Interpretations of Training Experiences
5.3 Separation, Therapy and Talk
relationship learnt by the student in the therapy practicals. The following section expands upon thist~eme.
upon Nolwazi's conception of it. In Interview Two (p6), and in the context of speaking about the division of 'empathy' and 'sympathy' taught in training, Nolwazi says,"How can I not be sympathetic? How can I not - if somebody comes with a problem. This person comes - for instance - for therapy having not eaten and I've got money to buy them food, how - why can't I just go and buy food for them - let them eat?"
And .later, in describing an incident occurring in her fourth year of study, after undergoing two years of controlled clinical practice (CST I) and failing the course at the first attempt, she tells of a woman coming to the University for therapy in winter from a local hospital, " ...she wasn't wearing shoes and I have stacks of shoes, and I had a nice pair for her in my mind, but I was, I was too scared to actually offer her, because I didn't know what was going to be said by the lecturers and staff - because I can't be separate."
As already pointed out, what is learnt from structuring clinical practice on the basis of disease is that the disease itself provides the text of the learning experience. As Foucault (1973; p59) states, "the patient is only that through which the text can be read". Yet, and as already described in the representational narrative of 'Learning Alone', prior to clinical exposure Nolwazi had already experienced a severe dislocation from the theoretical teaching 'text' of training, interpreting it as divisive in terms of human relationships. In approaching clinical learning, and as she points out in paragraph 14 of 'Learning Alone', she was unable to apply the conception of 'separation', as she had no fundamental understanding of it. In other words, she was unable to conceptualise the
"patient [as] the accident of his disease, the transitory object that it happens to have seized upon" (Foucault, 1973; p.59).
This inability to understand 'assistance' as the primary goal of the therapeutic encounter as opposed to 'care' is compounded by the aim of clinical teaching being the construction of 'ideal' teaching and learning experiences that allow students to develop expertise in assessing and treating particular pathologies. To do so, clients have to be 'captured' (Brandon, 1976) for practice upon by the student corps. Clinical teaching, therefore, occurs in contexts where firstly, individuals have been removed from their home environments, e.g. 'special' facilities for the disabled, the university speech/languagelhearing clinic or hospitals; and secondly, have been made available for practice upon by aspiring professional therapists.
In the creation of what Foucault (1979) terms 'functional sites' within which practice occurs, what actually moves are the people, not the architecture that serves to temporarily enclose them. What is learnt firstly from such an approach is that therapy occurs separate to the family and community. Assistance as regards the alleviation of the communication pathology, therefore, occurs 'naturally' as external to the person and her support systems. Secondly, and as a result of the availability of individuals with disease for practice upon, aspirant therapists learn that the provision of their services stand in a similar relationship to a 'functional site', with themselves as stationary, and clients moving towards them. Both these points, and as highlighted by the text excerpts in Figure 4: 'A Mother's Care' (4.1.1.1), do not follow the pattern of learning Nolwazi gained from her mother's example as a professional health worker.
As discussed in Chapter One, (1.2.1) South Africa has adopted Primary Health Care as the nation's health service delivery model of choice. The practice of Nolwazi's mother bears a striking resemblance to the ideals of PHC and its central tenets of democracy, equity, and access in a holistic approach to health care, involving prevention, promotion and rehabilitation - all encompassed within a framework of community involvement (Pillay, 1997. Emphasis mine). The points made above with regard to the context of clinical training may have implications therefore, for not only the promotion of a 'caring' curriculum, but for the national goals of primary healthcare.
For if a therapist is to learn her role as the provision of holistic health care, as opposed to discrete symptomaticassistance; and if she is to learn that her activities are integral to the community she finds herself within, then it would seem that the current orientation to clinical training needs re-examination. Itwould appear that the formative early years of therapeutic practice would need to occur in contexts that are constructed around - and actively practicing - the ideology of PHC, and that the student should be absorbed within these learning environments. The base-line aim of clinical training would not, therefore be focussed upon 'captured' communicatively diseased individuals in the second year of study, but constitute, and from the first day of training, an immersion in learning to respond to people's problems of communicationthat co-occur in the context of holistic welfare and health objectives. Contexts for training would need to be selected on the basis of their active fulfillmeI)t of national health/welfare policy.
Teaching and learning occurring in these - necessarily - politicised environments would represent a fundamental shift from the currently de-politicised and de-contextualised focus on pathology. By providing opportunities for students to seek out people in need, and to respond to their stated problems as communicative helpers, the evaluation of practice excellence would presumably be based on co-authored and reflective assessment of the nature and type of care offered by the student - and help received by the person (orpeop~e)concerned.
This notion, however, presumes that theoretical teaching is subsumed under the umbrella of care, and becomes responsive to it. If this occurred, it raises two major questions. The first refers to the role of the university in promoting such a conception of professional health worker training. Linked to this is the second: the abilities of the teacher-professionals to undertake it.
Presuming that a university acknowledged that establishing a caring health worker curriculum would be best served by its removal from its dominant discourse, then training may very well be re-located to the contexts of practice mentioned above. In other words, by the physical removal of students and teachers from the dominance of academic discourse, it would be hoped that new ways of thinking about the teaching and learning process would result from immersion in the practice discourse of the new environment. There are however, two major objections to this; both, I would argue, serving to promote a reformative, as opposed to a transformative, training agenda.
Firstly, it presumes that the discourse of the university system remains unchallenged. As the current model of professional development cannot be quickly divorced from its current epistemological origins; or the contexts it is located within; or the interests that are served in maintaining its current professional degree status, removal of it from the university system at this stage means its removal from the source of the struggle: the legitimacy of the discourse itself.
The second objection to re-locating training concerns the teaching and learning process.
The fact of re-location does not presume alteration to the thinking that underlies teaching practice, Qr the primacy of theoretical over therapeutic dialogue. Without a deep understanding of the 'separation' currently promoted by training, and an equal
conceptualisation of the provision of a 'caring' communicative context, the action of re- location may very well entrench the current model of professional development, yet in a different geographic environment. In other words, and through physical movement alone, there is no guarantee that the discourse of theory would be subordinated to the discourse of therapy/practice.
Itwould appear, therefore, that a more fundamental process is indicated, one centrally concerned with changing the way people think about the aims and objectives of professional teaching and learning. The Summary of this Chapter formalises this idea and presents it as: 'Connecting with Care: A Process Model of Development for a Therapeutic Discipline'
Chapter Summary
As stressed throughout this study, dialogue is the essence of the therapeutic encounter. Inserting the discourse of therapy into that training is at heart, therefore, a dialogic enterprise. As in all dialogic encounters, the skills of acute listening and s~aring are premised on the need to collude in a trustful, collaborative, joint making of meaning.
In proposing Figure 10: 'Connecting with Care: A Process Model of Development for a Therapeutic Discipline', therefore, I am arguing for a process of collusional making of meaning within the selfas the primary basis to consider the points already higWighted in this Chapter. Without understanding the impact of personal life experience on the interpretations that have led to uncritical absorption of the current professional 'separation' of people from each other, I would argue that no firm ground exists upon which to base transformative 'connective' action.
In other words, I am suggesting that the first and fundamental process would be an internal migration into the understanding of self as a caring actor in the world.
Without interpreting the overwhelming influence of the private past into the public present (and future) as teacher-professionals or as aspirant professionals, I do not believe that a transformative re-uniting of the teachers and students in creating a caring curriculum will occur.
The model presents four 'Internal Journeys'. The aims of each - taken separately and as a cycle - would be to understand the complex web of influence that has resulted in professional thinking de-legitimising the nurturing, interpersonal, and collusional nature of therapeutic discourse. At the same time, however, their purpose is that of encouraging personal responsibility in the finding of creative and caring solu~ions for its introduction as the foundation of the training programme. Methods such as reflective journals, creative writing, drawings and collages are all resources that - and as demonstrated in a preliminary way in this study - have significant power to reveal private patterns of thinking and to create new knowledge.
Subsequent to each 'journey', a dialogic process of listening and sharing with others would occur in order to collude in both the building of joint meaning about care, and also its foundational role in the teaching and learning process. This crucial dialogue would serve to build not only understanding and relationship between teachers and students, but by the exchange of interpretation, allow significant negotiation and learning to occur that would lead to the development of alternative points of view.
Deep engagement in this dialogue would necessarily lead to questions regarding the validity of a rational, objective and empirical approach to professional knowledge transmission and creation. So too, would it result in consideration of the current appr~ach to the teaching of communication disease as separate from people as communicating totalities. This may, perhaps, lead to alterations in the contexts of both clinical and theoretical teaching and learning. Most importantly, however, such dialogue would lead to the legitimating of sharing of stories;
stories bred and interpreted within the context of South Africa - and thus representing a contextualised and politicised foundation for knowledge creation.
While the results of this dialogue would result in plans of purpose and action, it is important to stress the circular nature of the arrows in Figure 10. The reason is that the understanding, learning, and acting from 'care' cannot be separated from a personal recognition and desire for its expression. The reference point of a curriculum based on care would be each individual involved in the process. It's
success - or failure - is therefore entirely dependent on all its participants taking care - as well as showing it.
Figure 10 presents the model, acknowledging its debt to the adaptation of Samuel's (1998) model of 'Inertial and Programmatic Forces Impacting on the Training Experience' (Table 7):
Figure 10: Connecting with Care: A Process Model of Development for a Therapeutic Discipline.
for
What's my responsibility in ensuring training is based on 'A DISCOURSE OF CARE?'
a) How I can make a 'discourse of care' the foundation of my teaching & learning activities.
c) How I can make a 'discourse of care' the foundation of my relationships with cl ients/teachers/
students.
b) How I can make a 'discourse of care' the foundation of my collegial relationships.
'What have I learnt/taught about care from the knowledge presented in training?'
'What haveIlearnt about care from teachersl students/
colleagues?'
'What haveIlearnt about care from my experience of
training?' The Second Internal Journey:
Programmatic Forces and Care:
Personal Reflection Upon:
HOW DO I UNDERSTAND
CAREIN TUE,-.."..-::=--+----:---' TRAINING
PROCESS?'
.HOW DOl REFERENCE MY UNDERSTANDING
OF CARE?
The Fourth Internal Journey:
Towards a Caring Training Programme:
Personal Reflection Upon:
What needs to change so that training is founded on 'A Discourse of Care.' CONSIDER:
Past experiences of learning and teaching about care.
Personal religiousl ideological/cultural philosophy of care:
('cultural forces') ie.
'WhatIbelieve about care."
Care, gender identity &
their projection: ('gender forces') ie. 'How my gender influences my thinking about care.' Care, racial identity&their projection to same/other race groups: ('racial forces') ie. 'How my race influences my thinking about care to same/other race groups.'
Care, class identity&their projection: ('class forces') ie. 'How does my class influence my thinking about care?' Care and language:
('linguistic forces') ie.
'How does my language influence my thinking about care?' t)
b)
d) c)
e) a)
The First Internal Journey:
Inertial Forces and Care:
Personal Reflection Upon:
• The propositional knowledge of training
• The contexts of training
• The methods&styles of communication in training
• The systems and structure of training
Having presented this model, however, it becomes important to introduce a degree of pessimism as to the likelihood of its adoption. This is because while Figure 10 formalises certain ideals, it does so by ignoring the [mal point of the existing model of professional development proposed in 2.1.6. In other words, that the current model holds 'significant ideological value to the institutions and sections of society concer.ned and [is] thus resistant to fundamental change' .
I have avoided this central discussion m order to create a clear division of argument, rather sweepingly assuming in this Chapter that both the profession and university system are able to attempt re-conceptualisation of the existing model of professional development.
The Conclusion of this study presents the counterpoint to this assumption. By returning to the core policy legislations of OBE and PHC discussed in Chapter One, I suggest there are significant contextual forces that will effectively prevent this re-conceptualisation from occurring.
Following that, however, and linked to her engagement with this narrative research process, Nowazi's 'final words' imply the development of an optimism within herself; an optimism resulting from the practice of care that was so central to this project.
Conclusion: Loss ofthe Story Force
'.. Wlten tlte magnetic substance is removed, the particles revert back to their random distribution and the magnetism - well, it just disappears. '
(www.technicoil.com/magnetism.html)
Overview
In the Preface of this study, I indicated my choice not to enter the complex policy debates between the Professional Board for Speech-Language Therapy and Audiology; the National Qualifications Framework (NQF); and the South African Qualification Authority (SAQA). It is sufficient to note that these latter two bodies are, and through their interaction with the IMDCSA (Interim Medi~aland Dental Council of South Africa), attempting to exert pressure upon the Professional Board to re-conceptualise professional training. The summary of Chapter Five has suggested a process whereby this re-conceptualisation could be explored. Having suggested this, however, the first part of this conclusion (6.1) re-visits the two policy contexts of PHC and OBE to examine the possibility of this exploration actually occurring. It does so in relation to Nolwazi's crucial sense that the aim of her training programme is to turn her into a 'coconut' ('white on the inside, Black on the outer'). From this position, the second section (6.2) notes several implications and limitations of this research study, while 6.3 offers final comments from Nolwazi.