The role of reflection in CBT

As we saw in the introduction to this work, Bennett-Levy, Thwaites et al. (2009) described an increasing dissatisfaction with the “fuzziness” of the term “reflection” to identify four ways in which the terms “reflective” and “reflection” have been used:

• • Reflective practice means the practice of reflecting on clinical experience including personal reactions
  • Reflective skill means both the general capacity to reflect on clinical events and develop new perspectives, and the ability to reflect on the ways that one’s own thoughts, feelings and behaviour have played a role in those clinical events
  • The reflective system is the component of the DPR (declarative-procedural-reflective) model of knowledge acquisition (i.e. learning) that enables reflective practice to take place
  • Reflection as a process, as in the Kolb model of experiential learning, means:
    • “intentionally focusing one’s attention on a particular content; observing and clarifying this focus; and using other knowledge and cognitive processes (such as self-questioning, logical analysis and problem-solving) to make meaningful links. Self-reflection is a specific form of reflection in which the content for reflection is self- referenced to one’s thoughts, feelings, behaviours or personal history” (p. 121, italics in original).

It could be argued that self-reflection has tended to be used in a more limited sense in CBT than in some other therapeutic approaches, and its use has tended to be focused on resolving situations where there is a focus on interpersonal challenges such as those that arise in working with personality disorder (Beck & Freeman, 1990), or in an approach to CBT that specifically focuses on interpersonal processes (e.g. Safran & Segal, 1996). Padesky’s phrase “not explored for their own sake” hints at a certain suspicion with regard to reflective self-awareness that perhaps implies that there is a threat that practitioners will engage in self-indulgent navel-gazing unless they are re-focused on the client. This seeming suspiciousness of self-reflection for its “own sake”, suggests that CBT has not fully embraced the importance of self-awareness as a contributor to therapeutic effectiveness, prevention of burnout, or as a valid end in its own right, although recent work by Bennett-Levy (2019) on the role of personal practice suggests that this view might be changing.

It might also be argued that the conceptualisation of reflection and self-reflection in CBT is technically robust but potentially constrained by a focus on the information processing components of reflection that downplays the hermeneutic (meaning making) elements of reflection and the affective content and context that makes the learning salient and more deeply embedded. The author would argue that in focusing on the cognitive information-processing features of reflection, CBT theorists are in danger of de-contextualising the work of the authors that their theories are founded on. The pedagogical context and philosophies that underlie Borton’s (1970), Kolb’s (1984) and Mezirow’s (1997) theories of learning all emphasise the context of learning and the role of reflection and reflective practice in socially aware and socially conscious change. Because the practice of therapy is inevitably interpersonal and social, it might be helpful to think of CBT as both a rational technical-conceptual approach and a reciprocally determined, interpersonal discourse that occurs in complex personal, cultural and political circumstances.

This is perhaps relevant when one considers the argument made by Rolfe (2002) among others, that reflective practice in training no longer reflects the original intentions of educators who promoted it and that it has become a “static, self-focused and passive approach” (Smith, 2016, p. 2). For Bolton (2010) reflection, and self-reflection especially, means something more than a dispassionate observation of one’s practice and its implications. We previously used the analogy of a mirror as a way of exploring different points of view by looking at an event or object from many angles, including those that we would not normally be able to see. But the one thing that a mirror cannot reflect is itself. How then might we learn to see ourselves as the object doing the reflecting when we are essentially trapped in the mirror? How might we reflect on reflecting? Perhaps one way is first of all to acknowledge that we are all imperfect mirrors and that we do not perceive the world from a position of objectivity but from the subjective positions that are the habitual frames of reference and habits of mind that Mezirow describes in Transformative Learning theory. In other words, that our perspective is situated in a socio-political reality that shapes the constructions of reality that we impose upon our experience. While we might not be able in some objective sense to see the mirror without also being the mirror, we can learn to understand that there are other perspectives that help inform the ways in which our experience privileges our version of reality.

The terms that are most often used to describe this process of reflection on reflection are reflexivity and self-reflexivity. Bolton (2010), who describes reflection as “a state of mind, an ongoing constituent of practice, not a technique or curriculum element” (p. 130) states that reflective practice is a way to “bring things out in the open, and frame appropriate and searching questions never asked before” (p. 130). Reflection challenges “assumptions, ideological illusions, damaging social and cultural biases, inequalities, and questions personal behaviours which perhaps silence the voices of others or otherwise marginalise them” (p. 132). This broader socio-political perspective takes us beyond reflecting on practice simply to extend our skilfulness, or to acknowledge and recognise the influence of our thoughts, beliefs and behaviours on the process of CBT. Instead, it encourages us to see ourselves, and CBT itself, as practitioners with a practice that is embedded in a series of socially privileged assumptions about people, their reality, the meaning of mental health and wellbeing, and the social structures that are legitimated in “treating” what is seen as “disorder”.

If reflexivity is a way of attempting to appreciate the socially constructed nature of the practice and context of psychological therapy, then to be self-reflexive is to strive to understand what Bolton (2010) calls “our complex roles in relation to others” (142). It is a process that involves:

“coming as close as possible to an awareness of the way I am experienced and perceived by others. It is being able to stay with personal uncertainty, critically informed curiosity as to how others perceive things as well as how I do, and flexibility to consider changing deeply held ways of being” (ibid p 143)

Following on from Bolton (2010), perhaps the concepts of reflection and self-reflection in CBT would benefit from a more explicit focus on reflexivity and self-reflexivity as forms of critical reflection. Critical reflection in this sense means a more nuanced and contextualised way of understanding one’s own development and the subtleties and complexities of clients’ lives, beliefs, affects, and behaviour. For example, reflexivity and self-reflexivity are commonly invoked in systemic approaches that emphasise culturally attuned psychotherapy, but there is no reason why these ideas could not also be appropriate in a culturally competent CBT. Reflexive practitioners engage in critical reflection in order to “ask critical questions of themselves and their practice, to be aware of themselves as agents and actors in clinical, education and research settings, and to become empowered to address the significant issues encountered in their lives and workplaces” (Smith, 2016, p.2). It might be argued that nothing could be further from the idea of studying one’s own reactions “for their own sake.”

Having said that, Bennett-Levy and colleagues have produced some extremely useful and influential advances in understanding reflective practice in CBT that have the explicit intention to bring greater conceptual rigour to the field of reflective practice. These include the articulation of an underlying model of knowledge acquisition known as the declarative, procedural and reflective model (DPR) (Bennett-Levy, 2006), a model of reflective practice and the reflective system (Bennett-Levy, Thwaites et al., 2009), and a model of personal practice (e.g. personal therapy, SP/SR) in practitioner development (Bennett-Levy & Finlay-Jones, 2019).

The background to these developments was the recognition that CBT, as a widely practised, evidence-based psychotherapy for common mental health problems, needed to train its practitioners to apply the principles and procedures associated with the therapy and, in addition, to become reflective, flexible therapists with a range of meta-competences to manage unforeseen or complex situations where standard procedures proved ineffective. As an evidence-based approach to treating common mental health problems such as depression and anxiety, CBT educators are interested in how best to teach, maintain and develop therapeutic competence to its practitioners across all stages of their careers.

However, in 2006 James Bennett-Levy identified a “theoretical vacuum” in terms of useful models of therapist skill development that could be used to guide researchers or trainers. He set out to develop a model that would help provide a framework to answer questions such as:

• What are the mechanisms by which novice therapists learn?
• What are the mechanisms by which more advanced therapists learn?
• Which skills are more trainable, and which are relatively immutable?
• What is the value of personal therapy or personal experiential work in training?
• What should be our goals in training therapists? (Bennett-Levy, 2006, pp. 58-9)

Bennett-Levy developed a model of therapist knowledge acquisition called the declarative-procedural-reflective (DPR) model (2006). The model describes three relevant memory or cognitive processing systems that inform the conceptual, technical and interpersonal domains of competence that practitioners need to master. Those systems are: 1) the declarative system, I.e. the system that enables the acquisition of a body of relevant factual knowledge; 2) the procedural system, i.e. the system that automates skilled actions, and: 3) the reflective system, I.e. the system that endows the capacity to critically analyse and reflect on experience relative to existing knowledge and skills in order to find solutions to novel problems.

In Bennett-Levy’s original DPR model (Figure 7) client communications, whether verbal or non-verbal, are processed by interpersonal perceptual skills, which are part of the procedural system. These perceptions are informed by the therapist’s self-schema, that is their personal self, and by the self-as-therapist schema. The self-schema is comprised of self-awareness, attitudes, interpersonal skills, personal knowledge and experience. The self-as-therapist schema is comprised of the therapist’s professional attitude, therapy-specific interpersonal relational skills, conceptual skills and technical skills, all of which feed into a set of procedural skills that can be articulated as when-then rules, plans, procedures and skills. This procedural system is itself informed by the declarative system, which comprises interpersonal, conceptual, and therapy-specific technical knowledge.

The reflective system influences both the procedural and declarative system. It consists of focused attention on a perceived problem stimulated when, for example, curiosity is aroused by a mismatch between expectations and experience. This attention is brought into awareness via mental representation (formerly described using Tulving’s term autonoetic consciousness) and then cognitive procedures are performed on it such as further elaboration, self-questioning, logical analysis, problem-solving or the use of imagination to construct models of alternatives in a process of conceptualising and synthesising that can lead to the enactment of problem-solving strategies (Bennett-Levy, Thwaites et al., 2009: Figure 8).

It is noticeable that Bennett-Levy, Thwaites et al.’s (2009) model of the reflective system has many elements in common with Boud et al.’s (1985) earlier model of reflective process which was developed in an educational context. In Boud et al.’s model, reflective processes mediate between experience and learning outcomes. Experience consists of behaviour, ideas and feelings that occur in a specific context, such as a student on a work placement. The reflective process involves returning to experience via mental representation while making as few judgements about the experience as possible. This is followed by attending to feelings that were present in the experience, whether positive or negative. Positive feelings can be enhanced to provide motivation to persist with challenging situations, while negative feelings may need to be set aside so that they don’t create a barrier to learning. Finally, the experience is re-evaluated through association (relating new data to what is already known), integration (seeking relationships among the data), validation (seeking internal consistency between new appreciations and prior beliefs), and appropriation (making the knowledge one’s own as part of one’s identity and values). Outcomes of reflection include new perspectives on experience, a change in behaviour, and a commitment to action. The process is shown in diagrammatic form in Figure 9.

Bennett-Levy, Thwaites et al.’s elaboration of the reflective system in 2009 was part of a shift in perspective on the DPR model that highlighted the centrality of the role of reflection and interpersonal skills in the development of therapist competence (Figure 10). In this version, the reflective system sits between the person of the therapist and the self-as-therapist. Declarative interpersonal knowledge, conceptual and technical procedural skills and declarative knowledge sit in the domain of self-as-therapist, whereas interpersonal perceptual skills, interpersonal relational skills and the therapist’s stance, attitudes and beliefs are properties of both the person of the therapist and the self-as-therapist.

Across the developmental lifespan of Bennett-Levy’s DPR and personal practice models it can be seen that the reflective system has taken on greater prominence, especially in the most recent version as a bridge between the personal and professional selves of the practitioner. As Bennett-Levy, Thwaites et al. (2009) point out, reflection and self-reflection are concepts that have been identified for a long time as critical to sensitive, informed psychotherapy across a range of modalities and indeed in adult education and learning more generally. In what is effectively a return to Schön’s (1983, 1987) original concept of the reflective practitioner, Bennett-Levy (2006) ascribes reflection a central role in the development of therapist expertise in CBT, stating that:

“Once basic skills are learned, reflection enables practitioners to discern in what context, under what conditions, and with what people, particular strategies may be useful. They learn when-then rules, plans, procedures and skills governing the application of particular techniques in particular contexts when they reflect on their own experience and that of their patients” (p. 60)

In summary, the role of reflection and a theory of reflection as a cognitive process, have been increasingly well-developed over the past decade and a half, transforming our understanding of the active, problem-solving role that practitioners take to tackling problems in practice. It is perhaps notable that models of reflection such as those offered by Boud et al. (1985) and Bennett-Levy (2006) focus on reflection as a process that is psychologically internal to the person reflecting. Indeed Bennett-Levy describes it as an information processing model, whereas Boud et al.’s model suggests more of a focus on the role of emotion than the DPR model. Perhaps as models of reflection develop they might benefit from a greater focus on the transactional nature of interpersonal communication and therefore the interpersonal nature of reflection. If we look back to Dewey’s concept of reflective thinking we can see that one of the conditions Dewey described is the notion that reflection needs to happen in community and in interaction with others (Rodgers, 2002). Whether reflection is online or offline, conducted through discussion with another or alone, the author would argue that it is inevitably a relational process. Meaning, it has been argued, is constructed dialogically either with an actual other or in a form of cognitive processes that rely heavily on inner speech as the endpoint of a developmental process in which social dialogues are internalised (Alderson-Day et al., 2016). As a consequence, inner speech often has a dialogic structure that involves the co-articulation of differing perspectives on reality and, can include direct representation of others’ voices.

Part 5: The role of self-reflective awareness in professional development and clinical practice

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