'It Was Great to Break Down the Walls between Patient and Provider': Liminality in a Co-Produced Advisory Course for Psychiatry Residents
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| Title: | 'It Was Great to Break Down the Walls between Patient and Provider': Liminality in a Co-Produced Advisory Course for Psychiatry Residents |
|---|---|
| Language: | English |
| Authors: | Agrawal, Sacha, Kalocsai, Csilla (ORCID |
| Source: | Advances in Health Sciences Education. May 2021 26(2):385-403. |
| Availability: | Springer. Available from: Springer Nature. One New York Plaza, Suite 4600, New York, NY 10004. Tel: 800-777-4643; Tel: 212-460-1500; Fax: 212-460-1700; e-mail: customerservice@springernature.com; Web site: https://link.springer.com/ |
| Peer Reviewed: | Y |
| Page Count: | 19 |
| Publication Date: | 2021 |
| Document Type: | Journal Articles Reports - Research |
| Education Level: | Higher Education Postsecondary Education |
| Descriptors: | Psychiatry, Physician Patient Relationship, Teaching Methods, Health Services, Mental Health, Mental Disorders, Graduate Medical Education, Student Attitudes, Transformative Learning, Foreign Countries, Graduate Students, Medical Students, Humanistic Education, Resistance (Psychology), Learning Experience, Change |
| Geographic Terms: | Canada (Toronto) |
| DOI: | 10.1007/s10459-020-09991-w |
| ISSN: | 1382-4996 |
| Abstract: | Although rhetoric abounds about the importance of patient-, person- and relationship-centered approaches to health care, little is known about how to address the problem of dehumanization through medical and health professions education. One promising but under-theorized strategy is to co-produce education in collaboration with health service users. To this end, we co-produced a longitudinal course in psychiatry that paired people with lived experience of mental health challenges as advisors to fourth-year psychiatry residents at the University of Toronto. The goal of this study was to examine this novel, relationship-based course in order to understand co-produced health professions education more broadly. Using qualitative interviews with residents and advisors after the first iteration of the course, we explored how participants made meaning of the course and of what learning, if any, occurred, for whom and how. We found that the anthropological theory of liminality allowed us to understand participants' complex experiences and illuminated how this type of pedagogy may work to achieve its effects. Liminality also helped us understand why some participants resisted the course, and how we could more carefully think about co-produced, humanistic education and transformative learning. |
| Abstractor: | As Provided |
| Entry Date: | 2021 |
| Accession Number: | EJ1292795 |
| Database: | ERIC |
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| FullText | Links: – Type: pdflink Url: https://content.ebscohost.com/cds/retrieve?content=AQICAHj0k_4E0hTGH8RJwT4gCJyBsGNe_WN95AvKlDbXJGqwxwEJALKPFSIfmV4AVl6aeguwAAAA4jCB3wYJKoZIhvcNAQcGoIHRMIHOAgEAMIHIBgkqhkiG9w0BBwEwHgYJYIZIAWUDBAEuMBEEDNk0dh0ENPW0CEaepAIBEICBmlpwrUVecps-wTq8B7ZcUS6dJaOJVPsB8FSfaZ_n5gDTOInuYB7XUMLZprL_aRqKxYNP_SacE0HX5YJeCzb491W4ojFUxF7dFq7IPKdEpRp4Hiy2zYk9GhH2gvDpAHAtrZodYIexa0vOX0DyXAoCEs3vjc73uguYU3xTeEUX7pV74pU7MPW7aorXo7ViRwZ5_O37Ymh6-SsF94g= Text: Availability: 1 Value: <anid>AN0149789496;oak01may.21;2021Apr15.05:08;v2.2.500</anid> <title id="AN0149789496-1">"It was great to break down the walls between patient and provider": liminality in a co-produced advisory course for psychiatry residents </title> <p>Although rhetoric abounds about the importance of patient-, person- and relationship-centered approaches to health care, little is known about how to address the problem of dehumanization through medical and health professions education. One promising but under-theorized strategy is to co-produce education in collaboration with health service users. To this end, we co-produced a longitudinal course in psychiatry that paired people with lived experience of mental health challenges as advisors to fourth-year psychiatry residents at the University of Toronto. The goal of this study was to examine this novel, relationship-based course in order to understand co-produced health professions education more broadly. Using qualitative interviews with residents and advisors after the first iteration of the course, we explored how participants made meaning of the course and of what learning, if any, occurred, for whom and how. We found that the anthropological theory of liminality allowed us to understand participants' complex experiences and illuminated how this type of pedagogy may work to achieve its effects. Liminality also helped us understand why some participants resisted the course, and how we could more carefully think about co-produced, humanistic education and transformative learning.</p> <p>Keywords: Co-production; Patient engagement; Medical education; Health professions education; Mental health and addiction; Liminality; Qualitative study</p> <p>Sacha Agrawal and Csilla Kalocsai are co-first authors.</p> <hd id="AN0149789496-2">Introduction</hd> <p>It has been argued that the culture and structure of modern Western medicine can lead physicians to adopt a dehumanizing view of their patients (Foucault [<reflink idref="bib17" id="ref1">17</reflink>]/1973; Gaufberg and Hodges [<reflink idref="bib20" id="ref2">20</reflink>]; Haque and Waytz [<reflink idref="bib25" id="ref3">25</reflink>]; Kumagai [<reflink idref="bib35" id="ref4">35</reflink>]). Psychiatrists, with their particular powers to diagnose, discredit and detain, are particularly vulnerable to adopting a "gaze" that reduces the other person's capacity and humanity (Foucault [<reflink idref="bib17" id="ref5">17</reflink>]/1973; Roberts [<reflink idref="bib51" id="ref6">51</reflink>]). Other physicians and health care professionals are also increasingly cited for similar forms of reductionism (Gaufberg and Hodges [<reflink idref="bib20" id="ref7">20</reflink>]). Notwithstanding recent attempts to advance patient-, person- and relationship-centered approaches to health care (Institute of Medicine [<reflink idref="bib29" id="ref8">29</reflink>]; McWhinney [<reflink idref="bib44" id="ref9">44</reflink>]; Soklaridis et al. [<reflink idref="bib57" id="ref10">57</reflink>]), a number of factors contribute to dehumanization. First, biomedical frameworks for understanding health and disease risk obscure the broader social, economic, political and cultural realities of people's lived experiences of illness (Costa et al. [<reflink idref="bib12" id="ref11">12</reflink>]). Second, the emphasis of health care systems on acuity fails to acknowledge complex processes of recovery that unfold over time (Jenkins and Carpenter-Song [<reflink idref="bib30" id="ref12">30</reflink>]; Leamy et al. [<reflink idref="bib38" id="ref13">38</reflink>]). Third, the structure of the health professions learning environment tends to relegate service users—patients—to the bottom of an implied hierarchy following service providers and learners, reinforcing an oppressive view and way of working with them (Bleakley and Bligh [<reflink idref="bib6" id="ref14">6</reflink>]).</p> <p>Given the magnitude of this problem of dehumanization, educators suggest intervening in the process of professionalization to enable future service providers to develop a deep commitment to humanism, caring, equity and justice in their practice (Bleakley and Bligh [<reflink idref="bib6" id="ref15">6</reflink>]; Kumagai [<reflink idref="bib35" id="ref16">35</reflink>]; Weinberg et al. [<reflink idref="bib65" id="ref17">65</reflink>]). One promising means to this end is to directly involve service users in health professions training. While learning from service users has been a strong component of health professions education for over a century, engaging them in the design, delivery and evaluation of curricula is a relatively new phenomenon (Rowland et al. [<reflink idref="bib52" id="ref18">52</reflink>]). In this approach, which is sometimes referred to as <emph>co-production</emph>, clinical educators and service users collaborate to design and deliver health professions education together.</p> <p>Research has shown that co-produced health professions education can have positive effects on both learners and service users (Agrawal et al. [<reflink idref="bib2" id="ref19">2</reflink>]; Byrne et al. [<reflink idref="bib10" id="ref20">10</reflink>]; Fokuo et al. [<reflink idref="bib16" id="ref21">16</reflink>]; Gaufberg and Hodges [<reflink idref="bib20" id="ref22">20</reflink>]; Happell et al. [<reflink idref="bib24" id="ref23">24</reflink>]; Henriksen and Ringsted [<reflink idref="bib26" id="ref24">26</reflink>]; Jha et al. [<reflink idref="bib31" id="ref25">31</reflink>]; Kumagai [<reflink idref="bib35" id="ref26">35</reflink>]; Kumagai et al. [<reflink idref="bib36" id="ref27">36</reflink>]; Kumagai and Naidu [<reflink idref="bib37" id="ref28">37</reflink>]; Luckner et al. [<reflink idref="bib40" id="ref29">40</reflink>]; Towle et al. [<reflink idref="bib58" id="ref30">58</reflink>]). Some studies have found increases in learners' understanding of illness, sensitivity to service user perspectives and lived experiences, and appreciation of the active role that service users play in their clinical journey (Byrne et al. [<reflink idref="bib10" id="ref31">10</reflink>]; Henriksen and Ringsted [<reflink idref="bib26" id="ref32">26</reflink>]; Kumagai [<reflink idref="bib35" id="ref33">35</reflink>]; Kumagai et al. [<reflink idref="bib36" id="ref34">36</reflink>]). Co-produced educational programs have also led to increased respect, empathy and compassion for service users among learners (Agrawal et al. [<reflink idref="bib2" id="ref35">2</reflink>], Kumagai [<reflink idref="bib35" id="ref36">35</reflink>]; Kumagai et al. [<reflink idref="bib36" id="ref37">36</reflink>]; Kumagai and Naidu [<reflink idref="bib37" id="ref38">37</reflink>]). These programs have motivated students in the health care professions to challenge socially entrenched forms of stigma and discrimination against people with disabilities (Byrne et al. [<reflink idref="bib10" id="ref39">10</reflink>]; Fokuo et al. [<reflink idref="bib16" id="ref40">16</reflink>]), and to recognize how power and privilege affect health care and society (Byrne et al. [<reflink idref="bib10" id="ref41">10</reflink>]; Gaufberg and Hodges [<reflink idref="bib20" id="ref42">20</reflink>]; Happell et al. [<reflink idref="bib24" id="ref43">24</reflink>]; Kumagai [<reflink idref="bib35" id="ref44">35</reflink>]). More specific to mental health professional training, a review of courses found that learners developed a better understanding of the lived experience of mental distress and service use, and how mental health services could be improved (Happell et al. [<reflink idref="bib24" id="ref45">24</reflink>]). Some service users have reported benefits such as empowerment, personal learning and making a valued contribution to health professions education and the future of health care (Jha et al. [<reflink idref="bib31" id="ref46">31</reflink>]; Luckner et al. [<reflink idref="bib40" id="ref47">40</reflink>]; Towle et al. [<reflink idref="bib58" id="ref48">58</reflink>]). Other service users have highlighted the challenging psychological impact and ethical dilemmas pertaining to confidentiality, co-optation, tokenism and exploitation in co-produced education (Jha et al. [<reflink idref="bib31" id="ref49">31</reflink>]; Luckner et al. [<reflink idref="bib40" id="ref50">40</reflink>]; Towle et al. [<reflink idref="bib58" id="ref51">58</reflink>]).</p> <p>The conceptual roots of co-produced education lie in participatory research methodologies and critical pedagogies, and their emancipatory ideal of disrupting historically constituted power relations between service providers and service users by shifting decision-making power (Madden and Speed [<reflink idref="bib41" id="ref52">41</reflink>]; Rowland et al. [<reflink idref="bib52" id="ref53">52</reflink>]). The approach also draws on democratic notions of individual rights, civic responsibility and social justice, recognizing people with lived experience of illness as "experts by experience" and as assets to health care systems (Social Care Institute for Excellence [<reflink idref="bib55" id="ref54">55</reflink>]; Madden and Speed [<reflink idref="bib41" id="ref55">41</reflink>]). Co-produced education has followed UK-based and Australian policy mandates for public and patient involvement in health care since the 1990 s (Greenhalgh et al. [<reflink idref="bib21" id="ref56">21</reflink>]; Kirkegaard and Andersen [<reflink idref="bib34" id="ref57">34</reflink>]; Madden and Speed [<reflink idref="bib41" id="ref58">41</reflink>]). It also intersects with the North American organizational discourse on engaging patients to improve quality in health care (Bombard et al. [<reflink idref="bib7" id="ref59">7</reflink>]; Institute of Medicine [<reflink idref="bib29" id="ref60">29</reflink>]).</p> <p>The co-production of health professions education differs from other types of service user involvement, including less critical and sometimes exploitative uses of first-person accounts of illness in health care (Costa et al. [<reflink idref="bib12" id="ref61">12</reflink>]), in emphasizing the redistribution of power among health professional educators, learners and service user educators (Bleakley and Bligh [<reflink idref="bib6" id="ref62">6</reflink>]; Soklaridis et al. [<reflink idref="bib56" id="ref63">56</reflink>]). Co-production extends beyond bedside and classroom teaching to curriculum development, student selection, feedback and assessment (Jha et al. [<reflink idref="bib31" id="ref64">31</reflink>]). This enables service users to contribute expertise beyond personal illness experiences by bringing forward their knowledge of peer communities, marginalization, systems advocacy and sociopolitical change (Costa et al. [<reflink idref="bib12" id="ref65">12</reflink>]; Happell et al. [<reflink idref="bib24" id="ref66">24</reflink>]). Proponents of the idea of involving service users in education argue that co-production has the potential to <emph>humanize</emph> the relationship between service providers and service users, and to support an understanding of the health professions as centering on human, social and moral activities (Kumagai [<reflink idref="bib35" id="ref67">35</reflink>]; Kumagai and Naidu [<reflink idref="bib37" id="ref68">37</reflink>]; Ng et al. [<reflink idref="bib48" id="ref69">48</reflink>]; Simpson et al. [<reflink idref="bib54" id="ref70">54</reflink>]). In other words, co-produced education aspires to transformative learning through which learners recognize their assumptions, biases, and experiences in the social world, prompting them to challenge and change their views, actions and the systems they inhabit (Freire [<reflink idref="bib19" id="ref71">19</reflink>]; Ng et al. [<reflink idref="bib47" id="ref72">47</reflink>]; Van Schalkwyk et al. [<reflink idref="bib62" id="ref73">62</reflink>]).</p> <p>While there are many case reports of co-produced health professions education in the literature, the results of a number of reviews show that this pedagogy remains under-theorized (Bleakley and Bligh [<reflink idref="bib6" id="ref74">6</reflink>]; Happell et al. [<reflink idref="bib24" id="ref75">24</reflink>]; Jha et al. [<reflink idref="bib31" id="ref76">31</reflink>]; Madden and Speed [<reflink idref="bib41" id="ref77">41</reflink>]; Towle et al. [<reflink idref="bib58" id="ref78">58</reflink>]). The mechanisms and contextual features that are important in shaping learning remain poorly understood (Haji et al. [<reflink idref="bib22" id="ref79">22</reflink>]; Parker [<reflink idref="bib50" id="ref80">50</reflink>]; Wong et al. [<reflink idref="bib66" id="ref81">66</reflink>]). Moreover, co-producing health professions education means much more than simply adding service users to existing processes or fine-tuning curriculum design and delivery. Truly partnering with service users implies a challenge to health professionals' claims to dominant professional expertise (Vinson [<reflink idref="bib64" id="ref82">64</reflink>]). Put another way, making space for service user knowledge about health, disease and disability challenges the epistemic authority that the health professions rely on to maintain their privileged status in society (Soklaridis et al. [<reflink idref="bib56" id="ref83">56</reflink>]). Given its potential to disrupt the status quo, we must expect that this pedagogy will create complex and sometimes unintended effects. Our objective in writing this paper was to closely examine a novel, relationship-based example of co-produced education in psychiatry with the aim of addressing this gap in theory.</p> <hd id="AN0149789496-3">The course: from surviving to advising</hd> <p>We examined a co-produced course that paired mental health service users as advisors with senior psychiatry residents at the University of Toronto over a 6-month period. The course, "From Surviving to Advising," was created in 2014, based in part on the experiences that one of the lead authors (SA), a psychiatrist and educator, had in a longitudinal advisory relationship with a service user educator during a fellowship in public psychiatry at Yale University the previous year (Agrawal and Edwards [<reflink idref="bib3" id="ref84">3</reflink>]). That serendipitous experience proved transformative in bringing into focus fundamental gaps in clinical training, including the many ways in which prejudice and discrimination operate against people with mental health challenges among mental health professionals and within services and systems. That relationship prompted changes not only in SA, but also in his service user advisor's thinking and practice, creating the opportunity to build trust and respect between them and, ultimately, reorienting them to their work with other service users and providers.</p> <p>Motivated by this experience, SA set about co-producing a course that had the potential to catalyze similar transformative changes in others. To do this, he partnered with PC who brought forward her own lived experience using psychiatric services and many years working closely as an advocate and educator with service users and other stakeholders (including qualified and trainee health professionals). The course engaged as "advisors" to psychiatry residents people who were in recovery from mental health and/or substance use challenges of at least five years duration—people who we refer to here and in our course as <emph>service users</emph>, the term commonly used in the co-production literature in the UK, intentionally avoiding the particular historical and political associations that other terms more often used locally, such as <emph>patient</emph> and <emph>consumer-survivor</emph>, evoke for many of our service user partners. We recruited 18 people, using electronic postings and word of mouth through a number of service user community organizations. The goal was to give residents an opportunity to explore the complex processes and meanings of recovery. The course was introduced as a mandatory component for psychiatry residents in their postgraduate fourth year. It aligned closely with the year's "chronic care" rotation, a 6-month period when residents work on inpatient and outpatient teams that serve people living with severe and persistent mental health challenges, including schizophrenia, trauma, severe mood- and substance-use disorders.</p> <p>The advisory pairs met monthly over this 6-month period at places and times of mutual agreement. The course directors (SA and PC) co-produced the learning objectives and gave example topics to be discussed, but there was no formal plan for the meetings. They also held monthly supervision meetings for the advisors. The development and structure of the course are described in a previous publication (Agrawal et al. [<reflink idref="bib2" id="ref85">2</reflink>]). The current study investigated this course at its inception.</p> <p>Our initial research question was: How did participants experience this course, including the advisory relationship? Over the subsequent years of directing the course and exploring the literature on co-produced education an additional question came into focus: How did the participants experience what learning occurred in this course, by whom and how? Here we present a qualitative study of the initial cohort of participants that attempts to answer these two, albeit overlapping, questions. We use the theory of <emph>liminality</emph> (Turner [<reflink idref="bib59" id="ref86">59</reflink>], [<reflink idref="bib60" id="ref87">60</reflink>], [<reflink idref="bib61" id="ref88">61</reflink>]) as an organizational and interpretive tool, showing that the course created liminality for its participants, through which we can see how this pedagogy may work to achieve its transformative potential.</p> <hd id="AN0149789496-4">The theory of liminality</hd> <p>We used the theory of liminality, as constructed by British anthropologist Victor Turner, to organize and interpret our findings. Working during the second half of the 20th century, Turner identified five important properties of liminality and initially used them to explain social processes at work in African initiation rituals (Turner [<reflink idref="bib59" id="ref89">59</reflink>]).</p> <p>The first property is a "betwixt and between" phase or space that is set apart from everyday life and its usual demands (Turner [<reflink idref="bib59" id="ref90">59</reflink>], [<reflink idref="bib60" id="ref91">60</reflink>], [<reflink idref="bib61" id="ref92">61</reflink>]). It is a gap within ordered, customary worlds, a condition of ambiguity and paradox, "whence novel configurations of ideas and relations may arise" (Turner [<reflink idref="bib59" id="ref93">59</reflink>], p. 97). The second property describes shifts in power relations between the actors in this betwixt and between phase/space. The "neophyte"—Turner's word for the person undergoing initiation—is stripped of status, property, office and rank, and experiences profound humiliation and humility (Turner [<reflink idref="bib60" id="ref94">60</reflink>], [<reflink idref="bib61" id="ref95">61</reflink>]). In liminality the neophyte becomes powerless, while the other individual assumes the position of power of an "elder" embodying the authority of tradition (Turner [<reflink idref="bib59" id="ref96">59</reflink>]). The third property of liminality is the communication of <emph>sacra</emph>—knowledge about the most significant values and norms of the given culture—from elder to neophyte (Turner [<reflink idref="bib59" id="ref97">59</reflink>], [<reflink idref="bib60" id="ref98">60</reflink>], [<reflink idref="bib61" id="ref99">61</reflink>]). The fourth property is contemplation or reflexivity, through which neophytes call into question the normative order of social life. The fifth and final property of liminality is transformation. In sum, Turner theorized the betwixt and between phase or space, with its neophytes and elders and their shifting power relations, which creates the conditions for the communication of sacra that generate deep reflections on self, other, and the social world, thus bringing about the possibility of transformation. Liminality is thus a process of <emph>becoming</emph> that can catalyze change in seeing and being (Turner [<reflink idref="bib59" id="ref100">59</reflink>]).</p> <p>Just as Turner applied the theory of liminality liberally in his later work (Turner [<reflink idref="bib61" id="ref101">61</reflink>]), and others have applied it to clinical relationships in mental health services (Kidd et al. [<reflink idref="bib32" id="ref102">32</reflink>]), scholars of education have started to use liminality to explain important aspects of learning in contemporary societies (Cook-Sather [<reflink idref="bib11" id="ref103">11</reflink>]; Dressman [<reflink idref="bib13" id="ref104">13</reflink>]). In health professions education, mostly in social work (e.g., Adorno et al. [<reflink idref="bib1" id="ref105">1</reflink>]; Hurlock et al. [<reflink idref="bib28" id="ref106">28</reflink>]; Morgan [<reflink idref="bib45" id="ref107">45</reflink>]) and nursing (e.g., Billay et al. [<reflink idref="bib5" id="ref108">5</reflink>]; Evans and Kevern [<reflink idref="bib15" id="ref109">15</reflink>]; McDermid et al. [<reflink idref="bib42" id="ref110">42</reflink>]; McKendry et al. [<reflink idref="bib43" id="ref111">43</reflink>]), and occasionally in medical education (Ellaway et al. [<reflink idref="bib14" id="ref112">14</reflink>]; Kumagai and Naidu [<reflink idref="bib37" id="ref113">37</reflink>]; Russell [<reflink idref="bib53" id="ref114">53</reflink>]), liminality has been used to examine questions of transitional periods in education and the formation of professional identity. These studies highlight some of the properties of liminality (the liminal phase/space and the neophyte's transformation) and suggest that health professions education as such is transformational in the sense that it supports the development of professional identities. Kumagai and Naidu ([<reflink idref="bib37" id="ref115">37</reflink>]), however, bring the theory of liminality to a particular type of learning within medical education, what they call a dialogic and reflective space. We follow Kumagai and Naidu in employing liminality to help us better understand a particular pedagogy—in our case, co-produced education—and to do so we return to Turner's original, more comprehensive formulation of the theory (Turner [<reflink idref="bib59" id="ref116">59</reflink>], [<reflink idref="bib60" id="ref117">60</reflink>], [<reflink idref="bib61" id="ref118">61</reflink>]).</p> <hd id="AN0149789496-5">Methods</hd> <p></p> <hd id="AN0149789496-6">Study design and setting</hd> <p>Drawing on some of the methodological tenets of interpretive phenomenology (Neubauer et al. [<reflink idref="bib46" id="ref119">46</reflink>]), we focused our qualitative inquiry on how residents and advisors understood the course and made sense of their experiences within it, including how the advisory relationship unfolded, and what learning, if any, occurred, for whom and how. Interested in participants' experiences and the way they interpreted those experiences and constructed meaning from them, we approached our study from a constructivist-interpretivist paradigm (Bunniss and Kelly [<reflink idref="bib9" id="ref120">9</reflink>]; Lincoln et al. [<reflink idref="bib39" id="ref121">39</reflink>]). Our interest in co-production as a means of addressing the shifting power relations in the advisory relationship and the inequitable access to knowledge and power between service users/educators and psychiatrists/learners also led us to include critical theory to inform our study design (Bunniss and Kelly [<reflink idref="bib9" id="ref122">9</reflink>]; Foucault [<reflink idref="bib17" id="ref123">17</reflink>]/1973; Lincoln et al. [<reflink idref="bib39" id="ref124">39</reflink>]; Paradis et al. [<reflink idref="bib49" id="ref125">49</reflink>]).</p> <p>The study included participants from the first full iteration of the course, which took place between January and June 2014 within the large, urban psychiatry residency program at the University of Toronto.</p> <hd id="AN0149789496-7">Participants</hd> <p>All 18 residents enrolled in the course were in their fourth year of training in psychiatry, and many (but not all) worked at the Centre of Addiction and Mental Health, the largest mental health and addictions institution in Canada. None had experienced a longitudinal co-produced educational experience earlier in their residency. Given the small pool of potential participants, we invited all 18 residents and 18 service user advisors to participate in the study. We offered a small honorarium to them to acknowledge their time spent in the interview.</p> <hd id="AN0149789496-8">Data collection and analysis</hd> <p>We conducted in-person semi-structured interviews with advisors and residents after the end of the course, between mid-June and mid-July 2014. The interview guide included questions about the advisory relationship and power, trust and disclosure, challenges encountered in the course, differences from other service user–provider relationships, and learning. A research coordinator conducted the interviews, which were audio-recorded and transcribed verbatim. NVivo 10 was used for data storage and management.</p> <p>The thematic analysis was inductive and theory-informing, and occurred in two cycles (Braun and Clarke [<reflink idref="bib8" id="ref126">8</reflink>]; Kiger and Varpio [<reflink idref="bib33" id="ref127">33</reflink>]; Varpio et al. [<reflink idref="bib63" id="ref128">63</reflink>]). The research coordinator conducted the first cycle of coding and analysis in the fall of 2014 and the winter of 2015. In discussion with the research team, she identified major themes and refined the coding schemes using the constant comparison method. An education scientist and cultural anthropologist (CK), one of the lead authors, later joined the research team, immersed herself in the data and led the second cycle of thematic analysis in the fall of 2017 and winter of 2018. She revisited and further refined the initial coding and found that the theory of liminality resonated with the findings and could guide further interpretation and analysis. By following a subjectivist theory-informing inductive data analysis, CK and the research team made the decision at this later stage that liminality and its associated properties would serve as a theory to inform the organization and the deeper interpretation of our data (Varpio et al. [<reflink idref="bib63" id="ref129">63</reflink>]).</p> <p>Given that SA and PC both developed and led the course, it was important to include other members in our research team who were not directly involved in the course to avoid unintentionally exaggerating the positive its impact. Having a research team consisting of members with diverse professional and academic backgrounds and who were at arm's length from the course helped to build trustworthiness and reflexivity into the research.</p> <hd id="AN0149789496-9">Ethics and funding</hd> <p>Participants' decisions to do the interviews were kept confidential by the research coordinator, and all transcripts were anonymized. The Research Ethics Board of the Centre for Addiction and Mental Health provided approval. The study was funded with a research grant from Associated Medical Services Inc.</p> <hd id="AN0149789496-10">Results</hd> <p>Eleven residents and thirteen service-user advisors agreed to participate in the study and were interviewed. In this section, we explore how each property of liminality was discussed by residents and advisors, presenting their multiple perspectives and experiences to highlight diversity and complexity in the data. We acknowledge that the act of organizing the data in this way is an interpretive act, and that other ways of organizing and representing the data were and are possible.</p> <hd id="AN0149789496-11">Betwixt and between phase/space</hd> <p>Pairs of residents and service user advisors met once a month at a mutually convenient time and public place <emph>between and betwixt</emph> the usual times and spaces of clinical, learning and personal encounters. Residents and advisors recognized their meetings as "removed from the clinical context," and spoke about this property of the course in various ways, emphasizing the ambiguity that this inter-structural situation created.</p> <p>Both residents and advisors referred to the first meeting as a "blind date" and associated it with feelings of discomfort: "a little bit awkward in the beginning to get introduced." Some "gave markers [such as what they wore] to distinguish" themselves and to facilitate recognition when they first met, but others had a hard time identifying one another: "I was sitting there for a while, and I wasn't sure whether to approach someone." Members of both groups acknowledged that they were "a bit nervous" at the beginning and pointed to the uncertainty that defines first interactions: "You're not always sure how it's going to go" and "things are likely going to be different than you anticipate."</p> <p>Many residents spoke about the difficulty they had fitting the meetings into their schedules, when they were "already being pulled in six thousand different directions." Residents spoke about the between and betwixt nature of the meetings by highlighting the absence of protected time for them, for example, expressing disappointment that "I could only spend a very short amount of time with [the advisor]", or needing to find a way of making and managing the time for it:He's lovely to speak with, and at the same time, things are very busy. So the first couple times we really went over. And afterwards I was more mindful of it, keeping in mind the time.Some pairs decided to meet outside of usual working hours, since "moving it inside of hours would probably have been more of a pain for me, because it would have been an hour I'm not on the unit doing things."</p> <p>Some residents described "the change of pace" that such encounters represented relative to their other work:On top of that you need to shift mindsets from whatever else we were doing, whether it's clinical work or anything like that. And suddenly having to discuss something that seemed required a pretty significant cognitive shift as well.Other residents discussed the "weirdness" of meeting in a café or going for a walk, when they usually did not leave the hospital during work hours.</p> <hd id="AN0149789496-12">Changing relationship and power</hd> <p>Participants often observed changes in the nature of their relationships and shifts in the established power differences between these psychiatrists-to-be, who appeared to have entered the inter-structural phase as neophytes, and service users, who acted as the elders or advisors.</p> <p>Many residents were "intrigued" by the idea of meeting people with lived experience "differently than just in a regular patient interaction." They recognized that "it was great to break down the artificial walls or boundaries that we erect between the so-called patient and provider or client and provider." This change in relationship was often characterized by a change in what was permissible to speak about: "You can ask questions that you wouldn't ask your patient." While clinical questions dominated residents' clinical encounters, here they could also ask other things about the lived experience such as what it is like to live on a disability pension or ask "questions that might sound weird or silly."</p> <p>Residents reported how they built a relationship based on trust with their advisors. The advisory encounters, for example, gave residents the possibility to "be a little bit more candid and a little bit more personable than what we perhaps normally feel comfortable with." They recognized the mutual sharing that emerged: "It's different than just a regular patient or client interaction that you would have, since [here] you do have that opportunity to talk about yourself and really for them to know your experience, as well as for them to explain theirs to you." Some residents also highlighted how "we're all people, we're all learning all the time, and we all have things to learn from each other," and "the more sincere, open, transparent and genuine you are, people for the most part will give you the benefit of the doubt and will engage with you at some level."</p> <p>Similarly, advisors commented on establishing trust with their residents. The informal, "conversational setting" and the "safe and non-judgmental environment" were important "to open up right from the get-go and ... because it created a level of trust that I could share personal experiences which I probably wouldn't have had the courage otherwise." Some advisors also appreciated how "open and receptive" their resident partners were. As one advisor observed about her resident: "She had the most interest of anyone I've ever seen in psychiatry about expanding her universe."</p> <p>Many residents and advisors also commented on the shifts in power between them, but how they understood these shifts varied. Some discussed equalization of power, including this advisor who described having dinner with her resident partner at a large grocery store:</p> <p>"So we wandered around for about 20 minutes just picking out food initially and chatting about food. And again, it was a different perspective to just be an advisor and advisee; it was much more of an equalizer into discussing things and just having a little bit more comfort level. I can see we're comfortable together, we can take on these things that are a little more difficult because we're discussing lamb shanks and duchess potatoes [laughs] and we sat there and ate and chatted for another hour and a half after that."</p> <p>Other residents discussed how advisors assumed a position of power in the dyad. Some residents understood "the premise that this person is coming along as an advisor and I have a lot to learn from them." They also reflected on the power of their advisors by expressing a fear of evaluation or confrontation:There was always that power dynamic, or that strangeness to it, that fear of evaluation.... The fear was more like that he might set me straight if need be. Educate me isn't the right word, but share with me his view on how things should or could be done, but really should be done, that's how I felt.Some residents also pointed to how they resigned their power, taking their "badge off" when meeting their advisors and going beyond the biomedical approach:To this date, I don't know what her diagnosis is because I never asked; I didn't really think that that was important for me to know.Shifting power relations was challenging for some advisors and residents. One advisor articulated this insecurity:I was scared at times, but I was also excited.... Do I have enough stuff to say? Is this person going to learn from me?Advisors' self-doubt sometimes linked to not having as much formal education as their advisees: "Always in the back of my mind was she has a lot more education, and because it was more official, it was about somebody's education." Their self-doubt also intertwined with their different class position, which was a barrier to building a relationship and shifting power. For example, an advisor reported that her resident partner was a third-generation doctor, "so she was quite wealthy, and for me, personally, that was a stumbling block to interpersonal communications, since I am below the poverty line."</p> <p>Conventional power relations were also re-inscribed when advisors accommodated residents as they scheduled their meetings. One advisor put it as follows:Well, a doctor [is] a busy person, so I went out of my way to accommodate her." Residents commented on their advisors' flexibility about meeting times, even when they also worked: "He was more than happy to come across the city to where I worked to meet me.</p> <hd id="AN0149789496-13">Communication of sacra</hd> <p>Both residents and advisors commented on the <emph>sacra</emph>—the knowledge, experience and wisdom—that was communicated by advisors and received by residents during these encounters. Many advisors used the list of topics provided by the course directors as a starting point for the conversations, "so we knew the intention and made sure we were on the same page." However, a few advisors stressed that they "didn't have a set of learning objectives." Advisors also asked their advisees what they were "interested in talking about and learning," aiming to meet the residents where they were at.</p> <p>Advisors highlighted that their job was to teach their advisees about recovery and show that people recover, even if psychiatrists "always see people when they're sick, when they're in crisis." As one advisor put it:I'd want her to be one of those who always believed.... She may not see it in her patients. She may not see down the road when they do get well. But to have that respect for people that they are people and that they can recover and gain their lives back just like I did.Advisors found it important to instill hope in residents and encouraged them to "be mindful of their language" because "the worst thing I heard [from a service provider] was 'Don't plan on working again.'" Advisors encouraged residents not to "limit people's expectations of how they can get well, or what they can do, so they can lead the lives they want to lead." They advised residents "to sit and hold hope, and say 'Whatever your better looks like, I know you can leave this space.'".</p> <p>Advisors used storytelling to educate residents. Some shared their own story: "I was just very real with her—this is what my experience has been, this is what's worked, this is what hasn't, and these are the ways I think it should be." Others "injected a little of my experience wherever I could," and also discussed "other things I've heard from other people." In other words, "I would talk about the larger picture of mental health and also talk about my lived experience." Advisors recognized that "stories are very powerful in the peer world," and conveyed that stories sometimes had "nothing to do with me, but it's all about whether it benefits the individual and whether they can get something out of it that will make them in some way richer, better, more enlightened or educated."</p> <p>Some residents and service user educators reflected on how "the conversation would just flow," and they could "talk about anything." One resident described this experience:At the first time, we were getting to know each other, what she does, what I do. I guess I shared some of our struggles and then later on, it evolved into... I had some questions about things. For example, my advisor happens to work in peer support so I just had questions about how people accessed peer support, what the different resources are around the city. We also talked about a recovery model, so things like that just came up as we went along.In this way, residents sought answers to questions such as "How was it to be in inpatient units?," "What was it like to show up for outpatient appointments?," "What made some psychiatrists more helpful than others?" and what did they "wish more health care providers would do?" Some residents were also interested in seeking their advisors' advice on "one particular case that caused a little bit of a challenge."</p> <p>For some pairs, the unstructured, "natural, relaxed conversation" came easily, but for others it didn't, leading to frustrations about the limited direction and minimal guidance. One advisor commented:I guess my frustration was more with wanting a bit of direction because recovery is such a big topic, because working with consumers is such a big topic that you could go anywhere with it. And I wanted to know that I was fulfilling what the program was hoping me to fulfill in terms of engaging the resident.Participants realized that the course's open-endedness could also lead to "things being left out that I really wanted her to know, and I thought a psychiatrist should really know; for example, what it's like to live on ODSP [Ontario Disability Support Program]."</p> <p>Many residents saw the knowledge that service users shared as unique, and accepted some of the criticisms of psychiatry that they brought to the conversation, for example, around the "history of ECT without consent" or people being "over-pathologized." Some even reflected on sharing some of these concerns with their advisors: "We both had similar visions and agreements, but coming from different angles." Other residents, however, challenged the significance of such knowledge sharing:It was nice to talk about their lives, what they do outside of being in the sick role, what their goals are, and how they conceptualize their illness, how they conceptualize their recovery, but we also do that sometimes with our patients.Instead, these residents emphasized the value of their professional knowledge and re-inscribed their expert role:I admit that a lot of treatments, a lot of medicines have awful side effects, but the end result is that hopefully they get better, but our patients lack insights, and that's part of their illness. But I feel like we as psychiatrists are punished for the nature of their illness, and we need to apologize for it, we need to make up for it, and we need to de-medicalize our profession: it's taboo to call them 'patients'; they must be 'clients,' and at the end of the day, I really disagree with that. They're our patients, we want to get them better, and we went through school and years of training.</p> <hd id="AN0149789496-14">Reflections on one other, the course and the learning environment</hd> <p>Residents and advisors contemplated some of the biases and "pre-judgments" that they brought into the encounter, and residents also reflected on the assumptions built into the course and questioned the power that governs their education.</p> <p>Many residents acknowledged their biases about service users, finding that their advisors were "less critical and less militant than anticipated." They expected more criticism and negativity about psychiatry, "rather than a more balanced view, which she definitely had." For advisors, it was also "eye-opening" to meet psychiatrists and learn how open and receptive they can be: "It gave me hope that things are changing."</p> <p>Residents also challenged some of the assumptions built into the course. For example, they pointed out that "it was assumed that we haven't reflected on these issues already or thought about them, or that we didn't have some lived experience or family members with lived experience." Even though some residents who identified having friends and family with severe mental health challenges recognized that the course offered something different, they were still concerned about this in-built assumption.</p> <p>While many residents wanted to learn about recovery, many did not agree that "anybody can recover." As one resident remarked about his advisor:Given his diagnosis, I wasn't surprised that he was able to make this kind of recovery because with that specific diagnosis, if you are treated, you can make that kind of recovery.Residents found it challenging to apply the recovery-oriented approach in their clinic:I have some patients that are really acutely unwell and delusional, and you're trying to be patient-centered and ask 'What do you want to do in the future?', but it's sometimes really hard.Many residents questioned the "mandated" nature of the course "because we're so used to not sharing anything with our clients, and now being forced to do that." Although some reflected on how patients might feel similarly when they come "to see us as mental health professionals," many residents pointed to the difference between themselves—"we have to do it, we have no choice"—and the advisors who volunteered to teach in the course and who were compensated for their participation. One resident noted:I have this guy in front of me who really wants to share his experience. He's obviously poured his heart and soul into this, and I have to find a way to fit this into my schedule. It just seemed there was a bit of a clash.For some, the course became "one of the stressors," bringing about resentment and negativity: "yet another thing was placed on us that we had to do." As residents recited their numerous obligations, they admitted: "I think had it been in a different circumstance, maybe I would have been a bit more open and receptive to the whole idea." Under these circumstances, however, it seemed to actually undermine one of the goals of the course: "There was a part of me that felt with this project less empathetic toward people with severe and persistent mental illness." Such critique also came from the experience of having "an anonymous or powerful authority figure" bringing about the course and making them take it: "It was trenchantly forced on us at a period in our development where we're just too taxed to care." Or in other words, "I found it patronizing that someone would mandate by his power that I do something like this."</p> <hd id="AN0149789496-15">Learning and transformation</hd> <p>Many residents found it difficult to identify what they learned in the course. However, learning and transformation were sometimes revealed indirectly:Did I learn anything specifically? No. But did I learn more about myself just because of what I was listening to? Yeah. Could I actually tell you specifically? Probably not.Another resident put it this way:I don't know if you could say 'learned' or it was a good reminder, but that was the more positive element of what I gained from the experience. The reason I say 'mostly no' is that I actually feel in some ways it really felt like coffee dates with somebody that you could have interesting conversation with. I don't know if I'd actually say I learned anything per se; they were interesting discussions that were very thought-provoking, but I wouldn't say that I actually learned something.However, some residents did identify how the conversations with their advisors directly influenced the clinical care they provide, as this resident explained:I found it very helpful to talk about specific cases or experiences. That was not only helpful for me, but it was helpful hopefully for my patients.Similarly, another resident indicated how the discussion she had with her advisor about stigma and re-entering the workforce would benefit her patients:[It] made me think about my patients that have been unemployed for ten years, and what I can do to help them volunteer or take some personal interest courses at college, like continuing education, not necessarily to get a degree or a diploma, but just to feel like they're learning something and being engaged.In contrast, other residents questioned what the course could teach them:Was it to teach us humility? Or were you supposed to come out of it thinking how awful psychiatrists were? I wasn't quite sure what we were supposed to learn from it.A few residents also challenged the impact of the course due to the late stage in their education at which it was delivered:At this point, at the end of PGY4 year, I can't think of anything that I would have seen or experienced that would have changed the way I perceive the mental health system. I think most of us have a structure of how we do things that's ingrained, and for something like this to change it, it would have to be profound.Interestingly, it was the advisors who more often were able to pinpoint learning among their residents and who recalled particular moments they thought were transformative. For example, one advisor took her resident partner to a performance of stand-up comedy by people with lived experience and described how it helped the resident develop a new understanding of recovery:She said, 'I almost felt if they knew I was a doctor they wouldn't want me there.' And I said it's actually the opposite—they'd want you front and centre, because it's only by telling you what's happening that you can avoid it. So I think it shook her up a little bit, but she genuinely liked it. She said, 'You know, seeing people get up there and talk about these experiences takes a lot of courage.' She said, 'I can see it's a very different recovery model from what we look at, but I think it's really effective.'Another advisor took his resident on a walk and verbalized the voices that were going through his head:We had a meeting after that a few weeks later and he told me his feedback—that it was a profound moment for him upon reflection because he realized I offered him an opportunity to see something that perhaps he would not have been able to witness otherwise.Advisors also revealed how the course changed them by helping them become better mental health advocates:I think one of the goals of the program for us as advisors is to empower us to be advocates. Prior to the program I've been involved in committees related to mental health and this was just another stepping stone in that direction to continue to advocate. And then we started just constantly teaching each other. This was really eye-opening for me in being an advocate because I think ultimately the mission of this program, the goal on my end, was achieved, it made me a stronger advocate.</p> <hd id="AN0149789496-16">Discussion</hd> <p>The current study offers an in-depth analysis of participants' experiences of a relationship-based co-produced course for fourth-year psychiatry residents, revealing how participants' experience of this course and its impact can be understood through Turner's five properties of liminality (Turner [<reflink idref="bib59" id="ref130">59</reflink>], [<reflink idref="bib60" id="ref131">60</reflink>], [<reflink idref="bib61" id="ref132">61</reflink>]). Psychiatry residents and service user advisors experienced their meetings as <emph>betwixt and between</emph> the frames that normally define clinical, learning and personal encounters, and described associated feelings of uncertainty, discomfort and even fear. As the advisory relationships unfolded and residents and advisors found their place as <emph>neophytes</emph> and <emph>elders</emph>, shifts emerged in the historically established power differences between psychiatrists-to-be and service users. These disruptions were associated with both groups of participants making themselves vulnerable to give or receive the <emph>sacra</emph> of service user knowledge, experience and wisdom. Advisors shared personal aspects of their lived experience of recovery, emphasizing, for example, the importance of holding hope, while residents in turn revealed important things about themselves, including gaps in their knowledge and struggles in training. Participants showed evidence of <emph>liminal reflexivity</emph>, reflecting on the self and other, on the assumptions and biases that they brought into the course and that were embedded in it, especially calling into question the <emph>normative order of life</emph>—that is, the power relations that govern the medical learning environment itself. We also found hints of <emph>transformation</emph>—that by engaging with one another, participants experienced changes in their ways of thinking and, occasionally, doing.</p> <p>The course thus appears to have set into motion a process by which the properties of liminality intersected and built on one another, which we can interpret as important mechanisms at work that may disrupt dominant notions embedded in traditional clinical learning environments and ultimately bringing about the possibility of a transformative process. These results extend the work of Kumagai and Naidu ([<reflink idref="bib37" id="ref133">37</reflink>]), who identify liminality in a narrower sense, an awareness of the transitory nature of education, as one condition necessary for humanistic learning. Our data suggest that a more comprehensive Turnerian understanding of liminality can offer a plausible model for relationship-based co-produced education, highlighting how its properties may work as mechanisms through which co-produced and humanistic pedagogies may achieve its effects. These results also extend the existing literature that describes the use of co-production in mental health professions education without theorizing or identifying putative mechanisms for learning (Happell et al. [<reflink idref="bib24" id="ref134">24</reflink>]; Jha et al. [<reflink idref="bib31" id="ref135">31</reflink>]; Madden and Speed [<reflink idref="bib41" id="ref136">41</reflink>]; Towle et al. [<reflink idref="bib58" id="ref137">58</reflink>]).</p> <p>One striking finding of this study is that while the course was experienced and negotiated in multiple ways, there were strong examples of resistance to it through each of its liminal properties (Foucault [<reflink idref="bib18" id="ref138">18</reflink>]). In part this resistance may simply have stemmed from the novelty of the course and the inevitable clumsiness of any first iteration of a new course. Another potential challenge for learners is its constructivist and transformative pedagogy, which stands in sharp contrast to a much more structured learning tradition in medical school and residency grounded in behaviorism and cognitivism, with clear learning objectives, formal instruction, problem solving, and outcome-based education (Baker et al. [<reflink idref="bib4" id="ref139">4</reflink>]).</p> <p>Yet we also propose that the difficulties described by participants reveal the inherently disruptive nature of co-produced education. For example, at one level, the frustration residents expressed about having to find time to meet with their advisors between their personal and clinical times can be understood as the result of the residents having numerous demands on their time and little control over their schedules. However, at a deeper level, we also hear an implicit de-prioritizing and devaluing of the course, or, put another way, a reluctance to enter into liminality with their advisor. When the advisors' limited education or lower class status made it difficult for them to assume the role of elder, participants struggled to shift away from their typical ways of relating to one another and the power relations that are embedded in them. Similarly, when residents held onto their traditional understanding of the doctor–patient relationship and the dominance of biomedical knowledge, or when residents had doubts about applying what they were learning from their advisors about recovery to their own patients, we observed resistance to the communication of <emph>sacra</emph>, liminal reflexivity and, ultimately, transformation. It is noteworthy that while most residents gave neutral or positive overall ratings to the course (Agrawal et al. [<reflink idref="bib2" id="ref140">2</reflink>]), resistance was widespread among residents and was observed even among some advisors, which suggests that discomfort and uncertainty were inherent in the transformative process, rather than being located within a few residents (Van Schalkwyk et al. [<reflink idref="bib62" id="ref141">62</reflink>]).</p> <p>The theory of liminality offers one explanation for why some participants seemed to struggle with the course. By repositioning service users as elders with epistemic authority and effectively stripping power from the residents as neophytes, it is possible that some residents were left feeling so vulnerable that they were unable to effectively engage in the learning process. Furthermore, for some residents, this challenging predicament appeared to have resonated strongly with an intense feeling of powerlessness within the hierarchy of the medical learning environment. In this sense, this study revealed the complex ways in which power operates (Foucault [<reflink idref="bib18" id="ref142">18</reflink>]), not only between residents and advisors, as it is usually discussed in the literature (Agrawal et al. [<reflink idref="bib2" id="ref143">2</reflink>]; Byrne et al. [<reflink idref="bib10" id="ref144">10</reflink>]; Gaufberg and Hodges [<reflink idref="bib20" id="ref145">20</reflink>]; Happell et al. [<reflink idref="bib24" id="ref146">24</reflink>]; Kumagai [<reflink idref="bib35" id="ref147">35</reflink>]), but also between both groups and the larger health care and educational structures. These findings about the dynamics of power relations and how they can challenge learner engagement echo the results of a recent review of the related pedagogical concept of critical consciousness: "HPE [health professions education] learners, despite being a privileged group either before or once they have entered HPE, may be at a disadvantaged and disempowered position in their educational context" (Halman et al. [<reflink idref="bib23" id="ref148">23</reflink>], p. 17). The authors go on to observe, as we did, that the "taxing nature of the pursuit [learning in critical pedagogy] may paradoxically trigger emotionally distancing reactions and become a barrier to engagement rather than a strength" (Halman et al. [<reflink idref="bib23" id="ref149">23</reflink>], p. 18).</p> <p>Whereas the theory of liminality tends to center on the transformative experiences of the neophytes and emphasizes the unidirectional communication of <emph>sacra</emph> from elder to neophytes, we found evidence that the advisors also learned and grew through the course. Some learning occurred through relationships with other advisors. We saw this, for example, when advisors commented on learning from one another, which made them better advocates. Mostly, however, we observed advisors learning through and with the residents, such as when they commented that it was "eye-opening" how receptive they found their resident partner to be—a discovery that led to a stronger sense of hope about the mental health care system. This mutuality of learning is an important feature of co-produced education and sets it apart from other, more exploitative ways of involving service users in health professions education. As in feminist-engaged pedagogy and transformative learning, both advisors and residents grew because they made themselves vulnerable by taking risks, sharing personal experiences and linking those experiences to broader discussions about institutions and systems (hooks [<reflink idref="bib27" id="ref150">27</reflink>]).</p> <p>With this course, we employed co-production as a means to address the problem of dehumanization in mental health services by catalyzing transformation of learners and, ultimately, the services and systems in which they work. In this sense, liminality is a well-suited theoretical model for relationship-based co-produced education because it too promises transformation (Turner [<reflink idref="bib59" id="ref151">59</reflink>], [<reflink idref="bib60" id="ref152">60</reflink>], [<reflink idref="bib61" id="ref153">61</reflink>]). Many study participants were able to bring their whole selves into the course to explore their thoughts and feelings, generate questions and discover the pervasive but hidden assumptions and biases that are built into the systems in which they work and live. However, as critical theorist Freire ([<reflink idref="bib19" id="ref154">19</reflink>]), one of the fathers of transformative learning, emphasized, these changes in thinking are not the end itself, but need to be joined by changes in action, or, as bell hooks, a feminist scholar of transformative learning, wrote, changes the ways in which we act in our daily lives (hooks [<reflink idref="bib27" id="ref155">27</reflink>]), so we can "become capable of transforming the world" (Freire [<reflink idref="bib19" id="ref156">19</reflink>]). We observed some tentative signs of transformed practices in participants who, for example, spoke about approaching their work differently as psychiatrists or as advocates in their communities after the course. However, we must acknowledge that there was relatively little direct evidence in our data of transformative changes in action. To make sense of this limited evidence, we return to Turner's theory of liminality, according to which transformation is a <emph>process of becoming</emph>, implying that changes of this nature could not be expected to have occurred in such a short timeframe (Turner [<reflink idref="bib59" id="ref157">59</reflink>]).</p> <p>While our study provided an opportunity both to develop a rich understanding of participants' experiences of the course and to theorize about how the course may work, it had two significant limitations that constrained our ability to understand its full impact. First, we interviewed participants within days to weeks of completing the course. While this short timeframe had the advantage of enabling fuller and more accurate recall, it precluded the possibility of capturing insights or consequences that occurred well after the course was completed. Second, our reliance on semi-structured interview data limited our ability to understand the course beyond the way that participants understood it. Developing a more robust understanding of the impact of co-produced education, particularly its transformative potential, will require studies that extend beyond the immediate timeframe and that use methods such as ethnographic observation and/or narrative interviewing that can capture changes participants may themselves be unable or unwilling to identify directly. Future research must continue to investigate the possibilities of co-produced programs while considering other factors in the learning and clinical environments that facilitate or hinder their transformative impact.</p> <hd id="AN0149789496-17">Conclusions</hd> <p>This study explored how senior psychiatry residents and their service user advisors made meaning of their mutual interactions in a longitudinal, relationship-based co-produced course. We have shown that the experience of participants can be understood as residents and their advisors entering into liminality as neophytes and elders, respectively. We have also shown that liminality's five properties—betwixt and between phase/space, shifting power relations, communication of <emph>sacra</emph>, reflexivity and transformation—reflect how they make sense of their learning journey, and may offer a plausible model for the mechanisms by which residents learn from and through their advisors about recovery from major mental health challenges, and by which both groups of participants learn about the self, the other and the context in which they all exist. The theory of liminality also helps us understand transformation as a process of becoming, an important effect of co-produced education, prompting us as educators and researchers to think more carefully about the methodologies and theories we bring to bear on co-produced, humanistic education and transformative learning. And ultimately, liminality can also guide health professions educators who are partnering with service users both in co-producing similar courses and making sense of service user educators' and learners' experiences in/of the process. In our view, a single course cannot be expected to generate, by itself, transformational change in the culture and structure of mental health professional education and a remedy to the problem of de-humanization in medicine or psychiatry, but overlapping sets of educational interventions and systems-level changes are needed.</p> <hd id="AN0149789496-18">Acknowledgements</hd> <p>We dedicate this article to our friend, colleague and co-author Pat Capponi, who passed away as we were preparing revisions for resubmission. We gratefully acknowledge the generosity of residents and advisors who participated in this study. We also acknowledge the contributions of Jenna Lopez for conducting the interviews and the first cycle of coding, Arno Kumagai and Rachel Cooper for providing thoughtful feedback on an earlier draft of this manuscript and Hema Zbogar for copyediting the manuscript. We also thank the Associated Medical Services Inc. for supporting this project.</p> <hd id="AN0149789496-19">Publisher's Note</hd> <p>Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.</p> <ref id="AN0149789496-20"> <title> References </title> <blist> <bibl id="bib1" idref="ref105" type="bt">1</bibl> <bibtext> Adorno G, Cronley C, Smith KS. A different kind of animal: Liminal experiences of social work doctoral students. Innovations in Education and Teaching International. 2015; 52: 632-641</bibtext> </blist> <blist> <bibl id="bib2" idref="ref19" type="bt">2</bibl> <bibtext> Agrawal S, Capponi P, Lopez J, Kidd S, Ringsted C, Wiljer D, Soklaridis S. From surviving to advising: A novel course pairing mental health and addictions service users as advisors to senior psychiatry residents. Academic Psychiatry. 2016; 40: 475-480</bibtext> </blist> <blist> <bibl id="bib3" idref="ref84" type="bt">3</bibl> <bibtext> Agrawal S, Edwards M. Upside down: The consumer as advisor to a psychiatrist. Psychiatric Services. 2013; 64: 301-302</bibtext> </blist> <blist> <bibl id="bib4" idref="ref139" type="bt">4</bibl> <bibtext> Baker L, Wright S, Mylopoulos M, Kulasegaram K, Ng S. Aligning and applying the paradigms and practices of education. Academic Medicine. 2019; 94: 1060</bibtext> </blist> <blist> <bibl id="bib5" idref="ref108" type="bt">5</bibl> <bibtext> Billay D, Myrick F, Yonge O. Preceptorship and the nurse practitioner student: Navigating the liminal space. Journal of Nursing Education. 2015; 54: 430-437</bibtext> </blist> <blist> <bibl id="bib6" idref="ref14" type="bt">6</bibl> <bibtext> Bleakley A, Bligh J. Students learning from patients: Let's get real in medical education. Advances in Health Sciences Education. 2008; 13: 89-107</bibtext> </blist> <blist> <bibl id="bib7" idref="ref59" type="bt">7</bibl> <bibtext> Bombard Y, Baker GR, Orlando E, Fancott C, Bhatia P, Casalino S. Engaging patients to improve quality of care: A systematic review. Implementation Science. 2018; 13: 98. 10.1186/s13012-018-0784</bibtext> </blist> <blist> <bibl id="bib8" idref="ref126" type="bt">8</bibl> <bibtext> Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology. 2006; 3: 77-101</bibtext> </blist> <blist> <bibl id="bib9" idref="ref120" type="bt">9</bibl> <bibtext> Bunnis S, Kelly DR. Research paradigms in medical education. Medical Education. 2010; 44: 358-366</bibtext> </blist> <blist> <bibtext> Byrne L, Happell B, Welch T, Moxham LJ. "Things you can't learn from books": Teaching recovery from a lived experience perspective. International Journal of Mental Health Nursing. 2013; 22: 195-204</bibtext> </blist> <blist> <bibtext> Cook-Sather A. Newly and between: Revising liminality in learning to teach. Anthropology and Education Quarterly. 2006; 37: 110-127</bibtext> </blist> <blist> <bibtext> Costa L, Voronka J, Landry D, Reid J, McFarlane B, Reville D, Church K. Recovering our stories: A small act of resistance. Studies in Social Justice. 2012; 6: 85-101</bibtext> </blist> <blist> <bibtext> Dressman M. Using social theory in education research: A practical guide. 2008: London; Routledge</bibtext> </blist> <blist> <bibtext> Ellaway RH, Cooper G, Al-Idrissi T, Dube T, Graves L. Discourses of student orientation to medical education programs. Medical Education Online. 2014. 10.3402/meo.v19.23714</bibtext> </blist> <blist> <bibtext> Evans C, Kevern P. Liminality in preregistration mental health nurse education: A review of the literature. Nurse Education in Practice. 2015; 15: 1-6</bibtext> </blist> <blist> <bibtext> Fokuo JK, Goldrick V, Rossetti J, Wahlstrom C, Kocurek C, Larson J, Corrigan P. Decreasing the stigma of mental illness through a student-nurse mentoring program: A qualitative study. Community Mental Health Journal. 2017; 53: 257-265</bibtext> </blist> <blist> <bibtext> Foucault, M. (1973). The birth of the clinic: An archeology of medical perception. (Alan Sheridan Smith, Trans.). New York: Pantheon Books. (Original work published 1963).</bibtext> </blist> <blist> <bibtext> Foucault M. The Subject and Power. Critical Inquiry. 1982; 8; 4: 777-795</bibtext> </blist> <blist> <bibtext> Freire P. Pedagogy of the oppressed. 1970: New York; Continuum</bibtext> </blist> <blist> <bibtext> Gaufberg E, Hodges B. Humanism, compassion and the call to caring. Medical Education. 2016; 50: 264-266</bibtext> </blist> <blist> <bibtext> Greenhalgh T, Jackson C, Shaw S, Janamian T. Achieving research impact through co-creation in community-based health services: Literature review and case study. Milbank Quarterly. 2016; 94: 392-429</bibtext> </blist> <blist> <bibtext> Haji F, Morin M, Parker K. Rethinking programme evaluation in health professions education: Beyond "did it work?. Medical Education. 2013; 47: 342-351</bibtext> </blist> <blist> <bibtext> Halman M, Baker L, Ng S. Using critical consciousness to inform health professions education: A literature review. Perspectives on Medical Education. 2017; 6: 12-20</bibtext> </blist> <blist> <bibtext> Happell B, Byrne L, McAllister M, Lampshire D, Roper C, Gaskin CJ. Consumer involvement in the tertiary-level of education of mental health professionals: A systematic review. International Journal of Mental Health Nursing. 2014; 23: 3-16</bibtext> </blist> <blist> <bibtext> Haque OS, Waytz A. Dehumanization in medicine: Causes, solutions, and functions. Perspectives on Psychological Science. 2012; 7: 176-186</bibtext> </blist> <blist> <bibtext> Henriksen A, Ringsted C. Learning from patients: Students' perceptions of patient-instructors. Medical Education. 2011; 45: 913-919</bibtext> </blist> <blist> <bibtext> Hooks B. Teaching to transgress: Education as the practice of freedom. 1994: New York; Routledge</bibtext> </blist> <blist> <bibtext> Hurlock D, Barlow C, Phelan A, Myrick F, Sawa R, Rogers G. Falls the shadow and the light: Liminality and natality in social work field education. Teaching in Higher Education. 2008; 13: 291-301</bibtext> </blist> <blist> <bibtext> Institute of Medicine. Crossing the quality chasm: A new health system for the 21st century. 2001: Washington, DC; National Academies Press</bibtext> </blist> <blist> <bibtext> Jenkins JH, Carpenter-Song EA. Stigma against recovery: Strategies for living in the aftermath of psychosis. Medical Anthropology Quarterly. 2008; 22: 381-409</bibtext> </blist> <blist> <bibtext> Jha V, Quinton ND, Bekkers HL, Roberts TE. Strategies and interventions for the involvement of real patients in medical education: A systematic review. Medical Education. 2009; 43: 10-20</bibtext> </blist> <blist> <bibtext> Kidd SA, Miller R, Boyd GM, Cardena I. Relationships between humor, subversion, and genuine connection among persons with severe mental illness. Qualitative Health Research. 2009; 19: 1421-1430</bibtext> </blist> <blist> <bibtext> Kiger ME, Varpio L. Thematic analysis of qualitative data: AMEE Guide No. 131. Medical Teacher. 2020. 10.1080/0142159X.2020.1755030</bibtext> </blist> <blist> <bibtext> Kirkegaard S, Andersen D. Co-production in community mental health services: Blurred boundaries or a game of pretend?. Sociology of Health &amp; Illness. 2018; 40: 828-842</bibtext> </blist> <blist> <bibtext> Kumagai AK. A conceptual framework for the use of illness narratives in medical education. Academic Medicine. 2008; 83: 653-658</bibtext> </blist> <blist> <bibtext> Kumagai AK, Murphy EA, Ross PT. Diabetes stories: Use of patient narratives of diabetes to teach patient-centered care. Advances in Health Sciences Education. 2009; 14: 315-326</bibtext> </blist> <blist> <bibtext> Kumagai AK, Naidu T. Reflection, dialogue, and the possibilities of space. Academic Medicine. 2015; 90: 283-288</bibtext> </blist> <blist> <bibtext> Leamy M, Bird V, Le Boutillier C, Williams J, Slide M. Conceptual framework for personal recovery in mental health: Systematic review and narrative synthesis. British Journal of Psychiatry. 2011; 199: 445-452</bibtext> </blist> <blist> <bibtext> Lincoln YS, Lynham SA, Guba EGDenzin NK, Lincoln YS. Paradigmatic controversies, contradictions, and emerging confluences, revisited. Sage handbook of qualitative research. 2011: Thousand Oaks; Sage: 97-129</bibtext> </blist> <blist> <bibtext> Luckner H, Doucet S, Wells S. Patients as educators: The challenges and benefits of sharing experiences with students. Medical Education. 2012; 46: 992-1000</bibtext> </blist> <blist> <bibtext> Madden M, Speed E. Beware zombies and unicorns: Toward critical patient and public involvement in health research in a neoliberal context. Frontiers in Sociology. 2017; 2: 7. 10.3389/fsoc.2017.00007</bibtext> </blist> <blist> <bibtext> McDermid F, Mannix J, Jackson D, Daly J, Peters K. Factors influencing progress through the liminal spaces: A model to assist transition into nurse academic life. Nurse Education Today. 2018; 61: 269-272</bibtext> </blist> <blist> <bibtext> McKendry S, Wright M, Stevenson K. Why here and why stay? Students' voices on the retention strategies of a widening participation university. Nurse Education Today. 2014; 34: 872-877</bibtext> </blist> <blist> <bibtext> McWhinney IRSheldon M, Brooke J, Rector A. Patient-centred and doctor-centred models of clinical decision-making. Decision-making in general practice. 1985: London; MacMillan Press: 31-46</bibtext> </blist> <blist> <bibtext> Morgan H. The social model of disability as a threshold concept: Troublesome knowledge and liminal spaces in social work education. Social Work Education. 2012; 31: 215-226</bibtext> </blist> <blist> <bibtext> Neubauer BE, Witkop CT, Varpio L. How phenomenology can help us learn from the experiences of others. Perspectives in Medical Education. 2019; 8: 90-97</bibtext> </blist> <blist> <bibtext> Ng, S, Baker, L, &amp; Friesen, F. (2018). Teaching for transformation. An online supplement. Retrieved November 8, 2019, from https://<ulink href="http://www.teachingfortransformation.com">www.teachingfortransformation.com</ulink>.</bibtext> </blist> <blist> <bibtext> Ng SL, Kinsella EA, Friesen F, Hodges B. Reclaiming a theoretical orientation to reflection in medical education research: A critical narrative review. Medical Education. 2015; 49: 461-475</bibtext> </blist> <blist> <bibtext> Paradis E, Nimmon L, Wondimagegn D, Whitehead C. Critical theory: Broadening our thinking to explore the structural factors at play in health professions education. Academic Medicine. 2020. 10.1097/ACM.0000000000003108</bibtext> </blist> <blist> <bibtext> Parker K. A better hammer in a better toolbox: Considerations for the future of programme evaluation. Medical Education. 2013; 47: 434-442</bibtext> </blist> <blist> <bibtext> Roberts M. The production of the psychiatric subject: Power, knowledge and Michel Foucault. Nursing Philosophy. 2005; 6: 33-42</bibtext> </blist> <blist> <bibtext> Rowland P, Anderson M, Kumagai AK, McMillan S, Sandhu VK, Langlois S. Patient involvement in health professionals' education: A meta-narrative review. Advances in Health Sciences Education. 2018; 24: 595-617</bibtext> </blist> <blist> <bibtext> Russell PC. The White coat ceremony: Turning trust into entitlement. Teaching and Learning in Medicine. 2002; 14: 56-59</bibtext> </blist> <blist> <bibtext> Simpson J, Ng S, Kangasjarvi E, Kalocsai C, Hindle A, Kumagai A. Humanistic education in surgery: A patient as teacher program for surgical clerkship. Canadian Journal of Surgery. 2020; 63; 3: E257-E260</bibtext> </blist> <blist> <bibtext> Social Care Institute for Excellence. (2013). Co-production in social care: What it is and how to do it. Retrieved November 8, 2019, from <ulink href="http://www.scie.org.uk/publications/guides/guide51/what-is-coproduction/principles-of-coproduction.asp">http://www.scie.org.uk/publications/guides/guide51/what-is-coproduction/principles-of-coproduction.asp</ulink>.</bibtext> </blist> <blist> <bibtext> Soklaridis S, de Bie A, Cooper RB, McCullough K, Beder M, McGovern B. Co-producing psychiatry education with service user educators: A collective autoethnographical case study of the meaning, ethics and importance of payment. Academic Psychiatry. 2020; 44: 159-167</bibtext> </blist> <blist> <bibtext> Soklaridis S, Ravitz P, Nevo A, Lieff S. Relationship-centred care in health: A 20-year scoping review. Patient Experience Journal. 2016; 3: 130-145</bibtext> </blist> <blist> <bibtext> Towle A, Bainbridge L, Godolphin W, Katz A, Kline C, Lown B. Active patient involvement in the education of health professionals. Medical Education. 2010; 44: 64-74</bibtext> </blist> <blist> <bibtext> Turner V. The forest of symbols: Aspects of Ndembu ritual. 1967: Ithaca; Cornell University Press</bibtext> </blist> <blist> <bibtext> Turner V. Dramas, fields, and metaphors: Symbolic action in human society. 1974: New York; Cornell University Press</bibtext> </blist> <blist> <bibtext> Turner V. Social dramas and stories about them. Critical Inquiry. 1980; 7: 141-168</bibtext> </blist> <blist> <bibtext> Van Schalkwyk SC, Hafler J, Brewer TF, Maley MA, Margolis C, McNamee L. Transformative learning as pedagogy for the health professions: A scoping review. Medical Education. 2019; 53: 547-558</bibtext> </blist> <blist> <bibtext> Varpio L, Paradis E, Uijtdehaage S, Younge M. The distinctions between theory, theoretical framework, and conceptual framework. Academic Medicine. 2020. 10.1997/ACM.0000000000003075</bibtext> </blist> <blist> <bibtext> Vinson AH. "Constrained collaboration": Patient empowerment discourse as resource for countervailing power. Sociology of Health &amp; Illness. 2016; 38: 1364-1378</bibtext> </blist> <blist> <bibtext> Weinberg SE, Johnson BH, Ness D. Patient- and family-centred medical education: The next revolution in medical education?. Annals of Internal Medicine. 2014; 16: 73-75</bibtext> </blist> <blist> <bibtext> Wong G, Greenhalgh T, Westhorp G, Pawson R. Realist methods in medical education research: What are they and what can they contribute?. Medical Education. 2012; 46: 89-96</bibtext> </blist> </ref> <aug> <p>By Sacha Agrawal; Csilla Kalocsai; Pat Capponi; Sean Kidd; Charlotte Ringsted; David Wiljer and Sophie Soklaridis</p> <p>Reported by Author; Author; Author; Author; Author; Author; Author</p> </aug> <nolink nlid="nl1" bibid="bib17" firstref="ref1"></nolink> <nolink nlid="nl2" bibid="bib20" firstref="ref2"></nolink> <nolink nlid="nl3" bibid="bib25" firstref="ref3"></nolink> <nolink nlid="nl4" bibid="bib35" firstref="ref4"></nolink> <nolink nlid="nl5" bibid="bib51" firstref="ref6"></nolink> <nolink nlid="nl6" bibid="bib29" firstref="ref8"></nolink> <nolink nlid="nl7" bibid="bib44" firstref="ref9"></nolink> <nolink nlid="nl8" bibid="bib57" firstref="ref10"></nolink> <nolink nlid="nl9" bibid="bib12" firstref="ref11"></nolink> <nolink nlid="nl10" bibid="bib30" firstref="ref12"></nolink> <nolink nlid="nl11" bibid="bib38" firstref="ref13"></nolink> <nolink nlid="nl12" bibid="bib65" firstref="ref17"></nolink> <nolink nlid="nl13" bibid="bib52" firstref="ref18"></nolink> <nolink nlid="nl14" bibid="bib10" firstref="ref20"></nolink> <nolink nlid="nl15" bibid="bib16" firstref="ref21"></nolink> <nolink nlid="nl16" bibid="bib24" firstref="ref23"></nolink> <nolink nlid="nl17" bibid="bib26" firstref="ref24"></nolink> <nolink nlid="nl18" bibid="bib31" firstref="ref25"></nolink> <nolink nlid="nl19" bibid="bib36" firstref="ref27"></nolink> <nolink nlid="nl20" bibid="bib37" firstref="ref28"></nolink> <nolink nlid="nl21" bibid="bib40" firstref="ref29"></nolink> <nolink nlid="nl22" bibid="bib58" firstref="ref30"></nolink> <nolink nlid="nl23" bibid="bib41" firstref="ref52"></nolink> <nolink nlid="nl24" bibid="bib55" firstref="ref54"></nolink> <nolink nlid="nl25" bibid="bib21" firstref="ref56"></nolink> <nolink nlid="nl26" bibid="bib34" firstref="ref57"></nolink> <nolink nlid="nl27" bibid="bib56" firstref="ref63"></nolink> <nolink nlid="nl28" bibid="bib48" firstref="ref69"></nolink> <nolink nlid="nl29" bibid="bib54" firstref="ref70"></nolink> <nolink nlid="nl30" bibid="bib19" firstref="ref71"></nolink> <nolink nlid="nl31" bibid="bib47" firstref="ref72"></nolink> <nolink nlid="nl32" bibid="bib62" firstref="ref73"></nolink> <nolink nlid="nl33" bibid="bib22" firstref="ref79"></nolink> <nolink nlid="nl34" bibid="bib50" firstref="ref80"></nolink> <nolink nlid="nl35" bibid="bib66" firstref="ref81"></nolink> <nolink nlid="nl36" bibid="bib64" firstref="ref82"></nolink> <nolink nlid="nl37" bibid="bib59" firstref="ref86"></nolink> <nolink nlid="nl38" bibid="bib60" firstref="ref87"></nolink> <nolink nlid="nl39" bibid="bib61" firstref="ref88"></nolink> <nolink nlid="nl40" bibid="bib32" firstref="ref102"></nolink> <nolink nlid="nl41" bibid="bib11" firstref="ref103"></nolink> <nolink nlid="nl42" bibid="bib13" firstref="ref104"></nolink> <nolink nlid="nl43" bibid="bib28" firstref="ref106"></nolink> <nolink nlid="nl44" bibid="bib45" firstref="ref107"></nolink> <nolink nlid="nl45" bibid="bib15" firstref="ref109"></nolink> <nolink nlid="nl46" bibid="bib42" firstref="ref110"></nolink> <nolink nlid="nl47" bibid="bib43" firstref="ref111"></nolink> <nolink nlid="nl48" bibid="bib14" firstref="ref112"></nolink> <nolink nlid="nl49" bibid="bib53" firstref="ref114"></nolink> <nolink nlid="nl50" bibid="bib46" firstref="ref119"></nolink> <nolink nlid="nl51" bibid="bib39" firstref="ref121"></nolink> <nolink nlid="nl52" bibid="bib49" firstref="ref125"></nolink> <nolink nlid="nl53" bibid="bib33" firstref="ref127"></nolink> <nolink nlid="nl54" bibid="bib63" firstref="ref128"></nolink> <nolink nlid="nl55" bibid="bib18" firstref="ref138"></nolink> <nolink nlid="nl56" bibid="bib23" firstref="ref148"></nolink> <nolink nlid="nl57" bibid="bib27" firstref="ref150"></nolink> |
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May 2021 26(2):385-403. – Name: Avail Label: Availability Group: Avail Data: Springer. Available from: Springer Nature. One New York Plaza, Suite 4600, New York, NY 10004. Tel: 800-777-4643; Tel: 212-460-1500; Fax: 212-460-1700; e-mail: customerservice@springernature.com; Web site: https://link.springer.com/ – Name: PeerReviewed Label: Peer Reviewed Group: SrcInfo Data: Y – Name: Pages Label: Page Count Group: Src Data: 19 – Name: DatePubCY Label: Publication Date Group: Date Data: 2021 – Name: TypeDocument Label: Document Type Group: TypDoc Data: Journal Articles<br />Reports - Research – Name: Audience Label: Education Level Group: Audnce Data: <searchLink fieldCode="EL" term="%22Higher+Education%22">Higher Education</searchLink><br /><searchLink fieldCode="EL" term="%22Postsecondary+Education%22">Postsecondary Education</searchLink> – Name: Subject Label: Descriptors Group: Su Data: <searchLink fieldCode="DE" term="%22Psychiatry%22">Psychiatry</searchLink><br /><searchLink fieldCode="DE" term="%22Physician+Patient+Relationship%22">Physician Patient Relationship</searchLink><br /><searchLink fieldCode="DE" term="%22Teaching+Methods%22">Teaching Methods</searchLink><br /><searchLink fieldCode="DE" term="%22Health+Services%22">Health Services</searchLink><br /><searchLink fieldCode="DE" term="%22Mental+Health%22">Mental Health</searchLink><br /><searchLink fieldCode="DE" term="%22Mental+Disorders%22">Mental Disorders</searchLink><br /><searchLink fieldCode="DE" term="%22Graduate+Medical+Education%22">Graduate Medical Education</searchLink><br /><searchLink fieldCode="DE" term="%22Student+Attitudes%22">Student Attitudes</searchLink><br /><searchLink fieldCode="DE" term="%22Transformative+Learning%22">Transformative Learning</searchLink><br /><searchLink fieldCode="DE" term="%22Foreign+Countries%22">Foreign Countries</searchLink><br /><searchLink fieldCode="DE" term="%22Graduate+Students%22">Graduate Students</searchLink><br /><searchLink fieldCode="DE" term="%22Medical+Students%22">Medical Students</searchLink><br /><searchLink fieldCode="DE" term="%22Humanistic+Education%22">Humanistic Education</searchLink><br /><searchLink fieldCode="DE" term="%22Resistance+%28Psychology%29%22">Resistance (Psychology)</searchLink><br /><searchLink fieldCode="DE" term="%22Learning+Experience%22">Learning Experience</searchLink><br /><searchLink fieldCode="DE" term="%22Change%22">Change</searchLink> – Name: Subject Label: Geographic Terms Group: Su Data: <searchLink fieldCode="DE" term="%22Canada+%28Toronto%29%22">Canada (Toronto)</searchLink> – Name: DOI Label: DOI Group: ID Data: 10.1007/s10459-020-09991-w – Name: ISSN Label: ISSN Group: ISSN Data: 1382-4996 – Name: Abstract Label: Abstract Group: Ab Data: Although rhetoric abounds about the importance of patient-, person- and relationship-centered approaches to health care, little is known about how to address the problem of dehumanization through medical and health professions education. One promising but under-theorized strategy is to co-produce education in collaboration with health service users. To this end, we co-produced a longitudinal course in psychiatry that paired people with lived experience of mental health challenges as advisors to fourth-year psychiatry residents at the University of Toronto. The goal of this study was to examine this novel, relationship-based course in order to understand co-produced health professions education more broadly. Using qualitative interviews with residents and advisors after the first iteration of the course, we explored how participants made meaning of the course and of what learning, if any, occurred, for whom and how. We found that the anthropological theory of liminality allowed us to understand participants' complex experiences and illuminated how this type of pedagogy may work to achieve its effects. Liminality also helped us understand why some participants resisted the course, and how we could more carefully think about co-produced, humanistic education and transformative learning. – Name: AbstractInfo Label: Abstractor Group: Ab Data: As Provided – Name: DateEntry Label: Entry Date Group: Date Data: 2021 – Name: AN Label: Accession Number Group: ID Data: EJ1292795 |
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