As a psychologist working in the NHS, we often talk about the idea of ‘co-production’ in the design of services or particular interventions. Basically this means that someone who has used the service or maybe has used it in the past, or a carer of someone who used the service, or more generally someone with lived experience of mental health problems helps to design or implement something within the service.
For example, this could be the development of service communications like leaflets, helping to design and run a group or contribute to meetings/decision making about the future of the service. It is not the same as ‘patient involvement’ as it is about an equal partnership at all stages.
As an idea, it completely makes sense, as who would be in a better place to know what is needed from a service than someone who has been there themselves as a user or carer? It’s also something of a counterbalance away from the previous, and indeed still prevalent, the dominance of professionals making all of the decisions about how services are run, sometimes at the detriment of what service users want and need. So, it seems like a great idea doesn’t it?
Co-production is currently understandably quite ‘trendy’ within services. However, there are also parts of it that can be tricky. In my experience it can be quite anxiety-provoking for staff, usually around concerns about accidentally saying the wrong thing or because it feels different to have service users take part in this way, and different means scary for some people (that doesn’t mean we shouldn’t be doing it, indeed it may be one of the reasons why we should be).
It does change the boundaries as you are seeing the person as a collaborator, or even colleague, rather than a client (and sometimes both, which can create a ‘dual relationship’). Then there are all the other dilemmas – should people be paid? How much? Should they be ‘recovered’?
How on earth do you decide what that means? Do one or two people actually represent the views of ‘service users’ more generally? Have we handpicked those people who agree with us or won’t be much trouble? Do we privilege certain service users who ‘fit’ well with what we want from co-production in terms of those who have had positive experiences of services, educational level, language use, race?
How do we make it meaningful and not tokenistic? I’m not saying this to indicate it shouldn’t happen, but everything is always more complicated than it initially seems, isn’t it? I’ve talked with quite a few people who have been involved in co-production things, mainly from the ‘service user’ side, and these dilemmas seem to be very much present in the experiences they described.
Just over a year ago I started an online peer support and resource sharing project for people (like me) who like heavy metal music and find it helpful for managing mental health (a bit niche I know!).
As part of this several people were very important in setting it up and continuing to run it, many of those people had lived experience of mental health difficulties, and some of them use or have used services. Although this is something I run outside of my NHS job, at first I felt that this was sort of like co-production, with people from mental health professional backgrounds and people who used services working together as equal partners to develop the project.
I momentarily basked in the glory of how clever and virtuous this was, but that didn’t really last. Firstly, I organically ended up talking about Heavy Metal Therapy (HMT)* in the context of my own experiences with stress and anxiety, and other people in the ‘mental health professional’ category did the same with the difficulties they had experienced.
People who were in the ‘lived experience’ role started sharing stuff with me that taught me some things I didn’t know about psychology, research, being a human and heavy metal. In fact, a couple of them are so knowledgable about certain genres of metal they have become like my specialist and trusted advisors (Chief Metalcore Advisor anyone? Come on, that is funny!).
The line started to blur, each person had a unique thing to contribute that wasn’t really related to their status as ‘professional’ or ‘service user’ or both (or neither), or if it was related to that status people often occupied dual roles or offered alternative perspectives.
There was also space for us to ‘fall out’, it isn’t just made up of people who generally agree with me, there has been genuine change and development of the project beyond, and at times away from, my original ‘vision’ of it It became unhelpful for me to see it as co-production, because that still implies a ‘them and us’ distinction (and that made me wonder how on a wider level people feel about being involved in co-production, particularly in the ‘service user’ role).
We all have mental health, we all have things to offer the project and most importantly, in this context anyway, we are all metalheads! I hugely respect and admire the people who help out with it regardless of how they came to us and what ‘roles’ they currently or previously occupied. So, I no longer talk about HMT as being ‘a bit like co-production’, I just say it is run by metalheads for metalheads which sounds pretty cool to me.
That process made me reflect (you know how we psychologists love to do that), on the role of psychologists working in more traditional settings and co-production, as it often seems to be something a lot of us push or are involved in. It reinforces the idea that we are ‘collaborative’ in our way of working, and we love that because it enables us to position ourselves away from the perceived dominant paternalistic narrative which fits with our training and I dare say supports our professional self-esteem (that is just a personal opinion and others may disagree).
However, I also wondered if the concept of co-production, in putting people into roles and categories, ironically may serve to perpetuate existing power dynamics, which is the opposite of what it is supposed to do! For me, for co-production to be useful we almost have to break down the barriers that are inherent in describing it as ‘co-production’ and become a group of people working together towards a common goal of improving services, from a diverse range of backgrounds, but without the ‘them and us’ bit.
Many people bring a range of perspectives, including those inconvenient to the ‘status quo’, that could be fit into the categories of ‘service user’, ‘person with lived experience’ and/or ‘person with professional training’; but I hope that there can also be acknowledgement that most of us could occupy multiple roles and have knowledge and expertise to contribute beyond the dominant role we have been ascribed in the process.
Of course, it may not work in the same way within NHS health settings, but my experiences with HMT have certainly made me consider the possibilities within the co-production model and how this may be applied more widely.
*You can follow Heavy Metal Therapy at heavymetaltherapy.co.uk or @heavymetaltherapy on Instagram and Facebook, or @HeavyTherapy on twitter
Dr Kate Quinn is a clinical psychologist from the UK, working in NHS services in Early Intervention in Psychosis. She is also a fan of heavy metal music and runs an online project about heavy metal and mental health called Heavy Metal Therapy. Kate’s background is in working with young people who have extreme or unusual experiences that may be conceptualised as psychosis, such as hearing voices. She is interested in voice dialogue and community psychology approaches, and how we can engage young people in mental health support beyond the therapy room, such as via social media.