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Reflective practice in the art and science of counselling: A scoping review

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Donnalee Taylor, PhD, Senior Lecturer, James Cook University.

 

Introduction

The counselling profession is considered to be a combination of art and science (Ivey, Ivey, & Zalaquett, 2018). Therefore, it would be fitting to have diverse and adaptable tools to support counsellors. Reflective practice is often touted in education, including in the health care professions, as important for professional development, growth, and professionalism. Yet what is reflective practice? What is its purpose? Does scientific research support its use? And what are the benefits to clients’ and counsellors’ wellbeing?

This paper is a scoping review (Arksey & O’Malley, 2007; Grant & Booth, 2009) of the literature on reflective practice in the counselling profession. This paper does not attempt to provide a balanced argument for or against reflective practice, nor does it attempt to support the author’s arguments or objectives for proposed research. Rather, it provides an overview of past decades’ literature by key reflective thinkers pertaining to the intention of reflective practice and the proposed benefits of reflective practice for counsellors, clients, cultural diversity, and personal and professional development.

History of Reflective Practice

This section briefly outlines a history of reflective thinking and practice in order to situate the scoping review that follows. The Ancient Greek aphorism “know thyself” and Socrates’ “wonder is the beginning of wisdom” are among the first recorded indications of reflective practice (Bolton, 2010). Dewey’s (1938, p. 44-45, 1986) view that “we learn by doing and the realization which comes from what we do,” influenced educationalists like Rogers (1959), who developed Dewey’s ideas on child-centred education and learning through discovery. Rogers (1959) believed that learning should be significant, meaningful, experiential, and  that individuals need to see the relevance of a lesson or theory, which became the foundation for Freire and da Veiga-Coutinho’s (1972) emancipatory perspective and the transformation of educational practices.

Later, Schön (1987, 2017) was one of the first to distinguish between two types of reflection: 1) reflection-on-action, and 2) reflection-in-action. Schön’s theory was that individuals progress from reflecting after they have done something (reflection-on-action) to having the ability to think about what they are doing while they are doing it (reflection-in-action), which enables them to be most effective and successful. Schön believed the ability to reflect was a hallmark of any professional.

Mezirow (1991, 2008) defined reflection as a process used to critically assess issues that do not seem to have clear solutions. Mezirow (1991) identified three forms of reflection: 1) content reflection, which takes place in critical learning and assessment of perceptions, thoughts, feelings, or actions; 2) in process, which involves reflection on how one carried out a process of perceiving, thinking, feeling, and/or action; and, 3) premise reflection, which entails critical examination of assumptions and beliefs that inform one’s approach based on perceptions, thoughts, feelings, and/or actions. Mezirow believed premise reflection to be the deepest and most meaningful form of reflection, transforming the way one looks at and perceives the world and interacts with others.

Table 1 provides a brief overview of major reflective practice thinkers in the 20th and 21st centuries, demonstrating the progression over these years toward more artistic forms of reflective practice. In the 20th century, reflective practice was generally accepted in principle as important, however, it was loosely defined (Hatton & Smith, 1994, 1995). For example, Calderhead (1989, p. 44) defined it as “a process of becoming aware of one’s context, influence and ideological constraints”. Cordingley (1999) associated reflection with research and evidence-led practice, while Imel (1992, p. 2) referred to reflection as “thinking about and critically analysing one’s actions”. In the 21st century, reflective practice has been characterised in various ways, from looking in a mirror (O’Sullivan, Tannehill, & Hinchion, 2008) and “introspection” into one’s own personal development and “embodied life” (Totten, 2003), to a “depth of practice” to tune into and be sensitive to clients (Sills, 2000).

The variations in reflective practice definitions have been noted by many (Ixer, 1999; Jay & Johnson, 2002; McArdle & Coutts, 2003; Tremmel, 1993), but a single definition is still not considered to be paramount to its application for professional development (Bennett-Levy, 2018; Edward & Nicoll, 2006). To be able to be open to, and aware of, one’s self in relation to experiences implies one must be self-aware (Brown & Ryan, 2004). With the varying perspectives and contexts in which reflective practice is used, it seems the “current” definition of reflection leans towards the analytical, critical, and problem-solving approach that tends to be favored by Western cultures (Leigh & Bailey, 2013; Edwards & Nicoll, 2006). Therefore, a non-Western approach would need to be aware of potential reflective practice limitations and how best to foster optimal reflection within cultural contexts for personal and professional development.

Similar to Schön’s (1987), Gibbs’ (1988), Hatton and Smith’s (1994, 1995), Tummons’ (2011), and Herrington, Parker, and Boase-Jelinek’s (2014) definitions, in this review, reflection is envisaged as a deliberate way of thinking about actions and experiences with the intention for critical assessment, monitoring, and improvement in learning, expertise, and behaviour to exceed professional requirements. Further, reflective practice is seen in the context of the helping professions, with an emphasis on counselling and psychotherapy.

Table 1: Overview of reflective practice thinkers in the 20th and 21st centuries and the progression over the years toward more artistic reflective practice.

20th Century Reflective Thinkers Models

Research Authors

Dewey’s Theory of Inquiry—5 Stage Model

(Dewey, 1938)

Model of Transformative Learning

(Mezirow, 1981, 2008)

4 Stage Reflective Cycle

(Kolb, 1984, 2014)

Gibbs Reflective Cycle

(Gibbs, 1988)

Schön Model

(Schön, 1991)

Atkins and Murphy Model

(Atikin & Murphy, 1995)

Driscoll Model

(Driscoll, 1994)

21st Century Reflective Thinkers Models

Research Authors

What, So What, Now What

(Rolfe, 2002; Rolfe, Freshwater, & Jasper, 2001; Brown, Holt-Macey, Martin, Sakura, & Vogt, 2015)

Dance/Choreography

(Cancienne & Snowber, 2003)

Cartoons

(Cavallaro-Johnson, 2009)

Brookfield Model

(Brookfield, 2017)

John’s Model for Structured Reflection

(Johns, 2009)

Storytelling, Reflective Conversations, and Metaphors

(Gray, 2007)

Writing Plays

(Chambers, Odeggard, & Rinaldi, 2007)

Drama

(Boggs, Mickel, & Holtom, 2007)

Letter Writing

(Yang & Bautista, 2008)

Diaries and Journals

(Boud, 2001; Woodbridge & Rust O’Beirne, 2017)

 

Methodology

This scoping study, guided by Arksey and O’Malley’s (2007) and Grant and Booth’s (2009) methodological framework, sought to examine the extent, range, and nature of research evidence of reflective practice in helping professions, with an emphasis on counselling and psychotherapy. The PubMed, One Search, and Google Scholar databases were searched using the following keyword configurations: “reflection AND (counselling OR counseling OR psychotherapy OR therapy) AND (practice OR writing OR development OR personal OR growth) AND (self reflection OR reflective practice)”. PubMed and One Search focus on academic journal publications with free full-text available, while Google Scholar indexes all research fields with review and seminal papers typically at the top of the search results list. The search initially identified a corpus of 75,355 psychology and 2,731 counselling papers, commentaries, and reviews of literature, which were further reduced with the use of SALSA methodology (Grant & Booth, 2009) to 47 peer reviewed quantitative and qualitative articles, seminal publications, and counselling guidelines (Arksey & O’Malley, 2007). Analysis was based on the ad hock corpus that was refined through a thematic analysis (Braun & Clarke, 2006), generating the headings within this paper to gain understanding of the origin, nature, methods, and limits of reflective practice and reflective quantitative and qualitative research. Note the headings within this paper were not the most prevalent themes across the data set, however the decision was made to focus on the areas most related to the art and science of counselling.

Themes in the Reflective Practice Literature

This section explores the major themes that were identified in the thematic analysis of the reflective practice literature: reflective purpose, reflective practice, reflective writing, quantitative versus qualitative rationale, therapeutic alliance and research results, reflecting practice in counselling, personal and professional development, counsellor self-care, and ethical guidelines.

Reflective Purpose

Reflective learning goes beyond the intake of knowledge to involve critical awareness of a social-cultural environment in which learning takes place through the contextualisation of knowledge within the world and learning about and exploring the learning process. Schön (1987, 2017) saw the importance of context and the creative role of the learner exploring improvisation, inventing, and testing rather than applying a set of rules. Schön expanded the scope of reflection from the classroom to real-world practice, challenging technical rationality and research evidence-based practice that Bines (1992) referred to as “technocratic education philosophy”. Mann, Gordon, and MacLeod (2009) suggested in their health care profession reflective practice education review that the implications for educational practice seemed to still be in early development with minimal conclusive quantifiable evidence.

Reflective Practice

Schön (1987, 2017) used the term “artistry” and the metaphor of a dance to describe reflection. Artistry describes the relationship between components working together within a learning situation, which implies new insights are brought into the technical rationality of the matter for optimal reflection. Schön also postulated that a dyad exists in which the student and teacher work together (a dance), rather than the traditional power relations of teacher and student, for optimal reflection and learning. This dyad would also be true of the relationship between counsellors/psychotherapists and their clients and supervisors.

Reflective practice has become mainstream in helping professions, with publications and associated models in teaching (Kuit, Reay, & Freeman, 2001; Mezirow, 1991, 2008), nursing (Bulman & Schutz, 2013; Chirema, 2007), medicine (Horowitz, Suchman, Branch, & Frankel, 2003; Verghese, 2001), sociology (McKenzie, 2003), psychology/psychotherapy (Paula, 2003; Sutton, Townend, & Wright, 2007; Wright, 2005) and other healthcare and social-care professions (Norrie, Hammond, D’Avery, Collington, & Fook, 2012). 

The counselling process is considered to be a combination of art and science (Ivey, Ivey & Zalaquett, 2018), therefore, the art and science approach to professional development seems appropriate. However, for a profession solely focused on helping clients to know themselves better to improve wellbeing there is a lack of published information on reflective practice in counselling (Bennett-Levy, Lee, Travers, Pohlman, & Hamernik, 2003). Thus, as there is no “perfect solution” or “one size fits all” in counselling (Corey, 2017) nor in reflective practice theories, it is reasonable to combine the most appropriate reflective practice to maintain ethical decision making processes to best suit the counsellor’s and/or the client’s needs.

Reflective practice involves observation and analytical skills being turned inward for self-evaluation and analysis of one’s own actions for personal review and critique of behaviour (Miles, 2011). Smears (2009) states that this reflective process enables individuals to regain control over their personal world, building self-confidence and full conscious awareness. This inward self-evaluation and analysis could contribute to optimal counsellor/psychotherapist supervision practices.

Reflective Writing

Words and writing, whether structured or creative, are natural communicative tools that have psychological and healing benefits (Bolton, 2010). The exploration of cognitive, emotional, and spiritual elements of one’s being can not only be expressed through writing diaries/journals and biographies, but other artistic outputs, such as poetry, plays, music, dance, choreography, cartoons, art, storytelling, and drama (Bolton, 2010). The writing process and the act of creating can increase one’s self-confidence and feelings of self-worth and motivation (Bolton, 2010). Writing requires minimal investment in paper, and a pencil/pen which are available around the clock, virtually anywhere, and are cost effective compared to counselling sessions that can be prohibitive due to geographic location, travel time, and costs.

Reflective writing can enable a client and counsellor to continue to work and support themselves between therapy or supervision sessions for optimal personal and professional development. However, judicious caution is required when sharing such personal creative expressions; therapeutic writing needs to be personal, private, and free from criticism, constrains of grammar, syntax, form, and any notion of an audience or consumer (Bolton, 2010). Hence, reflective therapeutic writing is best focused on the process of reflection rather than the product; when focused on product outputs, it can prevent one from discovering and/or fully making use of the power of reflective writing.

Quantitative versus Qualitative Rationale

Even though research focuses, approaches, and intended audiences differ between quantitative (often seen as more “scientific”) and qualitative (seen as more “artistic”) research, the motivation and overall research goals are essentially the same. In addition, the perceptions of both research types reviewed as both science and art are attempts to comprehend and define one’s experience of the world.

The technical rationale of the “scientific” approach is the quantifiable knowledge derived from research findings, which tend to overshadow the reflective practitioner’s own quantifiable knowledge derived from experience, and the client/supervision relationship that provides some level of “private intuition” (Blomfield & Hardy, 2000; Rolfe, 2002). The questioning of science-based research to gain insights into healthcare providers’ knowledge is challenging as reflective practice is best used as an additional source of knowledge due to its qualitative and descriptive nature (Rolfe, 2002). Knowledge gained from personal narrative is considered good reflective practice; however, in the rationale of quantitative evidence based practice, qualitative, descriptive and personal knowledge are very low on the “scientific” hierarchy of evidence as they are perceived as “too artistic”. It may be for this reason few studies using quantitative methods exist within the counselling disciplinary literature.

Therapeutic Alliance and Research Results

Therapeutic alliance is the combination of counsellors’ and clients’ experiences, history, education, training, interpersonal attachments, values, and so on (Crits-Christoph et al., 1991; Wampold, 2013). However, therapeutic alliance is not always factored into quantitative or qualitative research outcomes, even though therapeutic alliance can account for as much as 12-54% of the variation in explaining treatment outcomes (Orlinsky, Rönnestad, & Willutzki, 2004). Hence, this may be why few studies using a quantitative method describe the therapeutic alliance within the counselling disciplinary literature.

The literature in this review included less than ten qualitative research publications that were reliant on participant self-report. Authors included Bennett-Levey et al. (2001), Sutton et al. (2007), Parikh, Janson and Singleton (2012), Schmidt and Adkins (2012) and Woodbridge and Rust O’Beirne (2017) all with institutional ties to students in Australia, the United Kingdom, and the United States respectively. None of these studies seemed to consider the potential for therapeutic alliance between the educators or supervisors overseeing or grading the reflective practice and the students.

One quantitative study (i.e., Cologon, Schweitzer, King, & Nolte, 2017) found therapists with high reflective functioning capacities had significantly better client outcomes than therapists with lower reflective functioning. The authors argued reflective practice not only improves self-awareness, but can also improve therapeutic alliance, which can be beneficial to clients and counsellors (Cologon et al., 2017). Yet, self-awareness is such a multifactorial concept and is so difficult to measure that its relationship to client outcomes seems to remain speculative and generally unevaluated in research (Bennett-Levy & Finlay-Jones, 2018; Pieterse, Lee, Ritmeester, & Collins, 2013), much like therapeutic alliance.

Reflective Practice in Counselling

In counselling, the aim of reflective practice is personal discovery of one’s own experiential knowledge, which is knowledge gained from reflection-on-action moving an individual to reflection-in-action that requires practice to be able to modify, test, and re-modify in a reflective model in situ (Wong-Wylie, 2006). Counsellors need to know themselves—their values, beliefs, prejudices, experiences, wants, needs, and desires—to ensure cultural competencies (Wong-Wylie, 2007; Collins & Arthur, 2005), ethics of practice (Corey, 2017), appropriate analysis of power and oppression (Heron, 2005), for personal and professional development (Wong-Wyllie, 2007), and to use reflective practice as a supportive tool.

Much like counselling, reflective practice involves subjective thoughts, feelings, attitudes, behaviour, therapeutic experiences, life history, an inner cast of characters, personal stories, family life, philosophical beliefs, values, personal assumptions, biases, culture, ethnicity, and so on. Meier and Davis (1997) argued that in no other profession does a healthcare provider’s personality and behaviour make such a difference, hence the importance of a counsellor increasing their self-awareness and knowledge of counselling procedures and techniques. This self-knowledge facilitated by reflective processes in counsellors and clients can enhance the quality of interactions and accelerate therapy (Kramer, 2000), self-awareness, and the ongoing developmental process (Roysircar, 2004; Collins, Arthur, & Wong-Wylie, 2010).

There is a link between self-reflection and the increased ability to empathise, reduce distress, and reduce feelings of guilt and shame (Joireman, Parrott, & Hammersla, 2002). Writing reflectively and therapeutically can also provide better understanding of the writing process for supporting clients in their own reflective practices and in writing therapist referrals and/or client letters (Bolton, 2010). Writing therapy includes self-generated or counsellor suggested expressive and reflective writing (Wright, 2005). 

Reflective writing can enhance the psychotherapeutic process rather than detract from it. For example, similar to other therapeutic processes, client writing increases the client’s control of engagement in the activity and the process, including the rate, depth, and intensity of the process (Rasmussen & Tomm, 1992). The client is also in control of their disclosure of writing insights which can reduce talking therapy pressure for clients recovering from traumatic events (Lange, 1994). However, the psychological pain resulting from writing about traumatic events may be intolerable with recent trauma. Writing can enable one to form tacit knowledge that can be “voiced” through dialogue stories in which meaning is constructed, deconstructed, and reconstructed (Lengelle, Luken, & Meijers, 2016).

A therapist or practitioner implements their practice tools and takes time to reflect and analyse their actions and awareness of themselves, and uses these insights to improve their teaching while modelling a reflective practice for their students or clients. Brockbank and McGill (2007) suggested reflective practice enables one to gain qualitative perspectives and insights; however, the individual may have more questions than before they started the reflection (Hedberg, 2009), hence the importance of having a counselling supervisor (Australian Counselling Association [ACA], 2015; Psychotherapy and Counselling Federation of Australia [PACFA], 2017; Stoltenberg & McNeill, 2011).

Both supervisor and supervisee can benefit from recognition of fear and negativity. The supervisee is expected to appraise themselves and review these insights with their supervisor. Self-supervision through reflective practice provides the opportunity to process their development and ongoing self-development, self-care, self-awareness, and commitment to learning. Benefits include building self-esteem, self-worth, confidence, belief, and work-life balance, and reducing burnout and compassion fatigue, all of which contributes to self-direction and agency when thinking about one’s self and career (McMahon & Watson, 2015; Maree & Di Fabio, 2015). A lack of self- and external supervision can lead to burnout, rumination, inflexibility, defensiveness, and inhibited growth/development.

Personal and Professional Development

Where does one draw the line between the personal and professional development? Each seems inter-connected, with each influencing the other (Hughes & Youngson, 2009). Counsellors who consistently practice self-reflection and self-awareness appear to be able to manage complex clients who might otherwise trigger negative reactions in the therapist (Rosin, 2015; Wolf, Goldfried, & Muran, 2017), including the possibility of counter-transferences and/or inner reactions (Westra, Aviram, Connors, Kertes, & Ahmed, 2012).

Therapists need to “walk their talk”. The interpersonal qualities of the therapist play a key role in the client’s outcomes (especially through the development of therapeutic alliance). Bennett-Levy, Haartoff, and Dimidjian (2019) found that therapists’ personal practices are the most effective way to achieve changes in their personal and interpersonal qualities. Bennett-Levy and Finlay-Jones (2018) suggest that personal practices in psychological interventions, personal therapy, and meditation over an extended period of time (weeks, months, years), including self-practice and self-reflection (Bennett-Levy et al., 2019), enhanced therapy outcomes for the client’s and the counsellor’s wellbeing (Rønnestad & Skovholt, 2001).

Counsellor Self-Care

The quest for self-awareness and self-understanding is key to counselling and effective reflective practice. Awareness of one’s own skills, knowledge, and performance in the counselling profession are essential for client and counsellor wellbeing. The Australian Institute of Professional Counsellors (AIPC; 2019) outlines the benefits of effective reflective practice, including 1) evaluating own performance, 2) developing self-awareness, 3) monitoring potential for burnout, and 4) ensuring adequate self-care. The Australian Counselling Association (ACA, 2015) code of ethics notes ongoing and regular supervision helps maintain a professional level of awareness and professional development.

No one performs optimally 100 percent of the time, so objectively looking at one’s own performance is important to identify areas for improvement. Evaluation of performance can include reflecting on self-evaluation, client feedback, peer reviews, and professional supervision (Dewey, 1938, 1986; AIPC, 2019). Self-awareness is developed through reflection-on-action and reflection-in-action over time (Schön, 1987, 2017).

Burnout occurs due to the prolonged emotional strain of dealing with other people in a helping profession. Contributing factors to burnout can include personal (e.g., age, marital status, work behaviour, and personality) and organisational (e.g., overload, lack of control, co-workers, organisational guidelines and objective, and potential for opportunities) elements. Unlike most workplace stress, burnout affects individuals physically and emotionally (AIPC, 2019). Burnout prevention is important, and reflective practice can assist healthcare professionals in monitoring and preventing excessive physical and emotional strain and to improve work-life balance (Fouché & Martindale, 2011).

Cologon et al. (2017) and Baldwin and Imel (2013) found therapists with higher reflective functioning capacities had significantly better client outcomes than therapists with lower reflective functioning. The significance of their findings suggests that therapist reflective functioning seems to facilitate growth in the client’s reflective functioning. This indicates the therapist’s reflective functioning could potentially predict the therapist’s effectiveness. Adding counsellor reflective functioning capacities to therapeutic alliances implies there is something to the old phrase “practice what you preach” in relation to potential therapeutic outcomes for clients and counsellors.

Ethical Guidelines

Berg (2016) found that reflective practice forms a pivotal part of mental health interventions where language and cultural differences require working together with language interpreters. Berg’s research highlights the importance of culturally-informed   reflective practice for mental health workers to better understand clients who have been traumatised, displaced, and/or trying to find their way through perceived cultural barriers.

More broadly, Pompeo and Levitt (2014) suggest self-awareness and reflective practice as being central to ethical decision making for counselling professionals. The American Counselling Association (ACA; 2014) code of ethics references counsellor self-awareness pertaining to counselling relationship, counsellor roles, professional responsibility, competence, relationships, education, and supervision. The Psychotherapy and Counselling Federation of Australia (PACFA, 2017) code of ethics references counsellor self-awareness in relation to beneficence, promoting client wellbeing, supervision, and self-care. Ethical dilemmas arise in unique contexts, demonstrating the professional ethical codes are just guidelines, and ethical practice must exceed guidelines to strive for one’s highest ethical aspirations—an idea known as positive ethics (Handelsman, Knapp, & Gottlieb, 2002). Reflective practice can, therefore, be beneficial in building the art and science of counselling and counsellors’ self-awareness and ethical expertise.

Conclusion

Reflective practice has become more defined over the past two decades, yet still remains quite broad. The synthesis of the findings in this review outlines how reflective practice benefits can include building self-esteem, self-worth, confidence, belief, and work-life balance, while reducing burnout and compassion fatigue. These benefits contribute to counsellors’ self-direction and agency, which has the potential to lead to significantly better client outcomes.

Reflective practice styles have evolved from scripted “scientific”-type approaches to more “artistic” approaches. Either way, the art and/or science of reflective practice is a suitable tool to assist individuals to better comprehend themselves, their growth and development, and their experience of the world.

The sustained evolution of reflective practice means it is still a prudent tool to continually improve the art and science of counselling. Yet, the questioning of science-based research to gain insights into healthcare providers’ knowledge remains challenging. Whether quantitative or qualitative, more research is required on the effects of reflective practice on counsellors and their clients. The effect of therapeutic alliance on research outcomes also needs to be considered and reflected upon when reporting research results.

Reflective practice significantly improve counselling clients’ outcomes. Whether reflection is steeped in a scientific or artistic approach, reflective practice emboldens professional responsibility, competency, and relationships, which contributes to self-awareness in relation to beneficence, promoting client wellbeing, supervision, and self-care.

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