# ROUTLEDGE HANDBOOK OF MENTAL HEALTH LAW

*Edited by Brendan D. Kelly and Mary Donnelly*

First published 2024

ISBN: 978-1-032-12837-5 (hbk) ISBN: 978-1-032-12840-5 (pbk) ISBN: 978-1-003-22641-3 (ebk)

# Chapter 35 THE MENTAL HEALTH AND JUSTICE PROJECT

Reflections on strong interdisciplinarity

*Gareth Owen*

(CC-BY) 4.0

DOI: 10.4324/9781003226413-43

The funder of the Open Access version of this chapter is Wellcome Trust

10.4324/9781003226413-43

Gareth Owen

# THE MENTAL HEALTH AND JUSTICE PROJECT<sup>1</sup>

## Reflections on strong interdisciplinarity

### *Gareth Owen*

#### **Introduction <sup>1</sup>**

This chapter will explore opportunities and challenges in interdisciplinary collaborations using the Mental Health and Justice project (MHJ) as a case study.

MHJ was a five-year interdisciplinary research initiative funded by the Wellcome Trust in the UK. The project addressed a cluster of public policy challenges arising at the complex interface where mental health and mental healthcare interact with principles of human rights. Its principal aim was to develop clinical, legal and public policy strategies for jointly satisfying two fundamental imperatives: the imperative to protect people in contexts where they can be vulnerable, and the imperative to respect their agency and autonomy.

The chapter will outline some background to the project and give some reflections on what is meant by 'strong interdisciplinarity' (which I will argue MHJ was an instance of), ways the project navigated scholarship versus activism and the course of the project.

These are personal reflections limited by the fact that, at the time of writing, the MHJ project remains in a final phase and the fact that I am still digesting what was a complex, intense, fascinating project. <sup>2</sup> My main reflections are that strongly interdisciplinary projects offer multi-faceted opportunities for outputs, influences and impacts and that tension points are inherent and require a process of dynamic *balance*. I suggest that models of strong interdisciplinarity need to evolve and that MHJ achieved its original strategic aims without being entirely bound to them. Furthermore, I suggest that there was a positive phenomenon of interdisciplinary collaboration as *education* that I try to capture.

This chapter has been made available under a CC-BY license.

<sup>1</sup> Thanks to everyone who was involved in the MHJ research project and to the MHJ committee that continues to think about and care about its legacy and dissemination. Funding provided by Wellcome grant number 203376/Z/16/Z.

<sup>2</sup> My roles in the project were as project lead and co-lead for two of the workstreams (workstreams 3 and 6).

The Mental Health and Justice project

#### **Background**

Some background on the project may help to put into context how it started on its five-year timeline.

I am a psychiatrist with an interdisciplinary background involving philosophy. I had done my PhD and postdoctoral fellowships in the Department of Psychological Medicine, King's College London (KCL) in a loosely grouped collection of academics interested in mental capacity and mental health law. This work had been funded mainly by the Wellcome Trust and involved researchers at the Institute of Psychiatry and the Law School at KCL. It developed over time to involve academics in philosophy (both in the research itself and in an interdisciplinary postgraduate masters education initiative) and also service user involvement. These collaborations were quite small. I had found them very fruitful and stimulating but they were not going anywhere very clearly within the existing university structures, and thus it was apparent that to create opportunity and growth an expanded collaboration with external grant investment was needed.

A formative experience for me had been working at the Parliamentary Office of Science and Technology (POST) in 2011 as a Wellcome Trust–POST fellow. I worked on the Mental Capacity Act (2005) at a time of post legislative scrutiny. The work involved speaking to a wide range of policy makers involved with the Act including its implementation. One of the curious things about this ground-breaking piece of legislation is that it is entirely the responsibility of the Department of Justice whilst interpretation and implementation falls to the Department of Health (now Department of Health and Social Care) due to the fact that assessments very largely get done by professionals working in health and social care. The fact that the Act had been conceived in a department of 'Justice' yet had to be interpreted in a department of 'Health' intrigued me and resonated with the interdisciplinary issues I was grappling with as a researcher on mental capacity. The two government departments were not collaborating very much in relation to the Mental Capacity Act and some of the problems in its post legislative course seemed traceable to this fact. Again, this resonated with administrative issues I was facing in the University with researching mental capacity across departments of psychiatry, law and philosophy. How to collaborate across 'Justice' and 'Health' on mental capacity and related areas? It was this question in the context of silos of communication across government departments that prompted my initial use of the term 'Mental Health and Justice'.

I initiated discussions with the Wellcome Trust about a large collaborative research project. At this time the Wellcome was putting a lot of emphasis on collaborations in research. They were becoming more interested in social science and had longstanding interests in the neurosciences but this was not well connected to real-world issues in mental health. We decided to run a large workshop at the Wellcome with a diverse group of participants and deliberately drew in researchers in social sciences, cognitive neurosciences and also policy makers and service user researchers. It was a 'big tent' event and it greatly helped in expanding the pool of potential collaborators and moving to identify themes and research topics. However, it also created a somewhat bewilderingly large canvass and body of unsculpted material. So work was left to clarify which areas were ready to take forward and which were falling away so as to forge and refine a collaborative research programme.

In addition to this there had been a big international event in human rights law – ratification of the United Nations (UN) Convention on the Rights of Persons with Disabilities (CRPD) – and this was challenging the Mental Capacity Act in radical ways. It was clear

### *The Mental Health and Justice project*

that a contemporary research initiative on 'Mental Health and Justice' was going to have to tackle the challenges posed by the CRPD; yet the CRPD challenge was not posing a specific researchable question.

What emerged from the original 'big tent' workshop was a research project oriented around the problem of empowerment versus protection in mental health. This was framed broadly to accommodate the research workgroups that were forming, to keep to the 'big tent' spirit of the initial workshop and also to acknowledge that the CRPD was now part of the landscape. Six research workstreams emerged with leads or co-leads with the requisite energy for, and interest in, interdisciplinarity:


The workstreams (diverse as can be seen) were arranged as mini-collaborations within a larger collaborative structure. The workstreams had largely traditional academic aims of running studies and producing academic outputs but, unusually, each workstream was comprised of academics belonging to different established 'strong' disciplines (e.g. psychiatry, law, social science, philosophy, cognitive neuroscience) who had not worked together in this way before. The project also developed three key partnerships with organisations serving the aims of policy engagement (the King's Policy Institute), service user research involvement (McPin Foundation) and public engagement (Bethlem Gallery). These partnerships were planned from the start though with a degree of looseness built in as we knew that policy engagement, service user involvement in research and the public engagement approach we wanted to take (participatory arts) all had fluidities.

For a collaboration such as this, working on complex, heartfelt and controversial topics in mental health and justice, there were going to be opportunities as well as challenges.

#### **What is 'strong interdisciplinarity'?**

The MHJ project aimed for 'strong interdisciplinarity'. What do I mean by this term?

The standard definition of interdisciplinarity is that it involves bringing together two or more disciplines into a single activity where it is expected more will be gained than by one discipline alone. But disciplines have subdisciplines and some disciplines differ more than others (e.g. the difference between physics and chemistry compared to the difference between academic psychiatry and law). By 'strong interdisciplinarity' I mean bringing together disciplines with large differences as systems of knowledge which typically exist in separated administrative or departmental units within a university. Furthermore, the bringing together of disciplines should be characterised by co-working on problems over sustained periods of time. The MHJ project was strongly interdisciplinary in all these senses. It involved academics in established departments of psychiatry, law, social science, cognitive neuroscience and philosophy co-working on problems over five years where giving definition to the work was part of the work itself.

Ideally, interdisciplinarity needs some kind of self-understanding or theory of its own activity. If a clear, unambiguous theory of interdisciplinarity is needed for 'strong interdisciplinarity' then I think the MHJ project was not necessarily strong. However, given the lack of unity in the literature on interdisciplinary theory, and no compelling unified theory of interdisciplinarity, force fitting a non-compelling model to our processes was never going to be a strength. That said, it may be helpful here to consider two influential theories, or models, of interdisciplinarity in the literature and consider how the MHJ project measured relative to them.

The first model sees interdisciplinarity in problem-solving or epistemological terms. Karl Popper took this view when he wrote in a chapter entitled 'The Nature of Philosophical Problems and Their Roots in Science': "*We are not students of some subject matter, but students of problems*. And problems may cut right across the borders of any subject matter or discipline" (Popper, 1963, p. 88). Take the problem of who decides in health and social care situations where serious mental disorder or disability is in existence. That is a problem. But it is not a problem owned exclusively by the disciplines of academic psychiatry, law, social science, cognitive neuroscience or philosophy. The student of the problem however, following Popper, would be well advised to know how the problem looks from each of these disciplinary perspectives. Related to this problem-solving theory of interdisciplinarity is an intriguing notion of the 'superconcept'. This term has been coined by Alan Wilson (Wilson, 2010). The basic idea is that a concept developed in one discipline, for example, the concept of entropy developed in electrical engineering, can find similar expression in other disciplines (e.g. thermodynamics in physics) or application in other disciplines (e.g. biological systems or urban planning). Concepts like entropy or evolution are 'superconcepts'. Wilson says a superconcept is an idea which "cross[es] disciplines and which contribute[s] both to our depth of understanding and helps us to navigate the breadth [of knowledge]" (Gombrich, 2019; Wilson, 2010, section 4). Here the idea is not to deconstruct extant disciplines but rather to identify strong disciplines and then to identify a set of concepts that find application across them. Those superconcepts range from macro ones like entropy and evolution to those with a more circumscribed, or micro, domain.3 Core thinking skills related to this model of interdisciplinarity include 'critical thinking' and 'mental models' – generic problem-solving and decision-making skills such as probabilistic thinking, analogical thinking, bias and fallacy detection that can find application in pretty much all subject areas (Gombrich, 2021). On this model of interdisciplinarity, the goal is to educate in scientific problem solving so a new generation of students are best equipped to solve the most pressing problems which, as Popper indicated, may well cut across the borders of subject matters.

The second model sees interdisciplinarity in socio-political and social justice terms (Parker et al., 2010). It starts with a social justice problem in which a social group is recognised as having a power disadvantage and a relative exclusion from the social construction of knowledge.4 Examples include gender (Woodward and Woodward, 2015), disability, non-white race/ethnicity and combinations (intersections) of these. The social justice problem is then critiqued from different disciplinarity perspectives such that issues of power imbalance and epistemic disadvantage are surfaced and then righted through action. On radical versions of the model this critique may involve deconstructing, or abolishing, established disciplines showing them to be discriminatory or unjust systems of knowledge. The disciplines drawn upon for this model of interdisciplinarity tend to belong to the humanities and the social sciences and core skills include participatory understanding, empathy, ability to discern disparity/discrimination and activism – skills that can be applied across different areas of social justice.

Reflecting on the MHJ project I think there was a continuum between these two models in the project with no workstream adapting what might be considered a pure single model approach, and the project overall is probably best characterised as a hybrid. Notwithstanding, differences in approach existed in MHJ with the workstream on independent living being most aligned to the model of interdisciplinarity as social justice and the workstream on metacognition most aligned to the model of interdisciplinarity as problem solving. Other workstreams were variably in-between.

Superconcepts, as Wilson defines them, are interesting to reflect on using the MHJ case study. There were contenders for superconcepts in the project (e.g. mental capacity, advance decision-making, supported decision-making, metacognition, insight, independent living). Taking mental capacity as an example: originating in law, the concept outlived the critique from CRPD mental capacity abolitionists, showed a fair degree of transferability across professional and service user groups and kept arising in different forms across disciplines and workstreams. It also showed application. Personally speaking, I found research across MHJ moved my thinking on from my earlier interdisciplinary considerations of the concept of

<sup>3</sup> For example, Wilson calls 'Christensen units' a superconcept. These are units of new technology that successful businesses have to adapt to as well as risk being destroyed by (Wilson, 2010, 5.2.1). Here the scope of application is much more circumscribed compared to entropy or evolution.

<sup>4</sup> The socio-political approach to interdisciplinarity raises the question of values. It is important to note that this second model of interdisciplinarity is largely constrained to socio-political values relating to care and oppression. Haidt (2012) in his empirical work on values across cultures has identified the value cluster of care but also other value clusters he calls liberty, fairness, loyalty, authority and sanctity.

mental capacity (Owen et al., 2008) indicating that a superconcept is not static and can respond to new evidence and argument.

Socio-political considerations in interdisciplinarity also afford reflection based on MHJ experience. I think everyone in the MHJ project found that socio-political considerations were important and not fully separable from the interdisciplinary work. Working in mental health where upsetting realities of illness, stigma and discrimination are so present sensitised all of us. That said, some of us were more comfortable than others with socio-political and social justice considerations being tightly framed in terms of one value cluster (see footnote 4). One of the interesting and helpful symposiums we held in MHJ involved exploring the variety of meanings of justice and imperatives to action and some of the learning on MHJ involved realisation that felt imperatives to action can be collectively inconsistent. This raises the problem of reflective equilibrium in strong interdisciplinarity.

In summary, MHJ as a case study helps to see that interdisciplinarity is not just one thing. The project ranged across different models of interdisciplinarity and was not fully accounted for by any of them. For interdisciplinary projects I would recommend being aware of the kind of interdisciplinarity one is doing, or what different kinds are incorporated, or where on a continuum of kinds. The right emphasis will be hugely contextual. The in-between forms of interdisciplinarity (i.e. between the problem-solving kind and the socio-political kind) are harder to do because there are more emotional and conceptual tension points to navigate and less of a pre-defined blueprint to follow. But in the area of mental health the impactful interdisciplinary projects are very likely to require both knowledge-orientated problem solving and socio-political awareness and action. These blended, or hybrid, projects may need more planning and more continuous reflective practice built in. It would be helpful to see the socio-political literature on interdisciplinarity develop to become more diverse on values, in Haidt's moral psychology sense (Haidt, 2012), to guide collaborative processes and reflective equilibrium and help manage the risks of tendentiousness or polarisations. It would also be helpful to see the problem-solving literature on interdisciplinarity develop to accommodate the roles of values.

#### **Scholarship and activism**

In this section I want to reflect on how the MHJ project navigated between scholarship and action (or activism). This relates to the preceding discussion about interdisciplinarity but is a less abstract way of framing the discussion.

MHJ engaged a wide range of action organisations and persons outside the academy.5 Rather than trying to capture all of these, I will focus on one engagement which was particularly significant for the MHJ project. This was the engagement with policy makers and with the mental health law reform process in England and Wales in particular.

<sup>5</sup> These included organisations with specific mandates or campaigns to bring about social and political change (for example the UN Special Rapporteur on the right to health; the WHO Policy, Law and Human Rights Unit, the Mental Disability Advocacy Centre (Validity); non-governmental organisations (e.g. the Palestinian Counselling Centre); service user organisations with specific condition-specific charitable objectives (e.g. Bipolar UK, Supported Loving); state-funded clinical services (e.g. the South London and Maudsley NHS Foundation Trust); policy makers (e.g. the Independent Review of the Mental Health Act, the Scottish Mental Health Law Review, civil servants at the UK Ministry of Justice and Department of Health and Social Care, UK parliamentarians); courts (e.g. the Court of Protection)).

#### *The Mental Health and Justice project*

We also addressed action within the research methodology itself. Again, this was varied and I cannot cover it all, so I will give brief reflections on two examples which struck me personally. The first was a research method that might be best termed 'bracketing action' or 'bracketing belief'; the second might be termed 'enabling action' or 'enabling belief'. I will explain more what I mean below but let me first consider the engagement with the policy makers.

#### *Engagement with policy makers*

In its planning and inception, MHJ established a partnership with the King's Policy Institute for a series of 'policy labs' on topics related to protection and empowerment in mental health. Policy labs were a technique for policy deliberation that the Policy Institute had been developing (Hinrichs-Krapels et al., 2020). At the time I think it is safe to say we had no expectation of the UK government seeking substantial reform of mental health law. Within a few months of the project starting the then Prime Minister Theresa May announced, very unexpectedly, a major reform process. An independent review group was announced with Sir Simon Wessely as chair and MHJ had an opportunity for 'impact' using the policy lab mechanism that we had in place.

Two early policy labs were held with a diverse range of policy experts with briefing materials prepared on the main tension points in mental health law and the main policy options facing the independent review team (which was just being assembled) (Owen et al., 2018). The main approach we took was to present the deliberators with value choices that needed to be made in deciding the future course of law reform. Two key value choices were (1) individual autonomy and (2) legal formality and we represented these as orthogonal axes because we took the values to be largely independent of each other. This created a 2x2 grid with four prototype or 'ideal type' policy options (A–D). These were presented and summarised with examples. Figure 35.1 shows the scheme we used.

We understood compliance with the CRPD as the CRPD committee were stating it at the time (Committee on the Rights of Persons with Disabilities, 2014). This entailed abolition, or phasing out, of any formal legal system for mental health treatment without consent and maximum value placed on individual autonomy. This was option A. We also thought it important to be transparent about the option of what is sometimes called 'medicalism' or, in other words, permitting health professionals to make case-by- case judgements on mental health treatment (including treatment without consent) informally based on clinical context and relationship rather than formal legal rules and criteria. 'Medicalism' also placed value on public health and clinical expertise rather than individual autonomy. This was option C. Options B and D were both options for a mental health law with formal legal rules and criteria for treatment without consent. Option D was essentially the current provision in England and Wales with the Mental Health Act (1983) and option B was a mental capacitybased mental health law (sometimes called 'fusion'), a version of which Northern Ireland had recently enacted.

Following deliberations in the policy labs over workshops in November 2017 and February 2018, a consensus recommendation emerged that the direction of policy in mental health law should be legal formality with a shift towards an approach placing more value upon individual autonomy. In effect, this was a recommendation for a shift from D towards B.

We also used the policy labs for some deliberation on the positive right to health, but it became clear that moving mental health law in that direction was not a politically achiev-

#### Striking the balance between legal formality and individual autonomy

*Figure 35.1* Scheme for Mental Health and Justice project policy lab on reform of the Mental Health Act

able option. I think this was mainly due to two things: one was the politics of social and economic rights and their association with 'big state' and 'big public spending' – something which was not government policy in the UK at the time. The other was that the human rights discourse (from both the European Court of Human Rights and the UN CRPD committee) was very largely about autonomy rights with either no formulations about social rights or only very generalised ones. Practitioners, even those working within socialised healthcare systems like the English and Welsh National Health Services, had no clear idea of what the language of a right to health meant in practice. We therefore found it very difficult to get political or practitioner buy-in on discussion of social rights or, for that matter, very much specificity on what a mental health act with a right to health framing would even look like legislatively in the UK. On reflection that was a problem: we were in effect talking about moving from D to B (see Figure 35.1) in a public spending and resource vacuum. Subsequent work was done to focus on advance choice and the case for resources for their enablement (service user support, professional training, IT infrastructure) but even five years after a government commitment to advance decision-making in mental health (Owen et al., 2019), resource commitment for even modest implementation remains tenuous.

Our approach to engagement with mental health law reform was essentially one of outlining and deliberating policy options rather than campaigning – acknowledging that it is not ultimately for researchers to decide. It has been disappointing to see that even modest investments to enable meaningful change to what law means in practice to people with severe mental health problems remain very difficult to secure. It is not surprising therefore to see the British Medical Association recently take a more campaigning approach to social rights (Sheather and Norcliffe, 2022).

Future policy engagement research will need to provide more detailed options on social rights and more sophisticated deliberative work on what policy makers and the public prioritise when they understand mental health law reform *without* public spending commitments. I consider this learning an important learning point of the MHJ project's engagement with mental health act law reform.

Let me now turn to the issue of how action was managed within the research methodology itself.

#### *Action in the research itself*

As already mentioned, the MHJ project had to address a new landscape with the CRPD. We needed a normative steer on a human rights approach to mental health law with an answer to the fundamental question: what action was the UN Human Rights system recommending in relation to treatment without consent? Two researchers who believed different things about what was right action on the matter agreed to approach the task using a method that in effect 'bracketed' or 'suspended' their beliefs and rigorously surveyed what the different Human Rights committees within the UN system were recommending. This method gave a result that was important for the MHJ project early on even if it was difficult in terms of suggesting a coherent way forward with a human rights approach. The research showed that Human Rights committees were collectively recommending inconsistent action and had no internal decision-making mechanism to resolve the inconsistency (Martin and Gurbai, 2019). Using this research method to understand that a genuine 'impasse' existed helped us as a project to step back from aiming to achieve a clear and distinct international human rights framing for MHJ (we were going to have to embrace messiness and ambiguity in the normative 'steer'). The research result also helped us give more focus to specific areas where consensus for action was more likely to be found.

Work on advance directives was showing up as one area where consensus for action was emerging. Researching this area had a rather different problem to the belief one above. The problem was that a large, English, multi-centre randomised control trial (RCT) of a type of advance directive had reported a mainly null result on reduction of use of the Mental Health Act (1983) (Thornicroft et al., 2013). On the evidence-based perspective there was therefore not a strong case for action. However, on service user, clinical ethics, human rights and policy perspectives we were finding that there was a strong consensus for action (Owen et al., 2019). Our work was also indicating that the complexity of the advance directive

intervention and the plurality of values that stakeholders were attributing to it6 raised questions about the RCT methodology being top of the evidence-generating hierarchy on this subject. To resolve this methodological problem the workstream 3 spent some time early on learning about participatory action research from the workstream 2 with a view to *developing*<sup>7</sup> an advance directive intervention within the complex mental health services of the South London and Maudsley NHS Trust. This was an interesting turn for clinical research which was more familiar with putting the RCT first (or preparing for the definitive RCT study). In effect, there was a prior commitment, within the research itself, to action based on an essentially ethics-based analysis rather than a conventionally causal or RCT-based one. The resulting method we developed (a combination of literature reviews, wide stakeholder consultation, doing through showing, detailed iterative process development, qualitative inquiry, network development with key partners and implementation science) was a sort of hermeneutic clinical research trial – very different indeed from the method of RCT first, action second.8 But, as above, it has not (yet at least) had an impact on resource allocation – no doubt in large part due to the fact that RCT evidence with economic analysis remains the convention for how resource allocations in healthcare are made by governments.

In summary, the MHJ project navigated scholarship and activism in a variety of ways and with a variety of results. I have selected a few of these navigations to give a sense of the learning and to show that the balancing of action-impartial research and action-partial, or actionladen, research did not just exist as a matter of balancing between the academy and the 'outside world' but also within the research methodology itself. This balancing allowed us to innovate with policy engagement using policy labs, with methods to approach contested human rights questions and with complex interventions in clinical settings.

#### **Course of the project**

The project was an extraordinarily intense and fascinating one which followed a path laid down in its original project proposal of 2016. The varied outputs of the project are brought together on an MHJ project website https://mhj.org.uk9 and reflections on how we met our original strategic aims are also given there. Outputs and outcomes will not be the focus here, rather I will reflect on the course of the project.

MHJ had to react to external events unforeseen in 2016. Unforeseen events fundamentally shaped the work including reform of mental health legislation in the several jurisdictions of the UK but also the Black Lives Matter (BLM) movement and the Covid-19 pandemic with its social distancing impacts and its marked increase in population anxiety levels during

<sup>6</sup> For example, reduction of use of the Mental Health Act was just one of the things valued by stakeholders, others being: enhanced self-management, building shared understanding of the illness, building therapeutic alliance and communication, avoiding personally defined harms, reducing trauma of compulsory treatment, earlier presentation, shorter admissions and peace of mind.

<sup>7</sup> The methodology we focused on – 'Outcome Mapping' (*Outcome Mapping Learning Community*, available at www.outcomemapping.ca/download/OM-faq-en.pdf) – literally derives from development. It comes out of working on development projects in developing countries where the question of whether to act is not being studied or tested (that being assumed). Rather it is a method that addresses the way to achieve action and outcomes.

<sup>8</sup> Details of this 'trial' are available in the PhD thesis of Lucy Stephenson and associated publications.

<sup>9</sup> The website will be archived by KCL from 2024.

the first lockdown (Hamilton and Coates, 2020) and changing anxieties thereafter. As such we were stretched across multiple dimensions and challenged.

One example of the importance of the fluid, 'third space' nature of the public engagement partnership with the Bethlem Gallery was the response to the BLM movement. In June 2020 a large MHJ social art installation on the perimeter of the Bethlem Royal Hospital inspired by the Mental Capacity Act and called 'Some Questions About Us' was graffitied (a version of the original work 'Some Questions About Us' now forms part of the Government Art Collection). The letters 'RIP Seni' were painted in red by an unknown person. This was a reference to the death of a young black man called Seni Lewis under police restraint in the Bethlem Hospital in 2010. The transformation of 'Some Questions About Us' to 'RIP Seni' in the early phase of the BLM movement set in motion a new set of reflections and processes for the project. 'RIP Seni' was preserved and donated to Bethlem Museum of the Mind's permanent collection and an MHJ film was coproduced with the Lewis family exploring the moving but challenging emotions evoked by the graffiti.10

In 2022 the very terms 'mental health' and 'justice' do not have quite the same meanings that they had in 2016. Both terms have become more culturally and politically salient. These are big issues to reflect on: too big probably and too early to expect full reflection on now. So, I will reflect tentatively and imperfectly on just a few: management of the collaboration, collaborative processes and collaborative working as education.

#### *Management of the collaboration*

The project was overseen by an academic management group which gave it a useful central, coordinating management hub (we had over 40 meetings). Management of the project (including management of budgets) was devolved to workstreams otherwise.

The academic management group had active involvement from the leads of all the workstreams as well as from the service user advisory group. Formal aspects of line management for each of the people working in the project (there were over 50) followed the policies of each of the universities, the partnering organisations and the contracts agreed between them. King's College London was the host university from a grants management point of view with a project administrator and myself overseeing the grant and the running of the academic management group. The project required considerable administrative work to set up, sustain and bring to a close and one reflection is that collaborative projects are best served by administrative support that 'gets' interdisciplinarity and is willing to 'stick with it' over time. I would say that continuity in the management of interdisciplinary collaborations is important.

The balance of central versus devolved management was especially important to MHJ because of its diverse workstreams and partnerships. Sometimes there needed to be a central or 'tight' style of management but usually I found it better for it to be 'loose'. In part this was because 'MHJ' was actually not a formal 'entity' from a governance point of view (e.g. it didn't have any single line management structure), in part because the workstreams

<sup>10</sup> The film had its world premiere at Sheffield DocFest, was acquired by Guardian films and is available to be viewed for free on the Guardian website www.theguardian.com/news/ng-interactive/2021/aug/12/rip -seni-racism-graffiti-and-the-uks-mental-health-crisis-video.

To date, it has been screened at ten film festivals around the world including the London Short Film Festival.

themselves had strong identities and committed leadership and in part because high levels of engagement across the project allowed, to a large degree, a natural self-regulation to happen. There were times when the workstreams were all consuming centres of activity and progress and the central group less important and times when the academic management group was very important (e.g. in preparing the annual colloquia, policy labs, addressing interfaces and resolving problems). *Balance* was the theme of management: both understanding the balanced central and devolved management structure itself (its nuts and bolts) and knowing when the balance between central and devolved needed to shift. These balances were not always perfect but that there needed to be attention to balance I think was clear. Perfect, or ideal, balance is probably not the appropriate standard for governance of strongly interdisciplinary collaborations. In other words, expect some wobble and if no wobbles then consider whether you are actually achieving strong interdisciplinarity. But there are standards to aspire to on balance. I think these are around reasonableness, adaptive learning, trusted systems of communication and also the so-called 'via negativa'.11

The 'big tent' experience was part of the origin of MHJ's development as a research programme and was important to maintain but with this came a tension between, so to say, tightening the tent stays to keep a big tent pitched (especially during the stormy cross winds of the pandemic) and overtightening the stays (risking it being no longer a big tent). There was also the intellectual tension between fostering the richness of intellectual work within the big tent (i.e. maintaining the richness and diversity across the MHJ workstreams) and the overall conceptual coherence of the project (or to keep the tent metaphor: 'what' the MHJ tent was). The group found metaphors helpful in balancing these tensions – for example the metaphors of a 'garden' or 'octopus' emerged – as well as a reconciliation with ambiguity and uncertainty in any final formulation of the empowerment versus protection question. But, mostly, resolving these tensions was down to the resolution of the group itself and I think that, in large part, went back to the early 'big tent' identity which was formed, at the start, when sculpting the project. A final, no cost extension, for a dissemination year, was granted by the Wellcome Trust, which, at the time of writing the project is still in. That was helpful for planning further articulations and representations of what that 'big tent' MHJ object was/is,12 what the field can become, and for the process of letting MHJ as a grant go.

#### *Collaborative processes*

As mentioned already, it is to be expected that collaborations like MHJ will bring challenges to those working in them as well as opportunities. I will briefly reflect on some of the key challenges or 'bumps' we faced.13


<sup>11</sup> Nassim Taleb in his book, *Antifragile: Things That Gain from Disorder* (2013) defines the via negativa as a heuristic for what to avoid, what not to do, subtraction, not addition. In effect, the art of letting things go. Theodor Adorno in his abstract notion of 'negative dialectics', emphasised anti-system or anti-ideology as a way to act outside the sway, or lure, of unities. Theologians refer to via negativa as the approach to the divine which characterises it only in terms of what it is not.

#### *The Mental Health and Justice project*

After the joy and excitement of the MHJ award, the Wellcome Trust asked us to make a financial cut. That was an early bump to overcome because it meant us having to re-open a shaped collaborative structure or whole, remove research from it and put it back as a whole again. The fact that there were six workstreams made this easier to do in the respect that each workstream could be fairly asked to propose cuts to its research package in a way which it felt most comfortable with. But the task of putting it back together as a whole was more difficult and some lasting impact of having a reconstructed whole needing to fit into a new budget likely occurred.

Another bump related to organisational policy issues on equality, diversity and inclusion (EDI). MHJ lived through a period of rapid change in the EDI policy landscape in higher education in the UK and there were some uncertainties in relation to understanding need, protocol and expectation – both within the collaboration and within and across the organisations. EDI policies address complex matters of identity and power which carry strong emotions. The rapidity of the policy changes caused a bump. MHJ, like all collaborations, was entangled with a wider process of change which continues to be worked through and it may have been somewhat amplified in the project because of its emphasis on justice.

As already discussed, the very words 'mental health' and 'justice' have become more culturally and politically salient now than they were in 2016 when the project formed. That also raised a rather unexpected issue around the 'MHJ' brand which created a bump in relation to what was being assumed either by individuals or organisations. One thing that emerged for me was that we were dealing with an ambiguity in relation to what MHJ was a reference to: a grant (which has a specific reference) or an emerging field (which is a very open reference). These two things are very different. If the term 'MHJ' is to continue beyond the grant (which I hope it does) this will need to be disambiguated.

In summary, there were some bumps but adaptation occurred, and the group got through them. I think it was an indication that strongly interdisciplinary projects will have to be accepted with 'warts and all' but with an expectation of a will to adapt. With MHJ, I think that will to adapt, in large part, went back to the early 'big tent' mental health and justice identity as well as to a good will commitment, and sense of responsibility, to make things better (as well as not make them worse).

#### *Collaborative working as education*

A final reflection on MHJ I would like to capture relates to the education of all of those who worked on it. I don't mean this in any kind of didactic sense. I mean *the experience* of doing strong interdisciplinarity and the education afforded thereof.

Firstly, a curious feature of the project was a generational (or seniority/juniority) difference in that educational experience. For senior researchers who were leading the workstreams and running the whole project, the rarity of *large-scale* strongly interdisciplinary projects meant that none of us had been brought up in this way of working. Most of us had their research habits and skills shaped (from doctoral research days onwards) by more solo, unidisciplinarity or weakly interdisciplinary ways of working. In addition, we had only relatively sketchy blueprints or guidelines (discussed above) on how to lead and run strong interdisci-

over time. Laura was commissioned by the MHJ project to write a report on MHJ collaborative processes. These reports are freely available on the MHJ website. My account here draws on her work.

plinary projects. It was not even necessarily a case of 'see one, do one, teach one' because to see one there actually has to be one and it was not clear that there was a proto-MHJ project to 'see'. Also, there was not a, so to say, 'practical guide to strong interdisciplinarity for the new user' so we were in largely unchartered waters. That all said, nothing is completely new under the sun and we (i.e. the senior researchers) were able to draw on a blend of experience and learn on the way. It was possible to do a 'good enough' job of steering a course within the workstreams and across them.14

With the junior researchers, it was wonderful to see a phenomenon develop of semiautonomous assembly, peer support and interdisciplinary collaboration. The junior researchers had the lion's share of research time and the peer support and work in progress group they formed was an important and enduring part of the project and its course. I think they literally *grew up* in strong interdisciplinarity in the workstreams and across them in a way that was new and unusual. The junior researchers (seven doctoral candidates) have done their doctoral research as, say, a psychologist or a psychiatrist at ease with the idea that a lawyer or a philosopher or social scientist is in the team. And all of them have been able to assume that research is also about meaningful contact with service users and that it engages with the issue of action (as discussed above) and balances values. That is quite a new educational experience, I think. Talking to a MHJ junior researcher recently who was thinking on how their doctorate compared to university peers (not working in an interdisciplinary collaboration) brought that home to me.

For all the researchers (senior and junior), the MHJ project has provided a substantial and helpful base of experience in *doing* strong interdisciplinarity which can be carried forward. The junior researchers will be very interesting ones to watch in the future on interdisciplinary achievement – both inside and outside of the academy – because they have 'grown up' in it and had their intellectual habits and expectations formed accordingly.15

Finally, it was noteworthy how art featured in the educational experience of doing strong interdisciplinarity. At the inception of the project our hunch was that the participatory arts would be important because they were fitted to the subject area of MHJ where the very ambiguity of the human condition and the inherent tensions between freedom and dependency, protection and empowerment are exposed. We thought that art could mobilise a different type of learning on the grey areas that would crop up in the workstreams and so we linked a Bethlem Gallery artist with each of the workstreams. That hunch about a different kind of learning was borne out and one good example was the interplay of a Bethlem artist with the workstream on advance directives that brought a new kind of appreciation of selfbinding advance directives: both as sculpted objects and as a form of 'wrapping' rather than only 'binding'.16 But something in addition also happened in MHJ with how art featured in the educational experience which was not part of our original 'hunch'. This was to do with the way art can flow with events, and take them up into its own activity in a way that science cannot achieve. The BLM movement was a major cultural event and its interplay with MHJ

<sup>14</sup> On strong interdisciplinarity, the Wellcome 'Hearing the voices' project was a helpful point of external reference.

<sup>15</sup> The remark (I think attributable to Churchill) that 'we form institutions and institutions form us' captures what I am struggling to articulate here.

<sup>16</sup> The artwork was published by *The Lancet Psychiatry* together with a survey study of attitudes to the idea of self-binding co-produced with the service user organisation Bipolar UK.

within the participatory arts stream (see footnote 10) was a moving and enduring part of the MHJ educational experience. There was no clear anticipation of BLM at the start of MHJ and no research workstream was designed around it but the partnership with the Bethlem Gallery was able to respond to it as it unfolded in real time and create innovating forms of learning and influence.

#### **Conclusion**

It is too early to conclude what the MHJ project will transmit and not for me to judge it. The academic management group has reported on the original strategic aims of the project and it was a positive experience for us to reflect on how these have been met.17

What I hope, and relevant to how it started, is that the project has been an example of the kinds of influences, impacts and innovations that strongly interdisciplinary projects promise to provide. If so, then the project can be added to the background of experience for the research community (put in the extended interdisciplinary academic library, so to speak, for looking up by those wanting to work in an interdisciplinary way). We need to be able to say, and with good reason, about strong interdisciplinarity: 'this is what it can do', 'these are some things to do and not to do when running projects', 'do a project after being well taught in one' and 'do another one'!

On the problem of empowerment versus protection in mental health it is something of a cliché to refer to the number of lives affected by mental disorders or disabilities and quote figures like 1 in 4, etc. but the experience of doing MHJ has made me think that it is better to think that *everyone* is affected, directly or indirectly, by the problem of empowerment versus protection in mental health. The pandemic has shown how this is true but there are other examples.18

The MHJ project has been able to make just a small contribution to this vast problem of protection versus empowerment. It has been a wide-ranging 'big tent' type of contribution. I hope it helps further ships set sail. We all know that we need to keep struggling to achieve sustainability and growth in mental health and justice.

#### **References**

Committee on the rights of persons with disabilities. 2014. General Comment No. 1.


Haidt, J. 2012. *The Righteous Mind*. Why Good People Are Divided by Politics and Religion. Pantheon.

Hamilton, M. & Coates, S. 2020. *Coronavirus and Anxiety, Great Britain: 3 April 2020 to 10 May 2020*. Office for National Statistics.

Hinrichs-Krapels, *et al.* 2020. Using policy labs as a process to bring evidence closer to public policymaking: A guide to one approach. *Palgrave Communications*, 6(1), 101.

18 Dementia, for example, is now the leading cause of death in the UK. I have yet to meet someone unaffected by the empowerment/protection problems arising from dementia.

<sup>17</sup> The academic management group formally ended in January 2021.


Popper, K. 1963. *Conjectures and Refutations*. Routledge.

Sheather, J., Norcliffe Brown, D. 2022. *Health and Human Rights in the New World (Dis)Order: A Report from the British Medical Association*. BMA: British Medical Association. Avaible from: https://www.bma.org.uk/media/5491/20220104-bmas-human-rights-report-v4-compressed. pdf (Accessed June 13th 2022).

Talib, N. 2013. *Anti-Fragile: Things That Gain From Disorder*. Penguin.

