subjective, and what function this omission might serve applicants.

In line with the contemporary relational psychoanalytic tradition, I considered my own perception of reality, and feelings that I would unconsciously prefer to disavow or deny. As I reflected on my working life, I considered how the organisational context of the NHS has enacted frustration, disappointment and hopelessness, what Jonathan Shedler (2022) has described as finding ourselves 'adrift in therapeutic seas' (p.434). 

For balance, I also thought of poignant moments of relational depth and aliveness with patients (Mearns & Cooper, 2017; Schwartz-Cooney & Sopher, 2021), and I hope my former patients have internalised something of our work together over the years, in spite of the material deprivation that society has come to accept as a singular reality.

Perhaps many applicants would prefer not to name these realities in their applications, for unvoiced fears and anxieties that I cannot know as a shortlister. However, I think particularly in the context of an applicant wanting to work within the NHS, that it is worthwhile to interrogate in what ways our early lives have encouraged us to become society's 'helpers' (a topic well examined by Michael Sussman, 1992 and Karen Maroda, 2021) when many people choose to turn away from unpleasant emotions and from those in need (Rizq, 2011). 

Perhaps in our roles as therapists, supervisors, interviewers and managers, we should encourage a reflective cycle, a re-appraisal of our initial motivations to care. Some might go further, and consider how to integrate working with the psyche and the social more explicitly on and off the couch, such as through activist work (Winter & Charura, 2024).

In closing, it is worth considering my need in writing this, and what I wanted to communicate to you the reader. I am not advising future applicants to give up, or for those involved in the education, employability and training of future mental health professionals to give up either. After all, withdrawal is to abandon the struggle. 

Instead, I would argue there can be great potential in critically making use of our subjective experience, as long as we are aware of what we are working through for ourselves in doing this work, as argued by the late Group Analyst, Robyn Skynner in the paper 'i'll look after you, if you'll look after the bit of me I can't look after': 'The mental health professional automatically selects the ideal clientele in which to study himself or herself vicariously and discover what the missing, denied aspects are, though the knowledge cannot benefit us... until we acknowledge the fact our work, however "useful" has also been an evasion of the truth about ourselves' (p.233)

Dr Jonathan Day (PsychD) is a qualified and registered Counselling Psychologist. He works in the NHS in the domain of Complex Emotional Needs.

References

Maroda, K.J. (2021). The analyst's vulnerability: Impact on theory and practice. Routledge. 
Mearns, D. & Cooper, M. (2017). Working at relational depth in counselling and psychotherapy. Sage.
Rizq, R. (2011). IAPT, anxiety and envy. British Journal of Psychotherapy, 27(1), 37-55.
Schwartz-Cooney, A. & Sopher, R. (2021). Vitalization in psychoanalysis. Routledge.
Shedler, J. (2022). That Was Then, This Is Now: Psychoanalytic Psychotherapy For The Rest Of Us, Contemporary Psychoanalysis, 58:2-3, 405-437. 
Skynner, R. (1990). Institutes and How to Survive Them: Mental Health Training and Consultation. Routledge. 
Sullivan, H.S. (1940). Conceptions of modern psychiatry. Norton 
Sussman, M. (1992). A Curious Calling: Unconscious Motivations for Practising Psychotherapy. New Jersey: Jason Aronson. 
Winter, L.A. & Charura, D. (Eds.). (2023). The Handbook of Social Justice in Psychological Therapies: Power, Politics, Change. SAGE Publications Limited.

Is self-reflection genuinely a key part of the roles?

I am a Clinical Associate in Applied Psychology (CAAP) in Scotland, and I completed the CAAP Masters which is run by the Universities of Dundee and Stirling. I also completed a postgraduate diploma in Counselling from the University of Edinburgh. I would like to add to Dr Day's thoughts by thinking about what might be communicated to us by the aspiring psychologists and their applications. Doing so helps us to think about the role of CAAPs in the NHS, the skills they need and how we attempt to measure reflexivity as part of the application process. 

I will restrict my thoughts to CAAPs in Scotland.

Perhaps the observed lack of reflexivity in applicants tells us something about how they perceive its importance for CAAPs? When I look at the handbook for the Scottish CAAP course, there is no mention of reflecting on how our subjective experience influences how we think and behave in the therapy room. Instead, self-reflection for the course means reflecting on how the trainee has implemented CBT techniques in a session. In addition, the handbook for the 2024 intake states that the "…curriculum was designed by NHS based clinicians in psychological services and academics to meet specific service and social demand…" (p13, NES, 2024). The course is focused on teaching the technical skills required to assess and treat common mental health disorders.  

Firstly, it therefore seems natural then that aspiring CAAPs focus their applications on emphasising their technical skills and experiences and not on self-reflection since this appears to be what the course is "about".  Secondly, I think it highlights what the priority for CAAPs is post-qualification. The course is geared towards meeting service needs, and presumably the self-reflection of the type Dr Day speaks of is not seen as key in meeting those demands. This perhaps raises the question of whether such self-reflection should be considered a key part of the CAAP role.

The BPS includes reflective practice as part of its practice guidelines, and defines it as "…having a complex understanding of the self in the context of others" (BPS, 2017). If this is something that we think CAAPS should be able to do, perhaps we could learn from Counselling courses. The postgraduate diploma had several coursework pieces devoted to self-reflection, for example, a 4000 word essay on how issues of difference, diversity and power are present in the trainee's therapy room. I believe having a self-reflective piece of work would help trainee CAAPs develop and practice this as part of their training programme. 

A further issue that these aspiring CAAPS might be drawing our attention to is how measure and test for such a diffuse skill. CAAPs may be focusing on technical skills and experiences because they feel able to evidence these skills, in contrast to self-reflection. Applicants may feel that focusing on concrete skills is a "safer bet". Furthermore, could there be a fear of judgment should an applicant share their lived experience?

On the point of testing for reflexivity, consider UCAS, who recently changed their application process to include a question on why someone wants to study a course. Will this help UCAS identify more reflective and motivated students? Or will they only identify those students who are better at telling courses what they want to hear? What evidence is there that applicants who show reflexivity in their applications are more 'desirable' trainees than those who do not? If that is the case, is there a better way to test for reflective ability during the application process? Is the important thing with such testing the answer, or the process that leads to the answer?   

I do not suggest I have the answer to any of these questions, but perhaps they offer the opportunity for wider institutional self-reflection about the role of CAAPs in the NHS, the skills needed to fulfil this role and how to identify those skills in applicants. 

British Psychological Society. (2009). Practice Guidelines (3^rd ed).

NHS Education for Scotland, University of Stirling and University of Dundee. (2024). MSc in Psychological Therapy in Primary Care: Course Handbook 2024.