*Quote from Winston Churchill
Training in addiction psychiatry has been recognized as an essential part of psychiatric practice (1, 2, 3). It is much easier for psychiatry residents to acquire technical knowledge and skills than it is to develop professional attitudes and empathic capacity for working effectively with people with substance use disorders and pathological gambling. Attitudinal factors impact on professionalism, communication, scholarship, and collaboration capacities that in turn affect the treatment received by people with these problems (4, 5, 6).
Addiction psychiatry has long been cloaked in various false-beliefs, stigmas, and faulty assumptions (7, 8). Traditionally, these factors have contributed to a failure to understand and respect addictive disorders as chronic conditions similar to other physical and mental health conditions. To be able to properly treat individuals suffering from addictive disorders, it is important to be willing to explore how one’s own assumptions and biases can construct one’s professional attitude. There is evidence that inviting students to think about their attitudes and assumptions helps ground the knowledge and skills that they acquire more effectively (9, 10, 11, 12). The ability to actively reflect allows psychiatric practitioners to learn experientially in ways that lead to continued professional growth and development through the work of clinical practice itself. Instilling, supporting and evoking this professional competency can be explicitly included in the learning experiences that educators construct for their students. Reflection facilitates the development of increased awareness of deeply held but often unexamined attitudes, values, and beliefs about human problems, how they originate and develop, and how they should be addressed. Our behaviors as clinical practitioners implicitly embody, enact, and reveal these fundamental dispositions that people all have. Learning that intentionally includes self-reflective activities and exercises might help students become aware of their embedded beliefs. This then allows practitioners to shape their professional behavior more purposively. This fits the experiential learning cycle described by Kolb (13) who posited that understanding of reality is built upon experiences, which in turn shape ideas about what is valued as knowledge.
Critical reflection helps students and teachers alike to be more aware of how their perceptions and beliefs shape their professional comportment and to better understanding the impact of their behavior as professionals on their clinical practice (14). It draws on personal experience and behavior to enhance reflective skills, while encouraging growth and development through enhanced reflection of professional practice (15). Critical reflection facilitates the development of awareness and examination of unconsciously held values and beliefs and the ways they inform interpersonal behaviors, including professional practice (16).
All postgraduate year 1 (PGY-1) psychiatry residents at the University of Toronto receive a 1-month core rotation in addiction psychiatry. All teaching hospitals send their PGY-1 psychiatry residents to the addiction base site at the Centre for Addiction and Mental Health for this training. The clinical experiences include training in a medical detoxification unit, an addiction medicine outpatient clinic, nicotine cessation clinic, methadone clinic, concurrent disorders/mental health and addiction clinic, specialized therapy clinics (e.g., anger and addiction, eating disorders and addiction, borderline personality disorders), as well as visits to shelters, hostels, and 12-Step groups and other community resources. Students with special interests can have their last week tweaked to allow “minielectives” in specific areas (e.g., woman’s health groups, youth groups) (17).
In designing the rotation, the authors drew on the literature on reflection techniques and adapted materials to fit the short time frame for the rotation. On day one, as part of the orientation to the rotation, students were introduced to the reflection component. Residents were provided with a reflection journal. This was theirs alone, and they were informed that they would not have to share this material with anyone else. Time in the rotation schedule was reserved for reflection activities, including journaling and reading. Scholarly articles on the methods and merits of using critical reflection in professional practice were included in the information kit for the rotation. Three group process meetings were made available over the course of the month where the residents (usually two per rotation) could meet with the education coordinator. Finally, they prepared and submitted a final reflection paper at the end of the rotation. The purpose of the paper was to review and reflect on their experiences over the month-long rotation, to summarize key points, and identify what they were taking away from the experience. This task met the CanMEDS guideline requirements that residents demonstrate scholarship in their training (4, 17).
Learners were given instructions on how to do reflective journaling (please contact authors for documents). They were also informed that whatever they wrote in the journals was for their eyes only. Students were told that they could modify how they did the reflection journaling but asked that they at least give it a try. If they did not use it at all, it would not affect their performance marks. The only formal requirement was that they submit a reflection paper at the end of the rotation. Journaling would help them track issues and incidents that had happened and would be a resource to draw on for the reflection paper. Finally, journaling and reflection was encouraged as good preparation for the residents as potential educators themselves, given the emerging departmental expectation that educators have documented reflective components in their teaching dossiers.
During each week of the rotation, each resident was scheduled 3 hours for reading, journaling, or working on reflection paper as desired. There was no measurement of how the time was specifically used.
Once a week, the students would meet with the addiction psychiatry education coordinator, either alone or together, to discuss their reflections on the rotation. The goal was to offer a safe environment where they could talk not just about formal practice issues in addiction psychiatry but also about their own perceptions, beliefs, and values, as well as clinical practices they were observing that could include positive and not-so-positive encounters with clients, colleagues or community members related to addiction problems and how to deal with them. Encouraging and modeling reflective self-disclosure is one task for the mentor to attend to deliberately. Residents brought in topics related to their experiences in the rotation and elsewhere in their medical training. This often led to discussions of stigma, harm-reduction, motivation, diagnostic dilemmas, the ambiguity of many things in the realm of psychiatry, the reinforcement of why they chose psychiatry as a profession and how they would now treat patients who had concurrent mental health and addiction issues. These meetings were an hour in duration. The final meeting of the rotation incorporated 15 minutes of supervisor directed wrap-up administration issues and the rest of the hour was resident directed-discussion using the submitted reflection papers as the focus.
Residents were given instructions for the reflection paper at the very beginning of the rotation. They were asked to submit their paper at least 2 days before the final meeting with the supervisor to allow the supervisor time to review the papers for discussion. Students were informed that these papers would be the “open” comments submitted as part of their scholarly work. The papers collectively would provide an information base that would be analyzed over time to help keep shaping the addiction psychiatry curriculum.
Each student was expected to read Epstein’s article, “Mindful Practice” (19) that was included with other addiction papers as part of their orientation practice. This article discusses in further detail all the benefits of using reflection and mindfulness to enhance one’s clinical abilities. Additional papers were provided to emphasize the value of self-assessment, self-awareness, and reflection in personal and professional development as a psychiatrist. In preparation for gathering the papers for analysis, the authors received approval for their research design from the Centre for Addiction and Mental Health Research Ethics Board. For a 1-year period from January–December 2005, all residents who rotated through the PGY-1 addiction rotation had their reflection papers collected. Residents were informed that papers used would have the authors’ names removed and be coded by a third party researcher outside the institution. If any did not want to have their papers included in the project, their papers would be omitted with no penalty to the resident. Two independently hired researchers who were not employed by the University or hospitals of the authors or residents performed qualitative analysis. All papers submitted for analysis had the resident’s name removed along with any other identifying information. Content analysis using “open coding” was conducted in order to determine themes that emerged from the papers submitted (18, 20, 21). The papers were coded twice, first manually, then using N-Vivo software.
During January-December 2005, 28 residents were trained during the addiction psychiatry rotation.
While students were given the option to abstain from this study, there was 100% participation, with all of the 28 residents allowing use of their papers for the study. The papers did not have to follow a prescribed format. Examples were provided in the Reflection Journal Guidelines on how to structure the paper but each student was invited to draw on his or her own experience and write using his or her own voice.
Eighteen of the 28 residents endorsed using the journal. Ten of the 18 stated they used it daily. The other eight stated that they used the journal more for taking notes about interesting educational points. Three of the 10 who did not use the journal created alternative reflection methods including writing e-mails to themselves or keeping an e-journal in an MS Word document. Seven out of 10 who did not journal said they were not “journaling” types but found the reflection meetings useful and liked reflecting in a group rather than alone.
Summary of Reflection Papers
In the spirit of the guidelines for the activity, residents displayed real variety in the ways they approached writing their papers. Some used a very personal approach, focusing on how the learning affected them, and particularly their assumptions and beliefs about addiction and those afflicted by addictions. Others were far more focused on content issues such as the neurobiology of addiction or specific treatment options. Key themes and comments emerging from the papers included:
For many, reflection did not come easy. Some residents commented they did not really want to write their reflections, but when they began writing they saw the benefit. Many identified the act of self-reflection as leading to recognizing their own biases, which in turn led to cognitive dissonance, and then to a shift in their attitudes toward people with addictions. This attitudinal shift had an impact on their understanding of substance use disorders and their actual behavior in dealing with patients. Of the themes emerging from the data, the shift in attitude experienced through the rotation was the most evident.
Attitudes upon Entering the Rotation
Eighteen respondents commented on changes in their previously held beliefs or biases toward people with addictions to a more understanding point of view. Upon entry into the rotation, residents’ interests in addiction varied. Some had personal experience through friends, relatives, or even certain communities suffering because of addictions, and this gave them extra motivation to want to learn more. Others commented that they came in with a negative attitude, assuming that addicts were mainly street people who they expected to be of low intelligence and education, low functioning ability, and low socioeconomic class. Some perceived that addiction disorders were lower in importance than other areas of psychiatry and medicine, and anticipated a boring experience. The fact that they were able to disclose these comments in itself speaks to the value of encouraging self-reflective medical practice.
By being exposed to people who did not match the stereotypical images residents held of “addicts,” perceptions and attitudes frequently emerged in ways that could be constructively explored.
“I found myself amazed at the fact; despite his burning desire to quit he was unable to make progress. The impression I had before was that if someone really had the will to quit and the intelligence to make a good plan then they would have little difficulty in abstaining, but clearly I was wrong.”
“I believe that I will take with me for the rest of my career the understanding that you can never determine someone’s addiction status in a glance.”
“I feel ashamed about placing more stigma upon this already highly stigmatized population.”
With possibly one exception, the reflection papers noted a change in attitude in favor of the field of addiction and the people who suffer from its effects. Many residents mentioned developing an awareness of their own biases toward substance abuse, including skepticism and pessimism toward the treatment options available for patients. This led to an increased awareness of the impact of attitudes, values, and beliefs in the conduct of clinical practice.
“I now realize some of these biases could have potentially developed into avoidance of important psychiatric issues and negative countertransference to my patients.”
“ … The image of what addiction can look like will probably stay with me forever.”
“Compassion—some patients are very frustrating and attempt to tell lies about their drug use—I need to understand the person’s story.”
Fifteen respondents commented on their changing feelings or attitudes toward the field. Prior to the rotation, some residents felt that addiction disorders were an unrewarding area of psychiatry in which there was not much hope for recovery. At the end, several residents reported feeling more optimistic and experiencing a sense of gratification that was unanticipated.
Eleven students commented on the scope of addictions. Most residents were familiar with substance disorders, but for some the discovery of nonchemical addictive disorders was an “eye opener.” Problem gambling was mentioned most often, but the list included shopping, Internet addiction, and eating disorders as problems that could be understood through an addictions lens. Other comments mentioned a better understanding of the epidemiology, demographics, and neuroscience of addictive disorders as well as a greater knowledge of different treatment modalities and programs, such as withdrawal management centers (see Table 1
The topic of harm reduction drew more comments than any other theme. The concept was new to most residents and it challenged them to think more deeply about addictions than they had prior to the rotation.
“Prior to this my feeling was that as physicians the authors had a primary obligation to improve the health of our patients to the best possible standard and advocate complete abstinence from problematic substance use, but now I understand that in certain situations and individuals it is better to strive for some improvement and monitoring rather than repeated failed attempts at complete abstinence.”
There was one exception to the positive reactions to harm reduction. This person felt very strongly that it could be detrimental and was self-serving on the part of the government.
Residents’ reflections papers showed significant insight into the impact of addictions on a person’s mental health and quality of life. Themes that emerged included: erosion of self-confidence in the patient; the role of fear; the cycle of addiction; the role of the patient’s environment in development and perpetration of addiction; the cost of addiction on a patient’s life (e.g., loss of relationships, income, pride, health); and the importance of identifying addiction disorders in people with a wide range of health, social, and personal problems.
The residents endorsed a number of new skills acquired during the rotation. These included stratifying risk (medical status, safety status); how to take a thorough substance history and integrate it into psychiatric interview; how to talk with patients about substance use, gambling, and other behaviors with addictive potential; and motivational interviewing. The residents identified additional skills such as how to ask specific questions about substance use and other addictive behavior, including frequency and quantities of use, social context, consequences, and effects; how to explore the relationship between substance use and psychiatric symptoms; and ways to discuss substance use in nonjudgmental ways in order to build trust and facilitate disclosure.
“I learned how to discuss the topic of substance abuse in ways that were nonjudgmental or confrontational and provide a supportive environment for patients.”
“I was amazed at how forthcoming and truthful people were with respect to their drug use when you were frank and honest.”
The Perceived Value of the Rotation
Six residents commented on the value of the rotation. All of them were positive. The following comment was characteristic:
“This 4-week rotation in addiction psychiatry has provided a diverse experience in substance dependence and concurrent disorders, forming the springing board for ideas, biases, and skills at a very early stage of my training. … I feel I am more aware of the complex nature of addiction having seen it in medical, psychiatric, and social contexts during the rotation. I look forward to building on these insights throughout the rest of my training in Psychiatry.”
Comments on Reflective Journaling
Five residents commented directly on the activity of writing the reflective journal. All were positive, but the content of comments varied in their focus.
“Foremost I have learned the value of self-reflection through journals, discussion with colleagues and teachers and self-evaluation. Reflection has helped me realize my initial biases about substance abuse and treatment.”
“I have never been the journaling type. … I have been pleasantly surprised by how valuable the process seems to be … it pushed me toward being more aware of my own thoughts, biases and emotions—an internal dialogue.”
Almost all residents reported satisfaction with the teaching they received during the rotation, although they noted that the attention they received varied. The rotation in addiction raised some questions that suggest residents had become critically engaged in trying to understand addiction as a process and how to address it. Questions included:
Students who were aware of the neurological and genetic substrates of addiction were also going beyond a narrow biological lens and realizing that psychosocial factors need to be included in explaining the diverse range of people affected by these problems. Reflective awareness based on experience made it less easy to quickly reduce addiction problems to simple explanations, and made it more necessary to be able to tolerate complex formulations of the nature of these problems. The following quotes illustrate that residents emerged from the rotation with an enhanced motivation to learn more about addiction psychiatry.
“This rotation introduced me to a very complex aspect of psychiatry. I will no longer gloss over the addiction section of my interview without giving it the respect it deserves for having the ability to worsen mental illness, bring on physical illness, halt productivity, and alter quality of life.”
“I learned how important it is to screen for all addictions in all aspects of medicine. I also learned that addictions complicate the process of finding a diagnosis. Therefore, it is imperative that a good psychiatric history includes a thorough drug and alcohol history. One message to take away from this experience is that we should always screen for addictions because they can cause serious complications in our diagnosis and treatment plans and that it is impossible to guess who may be an addict or not.”
There are some obvious methodological limitations to the data gathering and analysis approaches taken here. In spite of efforts to not influence or bias student reports, there might have been an imbalanced reporting of positive points and an avoidance of negative feedback. The removal of formal negative contingencies and the explicit promotion of candor—and efforts to model and encourage it—might have been insufficient strategies to create a safe environment for honest disclosure. These are not just incidental comments, because much of the work of treating people with addiction and mental health problems is predicated on the presumption that interpersonal safety can be developed with clients. So much of psychiatric work is predicated on honest self-report and disclosure. This activity actually seeks to enhance self-awareness and understanding among psychiatric residents.
The requirement to submit a reflection paper was set on a pass/fail basis, with no adjudication of connect included as part of the process. On its own terms, it sought to model and encourage critical reflection and appraisal of learning experiences, but it is very much in keeping with the ethic of this activity that the limitations in the process be open for examination. That respected, the review here invites some positive conclusions about the value of reflective components in clinical addiction psychiatry education. Indeed, most residents directly endorsed the reflective elements as important and a few described it as crucial to the overall success of the rotation. Many of the actual themes of the reflection papers are congruent and consistent with issues and observations that were brought up in the review and reflection meetings that took place during the rotation. In those meetings the residents were comfortable disclosing negative experiences and providing critical feedback on aspects of the rotation that concerned them. This was actively invited, along with the commitment to work to customize and adapt the rotation to the learning interests and needs of the residents. In that way, the practice of reflective learning was an active ingredient of the whole rotation, regardless of whether and how the residents operationalized the suggestion that they journal as part of the experience. In that sense, the final reflection paper was summative of a process that characterized the rotation rather than appearing as an unusual add-on at the end.
This report describes in an exploratory way a recent innovation of using reflection techniques in teaching residents in addiction psychiatry. The papers are self-reports. They were not submitted anonymously, but were submitted individually (usually by e-mail) to the rotation coordinator for review, although for this analysis all names were removed. Nevertheless, the authors cannot rule out the potential effects of social influence and other factors as unmeasured confounds affecting the outcome measures. For example, residents may have written what they thought the supervisor wanted to read. If this were the case, the face-to-face meetings should have produced more underreporting of negative comments. But our impression is that the opposite is true. Perhaps discussing and processing negative concerns along the way led to a relatively more positive tone in the written reports than in the meetings. Certainly, different methodologies could be used here, to put data collection in the hands of third party investigators, but that might stand to undermine the important factors linked to successful critical reflection in learning (i.e., the creation of a healthy learning climate, building trust between the individuals reflecting, and other interpersonal dynamic issues).
The impact of the reflection activities alone on residents’ attitudinal shifts during the rotation is difficult to measure. These activities coexist along with other training components that impact on the resident’s learning. Reflection cannot be easily divorced from other educational techniques. Kolb (13) holds that all experiences must be reflected on to be absorbed as learning. Our strategic interest in intentionally using reflection techniques was to enhance and deepen the impact of educational experiences in the addiction psychiatry rotation. Despite these limitations, the current findings suggest supporting further research into reflection techniques. It will take time to develop a more solid base of evidence that this is not just a promising approach but a valid method to enhance the educational experiences of residents. One striking feature of many of the papers was the presence of comments that went beyond the formal expectations of the activity. This included powerful admissions of self-discovered biases, attitudes, and beliefs. It also meant that on occasion respondents used the activity to explore and share issues of addiction that were close to them personally. This supported our belief that reflection activities humanize the understanding of mental health and addiction problems, and enhance the compassionate and empathic understanding of these problems, which are too often stigmatized and left on the margins in psychiatry as in health care in general.
Qualitative analysis performed by Jane Tipping, MA, D.Ed., and Denise van Amsterdam, Med.; The authors thank Susan Lieff, M.D., M.Ed. FRCPC, for graciously allowing adaptation with permission of the Education Scholars Program reflection templates (15).