1 plus 1 is more than 2: mental health problems, financial difficulties, and social exclusion in a cross-sectional study of 28,047 general-population adults.

BACKGROUND: Mental health problems and financial difficulties each increase the risk of social exclusion. However, few large studies representing a broad age range have investigated the combined social effect of having both difficulties. The purpose of this cross-sectional study was to examine associations of mental health problems, financial difficulties, and the combination of both with social exclusion. METHODS: This analysis was based on responses from 28,047 adults (age > 18 years) from the general population participating in The Norwegian Counties Public Health Survey 2019. Respondents answered questions about their financial situation, mental health problems, and social exclusion. Social exclusion was measured as a lack of social support, low participation in organized social activities, low participation in other activities, missing someone to be with, feeling excluded, and feeling isolated. Adjustments for sex and age were made in multivariable logistic regression analyses. RESULTS: Having mental health problems or financial difficulties was associated with various measures of social exclusion (odds ratios [ORs] with 95% confidence intervals [CIs]: 1.33 [1.23-1.43] to 12.63 [10.90-14.64]). However, the odds of social exclusion strongly increased for respondents who reported a combination of mental health problems and financial difficulties compared with those who did not report either (ORs [CIs]: 2.08 [1.90-2.27] to 29.46 [25.32-34.27]). CONCLUSIONS: Having the combination of mental health problems and financial difficulties is strongly associated with increased risk for social exclusion, far beyond the effect of either factor alone.

'Living needs a landscape': A qualitative study about the role of enabling landscapes for people with mental health and substance abuse problems.

The deinstitutionalization of mental health institutions has enabled service users to live in the community and search for what Duff coins 'enabling places.' These places were explored through walking interviews, in which service-users led the way. This analysis revealed features which made places promote liveable lives: places help people explore, places help people stand out, places give people responsibilities, and places dare people. An adverse feature was also identified: places define people by their problems. Overall, we suggest that 'living needs a landscape' to capture how a diversity of places form an 'enabling landscape'. This suggests a shift of focus in research and treatment, from internal to external landscapes.

The Lost Social Context of Recovery Psychiatrization of a Social Process.

From being a concept questioning the core of psychiatric knowledge and practice, recovery has been adopted as a guiding vison for mental health policy and practice by different local, national, and international organizations. The aim of this article is to contextualize the different understandings of recovery and its psychiatrization through the emergence of an individualizing and de-contextualized definition which have gained a dominant position. It ends with an attempt to formulate a new definition of recovery which integrates people in their social context. Research results from various follow-up studies showing the possibility of recovery from severe mental distress have stressed the importance of societal, social and relational factors as well of the person's own agency when facing their distress and reactions from their environment. These researches were published in the 1970s and 80s; a period of struggle for liberation from colonialism, of struggle by women and black people for their civil rights, and a time of de-institutionalization of services directed toward the poor, elderly, handicapped, prisoners, and people with mental health problems. Recovery research pointed at the central role of individuals in their recovery journey and it was understood as a personal process in a social context. However, with neo-liberal political agenda, the personal role of individuals and their own responsibility for their well-being was stressed, and contextual understandings and the role of social, material and cultural changes to promote recovery faded away. Thus, during recent decades recovery has been mostly defined as an individualistic journey of changing the persons and their perception of their situation, but not of changing this situation. Contextual aspects are almost absent. The most quoted definition accepts the limits posed by an illness-based model. This kind of definition might be a reason for the wide acceptance of a phenomenon that was initially experienced as a break with the bio-medical paradigm. Recently, this dominant individualized understanding of recovery has been criticized by service users, clinicians and researchers, making possible a redefinition of recovery as a social process in material and cultural contexts.

You realise you are better when you want to live, want to go out, want to see people: Recovery as assemblage.

BACKGROUND: The lack of social and material perspectives in descriptions of recovery processes is almost common in recovery research. AIM: Consequently, we investigated recovery stories and how people with mental health and/or addiction challenges included social and material aspects in these stories. METHOD: We conducted focus group and individual interviews. We investigated how the participants narrated their stories and how they assembled places and people in their recovery stories. RESULTS: We found that narratives of recovery became assemblages where humans and their environments co-exist and are interdependent. CONCLUSION: As such, narratives about recovery are about everyday assemblages of well-being into which stories of insecurity are interwoven, without a start or stop point.

Mutual learning: exploring collaboration, knowledge and roles in the development of recovery-oriented services. A hermeneutic-phenomenological study.

PURPOSE: The concept of recovery is commonly described as multifaceted and contested in the field of mental health and substance abuse. The aim of this study is to explore how understandings of recovery and recovery orientation of services are developed through daily practices and collaboration between service users and professionals. METHODS: Eight pairs of participants were interviewed together, in accordance with the dyadic interview method. The dyads/pairs consisted of service users and professional helpers. A collaborative hermeneutic-phenomenological analysis was used to analyse data. RESULTS: Data were analysed into three overarching and entangled themes, exploring how recovery-oriented collaboration and knowledge encompasses (a) recovery as relational processes. These processes are entangled with (b) recovery as situated in time and place. Furthermore, relational processes and dimensions of time and place are situated in and supported or hindered by (c) recovery orientation as part of the municipal policies, understood as the regulations, frameworks and decisions guiding mental health and substance abuse services in the municipality. CONCLUSIONS: The further development of recovery-oriented services should focus on facilitating open-ended and flexible ways of developing practices and relationships. This involves recognizing how relationships contribute to the development of knowledge and practices.

Diversity, Complexity and Ordinality: Mental Health Services Outside the Institutions-Service Users' and Professionals' Experience-Based Practices and Knowledges, and New Public Management.

In conjunction with the dismantling of psychiatric hospitals, social workers have been commissioned to help service users in their daily living in their homes and in the community. The consequences of these changes for experience-based knowledge and practices in their contexts remain relatively unknown. In this study, eighteen service users and the social workers they described as helpful for them were interviewed. The interviews were recorded, transcribed, and analyzed using Thematic Analysis. The following themes emerged: "Here, there and everywhere", "Doing, being, becoming", "Talking" and "Order, planning and improvisation" concerning the contradictions service users and professionals mentioned about their practices and the conditions imposed by managerial methods connected to New Public Management. Finally, "Spontaneous planned complexity" was chosen as our overarching theme to characterize the new knowledge and practices which have been developed. The displacement of the place for the encounter and the introduction of non-medicalized professions have allowed community-based practices and thus the co-creation and emergence of new knowledge about the service users as persons and the professionals as qualified professionals. The challenge remains for managers to have trust in their colleagues and not impose rigid rules, schematized methods, and repeated controls.

"I will never forget him". A qualitative exploration of staff descriptions of helpful relationships in supportive housing.

WHAT IS KNOWN ON THE SUBJECT?: Recovery-oriented studies show that the quality of the professional relationship plays an essential role in the recovery from mental illness. Within mental health care in general, previous studies show that helpful professional relationships are characterized by several reciprocal aspects, such as friendship resemblance and self-disclosure. The literature is scarce on in-depth explorations of professional relationships within the often long-lasting and intimate help context of institutional supportive housing. Explorations of staff members' experiences are absent. The scientific rationale of this study was to expand the current knowledge about professional relationships in mental health care by exploring staff members' descriptions of helpful professional relationships in supportive housing institutions. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE: The study shows that helpful relationships may involve staff experiences of reciprocity in terms of both a two-way influence between staff and residents and a reciprocal gain from being part of the helpful relationships. A conceptualization of reciprocity that complements existing concepts is suggested and connected to a "good match" between staff and residents. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: When support and care are intended to be provided within a dyadic relationship, both parties' preferences should be considered when pairing service users and professionals. Practitioners should get involved in ways that open up for being influenced and inspired by the service user's characteristics, such as personality and attitude. Furthermore, they should dare to enjoy and make use of the company of the service user in ways that promote multifaceted reciprocity. ABSTRACT: Introduction In the aftermath of the deinstitutionalization in western countries, new community-based mental health services have been established. An essential object of studies in this new institutional landscape has been helpful professional relationships, but we still lack knowledge about helpful relationships in community-based institutional supportive housing. Aim To explore how staff members describe their relationships with residents who have identified them as helpful. Methods Qualitative interviews with nine staff members were analysed using thematic analysis. Results "Reciprocity" was identified as the main theme, and two subthemes were developed: "Something influential about the resident" and "Value for the staff member." Discussion The findings are discussed and related to existing conceptualizations of reciprocity in professional relationships, and an additional conceptualization is suggested. Implications for practice To promote reciprocity, managers should consider both parties' personal preferences when matching professionals and service users. Further, professionals should get involved in ways that open up for being influenced and inspired by several of the service user's characteristics. They should allow themselves to enjoy the company of the service user in ways that promote multifaceted reciprocity.

The Stockholm Follow-up Study of Users Diagnosed with Psychosis (SUPP): A 10-year Follow-up 2004-2013.

Since the 1970s, psychiatric care in the western world has undergone fundamental changes known as de-institutionalisation. This has changed the living conditions for people with severe mental illness. The purpose of this study was to investigate the living conditions and utilisation of care and social services for a group of people in Sweden with diagnosis of psychosis over a 10-year period, 2004-2013. During this period, psychiatric care decreased at the same time as interventions from the social services increased. Half of the persons in the studied group did not have any institutional care, that is, neither been hospitalised nor dwelling in supported housing, during the last 5 years, and just over 20% had no contact with either psychiatry or the municipality's social services during the last 2 years of the investigated period.

Things matter: about materiality and recovery from mental health difficulties.

PURPOSE: The aim of this study is to explore how material things might become involved in the recovery process of people with mental health difficulties. METHOD: Empirical material from three different studies on various aspects concerning mental health issues that each of the authors had conducted was reanalysed through a phenomenological item analysis. RESULTS: We discovered that mundane objects such as a mobile phone, a bench, a door and a key have agency to contribute to peoples' recovery and wellbeing. Things became agents that created contexts that initiated physical, social and emotional movements. CONCLUSION: By giving attention to materiality we might become aware of the importance of things as agents in living in general and in recovery processes for people with mental health difficulties in particular.

Materialities in supported housing for people with mental health problems: a blurry picture of the tenants.

Our daily lives and sense of self are partly formed by material surroundings that are often taken for granted. This materiality is also important for people with mental health problems living in supported housing with surroundings consisting of different healthcare services, neighbourhoods, buildings or furniture. In this study, we explored how understandings of tenants are expressed in the materialities of supported housing. We conducted ethnographic fieldwork in seven different supported accommodations in Norway and analysed the resultant field notes, interviews, photographs and documents using Situational Analysis. The analysis showed that supported housing materialities expressed a blurry picture comprising widening and narrowing understandings of tenants, both by others and by themselves. Widening understandings concerned how tenants were living their lives in their own ways in private rooms while maintaining a social life in common areas. Narrowing understandings pertained to understand the tenants based solely on their diagnosis and need for care and control in hospital-like buildings. The following discussion focusses on the ideas that underlie narrowing materialities and on the importance of striving for atmospheres that entail a sense of belonging.

Beyond formalized plans: User involvement in support in daily living - users' and support workers' experiences.

BACKGROUND: User involvement, based on respect and carried out through dialogue, has been shown to lead to increased self-respect, self-confidence and positive identity. In Sweden, the Social Service Act requires that interventions be designed and implemented together with the individual concerned. The basic criterion for social support is prolonged severe mental illness (usually at least 6 months), with no criteria for specific diagnosis or institutional history. The most common form of social support is 'support in daily living', a community care intervention for people aged 18 years or older who have their own homes and living arrangements. AIM: This article aims to deepen our understanding of user involvement at the individual level in the provision of an ongoing social work intervention. What elements of user involvement can be found in users' and support workers' descriptions of helpful support in daily living? METHOD: Qualitative interviews were conducted with 18 users, who had experienced support in daily living as helpful, and 16 interviews with the users' support workers. RESULTS: Three major, interconnected themes emerged: Constant dialogue; Framing the flexibility, in relation to formalized intervention plans and regulations; The importance of 'small things', decisions concerning daily life. CONCLUSION: Both users and support workers described user involvement at the individual, micro-level to be an integral part of helpful support in daily living. It was possible to create a space for dialogue and co-creation in which users were involved in formulating and deciding the contents of their support at an informal level, to influence their own everyday lives. While a formal framework of rules, restrictions and plans surrounds meetings between users and professionals, a facilitating factor may be the absence of too detailed plans and regulations, leaving trust to users and professionals and their capacity to manage most of the choices they have to make.

Nothing matters: the significance of the unidentifiable, the superficial and nonsense.

Purpose: The aim of this study is to explore the ways in which "small things" may be of importance for people with mental health difficulties.Method: Empirical material from three different studies was reanalysed through a phenomenological, dialogical, approach.Results: We discovered some paradoxical aspects of small things: i.e., they could be about "something" that was difficult or even impossible to identify. The unidentifiable could be about bodily, sensual experiences that are superficial (i.e., belonging to the surface). The interaction with others highlighted as significant could be about doing something fun, talking nonsense or kidding around, and hence not at all about making sense of something-a kind of important nonsense. We summarize these aspects in three themes: the importance of the unidentifiable, the superficial and nonsense. These aspects can be regarded as small things-even "nothings"-that make it possible "to stay in the world".Conclusion: We elaborate on the findings in relation to the following: Gumbrecht's critique of the prevailing hermeneutic world-view with its idea that "interpretation is humankind's exclusive way of relating to the world", Ingold's idea that social life is lived in relations of "interfacility" and hence a turn to surfaces is needed for a "restoration of social life", and Biesta's idea of existence as "coming into the world in the presence of others".

Studies regarding supported housing and the built environment for people with mental health problems: A mixed-methods literature review.

Places where people live are important for their personal and social lives. This is also the case for people with mental health problems living in supported housing. To summarise the existing knowledge, we conducted a systematic review of 13 studies with different methodologies regarding the built environment in supported housing and examined their findings in a thematic analysis. The built environment of supported housing involves three important and interrelated themes: well-being, social identity and privacy. If overregulated by professionals or located in problematic neighbourhoods or buildings, the settings could be an obstacle to recovery. If understood as meaningful places with scope for control by the tenants or with amenities nearby, the settings could aid recovery.

Recovery and economy; salary and allowances: a 10-year follow-up of income for persons diagnosed with first-time psychosis.

PURPOSE: Persons with severe mental health problems (SMHP) point out financial strain as one of their main problems. De-institutionalisation in welfare countries has aimed at normalisation of their living conditions. The aim of the study was to follow the changes in income and source of income during a 10-year period for persons with a first-time psychosis diagnosis (FTPD). METHODS: Data were gathered from different registers. Data from persons with FTPD were compared to data on the general population. Two groups with different recovery paths were also compared: one group without contact with the mental health services during the last five consecutive years of the 10-year follow-up, and the other with contact with both 24/7 and community-based services during the same period. RESULTS: SMHP led to poverty, even if the financial effects of SMHP were attenuated by welfare interventions. Even a recovery path associated with work did not resolve the inequalities generated by SMHP. CONCLUSIONS: Attention should be paid to the risks of confusing the effects of poverty with symptoms of SMHP and thus pathologizing poverty and its impact on human beings. Adequate interventions should consider to improve the financial situation of persons with SMHP.

Small Things, Micro-Affirmations and Helpful Professionals Everyday Recovery-Orientated Practices According to Persons with Mental Health Problems.

The aim of this study is to present concrete descriptions of the content in the construction of helpful relationships with staff, according to users. Starting with the re-occurring concept of the meaning of "little things" in recovery studies, a literature review was done. A thematic analysis shows that small things play an important role in improving a person's sense of self. Small things seem to be an invisible but effective parts of a recovery-orientated practice, but they might be defined as unprofessional and their efficacy negated.

Money, Social Relationships and the Sense of Self: The Consequences of an Improved Financial Situation for Persons Suffering from Serious Mental Illness.

During a 9-month period, 100 persons with SMI were given approx. 73 USD per month above their normal income. Sixteen of the subjects were interviewed. The interviews were analysed according to the methods of thematic analysis. The money was used for personal pleasure and to re-establish reciprocal relations to others. The ways in which different individuals used the money at their disposal impacted their sense of self through experiences of mastery, agency, reciprocity, recognition and security. The findings underline the importance of including social circumstances in our understanding of mental health problems, their trajectories and the recovery process.

A place for the heart: A journey in the post-asylum landscape. Metaphors and materiality.

The downsizing of psychiatric hospitals has created a new institutional landscape in the local community to support people with severe mental problems in their daily living. This study explores meeting places in Norway from the users' perspectives. The users used four metaphors to describe these meeting places: "like a home", "like a family", "like a landing ground" and "like a trampoline". The users have decorated the interiors of the meeting places with hearts made from various materials, and these could be considered as symbols of the places. The metaphors used: the hearts and the rooms and interiors, reflect old ideas about calmness and dignity rather than new ideas based on New Public Management.

A Balancing Act-How Mental Health Professionals Experience Being Personal in Their Relationships with Service Users.

BACKGROUND: Although being personal in relationships with service users is commonly described as an important aspect of the way that professionals help people with severe mental problems, this has also been described to bring with it a need to keep a distance and set boundaries. AIMS: This study aims to explore how professionals working in psychiatric care view being personal in their relationships with users. METHOD: Qualitative interviews with 21 professionals working in three outpatient psychiatric units, analyzed through thematic analysis. RESULTS: Being personal in their relationships with users was described as something that participants regarded to be helpful, but that also entails risks. Participants described how they balanced being personal by keeping a distance and maintaining boundaries in their relationships based on their "experience-based knowledge" to counter these risks. While these boundaries seemed to play an important part in the way that they act and behave, they were not seen as fixed, but rather as flexible and dynamic. Boundaries could sometimes be transgressed to the benefit of users. CONCLUSIONS: Being personal was viewed as something that may be helpful to users, but that also entails risks. Although boundaries may be a useful concept for use in balancing these risks, they should be understood as something complex and flexible.

Experience of Psychotropic Medication -An Interview Study of Persons with Psychosis.

Psychotropic drugs, particularly antipsychotic types, are a cornerstone of the treatment of people with psychosis. Despite numerous studies showing that drug treatment with psychotropic drugs initially alleviates psychiatric symptoms, the proportion of people with mental health problems and symptoms that do not follow doctors' prescriptions, thus exhibiting so-called non-adherence, is considerable. Non-adherence is predominantly seen as a clinical feature and as a patient characteristic that is especially due to patients' poor understanding that they are ill. There is also a widespread notion that non-adherence is of great disadvantage to the patient. This article is based on interviews with 19 persons diagnosed with psychosis. It challenges the notion of patients being either adherent or non-adherent to the doctor's orders. The findings show that persons with psychosis are active agents when it comes to adjusting medication. The interviewees created their own strategies to gain power over treatment with psychotropic drugs. The most common strategies were to adjust the doses or take breaks of varying lengths from the medication. These deviations from prescriptions were important to conceal, not only from their own psychiatrists, but from all psychiatric staff.

Non-helpful relationships with professionals - a literature review of the perspective of persons with severe mental illness.

BACKGROUND: The relationship with professionals has proved to be important with regard to outcome for persons with severe mental illness (SMI). The understanding of non-helpful relationships is important complementary knowledge to that regarding helpful relationships. AIM: To review the available qualitative research providing knowledge of non-helpful relationships from the perspective of persons with SMI. METHOD: A review of qualitative studies, based on an earlier systematic search, analyzed through thematic analysis. RESULTS: The main themes were "non-helpful professionals", "organization versus relation" and "the consequences of non-helpful relationships with professionals". Examples of professionals described as non-helpful were pessimistic and uncaring professionals who were paternalistic and disrespectful. Discontinuity, insufficient time and coercion were some of the contextual factors described as non-helpful. These sorts of relationships were non-helpful because they hindered helpful relationships from developing and contributed to further suffering, instilling hopelessness and hindering personal growth. CONCLUSIONS: Non-helpful relationships with professionals can be understood as impersonal relationships that contain no space for negotiation of the relationship nor of the support and treatment provided through it. It is important that organizations provide professionals with favorable conditions to negotiate the organizational framework and to treat persons with SMI as whole human beings.