Democratising the discourse: co-production in art therapy practice, research and publication

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© 2021 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group

By definition co-production actively invites diversity and participation, but some contexts lend themselves more easily to this approach than others. If art therapy is placed within the broader mental health treatment field, it must engage with a difficult history of power abuse, stigma and exclusion. We present an argument here that these issues at once make co-production methodology more challenging and more needed. However, in acknowledgement that power and exclusion have themselves so often been transacted through language and labels, we wish to clarify the terms we apply to the roles individuals may take in the co-production before proceeding to that argument.

We broadly define co-production as people who use and provide art therapy services working together to develop theory in such a way that values both the consensus and differences between each perspective. We use the term service user to describe an individual’s action of seeking help from an art therapist or professional but without implying any lasting personal characteristic of that individual. Service user is currently one accepted term used in the UK, but it is not without limitations, particular in potentially implying a transactional or passive stance which is not intended by our use of it. We refer to lived experience researcher or lived experience practitioner to denote the role of a non-professional involved in co-production, and explicitly differentiate that capacity from the term service user. Other authors in this special issue have chosen their own terms as they saw fit.

Co-production can be applied to both practice and research. In all cases, the methodology requires flexibility to ensure those contributing lived experience will share control and influence with professionals. To our reading, the matter of how lived experience is given form to be communicated amongst co-producers is a primary consideration in that flexibility. For example, approaches which assume all partners can use words to describe experience immediately disadvantages those whose verbal communication is challenged by developmental, cognitive or traumatic factors. Conversely, strategies which draw on a range of communication forms increase inclusion and thereby the potential effectiveness of projects. We suggest it is to this, arguably under-studied, area of co-production methodology that this special issue may make a particularly valuable contribution. We hope the examples presented will be of interest both within, and beyond art therapy in demonstrating how art can mediate co-production where people cannot find the words to otherwise be involved.

We are grateful to be offered space in this editorial to explore co-production in greater depth. Our aim in doing so is pragmatic: to draw on both literature and our project experience to elucidate practice points for those considering co-production approaches. One feature of practice we share with other authors published here, was that our initial collaboration was therapeutic, where Springham (NS) was Xenophontes’ (IX) art therapist in a National Health Service (NHS) setting. At the close of that therapy we moved from those roles to act as colleagues within the same organisation. We discuss the learning involved in that transition below. Our co-production experience then took various forms within and outside of art therapy, both together and in separate projects. Although this experience was varied, it shared a common feature in that no project we encountered ever simply progressed from plan to action to outcome. All involved negotiation, revision and effortful perseverance to succeed. By contrast, most published projects we read gave the impression that a linear process was the norm. For this reason, we wish to emphasise that we have chosen to focus our discussion on co-productivity principles, rather than procedures. This is because, in a practice reality where it is important to respond coherently to continuously changing circumstances, we found principles were the better guide. Moreover, clarity about those principles also offers a framework for us to discuss the wider potential impact co-production methodology may invite for BAAT and art therapy if the practice continues to grow.

Defining the principles of co-production methodology

Although the term co-production can simply refer to a method or research tool, its adoption as a methodological approach requires that certain epistemological assumptions have been visited. Epistemology is ‘the theory of knowledge, especially with regard to its methods, validity, and scope, and the distinction between justified belief and opinion’ (OED, 2021). We propose selecting co-production methodology as a focus for IJAT represents an ongoing paradigm change in how UK art therapists consider the validity of theory generated from within their professional body. How striking that, just as it nears its seventh decade, rather than opt for approaches which consolidate existing professional knowledge, BAAT knowingly embraces one of the most disruptive methodologies of all. To appreciate the scope of change such a paradigm-shift may involve, it is necessary to start by revisiting some fundamental concepts about how professions relate to the subjects they practice and represent.

Professions are formed when those involved in delivering a particular practice construct a group around an explicit shared purpose. Professional membership then defines who is either included or excluded from that group (Romme, 2016). Professionals seek trusted status by offering assurance that public good and practitioner commercial interests have been separated, primarily through standardisation of training, codes of ethics and regulation (Gardner & Shulman, 2005). Professions then form learned societies to collect membership experience and progress subject-specific knowledge. In BAAT this operates through special interest and regional groups, the art therapy practice research network and IJAT. Co-production perturbs the professionalisation sequence by questioning who has legitimacy to comment on a subject. The methodology cannot be merely inducted into a professional structure if the assumption is that only those who are registered practitioners can be take part in the learned society. Given IJAT is the organ of BAAT's learned society, the explicit invitation for non-members to co-produce theory reopens one of the most foundational questions, that of who actually owns art therapy as a subject.

Given the magnitude of disruption the question of subject ownership may pose, it would be reasonable to pause and reflect on potential costs or benefits such a revision may bring for BAAT. After all, professions have evolved because they are society's means of defending itself against quackery and exploitation. Professionalisation holds art therapist practitioners, as persons in positions of trust, to account. Yet, here it is helpful to re-clarify that co-production poses the most disruption to the end process of the professionalisation sequence, i.e., at the learned society phase. It is the subject of art therapy theory that is re-opened, and this question does not invite an experiment in letting anyone practice as an art therapist without training and regulation. Granted, any credible development in art therapy theory from co-production should impact on training and regulation, but unless a fundamental flaw is discovered through the process, the paradigm aims to improve, not reject, the professional practice for providers and users alike. Comparable precedents demonstrate that ceding professional subject enclosure can, perhaps paradoxically, increase that subject knowledge. For example, Engle's (1977) research challenge to the medical model argued that though cardiac surgeons were an essential component of treatment, they alone could never build a coherent model of heart disease. The biopsychosocial model he advocated did spread subject-ownership beyond the surgical profession, but the resulting knowledge-gain helped both individuals prevent disease and increased the effectiveness of cardiac surgeons. Co-production between professional disciplines has increasing become a mainstay of modern health research, treatment, and policy. It has been central to the strategy to address the COVID-19 pandemic where disproportionate negative effects on particular racial, cultural, or economic groups could never be understood solely by biological scientists (O'Dowd, 2020). The meaning of subject opening to art therapy may become clearer if Fonagy's observation of his own profession is applied: ‘The discourse of psychoanalysis is too important to be left to psychoanalysts’ (Fonagy, 2001, p. 630).

A biopsychosocial theory of art therapy has become a tantalising prize. Comprehensive theory cannot be fully realised solely between professional specialists because art therapy itself cannot be created by professional art therapists alone. In practice, art therapy is always a co-productive event between those who engage in and provide that service. The co-production of art therapy theory attempts to address a deficit where, with few exceptions, art therapy practice was solely represented and theorised by art therapists for many of the profession's formative decades (Springham, 2016). The historical neglect of user experience has been widespread across health research. Mental health services particularly have been criticised for equating people with the diagnosis given to them and then claiming they lack insight to be involved (Rose et al., 2006). Disability rights groups responded by calling for ‘nothing about us, without us,’ a principle which places their movement a centuries long democratic struggle starting with power sharing from monarchy to parliament (Davies, 1984). The current NHS long term plan reflects their success. It acknowledges how the passivity engendered by top-down approaches to treatment has not led to a healthier nation and asks professionals to work with, not on, patients (NHS, 2019). So, whilst the subject of this special issue of IJAT may be a revisionist choice for BAAT, it is also a rational one as co-production offers the potential to redress these historical ethical and methodological imbalances:

[Co-production] involves the close interaction of many actors throughout the process of knowledge production and this means that knowledge production is becoming more sociably accountable. Overall, the process of knowledge production is becoming more reflexive and affects at the deepest levels what shall count as good science. (Gibbons et al., 1994, p. 4)

Compelling arguments can be made for why art therapists might consider a co-productive approach to theory building. However, whilst forming a strategic rationale is an important first step, it does not by itself offer a guide for practice. For this reason, we wish now to describe the principles which guided our project work. Most of our learning about those principles happened in the reality of practice and given the central the value of lived experience in this methodology, we use our own to suggest practice points.

Co-production method

We have collaborated in numerous practice and research co-production ventures over a nine year period. We were supported by NHS structures which aimed to increase the co-production of mental health services. Following an 18-month mentalization based treatment programme, our service offered a number of volunteer roles within the organisation. The service benefits by gaining insights from those who have recently experienced its care and the ex-service user gains skills and confidence in a supportive environment to help recovery. The opportunity IX chose was ResearchNet; a network where people with experience of using the services, carers and staff come together to use lived experience to co-produce improvements to the trust mental health services (Springham et al., 2011). ResearchNet reported its activity into Patent Experience, which is a mandatory aspect of quality assurance for NHS. IX chose this option because she has always been unsatisfied with merely accepting received wisdom about subjects that matter. She felt her therapy had worked for her and she wanted to know why it worked. The opportunity to develop and spread that understanding alongside practice had greater potential to benefit others.

The projects undertaken in ResearchNet used a range of approaches including Audio Image Recording methods (Springham & Brooker, 2013); auto-ethnographic research (Johnson et al., 2016) and Experience-based Co-Design (Bate & Robert, 2007). ResearchNet also collaborated externally with groups such as Time to Change, London Ambulance Service and London Metropolitan Police. IX undertook a Lived Experience Practitioner training and began employed practice within the mental health services. IX and NS co-design of psychoeducation intervention to meet the needs of people in a community mental health service. The resulting common foundations groups were co-delivered between lived experience practitioners and psychological therapists. During the pandemic these were repurposed to form a common foundations online webinar which attracted between 200 and 300 weekly views (examples can be found at http://oxleas.nhs.uk/common-foundations-online/). Our evaluations showed the co-delivery between lived experience practitioners and professionals, including the declaration where deliverers had previously been service user and therapist, was particularly valued by users of these interventions.

Our experience in the field leads us to estimate that, at the point of publication, co-production must still be classed an emerging practice in health care. Some projects claiming to be co-produced are merely examples of user consultation. Others confuse user led-research as co-production. For us, the key definition is that co-production must involve a creative meeting of differentiated perspectives to generate new understanding in such a way that no single contribution dominates. In this respect Gillard's six co-production research principles summary is very instructive:

1. High-value research decision-making roles distributed across the research team.

2. Different interpretations of data within the research team owned and understood in terms of how who we are has shaped the knowledge we have produced.

3. Consideration given to whether all members of the team were involved in the production of knowledge throughout the research project and the impact of this considered.

4. Methodological flexibility allowed in the research process where scientific conventions constrains the input of particular team members.

5. Rigorous and critical reflection on why the research was done in the way it was as integral to the conduct of the research.

6. Research outputs that report critically on how knowledge was produced. (Goldsmith et al., 2019 and Gillard et al., 2012 )

The clarity of this description lays bare just how radical a divergence from traditional research approaches the methodology may demand. Not every professional is prepared to accept that disruption. Given how much invalidation users can experience from services, their reluctance to trust they would be equals in projects forms another understandable barrier. Such factors still inhibit the proliferation of co-productive projects. Consequently, those undertaking co-production can find themselves with little sense of peers to link with.

We confess that in the months between putting the call for papers out in May 2019 and receiving submissions, we feared there may be little or no response. We were delighted to be so wrong and felt excitement at the possibility of community the submissions we received represented. For this reason, IX suggested that we offer all author teams virtual meetings and email contact to share experience and learning. We greatly appreciated the sense of connection that resulted and are grateful to those teams for permitting us to reflect their views below (included in italics). To Gillard's list we now wish to add points of practice about the use of art, changing from clinical to collegial roles and the importance of community throughout and after projects.

Art and co-production

Co-production requires that experience be presented as data in such a way as to be communicable to others and for triangulated with other forms of evidence used. In the context of psychological therapy experience necessarily involves adversity and distress. Consequently, some associated factors may militate against words being an effective medium to convey experience, particularly where:

• Developmental or cognitive barriers to verbal language apply.

• A history of attachment neglect resulted in alexithymia, a general inability to find words for feeling states (Allen, 2013).

• Abuse suffered may have been accompanied by threats against speaking out.

• Traumatic experience remains unformulated because the neurobiology of fight/flight/freeze compromised the representational function of the pre-fontal cortex (Damasio, 2010).

• Verbal re-telling of trauma has the potential for re-traumatisation.

Here, we propose art therapy can offer some unique solutions. Artworks are developed through a process of establishing emotional security where control and pace are ceded to the service user. Artmakers have the choice of how to conceal or reveal the meaning of their artworks and this can reduce disclosure fears involved in verbal language. As one lived experience author reflected, he was told what not to say but no one told him what not to draw. Art therapists use trauma informed dialogue to link imagery with emotional states to create safe awareness. The communication involved in that art therapy process develops a language (verbal and pictorial) for feelings, thereby reducing alexithymia or other verbal barriers. These clinical approaches to art-making can translate to research. For example, timelines form an important process in utilising experience in co-production (Bate & Robert, 2007). Because artworks have given a form to feeling that is recorded in a material object, those art objects can be added to a timeline to form a narrative that includes lived experience. Art can then form the type of experiential data which can be viewed by others and triangulated with other evidence in a research process.

From clinical to collegial relationships

The consensus we found in our meetings with authors was that the trust between therapist and service user helped, rather than hindered their clarity and openness in research. This supports an earlier finding in Springham and Brooker (2013). However, it would be naive to assume this sample of opinion from successful teams implies that process is a given in all cases. The relational transition from therapy to research is a considerable matter which may impinge on capacity and duress. We therefore now wish to give attention to these issues and explore how boundary adjustment may be negotiated and what supports may assist.

Capacity and Duress : All papers involved authors combining therapeutic with co-theorist relationships. This mirrored our own and other ResearchNet experiences. Such dual relationships require consideration, particularly in relation to asymmetric power dynamics involved in therapy. Many intersectionalities between race, gender, class and more, are already at play in the therapeutic encounter. Locating both parties in their specific matrix of privilege and oppression must be a deliberate act of work (Eastwood, 2021). Therapy amplifies those differentials because it begins at a particular moment of vulnerability for those who use the service. The process then requires the service user develops epistemic trust in their art therapist. Epistemic trust affects how people value their own thinking or what they perceive is acceptable to say or not say (Fonagy et al., 2015). This feature can be misused by professionals (Springham & Huet, 2020) and so can pose ethical problems and threats to co-production research validity.

We asked author teams to address whether therapeutic mechanisms such as epistemic trust or transference might inhibit critical or unbiased participant involvement. Author teams described open discussions about duress issues as part of their process. Some lived experience authors admitted they had initially viewed publication as a means of validating their art therapist. The aim of theory building as understanding mechanisms which make therapy more generally effective, not validating their therapist, was new to some. Once understood it shifted their focus from helping the therapist to helping others and that became a powerful motivator. Lived experience authors countered that it would be stigmatising to assume they would be so consumed with their therapists that they were rendered incapable of differentiating between these two aims. They were surprised that any therapists would have such a low expectation of psychological outcome for the service they provide. We would also add that such a presumption would likely breach the 2005 UK Mental Capacity Act. Furthermore, one lived experience author suggested that if he did feel his therapist was good, that would be a very valid object of study because it meant that whatever it was they were doing could applied to other therapists to increase their effectiveness.

We accept these responses come from a particular set of successfully transitioned co-production cases. It may also be argued that such success is related to therapist transference biases the selection of who takes part to include those who appreciated their therapy. Co-production will be much more difficult where there has been a negative experience of therapy and lack of study in that area will be a loss to theory. We suggest this still represents a limitation to the co-production knowledge to date and does require more research. However, the case of ResearchNet may add some modest evidence to the discussion because most members are not selected by the therapist. They self select through the volunteering services. Moreover, where the selection has been made by the therapist there have only been two cases in 11 years across six groups where personal feeling became a barrier to collegial working. These were resolved by facilitated meetings which allowed discussion of the issues and resulted in other involvement opportunities being satisfactorily offered elsewhere. Compared to the volume of people who have transitioned from therapy to ResearchNet, these instances form a small subset of the total. In terms of addressing difficult issues, where groups involve a mix of people who worked with the therapist and those who did not, there was high consistency between opinions provided on key issues of treatment as inpatients, including negative experiences (Springham & Robert, 2015).

IX suggests generalisations about service user incapacity to take part in co-production fit within a more pervasive assumption that service users are not capable. She suggests this can often result from professionals having repetitive and narrowly problem focused encounters with people who use their service at their most vulnerable moments. This can drift into a presumption that service users have zero background other than the problems they came to services for help with. In ResearchNet we accept that some who have used services may have discrete areas of challenge, but these can be accommodated as reasonable adjustments under the 2010 Equalities Act as per any other employee. IX adds that co-production with professionals offers an opportunity for those who previously used services to bring strengths, work skills and capabilities to be experienced by the service user and professionals alike. This includes asking lived experience researchers to be open to staff perspectives, disagreements, and challenges. This can have many benefits to the general culture of care in service provision. NS notes experiencing ex-user competence has become important in recalibrating his therapeutic stance, particularly in addressing any unwitting ‘othering’ of service users which can accumulate from solely meeting via clinical contact. Working with lived experience researcher/practitioner’s competence has reduced his unhelpful fragilization of those currently using services.

Our experience of increasing the ways users and providers of services connect adds more confirmation to Allport's well supported contact hypothesis which states:

[Prejudice] may be reduced by equal status contact between majority and minority groups in the pursuit of common goals. The effect is greatly enhanced if this contact is sanctioned by institutional supports (i.e., by law, custom, or local atmosphere), and provided it is of a sort that leads to the perception of common interests and common humanity between members of the two groups. (Allport, 1954, p. 281)

However, that contact with user-competence can have a secondary cost of mildly amplifying personal anxiety in the provider role. Reflecting, NS notices co-production eventually dissolves any sense of essential differences between those who use or provide services. That realisation then generalises to therapeutic practice where it confronts him with the reality that ‘this could be me’ in all the distress situations encountered. This reaction fits Menzies Lyth's (1960) proposition that some professional boundaries may serve a defensive function for professional against the experience of shared human vulnerability the care task exposes them to.

Boundary adjustment and boundary violation. We suggest there are a number of considerations to be held in mind in this process. Co-production between ex-service user and therapist will always begin with the extent of personal information known about each other differing radically. The methodology requires a different form of presence for both parties, in some ways more personal for the therapist and less for the ex-service user. This requires monitoring because an increase in personal presence could become conflated with a personal relationship. Cases of boundary violation show a drift towards the therapist introducing their own needs into the relationship as if it were an equal personal relationship. However, it is useful to consider that this problematic move was typically accompanied by the therapist simultaneously isolating that relationship as they did so (Springham & Huet, 2020). Co-production projects can be structured to offer protective factors against this combination. Many teams, including our own, found project work placed the relationship in the public arena. Workplace norms were applied such as workplace/time meetings, a managerial context and supervision. In our case, ResearchNet is group-based, encourages participants to actively become involved in other beyond the group's own confines. These offer some considerable mitigation against those abuses of trust that require isolation to be imposed.

We also suggest it is possible success in the transition between clinical to collegial roles may be determined by the assumptions inherent in the original treatment model offered. Where the professional acts as an expert dispensing insight to an incapacitated service user, it is conceivable the equalising of power may be too great to change. It is helpful that some authors included the elements of their supervision in this respect. Hierarchical practice here also can act against co-production by exercising another form of asymmetric power in the therapeutic relationship, often in an unaccountable way. Della Cagnoletta, one of the supervisors and co-author, reflects:

We have been thinking and thinking about (the supervisory relationship), in order to eliminate that part of “superiority” in it, but I think we never managed to find a good word – even if intervision and co-researchers addressed the problem of creating a space in which each person is bringing her/his own competence, knowledge, experience, etc

This team offers an interesting perspective that co-production can position the service user in an additional supervisory role within the therapy. Hetherington states:

In terms of my relationship with Fabrizio (lived experience author), as his therapist, co-production was so important to me as a process to question myself, to understand where I had failed him, not in an absolute way, but in terms of being a good-enough therapist but not a perfect one. Working with him on the article, I realized at a much deeper level what it meant to come out as transgender, and I realized how I hadn’t realized this when I had actually been his therapist. This is positive in both ways, as it indicates that with sensitivity and humility you can still be a good enough therapist even when you haven’t understood some key things; and on the other hand, it makes me feel better prepared to carry on working with people transitioning (without falling into the trap that any two individuals have the same story).

For us, the non-expert mentalization model offered compatibilities with the ResearchNet role because both relationships are side-by-side partners in investigating perceptions. This form of power sharing as a therapeutic element has strong precedents. Similar power transitions within therapy, or ‘democratic analytic’ principles, were a core element of therapeutic community models from the York Retreat started in 1796 (Stanley, 2010) and Northfield Military hospital in WWII (Harrison, 2017) onwards.

Re-telling is a mixed experience, but community is protective. An LXR team states: We view lived experience-based research as vital to understanding if, how and in what ways a therapy is effective. We agree and see this as an essential component of theory building. The process of re-telling or depicting experience and then sharing it is powerful. IX suggests lived experience in publication is a multifaceted process, where pride is mixed with some anxiety about who may read what is said, no matter how anonymised it has been. Just as powerful is the sense of sadness for what has been described, at how bad things were on entering therapy. The distance writing brings the question; ‘was that really me?’ A lived experience author echoes this:

When I read your invitation I was quite happy about it until I had to type my experience on the computer. I remember dropping some tears in the first lines. I was thinking I do not want to remember my old past issues, but in the process of writing, I realized myself that I was quite relaxed and calm. It was a challenge for me to see how I can see my sad past. An experience that was quite sad, but it is over now. I am not living in the past, hurting myself remembering my sad life experiences.

There is a need for collegial support at the preparation and post-telling and publication phases of projects. This includes the lived experience researcher having explicit control of recordings (paper, audio, or film) at all points in the process until publication. We remain critical of projects where user experience is taken without an ongoing collegial relationship as this has been the most powerful way mitigating potential negative effects of publication. Many of us fear our story is odd, shameful or will bring us problems if revealed. Ongoing relationships, and particularly with others who have experienced similar experiences, are very helpful. When done well, the effect of re-telling can bring a sense of empowerment through ownership of one's own narrative. As another lived experience authors told us:

(Writing the paper) has been so transformative for me to feel like I have a voice and am not represented as ‘unwell’, ‘incapable’ or ‘infantilized’ by having my experience needing to be translated through the eyes and ears of a mental health ‘expert’.

This statement powerfully conveys that the purpose of finding an authentic voice in therapy is that it can be used beyond therapy: Epistemic trust can lead to epistemic justice.

Discussion

Revisiting assumptions about professional subject ownership can improve subject knowledge to benefit all. In the case of art therapy perhaps it was a helpful foresight that BAAT was founded as an association of art therapists, and not art therapy. Equally, whilst subsequent statutory regulation through the (now) Health and Care Professions Council legally protected the title art therapist/art psychotherapist in the UK, it also did not confer ownership of the practice of art therapy to anyone. Such definitions may clarify helpful limitations to subject ownership and invite co-production.

Art therapy has much to add to co-production and co-production has much to add to art therapy. Knowledge is accumulating about how to enact the methodology with greater effectiveness and safety. Indeed, it would be inaccurate to position this special issue as a starting point for art therapists’ engagement with co-production. The present publication adds to an observable trend towards the adoption of more inclusive methodologies across a range of BAAT's academic outputs. BAAT's annual conference series, Attachment and the Arts, has included lived experience presentations alongside those from external academics and art therapists as standard since its launch in 2010. Successive IJAT editors-in-chief have supported the increase of co-produced publications since 2008. The present editors-in-chief, Alex McDonald and Susan Carr, were purposefully appointed for their skills in co-production and have since instigated structural changes to IJAT that embed an expectation of increased lived experience inclusion. These include upgrading the journal's advisor system by appointing the first Lived Experience, Dual Experience and Young Person Liaison advisors who critique the journal's progress and appoint and train new associate editors. New IJAT templates for research papers, practice papers and opinion pieces require that: ‘When appropriate, submissions of co-produced papers written with rather than about service users are encouraged.’ Plain-language summaries have also been introduced to make art therapy literature more widely accessible beyond a professional audience. It is clear then, that there is an appetite in BAAT for approaches which widen the eligibility for contributing to art therapy theory and we hope this special issue will help to consolidate this direction of travel.

We now wish to introduce the rich set of papers that result from the above processes. In doing so we ask the reader to note that papers deliberately use the different voices and languages of the various parties involved. Equally, not all co-authors wished to be named and so pseudonyms or similar have been used at their request.

The papers

The transitioning from military to civilian life has never been simple. The concept of home can become fractured between those returning and those waiting. DeLucia and Kennedy (2021) describe how participants in a US veterans setting undertook a participatory action research approach to co-designing the therapy programme they would receive. Key to participants was how the goal of ‘readjustment’ can be defined and then addressed.

Four papers demonstrate co-production from within the UK NHS setting. In ‘“The silent intermediary”’, Winter and Coles (2021) co-develop the narrative of art therapy for complex trauma. Here, clinical and research aims coincide, where artworks help to create a sense of control and a creative distance from the trauma. Chilvers et al. (2021) use art therapy practice from an 18 month Mentalization based treatment programme for people diagnosed with mild to severe emotionally unstable personality disorder. Here, a mixed methods evaluation used standardised pre and post measures with the use of audio image recordings. Users of the service became lived experience researchers, form a focus group and then co-develop themes with art therapists. There work centres the role of art in creating communication. Sigal and ‘Rob’ (2021) began work in a trauma service together as service user and art therapist to then transition into co-researchers of that work. Psychoeducation was used as a means of equalising power and augmenting an art therapy approach which integrated Eye Movement Desensitisation and Reprocessing treatment. Psychoeducation also formed a means of knowledge sharing to increase co-productivity between provider and user of the service. Marshall-Tierney (2021) examines making the process of service user and art therapist making works side by side in the session in a forensic mental health setting. Using co-production evaluation then becomes a congruent approach to understand the effects of this co-productive art practice.

In ‘Not female-to-male’, Italian colleagues Hetherington et al. (2021) offer three perspectives on a body tracing (as distinct from body mapping) as art therapy approach in an LGBTQI treatment setting. Symbolic use of the body in art has a powerful resonance for transitioning from female to male. The inclusion of clinical supervisor adds greatly, and extends early co-produced art therapy case studies methods pioneered by Gabriel Rifkind (Dally et al., 1993) This matrix account reveals powerful issues of visibility and particularly so in subjugated identities for those outer body is currently pathologised by collective notions of normal.

Ford et al. (2021) formed a writing team in Australia which reversed traditional case study approaches and hierarchy of voices. Seven users of an art therapy service independently submit their narrative of that therapy with an image of their selection. Wake challenges herself to respond as the art therapist and actively describes the process of adjusting her theoretical models in the light of the feedback given.

Conclusion

The realisation of a rounded biopsychosocial theory depends on the user voice articulating their experience of how art therapy works. As a lived experience co-authors states, this helps better locates the healing mechanisms between those involved:

I'm the master of my own recovery, not the therapist. Only I can transform my brain and feeling the personal autonomy of my own voice as equal in this process is critical. At its heart is balancing the need to understand and support the deep vulnerability implicit in the process of articulating what you haven't been able to do before as you progress through recovery, but the process of co-production in art therapy addresses this through the expertise of the therapist to provide you with a completely safe space to find and express your ‘voice’ using whatever means works for your brain. This is the ‘art’ as a critical pathway to being the leader of your own recovery.

In all the papers received, art therapists reported surprise at what they discovered about the service they delivered from those who received it. This adds evidence that no professional, however skilled, can claim omniscient understanding of the whole therapeutic process they undertake. It challenges those psychotherapeutic tenets which suggest the therapist can access the service users mind through processes such as symbol reading or countertransference. It was heartening that art therapists embraced their surprise at discovery as an asset to developing better art therapy as a legitimate stance.

We hope this special edition encourages more co-production from art therapists and colleagues because there is always more to understand about art therapy and how it could help people. We feel the inclusion of more diverse art therapy populations, perhaps where disability or developmental issues require advanced forms of art-based communication are used in clinical practice might further strengthen our understanding of art in co-production. We suspect such work is taking place and look forward to it adding to the knowledge generated when published. We conclude that this special issue demonstrates the appetite for a democratisation of art therapy is growing.

Additional information

Notes on contributors

Neil Springham

Neil Springham is a consultant art therapist and executive director of therapies at Oxleas NHS foundation Trust. He originally trained in fine art, qualified in art therapy in 1988 and has a PhD in psychology. He has practiced in adult mental health, addictions and specialised in therapy for people who receive a diagnosis of personality disorder. He was a course leader at the Unit of Psychotherapeutic Studies, Goldsmiths College, co-founded the UK Art Therapy Practice Research Network and was twice elected chair of British Association of Art Therapists. He founded ResearchNet as a network of linked service user and provider collaborative groups which use co-produced research to create change within mental health services.

Ioanna Xenophontes

Ioanna Xenophontes previously worked within the print industry within managerial roles for many years. Ioanna had early contact with mental health counselling and has since experienced numerous mental health interventions but found that art therapy within a mentalization service most impactful. Subsequently she worked within ResearchNet at Oxleas NHS foundation trust and led a number of initiative including Experience Based Co-design projects. She is an associate trainer and project facilitator in the method at the Point of Care Foundation, an advisor to the International Journal of Art Therapy, and a lecturer and mentor in art therapy, nursing and clinical psychology trainings at Goldsmith College, University of London, Canterbury Christ Church University, Kingston University and Roehampton University. She has trained as a lived experience practitioner within Oxleas NHS Foundation Trust and has regularly delivered psychoeducation sessions within its personality disorder services. She is in her final year of a psychology BSc. Her research interests are borderline personality disorder, co-design and co-production of services. She has published on her experience of the recovery phase after mentalization based therapy.