104 British Journal of Learning Disabilities Vol. 22 (1 994) Changing Attitudes: A Teaching Initiative in the Medical-School David May, Senior Lecturer in Sociology, Department of Psychiatry, University of Dundee, Stan Phillips, Clinical Nurse Specialist, Tayside Health Board, Jenny Miller, Head Occupational Therapist, Strathmartine Hospital, Tayside, Pam Linton, St. Aidan’s Initiative, Tayside, Jim Forbes, Community Nurse, Tayside Health Board, Grace Culross, Tayside Region Social Work Department. In this paper we describe an innovatory teaching pro- gramme for medical students which is designed to pro- mote more positive images of people with learning dis- abilities (L.D.). The programme involves small groups of medical students working in partnership with equal numbers of people with L.D. on a specific task of mut- ual interest. In educational terms, the programme was highly successful; students enjoyed the experience and found it both interesting and relevant to their medical studies. At the end of the programme students had acquired a greater respect for the abilities of people with L.D. and were more positively inclined towards them and their rights as citizens. However, the evi- dence also suggested that they continued to regard people with L.D. as somehow qualitatively different from non-handicapped people - less able, more dependent and child-like. In their dealings with people with learning disabilities and their families, doctors have, over the years, come in for a good deal of criticism; ignorance, indifference, insensitivity, and high-handedness are just some of the charges levelled against them (Ayer & Alaszewski, 1984; Jacobs, 1977; Murdoch, 1984; DES, 1978). For many, the problem is an educational one, and the need for change starts at the undergraduate level (see for example, RCP, 1986). While there is no denying past neglect (Hollins, 1988; Pilkington, 1977), an already over-crowded cur- riculum affords little scope for any significant improve- ment. Indeed, as mental handicap is transformed into learning disability and the medical profession’s role is correspondingly diminished, it will do well to hang on to the teaching time currently allocated to this topic. In any event, what evidence we have suggests that teach- ing, of itself, has little effect on attitudes (Allan, 1986; Laking, 1988; May, 1991), and, if done badly or super- ficially, may actually reinforce negative stereotypes (Carsrud et al., 1984; Le Unes et al., 1975; Pilkington, 1977). At Dundee we are attempting to resolve this dilemma and promote more positive images of people with learn- ing disabilities by introducing students to the subject in their Second Year as part of the Behavioural Sciences course. This has two distinct advantages over the tra- ditional approach of teaching learning disability as a clinical subject. First, it allows the issues to be located within the wider context of disability and its treatment by Society, rather than confined to a separate and special minority. Second, Behavioural Sciences, with its person- centred concerns, offers a perspective and a vocabulary well suited to discussing modern concepts of care. In this paper, we describe the programme and examine its impact on students’ attitudes. The Dundee Learning Disabilities Seminar The learning disabilities seminar at Dundee has evolved from modest beginnings. It started, some years ago, with two mothers, accompanied by their handi- capped adolescent children, coming to talk to the stu- dents about the problems and pleasures of raising a dis- abled child in what was very much a classroom-bound exercise. It now occupies all nine Friday afternoons of the Spring term, with students spending much of their time at various local facilities for people with learning disabilities. Around 24 students are involved in the seminar each year. Lack of resources and time prevents us from extending the programme to the whole of the second year class (c. 130+ students). The learning disabilities seminar is only one of a number of seminar programmes (each different in content and organisation) to which students are randomly allocated as part of their Behav- ioural Sciences course.’ Each group, therefore, is a cross- section of the student body and not representative of particular interests or backgrounds, a point to bear in mind when considering the response to the seminar. The emphasis of the seminar is very much on involve- ment and experiential learning in the belief that medical students, like people with learning disabilities, learn best by doing. Formal, didactic teaching is kept to a mini-
Transcript
104 British Journal of Learning Disabilities Vol. 22 (1 994)
Changing Attitudes: A Teaching Initiative in the Medical-School
David May, Senior Lecturer in Sociology, Department of Psychiatry, University of Dundee, Stan Phillips, Clinical Nurse Specialist, Tayside Health Board, Jenny Miller, Head Occupational Therapist, Strathmartine Hospital, Tayside, Pam Linton, St. Aidan’s Initiative, Tayside, Jim Forbes, Community Nurse, Tayside Health Board, Grace Culross, Tayside Region Social Work Department.
In this paper we describe an innovatory teaching pro- gramme for medical students which is designed to pro- mote more positive images of people with learning dis- abilities (L.D.). The programme involves small groups of medical students working in partnership with equal numbers of people with L.D. on a specific task of mut- ual interest. In educational terms, the programme was highly successful; students enjoyed the experience and found it both interesting and relevant to their medical studies. At the end of the programme students had acquired a greater respect for the abilities of people with L.D. and were more positively inclined towards them and their rights as citizens. However, the evi- dence also suggested that they continued to regard people with L.D. as somehow qualitatively different from non-handicapped people - less able, more dependent and child-like.
In their dealings with people with learning disabilities and their families, doctors have, over the years, come in for a good deal of criticism; ignorance, indifference, insensitivity, and high-handedness are just some of the charges levelled against them (Ayer & Alaszewski, 1984; Jacobs, 1977; Murdoch, 1984; DES, 1978). For many, the problem is an educational one, and the need for change starts at the undergraduate level (see for example, RCP, 1986). While there is no denying past neglect (Hollins, 1988; Pilkington, 1977), an already over-crowded cur- riculum affords little scope for any significant improve- ment. Indeed, as mental handicap is transformed into learning disability and the medical profession’s role is correspondingly diminished, it will do well to hang on to the teaching time currently allocated to this topic. In any event, what evidence we have suggests that teach- ing, of itself, has little effect on attitudes (Allan, 1986; Laking, 1988; May, 1991), and, if done badly or super- ficially, may actually reinforce negative stereotypes (Carsrud et al., 1984; Le Unes et al., 1975; Pilkington, 1977).
At Dundee we are attempting to resolve this dilemma
and promote more positive images of people with learn- ing disabilities by introducing students to the subject in their Second Year as part of the Behavioural Sciences course. This has two distinct advantages over the tra- ditional approach of teaching learning disability as a clinical subject. First, it allows the issues to be located within the wider context of disability and its treatment by Society, rather than confined to a separate and special minority. Second, Behavioural Sciences, with its person- centred concerns, offers a perspective and a vocabulary well suited to discussing modern concepts of care. In this paper, we describe the programme and examine its impact on students’ attitudes.
The Dundee Learning Disabilities Seminar The learning disabilities seminar at Dundee has
evolved from modest beginnings. It started, some years ago, with two mothers, accompanied by their handi- capped adolescent children, coming to talk to the stu- dents about the problems and pleasures of raising a dis- abled child in what was very much a classroom-bound exercise. It now occupies all nine Friday afternoons of the Spring term, with students spending much of their time at various local facilities for people with learning disabilities.
Around 24 students are involved in the seminar each year. Lack of resources and time prevents us from extending the programme to the whole of the second year class (c. 130+ students). The learning disabilities seminar is only one of a number of seminar programmes (each different in content and organisation) to which students are randomly allocated as part of their Behav- ioural Sciences course.’ Each group, therefore, is a cross- section of the student body and not representative of particular interests or backgrounds, a point to bear in mind when considering the response to the seminar.
The emphasis of the seminar is very much on involve- ment and experiential learning in the belief that medical students, like people with learning disabilities, learn best by doing. Formal, didactic teaching is kept to a mini-
British Journal of Learning Disabilities Vol. 22 (1 994) . 105
mum. Our concerns are not clinical ones. Students are instructed quite firmly to put away their white coats. Instead, they are encouraged to think of people with learning disabilities, not as patients, still less as diagnos- tic categories, but as people first, and, moreover, people with interests and problems not far removed from their own.
The first encounter The tone of the whole exercise is set at the very first
session. For this, staff attached to the facilities participat- ing in the seminar are invited to bring their clients along to the medical school to meet the students with whom they will be working over the course of the term. We leave it up to them to select the clients. However, unlike the students, all are volunteers and have had the exercise carefully explained to them in advance. We encourage the staff members to involve as wide a range of clients as possible, and, although generally most are ambulant, their number always includes some who are in wheel- chairs and others with limited communicative abilities or who present challenging behaviours.
The format of the session is deceptively simple. Stu- dents and clients are quickly introduced to one another and organised into pairs. For the students, this is particu- larly unsettling for they have had no preparation and, until a few minutes before, had no idea that they were going to be talking to people with learning disabilities. It is interesting to note that it is often the people with learning disabilities who take the initiative at this social encounter.
Once the introductions are made, each pair is sent off to look around the medical school, have a cup of coffee, or do whatever else may appeal to them in the time allowed. They are told that they should use the time to get to know their partner. This exercise is not only a useful ’icebreaker’, but it also establishes, in a very prac- tical way, the character of the seminar. In this situation, the students are not protected by the social roles of doc- tor and patient. Instead, they are compelled to interact with the person, not the label. They begin to see how people with learning disabilities are constrained, not only by their intellectual and physical limitations but, also, by the deeply ingrained, but rarely acknowledged, attitudes and expectations of others. This understanding emerges in the written comments of one student, percep- tively entitled ‘A lesson on attitudes’:
Not only did we grasp an insight into the life of such individuals, but we also learned something of our own reactions towards others not as astute as those we [usually] come into contact (with) in our careers . . . I was impressed with the depth of knowledge he showed on certain topics, and our conversations were not far different from those which probably pass between any two individuals on a first meeting. This stirs the first question I found myself asking ‘Why did I expect there to be a difference?’ We talked about the army, pop-groups, Robin’s girl-friend, our families, in fact all the subjects which frequently are discussed over a coffee with my younger brother.
Not every one, however, finds him/herself with some- one quite so open and loquacious as Robin. Another student could barely suppress her anger at having been
asked to get to know someone who was unable (or unwilling) to speak. The problems she encountered, the (imperfect) solutions she adopted to deal with them, and the anxieties the exercise provoked provided the material for an interesting class discussion.
Strengthening student involvement While the programme has been well received by stu-
dents, its impact on attitudes was less obvious (May, 1991). Part of the problem it seemed, was that, despite all our best efforts to encourage involvement with cli- ents, the somewhat unstructured nature of the place- ment experience allowed students to revert to the comfortable and familiar role of observer, and, in this way, to preserve social distance.
To deal with this, we introduced a number of changes to the format and organisation of the 1992 programme. Firstly, we limited the placements used to just four facili- ties where we could be sure of providing adequate supervision - two local authority adult training centres, a vocational training project in the voluntary sector, and a hospital-based occupational therapy department. Each facility was allocated 6 students, who were then paired with clients who had volunteered to take part in the exercise.
Secondly, we constituted each facility-based group as a working party, with a specific remit to consider one of three problems that concern all young people - getting a job, leaving home, organising leisure time - and to report back to the whole seminar group (plus invited guests) at the final session of the term. This task, it was stressed, was not to be just a matter for internal debate within the group, but should involve group members going out to investigate the facilities and resources avail- able in the local area, conducting small ‘consumer’ sur- veys, and interviewing key personnel (e.g. job centre managers, hostel wardens). Each group had, as a ’facilit- ator’, a member of staff at the placement, who was there to provide advice and general assistance, but not in any way to direct the group’s activities.
Thirdly, we took steps to encourage maximum interac- tion between the two groups of participants by making the student-client ’pairs’ the basic unit of the working parties. Students were instructed to fully involve their client-partners in all stages of the group’s activities: organising the exercise, researching and assembling the material, and presenting the finished product to the full seminar group. Our aim was to encourage students not only to listen to people with learning disabilities, but, also, to learn how to create a working environment where their interests, needs, and abilities would be respected. Since this seminar work counted towards their final Behavioural Sciences mark, students were anxious to get on with things and, at first, found this requirement irksome and frustrating. But as the reason for it became clear, they rose to the challenge.
In order to see what effect, if any, these changes had on student responses, we asked those taking part in the 1992 programme to complete anonymous questionnaires at the beginning and end of the term. Twenty-one of the 23 participating students completed the ’before’ ques- tionnaire; 16 completed the questionnaire at the end of the programme. In this paper, we compare their answers
106 . British Jou rna l of Learning Disabilities Vol, 22 (1 994)
with those of a similar group of students who took part in the 1990 seminar.
Response to the seminar Students were asked whether they found the seminar
experience ’enjoyable’, ’interesting’, and ’relevant’. A five-point scale was used ranging from ’very positive’ (1) to ‘very negative’ (5). Mean scores were calculated for the group as a whole. A mean score of (1) would indicate perfect satisfaction, while a mean score of (5) would indicate the reverse. With this scoring system, any score under 2 can be considered as very positive indeed. The response to the 1992 seminar produced mean scores of 1.88 for ’enjoyment’, 1.75 for ’interest’, and 1.88 for ’relevance’, improving on the already very good response to the 1990 seminar’.
Two-thirds of the students claimed that their views of people with learning disabilities had changed as a result of their experience. Typically, they felt that they were now less inclined to stereotype such people or to lump them into an undifferentiated category of ’mentally handicapped’. As one put it, ’They are certainly all indi- viduals’. Of the five students who denied any change in their attitudes, three claimed previous experience of people with learning disabilities. All five suggested that their views had not changed primarily because they already held positive views.
Images of People with Learning Disabilities In order to obtain some insight into the nature of stu-
dents’ attitudes to people with learning disabilities and just what effect the seminar might have had on those attitudes, students were asked to choose from a list of 43 words (containing 23 positive and 20 negative descriptors) up to 10 which, in their opinion, best described people with learning disabilities, and then to repeat the exercise on completion of the seminar.
The 21 students who completed the questionnaire at the outset of the seminar chose a total of 183 words to describe people with learning disabilities, 58% of them ’negative‘ and 42% ‘positive‘. Only four words were chosen by more than half of the students, just one of which - affectionate - was positive. Seven words on the list were not chosen at all. Of these three were nega- tive (arrogant, idiots, lackadaisical) and four positive (studious, lucky, independent and dedicated). Overall, this was a significantly more negative image than that held by the 1990 students, whose choice of words was divided into 47% negative and 53% positive (Chi square 4.59, P < 0.05,l df), although, in both cases, the selection of words suggests highly ambivalent attitudes.
There was some resistance to repeating the exercise on completion of the seminar, some students arguing that it implied a group identity that was both inappropriate and invalid. Certainly the words chosen suggest a trans- formation of attitudes with 70% being positive and only 30% negative. The difference was highly significant (Chi square 24.5, P 6 0.001, 2df). No such change had fol- lowed the 1990 seminar. However, this shift to a more positive image is somewhat misleading, for the positive words that students selected were, by and large, the same ones that they had chosen before the start of the seminar, albeit then in fewer numbers. They were still
inclined to regard people with learning disabilities as, in some way, qualitatively different from other (non- handicapped) people.
This distinction is apparent when the words chosen to describe people with learning disabilities are compared with words chosen from the same list to describe medi- cal students. There is no evidence of ambivalence here. Of the 193 words chosen, the majority (91’/0) were posi- tive, and only 9% negative. Eight words were chosen by more than half the respondents, all positive. Of the 11 words never chosen only two were positive: ‘affection- ate’ and ’uncomplaining’. The most frequently chosen negative word was ’arrogant’. It was chosen by just four of the 21 respondents and was only the 13th most fre- quently chosen word.
Moreover, it was not simply that students were more inclined to see themselves in a positive light, since the positive words they selected were quite different from the ones they attached to people with learning dis- abilities. Words like ’affectionate’, ’friendly’, ’happy’, ’loving’ all have a distinctly ambiguous quality sugges- tive of the negative stereotyping of people with learning disabilities. The contrast with the words most frequently chosen to describe medical students (‘hardworking’, ’intelligent’, ’ambitious’ etc.) is stark. Only ’determined’ was applied more or less equally to both groups (see Table 1).
The Civil Rights of People with Learning Disabilities
Students were also asked to comment on the rights of people with learning disabilities (see Table 2). Once again their responses suggest a generally positive, if heavily qualified position. Of the eight ‘rights’ listed, four commanded majority support (the right to further education, to live in the community, to a job, and to get married), with students much less certain as regards the other four.
On completion of the seminar, student views were more liberal, with the proportion of positive responses increasing from 53% to 62% of the total, although the difference failed to reach statistical significance. All but two of the eight rights now commanded majority sup- port. The two which gave rise to considerable reser- vations were the right to have children and, perhaps more puzzlingly, the right to normal schooling.
Discussion The first thing to be said about the Dundee learning
disabilities seminar is that students enjoyed the experi- ence and felt that it would help them to become better doctors. More importantly, following the seminar, stu- dents were much more inclined to think of people with learning disabilities as individuals, and to see ability where before they had only seen handicap. The extent to which the seminar ’opened their eyes’ to these truths is revealed in the following comments:
[The seminar] gave me the chance to work closely with people that before this exercise I would have thought irresponsible, immature, and unintelligent. It has changed my view about mildly handicapped individ- uals. They are normal people [excepting] only that
British Journal of Learning Disabilities Vol. 22 (1 994) - 107
Table 1 Words most frequently chosen* to describe (A) medical students and (B) people with a learning disability
*Chosen by 50% or more of respondents, Figures in [ ] brackets represent the number of times the word was chosen to describe people with a learning disability. Figures in ( ) brackets represent the number of times the word was chosen to describe medical students.
Table 2 Medical students’ opinions of the rights of people with a learning disability
People with a learning disability have a right to:
Before (N= 21) After (N = 16)
Further education Live in community A Job Marry Independent living Make their own decisions Have children Normal schooling
they have a slight educational disability; this can be sorted, even though it may take some patience.
[I now have a] higher opinion of what they’re capable of and can achieve with support. For example, Steve is diabetic and knows more about it [sic], controls it better and takes more care with it than my diabetic friend who is at Law school.
I was amazed at their enthusiasm in communicating with us once everyone knew what was going on and what our overall objective was.
I was very open minded, but I was surprised how resourceful some of them can be and how similar they are to us, and just how difficult they are to stereotype.
Each individual has their own specific difficulties and needs: you cannot ’compartmentalise’ people with learning disabilities because the extent of their prob- lems and the way in which they deal with them vary so considerably.
Success was, however, qualified in two respects. First, on completion of the seminar, students were no more interested in working in this specialist area than they had been at the outset; if anything, the experience had merely confirmed their view that such work was not for them (see also May, 1991). Second, although they now had a much more positive opinion of people with learn- ing disabilities, they still regarded them as somehow qualitatively different from themselves and from other, non-disabled people; they were described as less able, more dependent, and child-like.
Such findings are hardly surprising; the first simply reflects current thinking and practice, the second, per- haps, a recognition of the obvious. At the same time, they suggest that there are aspects of the seminar that are not working as effectively as we would wish. We believe that improvements can be made by strengthen- ing the three principles which inform its organisation and implementation: activity, involvement, and recip- rocity.
The key to the success of the 1992 seminar was, we believe, to make it task oriented. This not only provided a structure and a purpose missing in previous years, but allowed students and clients to come together on a com- mon task for which they shared equal responsibility; it promoted involvement.
In assigning the tasks to the groups, we deliberately chose problems in which both students and clients might recognise a common interest. Lack of time and our fail- ure to respond to what was happening allowed the groups to operate only from the perspective of people with learning disabilities. In retrospect, this was unfortu- nate since it reinforced the helper-dependant relation- ship, and, although both sets of participants felt comfort- able with this, it undermined reciprocity.
Reciprocity is not only relevant to relationships between students and clients. We feel it should also guide the relationship between the medical school and the participating agencies. Sending students out on ’placement’ is a well-established feature of all forms of vocational training and an increasing part of the under-
108 - British Journal of Learning Disabilities Vol. 22 (1 994)
graduate medical curriculum as the profession becomes more ’community-aware’. Its development has largely been determined by the needs of the medical school and its students, with the host agencies responding in a gen- erally passive and often grudging fashion, as the demands on their time and space grow. But this is to ignore the opportunities that such a relationship could open up, particularly for people with learning dis- abilities and those working with them.
Our seminar provides access to integrated settings and valued social experiences which allow self-advocacy skills to be practiced in an unself-conscious way. It develops social and communication skills, encourages initiative, and promotes self-confidence. It certainly works in this way for medical students; there is no rea- son why it should not work in a similar fashion for people with learning disabilities.
If these opportunities are to be realised, two things must occur. There needs to be more thought given to client participation in the seminar and what they might expect to get out of it. They must be properly prepared for their participation in advance, and they must be pro- vided with ongoing support in recognition of the fact that they are entering into an inherently unequal relationship and may need help to assert themselves. Secondly, the participating facilities must accept a greater responsibility for the seminar, for shaping its organisation and content, and for ensuring its success. We believe firmly that the exercise should no longer be seen as a medical school initiative, but rather as a joint initiative - a true partnership. We are currently explor- ing ways of achieving this.
Notes 1. Further details of the Dundee Behavioural Sciences
course and the place of the Learning Disabilities sem- inar in that course are available on request.
2. A detailed analysis of the questionnaires can be obtained on request from the senior author.
Correspondence Any correspondence should be addressed to David
May, Department of Psychiatry, Ninewells Hospital, Dundee, DD1 9SY.
References
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