1. University of Oxford - Faculty of Philosophy - The Ups and Downs of Co-Production

This short film stems from the Faculty’s research project Therapeutic Conflicts: Co-Producing Meaning in Mental Health.

The Mental Health Foundation partnered with the Oxford University Faculty of Philosophy back in 2012-13 to run a series of interdisciplinary workshops exploring points of intersection between mental illness, psychiatry and philosophy. Covering a range of topics including, ‘Personality Disorders and Character’, ‘The Virtues of Ageing - Mental Health and Later Life’ and ‘Hallucination and Delusion’, the workshops sparked a huge range of ideas and everyone agreed that a more sustained collaboration would be worthwhile. This collaboration was Therapeutic Conflicts: Co-Producing Meaning in Mental Health.

Therapeutic Conflicts: Co-Producing Meaning in Mental Health A Report The Mental Health Foundation partnered with the Oxford University Faculty of Philosophy back in 2012-13 to run a series of interdisciplinary workshops exploring points of intersection between mental illness, psychiatry and philosophy. Covering a range of topics including, ‘Personality Disorders and Character’, ‘The Virtues of Ageing - Mental Health and Later Life’ and ‘Hallucination and Delusion’, the workshops sparked a huge range of ideas and everyone agreed that a more sustained collaboration would be worthwhile. This collaboration was Therapeutic Conflicts: Co-Producing Meaning in Mental Health, funded by the Oxford University/Wellcome Trust Institutional Strategic Support Fund (ISSF), the Oxford University John Fell Fund and the Laces Trust. Running until June 2016, the project was led by Edward Harcourt (Philosophy, Oxford), with Bill Fulford (Psychiatry/Philosophy, Oxford), Anita Avramides (Philosophy, Oxford) and Matthew Broome (Psychiatry/Philosophy, Oxford) as co-investigators, and Toby Williamson (then Head of Development & Later Life, MHF) and David Crepaz-Keay (Head of Empowerment and Social Inclusion, MHF) as collaborating partners. The funding supported a postdoctoral research fellow, Elianna Fetterolf (Philosophy, Oxford), team meetings, research on a small co-production-based project in the Avon and Wiltshire Mental Health Partnership NHS Trust, and further workshops to expand and develop the project’s themes and ideas. The point of departure for Therapeutic Conflicts was the idea that although the value of service user involvement has been widely acknowledged in UK mental health policy through words like recovery, person-centred care, and co-design, relatively little appears to have changed in practice. We focused on the emergent term ‘co-production’ as heralding a new model or paradigm for service user involvement and empowerment. As we initially understood it, ‘co-production’ stood for a relationship between clinicians and service users where care and treatment interventions are developed collaboratively, rather than being imposed by the clinician - an ideal of equality or symmetry between service user and clinician, thereby improving the possibility of recovery. We thus took coproduction to be a remedy for what we called ‘the problem of shared words, unshared understandings’: the idea that diverging understandings on the part of clinicians and service users of service users’ day-to-day experiences, and also of key words used in therapeutic settings, can undermine the therapeutic relationship and thus the prospect of recovery. With this understanding of co-production in mind we asked, what are the conditions under which co-production can succeed or fail? Is the aspiration to equality or symmetry realistic? How do the existing asymmetries of power and knowledge between service users and clinicians find expression in terms of shared words and unshared understanding? Different psychiatrists are, of course, different – as are different service users. But we can imagine that if the psychiatrist patronizes the service user, or dismisses their description of their experience of illness, uses language they do not understand, or fails adequately 2 to explain the rationale for a given intervention, that these things will count as barriers to developing shared understanding, and thereby blocks the possibility of a working therapeutic relationship. To help conceptualize these problems and offer potentially new ways of thinking about them, we turned to conceptual tools in philosophy relating to the social production of meaning and knowledge. Although the idea of the social production of meaning and knowledge has a philosophical life of its own quite apart from its application to any particular contexts, its aptness to theorize ethical problems in real-world contexts was pioneered by philosophers with a feminist orientation. These philosophers have theorized how features of realworld social contexts like power relations can impair or enhance the ways the meanings produced in them can be fully shared, and the ways in which power and prejudice can inflate or undermine a person’s standing as a knower, as someone who can claim to have knowledge. With respect to the social dimensions of language, the central idea is that linguistic meaning is the product of social processes and not of individual minds. Understanding the creation of meaning as social opens the way to recognizing how powerful social groups may, for example, exercise differential authority over the creation and use of meanings far beyond their own members, thereby shaping the thoughts and utterances of less powerful groups in ways to which the latter are unable to make a proper contribution. We hypothesised that this might be at work in the psychiatric context when, for example, service users struggle to express their experiences and are potentially coerced into using medical terms which they feel they do not own, leaving them feeling alienated from their own experience, and misunderstood by others. With respect to the social production of knowledge, the central idea is that social location can unjustly affect a subject’s standing as a knower. The fact that someone is a woman, disabled, mentally ill, a refugee, a doctor or a scientist may, for example, unjustly deflate, or alternatively inflate, a hearer’s credibility assessment of what that person is saying. Thus a person may enter A&E with a severe migraine but be turned away because she has a history of suffering from delusions. Despite her assurances and those of her sister that this experience is not a delusion, the doctors simply discount what she and her sister are asserting on the basis of a prejudice relating to the cognitive capacities of those who’ve suffered from mental illness. Although hypothetical, we imagined that further research and empirical investigation would uncover significant links between the conceptual tools and psychiatric practice. It turns out that we were not alone in our thinking, as research into these areas of intersection is growing in recent work. 1 1 A. Sanati & M.Kyratsous, ‘Epistemic injustice in assessment of delusions’, Journal of Evaluation in Clinical Practice (2015); ‘Epistemic Injustice and Responsibility in Borderline Personality Disorder’, Journal of Evaluation in Clinical Practice (2016); and K. Hutchison et al., ‘Addressing Deficits and Injustices: The Potential Epistemic Contributions of Patients to Research’, Health Care Analysis (2016). 3 Thanks to co-investigator Bill Fulford, we were able to make contact with the ‘3 Keys Group’ based in the Avon and Wiltshire Mental Health Partnership NHS Trust. The group formed with the explicit aim of taking a co-productive approach to exploring the applications of a values-based shared approach to assessment in mental health Three Keys to A Shared Approach in Mental Health (Dept. of Health 2008). During their first-hand experiences of practising co-production, the group collected notebooks, field diaries and audio-recordings, and conducted individual interviews about the challenges and difficulties of co-designing a mental health intervention. Across the duration of our project, we analyzed the group’s data from 2012 and 2013 alongside gathering remaining members’ present-day reflections on their experiences of co-production and mental healthcare. We came to recognize that rather than imposing our own commentary on the information and insights provided by the group, we ought to allow the material to speak for itself. So instead of producing a standard qualitative research case study we commissioned artist Alex Paveley to make a short animated film, “The Ups and Downs of Co-Production”, which you can find here. Our research with the 3 Keys Group ran together with our three workshops, which brought service users, service user researchers, carers, philosophers, anthropologists, psychologists, NHS Trust managers, psychiatrists, and social workers together to explore the problem of shared words and unshared understandings, the challenges of co-production and the scope and limits of service user involvement. For our third and final workshop in May 2016, we aimed at getting feedback from stakeholders on a draft proposal for an extended project based on the insights and understanding we had already developed. Short presentations by David Crepaz-Keay, Jackie Gough (then Head of Business and Performance, Oxford Health NHS Trust), Khaldoon Ahmed (ReCreate Psychiatry, Guy’s and St Thomas’ NHS Trust), Neil Armstrong (Anthropology, Oxford) and Tom Burns (Psychiatry, Oxford) helped clarify and articulate some of our central theoretical and practical concerns, and we ended up turning away from the aspiration to symmetry in relations between clinicians and service users, and towards the idea that the inevitable asymmetries between service users and clinicians need to be virtuous rather than vicious. Whether that is turning away from the ideal of co-production, or offering a new interpretation of what co-production means, is perhaps more an issue of vocabulary than of substance. Be that as it may, ‘co-production’ can certainly mean a great many different things. Though involving service users as equals in the design and delivery of their own and others’ care is an attractive ideal, coproduction is not easy to put into practice. Getting service users and professionals to work as equals may be unrealistic when, in many ways, they are not equal - for example because the clinical setting is a familiar place of work for 4 one party and often unfamiliar and sometimes even frightening place for the other, or because the format and language is bureaucratic and many service users have no experience in designing interventions, sitting in meetings or using jargon. Recognizing the range and ambiguity of the term ‘co-production’, however, didn’t persuade us that many of the barriers and difficulties in service user involvement cannot be fruitfully theorized in terms of the social production of meaning and knowledge. In this way, our project succeeded in giving rise to future fascinating research at the intersections of philosophy and of service user involvement in mental health care.

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