Status quo

A search of the Royal Academy of Psychiatrists website failed to yield ‘positionality’ as a keyword in its documents, as did the British Journal of Psychiatry in its published articles. A World Psychiatric Association search also failed, although two articles in World Psychiatry yielded papers on positionality and shared decision-making. Positionality has been more thoroughly developed in the USA. The American Psychiatric Association and one of its flagship journals, Psychiatric Services, instituted the Checklist for Reporting of Race/Racialization, Ethnicity, and Culture (REC) Data for reporting of individual studies. The guidelines suggest that transparency in REC data will assist research critiques regarding DEI goals. The American Psychological Association (APA) has a broader and more detailed set of guidelines, the Equity, Diversity, and Inclusion Toolkit for Journal Editors.¹ Positionality statements are explicitly mentioned in these guidelines, ‘to address potential author bias and to make transparent how the identities of the authors relate to the research and the researched’.¹ Much as ‘author contribution statements’ are currently expected in paper submissions to report an author’s specific effort on a study and paper, positionality statements ask that authors transparently report their identities as related to the research topic.

Positionality statements reflect ‘standpoint epistemology’, the idea that ways of knowing, including that embodied in the scientific method, are framed by personal histories as well as the research communities from which they come.^{Reference Harding2} Hence, knowledge about the authors’ place in the social world helps to interpret findings. There are increasing calls for positionality statements that reflect individual identities of each author, most commonly statements of race and gender identity at the time of publication. Positionality is believed to benefit both authors and readers. In terms of the former, positionality is the foundation of reflexivity in research, investigators involved in active consideration of how one’s lived experience influences development of hypotheses, methods, results and conclusions. For example, authors studying a mental health issue within a specific DEI group (e.g. African American) with which they do not identify (e.g. because they are White) might benefit from recognising their ethnic limitations in terms of theory development. Reflexivity also has implications for methods meant to test the hypotheses driving research.

Implications of positionality for journal readership are somewhat less clear. The assumption is that positionality information gives readers insight into potential biases that undermine author interpretations of the findings. Consider, however, possible challenges wrought by questions evoked by positionality. What specific shortfalls in hypothesis development or methods design are suggested by the difference in positionality from the focal group? While, in principle, we admit that a White research team may have relatively limited comprehension of the breadth and depth of schizophrenia in African Americans, we struggle with specific answers to questions like these. Similarly, what implications per se does this have for data interpretations and subsequent conclusions?

Positionality and mental health services research

Positionality scholars have noted that identity reports need to exceed ethnicity or gender.¹ President Joe Biden and the US government in 2021 added accessibility to the DEI definition (henceforth DEIA), thereby directly implicating disability as a protected class in the USA. As a result, people with psychiatric disabilities, among others, are explicitly part of DEIA. This suggests that mental health identity might be included in positionality statements. Note that terminology and narrative are the currency in which positionality is shared, and hence readers need to be mindful of unintended effects that correspond with their selection of words to describe their position. ‘Mental illness’, chosen for this editorial, might create negative responses from those who identify better as ‘neurodiverse’.

Highlighting one’s status with mental illness parallels the growing call for people with lived experience not only to be involved in services research, but also to assume leadership roles therein.^{Reference Jones, Atterbury, Byrne, Carras, Brown and Phalen3} Inclusion of people with lived experience in research reflects a community-based participatory research agenda where hypotheses, methods, analyses and interpretations are believed to be most accurate when this constituency is included as full partners in all levels of investigation.

Positionality statements suggest group affiliation. Ethnic and gender studies have distinguished between essential and identity definitions as a way to make sense of groupness. Essentialism presumes that group identity is marked by external objective criteria. Skin colour and body features are thought to unequivocally describe someone in terms of ethnicity or gender. Consider 19th-century models of physical anthropology, where ethnic phenotypes were linked to genotypes resulting in five definitive categories: Caucasoid, Capoid, Mongoloid, Australoid and Negroid. The DSM-5-TR⁴ or ICD-11⁵ could provide the same objective framework for mental illness. Someone legitimately belongs to the group called schizophrenia when they meet corresponding criteria in the DSM or ICD.

These essentials, however, oversimplify real-life experience by reducing complex groups to neat categories with seemingly well-defined and immutable boundaries. Among other things, essentialism mistakes the variation of phenotype for categorical differences (‘Black people are all alike’, ‘People with schizophrenia have the same symptoms and challenges’), leading to misattribution of individual choice and behaviour according to one’s group assignment (‘Harry decided to do X because of schizophrenia’) and opening the door to stereotypes and discrimination (‘People with schizophrenia are not able to do Y so Harry can’t do it’). These criticisms led the American Association of Physical Anthropology to dismiss essential conceptions of race and ethnicity, arguing that these often emerged from Western colonialism, oppression and discrimination.

Concerns about essentialism have been replaced with insights from social constructivism,^{Reference Berger and Luckmann6} the view that perceptions and experiences of DEIA groups (from both within and outside the group) are created in a social world with self-determined and asserted identity; individuals have sole authority in describing where they fall in terms of group-defining social constructions. These personally meaningful constructs are fluid, multidimensional and reflective of one’s lived world. Individual identity and self-concept are grounded in authenticity, the degree to which a particular behaviour is perceived as being congruent with one’s perceptions, beliefs and motives. Identity rests on public statement and commitment. People who identify as having mental illness say so. Hence, might self-report of mental health experience be added to positionality statements?

Scholars with lived experience of serious mental illness have expressed concern with what seems to be an overly inclusive statement of mental health identity.^{Reference Jones, Atterbury, Byrne, Carras, Brown and Phalen3} Open-ended definitions of ‘mental health’ identity may fail to focus on the most important constituency: people with serious mental illness (SMI). SMI is defined as people with psychiatric disabilities that have significantly and persistently interfered with life goals which, in turn, have led to negative social reactions from others such as rejection and forced treatment. Jones and colleagues^{Reference Jones, Atterbury, Byrne, Carras, Brown and Phalen3} believe that too broad a definition of mental illness may risk cultural appropriation; authors self-identify as people with mental illness in order to benefit from what the label suggests in mental health services and recovery-based systems. Nevertheless, ironic benefits here need to be balanced against the perceived risk of disclosing mental health experiences, which many authors might believe will open them up to stigma that, among other things, diminishes their credibility.

Requests for ‘personal’ statements like these from research and professionals are not foreign to current practice or research of mental health services. The American Medical Association Professional Code of Ethics, for example, recommended disclosure to promote openness in professional endeavours, stating what physicians should disclose in certain contexts, such as when informing a patient about clinical trials. This kind of disclosure may include information about financial interests of the providers, their spouse and dependent children. Might similar requirements be expected in positionality statements? Presumed expectations to disclose DEIA do not seem to rise to the same level as financial information or author contributions. In its 2021 guidelines, the APA said, ‘… submitting authors should not be mandated to disclose any aspect of their identities unless they consent and are comfortable doing so’.¹ Forced disclosure of one’s mental health experiences, including that of providers, is strongly discouraged in recovery-based programmes.

What implications might positionality statements have in the review process? In response to the apparent DEI imbalance among journal reviewers and the review process, Sharpe^{Reference Sharpe7} reasserts continued masking in the submission and revision process. He fears that absence of this masking exacerbates both explicit and implicit biases in publication considerations. Hence, Sharpe seems to argue that positionality statements should not be submitted at the onset of reviews.

This discussion shows the complexity of the issues calling for research positionality and disclosure; Rose and colleagues,^{Reference Rose, Sah, Dweik, Schmidt, Mercer and Mitchum8} for example, examined the effects of physician disclosure of receipt of more than US$20,000 from corporate interests, including pharmaceutical companies on their patients. Results from their randomised controlled trial found significantly increased patient knowledge of physician financial relationships in the disclosure condition; however, it had no impact on either physician trust or missed or cancelled appointments. A similar RCT framework could examine the impact of positionality statements with or without disclosure of mental health experience. Research outcomes here might vary because effects are expected to target reader judgements. Among other things, positionality statements could be used to assess reader confidence in, or perceived importance of, the article. Separately, research needs to determine effects on authors making the statements.

Positionality statements that reflect authors’ identities in terms of mental illness seem consistent with DEIA goals intended to enhance research transparency. Future scholarship needs to better describe the impact of these statements on journal readers and authors themselves. In addition, the research community needs to further develop its expectations about positionality reporting.