Recovery colleges (RCs) represent innovation in mental health services. People with lived experience are brought together with professionals to design and deliver all aspects of the RC. This paper examines the transmission of roles when co-creating new mental health services. We conducted a critical ethnographic study and collected data from participatory observations in RCs at two locations and interviews with leaders with professional backgrounds and lived experiences. The analysis based on perspectives of communitas by Turner and social ties drawing on Barnes shows that co-creation practices imply the interplay between structure and anti-structure. In RCs, traditional service roles and normative structures in existing mental health services are dissolved or redefined. Some elements in this interplay are initiating sharing rituals, leaders' continuous assessments of what they share, and inviting participants to take on new roles and positions. Course leaders facilitate the co-creation of knowledge sharing and course content by initiating sharing rituals that promote equality and communitas. We can understand this dissolution of the normative social structure as a liminal state in which leaders gradually transmit into a new position with a less prominent professional façade. However, significant differences in social status and the daily lives of leaders and participants challenge communitas, indicating that the dissolution of roles can be temporary. We need more in-depth studies to discover the sustainability of roles in transmission in mental health services.
Research Article
Professional roles in transmission through sharing rituals: A critical ethnographic study of Norwegian recovery colleges
https://doi.org/10.21203/rs.3.rs-3586038/v1
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Recovery colleges
co-creation
transmission of roles
structure
anti-structure
sharing rituals
professional roles
course leaders
Mental health services face the challenge of providing care and services that are efficient and responsive to the needs of their population [1]. In recent decades, researchers [such as 2, 3-9] have noted that there is a need for greater knowledge and understanding of mental disorders as alternatives to dominant medical understanding and treatment. The need for change involves changing service roles and a more significant influence of people with lived experience that complement, challenge and expand the professional role and existing knowledge to improve services [10].
An effort to move services in this direction is that municipalities in Norway have developed RCs since 2017 for people with substance and mental health problems, inspired by RCs in England. Co-creation is among the highest priorities in developing RCs [11] and is an innovative process to solve a public task or a social problem by exchanging and applying the diverse experiences, resources, competencies, and ideas of different people [12, 13]. In RCs, co-creation means that people with lived experience are brought together with professionals to design and deliver all aspects of the recovery colleges [14]. RCs seek to achieve a strong community through co-creation and sharing culture. Their way of practising co-creation challenges the traditional hierarchy through equal relationships, with a reduced distance and a 'they and us' distinction between professionals and service users [15].
Previous research acknowledges that co-creation is essential to RCs [1] without describing how leaders and participants practice the co-creation processes. Few empirical studies on RCs focus on roles and what co-creation entails in the course. Related to professional roles, previous research found that the participation of healthcare providers in co-creation processes in RC affects their perceptions of service users and their passion and motivation at work. It involves changes in attitudes and professional practices, such as power dynamics, language, and information sharing [1]. The most reported change is a softening of established roles between leaders and participants [11]. Their study identified a beneficial impact on the well-being of leaders in RCs, although the level of responsibility was problematic for some leaders with lived experience. Bester, McGlade and Darragh [16] determined that co-creation in RC positively affected professional attitudes and power dynamics between practitioners and service users. Professionals have adopted recovery-oriented practices and established equal relationships with service users. Some professionals now shared their mental health challenges and felt greater empathy and less stigma towards service users. Professional knowledge and lived experience are equally valued. The articles in their study have discussed the change in the balance of power positively. However, sometimes, professionals find it challenging to adapt to their new roles as equals to service users [16]. Steen and Tuurnas [17] have studied how co-creation defines the role of professionals. They found implications for professionals on relational competence and facilitating and mobilising others. Furthermore, they highlighted the need for professionals to demonstrate an open attitude towards collaboration to motivate service users to co-create.
The literature refers to the role of the course leader with different concepts, such as facilitator, practitioner, trainer, and peer trainer. In this article, we use leaders with professional backgrounds and leaders with lived experience.
This paper aims to examine the transmission of roles when co-creating new mental health practices. It intends to describe how leaders in RCs facilitate co-creation processes and discuss the findings considering the perspectives of Turner's term of communitas [18] and the social ties of Barnes [19]. We consider structural and cultural conditions when answering the research question: How do co-creation processes in mental health services alter professional roles in light of the perspectives of communitas and social ties?
We conducted a critical ethnographic study, a methodological approach that challenges power relations and political inequality, highlighting social exclusion, marginalisation, and injustice [20, 21], which seemed appropriate since the research context involves changes in power relations, roles and services for people prone to social exclusion and marginalisation. Critical ethnography concerns structural, historical, and cultural conditions that are relevant to roles and how leaders are affected by external factors [21]. The empirical foundation for this article is data from documents about RCs, participatory observations, focus groups, and in-depth interviews with leaders with professional and lived experience at two different RC sites.
As ethnographic researchers, we have spent time in the field and participated in two complete courses to develop an insider's perspective on what is happening in the RCs and to gain trust and close communication with leaders and participants. By observing and experiencing practice, we can discover changes in the professional role and reflect on what it means for co-creation and mental health services.
Setting and Participants
The courses were held at recovery colleges at two sites in Norway, one in a medium-sized municipality with 50,000 residents and the other in a region of municipalities that covered almost 300,000 residents. The first course, run by municipal mental health services, lasted six weeks, with two weekly sessions. The other course is part of a nonprofit organisation financed mainly by the County Governor and the Directorate of Health and runs across municipalities. It lasted five weeks, with one gathering a week.
Study participants are course leaders in RCs at two different locations. Two had a professional background, two had lived experience with substance and mental health problems, and two had dual competence of professional background and lived experience. Leaders with a professional background have health and social education, such as nursing and social work, and work in other mental health services when not leading recovery courses. Leaders with lived experience had their own experience with mental health problems or experiences as relatives. We followed six leaders through participatory observations over 12 days and interviewed three leaders in a focus group and two leaders through in-depth interviews.
We used document analysis as background material. In the first phase, the first author read brochures, reports, and quality requirements, which formed the basis for observations and interviews.
Table 1 is to be placed here
Table 1 Data Material
Analysis
We analysed and interpreted data from observations and interviews using what Fangen [22] refers to as three analytical levels: first-degree, second-degree, and third-degree interpretation. (See Table 2 for a description of the analysis). In the latter, we draw on the theories of Barnes and Turner. Through analysis, we connected what we have seen and heard to a broader context of meaning and put the observed into a new perspective. By first-degree interpretation, we determined what we observed and interpreted the event with the concepts used by the participants [22]. First, we read the field notes and interview transcripts line by line and noted common-sense categories. We divided the text into several parts and reorganised the data into thematic headings: 'Promote equality in the group', 'Continuous assessment of what leaders share', and 'Grow into a new position without a professional facade'.
We used experiential analysis to transcend the participants' common sense understanding in the second-degree interpretation. We identified patterns and themes in their experiences and included relevant contexts based on theoretical paradigms to understand the situation [22]. Here, we relate "equality" to normality. "Assessments of sharing" concern culture, while "growing into a new position" concerns structure.
In third-degree interpretation, we were critical of the participants' understanding and sought hidden agendas and needs. Without taking their views for granted, we critically interpreted them by drawing on different contexts of meaning [22]. Here, we used the theory of Turner [18, 23-25] that involves roles in transmission and communitas, an experience of community between people when their lives together achieve a mutual meaning. We used the analysis to understand the roles in transmission as an anti-structure, a dissolution of the normative social structure in traditional mental health services [18, p. 28]. The critical distinguishing features in the transmission of roles are detachment, liminality in rites of passage, and reincorporation. We used these characteristics of this process to present the data sorted in the final codes: 'Promote equality and communitas', 'Continuous assessment of what leaders share' and 'Grow into a new position with a less prominent professional façade'. Barnes' [19] theory about social bonds was relevant to understanding how participants in RCs interact. According to his theory, the social network is a system of ties between pairs of people arising from kinship, friendship, and acquaintance considerations. The connections are between people who regard each other as approximate social equals. Barnes refers to these relationships as class networks, including social activities such as mutual help, entertainment at home, and ties between people.
Table 2 is to be placed here.
Table 2 Analysis
Norwegian Recovery Colleges
The Norwegian RCs we investigated aim to supplement existing services and treatment for people with substance use and mental health problems. They promote opportunities and the belief that people can live meaningful and satisfying lives, even with significant challenges in daily life. There are short sections on theory and individual reflection exercises, and dialogue in groups and plenary sessions is prominent. There is an educational approach, and service users enter new social roles as students. Illustrating pictures, videos, and poems is essential to evoke emotions, memories, and thoughts. One of the courses introduces concrete tools to build healthy relationships and create the desired community for each participant.
Two course leaders, one with a professional background and one with lived experience, run the course. Leaders from different backgrounds experience that they are equal in their position as leaders and that no one owns the course more than the other. They practice co-creation by securing both competencies at all stages, from planning and precautionary interviews to drifting lessons, and strive for an equal distribution of tasks. A culture of communication from one's daily life appears essential to stimulate co-creation. The exchange of expertise and ideas about challenges, life skills and contributions of both participants and leaders represents the knowledge and content of the course.
Table 3 is to be placed here
Table 3 Results concerning co-creation rituals and the interplay of structure and anti-structure
Promote equality and communitas
Leaders strive to establish communitas in the RCs, and this can be understood as an experience of community between a group of people when their lives together achieve an ordinary, mutual meaning [23]. They promote equality in the group by avoiding paternalistic attitudes. In one of the interviews, one of the leaders with lived experience explained: We have been very aware that we should not perceive a top-down philosophy. There should be a course group, and it should participate equally. Yes, we are a group. The statement indicates reciprocity between participants who initially had different roles, such as leaders, researchers, and other mental health service staff (see Table 3, Box 1). They help each other by participating equally, regardless of their position, and giving each other mutual advantages. It implies sharing experiences of one's life, feelings, and vulnerability, including personal values, goals, networks, and strengths and supporting each other. Leaders are prepared to participate and facilitate lessons in which they share their personal lives to promote equality and communitas. Participants who are accustomed to being in a role where they receive help now support other participants, including people with a professional background.
Sharing rituals are essential to achieve communitas, as demonstrated in the field notes.
On the first day, the leaders introduced us to the illustration pictures that would become a regular ritual. The leaders had placed cards with different motives on the table before the lesson and invited everyone to find a card that said something about who they were. I chose a picture of a beach with two wooden chairs facing the sea, representing my love for the ocean. One of the leaders chose a square to demonstrate that the person valued the structure. Other participants chose cards with monkeys embracing each other to illustrate their caring ability and a picture of nature to illustrate their interest in outdoor activities. The last participant chose an instrument that showed an interest in music and a great talent with which we later became familiar. Once everyone had chosen their card, the leaders invited the participants to share their thoughts. We ended up with a structured round where each participant, including the leaders, after a turn, shared their reflections on the card and allowed everyone to take a small part of their personal lives.
Leaders facilitated similar sharing rituals in the lessons by reading poems, showing movies, performing exercises, and inviting everyone to share their reflections. They alternated between making rounds where everyone shared their thoughts and having open discussions where those who wanted to say something participated.
Leaders also promote equality by giving everyone room and valuing experience as much as professional knowledge. Leaders encourage participation in the group by reaching out to participants and ensuring that their opinions are essential to the group. They highlight that the participant's inside is just as valid as what the leaders present. One of the leaders with a professional background explained:
The leaders do not have the correct answer when we go through the CHIME elements. It is the answer that comes from the group. I think it is also essential in practice that we believe the group has the process and the knowledge. We focus on their opinion, which is crucial for the group. (...). What hope is for my colleague differs from what hope is for me. When the group realises that their thoughts of hope are also important, it is easier for them to share. In a way, it defuses the sharing practice.
Sharing individual experiences and thoughts on a topic contributes to knowledge and learning. To encourage participation, they encouraged participants to share their experiences before leaders shared their thoughts. One of the leaders with a professional background shared: After seeing a film, we are not the first to share our feelings, experiences, and impressions. We sit back and want input and get them on track before sharing ours. In this way, the leaders show that the information of the participants is appreciated. In practice, we observed that the leaders alternated between waiting for participants' contributions and modelling, where they shared their own experience first, for example, to demonstrate an exercise. Sometimes, the leaders asked about the participants' thoughts and shared them if no one else did.
Volunteering appears essential in the course, whether participants want to share or not, and what they want to present is voluntary. The leaders felt that the participants were inspired by each other when they gradually shared their thoughts and that they had a positive influence on each other. One of the leaders with a professional background said: Eventually, people understood that it is nice to hear and be inspired by other people's thoughts when people share. There is an influence there, and we influence each other very positively. The quote shows the positive impact that sharing had on the group and each participant.
Continuous Assessments of What Leaders Share in a Liminal State
Leaders acknowledged that it would inhibit the co-creation process if professionals did not contribute when facilitating a culture of sharing. It forces them into a liminal state [18] of temporariness, vulnerability, and uncertainty, where they continuously need to assess what they share with the group (see Table 3, box 2). What leaders choose to share depends on the group's needs. One of the leaders with lived experience said:
I usually consider the group and how deep I can go when I share something. Sometimes, I can go much deeper because I see that someone is on the edge of sharing but is scared. Perhaps it lies in the integrated shame of childhood. Then, I can take my baggage deeper and say I have chosen to use this as a strength (…). In contrast, other times, I am barely below the surface and talk very generally about things if a group is not ready to accept them like that. You learn to read the group. I think there is a regulation of the group and the need, and then you balance the sharing accordingly.
Continuous assessments involve knowledge regarding shame that can cause participants to refuse to talk about their situation. When sharing, the leader can influence the participants to communicate by looking at their own stories in more detail. Some leaders with professional backgrounds emphasised sharing something meaningful so that other participants did not perceive problems as superficial and minimised their concerns.
What could be problematic (...). It is as if they [the participants] have the idea that we as professionals do not have a problem and if they portray my problems as simple. I shared some concerns about family life and children (...). Sometimes, I could be afraid that something would hurt them if they did not have children or if they did not have that situation or family. You do not want to come across as somehow perfect, either. (...) After all, there is something about the balance of not sharing the deepest of the deepest that you have not finished or processed yourself but also not sharing so easily that people think your life is so easy.
Leaders with lived experience favour the fact that the roles are different. One said that she had never experienced participants who perceived other people's challenges as superficial. Professionals who have traditionally hidden behind a façade show more of who they are as a person, which has a significant effect and contributes to acceptance in the group. In practice, Facebook requests and examples from professionals included in the other participants' contributions demonstrated their acceptance.
I have never seen anyone comment or appear to have perceived something as shallow or too small. I think the setting is that a professional used to be completely shut down and now shares and shows there is more to the façade. I think it has such a significant impact that there will be no measurement of how much you share the truth and what your life looks like.
In discussions about sharing goals that tend to differ from the lives of participants and the fear that participants experience that professionals are trying to rise above them, one of the leaders with a professional background said:
As you said, I cannot share that I want to be a professor.' There is something about our old professional point of view. They will not deal with the news that my good life is improving. However, everyone here can hear that my life is going well; I am rebuilding my house. None of them owns a home. He [one participant] could not pay for a bus ticket, and I am putting an extension on my house. It is a great contrast.
Leaders from both backgrounds emphasised that the most important thing was that the contributions were genuine based on their experiences.
Several avoided being too vulnerable and did not share personal stories or problems they had not processed. A leader with lived experience described this as distinguishing the private from the personal. Everyone must consider what is okay to share and what they want to keep to themselves. Despite the confidentiality that the participants agree to, one must assume the information will leak. Therefore, it is essential to decide what information to provide others.
It would help if you went through what you want to share (…). In other words, one has separated the personal, private, and what one only wants to have for oneself that one can only share with a few. One has found the balance (…) because you have the moral duty of confidentiality, but some things will continue anyway. Right? And then you are ready to hear it outside. Do not say anything that you do not want to hear back.
This leader shared on a somewhat superficial level, without too much detail about painful experiences. For example, she could share bullying experiences without telling details of the events. In this way, she avoided making herself too vulnerable.
I share, but I like to share superficially, not superficially, but how I have experienced things. However, I do not go into detail or share, making me very vulnerable. (…). For example, being bullied in an elementary school is not good. You are very insecure, and I have been insecure all my life. (…). I do not share anything more than that. I will not go into what has happened. Those who have experienced bullying know this. You do not have to go into detail. After all, it is recognisable to those who are supposed to recognise it.
Here, the leader provides information about her life without discussing trauma. A leader with a professional background described a challenging experience with a course in which several participants with comorbid disorders were competitive in sharing the worst experiences of their personal stories. Then, it became difficult for participants with more extraordinary functional abilities who chose to quit the course. As part of the liminal state, the leaders agreed not to induce the trauma of the participants and strove to highlight valuable strategies in their recovery process.
Experience of the past when it becomes a competition to share the worst. Then, others think, 'You know what, we do not bother.' Therefore, they do not share because they do not want to be part of that 'worst carousel.' It can be a problem for the sharing culture if the compositions are not good enough; then, you can get a dichotomy in the group that makes one part withdraw a bit.
This example shows that poor group composition can cause some participants to dominate sessions and others to become passive or drop out. The leaders highlighted other challenges, such as when someone chooses not to share or contribute to the course. Furthermore, the lack of volunteerism or participation under the experience of coercion from others was an inhibitor of co-creation and the culture of sharing.
Transmitting to a new position with a less prominent professional façade
Leaders with a professional background challenged their traditional role by promoting communitas and changing their understanding of their role in the liminal state. A professional façade is a high priority in ordinary mental health services, and leaders said that employees could experience being seen as unprofessional when sharing information from their own lives. Now, they grow into a new position where they share their experiences, feelings, and vulnerability, and the professional façade becomes less prominent (see Table 3, Box 3). One of the leaders with a professional background explained:
You have an experience that you should not share a piece of sh*t! We are professionals (…). Everything we say and do should be factual and sensible. When we share our personal feelings and thoughts, there is something that takes time to improve. Therefore, it is time, but it is something to feel that you get acceptance in the group and that it is also okay to feel, and then you get acceptance from the group. (...) You are human, too. You are not just a professional.
The leaders experienced through the liminal state that sharing led to great respect and acceptance from the participants. They emphasised that stories of their life experiences could normalise problems, make participants feel less alone with their issues, and give them a broader perspective. Seeing the relational gains of sharing and seeing that their contributions are helpful to people with substance use and mental health problems, leaders show positive attitudes and enthusiasm to be more open to service users outside of the RC. One of the leaders with a professional background shared how his professional role had changed.
I have a lower threshold to share. When they present their problem, I can share that I have the same or similar problem. It helps to normalise their situation. It is no longer as large, harmful or heavy. More people are struggling with it. I work with them, the healthiest in society. There is something about it: When you feel like a crisis, you come in, and someone tells you that what you are experiencing is entirely normal. Only your feelings have 'jumped on the bus' slightly. In addition, then, in a way, when they understand that this is within what is okay, they manage to regulate themselves. Then, life goes much better. Moreover, knowing that the guy sitting here is not necessarily the best parent in the world either, who thinks it is nice to give the iPad to the kid to get some extra time off on the weekends? Therefore, being able to share a little here lowers the threshold for daring to come here and accept that things can improve.
This quote from this leader indicates that whether and what one shares depends on the service recipient. The leader quoted above worked with well-functioning people who received a low-threshold offer from the municipality. Another participant with a professional background worked in a municipal service where users had comorbid disorders and poorer functioning abilities. Despite some difficulties, the person also saw gains from sharing:
I have some of the same experiences that I can share more. At the same time, I have the patient group, so you must consider who… I judge based on who I am talking to. However, I think you have something to gain from sharing, especially in relational terms. However, what I can share is very individual.
This quote indicates that despite their enthusiasm for what is happening in RCs, they still need to assess what they can share with service users of other mental health services and how to transfer what they have experienced and learned in RCs.
For decades, mental health services have faced the challenge of providing care and services that are efficient and responsive to the needs of their population [1]. There are challenges in reintegrating people with substance use and mental health problems into the community. RCs represent a new attempt at socialisation by dissolving roles and offering new social positions, structures, and communitas. It involves an anti-structure regarding roles, culture, and social status. Previous studies have found that participation in co-creation in RCs affects professional attitudes and practices by softening established positions. Our research shows that we may understand this as a transmission of roles induced by facilitating co-creation and initiating and participating in sharing rituals. The leaders of Norwegian RCs facilitate co-creation by engendering an atmosphere of equality and communitas by using language as a tool and inviting everyone to share their experiences regardless of their previous roles and positions and power to impact (see Table 3, box 1). They continually assess the depth of what they share from their lives based on the needs of the group and their personal boundaries. Contributing from their personal lives, they grow into a new position with a less prominent professional façade, representing a professional role in transmission.
Professional Roles in Transmission
The findings exemplify the transmission of roles that Turner [23] divided into three phases: detachment, liminality, and reincorporation.
Detachment represents a passage from an earlier stage in the social structure and cultural conditions. Professionals detach themselves from the traditional professional role as they know it and traditional expectations towards holding a professional façade. Leaders change their mindset by not focussing on diagnosis, role sets, and status, except in their introduction, informing about their background. Quotes such as 'We are one group' and 'We are all participants' show that leaders 'intentionally use their language to create and carry out a reality' of equality and anti-structure that clash with the structure of traditional mental health services [21, p. 156]. Leaders do not consider themselves experts with a more valid knowledge of the needs of service users, which are characteristics of the medical tradition.
During the liminal state, individuals traverse a cultural realm with few or no attributes of the past or future state. Cultural scripts [18, 25] that dictate traditional expectations for healthcare workers' conduct change in this liminal state. These individuals are neither fully aligned with their past professional roles nor defined by future expectations. They are not strictly professionals, leaders, or participants but inhabit a transitional space between their prior roles or positions. This liminality presents a continuous challenge, prompting them to reassess best practices, such as determining what information is appropriate to share within the group and fostering equal contributions from all participants.
The anticipation of their roles in the liminal state remains unclear, and traditional expectations continue to influence leaders' interactions with consequences that can be uncomfortable [23, 25], leaving them feeling unprofessional and uncertain about their roles. Co-creation practices become feasible only through the dissolution or transformation of these cultural scripts. Consequently, the group of participants represents a society, in contrast to a traditional one, that is structured, differentiated, and often hierarchical system of political-legal-economic positions with many types of evaluation, which distinguishes men in terms of higher and lower status [23]. Both leaders and participants grapple with the absence of a prescribed recipe for behaviour as roles remain in flow. Uncertainty surrounds the detachment from and expectations of traditional roles. Leaders find themselves tethered to their professional roles while simultaneously exploring new ones. This uncertainty may elucidate previous research indicating that professionals sometimes struggle to adapt to new positions as equals to service users [16].
Structural and cultural conditions demonstrate the complexity of finding a new role. Leaders strive for equality, an essential value in Norwegian culture, which means treating others as equals, regardless of whether their income, education, interests, and occupation differ significantly from their own [19]. However, despite the core value of equality in RC, participants and leaders vary according to economic, social, and cultural dynamics. Significant differences in their financial situation become apparent in the course. Leaders have a fixed income and generally live A4 lives with Volvo, children, and dogs, while several participants have welfare funding and live below the poverty line in Norway. It gives them completely different conditions in life. The example of the leader who built his house and the participant who could not afford his bus ticket to attend the course shows this significant contrast. Leaders must consider this social inequality in their ongoing assessments of what they share. This awareness of inequality aligns with Barnes' [19] statement that people often hide their views on social inferiority, as it is inappropriate for anyone to show that they consider themselves superior openly.
Simultaneously, liminality allows one to introduce practices in line with new cultural scripts. Leaders organise sharing rituals to establish communitas to show their feelings and life experiences and achieve an ordinary, mutual meaning (communitas) with participants despite their differences. Drawing on Barnes' theory, the liminal state and striving for equality and communitas are about establishing stronger ties between the participants. Together with other participants, they experienced trials based on humility and homogeneity, which allowed them to establish a fellowship. Leaders share information from their own lives to invite others to share and adapt the depth of communication based on what is happening in the group. This new practice invites participants to recognise themselves in others, which is fundamental to experiencing connectedness. The new cultural script entails not going too deep into the bad experiences of their lives. They model behaviour and guide participants not to leave too much room for trauma and allow the 'worst carousel' to develop where misery flows freely.
The roles are in flow, leading to tension among leaders in RCs, as they feel uncertain about what they can share without offending participants and hurting them about something they lack in life. Leaders try not to appear snobbish when discussing their life challenges and present themselves as people with faults and shortcomings. They strive for communitas to allow participants with substance use and mental health problems to feel less alienated. Accordingly, the liminal state enables the transmission of new roles for both leaders and participants. In this way, the liminality of co-created practices can allow participants to establish a higher status and a socially accepted role as active participants.
In reincorporation, the professional has established a new role and a humbler status, with a less prominent professional facade, and appears more open in encounters with people with substance use and mental health problems. The data show that they see the benefits of being more vulnerable and honest with service users, and the result of the RCs is that they have a lower threshold of sharing in their relations with service users outside of the RCs. It aligns with previous studies of how co-creation processes soften the professional role and affect attitudes and practices concerning power dynamics, language and information sharing [1, 11, 16].
The liminal state, characterised by the equality and dissolution of roles, seems to last temporarily. At some point, we assume that leaders and participants return to the services where the different functions, such as service providers and service users, come into play. Barnes [19] found that the members of a society are no longer equal while doing their jobs, organised in chains of command, and differentiated according to function. Someone is in charge and gives orders, and their subordinates obey. It aligns with Turner's [18] statement that inclusiveness, the anti-structure of communities, is not permanent. According to him, it is impossible to eliminate roles, status, and order in a society. Eliminating the structure is also undesirable, as it regulates and preserves culture and provides safety to members. However, it is appropriate to reduce the negative aspects of the structure [18]. The findings show that leaders have positive attitudes towards the new cultural scripts emerging in RCs. Their attitudes indicate that the anti-structure they have worked to establish may reduce the negative aspects of previous structures in mental health services. Professionals have reincorporated a new role after experiencing anti-structure and communitas (Table 3, boxes 1 and 2), which they transfer to their approaches in other mental health services. It is also possible that sharing rituals can be used outside of RCs, thus allowing and encouraging leaders and participants to take new positions. If so, we can argue that co-creation practices can become a new structure that, to a lesser extent, separates people, defines their differences, and limits their actions. This new structure with a humbler professional role, equality, communitas, and stronger ties between service providers and users can help professionals gain acceptance and trust from service users. Hopefully, this will allow services to provide better mental health services that respond more effectively to the needs of the population by normalising problems, eliminating stigma, and giving people with substance use and mental health problems a broader perspective.
The transmission of roles, including the three phases and awareness of inequality, may transfer to other co-creation processes. The co-creation facilitators must distribute power to involve everyone in the co-creation processes regardless of background. Anti-structure, as seen in RCs, is a temporary dissolution of traditional roles that weaken and disguise the power imbalances between professionals and participants. The co-creation process involves creating new structures and exploring new roles in a state of liminality and anti-structure. Experiencing anti-structure together promotes communitas, equality, and stronger ties between participants. By dissolving roles and structure, they could strive for a mutual meaning and goal of the co-creation process. Participants who traditionally have had a low impact gain more power and confidence in contributing, and participants with a high impact enter a humbler role.
When practising co-creation, one must be aware that different participants represent economic, social, and cultural variations. The findings show that the professional role involves conscious judgments about what they share and the depths of sharing. Leaders must apply high-level professionalism, academic skills, and presence. It seems to be an expansion of the professional role in the way that their primary task becomes to understand how they can enable participants to engage, to be willing to engage and share on equal terms with participants and to understand what it entails to facilitate group processes in ways that enable growth for all. When examining the transmission of roles in co-creation, one must look at the interplay between anti-structure and structure and understand co-creation processes that require growing into new roles.
The strength of this study includes active participation in RCs over time, allowing a comprehensive understanding. Completing two comprehensive RC courses has contributed to in-depth insight into facilitating co-creation and the nuanced significance of structural and cultural factors. Including both leaders with professional backgrounds and those with lived experiences in focus groups enhances the richness and depth of the data, providing a well-rounded perspective. Nevertheless, the study's findings are based on a relatively small sample, as we have conducted the study in only two sites. A small sample may limit the generalisability of the results to a broader context and could affect the applicability of the findings to other settings. However, detailed descriptions in the study empower readers to grasp the research context, methodologies and conclusions thoroughly. Transparency supports the assessment of the potential transferability of results to diverse fields.
This article shows that the leaders of Norwegian RCs facilitate the co-creation of experience sharing and course content by engendering an atmosphere of equality and inclusiveness by inviting everyone to share their experiences regardless of their previous roles, positions, and differences in life contexts. We have shown that what is happening in RCs is a dissolution of traditional service roles and normative structures in mental health services, representing an anti-structure concerning role, culture, and social status. However, there are structural and cultural differences in co-created RCs regarding economics and life context.
The findings show that co-creation in mental health services implies the transmission of roles in the tension field between anti-structure and structure. Humility and the ability to make conscious judgments about what they share are essential to a professional role facilitating co-creation. Descriptions of professional roles in transmission and implications due to structural and cultural conditions complement existing knowledge of how co-creation processes in RCs affect the professional roles and qualities of facilitators of such methods. Due to significant structural differences, achieving permanent changes for the dissolution of roles in mental health services is difficult.
We do not know how society embraces them when they return to other mental health services and communities where the structure is still present. As we have seen here, co-creation and communitas may be appropriate in parts of mental health services within specific frameworks. There may be separate zones where other rules apply than other service parts. Such zones can be in life skills courses, job application courses, or other courses where it is essential to share experience. We need more in-depth studies to discover the sustainability of roles in transmission in mental health service research.
Recovery colleges
RC
CHIME
Commitment, hope, identity, meaning, and empowerment
Ethics approval and consent to participate
All procedures followed the ethical guidelines of the Declaration of Helsinki. The Norwegian Agency for Shared Services in Education and Research approved the study in 2022, project number 994561. We informed all participants in the course about the study, and the participants we interviewed gave their informed consent. We anonymised the informants by not differing from the different sites.
Consent for publication
Not applicable
Availability of data and materials
The data collected for this study consisted of transcribed interviews and field notes. The readers can access part of the data supporting the study's conclusions. Field notes and transcripts cannot be released due to ethical restrictions. An interview guide (additional file 1) is available. See Table 1 for further information on the data.
Competing interests
The authors declare that they have no competing interests.
Funding
The authors thank and acknowledge the funding the Norwegian Ministry of Education and Research, Western Norway University of Applied Sciences provides.
Authors' Contributions
TES conceived and drafted the study in close collaboration with KÅE and CØ. TES collected the data, while everyone contributed to the analysis. TES wrote the manuscript, and KÅE and CØ made significant contributions to the manuscript. All authors have read and approved the final manuscript.
Acknowledgements
We want to thank the people responsible for the recovery colleges and the participants who participated in our study.
Author information
TES is a PhD candidate in Responsible Innovation and Regional Development at Western Norway University of Applied Science. Her research focuses on public sector innovation and co-creation in Norwegian recovery colleges.
CØ is the vice dean of research at the Faculty of Health and Social Sciences at Western Norway University of Applied Science. Her research focuses on implementing, ethics, and co-creating knowledge in health and social care service and innovation studies.
KÅE is an Associate Professor in the Faculty of Health and Social Sciences at Western Norway University of Applied Science. Her research focuses on recovery-oriented services, facilitation of collaborative processes and research.
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No competing interests reported.