The Application of Critical Psychology to Facilitate Reflective Clinical Practice in Orthotics/Prosthetics

Abstract

The co-construction of a psychology module for a postgraduate training course in orthotics/prosthetics is socially constructed for the first time in Southern African history. This paper elucidates the integration of theory and practice in a model for the development of a professional identity as orthotist/prosthetist. In creating a context where trainees can learn to develop their practice while also enabling them to deconstruct notions of ‘expert knowledge’, orthotist/prosthetists move from a position of scientist-practitioner to negotiating an alternative position of reflective practitioner. In the process of co-constructing knowledge, an alternative story of teaching and learning evolves. The result is a celebration of life as it is really lived by health professionals.

Introduction

Psychology's contribution to the interdisciplinary education of orthotist/prosthetists has been recognized and narrated in Prosthetics and Orthotics International since 1977 (Desmond and MacLachlan 2002). Although the objective of such psychology training modules is not to qualify practitioners as therapists, the importance of developing an understanding of psychosocial issues that may affect physical rehabilitation cannot be overrated.

The authors acknowledge the fostering of practitioner's sensitivity for these psychosocial issues through traditional training modules in psychology. However, in practitioners' close clinical encounters with their patients, an alternative psychology of practice is proposed in which orthotist/prosthetists can move from a position of scientist-practitioner to negotiating an alternative position as reflective-practitioner.

Positioning orthotics and prosthetics in the national and international context

Only two institutions in English-speaking sub-Saharan Africa offer training in orthotics/prosthetics. The Tanzania Training Centre for Orthopaedic Technologists (TATCOT), Tanzania, and the Tshwane University of Technology (formerly Technikon Pretoria), South Africa catered for Category III (Orthotic/prosthetic technician) and Category II (Orthopaedic Technologist) training. However, at the International Society on Prosthetics and Orthotics (ISPO) Asian Prosthetics and Orthotics Workshop 1998 in Japan, the need for Category I (Prosthetist/Orthotist or Meister) training in developing countries was recognized. This marked a significant step forward in African history:

It is recognized that for the meantime training in Category I does not exist anywhere in the developing countries and is only available in the industrial world. Despite this it is felt important that some personnel in developing countries should be trained to this level to provide leadership for the prosthetic/orthotic profession and be responsible for education and training within their own countries. (Hughes 1998)

Furthermore, the ISPO (1998) indicated that only Category I professionals would be qualified to manage centres, supervise Category II and III practitioners, and act as educators for students and staff.

The ISPO Asian Prosthetics and Orthotics Workshop specifically highlighted the problems of disability in developing countries. According to Milan (1998), as many as 300 million people in the Asian and Pacific region are disabled, in contrast to the estimated 500 million people globally. Up to 80% of the disabled live in isolated rural areas and, for the most part, are subjected to poverty and deprived of accessible rehabilitation services (Milan 1998). Following a World Health Assembly resolution in 1976 and the Alma Ata Conference, the World Health Organization (WHO) launched community-based rehabilitation (CBR) as the innovative approach to enable developing countries to offer essential services to as many disabled persons as possible, in the areas where they live, at a low cost and at a convenient time. Implemented in the context of primary health care, CBR is believed to be the most viable strategy to meet the global challenge of disability.

However, the biggest challenge is to find some way to produce and adequately train prosthetists and orthotists, in sufficient numbers to tackle the developing world's problems: ‘it is probable that in the developing world there is a need for about 20,000 trained professionals and a current provision of at the most 2,000’ (Hughes 1998). In South Africa, only 69 orthotic/prosthetic practices are registered at the South African Orthotic and Prosthetic Association (http://www.saopa.co.za). Furthermore, it is predicted that by the year 2020, more than 1.5 million people nationwide will not have access to certified orthotic services, and over 227,000 will not be able to receive prosthetic care (Hovorka et al. 2002).

In the light of the needs of the disabled in developing countries and the efforts of the ISPO to upgrade the training of orthotist/prosthetists, Tumaini University through TATCOT (Tanzania) initiated a Bachelor of Science degree in Prosthetics and Orthotics in 1999, and Tshwane University of Technology (South Africa) initiated a Bachelor's degree in Technology: Medical Orthotics and Prosthetics in 2003 that would enable candidates to be classified as Category I practitioners.

The BTech Medical Orthotics and Prosthetics course is registered with the South African Qualifications Authority (SAQA) as a NQF level 8-qualification within the field of Health Sciences and Social Services. The entry requirement is a National Diploma in Medical Orthotics/Prosthetics or an equivalent first degree.

The curriculum includes the following modules:

• Applied Psychology and Pharmacology II (Psychology I—prerequisite subject);

• Business Management I;

• Research Methods & Techniques I;

• Orthotics & Prosthetics Theory IV.

Professionals from different disciplines (orthopaedic surgeon, psychologist, medical practitioner, pharmacist, and researcher) collaborated to develop the specified learning outcomes. These professionals, in consultation with the Prosthetic/Orthotic course coordinators, form a panel that co-constructs knowledge within the BTech Medical Orthotics and Prosthetics course. Continuous re-evaluation of knowledge and the co-creation of new knowledge and processes take place where all members are equal partners in the meeting point between the different disciplines. This process creates transparency in the teaching and learning environment.

TATCOT is currently seeking accreditation for the Tumaini University four-year Category I (B.Sc.) curriculum by the International Society of Prosthetics and Orthotics (ISPO). Its three-year Category II diploma has been accredited by ISPO since the 1980s. In 2003, the International Society of Prosthetics and Orthotics (ISPO) also recognized the wheelchair technologist qualification, offered by TATCOT, as equivalent to the Category II Lower Limb Prosthetics and Orthotics Technologist certificate courses (http://www.kcmc.ac.za/TATCOT/).

Positioning psychology in the national and international context

The development of psychology in South Africa parallels the discipline's international history. In the 1920s, psychology started out as a separate discipline in South Africa, but it was only after the Second World War that a time of exponential growth and rapid professionalism emerged (Louw and Foster 1991). Although psychology initially negotiated a position of scientific neutrality, the emergence of critical psycholog 1 in the 1980s revealed its political unconscious. Critical psychology succeeded in creating institutional spaces for itself in the 1980s and early 1990s (Terre Blanche 2004). The coming of democracy to South Africa in 1994 shaped the transformation of psychology as a discipline. The ‘turn to discourse’ in European social psychology informed present trends of driving towards higher standards of professionalism through restructuring within the profession (Terre Blanche 2004). The construction of a curriculum for Applied Psychology II reflects the historical shift envisaged for psychology's future and integrates ideas from social constructionism and critical psychology into a mainstream course for orthotists and prosthetists.

Burr (1998) describes social constructionism as ‘a theoretical orientation, which to a greater or lesser degree underpins all of these newer approaches, which are currently offering radical and critical alternatives in psychology and social psychology, as well as in other disciplines in the social sciences’. There is no single definition for social constructionism but rather a set of key assumptions that underlie a social constructionist position (Gergen 1985).

Critical stance towards taken-for-granted knowledge

Social constructionism invites us to take a critical stance towards our taken-for-granted ways of understanding the world. There are thus no ‘essences’ inside people or things that make them what they are; our realities are rather a product of our own construction and arise through our social interaction with one another (Burr 1998; Freedman and Combs 1996). What you and I regard as ‘truth’ is a product of the social processes and interactions in which we constantly engage with others, and ‘from a constructionist perspective, truth and falsehoods exist only within traditions of talk’ (Gergen 2001).

Historical and cultural specificity

Burr (1998) posits that the ways in which we commonly understand the world, and the categories and concepts that we use, are historically and culturally embedded. Cultural stories determine the shapes of our individual life narratives. Within a culture, certain narratives become dominant over others. These dominant narratives become the preferred way of believing and behaving in a certain culture. People narrate some events, while they do not narrate other events owing to the imposition of the narratives of the dominant cultures (Gergen 2001). The particular forms of knowledge that abound in any culture are, according to Burr (1998), ‘artefacts … and we should not assume that our ways of understanding are necessarily any better (in terms of being any nearer the truth) than other ways’.

Knowledge is sustained by social processes

Social constructionists believe that we fabricate our versions of knowledge through the daily interactions between people in the course of social life. Therefore, the only worlds we can know are the worlds we share in language. The language that we use and our current accepted ways of understanding the world are a product of social processes and interactions in which people constantly engage with each other.

Knowledge and social action go together

Social constructions of the world are a result of ‘negotiated understandings’ between people, and each different construction invites a different kind of action from people. Burr (1998) believes that descriptions or constructions of the world sustain some patterns of social action and exclude others.

Meeting point

The impetus for constructing an Applied Psychology II module came from the course coordinators for BTech Medical Orthotics and Prosthetics, who approached the first author (IG) in November 2002 with an invitation to become one of the facilitators for the BTech Medical Orthotics and Prosthetics course in South Africa. The aim of the proposed module would be to prepare orthotists and prosthetists for their profession. In designing such a module, at this meeting point between psychology and orthotics/prosthetics, the assumptions of social constructionism are utilized as part of the philosophy that underlies the learning experience. In this way, a connection between theory and teaching practice is created to achieve the goal of the module.

Philosophy underlying the Applied Psychology II module

The first author's passion for psychology and facilitation is the perfect origin story for the current philosophy underlying the Applied Psychology II module. She believes that the facilitator's own enthusiasm and love for psychology rubs off on her learners and assists them in creating their own personal meaning of the value of psychology in their lives—if she does not love psychology, why should she expect the learners to love it? Furthermore, she finds facilitation and the transference of skills extremely rewarding—at every opportunity, engaging with learners in the co-construction of knowledge energizes and uplifts the facilitator. From these intuitive beliefs, she has since developed a larger set of principles and an underlying philosophy to help her make the most of her strengths and the least of her weaknesses.

Privileging the orthotist/prosthetist

Michael White (1997) refers to ‘the culture of professional disciplines’ in which ‘the ways of knowing the world that relate to the more popular and more local discourses of “lay” communities are marginalized, often categorized as quaint, folk and naïve, and frequently disqualified’. The deficit model of teaching grants disproportionate privilege to expert knowledge and places the first author, as facilitator, in an expert position. From this position, health practitioners and learners are trained as scientist-practitioners in integrating theory and practice. The scientist-practitioner, furthermore, privileges certain ways of doing science and assumes that scientific knowledge is a mirror image of objective reality. Although it is believed that there are many good outcomes of the traditional approaches to training, the potential hegemonic exclusion and disqualification of alternatives to these traditions can be limiting to the orthotist/prosthetist-in-training.

At the core of the philosophy is the assumption that orthotist/prosthetist trainees have valuable lived experiences, knowledge, skills, and desires that have invited them into this helping field. In their sincere desire to help others and in their experience as practising orthotists and prosthetists, they probably have special skills in caring for others. The authors believe that exploring these skills and desire will bring forth and develop confidence in their abilities and experiences of personal agency in their work (Carlson and Erickson 2001). In creating a context where trainees can learn to develop their practice while also enabling them to deconstruct notions of ‘expert knowledge’, a reflective-practitioner model (Clegg 1998; Harper 2004; Walsh and Scaife 1998) was introduced in the Applied Psychology II module. In this model, orthotists and prosthetists are encouraged to reflect on their work from a number of perspectives, for example from thinking about the influence of personal experience to interpreting their work in accordance with relevant theory or empirical work.

In developing ‘knowledge of practice’ (Hoshmand and Polkinghorne 1992), orthotists and prosthetists are invited to ‘embrace uncertainty’ (Mason 1993) through exercises where they can examine the effects of expert knowledge models in their professional life, since they often find themselves in real-life situations that are more complicated than the expert solutions they are taught (Spellman and Harper 1996). The use of indigenous knowledge can contribute to the development of a critical practitioner identity as an orthotist/prosthetist. Orthotists and prosthetists are thus invited to reflect on the value of professional interventions for a specific client by using pragmatic criteria of whether an approach ‘fits’ for a client, or if it is going to be useful, and not by some abstract notion of ‘truth’. In honouring orthotists and prosthetists as experts of their lives, they can also see their patients as experts of their own lives.

Equal partners

In this philosophy, the first author has negotiated a position for herself as facilitator and learner, through respecting, inviting, and valuing each voice and being flexible and responsive (Anderson 2000). It is believed that she has much to learn from orthotists/prosthetists about their profession. The informal seating arrangement (in a circle or groups) encourages interaction among learners and between the learners and the facilitator. Collaboration does not need to be enforced upon learners; it is a spontaneous process that emerges out of the experience itself. Collaborative teaching and learning challenge both participants and facilitator to reconstruct how they think about teaching and learning. When facilitators position themselves differently, in other words, as learners too, there is a sharing of responsibility.

Co-constructing knowledge

In encouraging a decentring of the dominant professional accounts of knowledge and becoming more familiar with the very personal knowledges that come from the rich history of the lived experiences of orthotist/prosthetists, trainees are encouraged to become reflective practitioners. Participants utilize their previous knowledge constructions, beliefs, and attitudes in the knowledge-construction process. Learners and facilitator collaboratively co-construct knowledge, not judging it against some abstract notion of ‘truth’, but through a process of evaluating evidence from a variety of fields and resources, and establishing conceptual links to tailor conclusions to the specific needs of an individual patient (Lusardi et al. 2002). Anderson (2000) describes the knowledge-constructing process as follows:

Knowledge is fluid and communal, yet personalized. When we share our knowledge with one another, we cannot know what each brings to the sharing; determine how each will interact with the shared knowledge; nor predict what each will create with it. Whatever the outcome, it will be something different than either started with, something socially constructed.

The knowledge co-constructing process of psychology and orthotics/prosthetics continues as the first author collaborates with her co-authors in a doctorate study in further meaning creation.

Interdisciplinary perspective

Interdisciplinary education practices encourage orthotist/prosthetists to become collaborative members of the multidisciplinary health team. In addressing the complexity of problems facing health care, practitioners are invited to respect and value contributions from diverse allied health and medical professionals:

The complexity of problems facing health care in the 21st century are problems which often do not have a single answer, but require a very broad orientation. Health care providers must also listen to and work with each other, recognizing their diverse backgrounds and the multitude of agendas, values and priorities that affect the choices they make. (Warren, cited by Hovorka et al. 2002)

The objective in constructing the Applied Psychology curriculum is not only to ‘apply’ psychology to the profession of orthotist/prosthetist, but also to facilitate psychology in such a way that learners can apply their personal meaning of psychology in a wide variety of life experiences.

Putting psychology into practice

In an attempt to honour the foundational beliefs and underlying philosophy of the Applied Psychology II module, training/facilitation practices proposed by Carlson and Erickson (2001) have been found useful. Although the intention is not to train orthotist/prosthetists as psychologists or therapists, it is believed that they can apply basic principles of helping in their daily relations with their patients. Carlson and Erickson (2001) define ‘experience privileging practices’ as practices that ‘seek to grant privilege to and honour the personal experiences, desires, motivations, knowledge, and skills of new therapists’. Orthotists and prosthetists are encouraged, through the use of privileging questions, to share experiences from their lives during group discussions in class or in the form of assignments that form part of the process of continuous assessment. Some privileging questions include, among others: What experiences from your life do you think invited you into the field of orthotics and prosthetics? What ways of relating to others have you found to be most helpful? What skills of helping others have you developed in your life? How do you want others to experience themselves when they are in your presence?

The practice of remembering, as introduced by Myerhoff (1982) and White (1997, 2000), is about helping persons to find membership, or experience a return to membership with the significant relationships of their lives. Carlson and Erickson (2001) are of the opinion that ‘because the stories of our lives are lived through relationships, it is important for persons to remember the relationships that support their preferred ways of being’. Remembering practices are facilitated during class discussions by posing questions to orthotists and prosthetists such as: Could you share with us a story from your life where you felt particularly cared for? What was this experience like for you? What was it about this experience of being cared for that was most memorable to you? What did this experience teach you about how to care for others? Can you recall someone with whom you had a special caring relationship or who you think you were able to help out in a significant way? What was it about that relationship that allowed caring to take place? From whom do you think these desires to help and care for others came?

Freedman and Combs (1996) believe that people do not embrace their stories until they have performed them in front of an audience. As orthotists and prosthetists have experiences in helping relationships that represent their preferred ways of being, they are invited to share these experiences with others; and as others witness these stories, they enter into their stories of themselves as practitioners and persons. Through the practice of communities who are dedicated to honouring and privileging each other's experiences, they also enter into ‘fostering of communities of concern’ (Carlson and Erickson 2001). Participating in a life-analysis project invites orthotist/prosthetists to remember some personal life experiences and reflect on the ways in which their life experiences shaped their professional identity.

The practice of reflective journal writing also became part of the Applied Psychology II module. Learners have the opportunity to keep a reflective journal of the stories of their experiences throughout the year, as does the facilitator. Clandinin and Connelly (1998) have found many journal writers among teachers who weave the accounts of their private and professional experiences together to capture fragments of their experiences in attempts to sort themselves out. Kember et al. (2001) posit that journal writing by itself is a valuable stimulus to encourage reflection upon practice; they further find journal writing of particular value in the health professions context, and ‘the implications of this development are that the students may be able to apply these same principles of reflection when they are in clinical practice and dealing with the ill-defined problems of clients and client treatment’. Journal writing may thus be a successful spur to self-reflective thinking.

Myerhoff (1982) describes the practice of ‘definitional ceremonies’ as ‘collective self-definitions specifically intended to proclaim an interpretation to an audience not otherwise available’. At the conclusion of the academic year, ‘diplomas of special knowledge’ celebrate the lives of orthotist/prosthetists in a unique way indicating:

This diploma is bestowed in recognition of _________ achievement and so that those who were unable to witness his/her success of claiming his/her own special knowledge in psychology and orthotics/prosthetics may develop some understanding of the changes they are noticing in his/her ability to care for others.

Conclusion

This paper explored the integration of theory and practice in a training course for orthotist/prosthetists. In deconstructing notions of ‘expert knowledge’ training and the utilization of experience privileging practices, remembering, fostering communities of concern, reflective journal writing, and definitional ceremonies were introduced. In honouring the lived experiences, knowledge, skills, and desires that invited orthotists and prosthetists into this helping field, they are encouraged to reflect on the value of professional interventions by using pragmatic criteria of whether an approach fits or is useful for a client (and not by some abstract notion of ‘truth’). Orthotists/prosthetists can thus move from a scientist-practitioner position to negotiating an alternative position of reflective practitioner. The philosophy underlying the Applied Psychology II training module encourages orthotists and prosthetists to experience personal agency in the development of a professional identity.