Survivor supervision of trainee mental health professionals:
Keeping it real, challenging academic perspectives, creating new roles and breaking down boundaries
Louise Pembroke
As a survivor activist I’m committed to peer support & consciousness raising, building bridges and practise development with allies through collaboration in research and teaching, and developing survivor defined approaches to distress. An aspect of this I have explored further in recent years is one to one mentoring of students and will specifically refer to my field supervision of trainee psychologists undertaking their Major Research Projects. I have a special interest in relationships between service users and mental health professionals as an activist with valued friends who are mental health professionals - we view each other as experts by experience and profession. I’m keen to see the development of non-academic clinical supervision and mentoring of students across the disciplines of nursing, medicine, psychiatry and psychology.
It is my hope that the pockets of existing survivor supervision/mentoring will be broadened and embedded across all disciplines through the creation of funded posts whereby survivors would teach, mentor on clinical placement, and supervise research alongside university lecturers and clinical supervisors. It could be said that survivor supervision is akin to clinical supervision and there’s no reason why this supervision has to be academically orientated. So long as the survivor has a socio-political understanding of distress and ethical issues from the participants viewpoint, expertise in the subject area and good interpersonal skills in communicating about and exploring people’s experiences of surviving distress, social deprivation/marginalisation and services. Far fewer academics are also service users who have the experience of surviving [whilst being watched by services] with a grasp of power inbalances i.e. having to say and do one thing whilst feeling another in order to avoid sanctions or to access social supports.
Much of what is researched, promoted and developed is what suits policy makers and is politically and economically expedient. For example the so-called "recovery model" which is heavily promoted but privately survivors will discuss their scepticism about the viability of this approach within a political framework which dictates employment as recovery and is apparently what ‘all service users want’. An Advice worker said to me, "Can you show me where all these service users are who apparently want to work when they know in reality this could mean being stuck on the lowest levels of ESA for years interspersed with enforced "placements", and at best minimum wage manual work? .At least with their user involvement work for the charities they get to use their skills, maintain some security and feel a sense of value which they wouldn’t stacking shelves". This is an interesting question which mental health charities, universities and the statutory sector need to consider, how much of ‘user involvement’ depends upon the unemployment of service users who cannot be paid for their time because of being on benefits? Therefore if recovery equals employment then all this collaboration [noteably in teaching/research/supervision] might be turned into paid posts as a logical extension of Service User Development Workers, and might possibly be more successful than the underwhelming Pathways to Work.
Recovery and CBT are where it’s at but for service users for whom this is insubstantial or inconsequential the evangelical rhetoric is about as useful as a chocolate teapot. In saying this students have also rigorously questioned these concepts with me so an aspect of our time together has been in discussion of how do I would I run this group which is supposed to be CBT when that’s not what I’m going to do and exploring alternative concepts and language to ‘recovery’. Having conversations which go against the current tide and question the core concepts being taught in curriculum or expected in clinical practise can be easier to engage in with a non-academic supervisor who is not assessing or expecting that adherence to a particular intervention.
Services are frequently a pac-a-mac and not a tailor made suit. Clinical education requires the learning and regurgitation of a narrow set of theories and practise which may not relate to an individual’s needs. So another aspect of survivor mentoring is consideration of thinking outside taught frameworks; meeting people with a blank sheet, not letting diagnosis determine everything and utilising the practitioners most potent attributes – human qualities, humility, humanity, the ability to just ‘be’ with someone with an open heart and mind recognising that relationships and attitude count for far more than any intervention. Making a meaningful relationship with someone with good attitude and belief in the person is one of the most powerful acts in the world. For people who have had appalling lives it might just be that a single decent relationship makes the difference between surviving or not.
Dorothy Rowe says, "In the final analysis, power is the right to have your definition of reality prevail over all other people’s definitions of reality". This is real personal power and the greatest challenge to any practitioner is to be willing to work within the individual’s frame of reference no matter what it is and irrespective of agreement. This is the only valid starting point from my perspective and this is what I live by and promote.
Working one-to-one with a trainee means being a resource to the student, being prepared to give of yourself of your experiences and drawing upon acquired collective experience & knowledge and the analysis developed on the back of that collective experience.
It’s about saying it as it is without censorship and to explore with sensitivity the issues which arise in the relationships between users/professionals in health and social care. Survivors are in a unique position when in a supervisory role and outside of academia because we are not tied to the discourses and paradigms it insists upon. It means we can go in with a blank sheet and ask questions out of sheer curiosity, ‘why are you doing this, why do you want to know about that, have you considered this?’
It is easier for survivors to mentor students who have firsthand experience of distress which could or has been viewed as diagnosable, ditto previous or current contact with services. That’s not to say that university supervisors cannot do so but they are required to assess and determine whether a student can continue their studies therefore anyone taking those decisions could be compromised in terms of openly sharing firsthand experience, depending on their world view.
Thankfully we have moved forward in terms of student recruitment into psychology and nursing where the ‘Clothier Criteria’ as it became known from the Clothier Report [initially supported by the Royal College of Nursing] no longer applies, at least not formally.
It was the Chairman of the Association of NHS Occupational Physicians, who suggested ‘excessive absence through sickness, excessive use of counselling, or medical facilities, or self-harming behaviour such as attempted suicide, self-laceration or eating disorder are better guides than psychological testing.’ It stated that ‘applicants who show one or more of these patterns should not be accepted for training until they have shown the ability to live an independent life without professional support and have been in stable employment for at least 2 years'.
This ‘screening out’ of potential nursing students showing any experience of distress shared by convicted child killer Beverely Allitt never extended to medical schools attempting to prevent another Harold Shipman by screening out anyone in possession of a beard, glasses, tweed jacket and a nice bedside manner…
So we now have more nursing and psychology students who are able to be open about having firsthand experience and even using this experience in their MRP’s such as including themselves as a research subject. Medical schools are quite a different kettle of fish where students will confide that they would be "toast" if their school were aware of their difficulties, medicine has yet to catch up with where nursing and psychology is although I would stress all the disciplines still have a long way to go.
It is an especially brave move on the part of students to be ‘out’ during training and again survivor supervisors are in an good position to appreciate the psychological magnitude of doing so and to offer support in utilising experience as part of research and negotiating the oral viva.
My
trainee clinical psychologists had some firsthand experience of the topics they were researching and I believe we each discovered new things about ourselves so it became a personal and professional journey which was deeply enriching and informed our respective work. Researching topics that we feel passionately about may also come with discomfort, this I know as an activist speaking of issues which are painful to me but this is not to be avoided but embraced with care. It means that we learn about our limits, self care/protection, the importance of taking support/debriefing and recognising that using our experiences does carry an emotional cost i.e. speaking of traumatic experience in a professional manner in order to convey an educational message and having to put aside the feelings those experiences evoke.As Diana Rose a user-researcher at the IoP said to me. "When research and teaching is entwined with people’s experience of distress and using services it offers a new perspective of knowledge".
My first trainee was Jo Hadfield who’s research was a qualitative study exploring how doctors working in A&E respond to treating people who self harm. Jo interviewed the clinicians herself and the data analyzed drew out several themes and identified helpful and unhelpful aspects of the relationships between A&E doctors and people who self harm.
Her study was published in Qualitative Health Research journal, and an article about our experience of working with each other was featured in a Clinical Psychology Forum Special Edition and we undertook a teaching session together for trainee’s.
From this session another trainee, Asesha
Morjaria-Keval asked if I would field supervise her MRP exploring narratives of people of people who self harm and their experience of ‘healing’, we had some debate about the use of the word ‘recovery’! Asesha’s research is in progress and near completion.I experienced an immediate rapport with Jo and could see straightaway she was a critical thinker with knowledge of survivor activism and readily absorbed anything I gave her to read. Asesha equally impressed me at the teaching session as she was the most candid and open student within her group. Some students clearly felt uncomfortable in looking at their own vulnerabilities citing they had ‘unbreakable internal resources’ whereas Asesha was able to say at what point during an exercise where I asked students to look at their own methods of coping at which she wouldn’t be able to cope.
As a service user, activist and someone who has worked in mental health service provision I feel confidence in someone who knows their limits and can face their vulnerabilities. Students who believe themselves to be invulnerable scare the hell out of me because when life compromises their ability to cope, [as it does for everyone], then they will have a long way to fall personally. Professionally, if people believe themselves to be invulnerable then how does this position them in relation to a service user who is unable to cope?
As a non-academic supervisor I’ve not been constrained by having to adhere to the university standards dotting the ‘i’ and crossing the ‘t’ on the methodology, that’s the job of the university supervisor and because I’m not academic I will ask the awkward or stupid questions. My role has been to keep the research ‘survivor focussed’ in several respects.
Firstly the research question and the language used and then how and where the participants were recruited. Recruitment was trickier for Asesha because she mostly recruited participants via the web and was not conducting face to face interviews.
With both Jo and Asesha I looked at their research invitations, interview schedule/request for narratives and assisted Asesha by advising on appropriate forums and avenues from my experience in the field. When researchers are seeking service user participants it can be helpful, as in more inviting, to make a point of stating that one of the supervisors is also a survivor. This can encourage people to come forward when they know there is survivor input. I know for myself that if I were to be a research participant I would want to know that at least one survivor was involved in the research team, had considered [or instigated] the research question and was keeping the process ‘survivor informed’.
As a supervisor this has meant I pay attention to how it looks from the position of the participant. Will the participant have enough clear and accessible information and in plain English ? Will the participant have a clear understanding of consent, their right to withdraw and how the data will be used? Will the person be supported if required after participation or given information on where to access support? Will the participant be given a copy of the research publication if they so wish? These questions would be considered by any supervisor but the difference with a survivor supervisor is that I bring my experience of using services, advocating for others using services and an understanding of power imbalance to the table. I bring an appreciation of feeling or being used inappropriately by academics and clinicians i.e. an academic not being clear with me that seeking reproduction of my cartoons for a book was for the purpose of writing a mental state examination of them [something I would not have consented to], and surgeons assuming I’m happy to be used for a teaching session at the point of crisis or willing to divulge deeply personal information knowing that there would be no ongoing support after doing so.
My protectiveness of research participants unequivocally applies to health professionals as research participants. As an activist I’ve been equally privileged in listening to experts by profession who have used services and feared being ‘found out’, have experienced guilt and remorse at the realisation that previous practise may have been unhelpful to service users and those who have experienced significant discrimination or bullying for critical thinking and challenging colleagues or Trusts.
With Jo I used the ‘walk through’ approach to assist her in drawing up her interview questions, something I’ve used in previous research to help keep the process ‘survivor informed’ which involved me talking through the process of going from injury to A&E, reception, waiting area, assessment, treatment, discharge or transfer to other services and all the various pathways and range of experiences which can occur from the mundane and ordinary to the less common, from the positive/helpful to the negative/abusive.
I knew that the nature of her research would involve her listening to some material which would be hard to hear so I made a point of stating my availability to her if she wanted to debrief.
With Asesha, we have reflected on people’s narratives, marvelled at the participants resilience and for me I experienced a personal revelation which I shared with Asesha that in reading the narratives I realised that my own first act of self harm had occurred at an earlier point in my life than I had previously remembered. I felt really proud of Asesha including her own testimony in her research [and Jo contributing], my feeling is this demonstrates an emotional maturity and self acceptance which will positively contribute to their future work as psychologists.
Asesha has a Phd and as someone who only possesses a couple of O’Levels’ I did wonder if I might have enough to contribute in terms of methodology, problem solving and critique but I think so far I have been useful to Asesha [although that is for her to equally evaluate!] Breaking down pieces of writing and placing limits on the scope in order to achieve a basic framework felt clear enough for me to see with Asesha likewise drawing out the emerging themes from the narratives. I use the highly sophisticated ‘red pen approach’ whereby I read all the narratives, lay them out, look at the words and sentences which jump out at me from each of them and underline them in red pen, and then circle the words and sentences from each narrative which relate to one another. It’s been very interesting for us the emerging themes.
With Jo we discussed much outside of the research such as what kind of practitioner she wanted to be and surviving working in the NHS i.e constraints such as Trusts determining a set number of sessions to work with service users. Seeking like minded allies [professional and survivor] both within and outside the workplace for support, inspiration and exchange. Negotiating doing one thing whilst calling it something else, developing the courage to speak out and stand alone, infiltrating different ideas and keeping in touch with survivor literature and activists.
I strive to be open with students and to give as much of myself as possible, likewise Jo and Asesha have met me with openness and been prepared to look at their own fragility as people and possible frustrations in their professional lives, it’s been a grounded process for us.
I’m immensely proud of Jo and Asesha and will be watching their careers with interest. The good thing about working 1-1 with someone is that it offers the opportunity for more informal contact and my time with Jo and Asesha mostly occured at my home. I’ve really valued having the opportunity to help contribute to shaping practitioners of the future I think it’s very special thing to do and means an indepth connection can be made with a person as opposed to listening to a one-off conference presentation or teaching session. That can certainly impact but a longer term relationship fosters a deeper appreciation and understanding from different perspectives.
© Louise Pembroke 2010
With thanks to Jo to Asesha for their kind permission