Main theme 1: availability of people
One of the challenges when struggling with mental health issues relates both to developing relations and maintaining them over time. Social arenas such as the low threshold services (Lts) provide opportunities where supportive relationships like this can be forged and maintained. The question is whether healthcare is provided at these places. Our findings show that the availability of people is seen as healthcare for the participants in this study. In Lts, both healthcare professionals and peers are available, giving the opportunity to be part of a larger context. The Lts offer easy access to healthcare professionals and the relevant literature finds their role to be important [
6,
39,
40]. This enables healthcare professionals to support the service users over time, and to inspire hope, described as an important task within recovery-oriented services [
14]. Service users of services relevant for personal recovery have described that ongoing personal relationships contribute to experiencing continuous care [
41]. In a study about acute day units’ informal interactions with peers and staff are described as important for recovery from mental health challenges/crises [
42]. Peers and staff being available for interactions might through this contribute to personal recovery for the individual. At the Lts in this study, people are available so that relationships are established and last over time.
The participants said
it means something to be one of those who sit around the fire (…). We find here that it is meaningful to be part of a common community instead of being alone in the dark. This is in line with studies that have shown that day centres give service users a feeling of cohesion [
43,
44]. Spending time together with others may create valuable relations that might also develop into healing relationships. Social connections at the Lts are found to be valuable throughout our analysis, in the same way as Borg and Topor [
27] describe humans as social beings who develop themselves and relationships by spending time with others.
From our analysis, the bonfire photo in our findings is an example of this. The participants looked at this photo during the workshops and talked about the outdoor trips facilitated by the Lts, where each group member had the opportunity to contribute their resources. We find that this type of participation and cooperation makes the service users’ resources visible and contributes to the forming of relations and solidarity, and for them this was what healthcare was all about.
The participants in our study underline the importance of the freedom to choose within the Lts and they picture flexible services as healthcare. The researchers interpret flexibility to mean being able to come and see and talk to people when it suits them, as well as being able to choose who to talk to. This type of flexibility is recommended in the literature when it comes to recovery-oriented support [
19]. Furthermore, the autonomy this flexibility provides is also experienced as fundamental support for personal recovery [
19].
Our findings show that the Lts are social arenas where people are available that the service users can choose to attend. The participants refer to a sense of community at the Lts where they are experienced almost like a small village. Put in the context of the second picture of the big city with tight lines and no people, society at large, Lts might be understood as small communities of people that can provide safe relations within the greater society. This can represent stability at a time when other aspects of one’s everyday life seem unstable and difficult.
Our findings show that to manage personal recovery processes, people need to be around others and to support each other. This is supported by Reed, Josephsson and Alsaker [
3], who found that recovery unfolds as collective processes by doing everyday activities together with others. As the African proverb says, “it takes a village to raise a child” [
45], we argue that “it takes a community to support a person’s recovery processes”. The proverb is a metaphor for the idea of encouraging additional community involvement to achieve growth and development [
45]. Our findings show the value and the energy created as people come together, work together, and feel a sense of community, of fellowship, through the warmth spreading from the fire. If people in the smaller community come together to support each other in their recovery processes, the safe framework might expand to include larger parts of the community, giving today’s service users of Lts even more flexibility, a larger network and more availability.
When it comes to the question of whether or not healthcare can be defined as facilitating social gatherings and ensuring that people are available within the framework of Lts, our findings point in this direction, in line with Sæterstrand and Møllersen [
46], who showed that the most important task for nurses in a day centre was to facilitate for social togetherness. While we have found this to be a fundamental underpinning of healthcare at the lts, the traditional understanding of healthcare might find this to be challenging.
Summing up the findings from this main theme one might ask that if the availability of people providing support is expanded to reach beyond the low threshold service framework, how will it be defined under the healthcare term? Which actions and relations would then be considered as healthcare?
Low threshold services provide opportunities to spend time with others, focusing on both personal and social recovery processes. The literature, e.g., Ness, Borg and Davidson [
15] finds that supportive social relationships are facilitators of recovery. As community mental health services are aiming for a recovery orientation, it is important to discuss which place healthcare should have in this, and how we can connect the two concepts.
Being around others helps one to gain new insights and the motivation to act and progress in the recovery process. Reed, Josephsson and Alsaker [
3] have also found this, showing that recovery unfolds as unique and collective processes rather than as individual processes.
Main theme 2: availability of places
A city of some size might have many mental health services dedicated to people with challenges. In the referral-based services, healthcare professionals reserve the right to assess who is to receive healthcare, while in low threshold services like the studied meeting places, the service users can choose to use the service based on their self-defined needs [
16]. One of the participants said
(…) In the low threshold service you’re not caught in these tight lines and processes but have the freedom to choose. Flexible healthcare (…). It is thus found to be valuable when people have the flexibility to choose if and when they want to attend such places as Lts, and if they want to opt out of the service altogether. Flexible healthcare, as sited in our findings, is understood in this context as places where healthcare is available.
Our findings point out that having a place to go when the need presents itself and being aware of this possibility play an important role in one’s everyday life and serve as healthcare for the service users in the studied Lts. The literature describes Lts as available places in local communities that are both welcoming and provide the opportunity to spend time in a safe environment [
3]. The studied Lts have a recovery-oriented approach that enables the service users to have an active and participatory role in the facilitation of these places [
29]. Other researchers have also pointed out the importance of the facilitation concept within services and centres like Lts [
39,
47].
Our findings show that by providing the possibility for people to come and create a meaningful everyday life, the Lts contribute to the personal recovery process. Cocchi and DeIsabella [
47] point out the need to have a broad perspective on facilitating meeting places, as they address different needs within people’s everyday lives that might be challenging to manage in society at large. In a review study by Bachke and Larsen [
48], day centres are presented as good integrating places outside the greater society, and they highlight their function of protecting service users from society, while also problematising whether this might inhibit real integration in society [
48]. As our findings refer to Lts as safe platforms, we interpret them to be the first step towards a greater degree of integration into society at large.
In our findings one of the participants said,
I get healthcare at the low threshold centre when I need it. This concurs with Bachke [
39], who maintains that having staff available at a Norwegian meeting place underlines the importance of being there and offering support when the user is ready for it. Rise, Westerlund, Bjørgen, and Steinsbekk [
49] also advise healthcare professionals to provide flexible support. Bearing all this in mind, we find that it is important that the framework for places like Lts is visible in the community so that people who need healthcare will see the health-promoting effect such centres have. Places that are welcoming and promote participation in the community are found to contribute to health and well-being for people struggling with their mental health [
50].
In our finding’s healthcare is referred to as having a place like the Lts where you can come, spend time, and try things out in a safe environment. One of the participants said (…) At the low threshold service you can spend the time you need to find the right key. The findings show that the service user’s autonomy is an important aspect in the studied Lts, where having time to spend in a safe environment is a key element.
For some, just coming to the Lts is enough. One of the participants said:
to me it’s healthcare to come here. This is in line with recovery-oriented values that refer to people as powerful and resourceful. Places such as Lts enable people to use their resources, first to come to these places and then to participate there. One of the participants said, (…)
after a while I was confident enough to try things on my own. Places like Lts facilitate ongoing processes according to individual needs. This is supported by Brandal, Bratberg and Thorsen [
51] who find that it is important for health services to be available according to specific needs. But who has the power to define these needs? When in recovery, the user’s own defined goals are important, and there is no set, predetermined path. As the picture of all the keys suggests, there can be many suitable keys, meaning many possible paths, which in turn means that openness and availability are core elements in recovery-oriented Lts.
The legislation defines healthcare as actions taken by healthcare professionals that have health-preserving and rehabilitation purposes [
32]. Our findings present a wider understanding of healthcare in terms of facilitating Lts as a healthcare framework. Our findings support this: the service users need time to work towards their goals and to conduct rehabilitation actions as they participate at their own tempo.
As recovery is a collective and personal process [
3], we interpret that the framework of a social arena like Lts contributes good support from both healthcare professionals and peers that in turn serves as healthcare. Familiarity with Lts and being willing to attend them can offer an activity in the service users’ everyday life in addition to routines, stability and a safe platform, something our next finding will elaborate on. Considering this, we wonder if it is possible that the framework making Lts available is in itself a health-promoting measure.
Main theme 3: availability of activity
Our findings show that doing activities together has great value; when people do something they like, they learn new things and share the activity with others. In a historical review of day centres in Great Britain, Bryant [
52] found that the socialising aspect of the activities aids recovery. Furthermore, participation and contribution in ordinary everyday activities within social contexts where the service users feel valued is described as “recovery as doing” by Sommer et al. [
25]. The researchers find that activities like this have a health-preserving function, which is defined as healthcare in the legislation.
Healthcare professionals might facilitate activities within low threshold services, but our findings show that motivating service users to participate in activities might be equally important. Eklund and Sandlund [
53] point to the importance of having opportunities to choose an activity when motivating service users. Our findings have shown possible activities within the service, where the motivation to take part might come from multiple angles. As one of the participants said,
At the painting group we paint together, we work together and are motivated and help each other with tips. This togetherness reveals that a fellowship is created through participation in activities. Moreover, when participating in activities at Lts, new resources might surface. One of the participants said: (…)
I was able to out try new activities where I discovered latent talents and that helped me to grow. This has been healthcare for me as it has opened a new world to me. The researchers understand that the activity contributes to movement within personal processes, as referred to in recovery-oriented practices [
3] and supports social processes. Supporting such participation in meaningful activities is described as significant within recovery-oriented services [
14]. Further, research show that meaningful activities is a valued feature within mental health [
42], as it contributes to a sense of safety, making structure through activity. Furthermore, valued everyday activities for people attending meeting places are described in literature as encouraging social engagement and providing room to be creative and learn new things [
54]. One participant said (…):
I have participated in a painting exhibition with my paintings, facilitated by the low threshold service, and I sold some pictures (…). Activities like this might contribute to a considerable degree outside the services as well. Larsen [
55] supports this by seeing day-centre activities as a stepping-stone into society for some, while for others they are meaningful while they are attending the Lts. Our findings show that the painting activity at the studied Lts can be seen as a multi-layered contribution in a person’s everyday life. Such contributions are a) the concrete painting activity itself, b) spending time with others, c) sharing ideas, d) working on a product and finishing it, e) sharing the result with others and e) the powerful feeling of adding something valuable, such as a painting. This is also a recovery process providing individually adjusted and flexible support negotiated by several contributors [
16], in this case Lts, healthcare professionals, peers, community members and others.
In our findings one of the participants said:
baking is an activity I master and that contributes to my health. It makes me stronger. I work together with the staff, and they motivate me. Healthcare professionals motivating and supporting service users in a concrete activity is described in the literature as an important recovery-oriented service [
14]. The participant draws attention to the value of doing an activity, and when it is mastered, it is a valuable contribution to this user’s health. At the same time, working together with others substantiates the principle of equality that is a key part of recovery orientation [
8,
27]. Doing activities together, regardless of the roles at the low threshold centre, evens out any differences as the focus is on the activity itself. Furthermore, our findings show that when people do activities, they know they manage and enjoy doing, a feeling of joy is created, and even greater joy is experienced from sharing the activity with others. Engagement in different activities makes meaningful social roles visible and is described by Snethen et al. [
50] as a desirable feature and important opportunity within community locations.
Activities described in our findings, such as painting and baking, are two out of many possible activities found at the studied Lts. For some people it is sufficient to have an activity to come to in the Lts. Service users interviewed by Elstad [
2] described coming to the centre during difficult times as a type of mastering. The availability of activities at the low threshold services adds value and opportunities to people’s lives.
A question that arises is whether such activities are considered as healthcare, and if so in which context they are considered as such. Finally, will the same activity automatically function as healthcare for everyone attending?