Bardi, Josephine N.
(2021)
Ethnography of an informal community mental health service:
exploring the place, people and participation at The Dragon Café.
PhD thesis, University of Nottingham.
Abstract
Background: Mental health services in the era following deinstitutionalisation have strongly followed a social support framework of intervention; thereby attempting to increase social connections and support for people with mental health challenges (MHCs). This shift in mental health care provision led to the establishment of statutory community mental health services, but such services do not fully address the needs of people with MHCs who are in their communities. Therefore, with the unavailability and inadequate statutory community mental health services came several barriers for people with MHCs who were unable (or unwilling) to access these formal services. Nevertheless, there are informal community mental health services, such as: (a) faith communities, (b) clubhouses, (c) user-led organisations, (d) day centres and (e) mental health cafés, that may or may not receive funding from the government. However, these providers offer social facilities where people with (MHCs) can socialise, interact, and participate in activities, including employment, learning and creative activities.
Methods: This is a constructivist and interpretivist ethnographic study that seeks to understand what The Dragon Café is, as well as to establish the relationships between the place, people and participation in the café. The researcher has used visual and textual data collection methods, including a 3-dimensional video, a floor plan, photographs, fieldnotes from observation and informal conversations, semi-structured interviews, a reflective diary and memoing in order to gather information.
Findings: There were five key original findings from this study, not evident in previous literature, and as such, these data fill a gap in knowledge and provide important contributions to the empirical literature. First, the café in this study differs from other informal community mental health services established for specific populations based on diagnosis, work or activity only. The Dragon Café provides a space primarily for socialisation and reducing feelings of loneliness and isolation among those who attend.
Second, this study offers an original and detailed ethnographic description of the outdoor and indoor physical environment of a mental health café, using visual and textual data to provide a footprint of the research setting, activities and people in a way that has not been documented previously. Moreover, it provides empirically substantive information on the mental health café in this study, which can be used for future comparative research of informal community mental health services in general and mental health cafés in particular.
Third, this study provides the first narratives and experiences of the loss of the place, people (friendships) and participation (activities) among people with mental health challenges who attend a mental health café. They were obliged to deal with several difficult issues following the closure and reconfiguration of the mental health day centres in the UK they were attending. Fourth, this study contributes to the academic field by providing detailed information about how free access and participation in a mental health café offers participants more choice, without the structured and compulsory participation criteria common in other informal community mental health services such as Recovery Colleges. Notwithstanding the perception of choice among the participants, this study is unique in that it is the first to alert us to the differences in power and authority between the patrons and management in a mental health café; and in particular, how this dissonance determines attendees’ behaviour and actions.
Fifth, this study developed a novel conceptual model which established that relationships between place, people and participation in a mental health café are intertwined; each of these are connected in the interaction under study. The development of a conceptual model is not an effort to produce a discourse on space, but rather a thick description (Geertz, 1973) of the actual outdoor and indoor spaces of the crypt where The Dragon Café is located to assist in identifying the ways that the interactive modalities of place, people and participation, identified by observations and participants’ narratives, can contribute to understanding, and potentially developing, informal CMHS in general and mental health cafés in particular. By applying such a theoretical model, we can gain a greater sense of how elements of the whole environment under study are co-dependent and influence our understanding of what makes people with mental health challenges attend informal CMHS in general and The Dragon Café in particular.
Discussion: Mental health cafés are situated in the culture of informal community mental health services and align with the mainstream notion of public spaces, where people meet to socialise with others, while at the same time offering a particular and unique set of resources and social activities. This study found that The Dragon Café offers a more diverse and enriched environment for social engagement and connection than is available from the more basic informal community mental health services or drop-in centres.
Conclusions: Mental health cafés, such as The Dragon Café draw on the two cultures of mainstream cafés and informal community mental health services to provide a more enriched environment for patrons with MHCs to become involved in a space fostering social engagement and connection. In particular, the Dragon Café avoids the more structured and compulsory participation requirements of informal community mental health services. The less formal and more egalitarian approach of The Dragon Café resulted in high demand for its environment, resulting at times in overcrowding. This unintended consequence of its popularity, in turn, compromised the quality of social integration for those who attended.
Recommendations: This study argues for more research into the issue of authority and power dynamics in mental health cafés, together with an exploration of the factors that hinder or enable community integration for people with MHCs. In terms of methodology, this study recommends more ethnographic research using visual and textual data collection methods, in order to add to the limited research activity that has focused on: (a) mental health cafés, (b) informal community mental health services and (c) Recovery Colleges. Furthermore, it is suggested that quantitative studies should be employed to measure the cost-effectiveness of mental health cafés when compared to other mental health services, such as hospital admissions.
Practically, this study argues for the revalidation of the UK tertiary institutions mental health curricula to include the issue of informal community mental health services during training, lectures and placements. Also, this study suggests that future research should, at least theoretically, consider the use of socio-ecological model to explore factors that influence community integration for people with mental health challenges. The novel conceptual mode should be used alongside the detailed ethnographic descriptions of the outdoor and indoor physical environment for the future development and reconfiguration of informal community mental health services. In terms of treatment options and policy, this study suggests the re-evaluation of the National Institute for Health and Clinical Excellence (NICE) guidelines, so that the guidelines include informal community mental services as treatment options; thereby addressing people with MHCs, rather than psychiatric conditions.
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