notably negative feelings such as a sense of failure, frustration, distress, anger, fear of authority with its threat of sanction for doing the wrong thing. They create an emotional tension within us, making us pay attention to our experiences. Senge (1990) argues that we need to deal with emotional tension before we can focus on creative tension, as if emotions smudge the mirror and distort rational thought. Boud et al. (1985) also suggest we need to remove obstructive feelings as part of the reflective process. The feelings we experience also reflect the attitudes we hold.
Feelings reflect deeper underlying assumptions the practitioner may hold about the world but which they may not be aware of. As Cox (1988, p. 100) notes: ‘The therapist’s attitudes colour the atmosphere of therapeutic space. He is never as neutral as he thinks’. For example, ‘do I like this person?’ that link with theories of the unpopular patient (see later cue).
Clearly, feelings and attitudes influence decision‐making (Callahan 1988) and need to be understood and shifted if the practitioner is to realise desirable practice. Yet, they may not be easy to understand. They may stem from diverse sources. Ramos (1992) writes of an ‘emotional impasse’ where practitioners become emotionally entangled with patients. Dealing with the other’s suffering may be difficult for many practitioners. It may be easier to avert your eyes and turn away rather than engage. Maybe it is more comfortable to turn away, and yet that itself creates anxiety for the practitioner anxious to respond effectively.
Because negative feelings and fears are uncomfortable, practitioners are likely to reflect in order to defend themselves against negative feelings, drawing on defence mechanisms such as rationalization, sublimation, and projection,1 rather than face up to them. However, negative feelings drain the practitioner’s energy. How often you heard practitioners cry ‘I’m drained!’
The practitioner may reflect superficially to avoid going deeper that might reveal deeper psyche factors or emotional scars that may be better left alone (Sacks 1976). Guidance is certainly helpful to engage negative feelings and unhelpful attitudes (see Chapter 6).
By paying attention to their feelings, the practitioner learns to know and manage their emotional self (Salovey and Mayer 1990). Hence what made me frustrated, angry, or fearful, I can understand and work towards resolving. Understanding itself is a balm for the worried mind simply because it brings some element of control.
As we reflect, we can begin to accept the feelings as our own rather than something that might destroy us. As Rosenberg (1998) notes, ‘little by little, we’re not so enslaved to things’ (p. 145). At every point, reflection is freedom to become who we desire to be. Beck (1997) recognises the discomfort reflection on feelings may incur but that it is worth it in long run. She writes (p. 42/3):
For a time our life may feel worse than before, as what we have concealed becomes clear. But even as this occurs, we have a sense of growing sanity and understanding, of basic satisfaction. To continue practice through severe difficulties we must have patience, persistence and courage…. we learn in our guts not just in our brains.
Reading these words may give an impression that reflection is akin to therapy. Perhaps it will feel like that at times. It is these deeper reaches of the mind where old stuff lies buried, stuff that is fundamental to the assumptions we hold and which govern our practice. If we are to gain insight, then it is necessary to access and shake up these assumptions. If not, then we may merely scratch at the surface of our experience without meaning. Sometimes it may seem better to reflect superficially rather than get out of our depth. It depends on how significant such feelings are perceived.
Did Past Experiences Influence Me?
An experience is not an isolated moment in time. It is part of a continuous stream of unfolding experiences. How I respond today is strongly influenced by how I responded previously. As Blackwolf and Jones (1996, p. 78) write: ‘If we don’t stay connected and remember the lessons from the past, are we not doomed to repeat them?’
Every experience is unique. It has not been experienced before. So whilst past experiences may seem similar, they are not the same. They can inform but should not dictate the practitioner’s response. The cue prompts the practitioner to link their experience with past experiences, to reflect on the pattern of their day and whether they are stuck in inappropriate behaviours and routines. The cue urges – ‘wake up, pay attention! Get out of auto‐pilot!’
Did I Respond Ethically for the Best?
Every experience reveals the practitioner’s ability to act ‘for the good’ or ethically. Yet, how is the ‘ethical’ known? Some guidance is offered by a code of professional ethics that set out the practitioner’s responsibility to act ethically. These codes are constructed around the ethic of duty, or the way a practitioner should conduct self. An obvious example is that a healthcare practitioner should always act in caring manner and treat the patient with dignity and respect. This also means not causing suffering through careless action.
There are a number of ethical principles that the practitioner needs to appreciate; autonomy, benevolence, non‐malevolence, utilitarianism, justice, equality, and confidentiality set against a background of professional integrity and duty.
Ethical principles often contradict each other. As such, doing what was right always needs to be interpreted within each moment (Parker 1990; Cooper 1991). This may be problematic if practitioners have different values, agendas, and levels of authority to make decisions.
Autonomy
Autonomy is the person’s right to be self‐determining. Seedhouse (1988) views autonomy as the highest ethical principle. In respecting a person, the practitioner actively involves that person in decision‐making about their healthcare as much as possible. In past days, professional autonomy was universally accepted in a capitalist construction of healthcare whereby the patient gave up his rights in return for healthcare (Parsons 1951). Now the situation is very different, although a tension may exist between professional and patient autonomy as to who has the legitimate authority to make decisions.
Without a doubt, people are more informed about their health. Just ‘Google’ any health condition to reveal an overload of information, challenging the idea that professional knowledge is beyond the public’s general understanding. Hence the practitioner’s role shifts from doing things to, at or for patients, to working with them as far as they are able. However, for whatever reason, many people may be passive. As such, the practitioner should act in the person’s best interests.
Acting on behalf of others is termed ‘paternalism’. Benjamin and Curtis (1986) set out three criteria to legitimate such action:
Harm – would the patient come to some harm if I hadn’t act for them?
Autonomy – is the patient able to act for themselves?
Ratification – would the patient at a later time thank me for my actions?
Yet how easy is it to advocate for patients rather than respect their autonomy on the premise that we are the health professionals and we know what’s best for the patient. The risk is that the patient becomes an object we do things to. We do not see the patient just what needs doing to them.
Benevolence and Non‐malevolence
Beneficence and non‐malevolence are enshrined within the Hippocratic oath that doctors should do good (beneficence) and not do harm (non‐malevolence). This is the governing principle underlying all ethical actions. Often it involves an element of risk when outcomes are unpredictable. Hence, to involve patients as possible in their decision making.
Utilitarianism