Professional knowledge in therapeutic practice Item Type Thesis or dissertation Authors Runcorn, Nigel Alan Publisher University of Derby Download date 08/10/2021 08:33:23 Link to Item http://hdl.handle.net/10545/279058 UNIVERSITY OF DERBY PROFESSIONAL KNOWLEDGE IN THERAPEUTIC PRACTICE CLINICAL REASONINGAS A `HAZARDOUSJOURNEY' Nigel Alan Runcorn Doctor of Philosophy 2004 TABLE OF CONTENTS Contents 1 Statementof Ownership 3 Abstract 5 Acknowledgements 7 Introduction 9 Location in the Literature 1. Professional Knowledge 17 2. The Status of Professional Knowledge 57 3. The Use and Misuse of Professional Knowledge 75 The Enquiry 4. Methodology 91 5. The Interviews Martin 121 Mary 139 Mike 157 Amanda 171 Jo 189 Paul 205 Peter 227 Maria 247 i Findings 6. Findings 267 7. Discussion 317 8. Conclusions 329 References 335 Appendices: Appendix A: Scheduleof Interview Appendix B: Interview Consent Form Appendix C: Letter to PotentialInfomants Statementof Intellectual Ownership This thesis representsmy own work and no part of it has been reproduced in another form or another setting. ABSTRACT This thesis explores the therapist's use of professional knowledge in their relationship with patients. It addressesa gap between theory and practice and the challenges to therapist expertise in a postmodern climate in which there are a multiplicity of competing perspectives about psychological problems. In semi-structured interviews eight NHS PsychodynamicPsychotherapists revealed narratives that underpinned their practice about the nature and treatment of psychological problems. These were organised as narratives about living the `good life' psychologically, and the origins and treatment of psychological problems. The central finding of this thesis is that, rather than relying on professional knowledge conceived as conventional psychodynamic theory, therapists engage in a largely intuitive process I have termed `clinical reasoning' which is practice-based, `reflection-in-action' that involves tacking principally between their professional knowledge base, their experience with the patient and their personal beliefs and experience. Such a process, I argue, constitutes a `hazardous journey' in a postmodern climate in which the value of a psychodynamic perspective cannot be taken for granted. A key implication is the value of therapists becoming more explicitly aware of their own particular narratives and the effect these have on the therapeutic encounter. 5 ACKNOWLEDGEMENTS This researchhas been both a solitary and a companionable pursuit. I am grateful to my therapist colleagues who made the time to talk so openly to me about their work. Within my mind I have been in companionable dialogue with them for some years since they gave up their time for the original interviews. I am grateful to Gordon Riches and Gwen Wallace for their supervision, in particular for their encouragementthroughout and for their help in holding to a focus. The reading of drafts and sections by other people was vital in helping me move the research out of my head and on to the page. Tim Peacock offered a very patient and thoughtful reading of a disorganised draft. David Hewlett, Catriona Walker, Tom Schroder, David Runcorn and Brendan Murphy read sections and offered helpful comments. I am very grateful to them. I have appreciated throughout the support and patience of my colleagues at the Department of Psychotherapy in Derby. I am thankful that the Derbyshire Mental Health NHS Trust made it possible for me to incorporate this project within my professional development. My thanks go to my parents for their support and encouragement and to my family - Liz, Tom, for their Ben and Sam - for their tolerance of my pre-occupation and ability to pull me out of it. 7 INTRODUCTION In this thesis I describe my exploration of the use of professional knowledge by NHS psychodynamic psychotherapistsin their relationship with patients. I have addresseda gap that I perceived between theory and practice in psychotherapy where the professional knowledge of the therapist encounters the `reality' of the patient. I had not found an adequateconception of the processwhereby professional knowledge was applied in practice. I found this lack of clarity problematic for my own practice as a therapist. Therapists practise within a postmodern climate in which a simple correspondence between psychological theory and the inner space of the human mind is no longer accepted. Fact and value are now seen as inevitably intertwined in keeping with the saying in the Talmud that "we see things as we are not as they are" (quoted in Phillips, 1999). A therapist faces the hazard of practising in a climate of `truth without certainty', taking account of the inevitable element of relativity without losing the capacity to have something relevant to say. I explored the question of the application of professional knowledge in practice in a postmodern climate through qualitative, semi-structured interviews with eight NHS Psychodynamic Psychotherapists who worked in the South Trent Health Service Region. As I am myself an NHS Psychodynamic Psychotherapist working in the South Trent Region I have had the status of an `insider' in this investigation and knew my informants previously as colleagues,supervisors and trainers. This `insider' status has been a strength of the research but also an aspect to be monitored and taken account of. I have structured this thesis to reflect as far as possible the way the researchunfolded for me so that the reader can share the experience of the process. 9 Location in the Literature I undertook a preliminary literature search in the areas of professional knowledge, its status and the critiques of its use in order to ground my enquiry in contemporary debate about psychotherapy. I set out to establish the conceptual tools available to the therapist as described in the literature which could be said to constitute their professional knowledge. At this stage I was working with a rather `flat' conception of professional knowledge as the sort of knowledge that could be found in textbooks about therapy. I explored the nature of object relations theory as it provided the main theoretical base for the practice of the therapists I interviewed. I tracked shifts in this theory towards a more postmodern sense of theory as a perspective and towards a greater appreciation of the intersubjective nature of therapy. I summarised the perspectives of key theorists. I briefly considered the place of narrative in therapy but did not at this stage see its full significance. I also explored the literature concerning developmental stagesin the use of professional knowledge which offered a way of conceptualising a tension between creativity/integration and conformity/avoidance in the therapist's use of their professional knowledge. I explored the debate in the literature about the epistemological status of professional knowledge. I focused in on the debate about whether the therapist's professional knowledge could be viewed as being informed by a dependable body of knowledge and what criteria could be employed in a postmodern climate for judging this I looked question. at what empiricism, phenomenology and hermeneutics offered to this debate as traditional `ways of knowing'. I found that the absence of a simple between correspondence theory and the mind of the patient had not led to an epistemological `quagmire' for the therapist. The concept of `pragmatic rationality' (Bernstein, 1983) captured the sensethat therapist's professional knowledge could be located beyond objectivism and subjectivism and could claim a status as `dependable' 10 through an interweaving of epistemological criteria. Theory could thus be viewed as offering proven, emotionally powerful ways of organising experience I explored in the literature critiques of the use of professional knowledge in practice by therapists along with some responses made to these critiques by therapists. Some writers saw their critiques as invalidating practice while others saw `flaws' to be addressed in practice by therapists. Critiques centred around four areas. Therapist thinking was too clinically individualistic and failed to take enough account of the intersubjective nature of the therapy encounter. Therapists assigned too much objectivity to their thinking and failed to understand the nature of power and influence. These critiques provided me with a base against which to compare the therapist accounts in the interviews. Craib (1992) offered the metaphor of the dirty bathwater of professional practice that need not lead to baby and bathwater being thrown out together. The Enquiry For my enquiry I adopted a qualitative approach, using a semi-structured interview format, rooting the therapist's account in their practice by focusing on their work with two patients, one judged to be more `disturbed' and one less `disturbed'. I took the view that the interviews comprised eight individual case studies that offered significant pointers beyond themselves to the practice of NHS psychotherapists. I clarified the nature of my involvement as well as addressing the ethical issues involved in researching into practice. I have described how the categories I employed to organise my analysis evolved and settled later (as part of my core findings) on the concept of the therapists' narratives of practice which I found to fit and explain well the data. These consisted of a narrative of what constitutes `living the good life' psychologically, a narrative of how psychological problems