Observation in Health and Social Care

Applications for Learning, Research and Practice with Children and Adults

Clare Parkinson, Lucille Allain, Helen Hingley-Jones

• Publisher: Jessica Kingsley Publishers
• Year: 2017
• ISBN:
  9781784501815
• Topic: Medicina
• Subtopic: Formazione medica

Examining and exploring new approaches to therapeutic observation in health and social care, this multidisciplinary guide discusses and analyses its uses in a range of practical contexts with children, families and adults.

Developing good observation skills is paramount to sustaining relationships in the challenging settings that health and social care professionals find themselves in. This guide shows how observation is taught, applied in practice, and how it will be returned to throughout professionals' careers.

Drawing on psychoanalytic ideas and theories of human development as a base for professional learning, the experienced editors and authors offer theoretically informed models to teach observation skills in professional programmes, helping their readers prepare for successful intervention in any setting.

Chapter 1

INTRODUCTION

OBSERVATION FOR OUR TIMES

Clare Parkinson, Lucille Allain and Helen Hingley-Jones

The focus in infant observation on a slow and steady gathering of experiences, including those of discontinuity and incoherence, allows relationships and identities to come into focus.

(Wakelyn 2012, p.82)

The rationale for writing this book stems from the editors’ interests in teaching, practising, researching and using psychoanalytically informed (‘therapeutic’) observation in our professional lives. We share experiences of teaching infant and young child observation to trainee and qualified practitioners from a range of disciplines, and we have seen first-hand how undertaking an observation has the potential to transform a student’s understanding of babies and small children, helping them also to develop and deepen professional and analytic skills (Hingley-Jones, Parkinson and Allain 2016). Following an evaluation of social work students’ experiences we wanted to extend our own understanding and examine further how clinicians, other professions and researchers are engaging with observation. The aim of this book is to investigate and analyse how observation is used, and is useful, across the range of health and social care professions. For this purpose we have brought together author contributors who offer vibrant perspectives as clinicians, educators and scholars, and who provide a rich seam of creative exploration and analysis of observation and its contemporary applications.

The text has three main themes relating to observation: learning and teaching, practice and research. Although the demarcations between these themes are often quite fluid, we have grouped the chapters according to the dominant theme for each, as we will explain below. Chapters may be read alone as authors have provided substantial theoretical and practice-related explanation in each. We anticipate that readers will also see clear connections and continuities in the text as a whole. It is a book for students, practitioners, researchers, practice educators and mentors right across professional groupings. These include: midwives, doctors, occupational therapists, nurses, social workers, teachers, psychotherapists and counsellors, plus early years, later years and family work specialists.

There is a range of disciplinary and theoretical perspectives represented in the book. Whilst our approach is to centre on psycho-analytic observation, as represented by the majority of the chapters, we have also included contributions from authors whose perspectives we consider contrast with and enhance the central themes. In this way, the uses and development of observation in relation to mentalisation, as well as understandings of observation from sociological contexts have been included. The thematic organisation is outlined further below.

Our stance in this book is to consider observation in learning, teaching and practice, linked to research and in close relationship throughout, inviting the reader to reflect on the potential synergies and benefits of such an approach. Observation can be seen to be a tool that enables a deeper appreciation of a service user or patient’s needs and circumstances, and a teaching approach for the initial training and/or on-going development of professionals. It is also a methodological technique with which to research ethically those areas of interpersonal life and professional practice that can be hard to reach in other ways.

Background

…the observer’s conscious feeling response is often very painful, particularly if a child is ill, or if the observer witnesses miscommunications between parents and children and does not cut herself off from the distress that each one suffers. Time for discussion is essential if the observer is to be able to conceptualise the interactions she becomes part of and to consider how best to respond. (Rhode 2012, p.105)

An important reference point for us, when writing and editing this text, is Pat Le Riche and Karen Tanner’s 1998 book Observation and its Application to Social Work. Their motivation would seem to have been informed by a need to respond to a spate of serious case reviews and especially of infant deaths (Blom-Cooper, Harding and MacMilton 1987; London Borough of Lambeth 1987). Their book followed an important study published in the Journal of Social Work Practice by Trowell and Miles (1991). Here the authors write up a project commissioned by the then Central Council of Education and Training in Social Work (CCETSW) after the 1987 Cleveland Inquiry into child sexual abuse (Butler-Sloss 1988). This project was arguably a turning point in introducing social work educators in many different higher education institutions to the theory, skill and method of observation. The project entailed social work tutors themselves undertaking observations according to an appropriately adapted Bick (1964) method. This model was then and continues to be cascaded to future generations of social workers.

The question has been: how might social workers and other practitioners be enabled to connect and communicate more directly with the little children whose safety and well-being they are assessing? Psychoanalytic baby observation is identified as a means for preparing practitioners to come close to and learn to tolerate, painful states of mind in individuals and their carers; to think deeply about those states and, in discussion with others, to articulate and respond to them. This is still the principal reason why observation forms a part of professional trainings for health and social care workers and, for some, has been identified as ‘at the heart of’ professional training (Sternberg 2005).

In this book we suggest that for health and social care workers and their end users, the benefits of an observation approach are incontrovertible. Not everyone in the psychotherapeutic field is a proponent of the value of infant observation however. From what is perhaps a Lacanian-influenced perspective, André Green (as discussed by Sandler, Sandler and Davies 2000) debated this with developmental psychologist Daniel Stern. Green asserted that observation of babies does not tell us what babies are like. According to Green, who refers to Winnicott (1960) in adopting this position, it is only the baby who turns up in the inner world of the patient in the consulting room that has relevance for understanding what an individual’s experience of infancy has been. (See also Sternberg (2005, pp.9–10) for a detailed and illuminating summary of this debate.)

Following Alvarez (in Sandler, Sandler and Davies 2000) the underpinning model for our book is primarily that of ‘naturalistic infant observation’. It is this which follows most closely the model initiated by Esther Bick. As discussed by Sternberg (2005) naturalistic infant observation may be differentiated both from research on infants and from infant observation research. Sternberg argues that Green did not make this differentiation. It is this fact that is what may be thought to have led to the dismissal by Green, and others (see Wolff 1996) of what we understand here to be infant observation. Fascinating and informative though infant research studies are, there are certain unique characteristics contained within naturalistic infant observation that we consider to be essential in the teaching and practice of observation. Such characteristics include the length of the observation, the preparation and stance of the observer, and the provision of reflective seminars. These characteristics enable what Sternberg suggests the observer may gain from the observation in terms of developing particular practice sensibilities. From her grounded theory-based research into naturalistic infant observation Sternberg (2012, p.49) concludes that, in addition to the registering, tolerating and processing of the feelings the observer encounters in any observation, through reflecting on such feelings, the naturalistic observer comes to recognise the value of: not rushing to ‘understand prematurely’; drawing on theoretical models as a means of making sense of the experience; being aware of one’s own feelings as a source of information about the subject of the observation; and, following writing up and seminar discussion, having an awareness of how much the observer has ‘failed to notice or given sufficient weight to’.

What becomes clear, from contributing authors in this book, is that the conceptualisation and the place of observational studies for students and health and care professionals have developed apace. From the following chapters we can see not just the continuing potential for the professional to learn about how babies and children grow and develop interpersonally, nor only ways in which organisations and their members may be seen to process emotions such as anxiety. It becomes apparent that the study of observation in contemporary health and social care demonstrates new discoveries from experiential learning as individuals take up and sustain the observer role. This may be in family homes, consulting rooms, in group care settings or in research supervision. What is apparent from what follows is that those preparing to or currently working with vulnerable people of any age can, through observation, tune into how they are affected by the subjects of their observation as they consider and convey what this tells us about what is going on and about the possibilities generated thus for how to proceed.

Theme one: Learning and teaching

Within the learning and teaching section of the book there are four chapters that discuss observation in the light of a range of professional trainings, contexts and levels of experience. The first is Chapter 2, where Helen Hingley-Jones’ writing provides an important overarching link across all the chapters. The roots of psychoanalytic baby and young child observation and the ‘Tavistock model’ in training psychotherapists are presented here. Hingley-Jones then explores the close relationship between observation and intervention as she considers the concepts of triangular space and reflective capacity understood from different disciplinary and theoretical standpoints, and by drawing on examples from practice. The importance of professional and parental reflective capacity promoted by observation, in the example of child protection social work, is emphasised as Hingley-Jones makes the case for practitioners to hold on to ‘an observer state of mind’ throughout their work.

In Chapter 3, Lucille Allain explores and analyses how observation is used in teaching and learning across the professions including in the training of doctors, midwives, social workers and teachers. This chapter, alongside Chapter 5 by Pat Cartney, draws on psychosocial principles but it also ‘branches out’ from the main psychoanalytic, hardy tree trunk and draws on Foucauldian ideas about the potentially oppressive use of observation in the professions. Allain makes a link to the current political and policy context of austerity and its impact on health, care and welfare, both in relation to those receiving services and those delivering them. The focus on learning and teaching and analysis of students’ and educators’ experiences of observation provides a heady mix of pathos and joy. This is juxtaposed between a medical student’s happiness about observing a baby being born to the difficulties a teacher experiences whilst being observed and how it stifled pupils’ learning.

In Chapter 4, Clare Parkinson shows how, as experienced health and social care practitioners, we can learn a great deal about vulner-able people and about ourselves by undertaking an organisational observation in a hospital ward or care home as part of a continuing professional development course. The principles of baby observation are applied to this context and role. Parkinson gathers and theorises insights from Best Interests Assessors, who can be occupational therapists, social workers, nurses or psychologists, taking up the observer position whilst training for this complex and specialist role.

In Chapter 5, Patricia Cartney writes from a sociological position, which stands slightly apart from the predominantly psychoanalytic perspectives elsewhere in the book. Here, Cartney looks at the ways in which sensitivity to structure and agency influences trainee social work students’ appreciation of the lives and social circumstances of observed families and their households. From here the reader can make links back into more psychologically orientated perspectives, providing overall a rich psychosocial appreciation of the issues facing modern families. This then connects to the practice themes of the book, where there is reflection and analysis of managing risk, uncertainty and feelings of professionals’ limitations as the work is often conducted within time-driven organisations.

Theme two: Practice section

This section of our book includes four chapters that introduce applications of observation models in practice. The authors explore in turn contemporary features of observation. In Chapter 6, Stephen Briggs demonstrates the depth of awareness and understanding that can be achieved by observation-based approaches in work with troubled adolescents. Briggs considers the importance of sustaining a stance of free-floating attention when ‘doing’ infant observation in work with young people. He writes, ‘The infant observation method has the capacity to facilitate engaging with adolescent emotionality, and its often ambiguous and opaque expressions.’ Briggs draws on his understanding of the work of Esther Bick, for example, in his interpretation of the various ‘second-skin’ defences in one young woman from clinical practice. This chapter has relevance beyond the consulting room. The elucidati...