In a new article published in Academic Quarter, Michael John Norton and Calvin Swords explore coproduction in acute inpatient mental health services.
The authors examine the dominance of the biomedical model in mental health and how it makes genuine co-production difficult, substituting a tokenistic approach that merely pays lip service to honoring the experience of service users while reinforcing the power differential between providers and service users.
Drawing on the work of Elinor Ostrom and Edgar Cahn, the authors discuss the lived experience of service users as well as a social constructionism approach as it relates to coproduction in mental health. The present research presents lived experience, and social construction theory as possible ways practitioners can introduce co-production in a meaningful way to recovery-oriented mental health services.
“The 21st century has seen an increasing focus on the concept of coproduction in seeking to tackle the tokenistic approach often taken by services to recovery in mental health. It originated from the scholarly work of Elinor Ostrom in America in the 1970s and was further developed through the works of Edgar Cahn. In a bid to create a service that is more recovery orientated, many community mental health services have adopted co-production as a foundation for all work they conduct with service users/family members and carers. It is reported that co-production can be transformative in practice if done correctly. More specifically, this can include circumstances where individuals are presenting in crisis,” Norton and Swords write.
Coproduction refers to the mutual creation of knowledge by practitioners, service users, their families, and their community and the utilization of service user expertise in developing and applying treatment plans. Research has found that this collaborative approach to mental healthcare decreases the reliance on psychotropic medications, increases service user dignity in treatment, and leads to better outcomes. For example, the same research reported that one mental health facility utilizing coproduction decreased hospitalizations by 63% compared to more traditional treatment centers.
Similar to the current research, other authors have observed that the roadblocks to implementing co-production in mental health services, including institutional resistance to change, restrictive administrative procedures, and the demand for service users to conform to institutional rules that relegate them to an “obedient patient” role.
In addition to coproduction, participatory research and epistemic justice are similar approaches that attempt to squash the hierarchy between service users, practitioners, and researchers currently gaining traction in the field of mental health. Participatory health research seeks to involve service users in the research about their conditions as more than just participants.
Just as the current research explores the difficulty inherent in cutting through hierarchical power structures in mental health treatment, researchers have seen similar problems in participatory health research. Service users and researchers struggle to collaborate due to hierarchical power structures reinforcing the perspectives of researchers.
Epistemic injustice describes a situation in which a person’s knowledge and experience are disregarded in favor of an expert’s knowledge. This commonly occurs in mental health treatment when service users’ perspectives are disregarded unless they agree with the experts. This leads to bad relationships between practitioners and service users.
The authors note that although Ireland has largely embraced the ethic of recovery in mental health, the actual mental health services being offered operate under the biomedical model, one not focused on recovery. According to Norton and Swords, the dominance of the biomedical model is due to professionals’ unwillingness to change and the “risk-averse and blame culture” legislated into mental health systems.
The current research acknowledges that although there is a move towards recovery within the mental health system, there is very little research on co-production, a recovery-focused practice, in inpatient settings. This again is likely due to the dominance of the biomedical model of mental health and its insistence on maintaining the power imbalance between psy-professionals and service users.
Another barrier to researching co-production is the difficulty of working with vulnerable populations such as people participating, often against their will, in inpatient mental health services. The ethical question of whether or not a person in an inpatient mental health setting can give informed consent makes working with them as research participants and co-producers extremely difficult.
The current work tells the story of how a psychiatric nurse used the principles of co-production to facilitate healing in an inpatient setting. After being admitted to an inpatient mental health facility due to symptoms of schizophrenia, one of the authors had an interaction with a psychiatric nurse in which the nurse talked to them about their mutual profession of nursing. The nurse then asked the service user how they would like the bed dressed, and they dressed the bed together. For the author, this simple act was pivotal to their recovery because they felt seen for who they were rather than as a result of the disease.
To combat the issues for psy-professionals and researchers in using co-production practices in inpatient mental health settings, the authors recommend embracing the principles of social constructionism. Social constructionism is a philosophy that understands an individual’s reality as a product of their interactions with others and their own lived experience over time. For the authors, the principles of social constructionism to question all knowledge and “normalized” interactions between service users and providers can inform the ethical application of co-production in inpatient mental health settings.
The current research points to six implications from social constructionism that should inform the practice of co-production.
- The people operating within these mental health systems need to acknowledge that co-production looks very different in practice versus on paper which necessitates a closer examination of the everyday practices of those working and receiving treatment within these systems.
- Mental health staff should adopt a co-production approach to training that includes perspectives of lived experiences.
- These services must focus on human flourishing.
- More research on co-production within inpatient settings is necessary before being widely implemented.
- Services need to integrate the “capabilities model,” where services are focused on helping service users reach their full potential.
- Psy-professionals need to create national and international policies to guide the use of co-production in inpatient settings.
The authors acknowledge some limitations to the current research. First, the lack of research around co-production practices in inpatient mental health settings means there is little evidence for its efficacy. Second, the authors only considered these questions within the Irish context; therefore, no generalization can be made to non-Irish populations.
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Norton, M., Swords, C. (2021). Creating Equality for those in Crises: Transforming Acute Inpatient Mental Health Services through Co-Production. Academic Quarter, 23, 64-79. (Link)
“Epistemic injustice describes a situation in which a person’s knowledge and experience are disregarded in favor of an expert’s knowledge. This commonly occurs in mental health treatment when service users’ perspectives are disregarded unless they agree with the experts. This leads to bad relationships between practitioners and service users.”
Indeed, I had to leave my psychiatrist after he very literally declared my entire life to be “a credible fictional story.” But when a psychiatrist has a “not believed by doctor” problem, and gets all his misinformation about his client from a pathological lying, child abuse covering up psychologist and her child abusing pastor and pedophile friends. Well, one really does end up having the most delusional doctor on the planet. And most certainly, I do not need a relationship with a child abuse covering up psychiatrist, who believes my life is “fictional” – “bad,” and unneeded, relationship.
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“Co-production.” This makes sound like they are working together to create a commodity to be bought and sold. A commodity, something material like maybe a piece of furniture or a new vehicle. This just reinforces the idea that the “patient” is just a property of the “hospital” or the “state.” If this “co-production” concept is also utilized in “out-patient treatment” I would say it makes the “patient” even more like he or she is a “commodity” with an umbilical chord to the particular “clinic.” I, honestly, don’t mean to be so obviously cynical, but, in my opinion, it’s not “co-production” we need. It is the right of the “patient” to be treated as a unique individual with the God-given right to make decisions for him or herself. Of course, “drugging” the “patient” corrupts this concept for the drugs interfere with conscious, responsible judgement so the person no longer can make a good decision. Now, I know that this “co-production” model tries to deemphasize the use of these drugs in treatment. But, I question, if that can really be done. I say this because not only are the psychiatrists prescribing these drugs, they are addicted to prescribing these drugs. Like the gambler at Las Vegas or Atlantic City, they can’t stop. And the tragic part is that they get their “patients” “addicted” to these drugs in some fashion. Thank you.
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Maybe they should call it “Co-corruption!”
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