KKegan R: In Over Our Heads: The Mental Demandsof Modern Life. Cambridge, MA, Harvard University Press, 1994

In the prologue to this book Professor Robert Kegan reminds us of the outrage we feel when we observe children being asked to do something for which they are not mentally ready. We feel a strong urge to protect them from expectations to perform beyond their mental capacities. Our outrage is fueled by a concept we hold of the mind of a child as distinct from that of an adult. In this book Kegan attempts to extend to adults the sympathy that we have for children who are "in over their heads." Adults find themselves in similar situations when the demands of their work, modern technology, or their relationships are beyond their mental capacities. The book is based on the premise that "adulthood itself is not an end state but a vast evolutionary expanse encompassing a variety of capacities of mind."

Specifically, Kegan argues that modern life makes demands on individuals to possess a certain complexity of mind, a certain level of constructing experience. The deep structure of this mental organization is the subject—object relationship. We can operate on the "objects." We can be responsible for them and control them. But we are embedded, infused with the "subjects." We cannot be responsible for them or control them. Growth of mind is viewed as "making subject into object," being able to relate to the window rather than look through it. He uses a driving analogy to explain developmental differences in subject—object relations. Drivers of stick-shift cars can drive cars with automatic transmissions, but not all drivers of automatic cars can drive stick-shift cars. Stick-shift drivers can operate on the gears; they can take responsibility for shifting. Automatic drivers are subjected to gear changes as they drive. As level of consciousness increases with development, people acquire the capacity to operate on and take responsibility for an increasing range of aspects of their environment. Kegan offers a developmental theory containing five such "orders" of consciousness, each a qualitatively distinct order of mind as different from the others as concrete thinking is from abstract thinking. We are "in over our heads" whenever we are unable to reflect on the situation that confronts us, that is, when we cannot make it an object of our reflection.

This book has important implications both for education and for psychotherapy. It will help clinicians and teachers understand patients, residents, or medical students who are "in over their heads," not because they lack effort, knowledge, or compassion but because they cannot be responsible for what is beyond their mental world. Clinicians and teachers may find the hierarchical aspect of orders of consciousness "provocative, discomforting, even dangerous," to use Kegan's own words. For example, the ability to help patients, residents, or novice teachers without feeling personally violated or threatened requires the mental ability to stand apart from one's own values and definitions, to avoid being completely identified with them—an ability only possible at Kegan's fifth level of consciousness. This book is as provocative as it is intellectually stimulating. It challenged me to think about my own capacity to do the job that is required of me.

Kegan R, Lahey LL: How the Way We Talk Can Change the Way We Work. San Francisco, Jossey-Bass, 2001

This new book by Robert Kegan and Lisa Lahey is very different from In Over Our Heads. Kegan's earlier book is a broad, theoretical work that illustrates the different ways in which people make meaning by drawing examples and parallels from several literatures. The new book is a highly focused "how-to" book that invites the reader to work through a series of exercises aimed at fostering individual transformational learning and organizational transformation. The link between the books is their dependence on the deep structure of subject—object relations. The exercises in this new book are aimed at increasing the complexity of the mind through transformational learning to enable us to look at our internal contradictions and assumptions rather than to look through them.

I conducted a half-day workshop for a small educational unit in my medical school based on this book. The results were so encouraging that I am currently organizing a much larger group.

The logic of the book is that nothing less than transformational learning is required to overcome the most persistent obstacle to change in individuals and organizations, a force the authors call "dynamic equilibrium." Dynamic equilibrium is responsible for broken New Year's resolutions and the failure of groups to solve their problems. It continually manufactures mental immunity to change. Kegan and Lahey describe us as held captive by these mental immune systems. We live inside them. The book is aimed at learning how to diagnose this immunity to change and how to "disturb" the immunity by introducing safe experiments.

The authors use language forms as tools to help us break out of the state of dynamic equilibrium. Readers of Academic Psychiatry who have taken part in one of Kegan's conference addresses will be familiar with their methods. Typically Kegan invites the audience to engage in a number of exercises and then discuss these with a partner. The book follows the same procedure. Readers are prompted by a little clock face to stop reading, make entries on a sheet of paper, and take time out for reflection. Reflection is superbly suited to the goal of the book, since transformation learning is the goal. Passive reading would not be appropriate.

The authors define seven "internal languages" that prevent change. The first chapter targets the language of complaint, which focuses our attention on what we are against rather than what we stand for. The authors guide readers toward the positive commitments hidden in their complaints. The second chapter targets the language of blame. It helps readers recognize and take personal responsibility for engaging in behavior contradictory to this primary commitment rather than blaming themselves. The third chapter helps us escape the language of New Year's resolutions. It asks us to consider that the behaviors that prevent us from pursuing our primary goal do not derive from irrational "naughtiness" but from the logical consequences of other commitments that are in conflict with our primary one. The authors encourage us to respect our complexity, to embrace our contradictions. The fourth chapter helps readers become aware of the Big Assumptions underlying their competing commitments and provides suggestions for conducting safe experiments to test the validity of these assumptions. Three final chapters help readers use other language tools to foster growth at the interpersonal and organizational level.

Hicks LK, Lin Y, Robertson DW, et al: Understanding the clinical dilemmas that shape medical students' ethical development: questionnaire survey and focus group study. British Medical Journal 2001; 322:709—710

Most of the current research and teaching in medical ethics focuses on the ethical dilemmas that students may face in future practice rather than on the kinds of ethical problems they may encounter. The authors used a questionnaire survey and focus groups to reveal the nature of the ethical problems normally encountered by students. They surveyed 108 clinical students who were about one year from graduating from medical school. When students were asked how often they had been placed in a clinical situation in which they had "felt pressure to act unethically," nearly half (47%; 48/103) reported that this had happened to them very frequently, frequently, or occasionally. When students were asked to rate how often they "witnessed a clinical teacher acting unethically," 61% (62/102) reported that this happened to them very frequently, frequently, or occasionally.

Content analysis of four focus groups revealed three categories of ethically problematic situations: "conflict between the priorities of medical education and those of patient care," "responsibility beyond a student's capacities," and "involvement in patient care perceived to be substandard." Students said that these ethical problems were seldom discussed or resolved with clinical teachers. The authors discussed their results in the context of the literature on the "hidden curriculum," a major element of which is role modeling by teachers.

Although only two of the examples listed in the article were relevant to psychiatric education, these were enough to cause a shock wave throughout our department. (I am a member of the Department of Psychiatry at University of Toronto, where the study took place.) One example was "student expected to give weekly psychotherapy sessions without supervision" and another was "patients asked to return to clinic for follow-up visits and not informed that the visits were entirely for teaching purposes." The discussions have been very constructive. I included this article in the hope that it may stimulate similar discussions in your institutions before you have to read about it in the local newspapers.

Schön DA: Knowing-in-action: the new scholarship requires a new epistemology. Change, Nov-Dec 1995, pp 27—34

I would like to end this review section with a "golden oldie" for those of us who may have missed some articles over the last decade. Psychiatric educators whom I know seem to be keenly interested in the new forms of scholarship envisioned in Boyer's (1990) Scholarship Reconsidered. In addition to the scholarship of discovery, which is what most academics mean when they use the word "research," Boyer described three other categories of scholarship: 1) the scholarship of integration, aimed at putting isolated facts in perspective, making connections across disciplines, and placing specialties in a larger context; 2) the scholarship of application, aimed at applying knowledge to consequential problems; and 3) the scholarship of teaching, aimed at engaging scholars in the transmission and transformation of knowledge.

The epistemology underlying the traditional "scholarship of discovery" holds that systematic knowledge is generated by rigorously controlled experiments, statistical analysis, and disinterested theory, and is then applied to practice settings. Schön suggests that such an epistemology is inappropriate for the other three categories of scholarship. The kind of knowledge generated by the other three forms of scholarship is tacitly embedded in the work of practitioners and in the practices themselves; the practice settings are notoriously uncontrolled, their problems ill formed, and their actors clearly "interested."

If we are to take these new forms of research seriously, Schön argues, they must produce knowledge that is valid and actionable according to their own criteria of appropriate rigor. He concludes that the new scholarship requires an epistemology of reflective practice, precisely what Kurt Lewin had described as action research. Action research occurs through what Schön calls "design inquiry," a notion close to designing in the broad sense of the term, as a lawyer would design a legal argument. It proceeds through the practitioner's reflection in and on action and is "inimical to the conditions of control and distance that are essential to technical rationality." It legitimizes the knowledge that is generated in practice and that is "carried over, by reflective transfer, to new practice situations."

Schön predicts that attempts to introduce a new scholarship into research universities will precipitate a battle between the prevailing epistemology of technical rationality and that of reflective scholarship, particularly of action research: "It is a battle of snails, proceeding so slowly that you have to look very carefully in order to see it going on. But it is happening nonetheless."