Beyond the methodological binary: coproduction as the third pillar of mental health science

Abstract

Background

Mental health research has long been structured around qualitative and quantitative methodologies, often marginalising experiential knowledge and reinforcing hierarchies of expertise. Although coproduction has gained traction as a participatory approach, its methodological status remains contested, leading to inconsistent practices and risks of tokenism.

Objective

This paper explores whether coproduction should be recognised not merely as a participatory ideal but as a third methodological pillar in mental health research, with distinct philosophical, ethical and practical foundations.

Methods

This paper critically integrates interdisciplinary sources from empirical research and theoretical literature to examine coproduction as a distinct methodological paradigm in mental health research. The analysis is informed by the author’s reflexive engagement as a lived experience researcher.

Findings

Five inter-related challenges to meaningful coproduction are identified: persistent tokenism; the emotional labour required of lived experience contributors; power imbalances in decision-making and recognition; structural exclusions in participation and systemic barriers within academic governance and norms. In response, the paper proposes five strategies for integrating coproduction as a distinct methodological paradigm: creating sustainable fora for dialogue across difference; establishing coproduction as a core research competency; embedding a relational culture of care; fostering methodological innovation and evaluation; and challenging narrow definitions of academic value, authorship and output.

Conclusions

Reframing coproduction as a third methodological pillar offers a way to address the exclusion of knowledge derived from lived experience and can enhance the rigour, relevance and inclusivity of mental health science. This shift requires systemic changes in how research is conceptualised, taught, funded and evaluated.

Clinical implications

Embedding coproduction as a core methodology can improve the relevance and responsiveness of research to clinical realities. Grounding research in lived experience offers insights that enhance service design, build trust and support more equitable, person-centred care, ultimately contributing to better clinical outcomes and more inclusive mental health systems.

WHAT IS ALREADY KNOWN ON THIS TOPIC.

WHAT THIS STUDY ADDS

• This study reconceptualises coproduction as a third, distinct methodological pillar of mental health science, with its own epistemic, ethical and practical foundations. It identifies five key barriers to meaningful coproduction and offers a structured framework for embedding coproduction as a rigorous and teachable research practice.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• Recognising coproduction as a core methodology may transform how research is designed, taught and evaluated—promoting more inclusive, responsive and relational models of mental health inquiry. This has implications for funding, training, academic culture, research governance and clinical impact.

Introduction

Mental health science has long been shaped by the methodological binary of qualitative and quantitative research. In broad terms, quantitative research—rooted in positivist traditions—prioritises measurement, prediction and generalisability. Qualitative research, by contrast, provides tools to explore meaning, experience and context, often attending to complexity and nuance. Together with mixed methods approaches, which aim to integrate qualitative and quantitative data, these traditions are positioned as collectively sufficient within dominant frameworks for generating and validating knowledge in mental health.¹

This paper argues for a methodological reorientation in mental health science by proposing coproduction as a third, essential pillar of inquiry. This is not only an ethical challenge that requires greater equity between those involved in research, it is also an epistemic task, concerned with how knowledge is produced, validated and valued. In epistemic terms, coproduction enables access to forms of knowledge that are routinely marginalised within conventional research paradigms, particularly those grounded in lived experience, embodied understanding, dialogue and relational context.² These forms of knowing are not merely supplementary; they are essential for understanding mental health in ways that reflect the complexity, plurality and ambiguity of lived experience.³

Coproduction directly challenges hierarchies that privilege academic and clinical authority over embodied or experiential knowledge, confronting the ethical problem of epistemic injustice: the systematic devaluation, misrecognition or exclusion of certain knowers and knowledge forms within dominant research paradigms.2,5 Such injustice is not simply a matter of differing perspectives but reflects a structural privileging of knowledge deemed ‘objective’ or ‘learned’, which routinely marginalises lived experience. This critique builds on a longer lineage of survivor and disability rights advocacy, which has persistently called for a reconfiguration of epistemic authority in mental health research and policy.⁶

Coproduction is not only a way of accessing excluded knowledge; it also offers a methodological means of synthesising insights across diverse epistemological traditions and positionalities. It enables integration not just across data types but across the differing perspectives of those who generate and interpret that data, including clinicians, researchers, patients, caregivers and community members. Unlike current methods of data synthesis, which often retain conventional hierarchies of expertise, coproduction reframes the terms of inquiry altogether. It insists on methodological equity rather than mere combination; a transdisciplinary logic that reflects the lived complexity of mental health rather than reducing it to isolated dimensions.²

Despite its promise and growing uptake, coproduction remains conceptually underdeveloped as a methodological paradigm—inconsistently theorised, unevenly implemented and often reduced to participation or consultation.^{3 7} There remains a pressing need to articulate what coproduction entails when understood as a rigorous, epistemically distinct approach to inquiry. This paper addresses this gap by proposing a conceptual framework that positions coproduction as a core methodological pillar of mental health science, with implications for research design, ethics and disciplinary culture.

Methods

This paper adopts a conceptual review methodology, integrating multiple forms of evidence to develop a situated, critically informed analysis of coproduction as a distinct methodological paradigm. The approach is informed by critical interpretive synthesis (CIS), a flexible and iterative methodology that supports theoretical development by combining literature review, experiential insight and conceptual analysis.⁸ CIS is well-suited to complex, value-laden topics such as epistemic justice, lived experience expertise and research culture, where traditional systematic review methods may be less appropriate.

I drew on peer-reviewed literature across mental health research, participatory methods, medical humanities, critical epistemology and patient-led scholarship. Sources were identified through a combination of targeted database searches (eg, Scopus, Google Scholar), citation tracking and familiarity with the field developed through professional practice. Key search terms included “co-production,” “mental health research”, “epistemic (in)justice,” “lived experience,” “patient involvement,” etc. Selection criteria prioritised conceptual relevance, diversity of methodological perspectives and resonance with the ethical and practical challenges encountered in coproduced work.

The analysis was also informed by my own experience as a lived experience researcher involved in interdisciplinary collaborations, training initiatives and coproduced studies. Reflexive engagement with these experiences alongside published literature enabled a synthesis of theoretical critique and real-world practice,⁹ helping to identify recurring barriers, ethical tensions and opportunities for embedding coproduction more systematically within mental health science.

A note on terminology

Throughout this paper, I use the term ‘mental health difficulties’ to refer broadly to the diverse forms of psychological distress, diagnostic experiences and psychosocial challenges encountered by people with lived experience. While some may identify with the term ‘mental illness’, others may prefer alternative framings; this terminology is intended to be inclusive of those differing perspectives. I also refer to ‘codesign’, which is often used to describe collaborative processes within specific phases of a research project (such as intervention development or question setting). While codesign shares common principles with coproduction, the latter typically involves deeper and more sustained involvement across the full research lifecycle.

Findings

Beyond hybrids and hierarchies: the philosophical foundations of coproduction

In response to the limitations of the qualitative–quantitative binary, mental health research has increasingly embraced strategies to synthesise different methodologies and types of data to enhance the validity, depth and applicability of research findings.¹ For example, triangulation seeks to corroborate knowledge claims by drawing on multiple sources or methods,¹⁰ while mixed method designs intentionally combine qualitative and quantitative approaches within a single study to address complex research questions.¹¹

While these forms of hybridisation mark an important methodological advance, they often remain embedded within a limited integrationist framework. Triangulation and mixed methods typically aim to synthesise different types of knowledge within existing research paradigms and hierarchies of expertise. While these approaches do not inherently exclude lived experience, how they are enacted may nonetheless marginalise the knowledge-creating capacity, or ‘epistemic authority’, of People with Lived Experience (PWLE). For instance, participatory methods, when structured around predefined agendas, may invite contribution without redistributing power or reshaping how questions are formed and knowledge is valued.2,4 When the researcher retains epistemic authority—deciding how methods are combined, which voices are prioritised, and how conflicting insights are resolved—such approaches can inadvertently sustain ‘extractive’ dynamics, where PWLE are asked to contribute knowledge but have little say in how it is interpreted or used.^{5 7}

In contrast, coproduction, in theory, is not simply an enhanced form of integration, nor an additional methodological layer. It represents a qualitatively different orientation to knowledge production that does not merely combine perspectives but rethinks the terms on which knowledge is created and validated. While triangulation and mixed methods approaches seek to improve research through methodological breadth, coproduction insists on methodological equity. It treats lived experience not as something to be synthesised or corroborated, but as a foundational source of knowledge, central to shaping research questions, guiding interpretation and defining relevance.²

Crucially, this shift is not only epistemological but ontological (ie, concerned with the nature of reality and what is assumed to exist in the world that research seeks to understand). Coproduction disrupts the subject–object divide that underpins conventional psychiatric research, challenging the notion that mental distress can be understood solely through observation, classification or diagnosis. It aligns with critiques of essentialist models that frame mental health difficulties as discrete, biologically determined entities¹² and with scholarship emphasising the social, cultural and relational constitution of psychological suffering.¹³ Similarly, coproduction also resonates with decolonial and antioppressive perspectives that affirm the centrality of marginalised perspectives in knowledge-making.¹⁴

Taken together, these commitments entail a distinctive epistemic and ontological stance—relational, dialogic, and attentive to power—that lies outside the founding assumptions of traditional and hybrid methodologies. This divergence underpins the need for coproduction as a third methodological pillar in mental health science: complementing rather than displacing existing approaches, and enabling what they cannot achieve independently.

The clinical and practical imperative of coproduction

In addition to the theoretical value of including PWLE in mental health research, there is a compelling practical case for embedding coproduction as a methodological cornerstone of the field. For example, crucial gaps persist in inclusion within mental health research, whereby marginalised groups, such as racialised communities, LGBTQ+individuals and those with complex trauma histories, are often excluded from or inadequately represented in research.¹⁵ In turn, these groups frequently experience elevated distress, barriers in accessing mental health services, such as cultural stigma, mistrust in healthcare systems, and a lack of services that are culturally sensitive and appropriate to their lived realities.¹⁶

Coproduction offers a direct method for overcoming these barriers by centring the voices of those who are often excluded. For instance, black-led projects and work that holds a reflexive awareness of how the ‘white gaze’ of academic institutions tends to undervalue the knowledge of black communities—are more likely to disrupt the systemic racial oppression upheld by existing research cultures.¹⁷ Likewise, coproduced research with LGBTQIA+ communities has identified healthcare inequalities across Europe that must be addressed for services to better meet the mental health needs of queer people.¹⁸ Many other examples exist, whereby experiential expertise has been effectively applied in the coproduction of more acceptable, accessible and culturally sensitive interventions for specific populations. These include codesigned digital relapse prevention tools for long-term mental health conditions,¹⁹ patient-led quality improvement initiatives within specialist eating disorder services²⁰ and many others.

Building the third pillar

Despite these promising green shoots, coproduction remains inconsistently implemented within mental health research and presents a range of ethical challenges that require critical attention.²⁰ These challenges (visualised in figure 1) arise not from coproduction’s core principles but from the realities of its implementation within existing research cultures, institutional structures and funding models.

Figure 1. Ethical challenges of coproduction.

The following sections explore the main challenges to implementing ethical coproduction before outlining recommended strategies for building coproduction as the third pillar of mental health science, enabling it to perform as a core methodological competency in meeting the needs of the communities research aims to serve.

Ethical challenges of coproduction

Tokenism

While coproduction aspires to equitable collaboration, it is often practised in ways that marginalise or instrumentalise lived experience. PWLE may be included in research processes to signal inclusivity rather than to actively shape outcomes.^{5 7} This kind of decorative use of lived experience (ie, inclusion without influence) sits low on Arnstein’s ‘ladder of participation’, a framework that categorises levels of public involvement from non-participation to genuine power-sharing.²¹ Tokenistic involvement may offer the appearance of engagement but ultimately fails to redistribute power or challenge traditional hierarchies.

Emotional labour

Coproduction frequently asks PWLE to disclose personal experiences of distress and trauma in spaces that are not always supportive or safe. While some PWLE report positive experiences of inclusion in research,⁷ others note the structurally oppressive and potentially harmful nature of coproduction practices.²² Without appropriate safeguards, the emotional labour of involvement can give rise to retraumatisation and emotional exhaustion.^{7 23}

Power imbalances

Another ethical challenge concerns the distribution of responsibility and accountability. While coproduction aims to share power and decision-making, PWLE are often expected to take on significant responsibilities without the recognition, support or compensation afforded to their counterparts in more traditional academic roles.²⁴ The lack of reciprocal benefit not only undermines the principles of equitable collaboration but also places an undue burden on those already navigating marginalisation.

At worst, such power imbalances can lead to the silencing or erasure of marginalised forms of knowledge and specific forms of epistemic injustice. These include testimonial injustice, where PWLE are seen as unreliable narrators of their own experiences, and hermeneutic injustice, where their experiences are misinterpreted or rendered unintelligible within dominant frameworks.^{3 25} These dynamics can reinforce stigma and mirror the very disempowerment many PWLE have faced within other institutional settings and wider society.⁷

Language plays a key role in sustaining these hierarchies. Drawing on insights from medical anthropology and critical discourse studies, we can see how language helps constitute ‘discursive regimes’ that delineate what is seen as valid, pathological or knowable.²⁶ Clinical and academic language often functions as an invisible gatekeeper, appearing neutral to those fluent in its use, yet creating barriers to participation for those outside institutional norms. Even when PWLE are present, the dominance of technical language can reproduce exclusion, misinterpretation and epistemic marginalisation.

Selection and representation

Without careful attention to the structural barriers that shape participation, coproduction may continue to overlook those most affected by mental health inequalities.^{15 16} While PWLE with prior experience of involvement may offer practical insight and established rapport, this can also risk privileging voices that are already institutionally familiar, potentially reinforcing patterns of inclusion and exclusion.

Intersecting barriers related to factors such as class, race, gender, disability, geography and digital access mean that many individuals are excluded from research not by lack of relevance but by systemic conditions that limit their capacity to engage.²⁴ This creates a tension between forms of expertise recognised by research institutions and the need to centre those whose perspectives are less visible but no less valid. Unless interrogated, such dynamics can reproduce intersectional marginalisation, making coproduction more representative in appearance than in substance.^{15 16}

Structural barriers

Finally, institutional and systemic barriers continue to undermine the potential of coproduction.⁶ Research governance frameworks, funding structures and ethical review processes are often ill-equipped to accommodate coproductive approaches. Traditional metrics of academic success, such as authorship conventions and publication norms, frequently fail to recognise the contributions of lived experience experts. Lived experience-led research, in particular, may lack access to institutional privileges such as ethics review boards, research funding, conference attendance or the ability to cover article processing charges required by academic journals, further entrenching exclusion and limiting visibility and impact.

Creating a core methodological competency

Addressing these ethical challenges requires more than practical solutions: it requires a wholesale, radical and disruptive reorientation of both institutional frameworks and cultural attitudes. The recommendations summarised visually in figure 2 aim to support the rigorous development, application and embedding of coproduction methodologies:

Figure 2. Steps to making coproduction a core methodological competency.

Spaces for dialogue and collaboration across diverse communities and disciplines

As coproduction methodologies evolve, it is essential to create sustained spaces for dialogue, where research teams and communities can work together with the time and resources needed to build inclusive, relational practices.^{2 3} Such fora can act as sites for transdisciplinary engagement, bridging the gaps between basic science, clinical research, social science and lived experience expertise, helping to build a methodological common ground where coproduction is recognised as a central and distinct feature of mental health research. These might include cofacilitated learning spaces, joint practice-based communities across academic and lived experience roles or working groups that shape research culture over time rather than just advising on individual projects.

Addressing the challenges posed by exclusionary language is central if these fora are to be inclusive, and this can often be achieved through simple, practical steps, as evidenced in my own experiences of research involvement. For example, in one coproduced project, we developed a shared glossary of key terms—defining, querying and at times rejecting technical language that felt alienating or misrepresentative for the PWLE involved. This involves creating a space where all team members could reflect on language use without fear of judgement, and where meaning was actively conegotiated. Other groups I’ve worked with have used jargon-free briefing documents and reflective practices that have explored lived experience and academic framings side by side, helping make dialogue more accessible, participatory and inclusive.

Similarly, attention must also be paid to increasing the diversity of PWLE who are present in these spaces by removing barriers to meaningful participation. This may involve covering access and support costs, ensuring digital and sensory accessibility and adapting meeting formats to accommodate different health, energy or caring needs.⁷ It also means valuing the relational labour required to build trust, particularly with communities who have historically been excluded or harmed by research. For example, Fortuna et al coproduced a tool with psychiatric patient stakeholders to assess the quality of research partnerships, emphasising the importance of trust, mutual respect and shared decision-making as core features of meaningful community engagement in mental health research.²⁷ Similarly, research on civic engagement practices highlights the importance of adjusting meeting times, locations, accessibility supports and facilitation norms to centre the participation of working-class, black, Indigenous and disabled contributors, particularly in contexts where institutional processes have historically excluded them.²⁸

While such adaptations do not eliminate all barriers, they provide a foundation for more equitable, accessible and responsive research practices, grounded in the needs and perspectives of diverse communities.

Training and competency building

Repositioning coproduction as a third methodological pillar alongside qualitative and quantitative approaches demands equivalent attention to rigour, training infrastructure and evaluative standards. Just as training in statistical analysis or thematic coding forms a disciplinary baseline for quantitative and qualitative research, so too should coproduction be recognised as a core methodological competency. Meeting this standard requires dedicated, practical training and may include skills such as codesigning studies with lived experience contributors, running reflexive team meetings, negotiating collaborative decision-making processes and attending to relational factors such as maintaining alliance and repairing ruptures. Embracing the principles of coproduction, PWLE should lead the design, delivery and evaluation of this training, supported by appropriate recognition, payment and resourcing.

An example of good practice drawn from my own experience involved reciprocal training between academic researchers and experiential advisors within a cross-disciplinary international research collaboration. As a lived experience contributor, I participated in training on systematic review methodologies and attended a presentation of evidence derived from human and animal studies (described in accessible language) in preparation for triangulation meetings. In turn, PWLE were invited to deliver a presentation to the broader research team of academics and clinicians where we discussed the role of lived experience in the research. This exchange initiated broader conversations about how experiential expertise can shape methodological decisions and the types of training all team members require to support the development of more inclusive research cultures.²⁹

This need for structured, reciprocal learning has also been demonstrated in the coproduced training model developed by River, Bellingham et al.³⁰ Their framework emphasises cofacilitated learning spaces, emotional labour and relational ethics as core components of effective coproduction training. It provides a real-world example of how training can be codesigned and delivered to build shared capacities across PWLE and academic researchers alike.

Relational ethics and care

Coproduction may, by its very nature, be disruptive and involve friction between differing perspectives, and must therefore be grounded in an ethics of care, mutuality and respect.³¹ A culture of care requires recognising that emotional labour is not incidental to coproduction—it is central to the process. Research institutions must take active steps to implement governance procedures, safeguarding policies and budgeting processes to reflect the relational and ethical dimensions of this work. This includes adopting trauma-informed practices, which establish trust and psychological safety for PWLE involved in research.^{7 23}

In practical terms, this may involve choices for PWLE to opt out of distressing discussions without being excluded from projects entirely; premeeting and postmeeting check-ins; and building flexibility into timelines to accommodate fluctuating health or capacity. Similarly, it is important to value relationship-building itself as a legitimate use of research time and funding. Paying PWLE for informal peer support and allowing space for non-research conversations can be important for creating mutual empathy and understanding, as can planning meetings in accessible, sensory-considerate environments.³²

Innovation and evaluation of coproduction methodologies

Despite the appetite for coproduction, the lack of an agreed methodological framework gives rise to the need to create communities of practice, living methodological guidelines and dedicated funding streams that support ongoing methodological innovation. These would support the iterative development of coproduction by enabling collaborators to test, evaluate and refine specific practices, such as collaborative data analysis workshops, innovative ways of working and measures of success.

There is also a need to examine how decisions are made within data analysis, and how evidence is defined in coproductive research. For example, dialectical approaches have been proposed for when research teams encounter conflicts between experiential knowledge and statistical data and need to decide whose interpretations are prioritised when findings diverge.³³ Addressing such questions requires ongoing reflexive work and formal mechanisms for documenting and sharing both successful and unsuccessful methodological adaptations, so that learning can be cumulative and accessible across projects and institutions. As noted earlier, the work of River et al³⁰ offers a valuable example of this kind of evaluative practice, demonstrating how coproduced approaches can be systematically reflected on and written up.³⁰ Their study exemplifies how documenting the relational and ethical dimensions of coproduction can contribute to the field’s methodological development. Writing up what works—and what doesn’t work—in research partnerships is not only good practice in terms of transparency, it also builds a collective evidence base for coproduction as a rigorous and teachable practice.

Culture change in mental health research

Structural factors, such as rigid academic conventions, traditional funding models and narrow definitions of rigour, continue to sustain hierarchies that marginalise experiential expertise and undermine efforts towards coproduction.³⁴ As mentioned, funding for coproduction needs to allocate appropriate resources for widening access, providing training and offering relational and other forms of support. Beyond this, authorship conventions may need to be reformulated to reflect diverse forms of contribution, and ethics procedures must be rethought to avoid privileging academic control or institutional convenience.

However, structural adjustments can only go so far without parallel changes in research culture. Coproduction challenges not only the logistics of how research is done but also the deeper norms that govern whose knowledge is valued, how evidence is defined, and who benefits from inquiry. For instance, reimagining research culture also involves reconsidering what counts as impact. Rather than privileging peer-reviewed publications alone, space needs to be made to recognise the value of community dialogue, policy influence and relational change. Storytelling, cofacilitated conversations and arts-informed methods, for example, can capture the emotional and collaborative dimensions of coproduction in ways traditional outputs cannot.³⁵ Research evaluation must, therefore, reflect what impact means to participants themselves, not just institutions, by moving beyond citation metrics and conventional forms of dissemination.^{7 36}

By questioning who is recognised, how success is measured, and which forms of labour are made visible, we can begin to reimagine the symbolic and material structures of academic reward—creating a research culture in which coproduction is not only possible but meaningfully valued.

Conclusion: towards a triadic and transformative model of mental health science

Mental health science stands at a methodological crossroads. We can continue to rely on binary frameworks that, despite their best efforts, too often fail to capture the complexities of mental health, illness and recovery, even when combined. Or we can embrace a triadic model: one that recognises lived experience as an equitable and essential form of knowledge creation, alongside qualitative and quantitative approaches. This means shifting from simply valuing lived experience to establishing its viability as a credible methodological praxis.

Throughout this paper, I have argued that coproduction is not a theoretical ideal but a clinical and ethical necessity. It offers a practical means to address power imbalances, challenge dominant narratives and ensure research is grounded in the realities of those most affected by mental health difficulties. This requires moving beyond tokenism towards genuine collaboration, where lived experience shapes priorities, methods and outcomes from the outset.

Recognising coproduction as a third methodological pillar demands more than the development of new techniques; it requires a realignment of how research is taught, resourced and evaluated, ensuring that lived experience is not simply included but structurally embedded within the fabric of mental health science. A triadic model offers a way forward: bridging divides, restoring trust and ensuring mental health science fulfils its promise to those it seeks to serve.

Data availability statement

Data sharing not applicable as no datasets generated and/or analysed for this study.