Attending to Clinical Practice: A Phenomenological Study Exploring the Structure of Clinical Attention and its Relationship with Holistic Competence

Attention is an acknowledged component of the therapeutic relationship that is the heart of clinical work and the base of competence. The centrality of the therapeutic relationship itself has been recognized throughout the history of clinical work. The clinician’s work is based, in part, in attending to the client by actively and openly listening to the client with attention and engagement. However, attention has been lacking within mental health disciplines to what occurs within the process of clinical attention. As a result, little knowledge exists about the structure of clinical attention itself. This dissertation studied the structure of clinical attention to understand what occurs when clinicians attend to their clients in sessions. The thesis focused on the internal processes occurring within the clinician, not on actions or interventions taken in sessions. The literature review grounded the study theoretically in mind science and contemplative science, the study of reality grounded in both objective and subjective experience. The literature review also conceptualized attention in its sub processes of mindfulness, meditation, reflective practice and affect regulation, examining literature relevant to those constructs as well as to the history, philosophy and psychology of attention. The literature revealed a lack of knowledge of the structure and process of clinical attention. Using the extant literature, a new theoretical framework of attention was constructed. Attention was conceptualized as composed of levels of pre-reflective and reflective attention as related to the attention sub processes. A phenomenological methodology was used to study the structure of clinical attention in relation to holistic competence. Fourteen clinicians, all of whom met the criteria for attaining expertise in the use of attention in their clinical work, participated in an explicitation interview. Data analysis followed a modified phenomenological methodology in a series of steps as the data were grouped in invariant constituents, reduced to emergent themes and analyzed for a textural structural description from which a structural description was constructed. From the structural description was distilled the essence of clinical attention. Clinical attention was seen to consist of a dynamic and iterative process of intention and intuition. Intention and intuition were seen to be based in different attentional levels, both of which were recursively and iteratively related to attention’s construction as a process grounded in inner awareness providing the potential abilities to reflect on experience and regulate affective experience. The study concluded with a discussion of the relationship of the skill of clinical attention to a holistic competence based in levels of procedural capability focused on concrete behavioural action and meta competence focused on clinical judgment, self-awareness and self-reflection on the actions taken. The implications of the study’s findings for training clinicians in attention were discussed.

Keywords: attention
clinical practice
affect regulation
reflective practice
mindfulness
Advisor: Bogo, Marion