The aim of this study is to explore the characteristics of what is experienced in mental health recovery-oriented places and how these characteristics can facilitate social connections and participation.
This qualitative study has an explorative, interpretive and collaborative design. Dyadic interviews and participatory fieldwork observations were used as methods for data generation. Data were analyzed using a collaborative hermeneutic approach.
Characteristics of recovery-nurturing places involved how concrete and tangible features of place may nurture and enable actions and ways of being with oneself and others. Three broad themes explore the characteristics and how they can enable recovery: nurturing senses, nurturing practical skills and nurturing communication.
This study demonstrates how materiality and recovery are interconnected and expands the understanding of recovery as “in-the-mind processes.” It explores how places and material objects have a recovery-nurturing potential through enabling actions and participation and thereby supporting people in living, storying and restorying their lives.
Recovery has become an influential paradigm in the shaping of community mental health services in many western countries (Slade et al., 2014). Adhering to this paradigm involves finding community-based ways of supporting people struggling with mental health and substance use (MHSU) issues, taking an everyday life approach. An everyday approach to mental health recovery typically involves understanding recovery as a process rather than an outcome. These processes are both personal and social, and the interactions among the processes also play a role in recovery. Recovery focuses on finding ways of living well, either with or without what may be described as symptoms or clinical problems (Sommer et al., 2021). Positioning recovery within a processual and contextual understanding means that an important part of recovery-oriented services is facilitating community engagement and participation. Tailored support and flexible services are crucial for promoting community inclusion and participation (Nesse et al., 2022). In line with this understanding, recovery-oriented practices cannot be standardized and implemented but need to be developed in relation to the local contexts and by the people interacting in these contexts (Borg and Davidson, 2008). As such, recovery may aptly be understood as dynamic and constantly “in the making” (Sommer et al., 2021; Klevan et al., 2021a). Furthermore, recovery is understood as a relational process that is based on mutuality and reciprocity (Klevan et al., 2021a; Price-Robertson et al., 2017a).
Studies describing and exploring features of recovery-oriented practices commonly address both personal and interpersonal aspects (Borg and Davidson, 2008; Ness et al., 2014; Topor et al., 2006). However, processes of recovery also link human and nonhuman aspects, that is, linking the ways in which humans are affected by and affect both other persons and the specific material context (Duff, 2012; Price-Robertson et al., 2017b). Processes of recovery are situated in a time and a place, and people’s health and community health services are affected by places and contexts (Cummins et al., 2007; Larsen et al., 2020). According to Doroud et al. (2018), “place” extends beyond the objective and tangible context: the concept of “place” is “shaped, interpreted and created by people through their experiences, relations and interactions” (p. 119). Perceiving recovery-oriented practices as developed contextually through interactions among people suggests that what may be understood as recovery-nurturing places might not be set in stone but co-created and subject to ongoing change. Thus, a relational and mutual perspective on recovery and recovery-oriented practices and services aligns well with an understanding of recovery-nurturing places as being (co-)created by the people interacting in these places (Doroud et al., 2018).
The concept of place has been given various meanings. Gieryn (2000) suggests that place has three defining features: geographic location, material form and investment with meaning and value. How place is given meaning can be understood as relational processes that are brought forward through negotiations between people involved at a specific location and within certain material conditions. Place as something that has been negotiated is also described by Murdoch (1998, in Cummins et al., 2007, p. 1828), who makes a distinction between “spaces of prescription” (places that are prescribed in terms of formalized and standardized control and organization) and “spaces of negotiation” (places that are dynamic in time and space). The latter form of place is subject to negotiation and social construction among people (Cummins et al., 2007).
In this paper, we position ourselves within an understanding of mental health recovery as relational and contextual. In exploring how recovery is enabled, it is important to focus on enabling social and material contexts, as opposed to focusing on recovery as something that primarily happens “in the mind” (Hope et al., 2023; Karlsson and Borg, 2023). Following this idea and in line with Cummins et al. (2007, p. 1835), we suggest that there is a “a mutually reinforcing and reciprocal relationship between people and place.” Exploring the entanglement of people’s processes with their social and material environments is important in understanding what characterizes places that may be experienced as recovery-nurturing. Nurturing places have access to material, social and affective resources that can enable a livable everyday life and, thus, also enable mental health recovery (Duff, 2012; Hope et al., 2023). Such places cannot necessarily be identified in advance because what is experienced as an enabling and nurturing place varies among people, cultures and times. An important perspective is to focus on the activities and practices of place-making, thus understanding enabling places as constructed and negotiated (Duff, 2016; Femdal, 2018). In a mental health context, place is relevant because place enables access to social relations and material resources that are important to health, well-being and social inclusion (Cummins et al., 2007; Snethen et al., 2021). These ideas align well with research emphasizing that recovery is best understood as ongoing relational processes and that recovery constitutes and is constituted by social and material contexts (Klevan et al., 2021b; Sommer et al., 2021).
Several studies explore how recovery-oriented practices within and outside mental health services are described and experienced (Klevan et al., 2021b; Ness et al., 2014). Many of such studies focus on the content of these practices, whereas the importance of place in recovery-oriented practices has been explored less (Doroud et al., 2018; Friesinger et al., 2019; Hope et al., 2023). While place, meaningful activities, social participation and recovery can be perceived as connected, these relationships do not explain how place offers opportunities for involvement in activities or how place can facilitate social connections and community participation (Doroud et al., 2018).
In a community-based approach to mental health services, recovery-oriented practices happen in people’s homes and various locations in the local community as part of people’s everyday lives. Although there seems to be a general acceptance that people’s homes, the local community and locations like day centers are important loci for recovery-oriented practices, less is known about what characterizes these places and how various characteristics of these places may be perceived as recovery-nurturing.
The aim of this paper is to explore the characteristics of what is experienced in recovery-oriented places and how these characteristics can facilitate social connections and participation.
Methodology
In this qualitative study, we used an explorative, interpretive and collaborative design. This approach requires understanding knowledge as interpreted and ongoing processes, constructed and re-constructed via the interactions among the researchers and the research participants and both of their respective contexts (Klevan et al., 2021a).
Study context, procedures and participants
The study was carried out in a Norwegian municipality that has mandated that its mental health and substance use services be recovery-oriented. The municipality offers a range of mental health and substance use services, including outreach services, supported housing and day centers. This article is part of a qualitative study with the overall aim of exploring what a recovery-orientation of services in a municipality presupposes and involves. The study used:
dyadic interviews; and
field work as methods for data generation, perceiving knowledge as relational and contextually situated.
Dyadic interviews involve interviewing dyads (pairs) of participants. The researcher facilitates a conversation in which the comments of each participant draw forth responses from the other (Morgan, 2016). Here, each dyad consisted of a mental health service user and a professional working in MHSU services. Service user participants were recruited from a broad range of community MHSU services. All were receiving services on a regular basis and had previous experiences with receiving a variety of other services. Those who agreed to participate were asked to invite a professional (the person who they defined as being their most important helper from the service that was currently helping them) to be interviewed with them in a dyadic interview (Klevan et al., 2020; Morgan, 2016). Eight dyads (16 people) participated in interviews. Interviews explored how understandings of recovery and recovery orientation of services are developed through daily practices and collaboration between service users and professionals. Interviews were audio recorded, transcribed verbatim and analyzed thematically. An important theme in this analysis was the role that place played in recovery and in recovery-oriented collaboration (Klevan et al., 2021a).
To further explore the importance of place in recovery, the first and second authors conducted fieldwork in the same municipality using a participatory observation approach (Fangen, 2010). This approach involved being attentive to how people described the importance of places as part of recovery and observing possible characteristics of such places that could enable recovery through facilitating collaboration and participation. The fieldwork was done at a local day center that claims to be recovery-oriented. The center focuses on people’s resources and has a user-involving profile, offering various activities such as art, newsletter writing, swimming, fieldtrips and serving as a low-threshold meeting place. The center did not report having an organized collaboration with local meeting places, but participants could be introduced to facilities and activities in the nearby surroundings through the center.
The first and second authors were present on five occasions over three weeks, 3 h each time, during which regular activities at the day center were carried out. We did our best to avoid disturbing the everyday life at the center, and we were cautious not to take on staff-like roles (Elstad and Eide, 2017). Perhaps because the center is a meeting place where the number of people attending is fluid and where people come and go at different times, people seem to accept us as part of the environment. We participated in the conversations whenever it felt natural. Our observations were documented through fieldnotes that were taken shortly after the interactions and not in the actual setting, in agreement with the participants. As researchers, we agreed to try to include as much description as possible, but also to allow for their immediate reflections to be part of our notes. We took notes separately and then got together to share, compare and discuss notes. Our notes and any additions that were made after sharing notes were included as data material and were used in the analysis. The transcribed interviews from the dyadic interviews were also used as a data source.
Analysis
The data were analyzed using collaborative hermeneutic content analysis, inspired by the work of Hummelvoll (2008). A collaborative hermeneutic analysis involves a back-and-forth process between the descriptive and interpretive dimensions of the data, with the aim of developing meaning and knowledge through the dialogue between the two dimensions. This process is driven forward by the dialogue between the collaborating researchers. The analysis can be viewed as a data-guided, dialogic and creative process where various questions are posed to the different types of text through the lenses of the involved researchers to explore its possible meanings (Hummelvoll, 2008). The first and second authors conducted the analysis and had input and reflections from the third author regarding the final refinement and writing up of themes. The first and third authors have a clinical and academic background, whereas the second author, in addition to having a clinical background, is also an expert in experience. Through posing questions about each other’s interpretations of the data, we believe that the collaboration led to richer and more nuanced understandings (Hummelvoll, 2008).
A collaborative hermeneutic analysis is characterized by dwelling and reflexivity at all stages and does not follow a predefined set of analytical steps and procedures. However, the following summary describes our general procedure:
iterative reading of the data material (transcribed interviews and fieldwork notes), making notes of preliminary interpretations;
rereading of the material and identifying and coding meaning units;
abstracting the coded material into subthemes via a thorough revision of codes in relation to each interview, each fieldwork session and the data set as a whole;
a collaborative process on grouping subthemes into themes, and defining and refining those themes in a back-and-forth process between the text of each interview, each fieldwork note, the text as a whole and the evolving themes; and
testing and refining final themes, and writing the themes up.
Ethics
The study was carried out in accordance with the regulations of the Norwegian National Research Ethics Committee. Because of the nature of the study, the ethics committee concluded that the study did not require formal ethics approval (information blinded). The Norwegian Centre for Research Data approved the study (information blinded). Written informed consent was required before participation in the interviews, and the data were anonymized during the transcription process. For the fieldwork part of the study, information about the study was given at a meeting at the day center, in which both health professionals and peer workers participated. The health professionals and peer workers were given the assignment of sharing information about the study with the service users. Posters and flyers with information about the study were available at the day center before the field work, and prospective participants who had questions were urged to contact the main researcher, professionals or peer workers. On the days when field work was carried out, persons present were given oral information about the study, and oral consent was obtained. Fieldnotes were taken, but names and information that could lead to participants being recognized were omitted.
Results
Characteristics connected to place that may nurture recovery span from concrete and tangible features of place to how these features may also be perceived as enabling certain actions and ways of being with oneself and with others. The three main themes developed through the collaborative analysis were nurturing senses, nurturing practical skills and nurturing communication.
Nurturing senses
While place can be characterized as tangible and concrete, place can also facilitate the nurturing of one’s senses in that a place is an arena for smells, sights and touch. At the day center, often the first thing that people notice when they come in is the smell of food. Many participants at the center commented on this upon entering, and they shared the anticipation that the delicious smells could entail. We observed that the welcoming smell of dinner, pastry or waffles brought smiles to people’s faces when they entered, and that they would then make small, acknowledging verbal utterances. The welcoming smells appeared to set the scene for a place that was inviting and comforting. The kitchen is located just by the entrance of the day center venue, and thus the smells and promises of a possible meal are the first things that people meet. The smells of pasta Bolognese or homemade waffles that seeped out from the kitchen often sparked little conversations. Stories were told about the person responsible for the kitchen, and it was said, for example, that she was a “wizard with food, she is so creative and talented.” People also talked about what kinds of foods they liked and what they used to eat at home.
While the location of the day center is a rather anonymous building housing several public services, the staff and participants at the day center appeared to take pride in decorating the center with flowers, tablecloths and so on, giving the center a home-like appearance. They also decorated the center according to the holiday season. For instance, during our fieldwork period, we observed participants preparing for Halloween. Decorating the center and the food in scary and horror-inspired ways evoked enthusiasm and laughter and seemed to be greatly appreciated by the participants. It was something to sense, share and allow oneself to be thrilled about.
The ability to stimulate and awaken senses also appeared to characterize other places that could be perceived as recovery-nurturing. For example, in one of the dyadic interviews, the two participants (a mental health worker and a service user) shared how they would mostly spend time together outside the service user’s home or the location of the outreach team. By going out for walks in the park, to a coffee shop or to the grocery store together, they could observe, sense and talk about what they referred to as “life-things.”
Places that had the capacity to nurture and stimulate senses seemed to inspire and enable engaging in activities and social interactions with others. Through access to physical surroundings and material resources, places could awaken senses and thereby trigger memories, experiences and interests that inspired participation and something to talk about.
Nurturing practical skills
The key to how place could support and nurture recovery was how place could serve as an arena for practicing, learning and mastering skills. Performing concrete tasks provided opportunities for developing skills or discovering forgotten ones and enabled social interaction with others. At a fundamental level, a place can serve as an arena for tasks. For example, the kitchen was in many ways the heart of the day center and provided a place where one could be while also having a useful and concrete task – preparing meals or making waffles for others. The place was given meaning and purpose through its practical equipment; the baking bowl, the stove or the waffle maker gave legitimacy for being in the kitchen as these objects were connected to the carrying out of concrete and necessary tasks. Furthermore, these tasks were perceived as meaningful by others, as all participants at the day center expressed how they greatly valued the good and nutritious food served and the people in charge of making it. Examples were shared of how the kitchen could serve as a safe haven for some participants; even if one struggled to interact socially with others, the kitchen and its practical equipment gave a reason for being there and enabled doing something for others and being useful:
There was this person who roamed about here, talking to himself. And then we needed someone in the kitchen, and someone asked if “Hans” could make waffles, and “Hans” got so happy, he was so pleased. Made waffles, and then “Hans” felt useful, you know.
Adequate equipment was also a key to how a place could provide meaning and enable the development of other practical skills. For instance, there was a sewing workshop at the day center, and it was therefore crucial that the place had the necessary equipment for sewing. The participants said that some participants were more experienced with sewing and using sewing equipment than others, and this discrepancy allowed them to share and learn from each other. Having an allocated and adequate space for carrying out the specific activity was important. The sewing room was an arena that enabled doing something special that could not necessarily be done anywhere else. As such, places that nurtured skills were often related to and equipped for specific activities and were not just general places.
A place could also enable the doing and practicing of everyday-oriented skills that could enable living independently. Having the stability of a home could serve as an arena for practicing and learning. One interview participant said:
I take pride in cleaning the apartment and taking responsibility for having my own place. I clean and tidy up all by myself, and if I need help to say, hang up the curtains, then I can get help to do that.
This participant described that her home served as an arena for doing everyday tasks and developing skills like responsibility. While her home was a private sphere that she took pride in being responsible for, it was also a place to which she could invite others for support, for problem-solving and hence for developing new skills. A home, with its broad variety of material resources, provides numerous opportunities for practicing and developing skills.
The theme shows that specified and task-specific places can provide opportunities for practicing and developing skills, and that stable, safe and multiequipped places such as a home hold numerous opportunities for practicing practical skills. Furthermore, engaging with things and doing practical tasks are also ways of connecting with and mattering to others.
Nurturing communication
Some places invite having conversations with fellow human beings. A place offers concrete objects like flowers, coffee cups, clothes, books or music to talk about and can evoke memories and experiences. The communication-nurturing aspects of place partly seem to be connected to how place can provide a safe and inclusive frame for an actual conversation to take place. Furthermore, the previously described tangible objects of place were also important for sparking conversations. At the day center, these conversations could be about the flowers in the window or how the curtains had been washed and ironed. Being a group of people physically present in a shared place, each of whom had access to the same orchid in the windowsill, could be the starting point of a conversation involving sharing experiences with flowers and tips about how to care for them. The presence of a flower and the conversation revolving around the flower could also evoke memories and experiences from the past. For instance, some shared stories about how they used to have a house with a garden or how they loved caring for plants. Talking about the flowers in the room could lead to attentiveness and conversations about common interests and the possibility of future and shared projects connected to plants and gardening.
Food and sharing meals as part of the daily routine at the day center also provided opportunities for small talk. Food was something everybody could discuss and have opinions about. Enjoying a meal together was an accessible, inclusive and low-threshold activity. The serving of food gathered people in the dining room, and the meals thus gave the place a shared content. While the meal was shared and was something everyone could join in conversations about, the shared place that the meals facilitated also enabled conversations about previous meals, traditions and preferences. Sharing places through a common purpose appeared to facilitate numerous conversation topics.
While the day center provided a shared place for daily routines, other places that may be described as everyday places, like, for example, a grocery store, could also be important arenas for small talk. A service user said that joining such everyday places with his mental health worker could nurture conversations about daily life:
There is no point in sitting in your living room trying to have a conversation when you are hearing voices and things like that. It’s better to get out and do something. You shouldn’t underestimate those conversations you can have, going to and back from the grocery store, and in the store. Talking about healthy bread, fruits […] all those little, silly things.
The presence of tangible objects like flowers, waffles and groceries was an important characteristic of recovery-nurturing places. The presence of these objects provided the impetus to have conversations about the “little things.” These little conversations appeared to be easy to engage in, and could enable more abstract conversations linking to memories in the past and plans and aspirations for the future.
Discussion
This study demonstrates that recovery is part of people’s everyday lives and local contexts (Borg and Davidson, 2008). The study shows that places experienced as nurturing offer material, social and affective resources, and that these resources are interconnected (Duff, 2012). Places appear to be recovery-nurturing when they provide stability and coherence and through an inherent opportunity of being developed and negotiated by the persons interacting with them. Recovery-nurturing places seem to be characterized by being experienced as safe, welcoming and accessible and by their capacity to awaken the senses and enable communication and skills (Sells et al., 2006; Snethen et al., 2021). The study suggests that the tangible objects that equip places are important vehicles for supporting and nurturing recovery. As such, materiality – or what could be labeled as “things” – plays an important role. This conclusion is in line with findings from a study by Larsen et al. (2020), suggesting that material things have an impact on people’s lives and recovery processes. According to these authors, things create contexts and thereby allow people to interact and move physically, socially, and emotionally. This study supports the idea that things have an impact and can create movement through their capacity to stimulate interaction with the world in concrete ways and thereby also support curiosity and vitality. The term “life-things” used in this study suggests that material objects can awaken curiosity and provide connections to life in the present moment, and that people and material objects are entangled and presuppose and support one another (Price-Robertson et al., 2017b).
The study demonstrates that concrete things in the material world, in addition to providing important connections in the present, can also enable connections to memories in the past and awaken future hopes. Thus, recovery-nurturing places can support alternative narratives about who one is, who one can become, and who one has been, all of which are vital to nurturing recovery.
Through enabling connections to the past, present and future, we suggest that recovery-nurturing places may enable narrative restorying. A key assumption in a narrative perspective on mental health recovery is that the telling of stories creates reality rather than reflects it, and thus, storying and restorying who one is, can become and has been creates opportunities for multiple understandings and stories (Grant, 2023). Restorying can serve as a transformational tool and enable choices and alternatives for how to make sense of one’s past, present and future. Restorying may thus enable new ways of seeing oneself and alternative identities. Grant (2023, p. 121) used the term “selfing,” suggesting that one’s self is performed and produced through storying and restorying. Through working with these stories, one can not only develop and change but also craft and protect stories of oneself. In line with understanding recovery as processes entangled with social and material contexts, providing and facilitating concrete, material resources that can enable restorying is a vital element to recovery-nurturing practices and services (Klevan et al., 2023). A day center kitchen equipped with a waffle maker can support transformations and enable new possible identities; one is perhaps not first and foremost a “mental health service user” but someone who can master the skill of waffle making and who thereby helps others and contributes. Thus, the very existence of the day center kitchen and the waffle-maker enable interaction and participation, and the chance to be and become someone slightly different than one was when entering the kitchen for the first time. Recovery is related to gaining meaning and control, regaining hope, developing more positive identities and connecting with others and oneself. Things that can provide meaning for the person with mental health issues can support movement and transformations in recovery-oriented directions (Larsen et al., 2020).
Concluding remarks
Social and material resources are key to recovery, which emphasizes that recovery presupposes and takes place in what Hope et al. (2023) refer to as “an outer real landscape” (p. 7). These outer landscapes may be perceived as abstract, intangible and “out there.” However, as this study suggests, outer landscapes in terms of places equipped with concrete material objects may be perceived as recovery-nurturing through their ability to activate interactions among people.
The study suggests that places and objects have the capacity to nurture recovery through vitalization and connections. In line with Hope et al. (2023), we suggest that an important shift in what commonly goes under the label of recovery-oriented practices and services is recognizing the importance and potential of material objects that human beings interact with and are affected by. Furthermore, places and the material objects equipping them hold a recovery-nurturing potential through supporting people in living, storying and restorying their lives from past, present and future perspectives. An enhanced focus on how materiality and recovery are irrevocably connected is key to expanding the field of recovery from an inner project to an inner-outer interaction focus, where places, “life-things” and people interact and are given attention.
The authors wish to acknowledge Stiftelsen Dam (The Dam Foundation) for funding the project.
