This past week I attended the annual conference of the National Council of Schools of Professional Psychology in San Juan, Puerto Rico. Of course, San Juan is January is fabulous in and of itself, but the conference was also interesting and brought me face to face with the larger stories about education. Caught up in my smaller stories, I rarely think about the big picture. I like to teach because I like to learn, and teaching does that for me. I would not like to teach the same material over and over. I like to learn new things and share them with others. I like to think and to think about thinking. That is my story about teaching. However, there are other narratives, and I was exposed to them in Puerto Rico.
I am drawn to the work of Charles Whitehead at University College, London, and to the social constructionist movement in general. Whitehead writes (p. 9) that much of what we call culture is wholly believed-in make believe, which he supports through neuroscience and neuroimaging study. What we do in the world is mostly social play and role playing. We perform the teacher or the study role in accordance with the rules we have invented for how this should be done. Similarly, we perform the role of psychologist or physician according to the rules. If we do not follow the social conventions, we are accused of being unethical, incompetent, or mad.
Durkheim wrote about the ways in which we invent "things" that are actually nothing. He called these "things" collective representations. They have only the meaning we give them and nothing inherent or intrinsic. Schools and education fall into these categories. Polar bears do not, for they will eat us whether or not we believe in them. When we are professionals, we are supposed to take our collective representations very seriously. The hallmark of a good professional is that complete faith in the reality of the inventions we utilize.
At the meeting, I co-presented a poster on the use of art in the socialization of students to their role as psychologists. We used Amy Stein's approach of drawing self-portraits, as well as our own approach of making masks -" one to represent the professional self and one to represent the personal self. These approaches add much to the usual "talking heads" approach, and, in accordance with my bias, help to bring the body back into psychology, a sorely needed addition. At first, the students were hesitant, because we all know that "we can't do art". But, I brought in an artist who was also a therapist, who helped the students see that drawing is just measurement, and that it's not a matter of talent, but of skills. This is an important lesson for psychologists, since we need to recognize what Malcolm Gladwell writes so eloquently in Outliers, that skillful living is largely a matter of practicing and not inherited traits. To become good at drawing faces, we have to draw faces for 10,000 hours, to paraphrase Gladwell. Nevertheless, with less than an hour of instruction, the students and I found that we could improve our face drawing by at least 1000%. In less than an hour, I was drawing recognizable self-portraits. It's all in the measurement. The length of the face is 7 units and the width of the face is 5 units. The eyes are at a line that bisects the length. And so on. Following simple rules led us to fabulously improve our "artistic talents". Therapy is like this, I said. Learning simple skills (like mindfulness meditation, how to avoid overgeneralizing, how to self-soothe, etc.) makes life immediately and fabulously better. This is part of my diatribe against psychologists as passive report receiving agents who merely listen to patients recounting their exploits and fail to teach the simple skills that could make everyone live better. They are like art teachers who pay attention to the kids with "talent" and fail to teach the simple skills of measuring required for drawing.
My students also learned much from being uncomfortable with art at first. We discussed how patients feel the same discomfort with therapy at first, and it's good to recognize how we cope with being outside our comfort zone. In what I have learned from the developmental psychologist, Lev Vygotsky, therapy is a process in which we create a zone of proximate development in which clients can function with our help in ways they cannot function without our help. We provide the scaffolding for them to learn new skills. Once these skills are learned, they no longer need us. We are not ministering to defective people, but teaching skills and providing more functional stories to use in this business of life. With the help of our artist teacher, we were drawing well in less than an hour. We overcame our discomfort and discovered that we could do so much more than we thought ever possible. "This is the experience our clients should have," I said.
The poster presentation was about this, about taking what I learned from Santa Fe artist, Amy Stein, who leads self-portrait workshops all over the country to help physicians discover their professional and personal identity, and applying this work to the training of psychologists. I met Amy in Santa Fe at the annual Creativity and Madness conference, and am proud to have one of her beautiful art prints on my wall. Our artist teacher taught us another useful trick, turning the face we are drawing upside down. Immediately we draw it better because an upside down face doesn't so readily trigger our belief that we can't draw faces. It becomes just a collection of shadows and lines on a paper that we can copy. Of course, this has implications for psychology also. Amy teaches that all faces are self-portraits, no matter whom we are drawing. When we draw faces, we capture an aspect of our lived world and of the world of our clients that we can access in no other way. Sometimes we are better at recognizing emotion in other people's faces than within ourselves. When we see a self-portrait, we can look at our face as "an Other", thereby engaging our mirror neurons to recognize what we would feel if we looked like the face we are viewing. Only, the Other is us! My students are now including self-portraiture in their initial evaluation of clients, and using serial self-portrait drawing as a way to track how their clients are changing and also how they are changing.
In the midst of our self-discovery through art and other journeys to the unique and the personal, I learned more about the business of psychology. To my surprise and amazement, education is a $200 billion dollar per year industry in the United States. I suddenly understood the emergence of so-many for-profit Universities. The profit potential is huge. I also became aware of the criticisms of the for-profits. Their students have the lion's share of defaults on student loans, which apparently the U.S. government doesn't like. Questions are being asked. The suggestion has been made that the for-profits take any student, sign them up for federally guaranteed student loans and then shrugged and walked away when that student failed to graduate and thereby couldn't pay back his or her student loans. Since the for-profits are primarily offering income producing degrees that are costly (psychology, education, business, etc.), failure to graduate also means failure to earn the money required to pay off the loan.
My own experience with for-profit education was dismal. I naively began a teaching job with a for-profit University once upon a time, not realizing that such a beast existed. I thought all Universities and colleges were not-for-profit or governmentally owned. The first semester I got manipulated into teaching 14 units, which consisted of four one unit statistics laboratory sections, a course in psychopharmacology, a course in neuropsychological assessment, and a course in quantitative inquiry. The justification was that students wouldn't graduate on time if these courses weren't offered, and I was the only person available and qualified to teach them. I argued that the courses would not be perfect, but was told that imperfect with students graduating on time was better than perfect with students being unable to graduate on time. I did my best and I think the students had a great educational experience, but the train didn't always run on time, and there were glitches here and there. The largest glitch, however, I discovered was that some of the students didn't like experiential learning and didn't feel they should be made to do it. They wanted in-class lectures from PowerPoint, handouts from which to study, mid-term multiple choice examinations, and multiple choice final examinations. I was perplexed. I was used to forming students into small groups to tackle subject-related problems, to on-line class discussion groups so that we stayed engaged with each other throughout the class, to creative paper writing, and to students doing and presenting projects to each other. Of course, the educational research literature supports my way of teaching and not didactic lectures with studies showing lectures and exams (the old, conventional educational model) being 15% as effective in learning and retention as a problem-based, experiential approach. Plus, problem-based, experiential learning is so much more fun.
So here's what I learned. For profits cannot afford problem-based, experiential learning because it eats into profit! The goal of the for-profit is to standardize education so that anyone can deliver the contents of a course. No individuality or uniqueness is required or desired. If classes are modular and exactly the same material is presented on every campus in every class with the same name by every instructor, then instructors suddenly become exchangeable and replaceable. Core faculty is no longer needed, and indeed, one presentation told us that 2/3's of the classes at for-profits are being taught by adjunct faculty. I learned how cost-effective that is. If a core faculty teaches two classes per term and receives a salary of, let's say $80,000; an adjunct faculty can be paid $3000 per course to teach. If a year has three terms, then the six classes taught by an adjunct faculty cost $18,000, while a core faculty member would cost $80,000. Students pay on average $3000 per class and, one student pays the cost of the instructor. This is a useful economy of scale. Of course, core faculty eventually gets overloaded with administrative duties and advisees, but that happens later.
Making faculty interchangeable and replaceable requires a tight educational model with PowerPoint lectures, midterms, and finals. Everything must be objectified and standardized. Students can be convinced that lectures, midterms, and finals are the best education. In addition, in my experience with a for-profit, the risk of giving a "B" grade is so high, that one tries never to do it. Students complain bitterly if they receive a "B". I was told, "if two students have the same complaint, it's true." Students are bright. They quickly realize that if they band together and complain, they will be believed and action will be taken to remedy their complaint. My version of this was a class I was teaching about the body to students who wished to become certified to prescribe medications. I had designed a problem-based course in which students solved prescribing problems for patients with the two most common illnesses for each of 12 organ systems. To do that, they were asked to visit the parts of the hospital in which they already worked that corresponded to the organ system we were studying. For the lungs, they were to visit the pulmonary function laboratory and talk to the technicians about how lung function is assessed and about the two illnesses we were studying (asthma and chronic obstructive pulmonary disease). They were to talk to the pulmonologists about their work. They were to visit the autopsy suite and watch lungs being dissected that had been afflicted by COPD or asthma. They were to look at slides under the microscope and then talk to the pharmacists about drugs being used for these conditions and their interactions. Then they were to pick psychiatric medications that were the safest for several mental health diagnoses that could occur in patients with lung diseases. Similarly, for the week on the heart, they were to visit the cardiac catheterization laboratory, watch echocardiograms being done and interpreted, sit with cardiologists while they reviewed electrocardiograms, and attend autopsies of diseased hearts. The list continued like this for each organ system. I was quite proud of this course and time and effort had gone into setting it up.
My students were exhausted by class time. They were all post-doctoral students and had already earned their PhD's or PsyD's. They were putting in 10 to 12 hour days seeing patients. They were required to take this class in addition to their long days. The last thing they wanted was more work. As a group, all six of them went to the Campus President complaining about how I was wasting their time and shirking my didactic responsibilities. They should not be asked to run all around the hospital. They should be able to come to class and sit in their seats and receive lectures with PowerPoint presentations that gave them the information they needed to pass their examination. They should be evaluated with a mid-point and a final and should not have to make presentations. They requested another instructor who would do just that. The Campus President promptly replaced me and the new instructor did exactly what they wanted. He told me that mostly they slept through his lectures and he already knew that the examination had to be easy enough that they would all receive "A"s or he wouldn't be asked to teach again. I don't think this would have happened except in a for-profit institution, though I could be disillusioned. The competition for students and the dollars they bring is intense. To what degree do we need to please students to make them continue to pay tuition? To what degree do we need to make school easy so that students can graduate? To what degree do we need to teach students to pass examinations versus teaching competencies, critical thinking skills, and the capability of independent thought and action?
But this raises the question of what is professional education? I like teaching because I learn so much. I enjoy being part of process of mutual learning and sharing of information. I'm not so interested in participating in a trade school mentality. I don't think we should to examinations. To pass an examination, one should take the course designed to help one pass that examination. For example, for the national psychology examination, the average pass rate is 50%. A preparation course advertises a 95% pass rate for its graduates on their first attempt. The five percent who don't pass get to take the preparation class over and over again for free until they do pass. I think we can trust these people to help our students pass their licensing examination. I'm more interested in whether or not they have the necessary competencies to practice as a psychologist (or whatever profession we're discussing). Unfortunately, information based multiple-choice examinations don't actually assess that. One assumes that the professional school has assessed that, and, by graduating the student, has assured the public that the necessary competencies have been mastered. Does for-profit education erode this?
How do we teach clinical judgment? Computer-generated multiple-choice questions cannot assess that. It must be assessed by humans. In the for-profit where I briefly taught, we tried to bring practicing psychiatrists into the program for two days to independently assess the prescribing skills of our students, thereby giving us feedback about how well we were teaching and giving the student valuable feedback as well. We were vetoed since it was too expensive.
Psychology is an interesting field since it's not clear how much information is actually necessary. At minimum, thirty percent of change in psychotherapy relates to the quality of the relationship formed between the therapist and the patient, and probably more than that. All of the various psychotherapies begin to look like each other when we exam what experienced clinicians actually do.
Information has never been easier to obtain than today. Whenever I have a question, wherever I am, I pull out my Droid and consult the internet. I learn interesting things like what causes lake effect snow (a 13 degree difference between lake and air temperature), how high the Sri Lankan tsunami was (30 meters), and more. Whatever I say in class, my students are immediately "googling" to find out if I am correct and to further assess the question. Therefore, we can concentrate more on teaching relationship skills than shoveling information. We can focus more on teaching clinical judgment than on memorizing lists of facts. We can focus on building the clinical experience that allows for pattern recognition, which is what experienced clinicians do, and which comes from many hours of experience, and is difficult to teach.
Thus, I worry about the trend toward standardization and accreditation and teaching to examinations and evaluating education mostly on the basis of how many students graduate and pass national examinations. We also need to be concerned with what is learning and how do we learn and how do we become compassionate health care providers and how do we come to do a good job for our clients, which is not necessarily the same as passing examinations and might not be teachable through standardized methods.
