Background

For some time, the slogan ‘nothing about us without us’ (adapted from Billingham Reference Billingham1998) has been enshrined in mental health policy and standards around the world in terms of the requirement that service users and carers be involved at all levels in the planning, implementation, and evaluation of healthcare services. Similar policy expectations, including in the UK (Department of Health 2001) and Ireland (Government of Ireland 2006), require that such involvement be extended to the training of healthcare professionals. However, a systematic review of consumer involvement in the tertiary-level education of mental health professionals found such training to be limited and variable across professions, with the preponderance involving nursing education. Very few identified programmes related to the education of psychiatric trainees (Happell et al. Reference Happell, Byrne, McAllister, Lampshire, Roper, Gaskin, Martin, Wynaden, McKenna, Lakeman and Platania-Phung2014). The subject, examples and evaluations of service user and carer involvement in psychiatric education remain scarce in the more recent literature (Agrawal et al. Reference Agrawal, Capponi, López, Kidd, Ringsted, Wiljer and Soklaridis2016, Miller et al. Reference Miller, Pradeep, Mohamad, Izmeth, Reynolds and Gulati2016, Ramalho et al. Reference Ramalho, Montenegro, Djordjevic, Braš and Christodoulou2016).

New psychological medicine training programme

In 2011, the University of Otago, Wellington committed to reform of their psychological medicine education. The reform initially involved the introduction of a service user-led, recovery focused, contact-based programme that developed over time to include workshops, placement, tutorials and assessment being delivered to undergraduate medical students.

In terms of being service user-led, the programme has been fully developed, and is fully delivered, by people with lived experience of mental illness. The valued role of those with lived experience in training for psychiatrists has been recognized, particularly in terms of supporting the identified need for more person-centred and recovery-oriented approaches (Roberts & Boardman Reference Roberts and Boardman2014; Training, P.C., Curriculum Scoping Group and the Special Committee on Professional Practice and Ethics 2018).

The recovery focus of the programme is based on the conceptualization of personal recovery that stems from the work, writing, perspectives and advocacy of the consumer/user/survivor movement. More specifically, this aspect of the training utilizes the Rethink Personal Recovery Task framework (Slade Reference Slade2013). This framework emphasizes that recovery is supported by minimizing the impact of mental illness and maximizing well-being. The impact of mental illness can be minimized through supporting individuals to frame (make sense of the experience in a way that is meaningful to them) and self-manage. Maximizing well-being involves supporting individuals to develop a positive identity and valued social roles and relationships.

The programme is contact based where contact is defined as interpersonal contact between people with experience of mental illness and the target group. Health professionals, including those who specialize in psychiatry, are a group who hold stigmatizing attitudes and discriminatory behaviour towards those who experience mental distress (Corrigan, Vega et al. Reference Corrigan, Vega, Larson, Michaels, McClintock, Krzyzanowski, Gause and Buchholz2013; Stuart & Sartorius Reference Stuart and Sartorius2017), and contact is identified as the most effective approach to countering stigma and discrimination (Corrigan, Morris et al. Reference Corrigan, Morris, Michaels, Rafacz and Rüsch2012). However, we became increasingly cognizant that despite the contact-based aspect of the programme, the lack of systematic training on human rights as they apply to mental health allows stigma and discrimination to continue (United Nations Human Rights Council 2017). Hence, in 2018, we extended the programme – World of Difference – to include a human rights focus. It was also extended to include first- and second-stage psychiatric registrars (in addition to 5th and 6th year undergraduate medical students).Footnote ¹

In accord with the clarification of the application of human rights as they apply to people who experience mental illness through the entry into force of the Convention on the Rights of Persons with Disabilities (CRPD) (Committee on the Rights of Persons with Disabilities 2014). The emphasis of the human rights focus of the programme for stage 1 registrars is on shifting away from substitute decision-making and ending the use of seclusion, restraint and other coercive practices. For stage 2 registrars, this focus is on promoting and realizing supported decision-making, and engaging registrars in patient-centred approaches through the use of advance planning.

Structural elements of teaching include

• - one half-day teaching session,

• - one half-day workshop (facilitated to identify and explore application of personal and service-wide actions),

• - optional monthly one-on-one service user professional supervision.

Newton-Howes et al. (Reference Newton-Howes, Gordon and Fedchuk2019) provide a full description of the development, delivery and evaluation of the programme.

In terms of the service user supervision component, a similar initiative involved service users who had experience working as peer support workers and/or system advocates meeting monthly to advise residents over a period of 6 months (Agrawal et al. Reference Agrawal, Capponi, López, Kidd, Ringsted, Wiljer and Soklaridis2016). Residents described gaining a number of benefits from the engagement, including an enhanced understanding of the lived experience of recovery and a greater sense of shared humanity with service users. It was hence concluded that positioning service users as advisors to psychiatry residents specifically holds promise as a powerful way of reducing distance between future psychiatrists and service users and facilitating system reform towards person-centred recovery-oriented care.

This new teaching programme actively supports trainees to identify and apply alternative models and approaches, including through the service user supervision that is offered. One of the potential barriers to the programme is the receptiveness of senior clinicians to supporting trainees in application of the teaching in practice. Through recent literature, some high-profile clinical academics have, for example, been highly critical and dismissive of the recommendations for psychiatric practice stemming from interpretations of the CRPD (Freeman et al. Reference Freeman, Kolappa, de Almeida, Kleinman, Makhashvili, Phakathi, Saraceno and Thornicroft2015, Appelbaum, Reference Appelbaum2019). The main issue, upon which such criticism is based, is perspectives that the abolishment of substitute decision-making regimes would be perilous, particularly for those experiencing the most extreme states of mental distress. A recent study of relevance to these views investigated the extreme (up to 11 times) variation in rates of seclusion across New Zealand’s publicly adult mental health inpatient services as indicated by national data (Lai et al. Reference Lai, Jury, Long, Fergusson, Smith, Baxendine and Gruar2019). Anecdotally, this variation has been attributed to a range of factors directly relating to the people admitted to acute inpatient services. Results found that the variation could not be attributed to socio-demographic and clinical factors. Instead, this variation in rates of seclusion, arguably one of the most extreme methods of managing severe mental distress, may be explained by differences in service delivery models and practice approaches. Hence, it is important to support trainees in identifying and applying alternative models and approaches that are specifically focused on reducing substitute decision-making and promoting supported decision-making. The service user supervision that is being offered is intended to contribute to such support.

This paper describes the perspectives of a service user academic and a psychiatric trainee in response to their engagement in the service user supervision component of the newly established psychiatric registrar teaching programme.

Perspectives on supervision

At the end of the initial teaching session (that occurs at the beginning of the year), both stage 1 and stage 2 registrars are provided with a flier advising that monthly one-on-one service user supervision is available to enable them to regularly discuss their work and training with someone from a service user’s perspective; and providing details as to how to go about accessing this. Accessing the supervision as per the details on the flier is then at the discretion of the trainees.

In 2018, only one trainee pursued the option of the service user supervision. A number of others expressed interest but were concerned about pursuing an additional training-related undertaking that would involve a significant commitment. There were no other reasons given or concerns raised in response to trainees not pursuing engagement in the supervision. Initially, the lack of up-take was disappointing. However, upon reflection, it turned out to be valuable to focus on working together with just one person to begin with in order to progressively develop more specificity around what the supervision would actually involve.

After having engaged in a year of monthly supervision, the supervisor and the trainee discussed and were both keen to collaborate in writing up a paper based on each of our perspectives of the supervision. The first stage of this process involved us separately drafting content based on our perspectives of the experience of the supervision sessions, the impact of the supervision sessions on training/practice and any barriers faced. The supervisor collated this material and generated a draft paper, which the trainee then reviewed and revised. This resultant paper, authored by both of us, provides the perspectives of S.G. (as the service user supervisor) and M.H. (as the trainee) in response to our engagement in a year of monthly supervision.

Being in his 3rd year, stage 2 of the Royal Australian and New Zealand College of Psychiatrists trainee fellowship scheme, on his first run to becoming a Responsible Clinician, the trainee had always felt uncomfortable with the principle of coercive treatments in psychiatry, yet also recognized it as a ‘necessary evil’ in certain circumstances. He saw service user supervision as an opportunity to challenge his justifications for the use of compulsory treatment and to challenge beliefs held within the clinical culture where he worked. He also hoped to gain a deeper understanding of the recovery model by considering its principles in case-based discussions and to ultimately implement them in practice.

Prior to this initiative, the service user supervisor had only ever provided supervision to her peers – others working from a service user’s perspective. In that context, the focus was on supporting them to explore and address challenges they faced in their roles, particularly as a result of coming from a traditionally underprivileged perspective in terms of both position and knowledge, and then to identify solutions in response that could be applied in practice. In contrast, this supervision (of a psychiatric trainee) needed to ensure that service user’s perspectives were the privileged position and knowledge base of the supervision sessions, and that the trainee was then supported to explore responsiveness to that in practice. The model of supervision used was based on the co-reflection model espoused by Intentional Peer Support (IPS) (Mead, Reference Mead2014). This model involves a process of learning, practice, reflection using the three principles (from helping to learning together, individual to relationship and fear to hope and possibility) and four tasks (connection, worldview, mutuality and moving towards) of IPS.

Initially, the trainee was apprehensive because he did not really know what to expect and worried that he would not have enough material to fill the sessions; however, that proved to be short-lived. After a couple of sessions, he found that he would have several cases which he was wanting to discuss as different themes emerged in the sessions, and as he began to apply what he had learnt to clinical situations. The most profound moments came from instances where the supervisor challenged his assumptions about what it is like to be a service user receiving treatment from mental health services, and through reflections on cases from the service user’s perspective. It offered an experience that was vastly different to the clinical supervision which he received and led to significant changes in his attitudes to psychiatric care and his clinical practice.

From the supervisor’s perspective, the trainee started from a position of seeing potential value in the sessions (although not being entirely sure what they actually might consist of initially), and this was important. He was proactive in thinking about and bringing subject matter to the sessions. He welcomed and was actively responsive to the privileging of the service user position and knowledge base through both the sessions and in the subsequent application of that in his work.

In terms of the impact of the supervision sessions on his training and practice, the trainee realized he had not previously given enough thought to the power imbalance that exists in the psychiatrist–service user relationship or properly considered how it may impact upon the service user’s ability to trust the psychiatrist. As a result of the sessions, he became more aware of this in his practice, particularly when working with long-term clients who had likely had unpleasant experiences in services over the years. He found that actually talking about this with clients and explicitly expressing his intentions have been an effective way of improving the relationships he has with clients.

During case-based discussions, the trainee was really challenged to consider matters from the service user’s perspective, and he now finds himself routinely applying this in his clinical practice away from supervision. This has been particularly powerful when managing patients in restrictive environments, as he now questions firstly whether behaviours labelled as ‘agitation’ are in fact an understandable reaction to a situation from the service user’s perspective. There have been several instances where he has lessened restrictions as a result of this, the ‘agitation’ has resolved and the service user has made real progress in their recovery. The trainee now makes much more of an effort to take the time to talk with service users informally around the ward and he feels that this has helped him to gain their trust and to better get to know them as a person, rather than a patient. He also now regularly gives thought to supported decision-making as a gold standard of treatment planning and intentionally using the term in discussions with patients. He also gives much more thought in trying to maximize patient autonomy even in those situations where compulsory treatment is deemed necessary.

Ultimately, the consultant has the final say in bigger decisions regarding matters such as compulsory treatment, so there were instances where the trainee was not able to implement plans in accordance with the principles he was trying to adopt from the supervision sessions with the service user academic. Similarly, there were instances where he wanted to adopt less restrictive measures, but did not have the confidence to go against the opinion of colleagues owing to his relatively junior status.