The Illusion of Inclusion: Co-Production as Performance

Photo by Shane Rounce on Unsplash

The reality of mental health and substance abuse is the intertwined effect, rippling beyond the self and through the closest to us; family, loved ones and carers. Despite this reality, interventions often focus only on the person directly suffering, failing to apply intervention design to the rest of the patient’s life and those affected within it. Co-production appears to be an inclusive, insightful and beneficial to the development of treatments, but is this really ‘equal’? In this case, is it that co-production of mental health or substance use resources is with loved ones, family members and carers, or in consultation with them? The difference between the two is the difference between power shared and power performed.

Mental health and substance use rarely exist in isolation; they unfold within ecosystems of family, relationship, and care; rippling outward. How much of the key to developing mental health and substance use interventions can be found in the involvement of the co-survivors: the ecosystem?

In the review by Carhoun and colleagues of 40 studies of co-production (the involvement of loved ones in the development of interventions), there are three key conditions highlighted that transform contribution from the loved ones into meaningful change:

1.   Safety and trust – a non-judgemental space to allow participants to speak their knowledge without being dismissed as ‘emotional’ or ‘subjective

2. Accessibility – The ease of attending and understanding, without the barriers of jargon or unrealistic meeting hours

3. Diversity of voices – no two carers or families look the same, the acknowledgement of diversity

When co-production fits this criteria, the participants feel capable of challenging assumptions, allowing a human side through. But what happens once the interventions have been implemented?

If out of the 40 studies, only 8 actually evaluated the experiences of the loved ones as part of the co-production process, what is the outcome of the remaining groups? As the projects moved forward, family involvement would fade, and the research studied in the review frequently failed to identify how the decisions were implemented and if loved ones were even compensated for their time or their labour, reporting inconsistent terminology eluding to co-production (‘co-design’, ‘co-creation’). These gaps expose how ambition for equity in participation still falters in practical design and measurement…so is this true co-production? Or is it misrepresented and lacking in follow through?

Co-production is happening but perhaps in a way that comforts the professionals in the place of empowering the people they claim to collaborate with, and often, the communities most affected by resource limitations, stigma and social exclusion remain under-represented and unheard, despite being the groups with the most influential experience to offer.  

True co-production is radical and honest, demanding the redistribution of power, asking professionals to relinquish control, and instead, welcome disagreement and sit in tension. If calling it ‘co-production’ is a front to imply virtue and an ethical standpoint, the meaning behind it is erased and it may be that more damage is done. Genuine partnership with families and carers welcomes discomfort in authority, it requires hard questions to be asked that may not be immediately answerable and allows the rejection of intervention frameworks, because that is what the work is. That is the outcome of shared creation; a moral exercise challenging what exists and shedding light on what needs to change.

And beyond research, what of everyday life? What changes when others are truly invited in? As managers, clinicians, policymakers, parents; does inviting others into the conversation mean there is room for new perspectives? The creation of a safe, accessible and diverse space to allow participation and accept the consequences may be the real truth in creating meaningful change; exchanging the illusion of ownership for the potential of growth.

Depth psychology acknowledges the shadow, something that every collective process has; the repressed material that often comes through without choice. In co-production, the shadow is control disguised as care. The need to control the outcome, despite good intentions. The professional identity that has been built on expertise resists the ambiguity and chaos of shared authorship. The human condition of emotion, grief and anger, threatens objectivity, and yet, this is the point.

Trust cannot grow without the acceptance of the uncontrollable; authentic collaboration requires integration,  the collaboration not only of voices but between one another. Instead of projecting the shadow, allowing it into awareness becomes transformative, and in practice, relinquishing the need to manage and define is exactly what is required to grow. Collaboration is a practice, not a performance, and the valuable suggestions that co-production evokes serve as a reminder that experience is expertise. To build trust requires a cultural shift; the delicate conditions of mental health and substance use support cannot be designed by experts alone, but in conjunction with those who live it every day.

For the full article by Carhoun and colleagues, published in Research Involvement and Engagement 2025, follow this link:

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