Service-user perspectives on evidence: shaping participatory mental health and homelessness services

This qualitative study considered the potential for service-user participation and Evidence-based Practice (EBP) to contribute to socially just human services that aspire to improved parity of participation (Fraser, 2008a). A case study approach compared and contrasted the experiences and expectations of people who had used mental health services with those who had used homelessness services. The core data was derived from 11 interviews with mental health service users and 11 interviews with homelessness service users, with a sample of service providers (n=11) also interviewed to test for consistencies and tensions in perspectives. Key federal, state, and regional policy documents pertaining to mental health and homelessness were examined in order to compare policy intentions with the actual experiences of service users in relation to evidence and participation. Preliminary findings were presented back to small focus groups of service users (n=7) to test the accuracy and workability of findings. This study was the first of its kind to examine the compatibility – or otherwise – of EBP and social justice. Literature reviews in the distinct areas of EBP and service-user participation revealed that, though deriving from quite different discourses, both concepts had been thinly conceptualised and poorly implemented in Australian human services. While ideal models of both EBP and participation existed, it was unclear that they had been translated into actual practice. Respondents in both case studies reinforced the findings of the literature reviews that EBP was poorly understood and had failed to make an impression on the experiences of the most marginalised service users. While ‘consumer’ participation was prevalent within mental health policy and practice, it was just emerging in the homelessness sector and, in both the case studies the respondents revealed concerns about participation, given their broad and multifaceted identities, fluctuating capacities, and complex lives. Ultimately the study found that overly simplistic and inflexible models of EBP and participation were unsuitable for these service users and that a process, which emphasised the importance of relationship building between service users and service providers and which used the expertise and circumstances of individual service users as a lens through which to assess evidence, would contribute to a model of EBP that suited the social justice frame. The positivistic ideology of EBP was at odds with the subjective notion of service-user expertise, but it was seen that both could contribute to improved accountability where EBP was conceived as a process and evidence was construed in pragmatic terms.