'Toto, I've a feeling we're not in Kansas any more'

#025 Transition State

I qualified as a Clinical Psychologist 20 years ago this month. I have a vague recollection of going to the University of Birmingham bindery, and proudly collecting two hard bound copies of my thesis, and a soft bound copy of the case studies and clinical practice reports that I’d completed during my six training placements. The huge pile of photocopied sheets had been transformed into beautiful and professional looking purple books (did I get to choose the colour, it’s funny what details you forget?!), with my name embossed on the spine in gold, alongside ClinPsyD. I’d never had anything like it- this book was the culmination of three years postgraduate training, and with those post nominal letters, it conferred my status as a Doctor in Clinical Psychology (pending the graduation ceremony and official certificate). I felt proud, disbelieving it was complete!

I’m reflecting on this now, partly because 20 years is a significant milestone, but also because life cycle transition was the subject of my Doctoral thesis, and I’ve made some pretty big life transitions in the past six months. Relocation is a little word for a move to a job in a new country, with all that it involves. This is a transition that many people have made before me, but as with anything, it’s always easier to watch other people make these kinds of life changes than it is to do it yourself! Is there anything useful to be gained from my long-ago thesis, which might hold me in good stead, or offer interesting content for you, I wondered?!

My Doctoral research was to investigate the transition for young people with intellectual disabilities, from secondary school to college. There was a quantitative component to the research, repeating measures that had been conducted whilst participants were at school- standardised measures of self esteem, social comparison, and stigma which had been adapted for people with intellectual disabilities. Was there a difference in the measures of well-being of young people who attended special school, compared to those who attended mainstream school, the previous research asked? I am going off memory here, but there were a couple of significant group effects, and differences in self-reported scores across some of the indicators of psychological well-being.

My study followed up the same group of young people, after they had made the transition from school. What happened to people’s well-being once they had left school? Were there any group effects i.e. did it make a difference whether people had attended mainstream or special school? This was of particular interest at the time, as there had been an increasing culture towards inclusion, and for young people with intellectual disabilities to attend what were often referred to as ‘mainstream schools’, rather than ‘special schools’. Special education was often seen as stigmatising (yet many parents reported that their children / young people thrived in these schools, which were typically smaller, with greater levels of staff support). There was also an increasing move towards what is known as transition planning; the idea being that the move from child to adult services is important to get right, and requires additional planning. At the time, there was an expectation that planning started at 14, years in advance. Note: In practice, my experience was that it was rare for a young person’s needs and resources to be identified and agreed this far in advance, but this was the goal. In light of these cultural changes, researchers were keen to study outcomes e.g. young people’s educational attainment, and their psychological well-being.

The young people who took part in the research were all considered to meet the criteria for what we often refer to in services as a learning disability, or intellectual disability. This is typically defined as having an Intelligence Quotient(IQ) of under 70, AND having significant difficulties with adaptive functioning / daily living skills, AND for these difficulties to have commenced prior to the age of 18 (so it doesn’t include acquired brain injury, or dementia or other degenerative conditions in adulthood). Note: See this link for more information on some of the commonly used definitions, outlined by the National Institute for Health and Care Excellence (NICE).

In addition to the standardised measures, which were in the form of self-report questionnaires, I wanted to hear from young people themselves. One of the measures of wellbeing seemed to have an ableist bias e.g. I am able to do things as well as most people, and I wondered what young people regarded as a positive transition. Was proving themselves to be as good as other people at things, and other items in the self-esteem scale, the most useful measures of young people’s experience? My literature review had shown that although there was a lot of research into transition, these studies had mostly sought the views of parents, staff, or professionals, rather than young people themselves. I wanted to find out from young people themselves.

For this reason, I introduced a qualitative element to the study, and asked young people about their experiences, considering what they considered to be notable, and perhaps what they thought may have helped or hindered their transition. Inevitably in follow-up studies, the drop out rate of participants can be high. Qualitative interviews are much more of a time commitment for participants- they don’t just have to fill in a questionnaire. I needed to meet participants for an interview, and at that time, well before the age of virtual meetings, all of this was face to face. This meant the number of people who took part in the qualitative arm of my study was much smaller than those who completed the questionnaire / quantitative element.

I can’t speak for the young people who generously offered their time, but I loved these interviews. In therapy, we develop a shared plan of what we are there to do, consider the things we are likely to explore in sessions, identify a particular challenge to address, all of which informs the ways therapy progresses. In my research I was purely an active and interested listener, with no idea what people might tell me about their experiences. Of course my questions were influenced by my interest in their well-being, but after my initial prompts, the conversation could flow anywhere, depending on the individual.

I got to meet people in the context of their lives, sometimes at their home, sometimes at college, so I very quickly got a sense of who they were, how key people in their lives interacted with them, and how they were getting on, before I had even asked any questions. Observation is such a powerful information gathering tool (of course, only forming part of a picture). The young people got to tell me things in their own words, showing me how they made sense of events, and raising things that related to their transition and well-being that the standardised questionnaires could never capture. All of their transition experiences were different- some people had gone to college, another had entered into work placements, and another had started college but was on the verge of dropping out. Many of the young people had also experienced significant life events, unrelated to the transition under study. Again, the quantitative measures would’ve made no account of this. My grounded theory analysis resulted in a diagrammatic representation of the interview data, and though I cannot remember all of the data, I remember most of the people vividly (they will be in their late 30s now! I send them all my best wishes). What I went away with was a certainty that relationships, and security in relationships with trusted others who they can turn to, were key to success and well-being. It gave clues to what builds positive self esteem, and the capacity for making positive social comparisons, and as a clinician, I will always be more interested by these stories, and the rich details of people’s individual lives than generalisable stats. And as the external examiner dismissively stated in my viva, this perhaps IS obvious stuff, but isn’t that often what psychological research is, finding evidence for the stuff we already think we know (and yet no-one had asked!)? And what I am proud of, is that I asked the young people themselves about their experience.

We had for too long just been asking-

• What things do you think impacted on the transition for this young person?

Instead of-

• What things were significant in the transition FOR YOU?

We may or may not get the same answer to these two questions, but we only know if we ask. And if we’ve always just asked Question 1, and don’t see the different responses we get when we add Question 2, then of course it is easy to conclude that what we’ve found out is obvious, and nothing new. Yet of course it is new, both because we get a very different perspective when we ask Question 2, and because we shift the value base when we view the personal narrative of the individual with an intellectual disability as critical to our understanding.

Leaving the town of Kansas

So, with all this in mind, what has my experience of the transition to living in a new country been so far?

I am in the middle of it all, and there are so many differences and things to adjust to, culturally, with the climate, the people, and the environment around me. There will be more that is different when I start work on Monday, and it becomes more real that I’m not here for a holiday!

For now, I’ll tell you the unexpected things that have caught me out and made me smile!

• The on switch on the kettle pushes up instead of down.

• The car indicators are on the right hand stick, not the left, and you shift up and down for left and right in a counter-intuitive way.

• I’ve decided that geckos are the equivalent of squirrels, as I keep seeing them scurrying over the floor as I walk along the paths, rather like squirrels in the UK escape up the trees.

• There are middle lanes along the road, with arrows for traffic coming each way. These are for turning off or onto the roads, and so far there seems to be strange rules about how to use them. Hire cars are the worst for pulling out into them, cutting me up.

• Coconut milk is one of the cheaper items on the shelves.

• No matter how many times I remind myself, I seem to be spellbound by the cooling day, and go and sit outside at 6 pm, offering up my unprotected skin and blood to the mosquitos.

• You can spend an hour chatting to random strangers on the beach about their experience of coming to Grand Cayman, find out loads about their lives and loves, and walk away realising that you never even did the most basic thing of exchanging names.

And the thing that I anticipate being the most difficult to adjust to about Grand Cayman life (other than missing friends and family)…?

Not being able to just walk out of the door, and pootle to the places that I need to go to. The car is an essential body part here.

But today I walked to a place called Smith Cove. I went to snorkel, and on my way I found a beautiful, but very dead, butterfly. When I arrived at the cove the sand was scorching hot under foot. I tiptoed over it to get to the sea, and as I got out, the rain started to fall. Within a couple of moments, the sand was cool, and I was drenched. I headed home, and spotted a leaf that I couldn’t resist picking up. By the time I got home, the only sign of rain was the puddle beside the steps.

There is much to treasure here, and many things may feel challenging, but everything can change in an instant, this place seems to say.

These are the treasures of my walk.

What treasures have come into your day? What helps you through big life transitions?