The purpose of this paper is to explore student experiences of learning from mental health service users and carers.
In total, 30 clinical psychology trainees and ex-trainees took part in an online survey (n=21) or focus group (n=9). Responses were analysed using interpretative thematic analysis.
A number of themes were identified. There were two pre-conditions of learning: valuing the teaching and emotional arousal. Participants’ learning experiences were characterised by cognitive and meta-cognitive processes: active learning, reflection, increased attention and vivid memories. Furthermore, participants might have a meta-cognitive experience of having learned something, but being unsure what that something was. Participants reported learning about the lives of service users, about themselves and about the wider societal context for people with mental health difficulties.
In order to facilitate learning students should value the input of service users. This allows them to contain and use the emotional arousal the teaching produces. Furthermore, leaving students with a feeling that something has been learned but not being exactly sure what that has been may facilitate students seeking out further opportunities for service user involvement.
Few studies have explored the process of learning from mental health service users and carers. In the current study, the emotion aroused in participants was primary. Furthermore, a new meta-cognitive experience, namely, the experience of having learned something, but not being sure what has been learned, has been identified.
Wilson, C. (2019), "The experience of learning from mental health service users and carers", The Journal of Mental Health Training, Education and Practice, Vol. 14 No. 2, pp. 119-130. https://doi.org/10.1108/JMHTEP-06-2018-0036Download as .RIS
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Copyright © 2019, Emerald Publishing Limited
Research on the involvement of mental health service users in services is well established (Tambuyzer et al., 2014). There is also a flourishing literature on the involvement of mental health service users in producing or co-producing (Borg et al., 2009; Russo, 2012; Sweeney and Morgan, 2009). However, understanding the impact of mental health service users and carers have when they provide teaching in mental health professional training courses lags far behind. This could be considered surprising when several mental health professional bodies require the involvement of service users in their training, and others provide strong recommendations of the same. The evaluations of mental health service users being involved in the training of mental health professionals show that the outcomes are mixed. Many studies report positive benefits of service-user-led teaching including challenging misconceptions about people with mental health difficulties (Byrne et al., 2013), developing enhanced empathy (Wood and Wilson-Barnett, 1999), working with the values of clients rather than the values of the service providers (Khoo et al., 2004) and increased awareness of the wider societal and cultural influences on mental health (Maher et al., 2017). Furthermore, we are becoming increasingly aware that students and educators may themselves have experience of mental health services and/or of caring in a personal capacity and that teaching that bridges the gap between someone’s personal and professional identities can be powerful and a useful forum for learning (Wood et al., 2013). However, there are also difficulties and barriers within service user and carer-led teaching; not all students benefit from and value being taught by service users (Felton and Stickley, 2004), it can be too challenging and, therefore, learning does not take place (Grundy et al., 2017; Ikkos, 2005) and some students prefer to be taught by senior practitioners (Haeney et al., 2007). Even when the teaching is valued, there are barriers encountered. Institutional values can conflict with that of service user and carer involvement, and people within the institutions can agree with the students who think information from senior practitioners is more valuable (Felton and Stickley, 2004; Khoo et al., 2004). Mental health service users may have no training in teaching and, therefore, may need more institutional support to provide teaching (Barnes et al., 2006; Campbell and Wilson, 2017). Institutions may have no infrastructure or pay scales that are appropriate to pay service users for their input, or national rules on illness benefits might preclude service users from accepting the pay offered (Basset et al., 2006).
What is clear, however, is that research is in its infancy (Happell et al., 2014; Repper and Breeze, 2007). Much of the information about the impact of service users teaching mental health professionals during their training comes from naturalistic studies, with measures designed for the study, no control groups or experimental manipulations and sometimes no systematic analysis of quantitative or qualitative data. This is appropriate for the stage the field is at, but limits the conclusions about the impact this kind of teaching can have. A lack of a theoretical framework further limits our progress in this field. Many professionals and policy makers have, therefore, relied on value-based judgements in recommending this kind of teaching (Higgins et al., 2011).
One model of learning from mental health service users has been developed recently, specifically exploring involvement in clinical psychology training in the UK. Schreur et al. (2015) used a grounded theory approach to explore clinical psychology trainees’ and recently trained clinical psychologists’ experiences of mental health service user involvement in their training. In total, 12 participants were interviewed individually, and the transcripts of the interviews coded to develop key themes and a model of the impact of involvement. The model they developed is reproduced in Figure 1. It proposes that each teaching experience is an idiosyncratic involvement episode resulting from the individuality or uniqueness of the student interacting with the individuality or uniqueness of the service user providing the teaching. The teaching itself promotes reflection via the emotion evoked by hearing the lived experience, by the different roles occupied by student and service user and by students hearing things for the first time. Factors such as safety and congruent goals facilitate learning, whereas perceived disempowerment, lack of safety and de-individuation hinders learning. Positive outcomes include enhanced memory, validation, breaking down of barriers between “them” and “us”, and students being able to hold more hope. There is also increased clinical understanding, more person-centredness, heightened awareness of and motivation to engage with power issues and service user and carer involvement. Negative outcomes include the teaching having no impact, the inadvertent reinforcement of “them” and “us” boundaries and students feeling de-skilled and disempowered.
This model accords with the previous research, and provides a basis for further research, but in terms of the impact on teaching specifically, it only provides us with some ideas about how students benefit. It cannot answer questions about which kinds of students benefit more, whether there are particular topics that service users should teach, what kind of preparation students need to benefit most from this teaching, and whether the teaching has any kind of added value, compared to traditional teaching, from academics and senior practitioners. Given that there are known risks to student learning (Stacey et al., 2015), and there are known barriers to providing this kind of teaching (Felton and Stickley, 2004; Happell et al., 2015; Ikkos, 2005), a model of service user teaching could be very helpful to determine how to minimise these risks and how to overcome some of the barriers.
The current study uses a qualitative methodology to explore trainees’ experiences of learning from mental health service users. The key research question is:
What is the process and experience of learning when the educator is a mental health service user?
Ethical approval was granted by the University School of Education ethics committee. All participants gave electronic or written consent.
The participants were clinical psychology trainees, or recently graduated clinical psychologists from one clinical psychology doctoral course in Ireland. The course is situated in a research-intensive School of Psychology within a large university in a major city. The course is based on the reflective–scientist practitioner model of training and regards reflection, science and practice as equally important. At present, there is no requirement for involving service users in the training course from the professional accrediting body. On this course, all participants had experienced teaching from mental health service users and carers within their training, and had also had to engage in service user involvement in their clinical placements during their training.
All current or recently graduated students (n=91) were invited to take part by e-mail. As a number of them no longer worked in the geographical area in which they trained, and the researcher was personally known by the students, all participants were asked whether they would prefer to answer the online questions, take part in an individual interview which could take place over the phone, or to take part in a focus group. In total, 21 people opted to complete the online survey, and nine people took part in a focus group. To ensure that participants could not be personally identified the only demographic question that was asked was which year the individual was in (see Table I for details).
Participants were either asked to complete an online questionnaire with open-ended questions or to take part in an interview or focus group. The online questionnaire aimed to orient participants to their experiences of being taught by mental health service users using questions such as “What are your experiences of being taught by people with lived experience of mental health difficulties including carers?” and “What do you remember about teaching by people with lived experience of mental health services”? Following this, participants were asked direct questions about their teaching and learning experiences, using questions such as “How did the teaching impact on you”? and “What was your experience of learning in these sessions”? Overall participants were asked ten open-ended questions about their experience, finishing with, “Would you like to add anything else about being taught by people with lived experience”? Throughout the survey participants were encouraged to reflect on their experiences, reminded that there were no right or wrong answers and asked to provide as much detail as they could.
It was planned that the interview and focus group questions would follow a similar format to the online survey, but there was only one question with prompts when necessary. It turned out that no participants chose to be interviewed and therefore only the focus group procedure is detailed. Participants were asked “Can you tell me about your experiences of being taught by people with lived experience of mental health difficulties including carers”? They were then prompted with questions such as:
How did the teaching impact on you?
What was your experience of learning in these sessions?
Was there anything different in your learning in this teaching compared to other teaching? If so, what was different?
At the end of the focus group, participants were also given the opportunity to add any other comments.
The analysis took an interpretative thematic approach including coding for both manifest and latent content (Joffe, 2012). The responses from the online survey were collated and printed question by question. The focus group was transcribed verbatim by the researcher and memos of their initial responses made. The survey questions were analysed first comment by comment. Key points were highlighted and initial notes made in the margin. As ideas occured about possible themes or key issues these were noted in separate memos. The transcript of the focus group was analysed next. The transcript was analysed comment by comment, again, with key issues highlighted and notes made in the margin. Care was taken to notice new themes in these accounts and to make note of where the spoken word (in the focus group) differed from the written word (in the survey). It was not deemed necessary that themes should occur in both the written and spoken accounts, but in the end, this is what happened, with all themes being represented in both sets of participants. Following this initial coding theme titles were written down and described in as much detail as possible. The survey answers, transcripts and memos were then re-read keeping the themes in mind and additional themes were added and described. Once a list of comprehensive themes had been developed, further details about the themes, including how they related to each other, were added to the descriptions. Finally, themes were merged and named leading to the list of themes described below. Final descriptions of these were developed through going back to the transcript and survey answers.
The results are grouped under three main themes; pre-conditions for learning, processes of learning and impact of learning. Themes and sub-themes are described below.
Pre-conditions for learning
This theme reflected the factors participants mentioned that facilitated learning, including participants’ emotional arousal in the room, and the value the students and the course placed on the teaching:
So, it’s not just words, you are actively putting it out there like, look they are experts like, and they are coming to teach you.
(FG P6 (Focus Group Participant 6))
It was actually very useful to view the teacher as formally placed in the role of expert. It gave them now an official and recognised authority, endorsed by the training college.
(S P2 (Survey Participant 2))
Teaching as valued
Participants used many different individual words to describe the teaching by service users that indicated that they valued their teaching inputs. As well as words such as beneficial, positive, necessary, useful, worthwhile and valuable, participants used a number of adjectives that have implicit value, as judged by the researcher. These included comments that the teaching was “real”, “relatable”, “rich”, “nuanced”, “powerful”, “relevant” and “deep”:
My experience […] was enlightening and brought about a richness in understanding what it is like to live with MH difficulties. The learning became more “live” so to say, as it was more meaningful hearing from the individuals themselves.
The value participants put on the teaching appeared to allow participants to experience the discomfort the teaching produced in them without becoming disengaged or over aroused.
There were several accounts of the emotion participants experienced in the room. Many reported feeling nervous or apprehensive:
It definitely does feel different. There is something like you are watching yourself a little bit more; you are a little bit more on edge.
Three different things appeared to contribute to participants’ increased arousal; their own role and behaviour in the room, the emotional impact of the stories they were hearing and the uncertainty, ambiguity and unpredictability inherent in the teaching session.
Participants reported reflecting on their own role in the teaching session:
I felt like, I needed to change just a little bit, but actually I didn’t. I was still just a student, and that was powerful for me to realise that I had an urge to be different even when there was no reason for me to be different.
Participants felt that they had to be more careful of what they were saying, more respectful of the teacher and more aware of what they did not know:
I guess the atmosphere is different in some way, you have to be a lot more considerate, you have to be much more careful.
Also, the change from feeling like a knowledgeable psychology graduate/doctoral student with lots of experiences and insights, to feeling like I had very little to contribute.
This change in role that led to increased arousal was linked to issues around power. Having service users as teachers gave the service users power over the students as they chose to be involved and controlled what they taught the students. Discussions of “them and us” were pervasive throughout the focus group, with some participants seeing the teaching as breaking down a sense of them and us, and others seeing the division as something that could not be broken down, but that could be understood differently. Some participants were concerned that the teaching had the potential to reinforce a “them and us” mentality.
The emotional impact of the story
The content of the teaching had an emotional impact on the participants:
There was something about the experience of hearing her that touched a chord that never left me – I’ve never experienced that from hearing a second hand account or even a very good piece of research – they don’t have the emotional impact that comes from hearing a genuine first-hand account.
The telling of the story, or the narrative of the person’s life facilitated emotional engagement in the story, which in turn facilitated greater memory for both the story and the teaching itself:
Because they typically couch their message in a rich personal narrative you experience a greater level of empathy and I think that might influence how you store the information. (S P14)
Uncertainty, ambiguity, and unpredictability
The other factor which appeared to result in greater arousal was the ambiguous nature of the situation. Participants noted that there was more emotion in the room, often related to not knowing what was expected of them, or what was going to happen:
I think I was definitely confused when I was coming in to what it was.
Participants expressed uncertainty about the representativeness of the views of the service users, wondering simultaneously if they were being overly positive or if they had an “axe to grind”. Some were concerned that the service users felt compelled to tell certain stories, similar to participants’ experiences in services where service users had to tell certain stories in order to be viewed as acceptable or to not get certain labels attached to themselves. Others were concerned that participants could “become” the story they tell about themselves, rather than be their genuine self in the room.
These three factors: the participant’s role, the emotional impact of the story and the uncertainty and ambiguity in the situation interacted with each other and with the value participants placed on the teaching to produce a certain kind of learning experience:
There was an emotional aspect to my learning in these sessions.
Processes of learning
Participants demonstrated some awareness of their own processes of learning, but implicit understandings of learning also emerged within the focus group.
Cognitive processes of learning
In both the survey and focus group, participants were explicitly asked about their experiences of learning. Many of these were related back to the emotional arousal that appeared to be a pre-condition of learning. Participants related this emotional arousal to active learning and processing of the information in the room:
It was definitely a different kind of experience. […] I found that input from people with lived experience was generally more engaging than traditional learning experiences.
The nature of questioning their own role and what they could and could not say or ask prompted reflection:
I guess it creates extra self-reflection and self-awareness than other lectures.
It was much more experiential. It probably brought me much more into the present moment and I felt much more of an obligation to be present with the person(s) involved in the teaching.
A few participants commented on their ability to attend to the teaching and the link between the attention and being able to recall the teaching itself:
Yes – my attention span – could have listened to them for hours – I remember more of their teaching than normal lectures.
Linking these elements together participants themselves made links between the cognitive aspects of learning, their emotional arousal and their ability to recall the teaching:
I have a very strong memory for where people were sitting […] so the memory is stronger, but I also, like questioning yourself, there is more internal process going on than in a normal lecture.
That’s why we remember that class a lot more, your emotions are raised, and that’s what helps with the learning. […] It needs to be evocative and stimulating.
The associated empathy that arises when someone is speaking from a personal experience, for me anyway, creates a richer memory structure.
What was particularly interesting about the learning experiences in these sessions is that it was not particularly the content that was recalled. Some participants did recall specific content from the sessions and others recalled more the emotional tone of the session:
I probably remember the feelings more so than facts from those sessions.
Some recalled most clearly that there was a reflective process going on at the time, without fully recalling the outcome of the reflection:
It was probably the one aspect of formal training where I felt process at its strongest. Regardless of all the role plays, presentations, therapy oriented sessions, my strongest memory of that teaching session that included people with lived experience of mental health difficulties, was their presence in the room and a sense of authenticity in the teaching.
However, for some participants they talked about experiencing learning, but not being all that sure at the time what that learning was:
There was very little conscious learning.
I don’t think I fully got it at the time, and to be honest I still don’t think I fully get it.
The participants in the survey explicitly expressed this aspect of learning, but in the focus group it came through more implicitly in how conflicts in individual views were worked out through the group. Some participants started the group expressing uncertainty about whether they had learned anything particular from the service user input on the course, but then through discussion with their peers started to talk about things they had learned. It appeared that students had not fully appreciated their learning from these sessions until prompted to think more broadly about what they had taken away from the session. Their reports of changes they had observed in themselves came across as genuine and as participants freely reported both no change and positive change it was felt that participants were not particularly trying to represent themselves in a positive light, nor were they trying to say what they thought the researcher wanted to hear, but rather genuine learning within the focus group discussion occurred.
This sense of learning something, but not being sure what it was, appears to be a meta-cognitive experience. This might be an important aspect of learning as it leads to efforts to resolve the associated feeling.
The content of what is learned
Many participants spoke or wrote about specific aspects of what they had learned. These appeared to be broadly subsumed under three headings; the lives of service users, learning about self as a psychologist and learning about services and the wider societal context of mental health, although there were overlaps between these categories.
The lives of service users
In terms of content related to the lives of service users, what was learned was more global rather than specific facts or techniques. Participants spoke about learning about the life someone with significant mental health difficulties lives, about how mental health difficulties were integrated into the service users lives, rather than being a separate bit of them to be fixed, and how their difficulties were not all of them:
Some of the unwritten script is about learning about that the person is human, they are not just a representative of a diagnosis, it’s to humanise the other bits of learning, the other academic inputs that are taking place.
Learning about self as psychologist
Participants spoke clearly about the impact it had on their understanding of themselves as professional and the impact it had on their work. Several spoke about changing their values or attitudes towards people with mental health difficulties. Others spoke about how it made them think about the responsibility they had in their clinical work. Some spoke about how it helped them develop more empathy or perspective taking in their clinical role. Others had more specific things they learned, for example, the importance of collaboration, or the importance of keeping the client at the centre of the work. Some were not sure what the impact was on themselves, but they felt impacted and they were still working through this:
It really made me question myself and my own assumptions. It encouraged me to be slower, more patient and to take more time.
You’re just realising your responsibility, and your role and the impact you’d have on people’s lives.
On the whole, the lessons learned were not ones that could be taught directly through didactic teaching. Furthermore, some of them could not be learned within clinical work because the participant needed to have a somewhat stepped back position to learn it, and working clinically did not fully allow them to have this stepped back position:
So this is more about learning how to sit and how to deal, how to reflect and what it’s going to be like for you and what it’s going to be like for them coming in to tell the story.
Learning about services and the wider societal context
Although many of the participants had worked in a variety of services, what service user teaching offered them was different. Sometimes this was at an individual level, to do with one person’s experiences of services or of societal stigma and discrimination, but other times students felt that their learning went beyond this and allowed them to look at global issues:
It brought to the fore issues around power imbalance, staff attitude, access to resources, staff behaviour, use of language/terminology, etc. (FG P5)
I think there is an overwhelming sense of how in so many ways severe mental health difficulties lead to widespread marginalisation, loss of opportunities, loss of relationships jobs etc. and how there is this secondary negative effect which is in many ways more damaging and maintains the problems. (FG P8)
Three main themes were found in the data: pre-conditions for learning, cognitive and meta-cognitive processes involved in the learning itself and the content of the learning-focused round learning about the service user, learning about the self and learning about services and the wider societal context of mental health difficulties. The results suggested that emotional arousal in the teaching sessions was central to the learning. This emotional arousal was effectively contained if students valued the learning. The emotions led to more active learning, better memories for the teaching and the development of a reflective space. There was a sense that a meta-cognitive experience of having learned something, but not being sure what it was, was present for a number of participants and this meta-cognitive experience led to seeking out of further understanding, through individual reflection, and of further opportunities to be involved in service user projects.
The results of this study lead to some interesting and potentially testable hypotheses. The two pre-conditions for learning: students valuing the input and emotional arousal appear to interact. The value students place on teaching directly given by service users allows them to tolerate the emotions produced by this teaching. If the experience is not valued, then the risk is that the service user educators themselves are blamed for being too negative or attacking of services and mental health professionals (Ikkos, 2005). However, the emotional arousal is important because it is the emotion that facilitates active learning and enhanced memories for the teaching, and it is the emotion that creates a reflective space.
Other researchers have found a link between enhanced emotion and enhanced learning. Rush (2008) proposes that the emotion aroused by the impact of the personal story leads directly to reflection and attempts to make sense of the experience. For Schreur et al. (2015), reflection is also promoted by the emotion produced by hearing the personal story. In all three models, role change is also present and in both Schreur et al.’s model and the model developed here, there is an importance placed on novelty or uncertainty. The current study differs somewhat to Rush and Schreur et al. by making the emotional arousal primary, and role change and uncertainty/novelty secondary to this. Studies in cognitive psychology indicate that emotional arousal, if within certain limits, promotes learning and performance in a number of ways Indeed the Yerkes–Dodson law states that as arousal increases performance increases, up to a point, at which point if arousal continues to increase, performance will start to decrease. This was first proposed back in 1908 following a number of experiments with mice (Yerkes and Dodson, 1908). It is suggested that the relationship between stress and performance, especially on memory tasks, may be more complex for humans (Wolf, 2009), but it is recognised that this kind of relationship is present (Robertson, 2016). Future studies could therefore usefully explore links between the level of emotional arousal in service user teaching sessions and the extent of reflection, and remembering that occurs. If emotion is primary, then the importance of creating a safe space for the teaching, of containment of the emotion, and of suitable preparation of both students and educators (all important components of Rush and Schreur et al.’s models) is highlighted. Given the emotional nature of many mental health topics, and the potential for students to also be service users or carers, this could usefully also be explored in the training of mental health professionals more generally.
The second key component of the current study is the link between the meta-cognitive experience of learning something, but not being sure what it is, and changes for the student that project into the future. In the current study, this was characterised as students seeking out opportunities to engage in further service user involvement projects. However, it fits with other studies of the learning process. Rush (2008) proposes that attitude change precedes resolving to take action and then taking action. Schreur et al. (2015) conceptualise increased awareness of and motivation to engage with service user issues as one of the positive outcomes of the reflective process. There are clearly processes that occur in the room that lead to changes in attitude straight away. Attitude change is commonly reported in the literature (Happell et al., 2014; Perry et al., 2013) and it is often associated with change in behaviour and practice (Maher et al., 2017), but it might be that for some students it is what happens outside of the teaching room that leads to long-term change. This impetus to engage more fully with service user involvement projects appears to be more prominent in post-graduate training and it may be that at this stage of training students are more aware of their professional capabilities and possibilities. However, it may also be that more reflective students on encountering a sense of having learned something but not being sure what that is may well use further personal reflection to explore this, leading to on-going change. This finding is only preliminary and further research is required to determine whether this is indeed a valid meta-cognitive experience, and whether it can help us link reflective practice within professional training to lifelong learning.
This study recruited students and ex-students from only one clinical psychology course. Although the results are resonant with studies from other clinical psychology courses, and with studies of student nurses, it is not clear to what extent the results are generalisable to other countries or other mental health professional training courses. Despite a reasonable sample size, the participants only represent one-third of the possible participants, suggesting that there may be a bias in participation. As both negative and positive comments were received it is hoped that social desirability was not strong enough to unduly influence the results, but it cannot be ruled out.
The collection of data using both surveys and through a focus group could be considered to be either a limitation or a strength of the study. There was no a priori decision to include only themes that occurred in both data sets, but in the end the themes that were developed did appear to be represented in both data sets, suggesting that some triangulation of results occurred. It was clear reading the survey answers and the focus group transcript that there was a different timing to the reflection that occurred in the research process for the two groups of participants. The language used in the survey answers suggested that reflection on the process of learning had occurred prior to completing the survey, whilst reflection occurred in the room for the focus group participants. Further research may be able to determine whether these two different methods of data collection are compatible. In addition, no participants chose to be individually interviewed and it is unclear why this is. It was perhaps the relationship between the researcher and the participants which meant that the focus group perhaps provided a safer space to express a variety of views.
Finally, the analysis was undertaken by someone who knew the participants of the focus group, and who had some knowledge of the field. Despite best efforts at reflexivity, it is likely that this influenced the analysis.
There is a clearly agreement between the existing literature and the current study on many of the important components of the learning process when mental health professionals in training are taught by service users and carers. These include the role of emotional arousal in learning, the different pathways to learning, through change in attitude, behaviour or by further exploration of service user issues. This leaves a number of implications for educators including the importance of getting the level of arousal right, so that students are not alienated from learning through panic, but that a level of arousal is supported in the room safely so that learning is enhanced. Furthermore, it has implications for research in that if we only focus on change in one domain such as attitudes or behaviours, we are likely to miss some of the important outcomes that service user and carer teaching lead to.
One of the values of developing a model of learning from service user and carers is that these models could be further tested and, if their accuracy and utility can be supported in research, they may provide a way of mental health professionals, service users and carers, and students to think consciously about the learning process. They may allow us to map on what we know from practice (see Stickley and Basset, 2007 for practical advice) to what we know from theory in order to maximise the potential opportunities for mutual learning in the classroom.
Details about year group of participants
|Year of training||Type of data collection||Number of participants|
|1 year qualified||Online survey||3|
|2 years qualified||Online survey||2|
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The author would like to thank all the participants in the study and to John, Regina, Sally, Collette and Ray for conversations about the project. The author also thanks John, Andrew and Orla for their support in thinking about higher education practice. There was no external funding for this project.
About the author
Charlotte Wilson is based at the School of Psychology, Trinity College Dublin, Dublin, Ireland.