Narrative Matters: Hidden LIVE – Adam’s story – a mental health theatre production as an example of participatory principles and practices

This article presents the co-production principles underpinning the co-creation of a multimedia theatre production on young people’s mental health.


Introduction
The 'participatory arts' involve and engage public participation in the creative process of making and producing art-forms, whether that be film, music, photography, theatre, another medium of artwork, or a combination of art-forms.The value of participatory arts in health and healthcare has been seen to lie in enabling people to creatively express their perspectives and experiences of their condition, services, and treatments, from their unique point-of-view, as a therapeutic/cathartic process (Hine, 2022;Stickley, Wright, & Slade, 2018).Participatory arts can also provide creative spaces in which to challenge and engage healthcare professionals to learn and to reflect on their practice (Dalton et al., 2020;Halton & Cartwright, 2018).
Those involved in the participatory arts can learn from best practice in Patient and Public Involvement (PPI) and co-production approaches in health service design, delivery, and research, particularly in mental health (Grundy, 2018).These approaches can guide public participation in the creative processes for producing shared artforms.Similarly, researchers working with PPI and co-production approaches can learn from the potential of the participatory arts to enhance engagement and involvement (Hine, 2022).The aim of this article is to briefly outline the co-production principles that underpinned the co-creation of a theatre production on young people's mental health, providing examples of participatory principles and practices, and demonstrating the usefulness of the approach.
Hidden LIVE -Adam's story is a multimedia theatre piece about young people's mental health, first performed on 11 May 2022.The performance consisted of an immersive listening experience of a pre-recorded podcast narrating the fictional story of a young person, together with a live monologue from the perspective of their caseworker from Child and Adolescent Mental Health Services (CAMHS).The aim of the production was to challenge attendees to empathically encounter life as a young person struggling with their mental health, to raise awareness of the issues young people face, and to ask the question of what could be done to help.The performance was also followed by an interactive workshop that gave attendees the opportunity to share experiences and discuss what could be done to improve young people's wellbeing.
A diverse group of 10 young people, aged between 17 and 24, with experience of mental health problems (or of supporting a sibling or friend with their mental health), living in Greater Manchester (UK), were recruited to join the production team.The young people worked alongside a professional scriptwriter and a drama facilitator, with some input from health researchers, to work on the production.The group met for eight online workshops.In the first session, the group agreed the themeto explore the transition from CAMHS to adult mental health services; evidence suggests that this is a particularly challenging transition for young people (e.g., Broad, Sandhu, Sunderji, & Charach, 2017), but that young people's perspectives have been seldom heard.The group then worked on the character, script, recording, and soundtrack.
The formation of the production-team, the way the team worked together, how the workshops were conducted, and thus how the whole theatre piece was developed, were guided by core principles of co-production.Coproduction is often recognised as a high-level of PPI (Carr & Patel, 2016).Whilst there is currently no agreed definition, we used this more lay description: 'Co-production is about different stakeholders working together, sharing power and responsibility, in an equitable partnership, on a particular project from start to finish' (Grundy, Pearson, Willis, & Wilson, 2022).Co-production is a set of values, rather than a particular method, although the principles shape and guide practices (Carr & Patel, 2016).
The key principles of co-production guiding this venture are as follows.It requires a spirit of collaboration, of there being an equal and equitable partnership, between involved parties (Carr & Patel, 2016).To that end, ice-breaker questions were used at the beginning of each session to help people get to know one another, and to get people talking together comfortably.At the end of each session, there was opportunity to feedback on the experience of the workshop to see if things could be improved going forward.The team allowed sufficient time to develop these relationships, spending the first five workshops bouncing ideas off one another for the character and script, before then working on the actual recording and the soundtrack of the podcast.The young people were not merely consulted on their ideas, but they were included as collaborators on the production team.

Collaborative and supportive relationships
The young people were offered emotional and practical support from a designated team member throughout the project to aid their engagement and involvement.Out-ofsession support was offered to the young people, including text and phone conversations to encourage them and to provide any technical and administrative support.This was important to offer the young people per se, but it is also an often unrecognised but important part of building and maintaining good working relationships.Furthermore, a distress protocol was in place for the workshops themselves in case anyone felt upset during or after the sessions; this also helped to create a safe working space for all involved.After the production, the young people were signposted onto further involvement opportunities, which is sometimes a neglected aspect of best PPI practice; this is particularly important so that people do not feel used or exploited 'as a means to an end'.

Knowledge and expertise
Co-production acknowledges and values different, but equal, forms of knowledge and expertise (Carr & Patel, 2016).It was vitally important to have stakeholders (anyone with an interest in, or who could be affected by, a project) involved on the production-team itself.We also needed people with knowledge of podcast and theatre production, clinical/academic knowledge of mental health and of related services, as well as young people's experiential knowledge, in the dynamics of the team.Co-production then involves knowledge sharing, open communication, and active listening.It was important that the young people felt, and were, listened to.Coproduction also means that individuals recognise their own knowledge deficits; whilst some might have a textbook understanding of an issue, they might not understand what it feels like to live with the issue experientially (Grundy et al., 2022).Thus, the young people were acknowledged to be 'experts by experience'.One way in which the young people's expertise was acknowledged was that they were offered reimbursement for their participation time.
It was important that the young people's own words and phrases, their ideas, snippets of their own experience, and their imagination were incorporated into the developing script.Collectively, each participant could contribute to an aspect of Adam's character and story, such that the resultant character was a composite of all of them.This meant that each young person had a stake in the character they were forming together, that Adam represented an authentic young person with mental health challenges, without any individual feeling that their own story had been co-opted for the piece.Thus, the young people's experiential knowledge and expertise was essential and invaluable.The script for the live monologue from the CAMHS keyworker's perspective was also shared with the health researchers and clinicians on the wider team to ensure that this too was as authentic as possible.A clinical psychologist with knowledge of working in young people's mental health services also advised the production team.

Power and responsibility
Genuine co-production emphasises sharing power and responsibility between all parties (Carr & Patel, 2016).In this project, it was important to acknowledge the dynamics of young adults working with older adults, and the possibility of the young people simply deferring to age or to authority figures.Recognising that young people's voices are seldom heard in service transitions (Broad et al., 2017) also gave power to their perspectives and opinions.Furthermore, it was vital that at every stage the young people had real editorial control over the character development, the developing script, the recording, the soundtrack, and the final production; and that it was 'theirs'.Whilst a professional writer would begin to draft a script from all the discussions, this would be shared with the group at each workshop as it evolved, with the group having power to amend it and to make it more authentic.The feedback slots at the end of each workshop also gave space for people to share their overall reflections on the developing piece.The writer was always willing to listen and to learn and to make changes to the piece based on the feedback received.

Challenging 'roles'
The production team sought to overturn the roles of 'creator vs performer' and 'audience vs performers' of traditional theatre (Hine, 2022).The young creators became performers, as lines of the script were divided up amongst the group, rehearsed, and then recorded for the podcast; they were the narrators of their own storycreation.The attendees were not passive spectators, but they were immersed into, and engaged with, Adam's storythey were blindfolded so that they could focus on really listening, and they were made to feel responsible for Adam in different ways.These immersive features helped serve the production's key aim of enabling attendees to empathically encounter life as a young person struggling with their mental health, with the hope of producing culture change as a result (Dalton et al., 2020).That the team were creating something that could potentially be so impactful also added to the sense of empowerment for all involved.

Capturing impact
The engagement and discussion at the interactive workshop following the performance encouragingly demonstrated an initial impact, and attendees were invited to give further feedback.Comments included that it 'was good to see that so many people working in the mental health sector were present', with a number saying that the performance was 'eye-opening', with one person stating, 'you feel it inside of you'.Another stated that it was 'so important to see that young people were involved in making this'.

Conclusion
Established principles of co-production in health services and research can be usefully employed to guide public participation in participatory arts; similarly, the participatory arts can enhance involvement and engagement work.Furthermore, participatory arts are wellsuited to exploring sensitive issues in mental health in a way that can potentially bring culture change through empowering and giving voice to service users, whilst encouraging professional reflexivity.Further research is needed to qualitatively explore the benefits and challenges of involvement in this kind of participatory art project for young people themselves, and on formally evaluating the production from the perspective of attendees.We have demonstrated that co-production values can shape the co-development of a theatre piece and we encourage such approaches.
Co-production is fundamentally relational; it involves building open, trusting, reciprocal, working relationships.Ó 2023 The Authors.Child and Adolescent Mental Health published by John Wiley & Sons Ltd on behalf of Association for Child and Adolescent Mental Health.This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

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2023 The Authors.Child and Adolescent Mental Health published by John Wiley & Sons Ltd on behalf of Association for Child and Adolescent Mental Health.