Kiff, J A & Cushway, D (2006b)

Paper 7: Personal Development/Awareness Groups and Clinical Training

Joe Kiff, Dudley South PCT and Delia Cushway, Universities of Coventry and Warwick Doctorate in Clinical Psychology

Introduction
In this paper we will describe the Personal development/awareness groups that have been a longstanding feature of clinical psychology training in the West Midlands over the last 25 years. We have been involved with these groups both as organiser (DC) and Facilitator (JK) for the majority of this period. JK has for example run 12 groups in the past 21 years, which amounts to in excess of 750 hours of group experience.

Originally developed to facilitate the self care of trainees on the Birmingham course the groups now serve a wider purpose on the Coventry and Warwick course. Here the development of the reflective practioner model has meant the groups are positioned at the heart of training. We hope that this will clarify some of the challenges of training people in the reflective tradition, and illustrate how group work gives a window into the different realities we construct for ourselves. This paper represents our current thinking.

Group Characteristics
The groups have historically had between 7-10 members at the outset and have run for between one and two years on a term time basis. They have met for between 24 and 50 sessions. Initially they were on a voluntary basis but have become mandatory in recent years.

The current arrangements at Coventry have the intake of 15 trainees split into two groups of seven and eight. The groups are run for one and a half hours on a Friday afternoon. Attendance is a requirement of the course. Due to timetabling considerations they meet 24 times in the first year and 20 in the second. Because seminars are optional in the third year, and the wide geographical spread of trainee’s homes, it is not practical to hold them in the final year.

The focus of the group work
The work of the groups can be thought of as covering five main areas:
 * 1.	Group Issues. The life of the group raises its own agenda. What are we here for? How do we feel about each other? How do we cope with the differences between us?
 * 2.	Academic issues. This includes concerns about the academic workload, marks for written work, relationships with course staff, lecturers etc.
 * 3.	Clinical/Placement Issues. This includes experiences from clinical sessions, evaluations of supervision and supervisors and problems arising from working in teams.
 * 4.	Personal Issues. Life goes on outside the course: relationships break up, people get married, get pregnant, have car crashes, get defrauded. If it can happen, it can happen to a trainee!
 * 5.	Issues arising from past experience. Often what happens on the course, in clinical work or in current life, raises issues about the past. Sometimes the group can provide a save place within which these can be beneficially explored.

From any individual member’s perspective the issues they bring are examined to process the information, to address thoughts, feelings or behaviour around the issue and to look for resolution and professional or personal learning. Technically the challenge is to attend to the needs of each individual while facilitating the learning for other members of the group.

The main technique used is to take the material generated through discussion and to ask what relevance it has for learning in other areas. This encourages the use of metaphor and a questioning, working atmosphere in the group. This concept of different levels is important. For example, a discussion about a difficult relationship with an authoritarian supervisor might lead to discussions about power in relationships, and in therapy in particular; about the effects of parenting style in child work, as well as in our own lives; how this is reflected in conflicts with course staff and others in authority; and how we may prefer structured ways of working where we have control of the interaction.

The ways in which the group can be used
Each group is different. Different groups will emphasise different areas. Different trainees may take different things from the experience at different times. It is not possible to say what any particular person will get from any particular group, but by looking at each of the areas in turn, the following examples illustrate the way members can benefit.

1. The Group level:

 * Understanding group process. Most psychology training is light on group work. This setting gives trainees a direct experience of a formal group, which can help them think about the its clinical strengths and weaknesses.
 * The otherness of others. One of the important lessons of group work is the clarity with which our own interpretation of events is exposed. How is it possible that ten people in the same environment, experiencing the same event, can have such different reactions to it, remembering and evaluating it so differently? This leads to a concrete appraisal of the power of psychological forces to distort our sense of what is, and how groups can work to construct agreed realities, which in turn leads to further distortion. This can lead to important discussions about similar processes within the dyadic situation of everyday therapy and insights into the importance of the reflective practioner model.
 * Looking at the social aspect of self, skills, strategies, etc. Obviously the group acts as a social arena within which people can receive feedback about their social performance. Being a clinician within the NHS is socially demanding and it is often useful for people to evaluate their social skills and to develop strategies, for example, for navigating interpersonal conflicts with other professionals or surviving multidisciplinary teams where there is low morale.
 * Understanding how this affects performance as a colleague. The tolerance that the group can foster can make us more patient and respectful of our colleagues. Team working is seldom easy and relationships can be improved in the real world of work if we are appropriately aware of our own strengths and limitations and can evaluate others with similar maturity.
 * Group as a work group with a team of colleagues. Related to this is that experiences in the group can alert trainees to the difficulties of fostering a good working atmosphere in teams and the challenges of managing group processes e.g. scapegoating. With team working the norm now in the modern NHS it is vital they develop knowledge, theory and skills in this area.

2) The Academic level:

 * Support for academic work. Clearly the primary goal of most trainees is to get through the course. For some the support of the group is crucial in maintaining their focus through periods of failure, doubt and trial. Training can be a very infantilising experience for people who often have established adult lives and are put in a position where they sometimes feel they are expected to know nothing so they can be taught. Discussion of such feelings leads to the recognition of their existing strengths and helps them maintain their confidence.

3) The Placement/Clinical level:

 * Support with placement problems. Moving from placement to placement is demanding at a number of levels and the group can help people to negotiate the difficulties. For example, letting go of a person one has become attached to, a supervisor or a client, can be emotionally difficult. Facing the issues raised can lead to important learning about personal and professional boundaries.
 * Understanding what it is like to be a client/patient from the other side of the fence. This is perhaps one of the main strengths of the experience. It is hard to realise just how powerful and difficult the therapeutic setting can be for people. But in acknowledging their own fear and ambivalence, struggling with getting the right balance between exposing and protecting their histories and feelings and seeing how problematic significant personal change can be, members of the group can gain important insights into the patient role.
 * As an arena for looking at own character structure, defences, etc. An important function for the group can be to help participants accept that they too have problems like everyone else. None of us are perfect and the characteristics that allow us to cope may have a down side. Being aware of our own flaws, without pathologising them, opens us to the idea that our clients are not necessarily different from us. This has important implications for discussion of the role of power in the therapy and of the limitations of a mastery model.
 * A chance to observe a senior skilled clinician and one’s peers in action. A great deal of modelling of therapeutic behaviour and style goes on in the 45+ hours of the group’s life, more than provided by the rest of training. Both the facilitator and the various members of the group provide this modelling as they try to help each other. Of course it is not always best practice but it is hopefully a safe place within which to learn and to think about the issues raised.
 * Learning the limits of therapy. The group provides a real life learning experience in which trainees grapple with difficulties of personal change. For many it is a grounding experience enabling them to review their initial unrealistic expectations of the group and to adjust to the ordinariness of the business of therapy and to cope with the ‘good enough’ nature of the outcome.
 * Understanding how this affects performance as a clinician with clients. As we have seen in previous papers in this series one of the keys to the value of the reflective practioner model is the recognition that our personalities, values and attitudes affect the way we are as clinicians. The group provides a forum in which this proposition is explored in detail. The point is that we all have our strengths and weaknesses and how we fit into the broad church that is clinical psychology has a lot to do with making a long, productive and mentally healthy career. Starting to think about this, to understand and value ourselves, as well as those who think differently from us, is a vitally important benefit of the group.
 * Enculturation into the profession. Peer discussion can facilitate the consideration and adoption of professional values, mores and practises. Sometimes it is easier to absorb these through discussion with peers than through the pressures of placement, or the modelling of people old enough to be your parents!

4) The Current, Personal Level:

 * Support with personal problems from outside the course. From experience, between half and two thirds of the group will experience a significant life event during the first two years of the course. Discussion within the group can help people keep these in perspective and manage the resulting life changes while maintaining commitment to the course.
 * Support with personal clinical problems. While the group is explicitly not a therapy group it is inevitable that issues of anxiety, depression, etc do surface and can be successfully addressed within the group. Normalisation of problems is an important function of the group and support from members can help people contain and work to manage their difficulties.
 * As a bridge to personal therapy. Some participants find it helpful to take their personal issues to therapists outside the course. This is encouraged and a network of volunteer therapists has been established for this purpose. It is important to recognise that the group cannot be everything to everybody and that it is important to acknowledge boundaries and limitations. Unlike many exploratory groups, where the participants do not meet outside the group, on the course people will have a lot of contact and an appropriate level of psychological self protection is to be expected and valued.
 * Understanding what helps and hinders personal and social adjustment. Acknowledging our own necessary defensive systems of thoughts and feelings can have important personal consequences. When we acknowledge this from the inside it becomes possible to develop and grow, replacing and refining strategies and letting the scripts from our past fade. Doing this work sensitively and softly for our selves opens up a way for us to help others in a similar manner. One can learn that what is helpful and therapeutic is not necessarily the grand revolution, but often the accumulation of smaller changes that feed confidence and self esteem.
 * Arena where one can try out new ways of being. Indeed one of the keys to a successful group is that it provides a safe enough place in which one can experiment with changes, and at the same time feel some confidence that accurate feedback will be provided in a supportive fashion. Trying on the persona of a young health professional and making the transition from student or assistant is not necessarily straightforward and benefits from peer support.

5) The Past Personal Level:

 * Group as family. The group can act as an arena in which family dynamics are played out. This can provide an environment where old patterns can be identified and worked through. For example, someone who has in the past been expected to take a female submissive role in the family can be helped to avoid this within the group, in their private lives as well as within professional settings.

Conclusion
Personal awareness/development groups can be an important component in clinical training. They provide a rich environment where learning can go on at a number of professional and personal levels. This allows for the development of reflective skills and a sophisticated, contextual view of clinical psychology that complements, enhances and challenges other aspects of the course.