Improving family social and mental wellbeing in the COVID-19 pandemic and beyond: the case for deep listening

ABSTRACT Within mental health systems, families are often poorly integrated into planning and treatment yet tasked with unsustainable care and support responsibilities. The COVID-19 pandemic exacerbated impacts on families’ social and mental wellbeing. This study explores understanding family experiences through a co-operative inquiry methodology with staff who facilitated 26 meetings with over 300 mental health family, carer, and supporter participants. Deeper listening of challenges experienced by families, strengths and creativity in coping and recommendations for system reform have been reflected on through three cycles of inquiry: 1. Sharing experiences, 2. Discerning key messages, and 3. Consensus building towards the final text.


Introduction
Priority groups at risk of deterioration in their social and mental wellbeing during COVID-19 include people with mental health challenges and their family members who provide support and care (Bower et al., 2021;Irani et al., 2021;Onwumere et al., 2021).Understanding family carer needs, the context within which they live, and how best to engage with them is important to providing support and informing system change.Family carers are often the primary support for people who experience mental health challenges and psychological distress.Prior to the COVID-19 pandemic, the engagement of families and carers of people with mental health challenges within mental health services had been recognised internationally as highly valuable, and acknowledged as an area where mental health services can improve (Martin et al., 2017).Global impacts from the COVID-19 pandemic have included higher levels of distress in people with a history of mental illness and their family members, with studies citing family carers as experiencing concerns over the provision of support by services, increased practical demands placed on families to provide support and managing challenges that have arisen since the start of the COVID-19 pandemic (Clark Bryan et al., 2020;Dragioti et al., 2022;Onwumere et al., 2021).Both prior to and during the COVID-19 pandemic, mental health family carers have expressed several concerns including, being less likely to be identified as carers by statutory organisations and therefore less likely to receive financial and practical support, feelings of social isolation and being unable to access information to provide support (Blake-;Holmes & McGowan, 2022;Fusar-Poli et al., 2021).
Studies have identified mechanisms of support that family find beneficial include: social and emotional support; assistance accessing and navigating health services; psychoeducation where family gain both knowledge and skills on providing support; and creating opportunities for the exchange of information with professionals (Harvey & O'Hanlon, 2013;Hjarthag et al., 2017;McFarlane et al., 2003;Murray-Swank & Dixon, 2004;Walters & Petrakis, 2022).

Context of study
The effects of the COVID-19 pandemic within Australia have been varied, depending on the different responses and restrictions adopted within state jurisdictions.Subsequently, in understanding needs within defined geographic regions, it is vital for services to understand the unique experiences of families within a region and tailor service to meet these.The Australian State of Victoria is undergoing transformative mental health system reform, following a Royal Commission into the Victorian mental health system (State of Victoria, 2021).Subsequently, there exists an urgency in understanding and responding to the needs of family.A peak body supporting family and friends within mental health in Victoria facilitated 26 meetings with family carers during the month of March 2022.Over 300 family carers participated and gave voice to their experiences during COVID-19, offering insights about their needs, what meaningful service provision would be and ideas for system reform.To appreciate the rich data generated from the consultations and to understand the process of engagement and its effects, members of the peak body were motivated to reflect and learn from their experiences.
Co-operative inquiry has been identified as an accessible method of inquiry, applicable to a wide range of research topics, that encourages research that is inclusive and enables writing across a range of research expertise (Short & Healy, 2016).Further to this, the cooperative inquiry methodology has been shown to promote valuing lived experience and raising consciousness of the 'other', facilitating connections between practice wisdom, theory, and encouraging engagement with disadvantaged or marginalised populations (Short & Healy, 2016).

Aim
The aim of this study was -through a co-operative inquiry process -to explore engagement practices, used during the COVID-19 pandemic, that enabled understanding social and mental wellbeing experiences of families who support people with mental health challenges.

Study design
The conceptual framework that guided the study was a critical social work participatory action research approach (Carroll & Minkler, 2000).These frameworks established underlying principles recognising people are collectively able to understand their common problems and root causes to derive strategies and actions for transformation (Carroll & Minkler, 2000;Cocker & Hafford-Letchfield, 2022).Further to this, with the majority of mental health family carers being women (Walters & Petrakis, 2022), an awareness of gender brings responses to the intersectionality of experiences (Cocker & Hafford-Letchfield, 2022;Lauve-Moon et al., 2021).A co-operative inquiry methodology (Heron & Reason, 2006) was used to develop the research question at the first meeting, which was: What has been learnt about how to best connect with and include family carers in understanding their needs during the COVID-19 pandemic to enhance their social and mental wellbeing?
Co-operative inquiry is a research approach that enables those impacted by and experienced in a topic or line of inquiry to come together in a way that reduces hierarchical assumptions about knowledge (Heron & Reason, 2006).It is a process defined by Heron and Reason (2006) as A way of working with other people who have similar concerns and interests to yourself, to: • Understand your world, make sense of your life and develop new and creative ways of looking at things.
• Learn how to act to change things you may want to change and find out how to do things better (p.144).
Co-operative inquiry is a research process involving four phases.These can be conducted sequentially within a meeting or, more typically, across many meetings.The phases are: (1) Establishing the focus area and the research team, developing key ideas; (2) Discussing and reflecting on the focus and beginning to collect resources; (3) Becoming immersed in the topic, agreeing on and taking actions; and (4) Reflecting on actions and refining the focus; which can be repeated, enabling iterative cycles (Short & Healy, 2016).

Participants
A co-operative inquiry was undertaken with four family carer lived experience advisers and four project officers, who are staff of the peak body and all with lived experience of supporting people with mental health challenges, facilitated by a social work academic experienced in a co-operative inquiry.Five of the nine co-researchers involved in the cooperative inquiry were social workers.Due to the ongoing restrictions and concerns about the spread of the COVID-19 virus, the meetings occurred through a hybrid format with some of the co-researchers meeting in a room and others attending virtually in a Microsoft Teams format.This was after two years of the pandemic and at the point when the community was highly vaccinated and gradually returning to in-person interactions and activities.The meetings were recorded, transcribed, and made available for reflection at the next iteration meeting.Three iterations of the inquiry were held on the 9 May, 30 May and 27 June 2022, to reflect upon the participants' experiences of engagement across the 26 meetings with families in Victoria that had occurred either face to face or online.Three cycles of co-operative inquiry iterations resulted in the following stages: (1) Sharing of experiences; (2) Discerning key messages; and (3) Consensus building towards the final text.A new understanding of challenges experienced by families during the COVID-19 pandemic, strengths and creativity in coping and adaptive approaches fostered, and recommendations from families for system reform, were considered alongside important learnings about how to connect with families who have experienced disadvantage and marginalisation.

Important learnings about how to connect with and support families with their social and mental wellbeing
Several themes emerged from the co-operative inquiry, which the co-researchers felt warranted exploration and dissemination.These included: 1. Broadening who is represented through creativity in grassroots recruitment strategies 2. Active listening approaches, being engaged and co-learning with communities 3. Wondering together through verbalising and witnessing what should happen next in reform 4. Recording, documenting, and disseminating to honour and elevate voices and preferences of families.

Broadening who is represented through grassroots recruitment strategies
As an organisation interested in raising and supporting the voices of its members, the peak body held a preliminary online consultation with members, who had expressed an interest, to inform the design of the focus groups and survey for the consultation process.It was suggested in the preliminary consultation that finding familiar community spaces where participants would feel comfortable and travelling to regional areas to conduct face-to-face meetings would strengthen the validity of the consultation findings.
A number of creative approaches were used to spread the word about the focus groups with the specific aim of reaching cohorts who are younger, culturally and linguistically diverse and living within regional areas.Due to the tight timelines involved, digital communication strategies were used rather than distributing physical posters or having initial face-to-face engagements.
The peak body actively tried to engage across the state of Victoria.However, within regional and remote areas there were fewer existing members, and new approaches to reaching people were considered for the consultation project.Joining community Facebook groups for different regional towns enabled sharing to those groups, subsequently reaching considerably more people than through the peak bodies' existing Facebook channels.
I did things in a really different way to find people for specific locations and joined lots of community pages . . . in different regions.It wasn't a hard thing to do. . . . it will change and already has changed some of the way that I do what I do in terms of I keep going back to those community pages and sharing information.Now that I know that I can reach people in those areas (Co-researcher 1).
People would 'like' or comment on the post, or direct messaged the Communications Officer through Facebook pages, at times to verify if the consultation was real.Comments included 'It sounded too good to be true' (Co-researcher 1) -in wonderment that an organisation existed to support and recognise them, and that there would be family centres within their region aimed directly at meeting their needs as family supporting people with mental health challenges.Further to this, family carers were reimbursed for participation, making attendance accessible to more people and generating a sense that their involvement had real value.Many of the focus group participants, who were from regional areas or were young carers within metropolitan regions, stated they were unfamiliar with the peak body prior to the consultation process.When people attended the focus groups, they verbalised that they had seen the focus group on Facebook.Such comments validated that the adoption of new promotional approaches was working, and therefore the Communications Officer continued these strategies.
Other means of outreach included contacting known individuals who were prominent in the region and aware of carer groups.These people were able to distribute details about the opportunities to participate in the focus groups, raising the profile of the consultations.
It was found that Instagram was integral to reaching young carers; this was achieved by promoting Instagram posts, in which a fee was paid to have posts targeted to 18-to 25year olds.Minors under 18 years of age are unable to be targeted on Instagram.A similar approach was taken with Facebook in which targeting was also achieved via paid posts.The respondents to the targeted Facebook posts tended to be older populations.The targeting included geographic areas and care givers, however available target functions did not include some population groups, such as those with specific caring responsibilities (including mental health, alcohol and other drugs carers), or Aboriginal and Torres Strait Islander communities.The only approach Facebook had available to target culturally and linguistically diverse communities was to choose countries where people lived.This approach was not used.
Service providers who work with culturally and linguistically diverse communities, and where staff are part of these communities, were invited to participate in the consultation process.Most of those who attended as representatives of these service providers were people who had established links with the peak body.
Alongside the recruitment strategy, thought was given to where to hold focus groups to promote access for those within regional and remote areas.Creative approaches were considered, such as contacting local community groups, to discover where meetings occurred, such as libraries or neighbourhood centres.Time constraints prohibited travelling to regional areas, prior to the focus groups being held, to understand the availability of venues and to engage with local communities.However, it was recognised that; if you had the opportunity to, it would be good to spend more time actually in the communities from a content perspective, and I'm sure whole other perspectives as well (Co-researcher 1).
There was also a recognition that making the meeting comfortable with food and refreshments was important as people were taking time out of their day.It was also discussed how this supported local businesses, which built goodwill with the wider community in which the focus group was located.

Active listening approaches, being engaged and co-learning with communities
The co-researchers reflected on how active listening involved a complex range of skills, including the facilitators being alert to what was occurring between individual participants and across the whole group, and to be aware, open and sensitive to what was happening in the room.On reflection, this was recognised as not straightforward and required some trust in the group and in the facilitator's own skills.The facilitators were required to bring the conversation gently back to the questions being addressed, whilst allowing these other conversations, stories and anecdotes to enrich the material and also build a sense of safety and connection in the room.
Co-researchers noted the willingness of family carers engaged in the consultations to talk openly about their experiences.During the co-operative inquiry reflective discussions, coresearchers considered their observations of the process and reflected on feedback and comments made by family carers during the focus group consultations.The term 'liminal' was identified as a useful way of describing the active listening space.Facilitators listened to what fell outside and in-between the structured conversation of the formal discussion prompts.The sense of safety and inclusion fostered an evolution of the focus group to also include a therapeutic experience for the participants.Conversations occurred during breaks, or before or after the consultation session itself.
The co-researchers observed how quick and often intense connections formed between the participants during, before and after the focus group sessions.It was proposed that these connections and co-learning occurred when trust and a relationship was established, where people felt safe and 'nourished', leading to a sense of intimacy to form.They also formed from the sudden realisation of people who were very isolated in their day-to-day lives, that there were others 'out there', with similar experiences to their own.This connectivity also flourished in the liminal and active listening arena.
The sharing of lived experiences, of knowledge and practical information on resources and local area support available, were freely exchanged between focus group participants, and from participants to the facilitators through the set-up of a warm and safe space for connection and conversation.
"[In the in-person focus groups] There was such an urgency with which people wanted to share their experiences, but also the connections they were making with each other.The conversations of support that they were having during the focus group towards each other, as well as in the cups of tea time, and at the end, and also at the beginning, when people came in . . .Sometimes people knew each other from a local carer support group, but there were extra people that didn't know about that group, and were kind of recruited in through that focus group process, which isn't necessarily what the focus groups were there to do.But they had these consequences that were really significant."(Co-researcher 2)

Wondering together through verbalising and witnessing what should happen next in reform
Within the co-operative inquiry discussions, it was reflected that consultation participants; 'shared so much, because for a lot of people nobody had ever asked them before.[They were] just busting to unleash all of these experiences, they've never felt understood or seen before' (Co-researcher 1).The discussion within the focus groups indicated that this strong need to share experiences resulted in part from the marginalisation that family carers commonly experience within the mental health care system due to the deficit of family-inclusive practice.While the depth of need to share reflected their distress in relation to their family member's mental health challenges, it also appeared to reflect the system's lack of capacity to adequately respond to and support both the service user and family during COVID-19.
It was suggested within the co-operative inquiry sessions that the depth of need to share might also be indicative of many participants not having had the opportunity to engage in consultations about these issues before despite their enthusiasm to contribute to system reform.More specifically, it became evident that many participants had not been aware of the organisation's existence before hearing of the consultation opportunity.As mentioned within the co-operative inquiry; 'We have events for members, but a very small number of the same people come all the time.But there's this huge need out there and people who don't know that we exist' (Co-researcher 1).
It was felt that the peak body could continue to explore innovative ways to reach people, grow membership, and increase engagement and diversity within the membership base.The need to be proactive about reaching people within regional and rural areas as well as those from culturally and linguistically diverse communities was discussed.
It was acknowledged that the peak body having existing positive relationships, and the trust of a large number of family carers is of great benefit to enabling the genuine participation of those with lived and living experience in future reform activities.Some co-researchers wondered whether the influence of the COVID-19 pandemic, the context of reform, and general desperation of the voices to engage drove family to participate and hope for meaningful impact on outcomes.
I wonder how much the reform environment itself influenced participation . . .it's a pretty unique opportunity to influence the system.For the next how many decades, this is a once in a lifetime opportunity for me . . .I wonder how many people knew about this reform, these reforms?I mean, . . .it's an unusual kind of context as well, and how much that contextual stuff influenced participation (Co-researcher 3).
Supporting people to engage in the consultations through remuneration was highly valued by people who had to drive long distances to attend.Remuneration also enabled some people to attend who otherwise could not afford the fuel or transportation costs.
I think it really helped to get a more diverse group of people than we normally get as well.Not everyone can spend two hours traveling . . .some of the travel time for some other people was extraordinary . . .people spent four hours giving half of their day to us.And they couldn't have done it without the money.And they wouldn't come to members meetings perhaps because they don't have an hour or two hours on a Thursday . . .but you know, it [remuneration] meant that they didn't have to do an extra shift that week or something.And so, there were a noticeably different group to whom we normally get with a lot of younger people.You know, a lot of parents, young kids, . . .there were sort of some younger, gender diverse people who came, who hadn't encountered . . .events before.And I think the money really, made it [possible] to participate.(Co-researcher 1)

Recording, documenting and disseminating to honour and elevate the voices and preferences of families
Capturing the depth and breadth of family carer experiences and wisdom meant that an accurate recording of the consultations needed to be achieved using multiple methodologies -to ensure that language, meaning, and context were not lost.Facilitators recognised that audio recordings are useful for language accuracy, therefore audio recordings were made of those core discussions in the face-to-face sessions, and in all the online (conducted via Zoom) sessions.
I think we just took a really good backseat, really, in the way that it was structured.So, beyond sort of prompting, . . .they would start connecting and having their conversations and each were kind of feeding off one another, so we weren't.What's the word, we weren't intervening?Or having to do that, we just kind of had given enough thought to start up the conversation.Everybody felt so comfortable to just share.And it was very free flowing and the ideas came out and people were writing on the butcher's paper (Co-researcher 4).
It was further recognised that while asking participants to write their own, and in some instances, the group's collective reflections, other participants may prefer to respond using picture drawings.Large sheets of paper and coloured drawing tools were also provided in all face-to-face focus groups, with some participants choosing to draw pictorial responses rather than write.Additionally, requiring family carer participants to physically commit their insights and ideas to paper served to document their own expertise in a manner, which was both collaborative and powerful.This was particularly evident in an exercise where participants of face-to-face groups documented all the activities or structures that supported them as a family carer, on a post-it-note, and then displayed their offerings collectively on a wall.
To capture and elevate those carer voices who are most often excluded through systemic barriers, facilitators were focused on creating a safe space to share the experiences and insights of those most marginalised.Connectivity and relationality were considered vital in all recording, documentation, and dissemination processes, ensuring that participants felt included and valued -as opposed to part of a transactional exchange.
I think what helps people to be so generous in their sharing was that, as well as feeling like a friendly community space, what I would hope [is] that their experience wasn't one of it being a transactional exchange where we just extract information and head off again, but it was more about a relationship . . .But it strikes me that one of the strengths is that there is an emphasis on connection, . . . on the importance of a relational approach within mental health . . .I think I would hope [we] spoke to the sort of intuitive sense of our space that people [were] genuinely connecting.And it's not just this sort of cold exchange of information (Co-researcher 5) Participants of particularly marginalised groups had additional opportunities to share information-above and beyond the advertised sessions -these included membership of a co-design governance group, one-on-one feedback sessions with facilitators, or groups that focused on a particular population such as culturally and linguistically diverse families and carers, or LGBTQIA+ community members.In each of these sessions, expertise and experience were captured in a multiplicity of ways -from pictorial drawings, audio recording, emails, white board and flashcards.The multiplicity of methods was designed to capture participant perspectives in ways that were both meaningful for them, and useful in honouring the sentiment and words of family carers.
The sense of opportunity to influence the future system meant a strong commitment to getting the recording and documentation of evidence 'right'.The focus group facilitators demonstrated values in delivering the consultation process.These values included compassion, respect, transparency, and inclusion, and proved pivotal in ensuring that the process of gathering information always honoured and elevated the perspectives of all participants.Throughout the consultation process, the perspectives of participants were the only insights that have been captured, and they have been championed in all aspects of recording and dissemination.Participants have been involved in writing up of the final consultation products and presented outcomes and process insights at an Australasian conference in 2022.

Discussion
Several lessons were learnt through the co-operative inquiry process, both in understanding the processes of engagement with families, and the value of the co-operative inquiry methodology in facilitating a reflective and supportive approach to research.The co-operative inquiry process was seen by participants as a methodology that was accessible to 'lived experience' researchers.A similar view was expressed by Lloyd and Carson (2005, p. 191) where a co-operative inquiry was seen to 'bridge the gap between these two cultures [family carers and professionals]' and enhanced research paradigms that build ways of knowing that are shared.

Key learnings for ongoing practice of engagement
Engaging regional, culturally and linguistically diverse, and young carer families, has been noted as challenging (Janes, 2022;Tribe, 2019).Creative and alternative approaches were used in identifying and engaging with populations that were under-represented in the peak body's membership.Some of these engagement strategies had begun during COVID-19 as a response to the isolation that mental health families experienced within Victoria due to the extended lockdowns and restriction requirements.These included online meeting forums using the 'Zoom' platform.However, new approaches and alternative strategies of targeted social media posts -especially with Instagram -gained access to younger and regional people.Co-researchers reflected that the methods adopted during the engagement with families and carers embodied integrity.These methods included proactive recruitment, including through grassroot networks, and the focus group engagement that encouraged and facilitated active listening.
The consultation process and focus groups emerged as more than a data collection process.The co-researchers all noted the high value of the focus group meetings, especially in a face-to-face format.Skills were seen in practice where the facilitators in the room were able to observe what was happening and hold space for conversations.Being physically present in the room enabled active listening to intentionally create liminal spaces, observe non-verbal reactions to enable participants to hear each other, support and respond with kindness to expressed distress in the room.Whilst similar support was evident within online meetings, the ending of physical meetings allowed people to leave when they felt 'ready to go'.A similar approach was enacted in online forums, with facilitators remaining online and visible until the last participant was ready to leave.

Focussing on trust and respect in enhancing family social and mental wellbeing
Reciprocity and nurturance were seen as key to creating trust and a willingness to share.Nourishment was offered through the giving of food, provision of funds to travel and attend, and creation of a safe space through respectful relationships.The co-operative inquiry group recommended the development of a framework, that outlines the key ingredients for respectful and effective engagement, to guide working with families.The group felt the framework should include: how to establish connection, including early questions to stimulate sharing about one's experience of local areas; ways of listening that are helpful to working with families and diverse groups; how to ensure online forums as well as in-person engagements have a sense of safety and nourishment (especially when there were periods of isolation and restriction during COVID-19); and how to carry and support the voice of family.

Honouring and elevating the voices of family
Reflections within the co-operative inquiry group identified involving participants in the process of recording and documenting perspectives has benefits that extend beyond the data collection itself.There were several key learnings for honouring and elevating the voices and preferences of families and carers, through recording, documentation, and dissemination practices.Research suggests that 'a lack of time for researchers to build relationships and tokenism in engagement are the two most prominent barriers' within healthcare research in Australia (Anderst et al., 2020, pp. 808-809).The process of active listening is an iterative one.It requires the capacity to draw people out through acknowledgement of what is being said, without dominating or controlling the discussion: Active listening involves restating a paraphrased version of the speaker's message, asking questions when appropriate, and maintaining moderate to high nonverbal conversational involvement.(Weger et al., 2014, p. 13) The recent consultation exercise enabled the development of new connections with participants and the strengthening of existing connections, an asset that can continue to be built upon through the broadening and diversification of the membership base.

Implications
Implications from the current study for policy and social services include effective engagement with families through deep listening results in better quality and more representative community participation.For social workers across the Asia Pacific, and internationally, the co-operative inquiry methodology and described engagement processes are applicable to social work practice, research, and education.The study highlights the importance of reflecting together as practitioners to improve engagement with families.
For effective social development, community organisations, such as peak bodies (especially those arising from lived experience), require adequate support through government funding to undertake engagement and social development projects that enable deep exploration of experiences.A further strength of this project was it being led and facilitated by people with lived experience of being family carers of people with mental health challenges.Leaders and facilitators had experienced the challenges and distress experienced through the reduction and loss of mental health services, similar to the family participants' experiences during COVID-19.
To enable participation by carers, and especially women under-employed due to primary caring duties, financial remuneration for the cost of transportation and the time to offer their expertise is required.
The learnings are particularly relevant for the Asia Pacific regional setting, and international social work and welfare studies preparing students to work, given the cultural valuing of women as the primary holders of caring roles, responsibilities for family nurturing and duties towards those vulnerable and/or unwell.For social development to be advanced there is a need to examine how to engage, support and bring together women who are isolated or in isolating caring roles.

Conclusion
The COVID-19 pandemic resulted in increased isolation of families who support and care for people with mental health challenges and created challenges for engaging with families due to ongoing restrictions and associated risks.Understanding how to connect and engage with families and carers and centring them in promoting social development and social policy responses, is vital.This aids future collaborations and ensures the voices of those who use services, and who may not usually be present, are heard.
The co-operative inquiry process allowed co-researchers to reflect on the experiences of family during the dual context of the COVID-19 pandemic and systemic challenges.As a research methodology co-operative inquiry enabled exploration of the team's work in contributing to improving the experiences of family, provided the opportunity to share their experiences of doing the work, and highlighted some of the learnings for managing future pandemic responses.
Co-operative inquiry has been shown to be a useful practice research method for reflecting on engagement and consultation processes to raise the voice of people at the centre of a social problem or need.As a research method, co-operative inquiry contributes to the development of reflective skills enabling lived experience staff members to develop, refine and adapt practices to continue honouring and raising the voices of families and carers in the context of reform to enhance social and mental wellbeing.
Amaya Alvarez Amaya works as a Senior Lived Experience Advisor at Tandem, a Peak organisation for families and carers in mental health.Amaya brings her lived experience of providing support for a family member to her role.She is also a PhD scholar at RMIT University in the final stages of a PhD researching the lived experience of families and carers providing mental health support in the context of marketised disability support.
Melissa Petrakis Associate Professor Melissa Petrakis is Group Director of Social Work Innovation, Transformation and Collaboration in Health (SWITCH) Research Group and coordinates health and mental health units in the Department of Social Work, Monash University, Australia.She has worked in mental health for over 30 years, as a clinician, service manager, suicide-prevention national project lead, then practice-based researcher.She has authored over 100 publications and her expertise is regularly sought for national/international conference presentations.In 2016 she was awarded The Tom Trauer Evaluation and Research Award, Australian and New Zealand TheMHS Awards, acknowledging excellence in her approach to research, championing co-design, co-production and co-authorship, with clinicians, people with lived experience of mental illness and families.