Community mental health and social exclusion: Working appreciatively towards inclusion

Abstract

A central feature of community mental health practice is the social inclusion of its service users. This involves opening up life opportunities in the mainstream community, requiring collaboration with community partners. A group of mental health service managers, practitioners, service users and representatives from the Further Education community worked together for 18 months to promote social inclusion for local service users and used appreciative inquiry and co-operative inquiry methods to explore and enhance this work. This article discusses the methodological nuances of this fusion of approaches. It underlines the benefits of an appreciative approach for addressing historically rooted patterns of practice within statutory mental health services, and highlights how harnessing an extended epistemology can bring together impetus from ‘top down’ and ‘bottom up’ to create actionable plans. The article describes what was learned about optimal inter-agency working and about trying to be a change agent in a large organization. It concludes with reflections on the suitability of participatory action research methods for developing community-orientated mental health services.

Keywords

Appreciative inquiry community mental health community participation co-operative inquiry participatory action research social inclusion

Introduction

The evolution of community-based mental health care has witnessed a growing awareness of the depth and complexity of unmet needs amongst people with mental health problems. At the same time, the restorative potential of individuals’ participation in their community remains largely untapped (DH, 2006). Indeed, non-participation in the activities of the society in which a person lives, or social exclusion (Burchardt, Le Grand, & Piachaud, 2002), is recognized as a risk factor in deteriorating mental health (RCP, 2009). Consequently, the social inclusion of individuals with mental health problems is consistently centre-stage as a national and EU-wide priority (DH, 2011; MHE, 2007; ODPM, 2004).

Promoting social inclusion requires partnership working between mental health services and ordinary mainstream community services to open up life opportunities for people with mental health problems and to address societal stigma and other attitudinal barriers that prevent access to such opportunities (DH, 2011). However, in practice long-term commitment to cross-cutting partnership working is often elusive (Douglas, 2009).

This article explores partnership working within an inter-agency group focused on promoting community participation for people with mental health problems living in Bristol, UK. The group was the Community Involvement Subgroup (CIS) of Bristol’s Social Inclusion Forum. It comprised mental health service managers, practitioners, service users, and representatives of the Further Education (FE) community.

The article opens with an overview of the local practice setting, explains the choice of participatory action research (PAR) in this context, and points to the suitability of appreciative inquiry (AI) and co-operative inquiry (CI) methods for deriving actionable knowledge about effective partnership working. It then focuses on what underpinned optimal CIS working specifically; highlighting common inter-agency agendas, the importance of maintaining an evolutionary perspective of service development and an appreciative stance during the inquiry, and the value of independent facilitation.

The article’s purpose is methodological reflection therefore, rather than consideration of the implications of the inquiry for community mental health practice, which are discussed separately by Fieldhouse (2012a).

Choosing action research methodology

Action research deals with real life problems through collaboration, dialogue and mutual learning, and aims to produce tangible results (Denzin & Lincoln, 2008). Its processes are well-suited to practice development in healthcare settings because action research cycles have much in common with the cycles of quality improvement that characterize healthcare quality management guidance (Hughes, 2008).

In action research the inquirer is embedded in the field of inquiry (Marshall & Reason, 2007) and being reflexive is a means to achieving research validity (Burgess, 2006). Whilst this article disseminates findings that were collectively derived from a group experience the lead researcher and co-author (JF) was also a member of the CIS. This article is, therefore, to some degree a personal narrative achieved in a particular way – reflecting that people can only do action research ‘on’ themselves, not ‘on’ others (Kemmis & McTaggart, 2008). It tells a story about how learning was derived from practice, how that learning was significant for the people involved, and what it meant for their subsequent actions. In this way, it embodies first-, second-, and third-person approaches to action research (Torbert, 2001) in describing an inquiry that the lead researcher felt strongly motivated to undertake, exploring the shared experiences of a group of people who acted together as a community of inquiry, and aiming to produce generalizable ideas that are useful to others engaged in similar work elsewhere. In particular, it indicates ways to promote effective collaborative inter-agency working and how to effect change as a lobbying group within an organization. Quality issues are also considered on the premise that, for new learning to be actionable, the methods by which it is derived must be demonstrably valid (McNiff & Whitehead, 2009).

For this inquiry, PAR methods were chosen because they are rooted in the practices they investigate (Kemmis & McTaggart, 2008), ensuring the findings could be fed into the common agendas shared by partners who would implement change. This was important because community mental health is a contested field of practice (Bates, 2010). For example, although partnership working between mental health services and community partners is acknowledged good practice (NSIP/CSIP, 2007), locally there were contrasting views about the role of mental health practitioners working ‘in the community’. Some health service practitioners worried that their therapeutic skills might be lost or degraded if their input was provided through ordinary, mainstream agencies such as FE colleges, whilst some social care partners suggested that the presence of statutory mental health service workers in the community was implicitly about ‘policing’ behaviour rather than facilitating access to resources. Furthermore, although the UK’s mental health and social inclusion agenda required practitioners to support service users in taking qualified risks in order to promote community participation (ODPM, 2004) there was a widespread risk-averse view among services that community settings might prove too challenging for certain service users. There was also a small minority view that ‘social inclusion’ was a coercive, government-sponsored, ‘top-down’ agenda premised on dubious values, and which also represented an implied criticism of practitioners’ work.

Method

The inquiry was funded by the National Institute of Mental Health in England (NIMHE) and ethically approved by the local NHS Research Ethics Committee. It was conducted in two phases. First, in-depth qualitative interviews with eight purposively sampled mental health service users explored their subjective experiences of being supported to participate in mainstream community activities, which had lead to them feeling more socially included. These demonstrably good outcomes were noted by mental health practitioners who knew the individuals well and were also confirmed by a preparatory audit of service users' case notes by the co-author (JF). This first phase was, therefore, a post hoc ‘unpacking’ of what had worked well.

There was interest in this phenomenon because all the interviewees were service users of an assertive outreach (AO) team – a service model with a specific remit to work with ‘difficult to engage’ people with major mental health problems (DH, 1999). The fact that a number of these individuals had, with AO assistance, engaged with ordinary mainstream activities (such as FE or voluntary work) was seen to hold much potential learning for other local services aiming to promote social inclusion for their service users. Because the CIS’s remit was to address the barriers to community participation, the findings from interviewees’ personal accounts of participation and recovery were fed into the CIS.

The second phase (and the focus of this article) concerned the experiences of the CIS itself. These were explored in two focus groups, a month apart, which blended two practical inquiry models (CI and AI). Each holds, at its heart, a social constructionist view that ‘reality’ cannot be known separately from our experience of it and is constructed through people’s interactions with each other (Ekdawi, Gibbons, Bennett, & Hughes, 2000). ‘Narrated’ reality was of particular interest here because CIS members were asked to reflect on what happened from their own point of view; the aim being to harness tacit or experiential knowledge in the service of actionable knowledge, in order to facilitate change. A brief overview of CI and AI is provided to give some background to the composite method that unfolded in practice.

Co-operative inquiry

CI occurs when a group of people who share a concern that a particular problem (such as social exclusion) needs addressing come together because they recognize that their combined perspectives and efforts are required to see the problem whole and to bring about change (Reason, 2001). The CIS already operated much like a co-operative inquiry group because social inclusion was a common interest across the different agencies represented by its members (as seen in LSC, 2006; ODPM, 2004). Crucially, all parties in the partnership had particular expertise in helping the others meet their objectives.

At the heart of CI is the notion of an extended epistemology (Heron & Reason, 2008) which reaches beyond the primarily theoretical knowledge of academia and values experience and ‘know-how’ just as highly. CI intentionally brings together four different epistemologies: experiential knowing (from direct engagement with phenomena as they are experienced in real life); presentational knowing (using imagery and story-telling, for example, to shape what is embryonic into communicable form to convey the significance of experience); propositional knowing (intellectually knowing about something through theories and other received information), and practical knowing (‘know-how’ expressed as a skill, knack, or competence). Heron and Reason (2008) suggest that knowing through CI will be richer, deeper, more true to life and more useful if these four ways of knowing harmonize. This was seen as the key to generating actionable knowledge in the CIS.

Appreciative inquiry

AI is the exploration of what gives life to human systems when they operate at their best (Whitney & Trosten-Bloom, 2003). It works on the premise that dialogue about strengths or successes is itself transformational for the groups or organizations that undertake them:

Human systems grow in the direction of what they persistently ask questions about. (Cooperrider & Whitney, 2005, p. 9)

Mirroring the high value placed on the retrieval of experiential and presentational knowing in CI, AI also sees interaction as the starting point for change. Again, ‘stories’ have a high profile as AI posits that action is influenced by the images and stories we hold of the future:

In short, we create images of where we believe we’re going – and then we organize to those images. (Whitney & Trosten-Bloom, 2003, p. 64)

AI is characterized by its ‘4-D cycle’, comprising four steps: Discovery (recognition of the ‘best of what is’); Dream (exploring possibilities of ‘what might be’); Design (proposing ‘what should be’); and Destiny (committing to action regarding ‘what will be’). AI is said to work paradoxically. Instead of aiming to change things, ‘it aims to uncover and bring forth existing strengths, hopes, and dreams’ (Whitney & Trosten-Bloom, 2003, p. 15). Because this requires neither a diagnosis of the problem, nor remedial action, it was envisaged that the inquiry’s momentum would continue even when the PAR had concluded. AI therefore offered longevity (in terms of ongoing service development) for what was a comparatively brief period of inquiry.

To appreciate something can mean to understand it better and also to increase the value of it (Whitney & Trosten-Bloom, 2003) and both meanings were applicable in this inquiry. It was practitioners’ critical reflection on good outcomes that prompted the service user interviews and the CIS sought to increase the value of the findings (reported by Fieldhouse, 2012b) by using them to fuel service development.

Constructionism acknowledges that, through conversation, the story-teller makes ‘the world’ through the telling of the story and the researcher is seen as a co-creator of new knowledge (Silverman, 2010). This relational component of the inquiry was vital and rested on the insider/outsider teamwork implicit in the co-creation of a learning history (Roth & Bradbury, 2008). This learning history explored the factors underpinning optimal inter-agency working during the CIS’s first year; reflecting on issues of agency and implementation. It involved focus group reflection on experiences and accomplishments to ‘make sense’ of them: ‘to create the kinds of conversations inside an organization that allow its members to enact the future they want’ (Roth & Bradbury, 2008, p. 351). To support this emerging narrative the focus groups were audio-recorded (by unanimous consent) and transcripts were sent to participants.

The focus groups were loosely structured around the 4-D cycle. The facilitator’s background as a former NHS and Social Services manager, complemented by her experience in action inquiry group facilitation, was invaluable. The advantages of this independent facilitation are discussed later. It aimed to elicit CIS members’ experiential knowing through freefall writing and story circles.

Freefall writing (Goldberg, 1986) is essentially ‘talking on paper’ with each participant writing in silence for 10 minutes. It uses the act of writing almost as a projective technique to access unconscious material and help the writer cut through to their ‘first thoughts’ on the basis that these contain important truths about experiences and there is a value in coming to know them better. Freefall writing, therefore, allowed the lived experience (including personal experiences that had made individuals feel passionate about social inclusion in the first place) to mesh with propositional knowing from practice guidance emerging from the national social inclusion agenda (such as NSIP/CSIP, 2007). It aimed to prompt critical self-reflection on experience and turn tacit knowledge (including knowledge that was hitherto un-acknowledged) into communicable actionable form.

Story circles use the age-old tradition of story-telling to bring people and their first-hand experiences together to co-create new knowledge. Group members drew on insights gained from their freefall writing, taking turns to have facilitated three-minute periods of uninterrupted talk about their individual experiences in the CIS. This was a way of recovering personal and organizational histories, enhancing mutual understanding and envisioning better ways to achieve shared goals.

The writing and story-telling were complementary. As a form of self-reflexivity (examining the influence of one’s own beliefs, assumptions and prejudices on one’s interactions with co-participants) writing offered CIS members a solid basis from which to progress from the ‘I’ as actor-agent to a more critically reflective ‘I’. This allowed members to deconstruct what was seemingly ‘taken for granted’ in discussions (such as notions of ‘the community’, and ideas about mental health services’ role within it) and recognize the influence of members’ work-cultural norms (Flood, 2001; McNiff & Whitehead, 2009).

In CI terms it was anticipated that this reflexivity would translate into a more conscious appreciation of what already worked best in order to advance what was newly envisioned from that point forwards. In AI terms it represented a collective exploration of the CIS’s ‘positive core’; a consciousness-raising process identifying the ‘best of what is’ and ‘what has been’ (Whitney & Trosten-Bloom, 2003). The questions the facilitator put to CIS members (see Box 1) structured the process of co-creating the learning history into a series of tasks that stimulated and supported reflection. Confidence in the CI/AI process was fostered through the obvious truthfulness (validity) and utility of what was produced in the story circles – the stories themselves. Each member’s passionate account of their commitment to social inclusion was seen to infuse their CIS role, which was thus reinforced – strengthening the group as a whole.

Box 1.

Facilitators' instructions for freefall writing

I’d like you to write about the most significant change or event for you in the life of this group. Freefall writing will often surprise us, so there are some basic rules:

• No one but you will read what you write.

• Keep the hand moving and don’t take your pen off the page.

• Start with the thing you’re trying to capture and just keep going.

• Don’t worry about punctuation, spelling, crossings out, or where you are on the page.

• Don’t have the ‘think then write’ attitude – just write.

• Empty your head onto the page, and hopefully your heart as well.

• When different thoughts come up – go for the ones are ‘scary’ or ‘edgy’, or have ‘feeling’ – because they’re the ones that will take you somewhere interesting in your writing.

CIS focus group participants

It was essential that the focus group was the CIS, as far as possible. Its members had the unique, direct experiential knowledge that the inquiry wanted to access. All six CIS members (Box 2) consented to convene as a focus group. The names are pseudonyms but brief personal details are provided to contextualize verbatim quotations. The lead researcher has no pseudonym because he is identified as co-author of this article.

Box 2.

CIS/focus group members

Colin – community mental health nurse from the AO team.

Emily – service user researcher from Bristol MIND.

Dave – team manager for a Bristol Continuing Needs Rehab Service.

Kate – manager for Disability and Mental Health Support Services at City of Bristol College.

Jon – community occupational therapist from the AO team (and lead researcher).

Jenny – service user who was unable to attend but contributed by email.

What was learned about effective CIS working?

The learning history focused attention on two areas of learning. First, it indicated the key intra-group factors that had underpinned successful CIS work and fostered a ‘community of inquiry’ and, second, it revealed other external factors related to the wider organizational structures within which the CIS operated.

1) The CIS as a community of inquiry

It was evident from the outset that actionable learning would only occur from reflection on the real issues that arose from real life practice; not on abstractions regarding the ‘idea’ of social inclusion. Focusing on practice allowed CIS membership to crystallize around a practical, shared task – ending an initial period of inertia, characterized by unpredictable attendance:

Kate: If it was the task that we all have as an interest together individually, it’s brought us together as a group.

Collective dialogue about an action plan allowed CIS members to get to know one another in relationship rather than in role (Whitney & Trosten-Bloom, 2003). This highlighted how people’s work connected; what they could ‘do’ together – transcending habitual mindsets about practice. This was vital because, whilst individuals’ passionate commitment to social inclusion had spurred them to join the CIS and gave them a stake in determining how exclusion could be addressed, this ‘stake’ also brought with it unacknowledged assumptions about what should be done. The CI/AI approach liberated individuals from the individual shackles of should and re-focused them on the collective potential of could. Differing skills, knowledge-bases, and an extended range of colleagues were brought to bear on the same task. This offered new perspectives on ‘old’ and hitherto intractable problems and represented a source of social capital within the CIS. Social capital is a resource within communities comprising qualities such as trust, reciprocity, and engagement (HDA, 2004). This inquiry suggests this ‘capital’ was available within a ‘community of inquiry’ too.

These cross-functional relationships and the common language they fostered – born out of an urgent desire to plan action – were contributory factors in effective inter-agency working and outcomes of it:

Jon: Trying to develop socially inclusive services . . . is quite a conceptual process isn't it? It involves wrestling with ideas. And you have to translate them into what your task is. But you need that bit of consensus on what the ideas are to know what you’re doing, so I think the strength of this sub group is that we've had the chance to do both.

Dave: Yes, but not necessarily recognize that we’re doing both . . .

Kate: It just kind of happens.

Though the CIS was a task-orientated group, facilitated co-operative inquiry helped it claim the right to reflection as well as action. This was vital for CIS members, whose respective health and social care work cultures expected immediate action and quick results. Indeed, it was striking how readily the CIS took to co-operative inquiry:

Facilitator: It strikes me that what you’ve created is not just a group who want to do something well but also a group who comes together to ask questions of each other and of other things that you do and you know. So you enquire as a community, as well as being practitioners in all of your various skills. So holding that . . . being both the committee of inquiry for the wider practitioner community, and being a group that wants to make something happen, is I think quite often unusual in the structures that we all work in.

2. The wider organizational context

There are two themes in this consideration of the CIS’s organizational context: senior support for change implementation ideas that emerge at the grassroots level of an organization and the involvement of service user input in service development. Both are about power.

Senior support

The development work proposed by the CIS was difficult to implement. Although (or maybe because) four separate organizations were represented in the CIS no single commonly acknowledged lines of accountability for its collective work existed. Adopting a long-term perspective highlighted a need to locate the CIS within a stable local structure so it could exert some upward influence to address this. It also highlighted a need for protected time for its members to do the work and for senior support of the CIS’s action plan:

Emily: For me it’s about ‘the time thing’. For me that’s where it gets tricky, because we work for four different institutions effectively. So . . . how can the Social Inclusion Forum seek time . . . from our employers to do this work?

Kate: We could do that couldn’t we?

Emily: I mean we could do it, but we’d need – I suppose what I'm saying is

Dave: Where do we get the clout?

Whilst not having a structure was disabling it nevertheless allowed the CIS to create its own vision. Indeed, this contributed to the emergence of the CIS’s free-speaking forum. ‘Planning lite’ (as it was dubbed) was a way to create enough workable structure to enable progress – step-by-step:

Facilitator:It’s like ‘planning lite’, isn’t it. . . . It’s a bit like, you know, you get ‘lite spreads’, so ‘planning without the calories’ . . . that just about ticks other people’s boxes to get you what you need.

What the CIS needed, and lacked, was ‘clout’ or influence. A crucial aspect of AI is that it tries to get as much of the system working together as possible; aiming to be both ‘top-down and bottom-up’ (Whitney & Trosten-Bloom, 2003). In AI terms, the ‘right people’ are a group that can critically reflect on practice together, consider new solutions, and initiate change. Whilst the CIS did bring together stakeholders from education, mental health service provision and service use, hindsight suggests that this group needed to be expanded from the outset to include more senior managers, or (using hindsight to stimulate future learning perhaps) this inquiry should be the springboard for further co-operative inquiry that would include them.

Significantly, the decision to use AI in this inquiry was a pragmatic decision made by a single practitioner-researcher rather than a strategic decision by the powerful within the organizations concerned. Whilst the CIS was like a core group inquiry (Whitney & Trosten-Bloom, 2003) – where a small group of ‘representatives’ act in the service of the wider organization aiming to establish a base of enthusiasm and momentum – representation did not extend ‘upward’ far enough. There was no systematic take up or senior sponsorship. Ideally, the necessary role for leadership or management is that of ‘sponsors’ or ‘positive change catalysts’ and preparatory work (prior to engaging with AI) would first establish the parameters for change and explore what they are ‘customers for’ in terms of development (Cooperrider & Whitney, 2005; Watkins & Mohr, 2001). This was a fundamental lesson learned.

Nevertheless, the CIS acknowledged the need to take some authority for itself, regardless of context, by deciding to build on its core membership. It turned its ‘powerlessness’ into a development need. It communicated its ‘learning community agenda’ to the main forum, aiming to reinforce that forum’s lobbying power (it was the forum for promoting social inclusion locally and was ostensibly endorsed by local health and social care commissioners) and so gain greater access to community partners with ‘executive power’, who would be invited to attend.

Service user input

Service user input to mental health service development has long been good practice (NSIP/CSIP, 2007, 2008) and has also been seen as an issue of democratization within a historically paternalistic service (Campbell, 1999). Consequently, considerable effort went into ensuring an authentic service user voice was heard in the CIS.

However, in practice, the ‘service user voice’ appeared to be something widely sought but narrowly viewed. It has been acknowledged that service user input within mental health services can sometimes be tokenistic; with service users being invited to meetings ‘in which the ‘‘pause button’’ is subtly deployed whenever a service user speaks’ (Cowden & Singh, 2007, p. 20). Service user input to the CIS was initially poorly provided for in terms of clarification of its role and practical support given to it. When the CIS began, for example, service users’ attendance was unpaid and ad hoc. This undermined continuity of input and impacted negatively on the way service users’ contributions were viewed. They represented an important stakeholder view that felt itself overlooked in the normal course of professional deliberation about social inclusion. A service user member (Jenny) who was unable to attend the focus groups but was invited by the facilitator to do some freefall writing at home and share it by email commented:

Jenny: I’ve always been very conscious of the huge chasm between us as service users and those as staff . . . There are big differences in the understanding of social inclusion between service users and staff and staff’s interpretation is always somehow more valid. . . . Social inclusion can never move forward until there is consensus on what social inclusion means, and that definition cannot be decided solely by professionals . . . Our participation always feels very limited . . . My one comment regarding the subgroups is that staff have been paid to attend them while service users have not.

This observation (circulated to CIS members in the second focus group) prompted discussions about the support and briefing for service user representatives and an agreement was reached whereby two service user places would be identified in each subgroup, to be paid at the minimum wage rate. The result was regular commitment from a group of service users who were aware of each of other and able to confer and be more truly representative.

Discussion and interpretation

In terms of highlighting the generative capacity of co-operative inquiry with an appreciative stance, this inquiry helped individuals to find common ground, encouraged them to adopt a long-term, evolutionary perspective of service development and maintained an appreciative or affirming viewpoint. Some reflections on external facilitation are offered here also because this was an important catalyst in the inquiry process.

Finding common ground

In becoming more community-orientated, mental health services have necessarily come to engage with a wider range of stakeholders and perspectives regarding what constitutes a ‘good service’ – emphasizing the need for a whole system approach to community participation.

Bates (2010) invites stakeholders to acknowledge all dimensions of community mental health practice such as engagement, empowerment and citizenship, and to consider how the demands of each may be complementary or conflicting and in need of reconciliation. CI made these dialogues possible. By facilitating a shared understanding of differences (that may otherwise have been superficially viewed as ambivalence or resistance) it created a forum for discussing un-acknowledged historical cross-functional conflicts. These could have been all the more damaging for being felt but not necessarily understood. Instead, CI directed attention to areas where the social capital between agencies was most abundant.

Adopting an evolutionary perspective of service development

AI’s solution-focused approach was vital. For the lead researcher, it meant the initial sense of being beset by culturally entrenched views was quickly reframed as an opportunity, indeed a vantage point, for exploring different agency ‘cultures’ in search of common ground. The inquiry sought insights into the systemic patterns of thinking and acting within the partner organizations but also into the constructs and meanings which arose through collaboration. Systems thinking offered a way of recognizing the system which the researcher found himself in, of locating his place within it, and of engaging in dialogue about alternative constructs regarding people’s work settings and their actions within them (Coghlan & Brannick, 2010) – part of the critical reflection described earlier. Thus, a fusion of CI and AI was well-suited to the task of advancing knowledge in the complex, multi-stakeholder environment that community mental practitioners, their managers and community partners necessarily inhabit.

Significantly, by adopting an appreciative long-term perspective and occupying common ground, CIS members came to a better understanding of how current practices were caught in the web of the historical organizational cultures and practices that had produced them. In seeing the deficiencies of existing practices as a product of circumstances, they could recognize that these practices were (for the most part) devised as solutions in their own time to tackle a problem that existed at that time. Participants were therefore freer to develop ideas about how they themselves might transform the practices which they and their organizations were engaged in. Instead of feeling they were part of a problem they felt they were part of the overarching forward motion of service development.

The fact that inter-agency relationships were task-orientated and cross-functional meant that CIS members could acknowledge and try to address the problems of cultural ‘silo-working’, defensiveness and blaming. ‘Silo-working’ refers to the kind of introspective organizational culture and structures that offer only limited opportunities for exchange across departments, rendering the organization inflexible and defended in the face of change agendas (Douglas, 2009). Given the prevalence of silo-working senior sponsorship was essential.

Maintaining an appreciative stance

Remaining appreciative in the face of challenging work brought some dynamics between CI and AI into focus. There was much common ground but also some essential differences. Both CI and AI recognize the change-potential of experiential knowing and that such knowing is represented in people’s language, echoing the action research principle that inquiry is intervention (Koshy, Koshy, & Waterman, 2011). Furthermore, there is a shared emphasis on the practical utility of reflection; on deriving new learning about past and current activity in order to shape future activity. CI harnesses rich tacit knowledge in the service of actionable know-how, AI encourages a free-thinking ‘Dream’ phase to envision a desired future, and both can be seen as ‘emancipatory’ in helping people identify and release themselves from the constraints embedded in their habitual ways of working (Kemmis & McTaggart, 2008).

However, there are significant differences between CI and AI. Heron and Reason (2008) suggest that the social constructionist notion that knowledge is socially constructed and mediated by language may result in ‘missing out’ experiential knowing – that is, ‘knowing’ which is as yet unarticulated – which is so important in PAR.

For this reason CI with an appreciative stance accessed such tacit knowledge and gave prominence to experiential knowing at, arguably, the most crucial time – when inquiring into issues of agency and implementation in the CIS. The linchpin of the CI process was that CIS members stepped out of their working role and critically reflected on it. Developing practice as new ideas unfolded in reality was essential because services could not generate or describe a theoretical solution to the deep-rooted problems of social exclusion – things had to be ‘tried out’ – and the experiential knowing of those most intimately involved in delivering services was most valuable in unlocking and applying any new learning.

Critics of AI have questioned whether its ‘positive’ stance might miss the opportunities for positive change that can emerge from negative experiences (Fineman, 2006, cited in Zandee & Cooperrrider, 2008). Here, the CIS adopted a positive, asset-based view of difficulties (in relation to the lack of senior support and the challenge of accessing an authentic service user voice, for example) and regarded this as a way of positively framing the experience of challenging ‘real life’ work. It considered issues that came into view as it explored ‘what might be’ in the AI Design phase, recognized that it was not realistically possible to free itself completely from constraints in order to ‘dream’, and translated this into an acceptance of responsibility for taking some action – or finding some ‘clout’.

Barge and Oliver (2003, cited in Zandee & Copperrider, 2008) have suggested that an over-exclusive focus on positive narratives might also silence or stigmatize critical voices (from those whose experiences have not been positive) and merely bolster the ‘elite’. This too was an issue in the CIS. On the basis that AI’s essence is its ‘generative capacity’ – its ability to challenge the status quo (Zandee & Cooperrider, 2008) – these critical voices (such as Jenny’s, quoted earlier) were an essential component of the CIS’s co-operative inquiry. Their incorporation was made possible by external facilitation which counter-balanced the habitual dynamic referred to by Jenny, whereby those with greatest power might have had their customary say at the expense of more marginalized individuals and groups. Hearing this voice allowed positive change to occur; underlining that the ‘best help’ in co-creating a learning history may come from those offering criticism (Roth & Bradbury, 2008). Overall, a broad understanding of the term appreciative – one that recognizes that the greatest generative capacity is based on the most inclusive range of contributory voices – works best.

Reflecting on external facilitation

External facilitation was pivotal in accessing tacit knowledge, making it actionable and maintaining critical subjectivity. It supported authentic collaboration by helping to manage the equal contribution of all participants, guarding against self-delusion and/or collusion between participants and preventing domination by individuals or subgroups. Because the CIS included service providers and service users (between whom unacknowledged historically imbalanced power dynamics existed), and two service managers (one of whom chaired the CIS) it was important that members were helped to recognize any potentially damaging dynamics. Significantly, freefall writing allowed individuals to say what they felt, rather than what they thought they ought to say as part of a professional or hierarchical role.

Facilitation also structured the group’s progression through stages of individual reflection, conversations in pairs, and group discussions; ensuring personal ‘findings’ were shared with the group directly so that individual experience and reflection remained open to collective experience, and vice versa (De Venney-Tiernan, Goldband, Rackham, & Reilly, 1994). This research cycling or validity checking helped individuals to consciously hone themselves as reliable research instruments without sacrificing the richest resource they possessed – their experience – in a misguided quest for ‘objectivity’. It not only ensured that the personal and the collective were continuously shaped by each other so that the group was kept informed of what was happening for individual members, but it also meant that individuals’ experiential knowing could find expression. Overall, CI was not only a valuable inquiry tool but a milestone in the development of the CIS’s group cohesion and its sense of identity as a lobbying force. Group members felt fully represented in the collective action agreed.

Conclusion

The CIS was committed to a facilitated critical reflection on its achievements because it had lived through those experiences as a working group. This process allowed important qualities to be consciously developed as a resource for its ongoing work – highlighting how ‘action’ and ‘inquiry’ are entwined. In AI terms, the focus group only had to bring ‘into focus’ what already existed in order to learn from and replicate the root causes of its successes. This enabled the CIS to go on to identify further needs, such as identifying a clearer local structure within which to operate. In becoming more critically aware of its own experience the CIS was enabled to develop new understandings of its task and its potential, including new action.

The emphasis on synthesizing different ways of knowing was central in this inquiry. PAR deliberately sets up a two-way process. It involves reaching out from the specifics of individual experiences to explore the potential for change locally, but it also reaches in from the position of national agendas and drivers (in this case, about social inclusion) to explore how useful they are in providing those people most immediately involved in the local issues with a critical grasp of the problems and issues they are dealing with (Kemmis & McTaggart, 2008).

The CIS’s collective presentational knowing (built through discussion of individuals’ experiential knowing), and the capacity to use this to critically engage with propositional knowing from national drivers is considered to be a strength of this PAR. The key was allowing experiential knowing to inform other ways of knowing; and to bring this learning process to fruition through practice; that is, in terms of skills being brought to bear on a practical task (Heron & Reason, 2008). Features of the national social inclusion agenda (policy espoused) were critically engaged with by the CIS in order to promote inclusive practice locally (policy enacted) based on an appreciation of what service users found most acceptable (policy experienced).

The vital ‘bottom-up’ flow of knowledge drawn from individuals’ experience greatly enhanced its applicability in practice. Moving from the first-person research orientation of practitioners’ initial reflections (‘how do I change my practice’), to the second-person orientation (‘how do we as a team change our practices’), to the third-person orientation of collaborative CIS exploration (‘how do we work together to change our system of working’) this inquiry ultimately aims to disseminate learning more broadly, contributing to a wider community of inquiry in doing so.

Footnotes

Jon Fieldhouse is Senior Lecturer (Occupational Therapy), in the Department of Allied Health Professions, Faculty of Health and Life Sciences, University of the West of England, Glenside Campus, UK.

Steve Onyett is Director of Onyett Entero, Associate Professor at the University of Exeter, and Visiting Professor at the University of the West of England and the Inclusion Institute at the University of Central Lancashire, UK.

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