Introducing: The Lived Expertise Project
Research to find out 'where should we be going, anyways?'
The Lived Expertise Project is a research project within Psychcrisis, with the goal of finding common and surprising patterns of expertise amongst those who can successfully, repeatedly handle their own mental health crises.
The aim of the project is to find, understand and present these patterns of expertise as a starting point for developing further research, training programs and policy recommendations. This post explains the project in more detail.
Key assumptions:
We go in the direction we’re aiming
A whole load of mental health system reform focuses on one of two things:
Looking at, critiquing, suggesting fixes to, and pushing for fixes to, individual problems in current crisis systems
Developing and suggesting a particular kind of therapeutic approach and trying to prove that it is superior to the current approach
I believe that choosing the first strategy risks getting bogged down in details while not addressing how different kinds of changes interact with each other. Furthermore, it ignores the forest for the trees–it doesn’t offer a compelling vision of where to go, only insistent motivation to take each individual step.
Some groups address this by providing an alternate vision of crisis care, but because they tend to involve somewhat dogmatic prescriptions about the use of medication, or hospitalization, or specific therapies, they tend to be presented in competition with other crisis strategies, rather than discovering the vision of success that all the strategies are aiming towards.
Malcolm Ocean has an essay where he points out that ‘awayness can’t aim’; essentially, that if your aim is to avoid something, you can successfully avoid it (perhaps with great effort), but you can’t get to a better alternative because you aren’t steering towards it. Many current mental health reform efforts are like that; they focus on reducing hospitalization, or reducing medication use, or increasing the use of some service without specifying the vision of the future we would be enacting instead. I think this is one reason mental health reform goes in circles.
This project is an attempt at starting to articulate a multi-perspectival definition of ‘how we could deal with crises well’ that ideally includes diverse personalities, resource levels, and preferences for treatment. If this project works well, it starts to paint a picture of what ideal crisis care could look like, regardless of how or where it takes place.
Conflicting visions of good crisis care still have some things in common
It’s common to find people who have found success in navigating mental health crises in opposing camps–pro-medication versus anti-medication, spiritual versus scientific materialist worldview. This makes any one kind of reform harder, because it is fighting against the other kinds of reform.
I suspect the people who are successful within all these approaches have some things in common, and I’d like to learn what they are. In particular, I suspect the relevant strategies that are universal aren’t at the level of abstraction everyone’s already looking at, but I’m not yet confident about this.
It is possible to improve at managing, preventing, and adapting to episodic crises
Some proponents of better mental health crisis care basically believe that the only improvements to be made must come from top-down authorities, or from people allocating societal resources, or with the capacity to e.g. redistribute wealth. It’s very true that discrimination, economic inequality, and barriers like language and immigration status both make managing mental health crises more difficult and are difficult to impossible for an individual or their local community to change independently.
Yet, these difficult-to-change societal-level components are not the only contributors to psychiatric crises, and there are other components that are quite a bit more flexible. Because this organization consists currently of 1 ⅕ people, and we’re in the process of building more capacity, I’m choosing to focus on the aspects of crisis management that are easier to change at the individual, family and small-group level, because I believe there is still a lot of improvement that can be made there.
The process:
Find ‘experts’
So far, I’ve been searching for people to contribute to this survey via connections and online channels, and then deciding whether to interview them once they complete the survey. As much as possible I’m searching for people with a variety of backgrounds and approaches to their mental health.
Assess their level of ‘expertise’
This is inherently tricky. Defining ‘flourishing’ and ‘resilience’ are the sorts of things professional philosophers get paid to do, and this is not inherently a philosophy project. For this project I’ve asked interviewees to assess themselves in terms of their capabilities along five aspects of crisis response:
Prediction (can they predict episodes?)
Control (can they manage, stabilize and end episodes?)
Hospitalization (how well have they been able to avoid hospitalization, even when an episode happens or is imminent?)
General stability (how well can they stabilize the major components in their life, even when they get destabilized?)
Sensitivity (how resilient are they to stressors? Is it easy for stressors to trigger an episode, or do they almost always manage to avoid it?)
This creates a basic ‘expertise score’ that I can use to understand how much weight to put on particular interviews; combined with more informal judgment this allows me to prioritize expertise in particular aspects and from particular interviewees.
Interview them in concrete detail about aspects of the process of preventing and managing a crisis
In this project I am using a series of techniques developed by the Cognitive Task Analysis Institute for uncovering expertise, particularly in business, military, or high-stakes situations. This set of techniques is designed to be rigorous but practical, rather than academic–it is generally aimed at uncovering findings that can immediately inform a training program, a user interface, or a decision-aid system. The main techniques I’ll be using are:
Task diagrams–asking the expert to break the task down into a limited set of tasks, to understand their cognitive demand
Knowledge audits–a structured set of questions honing in on difficult parts of the task to understand how they do it and think about it, particularly compared to novices
Critical Decision Method–walking through a particularly key incident to understand what they paid attention to, what choices they made, etc.
Importantly, CTA is designed for processes where the difficulty is primarily cognitive, i.e. understanding the situation, making decisions with limited information etc. Whether the method will be useful for situations that also involve emotional, somatic, and social fluency is unknown.
Synthesize findings, weighting by expertise; find similarities, contradictions and gaps
Once all the interviews are done, I’ll be looking over them all in detail, and their knowledge outputs, to find patterns, contradictions, and gaps. Understanding these is necessary to present them all to you, and prepare further research!
Hopeful future applications
Teaching other people to handle crises similarly
One obvious initial application of the findings on expertise is finding processes, skills and concepts that can be taught to others facing similar situations. While initially we will present information and concepts (rather than teaching skills), it seems possible to develop more rigorous and ambitious curricula in the future.
Making recommendations to crisis services
Collecting these approaches also gives us an opportunity to develop recommendations for crisis services that want to improve their services.
Potential further work:
Repeating a similar research process with clinicians and clinics with an extremely good track record, and with family members with a successful history of working with a family member having psychiatric crises.
Finding and interviewing a larger sample of ‘experts’ to glean more strategies, and check how widely applicable strategies we discovered are.
What are we doing now?
I’m looking for more interview participants! If you have experienced psychiatric crises and are now flourishing, I’d love to hear from you–fill out the survey here or email me at jess@psychcrisis.org. Your interview findings will be anonymized and aggregated with the learnings from others.
We will be presenting the learnings from the initial round of interviews (focused on people who have experienced episodes of mania, psychosis and suicidality) in a publicly accessible zoom event on August 4. Register for free here!
Join us to learn what we discovered from our experts, and particularly to inform your understanding if you experience similar mental health challenges yourself.