When explaining to me why he had recommended a particular consultant for a particular patient (those were the days) my trainer would often say, ‘X is a “thoughtful” doctor’. It was his highest praise. And reading this new edition of Gillie Bolton's book, it is clear that Reflective Practice means ‘thoughtful practice’. These days, when patients are entitled to take technical competence in their doctors more or less for granted, thoughtfulness remains a cardinal parameter of excellence.
This book is describing one particular technique for the promotion of this desirable characteristic. It is one of my quarrels with the title that there are other techniques which achieve a similar end. The Balint Groups which shaped so many of the outstanding GPs of the past are one example. That Balint himself is absent from the index and from the long list of sources — as indeed is Neighbour — shows perhaps how quickly the generations move on.
But the particular technique Gillie Bolton describes is a powerful one. The enthusiasm of those who have experienced it under her guidance shines in the numerous quotations from their writings which illuminate the book. To say it was life-changing for some of them sounds like a platitude, but there can be no doubt that in many cases it was.
Her method is to use free, informal, honest writing, shared within a group of perhaps eight participants, overseen by an umpire. This last she describes variously as tutor, mentor, facilitator; settling firmly by the end on facilitator.
The heart of her message, as of her previous book, Writing myself: the therapeutic potential of creative writing, is that there is something special about writing. She makes a compelling case that as a means of reflecting on one's practice writing is quite different from talking, or thinking. Writing, for one thing, is safe, so it enables you to express painful and otherwise dangerous inner thoughts. Once set down these thoughts are fixed and can be looked at with relative objectivity. Crucially for her method, they can be shared — if desired — with one or more members of a trusted group. She shows how therapeutic the setting down of the story of a distressing episode in life can be, and how understanding can sometimes be transformed by re-writing the narrative from another character's point of view.
It is typical of her style that she uses quotations from her course members, always with permission, to make these important points. Often she lets their words stand and moves on without making any comment of her own. This speaks volumes about the gentle, self-effacing, affirming touch that surely accounts for the success of her own groups. But this approach may be more unusual than she thinks, and certainly not reproducible to order.
Reflection itself is a recurring theme in the book, and the way reflective writing enables people to enter different worlds. Alice, referred to repeatedly, does more than look at the reflection in her looking glass: she goes right through it and finds that things she couldn't see from outside now appear bizarrely different and reflect truths about the real world with great clarity.
All this is touchy-feely stuff, you may think, but perhaps that is the point. What is it about our generation that recoils from touch and feeling, even in the professions which we so glibly label ‘caring’?
It is not made entirely clear who the book is for, but perhaps this doesn't matter. Some will read it because they are intrigued by the techniques it describes for releasing their own thoughts through their pens — or though their 2B pencils, as the author herself prefers. This will be the more so because creative writing is currently enjoying something of a vogue. Some will enjoy reading what is special about the compressed experience of poetry, or of Haiku. Some will see the book as a powerful argument for the effectiveness of a particular technique for professional development. Some will relish it as a contrast from the target and protocol focussed managerialism of contemporary practice. And some aspiring or established group facilitators will find in it the practical advice of the person who probably has the most experience of anyone working in this field.
This book is an appetiser, a source and an inspiration. But as its author says, there is something odd about reading about writing — the great thing is to get on with it and do it. It is enormously to her credit that she does not erect a lot of obstacles to this but shows us how we could make a start today. ‘“I think — ” began Piglet nervously,’ she quotes at the head of her final chapter. ‘“Don't,” said Eeyore.’
- © British Journal of General Practice, 2006.