Valuing co-production in mental health

: exploring comics as a form of arts-based collaborative practice

Abstract

In recent years, public services in the UK have increasingly incorporated co-production and other participatory strategies into their design, commissioning and delivery. The stated aim of such strategies is that they should enable statutory, voluntary and community sectors to provide people with better value services, tailored to their needs, by involving them in decision-making about how they are run. However, the way ‘value’ is understood and how co-production is meant to achieve it remain contentious questions. This is markedly the case in the field of mental health, where service users and psychiatric system survivors are seen to be particularly disempowered, and the models for understanding the experience of distress are themselves contested. This thesis aims to develop an understanding of the value of co-production in relation to mental healthcare through engagement in, and analysis of, two examples of co-production processes. In so doing it asks: what does taking part in co-production mean to people who use mental health care and support services? In what ways can co-production be understood to create value?
To answer these questions, participants with lived experience of accessing support for distress were invited to engage in two separate phases of participatory comics-making, an innovative and potentially useful methodology for understanding distress, exploring social justice and promoting inclusion in mental health policy research. The first phase builds on service user and psychiatric survivor discourses that highlight the importance of subjective knowledge of distress, critiquing normative biomedical assumptions and challenging the imbalances of power that pertain between patients and practitioners, mental health service users and service providers. To do so, it draws on recent research, policy and the empirical materials generated over the course of two series of comics-making workshops, where people who have used mental health services reflected on their experiences of co-production, or the lack thereof, exploring ideas around creativity, empowerment and democratic inclusion. The second phase focuses on the co-production of a comic presenting work on participatory, person-centred strategies in social care and health by people who have experienced homelessness.
The thesis deploys critical perspectives from sociology, psychology and social policy, particularly the work of user/survivor academics such as Peter Beresford, Diana Rose, scholars of Mad Studies and their allies, to navigate the differing constructions of value used in health and social care and explore their relationship to the multiple and contested ways in which ‘mental health’ is understood. These perspectives are brought together to develop an ontological, epistemological and ethical basis for knowing and engaging with distress. This is then applied to the co-production processes of participatory comics-making and an analysis is offered of how the value of those processes was represented and experienced by participants.
The thesis finds that participants often experience co-production to be worthwhile, particularly in contexts where they work alongside service managers and commissioners to develop and implement care and support practices. However, there is often inadequate time and other resources available and participants in the research highlighted how a lack of person-centred approaches to support (among other factors) can preclude effective and meaningful co-production of services or broader system change. Participatory comics-making, while being similarly resource intensive and time-consuming, is shown to be effective in capturing complex ideas in an accessible form and promoting the viewpoints of those who take part. Nonetheless, the method risks replicating the inequalities that service users and survivors encounter elsewhere. For example, familiar tensions between open-ended and overly prescriptive approaches to co-production practice emerge, with both ways of working having potential to cause friction and result in equally disempowering approaches to co-producing knowledge.
The thesis concludes that co-production produces and elicits value in the eyes of people who engage in it where it is well-resourced and supported. Understanding the complexity of mental health and distress, particularly the entanglement of bodily experiences with socioeconomic and political discourse, is argued to benefit from a similarly complex understanding of methodology. Comics-making as a participatory process produces multiple experiences of value which, when contrasted with more conventional understandings of value within mental health care policy and practice, are novel in extending the possibilities of what may count as knowledge. The multiple inferences that can be drawn from comics offer an open space for stakeholders to understand value on their own terms and embed this in the services and policy they produce. The thesis therefore establishes that understanding how to mobilise the value produced through participatory comics-making and co-production more broadly requires moving beyond economic and biomedical arguments towards more nuanced constructions of social justice and wellbeing.

Date of Award	Aug 2026
Original language	English
Awarding Institution	University of Brighton
Supervisor	Mary Darking (Supervisor), Phil Haynes (Supervisor) & Helen Johnson (Supervisor)