From Montana to Ely via California and Nicaragua…

In February, Jill Winegardner won British Psychological Society Practitioner of the Year for her work in brain injury rehabilitation. One of her comments on receiving the award was: 'Although I miss the California coast, I was happy to trade it to work in a health system founded on principles of access and fairness to all.' How did her journey come about?

Jill grew up in Montana, which she tells me is bigger than the UK and still only has a population of just over a million. She proved to be a modest and drily funny raconteur. Thus, when I asked her why she chose to do psychology, she answered, 'I went to Stanford to do an undergraduate degree. I was a language major but I overslept and missed my language placement exam and had to choose another major, so I chose psychology. In the States you have to have a PhD to be a psychologist so I did my MA and PhD in clinical psychology at the University of Montana. That was in 1981.'

I wanted to backtrack. What appealed to you about psychology or was it really a question of over-tiredness!? 'I was lucky that Stanford was rather anti the approaches of clinical psychology and psychiatry at the time… I graduated in the mid-seventies. Stanford took a more social psychology approach, and that appealed to me. It made me think about how you "do" behaviour – was it defined by social constructs, by what happened inside the brain? In addition, my PhD clinical psychology course was clinically rich. We did clinical work for a large percentage of the course, so you were always brought back to reality by the real clients in front of you.'

And neuropsychology? 'At that time it had a more scientific basis than the psychiatric and clinical skills approaches. During an internship I was introduced to neuropsychology on a two-week rotation, and I loved it. After finishing graduate school I was pretty sure I didn't want to be a psychotherapist, so neuropsychology appealed. In retrospect it was great being in at the start of a discipline.' Later in the interview Jill mentions 'my family – my sister, brother and my parents were affected by brain illnesses. That has given me a motivation since family is very important to me.'

Jill completed her internship and a neuropsychology fellowship at Case Western Reserve School of Medicine in Cleveland, then joined the Cleveland Metrohealth Hospital, as well as holding an assistant professorship at Case Western Reserve University. She worked for five years consulting with a number of rehabilitation units, then worked for five years at the Cleveland Metro Brain Injury Rehabilitation Programme, which she founded. 'We thought we had a problem with lack of resources for brain injury rehabilitation at the time, but in hindsight I see that the programme I set up and worked in for five years was well funded and resourced. Most particularly we had a diverse team drawing on a variety of therapies.'

It was at this stage that she met Barbara Wilson, who 'was and still is a huge influence on me. I started to draw on more non-American approaches to rehabilitation.' I asked Jill to explain what she meant by that. 'Well, in the USA neuropsychology was all about testing, imaging, measuring. This was typified by huge neuropsychological test batteries such as the Luria Nebraska. Outside the US I found more humane and person-centred approaches and more interest in rehab. My mentor Dr James Mack influenced me hugely in this, emphasising that you must be driven by the need to help others and by your own hypotheses based on talking to patients, not by numbers. After this discussion I'm heading off to give a lecture about interviews in neuropsychological rehabilitation at UEA. I rely on interviews much more than formal number-generating assessments.'

4am in New Orleans

Perhaps it shouldn't have come as such a surprise, given the huge role that oversleeping had played in Jill's career moves, that on the strength of one conversation at 4am in New Orleans, she moved to Nicaragua to help set up the practice of neuropsychology. 'I couldn't pass up the opportunity even though it meant learning Spanish and writing a manual before going. It was a hugely life-changing experience. I then moved there, arriving in 1990, the year in which the Sandinista government was defeated in an election after, in effect, 20 years of revolution. I found myself in a completely different politico-social situation. I had to unlearn certain Western prejudices – such as the idea that norms on a spatial memory test in a "third world" country would be worse than the US ones. In fact, Nicaraguans were particularly good at that skill for very specific societal reasons.' You must have faced some criticism given the States' very different relationships with the Contras and the Sandinistas. 'I was, and still am, a strong, old-fashioned leftie. In my first week there, my picture was on the front of a Nicaraguan newspaper when I took part in a protest in front of the El Salvador embassy. So, yes, I got criticism. But I went there for a three-month sabbatical and ended up staying two and a half years! And my experience there only confirmed my professional views on the importance of a person-centred approach.'

Back in the US, Jill found that a lot of rehabilitation programmes had closed down and resources were in short supply. 'They're expensive. I worked in Cleveland and then moved to California, where I set up a private practice that assessed brain injury and provided legal evaluations among other services. I first consulted to an acute rehabilitation unit and then directed a residential brain injury programme.'

'We try to understand identity before moving on to injury'

How and when did you come to the Oliver Zangwill Centre in Ely? 'I've been here for six years. Originally I came here to offer someone else a break. While I was here the lead psychologist was leaving so I stayed on and took that job. The OZC has an international reputation and practises rehabilitation in exactly the way I feel it should be done – a way that is no longer possible in the States.'

Jill's book (co-written with Barbara Wilson and Fiona Ashworth) Life After Brain Injury: Survivors' Stories (2013, Psychology Press) gives a vivid account of that approach illuminated by wonderful case studies. In describing 'Tim's' case, for instance, Jill describes the 'therapeutic milieu' as 'an alliance of staff and clients in which the clients experience trust and safety through constructive feedback as they develop an understanding of the consequences of their injuries and try out new strategies to compensate for them'. The rehabilitation process focuses on three stages:
1.    Finding out what the problems are
2.    Trying out strategies
3.    Putting them into practice.

I suggested to Jill that her approach to brain injury rehabilitation is similar to the way Cordelia Galgut's experience of breast cancer affected her work with patients (as described in our interview with her in the June edition) – an understanding that pathologising a client didn't help. Jill agreed. 'We have the resources to understand clients here. We look at people as much, much more than just a brain injury. I start with interviews about where the people come from, who their friends are, what their values and interests are. I look for the underlying identity and his/her motivations. We try to understand identity before moving on to injury. We look at how the injury has affected clients existentially, not just how it's affected their skills. Many clients say "I'm not me any more": we try to understand who that "me" is. Rehabilitation is not about accepting the effects of brain injury but of tolerating them.'

Jill has said her Practitioner of the Year award was for all the staff at the centre. She means it. 'This is the best experience I've had of interdisciplinary team work. We work with clients over long periods, we value each other's skills, the atmosphere is great.'

Jill's explanation inspired me but she had a word of warning for people thinking of moving into the area. 'These sorts of holistic programmes are very expensive. It costs a lot to work with the clients, even though our success means later costs to society are much lower. So we need to look after this sort of work.'

And one way she's doing this is co-editing Neuropsychological Rehabilitation: An International Handbook – 'a book which will encompass this approach of putting the person first'.