Co-production in Coercive Environments Seminar
The seminar ‘Co-production in Coercive Environments’, which took place on 6th July 2017 at the University of Huddersfield, was the sixth seminar of seven in the ERSC Seminar Series ‘Re-imagining Professionalism in Mental Health: Towards Co-production’. About 35 delegates attended, these being a mixture of researchers, academics, professionals, carers, and service users. Appropriately, the seminar took place in co-production week which was organised by The Social Care Institute of Excellence (SCIE) to celebrate the benefits of co-production and share good practice.
The seminar day consisted of an introduction by Dr Christine Rhodes of the University of Huddersfield and Dr Pamela Fisher of Leeds Beckett University. There was then a keynote talk by Professor David Pilgrim, followed by a talk from social worker and PhD student Charlotte Scott. After lunch the room was divided into smaller groups for an activity co-produced by service users, carers, staff from the University of Huddersfield, and external partners. Information and videos of the talks will be available on the web at https://coproductionblog.wordpress.com/
The appropriate definition of co-production was a topic of discussion and debate at the seminar. Roughly speaking, however, the term ‘co-production’ refers to service users and professionals working in a genuinely collaborative way in relation to some project, which might be provision of services, research, public involvement and campaigning, or any other matter of shared interest or concern.
Christine Rhodes and Pamela Fisher opened the seminar and stated that the ultimate aim when working with ‘involuntary’ service users is co-production, if this is at all possible. They pointed out that there is no single agreed definition of ‘co-production’ and indicated the risk that the term might be misused.
Pamela Fisher gave an introduction to the topic. She made an interesting connection between postcolonial theory and co-production arguing that there needs to be a ‘decolonisation’ of knowledge. She argued that service user perspectives are often not taken seriously as legitimate forms of knowledge.
She proposed that co-production is about authentic power-sharing and requires a fundamental democratising of relationships; it is connected to wider questions of citizenship and is associated with significant challenges. She ended by emphasising that it is important not only that service users should be heard, but also that their voices should carry the power to effect real changes.
Professor David Pilgrim, ‘Co-production of Mental Health Services: The Art of the Impossible?’
David Pilgrim argued persuasively that true co-production in involuntary settings is impossible. He made his case in a clear, step by step fashion. Although involuntary services could be ‘humanised’ or ‘softened’, it was his contention that this would not be ‘co-production’.
He drew attention to something that many people in secure services are affected by, but rarely speak about, namely the ‘peculiarities’ of mental health services and mental health law. Looked at afresh, he argued, it is extraordinary that people are detained, often against their will, for periods of up to six months, without trial. In any other context, he said, the State would be accused of false imprisonment and possibly assault. He also contended that the act of detaining a service user under the Mental Health Act (MHA) is less about protecting or enhancing mental health, and more about removing people exhibiting deviant or transgressive behaviour from society. He said that this may or may not be a bad thing, but called for more honesty about what was being done, to whom, and for what reason.
He set out four characteristics that in combination define co-production:
- The citizenship of non-professionals is respected and enhanced.
- Citizens and professionals are mutually dependent.
- Both parties are agreed to be rational moral agents.
- Citizens and professionals have a common agenda.
He proceeded to argue that none of these four necessary features of co-production could be achieved under the conditions of enforced psychiatric treatment. This is because:
- Enforced psychiatric detention and treatment diminish citizenship rather than enhancing it.
- Mental health professionals and service users are not mutually dependent. Service users in detention are heavily dependent on professionals, but professionals are only dependent on service users in the sense that they need jobs and salaries, and not in any wider sense.
- Service users who have been detained under the MHA are presumed not to possess rationality and moral agency.
- Professionals and mental health service users do not have a shared agenda in involuntary settings. The interests of the patients are sacrificed in the interests of those who are not patients.
David Pilgrim pointed out the interesting fact that whereas poor people under-utilise healthcare in general, this is not the case in involuntary mental healthcare where poor people are over-represented. He also touched on the inequalities present in mental health services in regard to race. He argued that mental health law should be abolished and a form of ‘dangerousness act’ should replace it.
While David Pilgrim’s position was clearly stated and well argued, I disagree with his perspective on the MHA. As a service user who has been detained under the MHA a number of times, my view is that when employed well, the MHA protects vulnerable people from danger and risk of exploitation. While I agree that MHA legislation is distinctive and ‘peculiar’, I would put forward the argument that mental distress, specifically psychosis, is itself both distinctive and ‘peculiar’, and that the legislation cannot be properly assessed without acknowledging this. I did not get much of a sense of what a ‘dangerousness act’ would entail, but I would be very worried about any dismantling of the Mental Health Act. Home treatment sounds benign, but in reality it is about a lack of funding and it can put an unbearable strain on service users and carers.
During the discussion that followed David Pilgrim’s paper, a carer made the important point that she found the talk pessimistic and passionately argued for hope for change in services. This led to a discussion about whether co-production is a product or a process. Pamela Fisher wondered whether it was something you could work towards, a journey rather than simply a destination.
Charlotte Scott, ‘Power Sharing within Coercive Environments’
Charlotte Scott is a social worker with a background in community Mental Health. She is also an Approved Mental Health Practioner (AMHP). She is in the final stages of a PhD looking at how AMHPs make decisions during MHA assessments, drawing on service users’ views of these assessments.
Like David Pilgrim, Charlotte Scott drew attention to the extraordinary and unique situation whereby the MHA could deprive someone of their liberty. She argued that detention under the MHA produces a highly coercive environment and that co-production in this setting is not achievable.
Charlotte provided a very helpful overview of a MHA assessment. While for service users this might begin with a knock at the door, for AMHPs there would have been prior behind the scenes discussion. She referred to something known as the ‘dominant narrative’. I took this to be the predominating professionally-produced account of the service user’s episode which can help build up and shape a sense of what is going on for the service user, but which can also get in the way of listening to what the service user is actually saying.
Charlotte explained that she is interested in looking at how AMHPs could empower service users, promote rights, and work in the least restrictive way, specifically during a MHA assessment. In particular she is interested in how service users’ voices can be heard. Indeed, she pointed out that the guiding principles of the Mental Health Act code of practice set out that,
“Patients should be fully involved in decisions about care, support and treatment. The views of families, carers and others where appropriate should be fully considered when taking decisions. Where decisions are taken that are contradictory to views expressed, professionals should explain the reasons for this.”
Charlotte Scott stated that these guiding principles are all very well, but she said that what matters is how they are translated into practice. In her sample (which she acknowledged may be biased because practitioners willing to be observed may be more likely to be less coercive, and to adhere more closely to the guiding principles) she found that there was a will to find the least restrictive option. She suggested that there was a “stillness to listen” and a desire to advocate for the individual person being assessed; but she noted that there was also a sense that by the point of referral for a MHA assessment other options had usually already been explored.
Although co-production in a MHA assessment was felt to be impossible, Charlotte Scott did point out some things that could help mitigate the effects of the power imbalance. These include creating an environment that is more conducive to involving the person being assessed, ensuring that the individual being assessed has time to pack, time to phone people they need to, and has money in their pocket, and also a consideration of the impact of the means of transport, for example being aware of the stigma of having an ambulance or police car on a quiet cul de sac. In addition she stressed the relevance of advance directives. These might set out what the individual would prefer to be called, what language they would like used to describe what’s going on, and jointly agreed circumstances in which intervention would be necessary.
Charlotte Scott’s talk was followed by discussion. Questions arose around how she had got ethical approval to observe MHA assessments. She explained that she had worked with a service user group from the outset to shape the study and was guided by them. Another point that arose was made by a carer who was surprised to see the guiding principles of the MHA assessment, as she had never been consulted during the MHA assessment of her sons.
The small group discussion which then took place, ‘Team Hudd’, was co-produced by service users, carers, and staff from the University of Huddersfield and external partners. At the table where I was sitting there were approximately six delegates, a facilitator and a Trust service user who also had experience of being a carer. The facilitator asked the service user questions which related to the power imbalance he had experienced in mental health services and his experience of coercion. The service user spoke about being a service user, and also being a carer to his mother who had experienced mental health problems. His mother had been given Risperidone for long periods of time without review and this had had a bad effect on her. The group discussed this situation. Each table then fed back key points to the group as a whole.
Finally, there was a discussion initiated by a delegate called Jacqui Dyer focussing on the Conservative Party’s plan to re-write the Mental Health Act. Some discussion took place, and it was suggested that Jacqui should set out her initial thoughts and the opinions of people in the room in a blog.
The seminar day was fascinating and by the end there was a real buzz of energy and excitement in the room. The talks were high quality and the general feeling was that although co-production is not possible in coercive environments, this need not stop stakeholders from aspiring and working towards it and making significant changes.