International Journal of Psychosocial Rehabilitation
A Consumer-Driven Schizophrenia Workshop for Psychiatry Registrars
Dr Paul Kang Kai Pun (PP)
Psychiatrist - Senior Lecturer, Department of Psychiatry
Princess Alexandra Hospital - University of Queensland
Ipswich Road, Woolloongabba, Brisbane, Queensland, Australia
Ms Vivian Jarrett (VJ)
Mental Health Educator
Postgraduate Training In Psychiatry, Princess Alexandra Hospital
Ipswich Road, Woolloongabba, Brisbane, Queensland, Australia 4103.
Dr Pam McGrath (PM)
School of Nursing and Health Studies
Central Queensland University, Australia.
Dr Vaidyanathan Kalyanasundaram (VK)
Senior Psychiatrist and Director of Clinical Services
Senior Lecturer, Department of Psychiatry, University of Queensland.
Mental Health, Bayside Health Services District, Redlands Hospital
,Weippin Street, Cleveland, Queensland, Australia 4163
Pun, P.K.K., Jarrett,
V., McGrath, P., & Kalyanasundaram, V.(2005). Twin
Reflections: A Consumer-Driven Schizophrenia
Workshop for Psychiatry Registrars. International Journal of Psychosocial
Rehabilitation. 10 (1), 5-17.
The authors wish to thank the Queensland Health organisation, the
Queensland Branch Training Committee of the Royal Australian & NZ
College of Psychiatrists and the administrative staff in the office of
the Director of Training in Psychiatry, for their support in this
This report describes an innovative approach
in the education of trainee psychiatrists in Queensland,
Australia. Using a multidisciplinary panel with a central role of
a consumer, together with an interactive facilitative workshop
approach, a training package for schizophrenia was developed and
refined, concentrating on the streams of (1) evidence-based treatments
(2) modern psychiatry with a consumer centred and recovery oriented
approach (3) sensitising trainees to ethical issues. A unique feature
of this education approach is the way it brings together 2 paradigms:
the dominant professional one with its scientific background, with the
less dominant one of the body of knowledge in terms of consumer lived
experience. This report describes how the multidisciplinary,
multi-perspective group that comprised of this educational panel
planned for and managed the inevitable tensions that arise when
dominant preconceived beliefs are challenged. This ethical
perspective stresses a non-paternalistic approach, informed by
psychosocial factors but balanced by important principles regarding
professional responsibility. The result has been an involving,
richly complex and flexible workshop that has engaged successive
cohorts of psychiatrist trainees in reflective discussion that varies
according to individual need.
entering an exciting era of paradigm shifts: firstly, in modern public
psychiatry where the care of the mentally ill is embracing
collaborative and consumer-driven treatment models, with an emphasis on
supporting self directed recovery in community settings (Australian
Health Ministers, 2003; Onken, Dumont,
Ridgeway, Dornon & Ralph, 2002; US Department of Health and Human
Services, 1999) and
secondly, in educational programs where there has been a distinct shift
from didactic models of teaching to interactive learning methods with a
facilitative approach (Boud, 1987; Goldberg, 2001). Facilitative
approaches to teaching have been found to encourage deeper learning
(Kember & Gow, 1994). It is the authors’ belief that such
facilitative approaches are conducive to seeing and nurturing paradigm
shifts, that challenges the dominant models of working with persons
experiencing severe mental illness. This report
describes the local experience of a multi-disciplinary group comprising
of a consumer representative (an expert by experience), an ethicist and
psychiatrists in Queensland, Australia who
developed a training package for psychiatric trainees which embraced
both of these modern approaches.
In Australia, it is now government policy
to include consumer participation in all levels of mental health
service provision (Commonwealth of Australia, 1996; Connor, 1999). The
Australian and New Zealand College of Psychiatrists’ curriculum for
basic training includes mandatory experiences in consumer and
carer-related activity, requiring significant input from those that
have experienced mental illness (RANZCP, 2003). While these are
important developments, in order for these changes not to be merely
“lip-service” and tokenistic embellishments, it is well recognised that
a tidal change in terms of attitudes and knowledge of a new generation
of psychiatrist leaders will come only from meaningful training
experiences, which resonate with real-life clinical activity and that
focus on understanding and working with the lived experience of mental
distress and self directed recovery.
In 2001, the Academic
Subcommittee of the Queensland psychiatric training program
decided to move from a traditional student-style lecture program to a
series of seminar sessions which stressed adult learning concepts using
case studies, interactive discussion and expert facilitation. One of
the authors (PP) was given the brief to design and conduct a seminar in
the most common chronic conditions encountered by public mental health
services, namely schizophrenia. It was felt that
the seminar should incorporate 3 streams: (1) Evidence-based treatments
(2) Modern psychiatry with a consumer centred and recovery oriented
approach (3) Sensitising trainees to ethical issues. To
this end, a multidisciplinary “expert panel” was formed by invitation,
including a consumer representative (VJ), the psychiatrist facilitator/
moderator (PP), an ethicist (PM) and a psychiatrist with a major
interest in the consumer and recovery movement (VK). An important
outcome of the initiative was the development of a consumer-focused
case study for interactive, reflective educational workshops. The
educational session proved to be highly effective in terms of richness
of discussion, reflection and student initiated participation. The case
study focuses on multiple presentations to a service, across the
lifespan (Harvey, 2001) of two adult identical
male twins experiencing schizophrenia with varied outcomes.
The lifespan perspective being important when discussing the
biopsychosocial changes that occurs during illness and recovery.
Furthermore, there are ethical challenges posed at each stage of the
twins’ lifespan and history with the mental health system. For this
reason, this article has been written to provide a full description of
the content and process of the workshop to assist other educators
embracing the philosophy of modern public psychiatry with its focus on
consumer advocacy. The focus of this three hour training was to create
an opportunity for reflective discussions by the trainees about factors
that promoted or hindered recovery from different perspectives.
A flexible approach was planned, to allow the discussion to
respond to individual needs of different cohorts of trainees.
This would also allow the training package to be adaptable to
different working environments.
Queensland Rotation Psychiatry Training Program
Rotational Psychiatry Training Program is the only pathway by which
psychiatric trainees in Queensland, Australia meet their training
objectives before sitting examinations which qualify them for advanced
training and subsequently, to become specialist psychiatrists.
Requirements of training include approved training posts where the
trainees garner clinical experience, supervision by specialist
psychiatrists, and attendance at an academic program put together by a
voluntary body of psychiatrist educators, the Academic Subcommittee of
the Queensland Rotational Psychiatric Training Program.
This academic program spans 3 years: the first year
dealing with basic assessment and aetiology of mental disorders, the
second year dealing with clinical case examples and treatment concepts,
and the third year addressing sub-specialty areas of psychiatry. The
case study educational session is one of the 3-hour seminars in the
second year of the academic program.
Teaching Strategy– An Interactive,
Multi-disciplinary Collaborative Approach
Contribution of moderator (Dr Paul Pun):
Recognising that the
trainees would have a solid grounding in clinical presentations of
mental disorder as well as aetiological concepts, these workshops were
designed to capture nuances of management which would be virtually
impossible to do in a didactic fashion. There was a
deliberate continuity with regard to the vignettes to sensitise the
trainees to the subtleties of differences in management depending on
the stage of the disorder. The scenarios were based
on real clinical scenarios, which most of the trainees would be
familiar with, to maximise the opportunities of interactive
problem-based learning. The advantage of the case
vignettes was the mix of evidence-based treatment, ethical conflicts
and attitudinal issues regarding collaborative treatment blending
together as in real life, providing a richness and level of complexity
to the discussion. Another task of the moderator
was to manage the tension that inevitably arises where preconceived
beliefs are challenged, and provide balance to debates.
An issue that is perhaps poorly recognised where a
consumer is part of a professional panel, is the negative effect of
disclosure on interpersonal and academic performance (Farina, Allen, & Saul, 1968; Quinn, Kahng, &
Crocker, 2004). This can be managed by:
the facilitator providing
adequate time prior to the workshop, so the consumer may read materials
and ask questions about the intended teaching plan
the consumer meeting the
facilitator prior to the workshop to discuss how trainees are normally
trained and how this is approach will different
the consumer being given an
explanation of medical terms to be used in the workshop
the facilitator ensuring that
the consumer has time to digest complex statements and respond during
the workshop, perhaps even rephrasing comments made
making sure that payment has
been organised for the consumer
the consumer being made welcome
to bring a “silent observer” if that would help them feel comfortable
during the workshop
ensuring that debriefing is
offered to the consumer as part of the plan for the workshop.
This should happen immediately afterwards if possible and there
should be opportunity to talk at a later stage if required.
the consumer being given copies
of papers (especially this one) and references suggested in this paper.
There is also a need to discuss that personal disclosure will
most likely result in a temporary drop in ability (interpersonal and
academic skills) and this is not due to a psychiatric illness but part
of the normal response of fearing stigma by others.
consumer perspective (Vivian Jarrett):
experiences need to play a significant role in education of
professionals (Corrigan & Penn, 2004). Negative
stereotypes are likely to change when through working together on
problem-solving activities during the workshop. The
role of the consumer in the educator role is complex, as it attempts to
harvest the phenomenological or holistic experience of living with a
serious mental illness. The consumer perspective permits reflection on
a range of similar personal experiences, which not only enriches the
discussion, but promotes critical analysis of current practice and the
implications of decisions on the consumer. Consumers bring not only
their own experiences of the disorder, but experiences of using systems
of care, medications and psychotherapy. More importantly there is
opportunity to share experiences which bring out the human side of
consumer’s experience. Corrigan and Penn (1997)
suggest that the disease
and discrimination paradigms are conflicting views and interventions
not embracing the knowledge of both may cause confusion and tension for
consumers in treatment settings. The consumer’s participation in this
educator role enables discussions around interventions that could be
viewed as discriminatory. This may occur when interventions are overly
forceful or insensitive to the human suffering that occurs during
episodes of severe mental illness (Allen et al., 2003; Carpenter,
2002). The mere presence of the consumer educator also provides a more
respectful discussion that prevents over-categorising and inappropriate
labelling of experiences that are not part of the disorder (ie. sadness
is not always depression). Furthermore there is abundant literature
showing that a reduction in negative stereotyping occurs when
interpersonal contact is made with a consumer in a respected role
(Kolodziej & Johnson, 1996).
In approaching the
consumer educator role it is suggested that the consumer is offered
adequate educational information (ie. handouts that may be given to
trainees), support and adequate reimbursement for participation (NCCF,
2004). Educational support could occur through an opportunity to liaise
with the workshop facilitator prior to the workshop and for debriefing
after the session. Discussion of the session also contributes to
improvements for future sessions, ensuring that the discussion is
relevant at the local level. Consumers must also be confident and
experienced in the educator role, as it is a daunting task to work
freely with personal experiences at such a high academic level. The
consumer needs to have an appreciation of environmental or social
factors that help or hinder recovery (Onken et al., 2002) and be
encouraging to trainees when they have been successful at utilising
strategies that they feel would be helpful. This workshop utilises the
expertise of the consumer’s personal knowledge base as proposed by
Trainor, Pomeroy and Pape (2004) and the impact of discrimination
knowledge ( Corrigan & Penn, 1997)
in this way creates some amount tension with the medically sourced
knowledge base of professionals. One of the desired
outcomes of the workshop is a mutual appreciation of both professionals
and consumers knowledge, which will work to help bridge the gap in
understanding the experience of a mental illness.
Contribution of multi-disciplinary panel:
The interactive, multi-disciplinary collaborative,
consumer-friendly approach also informs the ethics teaching strategy
for the case-study session. The pedagogical raison d’etre is to ‘lead
from behind’ by building a non-judgemental space where participants are
encouraged to articulate and explore their beliefs and assumptions
about ethical responses to practice dilemmas that arise from the case
material. The approach is Rogerian, rather than didactic, affirming and
welcoming all analytic insights. Educational strategies include
information giving, concept introduction, issue clarification and
encouragement of ownership by the group of ethical reflective
Putting ‘Recovery’ on the Agenda
only in recent years that the idea of the possibility of ‘recovery’
from mental illness has been embraced by the mental health literature
(Andersen, Oades & Caputi, 2003; Bishop, 2001; Jacobson &
Curtis, 2000; McGrath & Jarrett, 2004) even though there are
numerous first person accounts of recovery from serious mental
disorders dating back over 160 years (Beers, 1935; Percival, 1840).
Prior to the collaborative work presented in this article, the
trajectory of the case study used in psychiatry training in our
department documented a strong bio-medical focus with an escalation of
drug therapy and enmeshment of the consumer in the mental health system.
One of the significant factors of the present work is that it
provides openness to alternative trajectories from the one starting
point (that is, identical twins with the same diagnostic condition).
The rationale for such change is to affirm and extend the work
initiate in recent decades that shifted the mental health paradigm from
predictable deteriorative/maintenance course to a therapeutic
engagement with the potential for recovery (Drake, Green, Mueser &
Goldman, 2003; Harding, Brooks, Ashikaga, Strauss & Breier, 1987a;
1987b). By the very presence of a consumer advocate who is an excellent
role model of recovery, the message of the possibility of recovery from
serious mental illness is a fact to be observed, not simply abstract
theoretical or research evidence (Ahern & Fisher, 2001). The
consumer’s insights and life story is a powerful medium for embracing
the present metaphor of recovery as personal journal, rather than
biomedical ‘cure’ from ‘disease’ where medication and institutional
mental health are the treatments of choice (Deegan, 1997). This
educational strategy echoes the present mental health literature that
calls for the insights of the lived experience of individuals who have
recovered from mental illness to be central to mental health reform
(Anthony, 2001; Deegan, 2003; Kirkpatrick et al., 2001; Tooth, Kalyanasundaram, Glover & Momedsadah, 2003). The differential outcomes of the twins gives an
opportunity for the educators to facilitate rich discussions about the
treatment conditions that impede the recovery process and entrap a
person in a life of disability managed entirely with professional
dependency. This is in contrast to therapeutic
relationships and conditions that recognise and support self directed
recovery and promote citizenship through well thought out frameworks of
support that are informed by the knowledge of lived experience and
traditional knowledge (Trainor, Pomeroy &
THE CASE STUDY – Format, context and issues
outlines a verbatim copy of the case study as it is presented to
students. As the modus operandi for the case study is to
suggest rather than prescribe, the following discussion will elaborate
on background issues to provide the full context for the detail in the
vignette. This discussion will be approached from the perspectives of
various members of the panel, namely the psychiatrist, the consumer and
Psychiatrist perspective on slides:
The first scenario
(slides 1 and 2) is packed with discussion points. Apart
from the obvious clinical issues of confidentiality and the role of the
carer, it allows discussion of the current level of evidence of the
association between cannabis and schizophrenia, as well as the
burgeoning area of early intervention in this chronic disorder.
Slide 3-5 brings about a discussion of alternative
models of psychiatric care (mobile teams, assertive outreach, 24-hour
community availability, alternatives to hospital admission,
psychosocial interventions) and the level of evidence supporting these
modern interventions. Slide 4 mentions ARAFMI
(2005) which refers to the local support network for carers of those
experiencing mental illness.
Slide 6 brings forward the discussion about rational
antipsychotic pharmacotherapy in an inpatient unit. Traditional
methods of using “as required” antipsychotic medication for sedation
are now being replaced by alternative anxiolytics (e.g.
benzodiazepines). Intravenous injections of drugs
to induce a “sleeping state” level of sedation are also being replaced
by other delivery mediums (e.g. wafers, intra-muscular injections) to
control agitation without necessarily inducing a non-responsive state
in the patient.
Slide 7-8 triggers the clinical management of
patients with schizophrenia who are treatment-refractory to
conventional antipsychotic agents. The level of
evidence for electroconvulsive therapy in treatment-refractory
psychosis is explored, as well as the ethical issue of using clozapine,
an agent proven in this condition but accompanied by dangerous
Slide 9-10 provokes discussion about competency in
chronic residual schizophrenia, by putting forward a scenario where the
patient receives a substantial inheritance, and is living in
sub-optimal conditions. Trainees report that it
allows reflection on their “knee-jerk” paternalistic response, rather
than respecting the patient’s choices and maximising their
Slide 11-12 deals with the controversial issue of
rechallenging patients with clozapine after a previous drop in white
blood cell numbers. The balance involves
considering the previous positive response to medications as opposed to
the problem of subjecting the patient to further harm.
Consumer Perspective on Slides:
The consumer perspective emphasises the need for
personal empowerment, choice and ways to manage the effects of fear of
discrimination and stigma from others (Brown & Bradley, 2002; Corrigan & Penn, 2004)
Slides 1 and 2 bring forth a discussion on the
process of becoming independent in late adolescence. Life
goals are hampered by the onset of a mental disorder like schizophrenia.
Often families are closely involved with their children in late
adolescence, and the impact of the home environment is still very
important. A family history of a serious mental
illness may infer the family is stigma conscious and sensitive about
labelling members in this way, there may also be fear of treatments
used in the past.
Slides 3, 4 and 5 discuss the impact of the disorder
over time, with the loss of education and work roles. Understanding the
difficulty of regaining life roles in the face of stigma from others is
valuable. It would also be important to advocate for services that are
affordable and accessible in the community. Treatment in the community
minimises stigma by focusing on meeting emotional needs, providing
self-awareness education and a human face to the assistance. It is
important to advocate that medication is only a small part of the
multitude of other services that a community can offer an individual in
recovery from a mental disorder. The opportunities would be different
depending on the local culture.
Slides 6, 7 and 8 give an opportunity to share the
personal experience of being medicated and hospitalised. The process of
admission can be traumatic (Cohen, 1994) and often the system through
which care is accessed, can cause harm to the consumer through
excessive administrative processes and assessments. It could be
discussed how the consumer is able to maintain choice and empowerment
during a hospital admission.
Slides 9 and 10 demonstrate the possibility of
positive outcomes when a consumer is given choice and opportunity to
recover. It is helpful to discuss how an individual
recovers and may take up normal life roles even in the face of some
Slides 11 and 12 highlight the differences in
possible outcomes for recovery when experiencing schizophrenia. There
is a danger in institutional care for consumers to not be permitted
negotiate life’s natural emotional highs and lows without it being
categorised into a disordered state of being. The
final summary gives a chance to highlight ideas that were useful to the
consumer’s experience of recovery during the workshop.
The conceptual starting point for the discussion is
that ethical reasoning is rarely situated in an unqualified ‘good’ but
rather necessitates at its core the tension between conflicting
interest of both ‘goods’ and ‘harms’. Engaging
openly with the tension within a non-paternalistic framework is posited
as one of key factors operating in professional ethics. While using the
language of ethical reflection informed by notions of Principlism (for
example, Autonomy, Beneficence, Non-maleficence, Justice), the
ethicist encourages participants to embrace a sociological
perspective. Thus, the framework
for discussion is at the cutting edge of ethical theory that in recent
years is moving from abstract philosophical reasoning to embrace a
sociological understanding of discourse and power (Frank, 2004;
Figure 1: Schizophrenia Workshop - Case Vignette
Mr A and Mr B are identical twins and 17 years old.
Both live with their parents and Mr A is unemployed since
dropping out of school the previous year. Mr A has
been brought to your mental health service by his mother, a general
nurse. She is concerned about his mental state,
having heard her son describe a device in his head. An
uncle and grandparent have also had schizophrenia. Mr A is reluctant to
be at the service, stating that his brother says he does not need to
see a shrink.
Mr A smokes 4 cones of cannabis per day. The mother has
heard from colleagues about “schizophrenia being caused by drugs”,
“psychosis being toxic to the brain” and the “importance of early
intervention”. The mother wishes that Mr A could be
like Mr B who is doing computer studies at university. She
mentioned that Mr A had made friends with a bad group of teenagers, and
it was typical of him to do the wrong thing.
Mr A is now 21 and has an established diagnosis of
schizophrenia. He has moved out of home and is
living with his friends. Mr B also moved into the
flat after finding a job in the local area, even though he had dropped
out of university several times before finishing. While Mr A has been
lost to follow-up for the last year, one day he self-presents to the
community health centre describing distressing voices. Mr
A does not want to be admitted and asks if he can have intensive
counselling rather than medication for his problem, as his brother has
suggested this would help. He does not have
transport and finds it difficult to get to the centre.
Mr A and Mr B are now 23 years old. Mr
B has moved back to his parents’ house, and they have bought him a car
to get around in. While Mr B has not used illicit
drugs, he also starts developing ideas about his workmates planting a
bug in his computer, and that they are monitoring him. Mr
B does not want to talk to anyone but his parents can’t seem to do
enough to help him out. Through their membership of
ARAFMI, they put Mr B in contact with the local mental health consumer
group. They, in turn, suggest he enrol in a brand
new young person’s program.
5. The “at risk” clinic
turns out to be the early psychosis program, which runs out of a
shopfront in the local shopping mall. Mr B makes a
good connection with one of the counsellors, who persuades him to try a
“Feeling Good” CBT course. Despite initial
reservations, Mr B later goes on a low-dose of risperidone.
His compliance is encouraged by a good support network
including counsellor, parents and members of the consumer group.
6. Mr A’s crisis
Mr A is now 24, and one night is admitted to hospital,
having been brought in by police who state that he had punched a
passer-by in the street. This was reported as a
psychotically driven assault. He is put on
olanzapine 20mg/day in hospital, but the nursing staff request that
they have prn antipsychotics to manage his unpredictable aggression.
The charge nurse also raises the query about intravenous
neuroleptisation with IV haloperidol and diazepam as there are only
female nurses on the night shift.
A’s not getting better
Mr A’s admission has been prolonged and complicated by
the treatment-refractory nature of his illness. He
has not responded to adequate trials of olanzapine, risperidone,
quetiapine and depot antipsychotic medication. He
refuses clozapine because of the blood tests. The
nursing staff raise the possibility of ECT, reporting that they have
seen other similar patients respond to this treatment. As
far as you can see, there isn’t an affective component to his illness,
although the uncle that was diagnosed with schizophrenia did suicide.
Mr A does not remember the assault that landed him in
hospital. He feels that the medication is poisoning
him, but his parents say they’ll never speak to him again if he stops
it. Mr B visits Mr A often and seems really worried
about him. One day Mr B comes to visit and seems
very upset. Mr B says that he feels so guilty
because it was him, not Mr A, that hit the guy in the street.
He explains that the guy in the street was drunk and
confronted both of them. As Mr A had the mental
health record and looked more dishevelled, Mr B thinks this is why Mr A
was picked out as the one that hit the stranger. He
asks you to explain Mr A’s illness and what treatments are available.
9. Six years on
After that event at age 24 Mr B chose to not see Mr A
again. Mr A is now in his late 30’s and is on
clozapine. He lives in a hostel, where his
medication is supervised. He has a predominantly
deficit state illness, with poverty of thought, amotivation and anergia.
He manages his own money, after the hostel deducts his
board, which he spends exclusively on cigarettes. Mr
A and Mr B receive an inheritance of $500,000 each. Mr
A’s psychiatrist thinks it should be spent on his rehabilitation.
10. The other half
Mr A talks about Mr B often. Mr B is
now married, has 2 children and runs a security business. Mr
A complains that Mr B does not contact him any more and seems boring
as he is preoccupied with security systems and talking
about how to stop others from breaking into your home.
11. ? Rechallenge
Mr A develops neutropenia on clozapine, and this drug has
to be stopped precipitously. After a long period of
stability on clozapine he suffers a severe relapse of psychosis with
its withdrawal, which is poorly responsive to all the other
antipsychotic agents. His neutrophils are currently
in the normal range. He wishes to go back on
clozapine, although at the same time he believes that aliens are
tracking his movements via a device in his head
Mr A seems upset and says he is depressed and asks you to
treat it. He says that Mr B recently went overseas
on a holiday with his mother. His father passed
away last year and he is upset that he wasn’t allowed to visit him
before he died. The family said it would be too
upsetting for the father to see Mr A, so they told him to stay away and
that he should just learn to stay on his medication and stop giving
everyone in the family problems. The father had
phoned Mr A before he died and said that he did want him to visit.
Summary Overview – Prognostic Factors Affecting Trajectory
13. ? Prognostic factors
of supportive friends
(actual and fear of discrimination)
and poor living conditions
of work role, minimal education
Complications from effects of medication
family and friends
treatment embedded in the community
connections to work, family, peers
use of services
The team’s experience of collaboration on the development of the case
study, trialling and perfecting the content, and engaging interactively
with students, affirmed the value and importance of the
multi-disciplinary case study perspective. To
complement the content outlined in Figure 1 and the prior discussion on
process, the team would re-iterate the following recommendations:
- The case study is not
prescriptive; rather it is suggestive of possibilities both in terms of
openness to interpreting the consumer experience and the varied
therapeutic responses. The case study needs to be used in the spirit of
openness as a discussion starter. If used appropriately, educators will
find that each session will lead in different directions depending on
the interest and experiences of the practitioner study group.
- The case study is designed
to be used with Rogerian reflective style of interaction. The modus
operandi is to encourage reflexivity in students in a trusting and
encouraging environment order where they feel safe to express ideas and
attitudes and share exploration of alternate therapeutic possibilities.
- The provision of information
is not pedantic or structured. Clinical information and evidence-based
directions are introduced in response to issues arising consequentially
from the discussion and are open for critique.
- The case study is to be
share in small groups (under 15 participants) to allow the time and
space for participation from all members of the study group.
- A multi-disciplinary,
multi-perspective panel is an essential part of the case study
experience. All members of the team are briefed to input into the
discussion when issues arise that relate to their particular expertise.
The students need to be provided with information on the background and
expertise of each presenter along with a message affirming the
importance of respecting difference in perspective.
- The consumer perspective is
considered to be an essential and perhaps crucial aspect of the case
study. Where possible, it is recommended that the team incorporates a
consumer advocate with personal experience in the mental health system.
The consumer’s presence and response to questions conveys an
authenticity and experiential learning experience for the study group
that would not be captured by just theorising about consumer issues and
To date, the case study has been developed, trialled
and perfected for use with psychiatry graduates. The multi-disciplinary
perspective suggests it would be an effective educational medium for
other groups including mental health nursing, psychology, social work,
allied health and consumer groups. However, as yet the case study has
not been trialled with this broad range of groups. Furthermore,
there are several areas that are not covered in this case study. A
further teaching session incorporating bipolar disorder, women’s
issues, pregnancy and parenting is being developed to complement this
Engaging in the
collaborative process of developing and trialling this educational case
study has been an exciting and satisfying experience. It is gratifying
to be involved in an educational experience where students engage with
trust and humility in a group process and demonstrate their capacity to
be reflexive and open to attitude change. It is the
experience of our team that this educational instrument goes some way
to addressing the enormous challenges of attitudinal change presently
required of the mental health system. It is thus our hope and
expectation that in sharing our collaborative efforts, others will also
find the content and process of the case study a useful medium for
responding to the stimulating way forward offered by the philosophy and
practice of modern public psychiatry.
Australian Government. (2003).
Health Ministers, National Mental Health Plan 2003-2008. Canberra:
Allen, M. H., Carpenter, D., Sheets, J. L., Miccio, S., &
Ross, R. (2003). What do Consumers say they want and need during a
psychiatric emergency? Journal of Psychiatric Practice,
Ahern, L., & Fisher, D. (2001). Recovery at your own PACE.
Journal of Psychosocial Nursing and Mental Health Services, 39(4),
Andersen, R., Oades, L., & Caputi, P. (2003). The experience
of recovery from Schizophrenia: towards an empirically validated stage
model. Australian and New Zealand Journal of Psychiatry, 37(5), 586-601.
Anthony, W. (2001). The need for recovery-compatible
evidence-based practices. Mental Health Weekly, 11(42), 5.
ARAFMI Queensland. (2005), You are not alone. Retrieved 27
April, 2005, from http://www.arafmi.org.au/
Beers, C. W. (1935). A mind that found itself: an autobiography
(25th Anniversary edition). New York: National Committee for Mental
Bishop, M. (2001). The recovery process and chronic illness and
disability: applications and implications. Journal of Vocational
Rehabilitation, 16(1), 47-52.
Boud, D. (1987). A facilitator's view of adult learning. In D.
Boud & V. Griffin (Eds.), Appreciating adults learning: From the
learners' perspective (pp. 222-239). London: Kogon Page.
Brown, K., & Bradley, L. (2002). Reducing the stigma of
mental illness. Journal of Mental Health Counseling, 24(1), 81-87.
Bustillo, J. R., Lauriello, J., Horan, W. P., & Keith, S. J.
(2001). The psychosocial treatment of schizophrenia: An update.
American Journal of Psychiatry, 158, 163-175.
Carpenter, J. (2002). Outpatient commitment for adults with
psychiatric disabilities: examining the underlying assumptions.
Families in Society, 83(3), 293-301.
Cohen, L.J. (1994). Psychiatric hospitalisation as an experience
of trauma. Archives of Psychiatric Nursing, 8(2), 78-81.
Commonwealth of Australia. (1996). National standards for
mental health services. Canberra: Author.
Connor, H. (1999). Collaboration or chaos: A consumer
perspective. Australian and New Zealand Journal of Mental Health
Nursing, 8(3), 79-85.
Corrigan, P., & Penn, D. (2004). The interface of social and
clinical psychology. In R. M. Kowalski & M. R. Leary (Eds.),
Lessons from social psychology on discrediting psychiatric stigma (pp.
258-274). New York: Psychology Press.
Corrigan, P., & Penn, D. (1997). Disease and discrimination:
Two paradigms that describe severe mental illness. Journal of Mental
Health, 6(4), 355-366.
Deegan, P. (1997). Recovery and empowerment for people with
psychiatric disabilities. Social Work in Health Care, 25(3), 11-24.
Deegan, G. (2003). Discovering recovery. Psychiatric
Rehabilitation Journal, 26(4), 368-376.
Drake, R., Green, A., Mueser, K., & Goldman, H. (2003). The
history of community mental health treatment and rehabilitation for
persons with severe mental illness, Community Mental Health Journal,
Farina, A., Allen, J. G., & Saul, B. B. (1968). The role of
the stigmatized person in affecting social relationships. Journal of
Personality, 36, 169-182.
Frank, A. (2004). Ethics in Medicine: Ethics as process and
practice. Internal Medicine Journal, 34, 355-357.
Goldberg, D. A. (2001). Model curricula: The way we teach, the
way we learn. Academic Psychiatry, 25(2), 98-101.
Harding, C., Brooks, G., Ashikaga, T., Strauss, J., &
Breier, A. (1987a). The Vermont longitudinal study of persons with
severe mental illness: 1. Methodology, study sample, and overall status
32 years later. American Journal of Psychiatry, 144, 718-726.
Harding, C., Brooks, G., Ashikaga, T., Strauss, J., &
Breier, A. (1987b). The Vermont longitudinal study of persons with
severe mental illness: 11. Long-term outcome of subjects who
retrospectively met DSM-III criteria for schizophrenia. American
Journal of Psychiatry, 144, 727-735.
Harvey, P. D. (2001). Vulnerability to schizophrenia in
adulthood. In R. E. Ingram & J. M. Price (Eds.), Vulnerability to
psychopathology (pp. 355-381). New York: The Guilford Press.
Jacobson, N., & Curtis, L., (2000). Recovery as policy in
mental health services: strategies emerging from states. Psychiatric
Rehabilitation, 24(4), 333-41.
Kember, D., & Gow, L. (1994). Orientations to teaching and
their effect on the quality of student learning. Journal of Higher
Eduction, 65(1), 58-76.
Kirkpatrick, H., Landeen, J., Woodside, H., & Byrne, C.
(2001). How people with schizophrenia build their hope. Journal of
Psychosocial Nursing and Mental Health Services, 39(1),46-55.
Kolodziej, M. E., & Johnson, B. T. (1996). Interpersonal
contact and acceptance of persons with psychiatric disorders: A
Research Synthesis. Journal of Consulting and Clinical Psychology,
Marshall, M., & Lockwood, A. (2001). Assertive community
treatment for people with severe mental disorders (Cochrane
Review). In The Cochrane Library, Issue 2, 2001. Oxford: Update
McGrath, P. (1998). “Autonomy, discourse and power: A postmodern
reflection on rationality in bioethics”. The Journal of Medicine and
Philosophy, 23(5), 516-532.
McGrath, P., & Jarrett, V. (2004). A slab over my head:
Recovery insights from a consumer’s perspective. International Journal
of Psychosocial Rehabilitation, 9(1), 61-78.
National Consumer and Carer Forum. (2004). Consumer and carer
participation policy. Retrieved 27 April, 2005, from
Onken, S. J., Dumont, J. M., Ridgeway, P., Dornon, D. H., &
Ralph, R. O. (2002). Mental health recovery. What helps and what
hinders? A national research project for the development of recovery
facilitating system performance indicators. Phase 1 research report. A
national study of consumer perspectives on what helps and what hinders
recovery. Alexandria, VA: National Technical Assistance Centre
for State Mental Health Planning.
Percival, J. Esq. (1840). A narrative of the experience of the
treatment experiences by a gentleman during a state of mental
derangements designed to explain the causes and nature of insanity and
to expose the injudicious conduct pursued towards many unfortunate
sufferers under that climate. London: Effingham Wilson, Royal Exchange.
Quinn, D. M., Kahng, S. K., & Crocker, J. (2004).
Discreditable: Stigma effects of revealing a mental illness history on
test performance. Personality and Social Psychology Bulletin, 30(7),
The Royal Australian and New Zealand College of Psychiatrists.
(1995). Curriculum for fellowship. Retrieved 27 April, 2005 from
Tooth, B. J., Kalyanasundaram, V., Glover, H., & Momedsadah,
S. C. (2003). Factors consumers identify as important to recovery
from schizophrenia. .Australasian Psychiatry, 11 (Supplement), 70-S77.
Trainor, J., Pomeroy, F., & Pape, B. (2004). A framework for
support. (3rd ed). Toronto: Canadian Mental Health Association.
US Department of Health and Human Services. (1999). A report of
the Surgeon General. Rookville MD: US Department of Health and
Human Services. Substance abuse and Mental Health Service
Administration. Centre for Mental Health Services, National
Institute of Mental Health.