People often talk about responding to things on different ‘levels’. For instance, someone might say that some experience was negative on one level but positive on another level. In the way our brain works there are natural hierarchies or levels of experience. The effect of each level is to organise and control the information on the level below it. Changing something on an upper level would necessarily change things on the lower levels. Changing something on a lower level could, but would not necessarily, affect the upper levels.
Robert Dilts, a Californian psychologist, has built a simple elegant model for thinking about personal change, learning and communication that brings together these ideas of context, levels of learning and perceptual position. It gives a framework for organising and gathering information, so you can identify the best point to intervene to make any desired change.
Identity – who
This answers the question: who am I?
Identity gives me my basic sense of self and my core values. Identity has primarily to do with mission. It is the deepest (or highest) level.
Beliefs – why
This level has to do with the values and beliefs of the individual. It answers the question: why am I doing this?
Beliefs and values are the various ideas we think are true and use as a basis for daily action. Beliefs can be both permissive and limiting.
Capability – how
This level describes what we are capable of. They are the groups or sets of behaviours, general skills and strategies that we can use in our life.
This level answers the question: how could I deal with this? At this level we use a variety of mental maps, plans or strategies to generate specific behaviour.
Behaviour – what
Behaviour is made up of the specific actions or reactions taken within our daily environment.
Regardless of our capabilities, behaviour describes what we actually do. It answers the question: what am I doing?
Environment – where and when
This has to do with the external context in which behaviour occurs.
It answers the question: when and where does this behaviour occur?
Example – Use to make an educational diagnosis
A trainee is not providing enough evidence in the e-portfolio and says it is because there is nowhere in the practice peaceful enough for them to put entries in at work. (Environment) But is it because they find reflective practice difficult (Capability) or they believe the e-portfolio is a poor tool and too difficult to use (Beliefs) or they value work life balance and expect to be given plenty of time at work for writing log entries (Values)
Example 1 – use to problem solve
A trainee is avoiding certain tasks and in particular refusing requests by reception staff to speak to patients on the phone. Their behaviour is causing difficulty in the practice and the trainer is irritated and thinks is work avoidance. He behaves by telling the trainee to be more sensitive to the needs of staff and patients and he will be monitoring their work closely. The trainee complains to the TPD who identifies the trainee has a capability issue in that she finds the local accent difficult to follow on the phone and is afraid of making mistakes. Capability issues can be addressed if they are identified (remember many trainees are defensive about exposing their lack of ability)
The trainer thinks their trainee is lazy and not showing a proper GP work ethic. The trainer believes passionately in continuity of care and ensuring that all the work of the day is completed before leaving. The trainee comes from a shift system in hospital and values the ability to delegate work and provide patient accessibility. They also firmly believe in a clear work life balance and think the trainer very old fashioned in their approach. The working relationship is breaking down and the trainer takes the situation to his trainer group. There a colleague uses logical levels and role play to identify that the issue relates to different values and that these need to be shared and understood otherwise the behaviour will not resolve. During the discussion both need to keep in mind that the goal for both is that the trainee meets the requirements of the MRCGP.