Episode 6: Recovery (Part 1)

[Music] Hello and welcome to the Irish Journal of Psychological Medicine podcast, the podcast looking at the best and most exciting research from the Irish Journal of Psychological Medicine. My name is Sean Crowley, I'm a training editor with the journal and a HST psychiatrist trainee working in Cork. I'm joined today for a special panel discussion on the recovery approach in Ireland with four very esteemed guests who I'll have introduced themselves there in a second. To start the episode we might do that, so we might go around the table, agnously might start with yourself and do a quick introduction of your work and relevance to recovery. Hi everybody, my name is Agnes Higgins and I work in School in Nursing and Midwifery in Trinity College in Dublin. My clinical background is nursing and I suppose in terms of recovery, I have been working in the mental health services for more years than I care to remember, long before we even started talking about recovery. And I would have been part of writing a paper I think back in 2008 for the Mental Health Commission around recovery and translating some of the principles into practice and have been connected in with service use of movement, mental health reform, over the years we shared their board and now we're involved with another initiative called CurieFive. Sables, thank you so much for joining us and we might go on to your self-pass. I'm Pat Bracken, I'm a consultant psychiatrist. I have worked in a number of different places around the world. I was clinical director in West Cork for quite a long time. At the moment I work independently, I mainly do medical legal report writing for victims of torture, silent seekers in the international protection system in Ireland and some in the UK. I have a long association with the idea of recovery and the importance of critical thinking in mental health. I promote the idea that critical thinking is not a negative process when it comes to mental health but a vital way of helping practitioners get into the right headspace so to speak of engaging with people with mental health difficulties in a more positive way than perhaps we have done in the past. Great. And Karen. I'm Karen O'Connor, I'm a consultant psychiatrist as well as general adult psychiatrist. I am also the National Clinical Lead for the Early Intervention Psychosis Clinical Program. I think I first came in contact with the concepts around recovery when I worked in Australia. I worked there for a year and that was my first real contact with Early Intervention and Psychosis and to use mental health as well together. And I think I experienced it before I knew maybe all the language around us. And I experienced it as a very service user lead approach, a very hopeful approach and it really aligned with my values. I think and the values of lots of my peers and it was only afterwards I think I understood the movement piece of it. And so it was an experiential kind of experience and since then I've understood more about the movement. Yeah. Fabulous. Thank you so much. And next we have Donal who's also guest editing the special issue of the recovery approach issue for the journal. Donal, do you want to introduce yourself there? Hi everyone. I'm Donal Keefe. I am, I suppose, professionally an academic psychologist but as a human being I somebody who has this was navigated to the challenge of supporting somebody I love and with their own mental health difficulties and their struggles throughout their lives. And but also my own and and really interested in me. I suppose I had a really profound experience happen to me where I was researching psychosis for eight years and specializing in recovery in that area. I was traveling around the world and speaking to that academic knowledge and then it was only during COVID-19 that I experienced first episodes that causes myself and that completely refrained and shifted my my way of viewing the way in which people are spoken about in research. And also I suppose my own direct experience of using mental health services taught me a huge event. So in terms of my day to day work I manage archers recovery college so this is a service user led service where we collaborate with mental professionals to develop a program that helps people make sense of their distress and learn different coping strategies and feel a sense of belonging meaning and empowerment and my most so the public and patient involvement lead on the viscer research program which is focused on implementation science around sharing the vision. Right so I feel very lucky to be here. You're all extremely experienced from coming from lots of different angles with regards to recovery but I suppose for people at home who might not have a huge amount of knowledge about the terminology and things like that. I might come back to yourself don't know to start. How would you maybe define the recovery approach? A nice way to look at it first of all is in terms of how it's defined in the way in which we provide services today so it's the cornerstone of mental health policy globally. Its aim is to evolve services so that they consider the perspectives and priorities of the people who come to the system seeking help. So it's about prioritizing what outcomes they think are really important and also pursuing the way in which they would like their world view to be seen and that particular perspective that they hold at its essence. It's really important that it focuses first of all on holding recovery optimism for all and that's a perspective of diagnosis or your perspective of how someone is deemed potentially to be in this chronic or enduring category and it's about developing relationships with people centered on the principles of honesty, openness, compassion and trust. It's about focusing on a paramount collaborative decision making in the words of one of my heroes Patricia Deegan, the dignity of risk and right to fail. And it's about prioritizing access, engagement, continuity, care but really importantly the idea that we as people who struggle with their mental health have something to give and in that place it's about co-producing with us. So it's developing services based on our insights and our wisdom and on the knowledge that we've gained in our own right from that lived experience. And then there's another piece where we're looking in mental health services can't fix all the else but we're looking for that the system to really consider the fact that there are social, political and economic barriers to recovery and that they really need to be addressed and I can't just be us in isolation as a human being in our journey moving forward. Absolutely yeah okay and I suppose the other thing I'm just wondering as you're kind of talking about that those are all the kind of concepts in the area and those are going to be key to our discussion going forward. Do you want to speak about it as a kind of a movement or what the origins of this movement are small because I think there's a bit of a difference there. Yeah I think it would be lovely for a part of predictor to maybe speak about this as well with me but first and foremost the movement really stands from this idea that we've conducted research in mental health now for decades and particularly over the last 60 years this has been our merging evidence-based is just growing stronger and stronger that demonstrates the likelihood of recovery. So recovery in mental health isn't just possible it's likely but it's all about how you define it yourself. So even the I hope 20 study that I coordinated with Presumery Clark in in Detect which is the best science we can use to track outcome we found that 53% of people felt fully recovered according to every definition that they can come up with in the sounds another 30% felt that they were partially recovered. So it's that I suppose acknowledgement that throughout the year is a lot of times when people hit the mental health system they receive a diagnosis that then leads to pessimism being built in and sometimes that's to do with the fact that clinicians there's a terminal literature called the clinical illusion of poor outcome and what that simply means is that mental professionals tend to see people when they're struggling and because of that there's a bias built in there. So it's that movement to really shift the dialogue and shift the conversation. The almost more important piece is this idea that it's like every civil rights fight out there. I see it as probably one of the last areas where civil rights are still very much in debate. There are constraints there in a way particularly when voluntary admission is involved and thankfully the changes now are coming into play around and the UNCRPD but I suppose from a very human perspective what happened was decades ago people left psychiatric hospitals and they gathered together and that's whole period of deinstitutionalization as human beings to advocate for services, resources and social opportunities. So they wanted to be supported there in the community in the way that they felt that they needed. So as suppose it's been a huge service user movement and mad studies as a concept where the language is now to define a particular discourse within the literature. What services have campaigned against the power and balance that they experienced in the psychiatric system? How the meaning that they made from their experience and mental difficulties was neglected? And what also how the limited focus on diagnosis, psychiatric symptoms and functioning ignored their strength in their resilience. So it's that parallel movement with the shift to human rights and we're just focused on ensuring that human beings irrespective of being diagnosed with the MFLs or not are are are are are equations and treated equally and they're protected around, you know, all the rights to non-discrimination legal capacity in form consent and community inclusion. Yeah, well thank you. I mean obviously with the upcoming changes in legislation there's a massive discourse around that in our country at the minute. As you had mentioned Patrick, I might come back over to Pat there. I mean that there's a lot there in the origins. I mean, personally, I think it's very hopeful, even here, that data about how prevalent recovery is, you're quite right. I think I'm personally subjected to that bias, the clinician bias, you know, seeing people who are unwell, Pat, I know you've obviously an extremely extensive background in philosophy being, you know, would there be anything you'd say about the philosophical origins of the movement or anything like that? I looked at it in different ways but I think of it as a paradigm shift in how we approach the whole territory of what we call conventionally called mental health problems. And I think there is something important when we put that term mental in front of the word health. Whether we like it or not, I think we are delineating a territory of human suffering that has a different set of dynamics, if you like, then things going on in the organs of the body because that territory of the mental is social through and through, it's cultural through and through and it can't be grasped, I think, with the same logic that we would grasp problems in the lungs or the liver. And so when I talk about a paradigm shift, I'm thinking of the, you know, going right back to the classic paradigm shift when Copernicus got us to stop seeing the earth as being at the centre of the solar system and instead put the sun at the centre of that. And it's not that anything new showed up in that. Copernicus was dealing with the same data and research that everyone else had been dealing with but he saw it differently. And I think what I advocate for when it comes to mental health is that we start to see it's about the place of technology in mental health care. And traditionally, I think mental health problems show up as primarily technical challenges to be categorized, to be explained, to be got rid of in a similar way that we would deal with symptoms of liver disease or whatever. And the non-technical aspects of mental health care, things like relationships, meanings and values, while not ignored in the traditional medical model, so to speak, they're very much of a secondary importance. At the centre of our work, certainly for us as psychiatrists, I think, our history has been, we've spent a lot of time and effort on classification systems on issues to do with the biology of mental health and researching that. And primarily, if you think of the evidence-based treatment approach, which I'm not against, but that is very much about seeing the identifying the problem and finding the fix to that problem. So our whole way of thinking has been technological at the centre. As I say, we've not ignored issues to do with relationships or values or meanings, but they're not the centre ground, the real meat of our work has been the technological aspects of mental health care. Now, what I think the recovery approach does is it involves a paradigm shift in that we shift what has been seen as the secondary issues of mental health care, relationships, meanings, values, culture, power, those aspects of our work actually become seen as the most important. Crucially, we don't reject the technical aspects, but we see them now in a secondary position. So the recovery literature points to the importance of things like hope, finding meaning, being respected, and centrally the issue of relationships as the path to healing, not only as the path to healing, but also very much so where mental health problems come from in the first place, when you actually track back where our states of madness and distress and dislocation come from, very often those come from being disrespected either because of one's background, one's economic position, be marginalised, are in messed up relationships in the family and elsewhere. So for me, the recovery approach involves that key shift in perspective. And crucially, it's not anti the technical aspects, it is not against classification, it is not against diagnosis, but it doesn't see that as the central territory. And it tries to get us as professionals, I think, to engage with that world of mental health issues, with that different focus, with that different way of seeing and relating to problems. And I think with that, you see, comes a political shift because, well, us professionals might be the experts in the technology. Actually, it is people with lived experience very often, who are the experts when it comes to meanings, when it comes to issues around respect, and when it comes to relationships. It shifts the ground politically away from the expertise of the professional, to actually having to foreground the expertise of the person with lived experience. And their families very often, who often have a great deal of expertise to bring to the table as well. And the challenge in the recovery approach is how all the service users are there waiting to engage, waiting to be heard, families are banging at our doors, waiting to be heard, listened to, taken seriously. The challenge is how we get our professionals, our psychiatrists, others working in the field, into a headspace where we can actually engage in dialogue, meaningful dialogue, without thinking we know best because we have the technology. So that's how I've come to kind of see it. And I think in the end, the politics, whether we like it or not, are real. The power is invested in us as professionals. That's how the system is set up, particularly for us as psychiatrists, legally, professionally. We have a great deal of power even though we might not feel it sometimes when we're actually trying to deliver services, trying to organize things, trying to get funding for things we might feel very powerless, but in reality how people experience us is as very powerful people, often with the power to say what is going on, to name the problem, name the solution, in a way that I think sometimes can be disempowering for people. So it's about, as I say, a paradigm shift, but it's also about a political dynamic that I think comes with that. And we've already mentioned legislation and legislation changes and there's a big challenge to us as professionals to start thinking less paternalistically and more about autonomy and rights. And that's difficult for us to do because we're doctors. We want to look after people. We want to make them better. But sometimes in doing that, we actually are harming, I think, and we need to learn about that and be open to learn about that. Wow. Okay. There's a lot of powerful messages there. I suppose I'm struck by the various balances, kind of that you've discussed. Maybe the balance between providing kind of technical expertise and then also the balance that has with how that message is going to be interpreted versus respecting the service users, kind of perspective and narrative. And I know we're, I feel like that's a discussion we'll come back to later in the conversation. I was just seeing Agnes and Karen nodding and some of them were scribbling down thoughts and stuff there. So we might come to get a little bit of their thoughts on maybe that what's been discussed so far and the definitions and the origins and before we go into some of the content of this actual kind of the actual recovery approach issue. So we might come to yourself Agnes. Have you any thoughts about what we've been talking about so far? When I think of the origins and when I was reading people's accounts, two things that's kind of struck me is one in terms of what people would live to experience have to say about their rights and their and their right to voice and their right to construct identity. And equally what they had to say about the services and the way mental health services have engaged. And our kind of way of engaging that maybe has impacted on people's dignity. And in fact that people rose in those earlier years about they weren't just recovering from the distress of the mental health issue, but they were recovering from the distress of the mental health system and the distress that the mental health system had brought. That I think was one of them you know the real things that hit me as a clinician. You know I'm going back to Pat's that need for that paradigm shift in the way we think about people because I kind of see recovery is not something that I particularly do. It's a way of being. It's a network that I live by. It's the way I look at another human being aside me. Well we might have this technical knowledge as Pat would call it. I think that we have got to have a certain level of humility about the knowledge that we have and hold it very tentatively. You know, I suppose as a researcher you are nearly schooled to say that this is the outcome and this is the p-value and this is as if there's a surety in this. And so I think for recovery, for you know, my message, you know, to myself, how to continue whose basis as you can as a researcher and as two students is that, you know, discipline reshorety might be really good for not in crisis situation when a surgeon is in there and he has to put his slice somewhere. But discipline reshorety in mental health can be very, very destructive. Yeah, absolutely. I think he about that in a personal level and my own clinical practice now. Well, I suppose Karen, would you have any thought about what we've been discussing so far, about just the origins and definitions? Yeah, I think for me probably over the last 20 years I've been working as a psychiatrist. So I started training in 2005. That was my first year training in psychiatry and like being around over the last 20 years, I think there has been a lot of rebalancing happening and I can certainly see from my first year or two where the focus may have been much more on the medical treatments and the diagnosis. I think we are leaving lots more perspectives in now. I think we're, you know, really trying to see people in the whole in a way that we didn't then. Now, you know, we still have a long way to go completely acknowledge that. But I think another bit that maybe is in the backdrop that I feel like I need to comment on is I suppose the financial, the political, the social context we're in with regards to mental health and how mental health is perceived as a society, how, you know, the reality that stigma is still very significant and, you know, it's improved in some areas, but we do an annual survey in collaboration with mental health reform and shine and people with lived experience of psychosis and their families will say, no, they experience very, very high levels of stigma across almost all domains of society still. And that's still a reality. And so to support us in this shift, which we absolutely have to do into a less technically orientated broader range of understanding and interventions, we also need a very significant investment at a societal level that this is important, that as a society, we were going to tackle this, we're going to go for this and also at a, you know, a political level financially that, you know, that we will invest in people having enough time to spend with people to help some make sense of the meaning. That's more expensive in a time way than medication is, you know, and so when you're going to try and rebalance that, there are realities to the resourcing and the time and the energy that's required for that, that we absolutely have to do, but we need to invest in it as a society, I think. Yeah, I totally agree. Yeah, that's interesting. And so I suppose we might have a discussion of some of the key topics raised by this upcoming issue in the recovery approach. And as we were talking about, you know, having the time to make meaning there or rather I suppose the clinical reality of the lack of time to make meaning because of investment and things like that. But kind of on that topic of making meaning in very difficult experiences, we might come back to Donald and ask because you have a piece in the upcoming issue about meaning making in psychosis, Donald. And I might just get a bit of information about that piece because I think it's going to, you know, it's very interesting. Okay, so the important caveat I experienced is that I was after I competed in my PhD work, which is the paper that's published in the special issue. But I think from a very early stage in my training in psychology and in my, my, this was emerging career as a researcher, I noticed there was this profoundly neglect that occurred when people experience psychosis and sometimes this would happen where they would hit the mental system and their experience would be profoundly devalued and to the degree that it was almost perceived as meaningless or the fact of where I suppose there, everything was interpreted to a very specific frame of reference and that was pathology and symptoms. This somebody navigating the profound experience that they were having, they fed themselves in a situation where they were told really their understanding was wrong. And that there was no marriage to the way in which the main sense of things. So that inspired me where I would have interviewed people 20 years after they were diagnosed with the first episodes of psychosis to explore what recovery meant to them and what their experience using mental services was like, which is really interesting because they had experience of 10 years before and 10 years after the recovery approach. So they'd love to say about that. The real kind of powerful key message that came across to me was that particularly when they were seen in the early part of the 90s, there was this sense that I suppose they never really had this opportunity to explore what the meaning meant to them in that professional setting. So I decided from kind of learning about that experience, I decided to contact my PhD in the experience of A, to explore with people. So it was following up with people 21 years after we were diagnosed with the first episodes of the courses. So we explored with them, A, what did that experience mean to them? How did they navigate, find and make meaning from that experience? And B, did that contribute to or what was the relationship between that and meaning in life, which a very broad definition would be purpose, coherence and significance, maybe bit of authenticity in there as well. So that's kind of like my understanding was very much grounded on this idea that, okay, so for many people I interviewed in the previous research, they described their experience as being profoundly important, if not the most significant experience of their life. So my question was, is there something going on there that we need to experience more, or need to explore more, we need to understand more because these people haven't had this opportunity, I'd said, of a research setting. Some of them, and a lot of them hadn't spoken about this in this way. So my PhD looked at what meaning the people get from experience and how it contributed to or a roaded meaning in life. Really interestingly, it was a labor of love. We tracked back. I met people in many different parts of Ireland to conduct the research, but what I found was that psychotic experiences are roaded meaning in life. So they threatened our damage to a person's sense of self, their pre-psychosis, or preferred identity, their relationship with time and control in their lives. But also really importantly, they contributed to meaning in life. So they allowed participants to fill a meaning in life, like giving their life value, significance, purpose, coherence and connectedness. And then really importantly, they prevented people from actually having memories. So there was nothing to make meaning from. Consequently, that didn't have any impact in meaning in life because there was nothing, there was no way you could make coherence from that because it was gone. So I suppose what's really important and one of the key kind of findings from that PhD work is that if mental health services and systems, like Pat mentioned earlier on, are a diminishing or indeed eradicating psychotic experiences from people's lives, what are we doing as a system to help people fill that meaning vacuum when that's gone? So how do we respond in a way that allows people, if the most important relationship that they had is now taken from them because they've been treated, what happens then? And how do we bridge that gap then in people's lives? So how do we do it in a way that's psychologically costly to the person that's psychosis? I think the whole panel is probably interested in that question. Does anyone have anything to particularly care? And I know you lead the early intervention service in Cork. I mean, would there be anything any thoughts that come to mind? I think so, Donald knows this way better even than I do. But a big part of the early intervention movement is around broadening things out. So, and supporting people in their social aspects of their life, their occupational aspects of the life of that's what they want. And working with people as to what do they want for themselves. Let me explain that in a small way. So a small way that might be that someone has just had an epistytocosis and they're really, really struggling. And when they come to see us as a team, they don't want to talk about that. Maybe at that time there isn't what they want to talk about. What they want to talk about maybe is sleep or work. That's what we work on. That's what we focus on. That's what we're going to work on until this person decides that they don't want to work on that anymore. There's something else they want to focus on. So I think I'm trying to explain maybe how I think some of the improvement in this space is starting to look now. And that's in a small scale. And then at the kind of EIP clinical programme level, we try and make sure people have a range of interventions available to them. So medication can be important, especially in the acute phase. It's only one component and many people don't want to stay on medication long term. And actually right now we don't have good advice about to say to people, how long? What dose? We actually don't. And don't know if there's some really good work going on in Ireland at the moment to try to clarify, you know, to give people some solid advice about that. But we don't have solid advice about that. And some of it depends on where you are. If you're in America, you'll probably be told you should be on a forever. You know, we don't tend to go that way in Europe. And so, and then we're trying to figure out what the evidence is around that. But right now we don't really know. But the other quick things I was going to say is just around we make sure people have access to psychological interventions. CBT has the best evidence-based, but we don't just tie ourselves to CBT. If this person is coming with very significant trauma here at History and that that's what they want to work on, we have staff we're trained in that space and that's what they'll work on. And then the other piece is surround occupational. So we have employment support workers on the teams and we all try and tackle physical health and support people around lifestyle. So yeah, so that's what I'm saying in the small and then in the bigger that's what we're trying to do. The beauty I think then is when within that incredibly wonderful new model of care for psychoso the current needs on and it's the clinicians themselves who are involved in providing that care. It's when they're able to step into that space where they're opening up an opportunity for I suppose the embracing of multiple complex and different idiosyncratic explanatory models that people have. So you know it's not just saying this is a delusion, this is hallucination, you know we got you on these drugs and we're hoping that'll produce things. It's going well what does that mean to you? You know I mean whatever it is that you're struggling with, you know if people are convinced there's a threat, you know, and I'm going to go back into time in terms of their narrative and ask them and do that work and obviously as Karen said it's extremely you know therapy is expensive and I think it's like I'll just I can't say college is so extremely rare as well and in some parts of the service but it's just it's giving people the opportunity to open or to be facilitated to do that work themselves with with the professional in a way that's not simply asking a question do you hear voices or are you seeing something or you know it's so it's just it's that as Pat mentioned in Iran it's the idea that we could change even the diet the whole conversation so it's a dialogue rather than that we're explaining to you that this is a pathology and we're going to try and just one quick thing that those like and so we're not prescribing anything we're trying not to prescribe what I mean by that is you know we have access in the IP teams to rapid enough access to psychological interventions but lots of people don't want psychological interventions you know that's not what they want or they don't want it now you know are at some leisure time they might be ready so I think it's really important that we we offer people a range of interventions and that ideally they're evidence-based but sometimes you know we we don't have all the evidence but that's what we should be working towards but also we need to remember not everybody wants all of those things people will want different things at different times and that's part of the flexibility hopefully any IP and an MDTs where you need to work with the person around what it is they want and yeah I suppose even listening to you there a second ago don't know what was kind of coming to mind was you know you need the time but you also need a level of kind of authentic presence or maybe compassion from the clinician it's it's the value system and the principles that are coming into play it's setting I suppose it's setting the the expert knowledge of the mental health professional alongside service users own explanations for their experience and not deeming one is being more valuable or important than the other and I think it's also about recognizing what frame of reference I as a clinician that I'm coming from because if I'm coming from a particular frame of reference it's very hard sometimes to to hear and not frame things so like we hear a lot about chain you know that they asking a different question you know moving from kind of what's wrong with you to what happened to you and certainly you know that's one of the things you say but if I hear it through a frame of reference when I hear somebody talk to me and I am listening to a true kind of a diagnostic lens then you know that I listen in that way and I then start to record somebody's experience in that space so I think it's about really having that authentic presence and humility in our ear that people have various ways of making sense of things and that when I hear something that is the way somebody makes sense of it that is not the way I think you know that I don't see it again as kind of a problem or a symptom or that because it may be culturally bounded you know you know people may have a spiritual explanation for it that requires us to start to think about the frames of reference that we use in mental health so it's not about just saying we are going to be recovery oriented we need to push back to look at you know what frame or and what frame of reference are we educating people in what frame of reference are we not re educating our clinicians in but what frame of reference are we constantly educating the public and I do think we have made you know strides in in particular ways in in the in the mental health space but you know to be truly kind of if we want to be that kind of recovery oriented with the person's voice at the center we still have a novel lot of work to do and that goes all the way back to the way we think about mental health problems the way we think about the cause the way we think about how people express themselves and because our fall back in our ear has been conditioned so much and it's not just conditioned in our education as clinicians we've been conditioned since we were knee high listening to the radio you know looking at programs where differences of experiences have been framed in a particular diagnostic way and people have expectations of you before they ever meet you you know and people will sometimes say you've probably all had this well I didn't expect you to be like this you know and you're like what did you expect me to be like you know so you know we're all within different concentric's aren't we yeah and and I think it can take an awful lot of confidence clinically to step out you know it's easier to stay you know and with what you're very comfortable with you know but then trying to step out and and be kind of look at things a little bit differently and yeah it can be hard and like sometimes we talk about dialogue and in fact what people really at me are doing are either I say call it torn taking yeah I know yeah or even worse parallel so I think dialogue is about a disposition that you hold for kind of mutual exploration of it well probably you know one of the things one of the researchers I've been doing with people's experiences of coming off medication and that and like when you hear people talk about when they raise this kind topic that the whole hearing ear is around why do you want to come off not so I may may support but why you might like need to stay on and even our research is you know has started with that premise that we we want to explore this because we want to keep people in in this space so to me that's not dialogue or maybe I'm very naive but I think that that that piece is so much more important in the context of psychosis because very definition as definition as a ghost is that nobody believes you so you are profoundly isolated in that space so you're coming into a mental system where every all the supports that you have previously and all the believers in your life are no longer there or there for this one issue they don't believe you so that that requires a huge amount of humility on behalf of the commission to welcome someone in that space and to consider and discuss many different explanations for why the person's experiencing what their experience and when your talking about not people and being not believed in the in the system I you know that's you know I kind of think and I've been thinking about this in terms of what that does to me you know like we talk about trauma informed care and we're saying that so many people who use our system have come from a trauma background you know and a lot of people would say that have the experience trauma of also experience their voices not being believed yeah I'm just listening to their don't I just kind of struck it like I know you mentioned that the PhD findings were obviously quite some time ago today is anything changed in your perspective on those findings or is it much the same you know with the lived experience great question well I think one of the things that I got a huge amount of joy from was rereading the PhD after I had my own experience the scene did it reflect and I did see myself in there so it was now obviously it's a small from a research perspective a small etiographic study was IPA and it was only 18 people in food but saying that I think for that transition afterwards what what it meant to me was you know I thought I knew everything there was to know about the recovery approach in mental health and everything there was to do about recovery in psychosis until I experienced it myself and and that shift very much was I suppose the language like autonomy choice you know the opportunity to be able to have shared decision making in your treatment all those beautiful words became my life you know so the so I think that that made it almost more important to continue to do the work that we do and from kind of learning from you know how as a human being you know we're all just there for the grace of God on this side of the table versus the other side of the table and it's that kind of if I suppose awareness that I took anyway was how vulnerable we all are as human beings in our lives and but I think that the particular reality that hit home for me after my own experience was how much I suppose hope there was in personal narratives people don't recover because you know someone hands the machine at paper and says this is the data they recover because they meet all the human beings who have navigated the journey and that's one of the things that I love about the work that I do now is we work both me and the staff members and archers. We have that type of experience within our tool belt to draw from and that's a gift that we can share with others. One of my favorite things to do is meet people in particular who have experiences like I was just unexplained but not just one stage where we have an amazing course in archers called Willow. It's about helping family members and friends focus on their own identity and shift their relationship around empowerment rather than doing for and I remember this moment where one of the the participants left and said lucky was really powerful to me to know that the facility in the room had experienced psychosis like my son has. That was that just blew my mind and I said yeah but I've experienced as I go as well and then she went wow she just says I don't know what to say to that that's just stunning moment. But it's that because something like psychosis is so profoundly stigmatized and there's so many misconceptions out there like between from everything from split personality to likelihood of violence and we've decades of research now to contradict them all but it's still inbuilt there in society itself and there's wonderful work for example broken talkers it's an amazing theater group that are taking cystar work agnases involved in six PhD students to create theater piece directly challenging all of those. So I think for me I always saw that the social or the profound injustice built into people's I suppose people being maybe not seen as authentic or real or are legitimate sources of knowledge and that profound epistemic injustice that's always been there and it's always something that bothered me from a societal perspective but since my own experience it's my life. And that's why like even in terms of my own disclosure I will choose the environment to disclose that in because it will either have it will have an impact in one way or another depending on what the environment is what the audience is. Of course yeah that's that's a very difficult space to navigate like normally imagine. The gift treaty that my psychosis gave me in my life is it allowed me to apply for the job I have now like so that's and that gives me access to a whole other world of meaning in terms of bringing together mental professionals services and family members and fundamentally trying to develop you know both of our program but change the mental health system as well in terms of we we it's really training mental professionals in valuing lived experience more. This is the end of part one of our conversation on the special issue surrounding the recovery approach. The conversation continues in part two thank you for listening to the Irish Journal of Psychological Medicine podcast you can read more about the journal on Blue Sky at Irish J Psych thank you so much and we'll see you next time.