Personal Reflections On Case Discussion Group Medical Essay

It seems an extremely difficult task to me to have the ability to encapsulate all my reflections on days gone by year of the CDG in this statement. At this time in writing I am wanting to know whether this thought is a representation of feeling overcome by my memories of days gone by year. Therefore, I've decided to split up certain areas of the group to be able to help me seem sensible of my encounters and reflect on what was learnt.

Diversity and difference within the group

There are seven trainee people in our group (one male and six females) and we'd a male facilitator. We quickly discovered the great quantity of similarities between customers of the group. All the trainee members in our group stay in London and most of us possessed our adult mental health placement in the same trust in London. Interestingly, we also uncovered that our facilitator was located in London on his scientific days and lived in the same area as two of the trainees in the group. All of the trainee customers are also relatively close in era (25-32 years). Our group users come from a range of communal and ethnical backgrounds, which was illustrated whenever we completed cultural genograms in a single CDG session. One could consider our group to be racially, ethnically and culturally diverse, with participants from the variety of different interpersonal economic backgrounds, countries and cultural influences. Several of our group participants had also spent a number years surviving in African and Asian continents and some speak a number of different languages.

Structure of the group

Reflecting back again I realise the way in which our consultations were organised was very original and added a depth to your experience of the situation Discussion group (CDG). Every week two trainees would present an instance to all of those other group, with one demonstration lasting just a little longer than the other (depending on whether it was a significant or minor circumstance). Lots of the cases that our group members presented were not specific client situations, but more systemic situations which we were struggling with. Once the trainee had offered their circumstance they remaining the group and sat in some other part of the room. This left the rest of the group members to discuss their ideas about the situation in the style of a 'reflecting group'.

I found this experience important as it as it provided me information into how it must feel to truly have a reflecting team to you when working as a therapist. Reflecting clubs have been used since the 1980's (Anderson, 1987) and are now to certainly be a form of therapy in itself. The primary concentration of the reflecting team is to create 'multiple perspectives' (White & Epston, 1990) for the therapist and client.

'Without the era of alternate knowledges, people are perhaps "stuck" or "standing still" and cannot progress using their lives' (Dawson et al, 2003; p2).

Indeed, whenever i presented a customer who was very trapped in her strange beliefs, I realised i too was caught up in by domain flipping was dealing with her. Listening to the other trainees discuss her circumstance made me realize that I would have to be more flexible in my approach to working with her and think creatively.

What was interesting was how incredibly frustrating it believed being sat from the group and being struggling to verbally 'protect' areas of your work. This made me echo how clients may feel when decisions about their care and attention are made without them being present. For instance, I was lately invited to attend an Assertive Outreach team conference which engaged sixteen other mental health professionals. The purpose was to review a young man who got complex mental health issues and had not been complying along with his medication routine. It was only by the end of the meeting that I asked why he previously not been invited and it became clear that no-one got considered responsibility for connecting with him so he had not even been asked. Reflecting back again on this had made me strongly aware of the need to work collaboratively with clients, specifically in relation to keeping them informed about decisions or changes in their care.

The group process

The model that i feel best encapsulates the process in our CDG is Manors' phase-model of group development:

Figure 1 - Model of group development (Manor, 2000)

Forming the group and proposal phase

Authority problems and the empowerment phase

Intimacy crisis and the mutuality phase

Separation problems and the termination phase

In the first few CDG consultations we were primarily concerned with determining the goal of the group (i. e. what's the group for?), allocating tasks (e. g. chair and scribe tasks) and defining the leadership position of the facilitator (i. e. Will he reveal how to proceed?). This is defined as phase 1 in the model and appears to be a perfect profile of the confusing and relatively frustrating formation amount of the group. Each one of the subsequent levels of the group includes a 'turmoil period'. The second crisis (power) seems similar to the 'storming' level in Tuckman and Jensen's style of group development (1965) which I identified as another model in my PBL reflective consideration. In our early CDG sessions there is a power struggle between your facilitator and the trainee group users, in as much as the facilitator seemed to make suggestions in the sessions (e. g. styles of display for the PBL, matters we have to cover) that have been opposite to the ideas we had produced.

"I felt that he was somewhat patronising towards us today, he seemed to go against every suggestion that ****** made" (3rd CDG period entry)

Reflecting back upon this entry I wonder whether we ousted him so that they can make our cohesion as a 'trainee group' stronger. I also speculate whether we subsequently attemptedto create 'a group from the group', by organizing cultural outings for our CDG trainee members and speaking about the CDG sessions on the teach quest home. Admittedly there have been two strong characters inside our group who led these discussions plus some who just sat there silently. It is merely with hindsight that we realize we were experiencing an authority turmoil and our way of regaining electricity was to reform and bond as a trainee group.

The next stage in Manor's model can be involved with the intimacy of the group and their capacity to start personal discussions. For our CDG I don't think this took place until about 7 weeks in. Until this time we were very restrained as an organization in speaking about personal issues and I observed we never talked about our own emotions in the CDG trainings. Our strong use of humour may are also a defence for 'protecting' the group from achieving this stage. I remember one of the more robust participants of the group joking that we 'were not really a group who need to cry over things'. I believe it was remarks such as this that made us feel cohesive as an organization; however it also meant sometimes I felt unable to disclose my true emotions about a concern for concern with going resistant to the essence of your group. Interestingly, this recently transformed whenever we completed personal ethnic genograms in a CDG period. This was a pinnacle point inside our group process as it appeared to break all the intimacy restrictions we'd created and allowed certain users expressing their emotions of annoyance when speaking about certain conditions or professional medical situations. Our marriage with the facilitator also evolved following this point and became more mutual.

A major advantage of this model is that it makes up about the group changes as time passes, particularly based on the ending of your group. Reading about the ultimate separation problems and termination period reminded me of your last CDG time in July to which only three trainees were present. I recall a solid sense of dread and despair in the period, and we spent over 50 % of the period talking about the original problems of the group. That is referred to as re-capitulation in the model and sometimes appears as an effort to prolong the life of the group.

Given that people recognized the group was not truly ending, why performed we go through the process of separation crisis?

Despite knowing there would be a continuation of our own group in the second yr of training I think we battled with being 'segregated' from our facilitator. This made me think about how precisely clients must feel when they are going to finish a restorative group and the stress and anxiety it must create. Yalom eloquently explains the benefits from this crisis:

'Learning that I have to take ultimate responsibility for just how I live my life no subject how much guidance and support I get from others' (Yalom, 1995; p88)

With hindsight it is clear that experiencing the termination of an organization process is one of the very most valuable phases as it essentially installs a sense of expectation and helps a handover of responsibility. Understanding this model has been an important learning level for me as I have been able to use my own learning of the CDG process and copy it to my scientific work with categories. At present I am just finishing with three restoration categories for clients on inpatient wards and also have used Manor's model to help them understand their own group dynamics.

Personal and Professional Development

Personally, I must say i valued the opportunity to learn about the several models that other group participants were dealing with as it includes helped me broaden my specialized medical procedure. Our facilitator brought systemic thinking to your classes, which essentially designed the discussions we had about clinical conditions. Given that most of our lectures and placements were led with a CBT procedure, it felt new and somewhat overwhelming to be asked questions from a systemic perspective. In my first case demonstration regarding a lady who had been emotionally and bodily abused as an adolescent. I recall the facilitator opening up a discourse with the other trainees about her accessories and role in the family composition. It was fascinating listening to how this transformed the content of the chat. At first I pointed out that the other trainees were trying to 'problem-solve' my case, but this immediately evolved plus they were making more thoughtful and curious conversation which delved into areas I had not even considered. It made me appreciate the value of considering and understanding systems as part of the therapeutic process. Indeed, I have since discovered the benefit for using systemic tools such as Genograms and ecomaps when aiding clients speak about and make links to their past.

Interestingly, I was initially quite resistant to thinking in a systemic way and realise I had been 'clutching' to the model which was found in my position. Writing this report has made me speculate whether the amount of resistance I proved is a parallel to the resistance often within multi-disciplinary clubs when change is imminent. For instance, the service where my position is has adopted the Restoration model (Repper & Perkins, 2003) as a platform for mental healthcare delivery. After going to a lot of their team conferences I realised just how defensive many of the team members believed about this, and they created it 'as yet another new novelty in the system'. It made me understand how resistance can be important in revealing us something about the actual feelings and worries people hold. Similarly, there is research to claim that the role many Psychologists and therapists carry in teams stirs amount of resistance from other healthcare professionals. Hook (2001) discusses worries which some personnel have regarding the notion of internal processes, as possible regarded as a threat with their knowledge. Hook (2001) explains this as 'brain technology' versus 'brain technology'. True enough; the issue of Psychologists' integration in teams is one that draws in much attention in current health policy literature:

"Stakeholders revealed an overwhelming preference for the integration of psychologists within teams but only if psychologists retained their unique individuality and contribution (e. g. offering an authoritative and constructive counter-balance to the 'medical model')" (Team of Health, 2007; p2)

With the fast-changing weather of the NHS I realise that the roles of health care professionals are regularly adapting and I ask yourself how resistance and institutional defences will participate that. These are issues which developed for me after reflecting on the CDG process, and ones that i will continue to grapple with throughout my training.

Another valuable experience for me personally was learning more about diversity issues and how they make a difference the therapeutic romantic relationship. This theme arose after we put in two CDG consultations completing social genograms independently and then provided them to the rest of the group. Not merely was this an release to a good scientific tool, but it empowered me to think about what culture really means and exactly how it is different to ethnicity and contest. These terms got caused great dilemma in our initial group conversation about culture, and I did not even understand that they recommended various things until our facilitator kindly described them for us.

Thinking about my own cultural identity also made me aware and delicate to my clients' different ethnic affiliations. Indeed, Hardy & Laszloffy (1995) argues that:

"Trainees are rarely challenged to examine how their individual ethnical identities influence understanding and acceptance of these who are both culturally similar and dissimilar" (Hardy & Laszloffy, 1995, p227)

Most of my current clients come from very different backgrounds if you ask me plus some have strong religious attachments which affect just how they understand and cope with their mental health difficulty. After doing the genogram inside our CDG I mirrored in my supervision sessions about how regions of difference may interplay with the healing relationship. For example, one client I had been seeing referred to herself as a modern-day Christian and her beliefs meant she created her mental health difficulty to be a punishment from God. After reflecting upon this in guidance, I realised that there is a huge difference inside our religious affiliations (I would consider myself to be an atheist), that was affecting my acceptance of her structure. Once I grasped this our trainings all of the sudden shifted and we were able to progress with her treatment. Furthermore, I now regularly acknowledge any regions of difference when I first see a client separately and feel this had always had a positive impact on the healing alliance.

On a more personal level, writing this bank account has allowed me to think about what role I played out in the group and what this informs me about my role as a specialist in training. As I am writing I know that it has been easier for me personally to create about the group process than think about my very own involvement and efforts to it. Upon better inspection I am curious as to whether my narrative of the group process reflects the position of 'the follower'. This role has been well-documented in control books, and the name encapsulates someone who can sometimes be pushed besides by others with regards to management decisions (Dvir & Shamir, 2003). Certainly my behaviour in the CDG this season meets with this information, and has made me think about how precisely I present myself to my professional network. Whilst this pays to for me personally to understand, it also seems slightly uneasy to recognize this, as acknowledgement for me personally means action should be studied. I send here to the eloquent words from Bolton (2001):

"Representation is not really a cosy procedure for quiet contemplation. It really is an active, strong, often intimidating process which demands total participation of the personal and a commitment to action. In reflective practice you can find nowhere to hide".

In many ways the characteristics of 'the follower' mirrors that in Yalom's (2005) information of the silent consumer in group remedy. Yalom stipulates that such clients result in feelings of disappointment in other group associates but can also be valuable for the group as, 'silence is never silent' (Yalom, 2005). Yalom (2005) asserts that you will get meaning in the 'here-and-now' of their behaviour which informs you about their way of relating with others in the outside world. Learning this made me think about a customer whom I used to see who was 'silent' for much of our consultations. I ponder now whether her silence was the most readily useful piece of information that was open to me, yet I did not recognise that at the time. This is something I am going to make a mindful effort to take into account in future clinical work.

Final thoughts

One of my summary is just about the name chosen to signify the group experience. I speculate whether it might be more fitting to call the organizations, 'Reflective Practice Organizations' rather than 'Case Discussion Groupings'? The latter name tasks an expectation of a far more formal and typical structure to the group where one would expect presentation and debate to be the crux of it. In fact, my experience of the CDG trainings challenges this expectation as the actual time spent focusing on cases was little. I personally feel that 'Reflective Practice' incorporates thinking about other areas of medical work which are important and could impact upon our use clients. For example, pondering systemically about working with staff or critically about organisational stress and the consequences this has on specialized medical work. Reflecting back again I appreciate such issues are relevant to your development as first years and the groupings will be a perfect chance to explore and contain them. By changing the name of the groups it would accept such explorations and therefore add a reflective element to our practice which simply cannot be satisfied by guidance alone.

Finally I feel that the group has added an expansive dimensions to my thinking as a trainee psychologist. My objectives of the CDG were continuously challenged by my real experience of it. I came across that it enabled me to become more open, more honest and far more curious in my clinical work, as well as for that we am extremely pleased.

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