The crucible of co-production: Case study interviews with Recovery College practitioner trainers

Abstract

Objectives:

This study explored healthcare professionals’ accounts of being practitioner trainers in a mental health Recovery College, where they worked with peer trainers, who were people with lived experience of mental illness, to co-produce workshops for mental health service users and staff. The aim of this study was to understand the process of co-production in the Recovery College from the perspective of practitioner trainers.

Design:

Single-site case study.

Setting:

A Recovery College in the South of England, open to staff and service users from one mental health care provider organisation.

Methods:

Semi-structured interviews with eight mental healthcare professionals. Transcripts were thematically analysed.

Results:

A central image of ‘the workshop as crucible’ emerged from the three themes derived from the analysis. Co-facilitating the workshop was a ‘structured’ encounter, within which health professionals experienced ‘dynamism’ and change. For them, this involved experiences of ‘challenge and discomfort’.

Conclusion:

Findings from this study contribute to the evidence base for the evaluation of Recovery Colleges by focusing on the training impact on staff. Findings suggest that taking on a trainer role in Recovery College co-production is beneficial for healthcare professionals as well as mental health service users, especially if healthcare professionals are open to the dynamism and possible discomfort of these workshop encounters. Future research, however, should expand beyond single-site case studies to test the extent to which this metaphor and themes are appropriate to describing the ‘transformative’ element of co-production.

Keywords

Educational co-production mental health recovery Recovery Colleges training

Introduction

The process of educational co-production between mental health service users and practitioners in a Recovery College is explored in this article. Co-production is a term used to encapsulate a range of approaches to how people from different social groups, often professionals alongside marginalised individuals, work together in ways that aim to democratise the power dynamic between them (Boyle and Harris, 2009). Co-production in mental health settings at an individual level can be about service users collaborating with clinicians in planning their care. At a service level, it might be about service user involvement in the design and delivery of services, as peer workers or ‘expert by experience’ advisors. Co-production at a system level might be about service users directing local and national mental health vision and strategy, for example, as governing body members. Key aspects of co-production include a focus on assets and strengths rather than deficits, valuing ‘lived experience’, mutual and reciprocal exchange, peer support, equal power and a focus on facilitation over delivery (Slay and Stephens, 2013).

The benefits of co-production as an approach to working with mental health service users have been well documented (Clark, 2015; Slay and Stephens, 2013). These include reduced stigma, strengthened social networks, improved employability and better general wellbeing (Boyle et al., 2010). Needham and Carr (2009), who have written extensively on co-production in health and social care settings, argue that ‘true’ co-production involves a shift in relational power that can be transformative, when citizens (here mental health service users) are integral to all aspects of a service, from commissioning to design to delivery.

Recovery Colleges are sites of mental health service user and service provider education, based on a prototype in Boston, USA. There are now over 90 such colleges in the UK alone (Anfossi, 2017). There are a number of different operational models of Recovery College, although a number of key principles are usually adhered to. They are service user-led or co-led, with an educational rather than therapeutic focus, an emphasis on co-production, and aim to supplement but not replace mainstream services (Meddings et al., 2014). Typically, Recovery Colleges offer workshops open to mental health service users, carers and staff on topics such as ‘improving your sleep’ or ‘coping with anxiety’. The workshops are co-produced and co-facilitated by people with lived experience of mental health problems (peer trainers) and people with lived experience of working in mental health (practitioner trainers).

Recovery Colleges are becoming major sites of service user education and support in mental health. By definition, Recovery Colleges should not aim to replace traditional mental health services or traditional colleges (Perkins et al., 2012); however, their funding in the UK comes in the majority from health commissioners or provider trust organisations (Anfossi, 2017), meaning that a decision to invest limited health funds in Recovery Colleges often takes place instead of investment in other statutorily provided services. Where there are finite resources available, funding decisions must be based on sound evidence of benefit, even if there is good fit with the prevailing ideology (as is the case with Recovery Colleges and ‘recovery’ more generally).

Empirical research on the impact and effectiveness of Recovery Colleges is a growing field (Western Australia Mental Health Commission, 2018), but the focus to date has been on case studies and audits, and on the impact of the Recovery College experience on service users rather than on the practitioner trainers or mental health professionals who attend workshops. There is also a lack of experimental or comparative studies (Western Australia Mental Health Commission, 2018). One study of a Scottish Recovery College included findings that a consultant psychiatrist had found taking part a positive experience of collaborative working (McGregor et al., 2014). There has been one case study on mental health staff who attended a Recovery College as students (Perkins et al., 2017) in which participants reported improved morale, improved wellbeing, having grasped ‘the true meaning of recovery’ and being ‘inspired’ by the co-produced approach. Previously, we have published findings from our study, on the ‘meaning of co-production’ for Recovery College Practitioner Trainers (Dalgarno and Oates, 2018).

Since the early 2000s, the prevailing ethos in mental health care in the UK has been ‘recovery-oriented’ (Department of Health [DH], 2011). Personal recovery in the mental health service context does not mean freedom from symptoms or cure. Rather it is a more complex concept which has been described as incorporating five ‘processes’: connectedness, hope, identity, meaning in life and empowerment (Leamy et al., 2011). Recovery-oriented mental healthcare aims to enable service users to define and pursue their own recovery, usually incorporating some or all of these five aspects. ‘Promoting recovery’ was an expectation of the National Health Service (NHS) England’s (2014) Five Year Forward View for Mental Health. The creation of Recovery Colleges has been one way for service commissioners and providers to demonstrate their commitment to the recovery ethos (ImROC, 2017). That said, the recovery approach, as the dominant discourse in mental health, has been criticised as typical of neoliberal social policy (McWade, 2016). On the one hand, the state mandate to promote recovery is seen as progressive, a step away from medico-legal dominance towards mental health service users having increasing personal agency. On the other hand, recovery rhetoric diminishes the responsibility of the state and fosters individual self-interest in line with a neoliberal ethos (Ramon, 2008).

The possibility that some approaches to co-production may transcend neoliberal discourse has been posited in relation to higher education (Bell and Pahl, 2018; Matthews et al., 2018, 2019) and by Fisher and Lees (2016) in relation to mental health, who argue for an attitude of ‘recovery together’ between all involved parties, not just recovery for service users. When health professionals take on practitioner trainer roles in Recovery Colleges they are subjecting themselves to a potentially transformational experience just as much as their peer trainer colleagues. The aim of the present study was to explore health professionals’ perspectives on being practitioner trainers. Previously, we have presented study findings suggesting that the Recovery College experience was potentially ‘transformative’ because it led practitioner trainers to reassess their expert role and power relations with service user, with the potential to alter their approach to service users in clinical practice (Dalgarno and Oates, 2018). They contrasted somewhat with Cameron et al’.s (2018) analysis of student and tutor perspectives on Recovery College course design and delivery, which described how collaboration in the Recovery College drew on clinicians’ previous educational and clinical skills, with less emphasis on role transformation. In this article, we present findings from the study relating to the process of co-production, answering the research questions: what are the elements of the process of co-production as experienced by participants?

Methods

Study design

A qualitative case study approach was used (Baxter and Jack, 2008; Yin, 2003). Semi structured interviews were undertaken by the first author (M.D.). Interview transcripts were analysed by both authors using the six-phase thematic approach defined by Braun and Clarke (2006). The study is reported here in accordance with the COnsolidated criteria for REporting Qualitative research (COREQ) (Tong et al., 2007).

Data collection

The study was approved by the Research Ethics Committee of King’s College London and by the English National Health Service Health Research Authority. Study participants were recruited from one Recovery College in London, via advertisements in the college and an email sent by the service manager. This was an appropriate purposive sampling approach for a single site case study (Baxter and Jack, 2008). Study participants were aware that the research was being undertaken as part of a postgraduate study conducted by the M.D., supervised by the second author (J.O.). MD was employed in the Recovery College service being studied but had not worked directly with any of the participants.

Eight practitioner trainers volunteered for interview, representing around one-third of the College’s practitioner trainer workforce. All self-selecting volunteers were invited to take part. Interviews were conducted face-to-face in private rooms in the workplace. Interviews were semi-structured, using a topic guide covering the topics of co-production and collaborative working, strengths and challenges, role distinction, and impact on teaching and practice. They were audio recorded. The interviewer made field notes during the interviews. The interview format had been piloted with a member of Recovery College staff prior to the study. The interview participant information sheet, consent form and topic guide were reviewed by the Recovery College peer trainers, reflecting the principle of service user involvement in research (Hayes et al., 2012). The interviews were between 28 and 56 minutes in length. Interviewees were offered copies of their transcripts for review and comment.

Data analysis

In the absence of a pre-existing theoretical understanding of practitioner trainers’ experience of the Recovery College, a single site case study approach using a six-phase thematic analysis of interview data was used. First, both researchers familiarised themselves with the data by reading the interview transcripts. Next, initial codes were generated through thematic analysis, using NVivo 11 software to organise the data into nodes. In line with Braun and Clarke’s (2006) methodology, codes were mapped against themes derived from the research question: how do study participants describe the process of co-production? Themes were reviewed to identify those most prominently addressing the research question. Next themes were defined and named. Finally, the findings were written up in order to develop a discussion and formulate conclusions. The diversity of cases is reflected in the description of themes, which include contrasting views on the same theme.

Findings

Sample characteristics

Five participants were female, three were male. Their ages ranged between 30 and 55. Two participants identified their ethnicity as Irish. Three self-identified as White British. Three self-identified as Black British or Black African/Caribbean. All participants occupied senior roles in the NHS or social services, at management grades. Their length of association with the Recovery College had been between 2 and 4 years. Three participants were nurses. Three were psychologists. One participant was an occupational therapist. One was a psychiatrist and one was a social worker. Minimal personally identifiable information has been presented here in order to maintain anonymity, given this was a single site study.

The co-production literature places emphasis on the experience of co-production at its best, being transformative, having consequences beyond the co-produced activity. Our data provides some insight into what may be taking place in those co-produced encounters that is essential to professionals’ experience of transformation. A central image of the Recovery College workshop as a ‘crucible’ emerged: a crucible being ‘a place or situation in which concentrated forces interact to cause or influence change or development’ (https://www.merriam-webster.com/dictionary/crucible). Three essential components of the Recovery College encounter for Practitioner Trainers were identified as themes: co-production as structure, co-production as dynamic, and co-production as challenge and discomfort.

Co-production as structure

The first theme to emerge from the analysis was one of co-production as structure. A degree of structure, meaning planning of content, allocation of tasks and scheduling of activities was viewed as vital for the transformational process of co-production to happen. Different study participants valued structure to different extents. Irene, who ‘always’ worked with a ‘clear plan’ valued working with a particular peer trainer for her organisation and planning. For Irene and her co-trainer, the key co-produced element formed the ‘content’ of the workshops, which started in ‘a neutral space’:

We pretty much had a blank sheet at the beginning, in fact we started off with a different title altogether; it was going to be ‘understanding’… and then we thought ‘“That’s far too ambitious for a one-day workshop” and it’s more like an introduction’ and then we thought ‘Okay, what do people need to know’ …

For Sophie, in contrast, both workshop structure and content were co-created:

… when I got invited by the Recovery College to join up with my co-trainer, so I brought in what I had. What she contributed was her life experience, which was most useful because actually looking at some of this. We looked at the structure. We developed the structure together.

For Andrew and Simon, structured and directive approaches were associated with the early days of a collaboration, which would become more flexible as the partnership developed. For Simon, an earlier workshop ‘didn’t feel so co-produced’ because he and his co-trainer took on very distinct roles. This changed over time. He described initial anxiety about their work not being co-produced enough, not fitting the ‘spirit’ of the College implying that something too structured, with too clear a distinction of roles did not meet his expectations of this way of working:

So, yeah, he (the peer trainer) brought a lot to it in terms of structure of how the course looked … what (the peer trainer) could bring to the course that would sort of fit within the frame, to what extent could you prepare and work and the technical parts of it which he wanted to bring alongside him talking about his possible experiences.

As his rapport with a co-trainer developed, Simon described how workshops had a common structure, a set of principles, but

… we kind of have an overarching set of principles which we want sort of people to get … to kind of bring through in a conversation but actually the trajectory of that completely depends on what people bring in that respect that’s why it feels a bit more therapeutic.

A similar point was made by Jason who described the workshop structure as a framework to ‘bounce back’ from, reacting to the elements in the room, namely the interaction between workshop attendees and trainers. Study participants tended to describe the peer trainer as taking a lead on how to structure workshops because they were seen as the more experienced educator or facilitator (not just in the context of a co-produced Recovery College workshop). Christine said,

… we just had a chat and she made me feel that, you know, supportive, cause I’d never done training before. And she, sort of, had a clear protocol about putting … not protocol, but idea of how to structure it and it made it easier for me to keep focused, and together.

Jane described learning the co-production’ ‘ground rules’ from her co-trainer:

We had one meeting where we’d talk; so the peer told me about how the course is run in practice and what the ground rules are and how that’s managed really.

These ground rules included confidentiality, not using technical jargon, and being open to challenge from workshop attendees. A further essential element of the co-produced workshop structure was the debrief or reflective time at the end of the workshop. Abi said,

We try to make sure that unless there’s an exceptional reason why people can’t stay at the end. I think it doesn’t have to be laborious or painful. It’s just about listening to each other.

Irene, again at the more structured end of the spectrum described this as

After every workshop we sit together and go through the feedback and we take out the points and discuss them and we think about tweaking the training for the next time in light of the feedback.

Debriefs were opportunities to evaluate the workshops and consider how difficult moments had been navigated. Jason described the debrief as an opportunity to say how he ‘felt’ during the session, for example, regarding any personal stories that were shared during the workshop.

Co-production as dynamic

The second theme was co-production as dynamic, meaning that it evolved and changed over time. This was complimentary rather than contrary to the structure described above. As a dynamic process each workshop had its own distinct nature, described by Abi as: ‘It really felt like it was a complete experiment’. She said,

… what we do within that time, within that space together is different every single time, every place we go and every group of people that we’re with. I love that.

The dynamism began before getting into the workshop, as the co-trainers prepared for the workshop encounter, which, no matter how well prepared they were, could not be predicted. A commitment to a co-production ethos meant a commitment to working in an ‘unfinished’ way, or to continuous evolution as described by Jason:

so, it’s that beginning process, but then after you’ve given and while you’re giving it, even years after giving it, you’re still changing, still tweaking, so it’s ongoing but in a, kind of, dynamic way. (Jason)

Jason used the image of ‘fermenting’ to describe the process. The co-produced experience ‘worked’ when interactions were complex, when the co-trainers were open to adaptation and change, whether (for one participant and her co-trainer) by inviting actors into the classroom to ‘bring case studies alive’ or by encouraging discussion and sharing of experiences between workshop attendees. This meant that the dynamic of the relationship between trainers had to progress beyond politeness:

until we got to know each other we were very, very polite with each other; it was not that we became impolite but once we got to know each other a bit better, I think we both had confidence to say actually that doesn’t sound quite right and that’s a bit exclusive. So, it was just about sharing things and working together and explaining each other’s points of view and where they were coming from really. (Jane)

This did not happen every time, with every pair of trainers or workshop. Health professional trainers had better rapport with some co-trainers than others and relationships evolved. Study participants described how as co-trainers got to know each other, a rhythm developed, with Simon and Irene noting that preparation time and post-workshop reflection were reduced. What also ‘reduced’ was their ‘professional’ stance. Sophie described how her ‘need to be in charge’ diminished. Jane described how she gradually felt able to discuss her own mental health, even as a clinician. She said,

… there’s something about I think when you feel sort of contained and supported and sort of mutually sharing in something where you feel more able to perhaps talk honestly about what’s going on with yourself and I think that’s helpful for the group and for the learning as a whole …

Within the crucible, identities as professional, service user and facilitator were subject to change. This educational environment was contrasted with other educational experiences. This was particularly salient for Jason, whose prior experience of ‘teaching’ was:

I was used to creating teaching sessions and things, either for peers or my seniors for them to appraise and rip apart if they wanted, but very seldom, if at all, for patients or for public.

Challenge and discomfort

The third theme to emerge was that of challenge and discomfort. An essential element of the workshops was that they were spaces where all parties felt able to challenge others and disagree with them. This challenging space was the site of meaningful collaboration where health professionals moved from an ‘intellectual’ grasp of co-production to ‘absorbing it’ (Jane). They had to work with their co-trainer to respond to a diverse group of workshop attendees. This required quick thinking and flexibility, as summed up by Jason:

That is a huge aspect of the challenge … that constant flexibility to be able to deliver something to one person who might have asked the question and then to … immediately change tack and then to be able to deliver it again for someone else who hasn’t quite understood that, or want it, kind of, reframed.

For Simon, alongside developing flexible responses to challenges from workshop participants, trainers had to acknowledge and work with the pre-existing power relationships that might exist between trainers and between trainers and workshop attendees. A good workshop meant ‘owning’ that discomfort rather than ignoring it:

… you’ve got to, I think, own the realities of the dilemmas which you do face in doing this sort of thing and not pretend it’s not there, not try and sort of pretend that we’re coming from it from a sort of mutual kind of stand point with regard to what we’re focusing on …

Specific challenging situations were described: when service user attendees were distressed during workshops or when clinical staff attendees ‘did not really get’ (Christine) the co-production ethos, and directed all their comments and questions to the practitioner over the peer trainer. Participants were mindful of why such moments may occur. First, mental health service users may bring a mental health history of years of discomfort and distress to their encounters with peers and practitioners in the Recovery College setting and clinicians may not have been in educational settings with mental health service users before. Christine pointed out that ‘this is not for everybody’ and workshop attendees have to be open to co-production as an approach. When such moments happened, they had to be handled according to the College ethos, meaning that trainers may have to make changes to their planned activity or focus. Again, this was well encapsulated by Jason:

you can’t preach about, kind of, trying to create a safe and open environment and the second someone brings something up, which is something quite evocative or whatever, to them, put a barrier up.

In summary, we found that within the confines of a workshop structure, which was continually being refined, health professional trainers experienced co-production as a dynamic process. A vital element of the process as transformative encounter was for practitioner trainers to experience and negotiate some challenge and discomfort.

Discussion

Findings from this study add to the empirical research literature on Recovery Colleges by describing the experience of co-production from the perspective of mental health professionals. It is common for co-production in mental health to be described as a process (National Development Team for Inclusion, 2016; Western Australia Mental Health Commission, 2018), but without an accompanying exploration of what the ‘process’ entails from the perspective of health professional participants who stand to experience diminished professional authority as a result. Where the main focus of research on co-production in mental health has been on its impact on service users, it seems that these encounters also have an effect on health professionals. What can be surmised so far is that professionals who participate in co-produced workshops in Recovery Colleges value the opportunity to collaborate and interact with mental health service users in ways that differ from both the traditional service user-health professional dynamic and the teacher–student dynamic (Cameron et al., 2018; Perkins et al., 2017). Where Cameron et al’.s (2018) findings make the case for collaboration between practitioners and peers as a means of empowering all parties, our study offers an insight into the features of Recovery College co-production that elicit a feeling of transformation for those involved. While the themes of dynamism and structure may be reasonably expected in many descriptions of collaborative work and co-teaching, the ‘challenge and discomfort’ documented here may be a unique feature for practitioner trainers in this setting. Our finding that challenge and discomfort may be essential to that experience within a containing structure and dynamic process, suggests that these collaborative relationships in the Recovery College setting do not have to be a thoroughly harmonious antidote to hierarchy. Dealing with disharmony in the workshop may be an essential element of the process, at least for practitioner trainers, for whom transformation may mean a reformation of their professional power in relation to service users. This is the crucible. The individual elements that are added to it emerge in an altered state.

These findings also add to the debate on the extent to which recovery-oriented mental health practices are symptomatic of and promote a neoliberal approach to social policy. The decision to become a peer or practitioner trainer in a Recovery College may be motivated by individual self-interest, but what happens in the College setting for health professionals is as a result of collective endeavour, and one outcome for health professional participants seems to be a revised sense of identity, not just as a health professional. Practitioner trainers are engaging in a process which reduces their professional power, with the experience of challenge and discomfort being a key feature of that process. Bell and Pahl (2018) and Matthews et al. (2018) have argued that educational co-production in higher education can be an antidote to neoliberalism, working against dominant power relations. Their analysis suggests that that the ‘utopian potentials’ to address hierarchy and inequality (Bella and Pahl, 2018: 113) have not yet been realised in the higher education setting. Perhaps Recovery Colleges are such ‘utopian’ places in which co-production can mean ‘recovery together’ (Fisher and Lees, 2016: 608) between service users and professionals, and between trainers and workshop attendees, rather than ‘recovery’ solely for the service user.

Limitations

There are limitations of this study that could be addressed in future work. Like work by Meddings et al. (2014), McGregor et al. (2014) and Cameron et al. (2018), this is a case study of one Recovery College. Given that there are various models of Recovery College in operation, it is important for the findings here to be tested against those from other colleges. In further studies, the practitioner trainer perspective must be contrasted with that of peer trainers and workshop attendee and could be contrasted with mental health practitioner experiences of co-production in other settings. Importantly, the participants in this study were self-selecting enthusiasts for co-production. They had volunteered to become practitioner trainers as well as volunteering to be interviewed. The effectiveness of Recovery Colleges should therefore be tested with service users and clinicians without a prior background in or enthusiasm for co-production.

Conclusion

Findings indicate that the process of educational workshop co-production in Recovery Colleges has three characteristics: it is dynamic, it requires structure, and it involves the experience of challenge and discomfort, at least for the practitioner trainer. Prospective Recovery College practitioner trainers should be forewarned that co-produced workshops involve planning, structure and a flexible approach. They should be advised that co-production with mental health service user peer trainers is a complex process, which will likely include some experience of challenge and discomfort.

Case study research has shown that peer trainers, practitioner trainers and students value Recovery Colleges as sites of co-produced mental health education. This study has provided insight into aspects of educational co-production in one college, in one context. Future studies must use comparative and experimental research methods to determine the extent to which specific approaches used by Recovery Colleges and specific contexts in which they operate contribute to the positive experiences of trainers and students.

Footnotes

Acknowledgements

We thank the participants who gave their time to be interviewed and the Recovery College that allowed us to access its practitioners.

Declaration of conflicting interests

The author(s) declared following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Mark Dalgarno was an employee at the case study site but had no prior direct working relationship with the participants.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Jennifer Oates

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