“Interview” features Q&As with both professionals and users of the mental health system on topics of special interest to parents and families. They are designed to provide a closer look at new research, trends, and people.
This interview is with Jim Probert, Ph.D., a licensed psychologist and coordinator at the University of Florida Counseling and Wellness Center and a Clinical Associate Professor in the school’s Department of Psychology. His paper, “Moving Toward a Human Rights Approach to Mental Health,” was recently published in Community Mental Health Journal, and is summarized in MIA’s Research News section.
Probert’s article describes the steps he has overseen to emphasize rights-based professional training for the center’s staff and to ensure genuine informed consent for student service users. It also details the programs offered at CWC, including intentional and experiential peer support, non-coercive approaches to suicide danger, and Wellness Recovery Action Plans, all of which center service users and their experience.
Q: Your paper discussed your efforts between 2010 and 2015 to educate your university’s counseling center staff on mental health care approaches advocated by the service-user movement and human rights communities and then to offer services using those approaches. These are led by people with lived experience as service users in the mental health system, correct?
A: Yes. Our Student Mental Health center and counseling center were consolidated in 2010, and it gave an opportunity to get these programs started. So where we got started was in the training of [American Psychological Association] interns.
The formal leadership roles are still by professionals, who have co-facilitated [peer support] groups and have been willing to risk publicly making their lived experience known. The work in those groups is very different than therapy, and it comes out of that lived experience. Informally, a number of students have also been part of the leadership of those groups; we’ve done two intentional peer support core trainings for students.
Q: What was your goal in publishing the article?
A: Maybe two goals. Our vision has always been to influence mental health services, certainly including other college counseling organizations, but even more broadly than that. Our hope all along was to do something that might lead to other people also trying to build more rights-based approaches, not necessarily copying ours, but just that sense of wanting to break the ice.
Q: So that others could potentially replicate it?
A: It may not be as much replicating exactly the same thing as being inspired to create their own localized, rights-based, trauma-informed [practice] that incorporates the voices of lived experience.
One of my reasons for seeking to have it published in a broader journal was not just limit it to being read by clinicians or people involved in college mental health.
Q: Obviously, any college counseling center fills a need. Why are the college years, which usually occur in late adolescence, so challenging for so many youths and young adults?
A: If I talk to people who’ve just arrived for the first time to attend the University of Florida and they’re experiencing distress, one of the things I point out is that in many ways, these are two of the biggest changes that people ever make in their life.
For most people, they’ve moved out of their home for the first time. I have had some people who may not have had a typical family home, or they may have had an incredibly traumatic family home, so that moving out may be a very different experience for them. But it’s a big change just leaving home, being on their own, which for most is their first time.
It’s also typically a pretty big leap for people in terms of difficulty of the classes. Most of the people who make it to UF are used to being stars in their own school, and to come here and everyone is that smart, everyone is that capable, those are two huge changes all at once.
If students have experienced complex trauma in their lives, this may be a time where that trauma emerges. And it’s a time where people are developing their world view, and their way of being in the world for the first time. It’s a lot of forces coming together at one time.
Q: I can imagine a lot of people probably think about dropping out because it is such a challenging time.
A: And for some of us, it becomes so overwhelming, and there aren’t resources to support us to know how to deal with that overwhelm.
Q: In light of that, what prompted you and your colleagues to develop the rights-based counseling programs at UFC that you describe in the article?
A: I did a lot of training at the Alachua County Crisis Center here in Alachua County. It’s a pretty special place. I was [also] a certification examiner for the American Association of Suicidology, and so had some perspective on that. About the time that I started working at the university at the beginning of 2000, there was a really terrible experience that happened at MIT with Elizabeth Shin, who died by suicide in a particularly horrifying way.
There was a lawsuit. While the lawsuit may have been aimed to try to increase care, what ended up happening in a lot of cases was that universities became scared of students struggling with suicide, and there were pressures to respond to them in mechanical ways.
I came out of this experience working in a rights-based way of building trusting relationships, listening deeply, and working to empower people, working to respect their rights. That sense to try not to take power away from people in crisis— because it can be very hard to get it back. Seeing crisis as a transition time where people might develop more resources, or they might lose resources.
So, I also happened to be a certification examiner when the American Association of Suicidology made a significant change in its certification manual. I was able to write a piece that went in the certification manual about doing work with people facing suicide danger consistent with what I learned to do. So I was also able to start advocating for doing that kind of work on college campuses.
So one of the threads that led to this work was: how are we training professionals? Because professionals often get trained that if someone scares you, put them in the hospital. I’ve seen documents [saying], “the safest place to assess lethality is in the safety of a hospital.” Those of us who’ve been involuntarily hospitalized would say that that was pretty opposite of our experience.
Another thread was that in my late teens and early 20s, I had what professionals understood as a psychotic break, and ended up hospitalized. And a lot of the response to my distress was very traumatic, limited my options for regaining my life. This impacted my becoming a psychologist because I found a really good therapist who helped me get my voice back and helped me be able to be complex inside and put things together and heal. I then hit roadblocks in grad school, discovering maybe how fully things were shifting [to the medical model of psychiatry].
But in 2006, I discovered the International Service User Movement that’s sometimes been called the Consumer/Survivor/Ex Patient Movement. Discovering that movement changed my life in a drastic way.
But also, they developed approaches and ways of supporting people that were really consistent with a lot of the things that I found on my own. When I had my crisis, I ended up falling out of school for five years. And I often thought about what would it have been like if I could have had supports like that, what might that have been like?
Then when I saw this movement, and saw people speaking from their own voices, I began talking to the psychiatrists at Student Mental Health one at a time. I wanted to talk about what I now understand as harm reduction. So I would tell one psychiatrist. I’d wait a month, because I think they may suddenly be seeing me differently, and things could get strange between us. And then I would tell another.
Q: It sounds like you’re trying to create the kind of counseling center you wish you had had when you were a college student?
A: Yes, but also with that context of discovering that there’s actually an international [service user] movement –to be able to look at: What are folks in the movement wanting? What are they needing … what, as a whole, do folks with this kind of lived experience say would have helped them? Or what did they create that has helped them, and what are the things that they’ve acknowledged are very traumatic, and those traumatic parts that typically they won’t tell professionals because it’s too dangerous?
Q: So what does a rights-based approach look like when implemented on a college campus? What does it mean for the students’ experience in coming in and asking for help?
A: There may be some things that are not that different. One is we have a big staff, but we’re also one of the larger universities in the country. There was a study by a consortium out of UT Austin about suicide danger in 2009, where they said just to deal with the people in suicide crisis, most universities would need a 75% increase in staff.
But for the people who are going to walk in the door, the first meeting is called the Brief Consultation and Referral or BCR. It’s intended to be a 30-minute meeting. Unless it’s a more extreme crisis, then we take longer and do the crisis work. Out of that meeting, they’re going to try to determine where do people go, what’s the next step. Our real goal is that if people walk in the door, we want to make sure they end up somewhere getting support.
One of the pieces is that if people need longer-term therapy, and they have resources, we try to get them into the community [to access services]. We have three case managers, also working from a largely trauma-informed perspective, often working with students with the most struggles.
We do have a predominantly shorter-term approach because there are so many students. We don’t often do longer-term individual support with people. You know, it’s a balance — there has been a commitment to trying to do this different thing. But it’s also a realization that our center is embedded in broader systems with more conventional understanding and approaches. So [staff] try to make sure that people really do end up getting the best possible support they’re seeking somewhere. As opposed to just falling through the cracks.
What I think may be different is that the team of folks that does this BCR session is also the team that does most of our on-call crisis response now. A good number of them have had training at that crisis center that I was talking about. And a lot of the philosophy for that care is consistent with the training that I’ve done. Involuntary interventions are our last resort and should only be done when everything else has failed. Really trying to not just have that kind of gut-level move toward hospitalization, but really working to support [the person]: Let’s try to build a relationship, let’s try to create some trust and safety. Which, often, in and of itself, can allow folks to survive through a crisis. And then talk about what your options are.
Q: What are some of those options? Can you briefly summarize the nontraditional programs you offer, for example, intentional peer support?
A: So, Intentional Peer Support (IPS) is a program that was originally created by Shery Mead as a part of the service-user movement. And I think the simplest way that I talk about in the paper, is to talk about the “tasks,” which might be thought of as values. Shery thought of them as things we should be doing when we’re interacting.
One is connection. If we’re connected, we can maybe be more likely to create some real change. If we’re connected, we’re more likely to talk about what you’re really experiencing, right? And so connection is a given, but also the intention and commitment to talk about this connection. That should be the first task.
The second task is worldview. This was one of my reasons for wanting to be sure that IPS was one of the original parts of our program. Worldview is really sacred in most forms of peer support from these movements, [the idea] that each of us gets to be in charge of our own world view.
When I was hospitalized [as a youth], I was having profound, sometimes beautiful, sometimes terrifying spiritual experiences. I was told that I had to understand them as a chemical imbalance in my brain, which took away from me a resource that then became ultimately a part of my healing my life. There might be a temptation, then, for someone with experience like mine, to kind of do a mirror image. All right, that diagnostic perspective was largely toxic to me, so you can’t have that. You’re going to look at things my way. And then I create a different kind of prison.
There’s this really consistent [thing] within IPS and more broadly, that it may be very helpful for us to look at how did we come to see things the way we did? It may be freeing to consider there may be other ways of looking at them. But each of us gets to be in charge of our own world view the whole way. And so if someone starts to say, “well, what you need to understand is…” we would be like, no. And then our group members will say, no, no, no, that we’re really coming out of our own lived experience, and this is what I’ve experienced is helpful, [but] you may or may not.
I think more therapies are getting down to worldview now. As we start seeing therapists being challenged to deal with racial disparities, being challenged to deal with sexual identity and gender identity more openly, I think world view is starting to make its way. When I went to grad school, you know, all the therapy was done in the world view of the professionals. I think that’s starting to be challenged more.
The next [IPS task], though, may be an even bigger challenge, which is mutuality. And I think a way of understanding that [is], I’m still a therapist. For many but not all of us, the role of becoming a mental health patient was profoundly disempowering. If you’re the professional, and I am the service user, if there have been scary things like suicide, or what professionals understand as psychosis or mania, it may be understood you’re going to make a lot of important decisions for me. Even if you don’t hospitalize me, you’re making that decision whether or not to do it.
And ethically, you [the therapist] shouldn’t talk about yourself, or your own needs, or your own experience, unless it’s strategically to help me. You have to be able to justify it. And the therapy is all about me. It’s not about you.
But it doesn’t translate without mutuality, that sense of it needs to work for all of us. In this group, we’re working on mutual ways of talking among people, so that if you say something from your heart, I hope someone will try to reflect it: “Sounds like from your world view, this is what you’re experiencing,” trying to understand what it means to you, hoping to get to that, “Yes, you get it.”
Often someone may say, “You know, when I went through something, that at least resonates, in my world view, here’s what helped me. May or may not help you. I’m not going to assume that it will, but let me talk about it.” You’re maybe not feeling as alone, and maybe someone will say something that you’ll find helpful.
Another thing might happen. Someone may respond, ‘What you’re saying is also opening up something I experienced” that they acknowledge carefully may not resonate at all with what the first person is experiencing, but that may open up healing for themselves and others in that moment. That’s another part of mutuality.
Q: I believe you have a Hearing Voices group at the center?
A: We are not a chartered Hearing Voices Network group. One, we take roll. Two, we take a kind of very general group notes.
But my goal is a couple things. One, I want to offer a place where you can go and talk about what you experienced freely with other people who can talk about what they experienced freely and share what’s helped without prescribing. So it’s called “Experiential Peer Support,” because I certainly don’t want “hearing voices” on anyone’s record. If you tell people you’ve had these experiences that many of us have had, your life may be irreparably changed. You get diagnosed with schizophrenia or bipolar.
Two, I want it to be more intentionally inclusive of other experiences, not just voices. So our definition includes experiencing voices, visions, plurality, presences, premonitions, and “extreme, unusual” poetic, spiritual, or otherwise alternative beliefs, perspectives, or experiences. So that just being in the group isn’t by itself necessarily something that professionals can pathologize.
Q: Let’s talk about suicide prevention. Your article mentions a radical reduction in non-consensual measures, except as a last resort, and a goal to promote recovery and healing along the way.
A: The most dangerous time in a service user’s life, as far as suicide danger, is generally right after being released from the hospital. And professionals have interpreted that as meaning, well, because they just lost all the great support that they had in the hospital. But if you talk to service users, much more often, people experience hospitalization as profoundly traumatizing.
And, I mentioned that in the article, people who’ve been hospitalized often learn to say “I’m fine. I’m not thinking of killing myself anymore.” They may be at more risk when they get out.
I’ve wrestled with this as a human being, not just as a professional, but I’m going to probably try to stop you if I think you’re going to kill yourself, which may mean law enforcement. Even if you’re not a person of color, people die in that interaction. I was cuffed, nearly hit in the head with a nightstick, put in the back of a car and then put in restraints. That’s not safety. That has an impact.
But even if you could get in [the hospital] without it, it’s a loss of rights. So I will tell people ahead of time, “If we were in that circumstance and you said, ‘I’m headed for the door, I’ll kill myself,’ I would beg you, ‘For God’s sake, please don’t leave. I’m not going to let you die, but I really don’t want to take your rights away. Can we try to stick with this and take more time to do what it takes to get to what’s going on?’”
Q: So you’re not working from one of the “if this, then that” scripts, it’s more like working with the individual to solve their situation.
A: Suicide danger comes with hopelessness and powerlessness, which are also kind of signature experiences at the heart of trauma, inescapable defeat. So that if we can find a way to help them choose to live through [the experience that’s brought them to this point], we look at this as an opportunity for healing.
The odds are we’re not going to hospitalize people. I won’t rule that out. But it’s just I have to trust that if we were able to have this kind of dialogue and stick with it as long as it takes, then usually we can find some way to help people make some plan to get through.
Q: The last thing I want to ask about in terms of the services is the Wellness Recovery Action Plan, or WRAP.
A: WRAP was developed by Mary Ellen Copeland, again with a group of other folks with lived experience. And it’s a more systematic way of kind of working through trial and error to figure out what resources work best for each individual. It’s within the same kind of context of peer support and within the same context of not prescribing.
It’s much more a framework of brainstorming what wellness tools would you like to use on a daily basis, not what does your therapist, psychiatrist, parent, significant other, [or] Oprah [say]. What are the things that you already do, even little things? What might be helpful if you did more consistently? Then we look at patterns. Right? It’s not “I’m going to tell you what should be in this plan.” We’re brainstorming them as a group. Everyone’s saying, “here’s what I find helpful,” without saying “Here’s what you should do.”
But then we look at patterns of stressors. What are external events that if they happen and I don’t do anything, my life may go downhill? Then, what wellness tools might I want to experiment with trying when those things happen? For some people, it may be “go talk to my psychiatrist and talk about changing meds.” But we work to use language that’s inclusive of those people and folks who say “No, no, God, I don’t want to do that at all.”
Q: You try and meet people where they are.
A: Where they are, and also what resources are working for them.
Q: What do “rights-based non-compromised services” mean in practical terms when it comes to training staff?
A: Well, [the term] non-compromised was something that the UN Special Rapporteur used to talk about peer-support alternatives. Peer support gets co-opted. A lot of times conventional systems will hire people with lived experience to try to support people to comply with mainstream approaches.
We talked about suicide danger. At most places, eventually, if you talk about enough danger, people may shift out of that neutral mode to more taking over. Right? So what Shery Mead talked about is being transparent about at what point would you shift. And our goal, and almost always, is not to take the steering wheel out of the person’s hands. It may involve people saying, “Can we find a way to share risk that feels adequate and safe to both of us and that system?”
So for me, [there’s] the need to go back to a rights-based approach. The human right to avoid traumatizing interventions, the human right to informed consent, the human right to make sense of my own experience within my own worldview; these are basic human rights.
Q: What would you like to see happen in terms of school counseling in other universities and colleges in terms of taking this approach?
A: I would love to see counseling centers try to make some effort to support people with lived experience being able to have a voice, a real voice, not a token voice. I guarantee you there are people with lived experience [already] working in these counseling centers. How many of them experience enough support to be able to be out and open about it? And then how many of those have a genuine voice in the process of really being able to try to move toward making changes? If that were there, that would be necessary to have the kind of peer support we’re talking about.
One [thing] would be really starting to have conversations about rights-based approaches to involuntary interventions—are we really working to decrease involuntary interventions whenever possible? And the other one is human rights related to the diversity of ways people process and experience life: voices, visions, plurality, presences, premonitions, and others. Many counseling centers have worked to recognize diversity around sexual orientation, gender identity, racial identity. But [we need] to have these issues on the table with it.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.