Abstract
Higher education of mental health professionals faces the overwhelming complexity of the mental health field—a field infested with personal distress, professional disagreement, conceptual confusion, cultural clashes, political and ideological debate, and commercial competition (Bracken & Thomas, 2005). Human existence colors the field’s surface and determines its depth. The phenomena involved are as human as can be; everything in the mental health field is about man and thus as complicated as we are (May, Angel, & Ellenberger, 1958). This is reflected in the plethora of professions and sciences that act and reflect on mental health in some shape or form. Philosophy, theology, sociology, social work, the psy-sciences, medicine, neurobiology, and others contribute with influential perspectives on mental health; these perspectives are influential, but not necessarily compatible or mutually reducible. The history and theory of mental health is inflamed with debate and controversy, within and between the sciences, professions, and clients (cf. Coppock & Hopton, 2000; Szasz, 2008). These debates often extend to politics and ideology: At stake is not only what is healthy or pathological, effective or relevant, but also what is normal or asocial, morally good or bad. In short, between the mutuality of human existence and mental health, and the related scientific-professional debates, emerges a field that is of overwhelming complexity for any scientist, professional care worker, and educator.
In its effort to handle this complexity, professional higher education of mental health workers creates access to this field by excluding large parts of it and including only a few preferred areas—compartimentalization is preferred to interdisciplinarity (cf. Hillocks, 1999). Compartmentalization supports established professional boundaries and is sustained by conventional pedagogy, that is, pedagogy that teaches information and skills based on accepted theory without specific regard to the student’s own experience from the field and his or her individual learning process (Dahlberg, Ekebergh, & Ironside, 2003; Ironside, 2001). In this article, we present an alternative solution to accessing the mental health field in the higher education of adult students. Phenomenology provides both the rationale that undergirds our pedagogy and the research method that the students learn to use to advance the knowledge base of their practice. We first describe and then reflect on our phenomenology-based curriculum that teaches adult students how to use their own life and work experiences as a privileged starting point for professional development. In conclusion, we suggest that phenomenological pedagogy promotes the integration of personal, relational and research-based knowledge, which is invaluable for crossing traditional professional boundaries and transforming the student’s professional competency.
Interdisciplinarity and Evidence-Based Practice (EBP) in the Norwegian State Curriculum
To overcome profession-based compartmentalization, the Norwegian government has decreed a national standard curriculum for all postgraduate education in mental health work (Forskrift til rammeplan for videreutdanning i psykisk helsearbeid, 2005; henceforth referred to as the “state curriculum”). The backdrop for this state curriculum was a mid-1990s report (the first of its kind in Norway) about the Norwegian mental health services that concluded that these services had “cracks at all levels.” The treatment levels, from prevention and community services to institution-based treatment and follow-up after discharge, were so weak that the users of the services missed out on help needed, and the health care workers could not work satisfactorily (Norwegian Government White Paper No. 25, 1996-1997). Later, it was pointed out that the report could even have understated the situation, missing out on problems such as one-sided (biomedical) views of mental illness and treatment, upholding societal us–them distinctions, and skewed power balances in face-to-face treatment situations (Østravik, 2008); all of these are consistent with compartmentalization and conventional pedagogy. There was enough ground, in other words, for the development of a new national curriculum in mental health work at the postgraduate level.
The state curriculum aims to improve and equalize the standard of the mental health work competency of all professional groups within Norway’s health and social services. Mental health is to be understood as a relational phenomenon, making compulsory a relational perspective on the client, and his or her social network and environment. The curriculum emphasizes the relationship between and among workers and clients. The psychiatric perspectives on mental illness and psychiatric nursing are thus to become subservient to a larger constellation bringing together the perspectives of many professions and approaches (such as social work, psychomotor therapy, child care, and psychiatric nursing), and the services at various levels of organization within the health care system. A vision of interdisciplinary collaboration hence underpins the program.
With hindsight, we recognize that the state has also created a platform for learning EBP. The best available research knowledge from various academic fields is to be applied by the professional expert who, preferably together with colleagues, judges the demands of the actual clinical situation in concordance with the client’s expressed preferences (Melnyk & Fineout-Overholt, 2005). But in contradiction to evidence-based medicine, where research-based knowledge often takes precedence over client experience, the state curriculum promotes EBP in which the client’s individual “resources, wishes and needs” are the starting point for care and treatment (Forskrift til rammeplan for videreutdanning i psykisk helsearbeid, 2005, Section 2; authors’ translation). Client collaboration, empowerment, and relational work become obligatory teaching topics. The client is placed at the core of mental health work, along with interdisciplinarity and EBP.
Although the main intention of the state curriculum is to ensure a higher and stable standard of teaching countrywide, it leaves room for developing educational solutions dependent on regional circumstances. We have embraced this room because neither “interdisciplinarity” nor “EBP” reduce the complexity of the field sufficiently; there is still too much uncertainty for a postgraduate 1-year program. How does our pedagogical approach simplify the complexity that remains after the state curriculum?
Embedded Alternation of Description and Reflection in Our Curriculum
Our postgraduate program at a university college in the southeast of Norway is the equivalent of 1 year’s full-time study, divided equally over four semesters part-time. About 35 adult students are enrolled annually. Almost all have practical experience from a health or social care profession. Many of them return to higher education with the aim to satisfy personal–professional or, in some cases, employer interests. The typical expectation is to acquire more and newer information about mental illness and how to treat it. However, we consider that meeting the expectation of providing more information would imply a pedagogy that sustains compartmentalization: It would force us to determine beforehand which themes to include and exclude in our program, regardless of the enrolled student group. Furthermore, we do not regard our students and the professional field as separate units that must be bridged by an information load. That is because our students are already part of the field. Therefore, we see it as our task to teach students how to emerge from their embeddedness in this complex field—that is, how to transform their way of knowing the field (Mayo, 2003).
Each student brings into our program experiences at the personal, relational, and
organizational levels of work and life. They are all
We apply Husserl’s phenomenology as modified by Giorgi (2009) for use in psychology. Giorgi’s phenomenological research method leads to descriptions of human phenomena relevant for psychology, such as learning, depression, or becoming a parent. These descriptions are preferably minimally colored by theoretical or common-sense understanding of the phenomenon at hand—Husserl spoke of returning to the “thing itself.” Giorgi’s phenomenology doubles as a research method that our students learn to enable them to analyze data derived from first-person experiences and a rationale that shapes our curriculum. We explicate this further in what follows, where we describe the six-phase composition of one large part of our program, which we refer to as the critical-analytical part. The other parts of our program pertain, respectively, to practicing relational skills and the national laws and formal regulations of Norwegian mental health work. A full discussion of these two other parts is beyond the scope of this article, but we sketch “practicing relational skills” in our description of Phase 5.
Phase 1: Describing Experiences of Good Mental Health and Meeting Mental Illness
Collection of data and analysis are related yet distinct parts of any research process.
In our curriculum, we also distinguish between these two parts. Early in the program, we
collect the students’ previous experiences of “good mental health” and “meeting mental
suffering.” These two phenomena represent key experiences in the mental health field at
opposite ends of a long continuum. We invite students to write a response to the following
stimuli:
We divide the class into six interdisciplinary groups, and assign one theme to each group. Then the groups select four or five texts (from about 35) concerning their respective themes. Next, each group analyzes these descriptions along clearly demarcated steps as recommended by Giorgi (2009). We urge the students to refrain from theoretical or common-sense interpretation during the analysis and to dwell on the data to let the phenomenon “speak for itself.” We explain that this so-called “phenomenological attitude” is not unlike “withholding judgment” in therapeutic settings, which are discussed later in the study. Step 1 in the analysis consists of each group member reading carefully all selected descriptions to get a sense of the entire phenomenon at hand. In Step 2, the students jointly mark each text every time they sense a shift in the meaning of the writer’s subject matter, resulting in a division of each text into so-called meaning units. In Step 3, these meaning units are rewritten in a language typical of the mental health field as understood by the group. The result is that the texts under analysis are rewritten in similar and more easily comparable language. In Step 4, the resulting rewritten meaning units may now be clustered across the texts forming core constituents of the phenomenon at hand. Step 5 involves the students writing a summary of what the phenomenon entails. In this summary, the phenomenon’s core constituents are related to each other, and as parts of a whole form one meaning structure. This task completes the initial phase.
Phase 2: Reflecting Theoretically on a Theme Within the Phenomenological Description
Here, we leave the phenomenological reduction and open up for reflection on the description. The three modes of reflection presented are from a cause–effect, social context, and human-existential perspective. The groups choose one perspective and are advised to use the library under supervision to find up-to-date research that, from their chosen perspective of reflection, can shed further light on the phenomenon at hand. For instance, if the described phenomenon was “living in a family where one of the parents is diagnosed with a major depression,” one of the following reflections is possible: Epidemiological research shows an increased risk of children becoming depressed later in life when one or two parents have a diagnosed major depression—a cause–effect perspective. Or qualitative research demonstrates that living with a depressed parent may be experienced positively, leading the individual to spread a message of hope among others in the same situation—a human-existential perspective. Or it may be pointed out that such family experiences are seldom reported in the popular media, which prefer to uphold a cultural image of happy nuclear families, implicitly evoking shame among those who do not meet such societal standards—a (critical) social context perspective.
This phase is completed with a group paper, which must incorporate the phenomenological meaning structure and research-based reflection, and largely follow the IMRAD format: introduction, method, result, and discussion (Day, 1989).
Phase 3: Comments by a Professional Expert on the Paper
When we know the direction of the papers, we invite local mental health work experts to come to class and comment on one paper each. The experts receive the papers two weeks before the classroom session. They are asked to offer a broader perspective or deeper insight into the theme from their expert point of view.
Each group presents its paper to the whole class, directly followed by the expert commentary. This situation easily generates discussion among everyone present—students, teachers, and experts—because reflections and descriptions from different professional, experiential, and research perspectives may not easily align or may even be mutually exclusive and controversial. This is the first time in the program that the students engage in a discussion in an interdisciplinary group of professionals about EBP that is anchored in first-person experiences. In doing so, many may still be embedded—unwittingly and exclusively—in the perspective of only the experiencing person, professional expert, or researcher.
Phase 4: Dialoguing Between the Rationale of EBP and Hands-On Practical Experience
Through the first three phases, the students slowly build up a sense of how three different sources of knowledge, that is, personal experience, expert judgment, and research, mingle and merge in a mental health issue. Many students, however, may still be embedded in one of these perspectives. In Phase 4 of the program, we explicitly address EBP to help students emerge from this embeddedness. We present the “who’s first” debate in the field; which of the three sources of knowledge should have primacy in daily practice. We also present the “best evidence” debate, which takes place within each of the knowledge source areas: Which research method has highest status? Which expert judgment carries most weight? or Which user experience is trustworthy?
Then, we ask the students to sum up the debate in an individual paper and take a stand based on their experiences with past clinical practice or their expectations about future clinical practice. They are encouraged to describe and analyze these experiences or expectations using the phenomenological method. We offer individual supervision to help the student focus on a specific theme that somehow links his or her understanding of the EBP debate to what he or she considers relevant in clinical practice. “Who are you as a professional mental health worker, viewed from the angle of evidence-based practice?” “Where do you stand, or prefer to stand?” When we grade these papers, we are less interested in clear overviews of the EBP debate or univocal statements about who the student is in a practice situation. We rather evaluate how the student approaches the issue: To what extent is he or she able to negotiate the ever-present ambiguity of practice situations with the inherent uncertainty in the debates? In other words, does the student challenge the assumptions in the debate or challenge the perception of himself or herself at work, as a result of the tension between the two issues? We contend that such an exploration of the edges of knowledge promotes the way of learning that is required in this field (see also the “Discussion” section).
Phase 5: Practicing EBP
The students have a 10-week placement in the field where they can practice what they have learned so far. At this point, the “practicing skills” part of our program becomes involved. This runs parallel with Phases 1 to 4, and focuses on practicing dialogue in student groups, using role-play, video, and written descriptions of actual situations from clinical practice. These descriptions are analyzed in plenary class sessions, with special emphasis on human relational interaction, such as how to exert good judgment in the situation.
Before the clinical placement, the students learn a supervision technique called “reflecting team” (Andersen, 1994). A student group is divided into three functional units: One person who describes a challenging situation from work from a first-person perspective, one supervisor who guides the process, and the rest of the group that first listens to the description and then reflects on it. The group is not to jump to conclusions or offer solutions. It simply reflects on the situation described. The supervisor guards these boundaries and will not comment on content. After the explorations, the first person returns to the stage and conveys how his or her understanding has advanced as a result of the group’s reflections; he or she thus engages with the group in metacommunication about himself or herself in the situation at hand.
Within clinical practice, each student receives an obligatory assignment to define his or her learning goals, which is evaluated halfway and on completion of the placement. The learning goals express how the student aims to shift focus between acting in the situation exercising relational competency and reflecting on the situation using relevant theory. The student is expected to use judgment to situate himself or herself correctly within the organization of the workplace and in relation to the client. Thus EBP—balancing expert judgment, theoretical knowledge, and clients’ expressed needs—is practiced and evaluated individually.
Phase 6: Advancing EBP Through a Research and Development (R&D) Project
Work experiences are the starting point for an R&D project. Groups of four to six students are invited to write a summary of a phenomenon of their own interest stemming from a clinical or work situation. This assignment is aimed at providing a deeper understanding of this situation through theoretical reflection. The overall objective is to contribute to EBP in mental health work. The difference from Phases 1 and 2 is that this phase implies collecting original data from respondents in the field. For practical reasons, the respondents are not clients but other professionals (applying for approval from the medical research ethics committee is not feasible within the time frame of this phase). The data can be collected and analyzed using the phenomenological research method that we have introduced earlier in the program, but not necessarily so. Students may also opt for a theoretical analysis of, for example, an existing mental health promotion program or other interventions from the field. Strong personal–professional engagement with the chosen phenomenon means that the papers may approach or even push the frontiers of professional knowledge about the phenomenon at hand. We often point out that the students’ daily involvement in professional practice makes them preferred researchers or developers of projects about current pressing issues in the field.
This six-step repeated alternation between experience-based description and
research-based reflection is the
Discussion
In short summary, the rationale of our curriculum is as follows: An individual’s experience with a phenomenon is opened up by systematic phenomenological description stripped of theory or common sense, and closure is sought by reflection on the phenomenon guided by its essential features—theory follows phenomenon, not vice versa. In structuring this article, we have tried to stay true to this rationale. Above, we have described the background and structure of our curriculum. In this section, we reflect on using phenomenological description in higher education as well as on using reflection as a means of promoting transformative learning in mental health work.
Spiegelberg (1975), a
philosopher and important historian and developer of phenomenology, describes in his book
one of the most meaningful and revealing occurrences may be when one of the partners
suddenly exclaims “aha” in a tone of voice indicating that he has not only just become
aware of something new but also realizes that he has discovered what the other partner
meant all along. (Spiegelberg,
1975, p. 33)
Such outcomes of group dwelling on a phenomenon are important contributions to any curriculum, including the curriculum we have described above. However, the strength of Spiegelberg’s workshops may also have been their weakness: Their focus on the process of doing “joint phenomenologizing” came with the price of a reduced focus on core existential phenomena such as death, freedom, control, and, most relevant here, health.
In the context of health care, the use of phenomenology in higher education is discussed in
The emphasis in our own program is on first-person experiences with mental health that come from the student’s personal or professional life. That emphasis is possible because we are privileged to work with adult students who all have such significant experiences. Naturally, our students are challenged by our request—presented on their first day in the program—to capitalize on these experiences and at the same time shortcut their reflex action of judging the clinical situation, which has often been painstakingly acquired in the field. The impact that our approach may have on students is made explicit by narrative and lifeworld phenomenological pedagogy as described above: We are aware of our responsibility as teachers carefully to balance the request for suspension of judgment (openness) with practice-directed reflection on the phenomenon under scrutiny (closure). A postmodern “Open 24/7,” as a celebration of differences or an opposition to traditional power relations (cf. Burbules & Rice, 1991), is not an option for the higher education of professionals in the mental health field, as neither care worker nor client has such an option at hand at all times in real life beyond university college (cf. Giorgi, 2000).
How then to achieve closure? When adopting the phenomenological attitude, students are
submerged in the description of a phenomenon. But they must surface as well: “It doesn’t
suffice that you unfold an experience. . . . The
Kegan (1982, 1994) conceptualizes what is at stake in the simplest of terms: What is subject must become object. Piaget’s conceptual pair of assimilation and accommodation forms the inspiration of his approach (Lahey, Souvaine, Kegan, Goodman, & Felix, 1988). It addresses how people structure meaning in their world and how this structuring may change throughout life. Kegan distinguishes different qualitative levels of complexity in meaning making; we are at any point in our life subject to (embedded in) one level of complexity, and we can make object (emerge from) a lower level of complexity. For instance, we can be subject to the ideology that shapes our experience of self, which is firmly fenced off from another person’s different ideology of self; here, we do not easily open up to “negotiation” because we do not have the metaview of our ideology that is required. But then, we can take as object the way another person’s feelings and emotions influence our own, always letting our sense of self guide these feelings and emotions.
We have object; we are subject. We cannot be responsible for, or in control of, or
reflect upon what is subject. . . . “Object” refers to those elements of our knowing or
organization that we can reflect on, handle, look at, be responsible for. (Kegan, 1994, p. 32)
The transformation from subject to object is often gradual and comes in discernible intermediate stages: We get to know what we do not know slowly, only step-by-step adjusting our overall way of making meaning to new situation-bound insights.
Kegan’s (1994) main point in
Conclusion
We argue for the primacy of simplifying complexity in the higher education of mental health
workers by appropriating descriptive phenomenology. Such simplification derives in the first
instance from a curriculum decreed by the Norwegian government and in the second instance
from a “self-simplification” based on the students’ own experiences with life and work (cf.
Pattee, 1972). While a
conventional pedagogy may emphasize
