From our qualitative data analysis, we see potential for people with SMI to become even more active managers of their own networks regardless of current network type; the building blocks of hope that the lived experience researchers first identified are found across the data set. The health and social care system currently did not deliver multiagency integrated networking solutions to support SMI and recovery. We also found competing tensions in policy agendas shaping provision of mental health services; primary and secondary care were not using the same approach to the management of SMI. The network types we have produced could be a very useful way of viewing the lives of people with SMI; understanding the dynamics of an individual’s connections with people activities and places, alongside diagnosis, provides a more person-centred approach to plan treatment and care.
Commissioner, organisation and practitioner level
The health and social care system for people with SMI is undergoing rapid change. Such change offers up opportunities to develop new solutions for how services support recovery but there are risks if there is no clear planning on how changes to community resources might impact on vulnerable groups. In such periods of flux, understanding the resources that individuals have and where they come from is of value, particularly if these are fragile and reliant on services. Offering values-based leadership to people with SMI is a very important role for both organisations and the practitioners who work within them; creating joint mental health strategies to guide these practices across current service silos is vital. We found evidence for a strong vision for delivering recovery-focused services in secondary mental health care and the third sector, but not in primary care. There was a lack of strategy across the service silos.
Practitioners understand and value aspects of social recovery from SMI but many, particularly GPs, and also community mental health practitioners, did not believe they had the time in their job role to focus on‘the social’. Service systems appeared to thwart the agency of practitioners and created obstacles to person-centred outcome-focused care, even within the third sector, whose practitioners wanted to work in this way far more but found it was not currently feasible within available commissioning arrangements. This identified lack of focus on social recovery was a barrier to working using a networking approach. This study suggests that an alignment between the recovery approach and a networking model using the CHN method could be useful in the delivery of mental health care, although more work is required to adapt a research process into a clinical intervention. This constitutes an area that newly formed bodies such as Public Health England, local health and well-being boards and CCGs may all be interested in: mapping community assets and the potential within individuals to become more active managers in their recovery journey.
Individual network level
A striking issue emerging in our work was how heterogeneous people with SMI were and the implications for working with people to manage their health problems. Yet network types were found which reflected connectedness patterns that could guide the work of practitioners. We found connections to people, places and activities to be an important aspect of individual’s lives which impacted on access to resources used to support well-being, and were not related to diagnosis. Individual agency in developing and maintaining networks was uncovered but most people required some support, even if this support was received reluctantly. Many with SMI were living out the majority of their lives away from mental health services and away from other people using services. However, a minority had significant proportions of their social network formed by mental health-related contacts.
Identifying the building blocks of individual agency that can be enhanced or nurtured with the help of others was a vital aspect of recovery, particularly where individuals lacked belief in both themselves and inner resources. The change agent might be within a person, drawing on their interests, identity and goals. Change agents might also be found in family, friend, wider contact or practitioner relationship groups. Developing the personal networks of individual’s with SMI was not identified as an organisational priority alongside management of medication and symptoms. While this remains the case it seems unlikely that this population will be able to build personal networks that make use of thefullpotential of inner and external resources. We note that there was potential in all networks to develop.
Network theory
This pilot study attempted to combine applied SNA to identify form and structure in networks, with qualitative data collection based on a hybrid approach of two traditions. It has merged qualitative SNA, unpicking meaning in network structures, and narrative research, exploring meaning in people’s lives, using the emotional closeness map as a‘way in’to the conversations that explored connectedness, well-being and recovery. Our network mapping was guided by SNA theory,24as it offered a framework to measure connections (or a lack of connections) using name-generating and name-interpreting procedures.76The benefits of the approach were that networks provide a top-down view, generated by the individual, of their current social world and meaningful activities. Once mapped, these networks were reflected on and we found this perspective helped conversations about how resources in the wider community impact on, or were used to support, both mental and physical health. This approach allows for consideration of what connections are important to individuals as well as what is missing; the latter provides a springboard to goal-planning. Including place and activity dimensions to create a multidimensional network, although time-consuming, added to the explanatory potential of network types. We found that many participants reported the mapping interview procedure useful in terms of their own thinking and understanding about their networks, and at follow-up interviews some had already begun to make changes. This framework has therapeutic potential, is a whole-person rather than illness-focused approach and could help both individuals and practitioners to consider new opportunities, or steps toward these, that improve well-being, promote recovery and increase access to resources.
The analysis we undertook also took a person-centred focus for understanding the lives of people with SMI, as recommended in the recovery literature,74through drawing out what was important to people and understandingwhyin terms of impact on well-being. The qualitative follow-up interviews were particularly helpful in understanding the dynamics of networks, how things change over time and the role of self or others in shaping‘form’or‘content’, and why.
Aside from the individual’s perspective, the structure and composition of networks that this approach provides gives insights for practitioners into stage of recovery for an individual.9This can help identify areas of potential to address through goal-setting: isolation or lack of diversity, lack of family or friends can all be identified. The dimension of activity offers an insight into the individual’s identity beyond mental health. Through identifying what is meaningful and important to each person, interventions to build new
connections can be targeted. Place is an important dimension because it situates the individual’s network inside the context of their local area; networks are constrained by and enabled by environment (social, cultural, economic). Both opportunities, such as local groups related to an individual’s interests, and barriers, such as transport, antisocial neighbours and safety, can be identified through consideration of place networks. People, place and activity networks interact. A framework can help both the individual and practitioners to build new connections that improve well-being, promote recovery and increase access to resources.