Social support and recovery from mental health problems: a scoping review

ABSTRACT

Several systematic reviews have suggested the linkages between social support and mental health or the use of mental health services in general. There is a need to develop the knowledge on different associations between social support, social work and mental health recovery, and the various features of social support. Inequality in health is a rising problem. Broader integration of social support-orientation in services and policy can play an important role in reducing health inequalities and enhance recovery. In this article we aim to scope existing literature regarding (a) the associations between social support, mental health and recovery, and (b) describe features of community mental health services that incorporate social support. Further, we discuss facilitators and barriers for social work and social support. Advanced searches were conducted in five relevant databases: Social Science Premium Collection, CINAHL, SweMed+, Idunn, and PsychInfo Ovid, and we did a qualitative synthesis of the included papers. Twenty-nine papers met the inclusion criteria in this scope and are organized into two major themes: a) Associations between mental health and social support, and b) Key features of social support-oriented community mental health services.

KEYWORDS:

• Social support
• social work
• mental health
• recovery
• community mental health

Introduction

This scope review maps out the literature on the association between social support and mental health by focusing on recovery from mental health problems, and the features of social support and community mental health services. The scope begins with the notion that social support plays a substantial role in attaining and maintaining good mental health, in the prevention of and recovery from mental health problems (Topor et al. 2011; UN 2020; Wang et al. 2018) and have a potential in reducing inequalities in health (Stoltenberg 2015).

Social support is often conceptualized in the following categories: (a) emotional, (b) instrumental, (c) informational, and (d) appraisal (Langford et al. 1997; Sarason et al. 1987). Emotional support refers to having someone to talk to, having close relationships with family and friends, and feeling loved and cared for. Instrumental support refers to having someone to trust and count on in difficult life circumstances and dealing with the demands of daily living such as getting to appointments, shopping, cleaning, help with money matters, paying bills, and so forth (Baiden, Den Dunnen, and Fallon 2017; Sarason et al. 1987).

Several systematic reviews of the literature have suggested linkages between social support and mental health or mental health service use in general (Beauregard, Marchand, and Blanc 2011; Leigh-Hunt et al. 2017; Terry and Townley 2019; Tol et al. 2011; Wang et al. 2018) and in specific population groups (McDonald 2018; Tough, Siegrist, and Fekete 2017). Findings in previous studies suggest that social support, which may be provided by a variety of individuals and services, plays an important role in promoting community integration and social networks for individuals with serious mental health challenges (Salehi et al. 2019; Terry et al. 2019). There is no review in the literature that addresses the relationship between social support and mental health in the context of identifying the state of the knowledge, with a specific focus of understanding the variations of social support. Further, we found a need for a scope review providing a more comprehensive understanding in the development of social support-oriented mental health services in facilitation of mental health recovery.

Aims

This study objects to explore the role of social support in the development of, experience of, and recovery from mental health problems. The main aims of this article are to map and explore existing literature regarding (a) the associations between social support, mental health and recovery, and (b) explore the key features of community mental health services that integrate social support in practice. We also aim to address the increasing inequality in health and propose that social support-orientation plays an important role when meeting this rising problem.

Recovery and recovery capital

The recovery tradition in mental health is deeply rooted in service user movements and professionals that have emphasized psychosocial aspects of working with and recovering from severe mental health challenges (Bengt Karlsson and Borg 2017). This orientation marked early that it wanted to go beyond the biopsychosocial model (Davidson and Strauss 1995). However, it also faces extensive critique, especially considering its way of defining what recovery practice actually is, where some argue that within this tradition the attention now is directed more towards excessive individual orientation (Bengt Karlsson and Borg 2017; Price-Robertson, Obradovic, and Morgan 2017). Consequently, one can here lose focus of the very nature of recovery as relational. Nevertheless, we can say that this tradition relates to a broader range than, for example, how the psychiatric tradition works with the different layers of social support. The recovery tradition created new perspectives that unfold in the field from the scale of building recovery communities to its influence in social policy in the wholesome work to support the individual recovery process. Recovery does not necessarily imply becoming symptom free. Instead, it involves reclaiming control over one’s life and negotiating a valued and satisfying ‘place in the world’ and finding personal strategies for managing any ongoing distress experiences (Anthony 1993). Conceived in this way, recovery is both a personal and a social process – in which resolution of internal distress takes place alongside social reengagement in ways that may be mutually reinforcing (Jacob 2015; Tew 2013; Topor et al. 2011). The terms recovery and mental health recovery will be used as an understanding of this concept during this article.

Another term of importance related to social support and mental health recovery is recovery capital. Tew (2013) proposes that recovery capital includes four different types: (1) economic capital (2) social and relational capital (3) identity capital and (4) personal (or mental) capital. Social support-oriented services can and should work with the recovery capital at these different levels.

Social inequalities in mental health – a Nordic paradox and global problem

Mental health services are constantly evolving and trying to incorporate that social factors are crucial when understanding and solving mental health problems. These services often work with people that lives in scarcity, e.g. poor economy and deprived living conditions. However, the current levels and types of services seem insufficient in incorporating the social perspectives in mental health care and often offers inadequate help (Cottam 2018; Giacco et al. 2017; Bengt Karlsson and Borg 2017; Topor et al. 2011).

Social inequality in health is a rising problem at a global scale (Wilkinson and Pickett 2020) and is a significant component to include when exploring social support and mental health recovery (Sælør et al. 2019). Inequalities in mortality have even been rising ever since the 1960s in Norway, a country often referred to as one of the world’s most equal countries (Dahl and van der Wel 2016). In Norway inequalities in health are therefore addressed as a rising problem and concern (Dahl and van der Wel 2016; Stoltenberg 2015). In Nordic countries such as Norway, Denmark and Sweden there have been concrete political strategies to reduce this problem (Dahl and van der Wel 2016). A white paper on public health in Norway describes the problem and specifically points out social inequality in mental health as a mounting problem that requires strategies for solutions, e.g. increased social support-orientation (Ministry of Health and Care Services 2014-2015). Inequality in health is sometimes debated as a paradox in the Nordic welfare states, because despite social inequality (in general) in Nordic countries is lower compared to other countries on a global scale, inequalities in health are mounting (Dahl and van der Wel 2016). At the same time the inequality related to income is steadily increasing in Norway, and is greater than the statistics is showing, something newly reported by Statistics Norway (Aaberge, Modalsli, and Vestad 2020). In a (mental) health-perspective this is an argument to work with varieties of support and features of social support in a more systematic and broad matter, so that services can integrate and be inspired by social support-orientations from different practices. This comes with the assumption that increased social support, and active social policy that facilitates social support and economic equality, are important dimensions in battling increased inequality in health and facilitate mental health recovery (Sælør et al. 2019; Stoltenberg 2015)

Method

Colquhoun et al. (2014) has defined a scoping review as ‘a form of knowledge synthesis that addresses an exploratory research question, aimed at mapping key concepts, types of evidence, and gaps in research related to a defined area or field by systematically searching, selecting, and synthesizing existing knowledge’ (p. 1292). Where a strict systematic review typically focuses on well-defined questions and accurate study designs that will often be identified in advance, a scoping study tends to address broader topics that can include a greater variety of study designs (Arksey and O’Malley 2005).

This scoping review applied the following steps in its process by drawing on Arksey and O’Malley (2005): (a) identifying the research aims/questions, (b) identifying relevant studies and scientific work, (c) study selection, (d) charting the data, and collating, summarizing, and reporting the results. We also added a broader discussion. The scope process began in February 2018 and we had an updated search January 2020. We did not register the study in Prospero, since this is a scope review without direct health-related outcomes.

The search process

The starting point was to formulate the aim of this scope review, followed by advanced search in five relevant databases, namely Social Science Premium Collection, CINAHL, SweMed+, Idunn, and PsychInfo Ovid. The rationale for the use of these databases is that they capture articles both in the English language and Nordic languages and interdisciplinary research. The search was conducted with the support of a health librarian at one of the affiliated universities. The main terms, combinations, and variations in the search strategy used in all databases were as follows: ‘Community Mental health services,’ ‘Mental health services,’ ‘Social support,’ ‘Mental health recovery,’ ‘Community mental health work,’ ‘Psychosocial interventions,’ and ‘Social Work, psychiatric.’ We included Medical Subject Headings (MESH) in some databases where it was an option to ensure a broad scope and better rigour in our search process, and we used relevant synonyms. The search was limited to the period from January 2000 to January 2020. We limited our search to the mentioned period because of the large body of literature and decided to focus on peer-reviewed articles.

Inclusion criteria applied: Full-text articles published in peer-reviewed journals, studies published in English and Nordic languages, qualitative and quantitative studies, and relevant papers in the research network.

Exclusion criteria: Personal viewpoints. The full-text articles excluded with reasons consisted of articles that had poor study design or personal viewpoints that did not supplement the already elected articles.

There were 2,819 hits in all five databases after limiting the focus to peer-reviewed articles. After importing all the studies to EndNote, Author 1 removed all the duplicates, and then sorted and screened out the most relevant studies for closer abstract-reading. A large number of articles identified in the search were considered inappropriate or inapplicable mostly because their foci did not fit our research aims. This resulted in a total of 53 full-text articles from the search results in the databases that were considered to align with the research aim and still ensure a good scope. The final step in the review and selection by reading the full texts was to select those articles that were relevant to the aim of this scoping review, and to exclude the ones with poor study design or personal viewpoints that did not contribute with relevant empirical material. This review process involved the construction of a classification table that presented the relevance and the quality of the study design, which all authors contributed. This resulted in a set of 29 articles as the base for the review, as shown in Figure 1.

Figure 1. The search and data selection process (flow diagram, The prisma group, 2009).

Systematizing the findings

The 29 articles were reviewed carefully for their relevance, with focus on research design. We applied the qualitative thematic synthesis to systematize the findings in these papers and to extract major themes addressing the research aims. The thematic synthesis was organized into two major topical themes: (a) association between mental health and social support, and (b) features of social support-based community mental health services. This allowed the differentiation between the literature on the complexities of the association between mental health and social support on the one hand, and the social support-oriented approaches in mental health care on the other. Of the total, 13 papers were oriented to the first topic (a) and 16 were oriented to the second topic (b).

Findings

Table 1 presents information on the 29 papers that are included in this scope by chronicling the research questions or hypotheses, the study participants, the major findings, the research design, and the internal and external validity. The findings are sorted out in relation to the two foci/aims of the review and our qualitative synthesis.

Table 1. Selection and description of studies (N = 29) for the scope. almost all studies except two (Malaysia and China) were conducted in western countries.Findings sorted in to sections a) associations between mental health and social support and b) features of social support oriented services.

Reviewed studies: author(s) & title	Research question(s)/aim(s)	Study subjects	Major findings	Research design & internal validity	External validity/Transferability of the findings
SECTION a) Associations N = 13
Andrea, Siegel, and Teo (2016) Social support and health service use in depressed adults: findings from a national health and nutrition examination study (US)	Investigated the relationship between social support and health service use among men and women with depression	N = 1379 The present analysis was limited to adults aged 40 years and older, experiencing depression	Among those with adequate social support, odds of seeing a non mental health provider were much higher when depression was moderate [Odds Ratio (OR): 2.6 (1.3–5.3)] or severe [OR: 3.2 (1.2–8.7)], compared to those lacking social support. Conversely, odds of mental health service use were 60% lower among those with moderate depression [OR: 0.4 (0.2–1.0)] when social support was adequate as opposed to inadequate	Cross-sectional study design Analysis of data drawn from the 2005–2006 and 2007–2008 waves of the National Health and Nutrition Examination Survey (NHANES), an annual survey of health and nutritional status in the US conducted by the National Centre for Health Statistics (NCHS), Centres for Disease Control and Prevention	By stratifying results by severity of depression, this study first reveals that social support is associated with health service use, almost exclusively among individuals with at least moderate depression
Bjørnestad et al (2017) With a little help from my friends – social predictors of clinical recovery in first-episode psychosis (Norway)	Hypothesized satisfaction with social relationships predicts clinical recovery; secondly, frequency of social interaction predicts clinical recovery; and third, effect of friend relationship satisfaction and frequency will be greater than that of family relationships satisfaction and frequency	N = 178, age 15–65 years; meeting the DSM-IV criteria for a first-episode of schizophrenia, schizophreniform psychosis, schizoaffective psychosis, delusional disorder, brief psychosis, affective disorder with mood incongruent delusions, or psychosis	Main finding was, in line with our hypothesis, that frequency of friendship interaction predicted clinical recovery during a two-year period. This effect was sustained even when we removed the friendship criterion from the recovery measure, indicating that the effect was not simply due to pre-existing friendships. Contrary to our hypothesis, neither social satisfaction variables, nor frequency of social interaction with family members, contributed significantly to the prediction of recovery Findings suggests the possibility of facilitating recovery through helping patients increase frequency of social contacts	Longitudinally comparison design, using different instruments to measure recovery The sample was recruited from the ongoing TIPS-2 study (Early treatment and intervention in psychosis) a Naturalistic follow-along study including a population-based cohort (350.000 individuals) of FEP individuals from January 2002, until August 2013. Univariate and generalized estimating equation analysis	Attrition appears to be random, and the sample can be assumed representative with regard to baseline characteristics
Baiden, Den Dunnen, and Fallon (2017) Examining the independent effect of social support on unmet mental health care needs among Canadians: findings from a population based study (Canada)	Examine the independent effect of social support on unmet mental healthcare needs among adult Canadians after taking into account predisposing, enabling, and need factors of the behavioural model of healthcare service use	N = 3857 20 years and older with some form of perceived mental healthcare need	The study found that close to one in five Canadians (19.6%) had mental healthcare needs, of which 68% had their needs fully met and 32% had unmet needs. Social support was the strongest factor to be associated with unmet needs	Cross-sectional study design Gathers information on factors that influence mental health through a multidisciplinary approach, focusing on social and economic determinants of health. The survey covers individuals aged 15 and above residing in the 10 provinces and uses a multistage cluster sampling design with a random sampling method to select a sample that is representative of the Canadian population	It is likely that the sample is transferable to other contexts. Enhance understanding of the need for developing services towards more social support oriented organization
Finfgled-Connet (2005) Clarification of social support	To clarify the concept of social support	Meta-synthesis strategies	Social support is composed of emotional and instrumental support. It is an advocative interpersonal process characterized by reciprocal exchange of information, it is context specific, and it results in improved mental health. Antecedents of emotional and instrumental support include a perceived need plus a social network and climate that are conducive to the exchange of social support	Review (systematic) Template Verification and Expansion Model. Meta-synthesis strategies. Systematic search/review with rigour in method	All the linguistic analyses and qualitative studies were included in this study. Makes the concept of social support more perceptible
Forrester-Jones et al. (2012) Good friends are hard to find? The social networks of people with mental health illness 12 years after deinstitutionalization (UK)	Assess the social networks of a cohort of people with long-term mental illness living in the community for over a decade	N = 85 39 men and 46 women (mean age: 61 years; range: 38–88). Forty nine (60%) were 65 years or under and 32 (40%) were over 65	Social networks (median 19; range 2–85) were generally larger than those reported in previous studies. Older residents (over 65 years) had closer ties than younger residents. Congregate types of community settings were relatively devoid of social support. Participants living in hostels/small group homes reported higher levels of social support than those currently in hospitals	Mixed-methods design (?) Participants were interviewed using the Social Network Guide. Comparisons were made using generalized linear modelling. Data were analysed in terms of the frequencies of social support and interactional behaviours	Data were analysed in terms of the frequencies of social support and interactional behaviours. Comparisons between participants in the two age groups and those living in different types of accommodation were made using generalized linear modelling for multi-nominal responses (McCullagh & Nelder, 1989)
Kogstad, Mönness, and Sörensen (2013) Social networks for mental health clients: resources and solution (Norway)	Explore to what degree social networks provide relief, recovery and healing, and how the networks interact with professional help	N = 850 Service users with a variety of mental health difficulties Approximately 1/3 of the respondents were men and 2/3 women. Age between 20 and 80	There is a positive statistical correlation between network and wellbeing. The network component is the dominant factor, but another significant factor is “income situation”, discriminating between those engaged in some kind of work/study or not. Social networks emerge as the most important help system	Survey design Quantitative analyses of a sample of 850 informants The questionnaire contained 16 questions,3 dealing with gender, age, living area, job/social security, family and living situation, experiences from different help services, and opportunity to talk through bad experiences	Enables understanding of the association between social network and mental health recovery
Munikanan et al. (2017) Association of social support and quality of life among people with schizophrenia receiving community psychiatric services: A cross sectional study (Malaysia)	Assessing the association between social support and QOL	N = 160 aged 18 years and above diagnosed as having schizophrenia predominantly Malay, aged less than 40	The majority of the respondents (71.9%, N = 115) had poor perceived social support, followed by a lower proportion (44%, N = 27.5) with moderate scores and only one person had a high score (0.6%, N = 1) There was significant positive correlation between the different types of social support (total, family, friends and significant others) and QOL (total). The higher the social support levels in all types of social support perceived by respondents, the higher the quality of life they experienced	A cross-sectional study design. Conducted on 160 individuals with schizophrenia receiving community psychiatric services in Hospital Kuala Lumpur (HKL). The WHOQOL-BREF, Brief Psychiatric Rating Scale (BPRS) and Multidimensional Scale of Perceived Social Support (MSPSS) were used to assess QOL, severity of symptoms and social support, respectively	Conducted over a 3-month period in 2015 with data mostly collected at patients’ homes and outpatient psychiatric clinic, whenever patients came for follow up visits The Malay version of MSPSS (validated) demonstrated good psychometric properties in measuring social support Relevant for target group in other settings
Puyat (2013) Is the influence of social support in mental health the same for immigrants and non-immigrants? (Canada)	Examine association between social support and mental health across immigrant groups	N = 42,556 individuals between the ages of 12 and 85 who completed the social support survey module	In comparison with individuals who had moderate levels of social support, individuals with low social support had higher odds of reporting mental disorders and this association appeared strongest among recent immigrants. Using the same comparison group, individuals with high social support had lower odds of reporting mental disorders and this association appeared stronger among longterm immigrants.	Retrospective cross sectional study design. Descriptive statistics for each variable were first calculated. v2 tests were then performed to determine if mental health differed by social support levels, immigration status, age, sex, marital status, education, self-rated health and perceived stress	Applicable to understand mental health in broader contextual way, and the importance of extra social support efforts for recent immigrants. All statistical outputs were weighted to obtain population-based point-estimates of the association between social support and mental health
Smolak et al. (2013) Social support and religion: Mental health service use and treatment of schizophrenia (US)	Examine: (1) the religious perceptions of families, professionals, and the public towards schizophrenia; (2) religious perceptions of the aetiology of schizophrenia; (3) how others perceive religion as a coping mechanism; and (4) how religion influences treatment engagement and help-seeking behaviours	N = 43 Family members and caregivers	Religious beliefs influence the treatment of schizophrenia in the following ways: Religious themes were positively associated with coping, treatment engagement and help-seeking behaviour. Evidence of religious underpinnings was found in perceptions of aetiology. The findings also indicate that there is often both a preference among family members and caregivers to utilize religious based professionals and caution towards mental health professionals	Review (systematic) Forty-three studies were included in this review. One (2%) study was published in the 1980s, 10 (23%) studies were published in the 1990s, and 32 (74%) were published between 2000 and 2010. Twelve (28%) of the studies described studies conducted in the United States, and 18 (42%) were from other countries. The studies investigated the perspectives of family members, professionals, and/or the larger public	Limitations in this investigation include the reliance on published, peer-reviewed English language journals, which consequently limits its analysis to these studies. Also, the methodological calibre and quality of the existing literature, such as the absence of longitudinal studies or randomized controlled trials, is a limitation
Sun et al. (2019) The Influence of Social Support and Care Burden on Depression among Caregivers of Patients with SMI (CN)	Examine the influence of social support and care burden on depression among caregivers of SMI patients	N = 256	Results strongly demonstrates that social support and care burden were predictors of depression, especially social support. Shows that social income and status plays an important role when it comes to the ability to create strong social networks and prevent depression among caregivers	Structural equation modelling (SEM) to test hypothesized relationships among variables	Especially relevant for understanding the burden of caregiving and specific types of social support – relates to social context and recommends improving social network. Opens up the multi-factor complexity of social support
Stockdale et al. (2007) The importance of social context: neighbourhood stressors, stress-buffering mechanisms, and alcohol, drug and mental helath disorders (US)	Examine the relationship among neighbourhood stressors, stress-buffering mechanisms, and likelihood of alcohol, drug, and mental health (ADM)	Adults from 60 US communities (n = 12,716)	Cross-level interactions revealed that violence-exposed individuals in high crime neighbourhoods are vulnerable to depressive/anxiety disorders. Likewise, individuals with low social support in neighbourhoods with high social isolation (i.e., low-average household occupancy) had a higher likelihood of disorders	Conceptual framework design Test a conceptual model that explores effects of neighbourhood stressors and stress-buffering mechanisms on ADM disorders	Wherever possible study use data for the smallest geographic entity to more accurately represent neighbourhood characteristics. Important knowledge considering social environment factors that effects social support
Townley, Miller, and Kloos (2013) A Little Goes a Long Way: The Impact of Distal Social Support on Community Integration and Recovery of Individuals with Psychiatric Disabilities (US)	Document and describe distal supports for individuals with psychiatric disabilities. Focus primarily on the type of social support provided	N = 300 adults using outpatient mental health services and living in independent housing in Columbia, the largest city in South Carolina. 66% female; 64% self-identified as Black, 28% as White, 3% as Latino, 2% as Alaskan Native/Native American, 2% as Asian, and 1% other	Found that distal supports predicted both recovery and community integration after accounting for the influence of traditional social support networks. Traditional social support had larger standardized beta weights and accounted for the most variance in both community integration and recovery; however, distal support still explained a significant amount of unique variance. having traditional social support is perhaps more influential in the community integration and recovery process, the establishment of casual ties with community members plays a unique role in supporting individuals to engage in community life and lead satisfying, productive, and healthy lives	Cross-sectional study design Data collected from a sample of 300 adults using outpatient mental health services and living in independent housing in Columbia, the largest city in South Carolina. Distal supports were assessed using a modified version of the Distal Support Measure. Mixed-methods data preparation and analysis	Relevant to understand different types of social support – transferable to other contexts
Wesselmann et al. (2015) Religious believes about mental illness influence social support preferences (US)	Hypothesized that individuals’ endorsement of the spiritually-oriented causes/treatments belief factor will predict a positive relation with willingness to provide spiritually oriented social support	N = 262 University students in an undergraduate psychology course	Found evidence that individuals’ religious beliefs influence the types of social support they would be willing to give a hypothetical friend who had a mental illness. Christians’ beliefs that mental illness results from immorality/sinfulness and that mental illnesses have spiritual causes/treatments both predicted preference for giving spiritual social support to a hypothetical friend with depression. Evangelical Christians endorsed more beliefs that mental illness has spiritual causes/treatments than Protestant and Roman Catholic Christians, and they endorsed more preference for giving spiritual social support than Roman Catholic Christians. These data, to our knowledge, are the first examining preferences for the types of social support religious individuals are willing to give someone with a mental illness	Survey design Used established measure of religious beliefs about mental illness (Wesselmann & Graziano, 2010) Participants entered the lab individually or in groups and completed the measures at individual workstations. Participants indicated their religious affiliation and then answered subsequent measures. Measures were embedded in various pilot-testing materials.1 These data were collected across two semesters	The factor structure of social support measure did not support the anticipated conceptual structure found in previous social support literature Rather than finding spiritual and secular equivalents of the four types of social support (i.e., appraisal, emotional, informational, and instrumental support) instead found three factors: spiritual, secular counselling and secular instrumental support
SECTION b) features of social support N = 16
de Jong et al. (2016) Enabling social support and resilience: outcomes of a family group conferencing in public mental health care (Netherlands)	Explore effects of Family Group Conf. #1 Has the (quality of) social support for the main actor(s) been increased? 2. Has the main actor(s’)’s resilience been increased? #3 Did the conference have an influence on the improvement of the living conditions of PMHC clients, client systems and neighbourhoods wherein PMHC clients are living? #4 Has the demand for professional care been decreased?	N = 312 Everyone who attended the conference or could reflect on its outcomes	Family Group Conferencing (FGC) is a decision-making model where clients with their social network formulate their own plan. In the analysed cases, the resilience of clients, client systems and neighbourhoods as perceived by several respondent groups increased after the conferences, though not with spectacular amounts. The perceived living conditions of the main actors also improved, the same applies for the quality and quantity of social support	Naturalistic case study-design In 33 cases, it was possible to obtain scores from 245 respondents on scales ranging from 0 to 10 about the situation prior and after the conference on three outcome measures, namely the quality of: (1) social support, (2) resilience and (3) living conditions	Adresses the importance of network gatherings and that it might increase potential considering quality of social support
Gidugu et al. (2015) Individual peer support: A qualitative study of mechanisms of its effectiveness (US)	Clarifying ambiguities in the role of the peer support specialist, to further elucidate the nature and processes of individual peer support, and to clarify what makes peer support effective from the point of view of the recipient	N = 19 To be eligible for the study individuals had to: (a) be an adult with a psychiatric condition, (b) be served by the local behavioural healthcare organization, (c) have received a minimum of 10 sessions of individual peer support	This qualitative study suggests that peer support relationships have hallmarks of traditional helping relationships. Practical supports, role modelling and mentoring, and social opportunities alongside getting emotional support through a normalizing relationship with someone with similar experiences stand out as possibly the most critical and effective aspects of the peer support specialist’s roles	In debth interviews/explorative design Grounded theory/constructivist approach	Relevant experience and sample that can transfer to the target group and services
Horghagen, Fostvedt, and Alsaker (2014) Craft activities in groups at meeting places: supporting mental health users everyday occupations (Norway)	Explore how the participants’ engagements in craft activities in a group supported their way of managing everyday occupations	N = 12 participants had long-lasting mental health illness, were receivers of disability benefits, and participated in the craft group almost daily	Procedures for paradigmatic analysis were followed, and brought forward three themes: doing crafts in a group facilitated stability and routines, skills and abilities, and peer support. The discussion reflected knowledge and experiences of crafts as an activity with a low-risk threshold for participation and its healing value	Focused Ethnography was chosen as a design, to meet the study’s exploratory aim	Allows perspectives from persons with long term mental health problems and direct strategies that can enable social support
Karlsson et al. (2017) Aspects of collaboration and relationships between peer support workers and service users in mental health and substance abuse services – A qualitative study (Norway)	How do service users experience collaboration with peer support workers? What do service users describe as useful and supportive in relationship with peer support workers?	N = 26 17 women and 9 men with a variety of mental health and/or substance abuse challenges	The study describes that service users in this context over all seem to have positive experiences in the collaboration with peer support workers. Collaboration is described as unique, loving and that it can be easier to develop trust than with professional mental health workers. The study also points out that peer support workers can facilitate positive change in mental health services	Five focus group interviews/in depth design Descriptive and explorative design, based in a phenomenological hermeneutical approach	Study not generalizable, but enables important perspectives on social support oriented service and aspects important to develop services
Kloos and Shah (2009) A social ecological to investigating relationships between housing and adaptive functioning for persons with serious mental illness (UK)	Investigate impact of social ecology theory can develop treatment	Account of how social ecology theory transformed a research programme, from examining individual risk factors to investigating the functioning of persons in the contexts of their housing and neighbourhood experiences	Paper reports on how social ecology theory transformed a research programme, focused on risk factors associated with housing into a more comprehensive understanding- the contexts of housing and neighbourhoods can address housing problems and can promote health and recovery from mental illness	Conceptual framework design	Uses relevant research/evidence to build up the investigation and study. Can inspire development in services in different contexts with focus on ecology
Langeland and Wahl (2009) The impact of social support on mental health service users’ sense of coherence: A longitudinal panel survey (Norway)	Investigate the ability of the six social provisions in Weiss’s theory of social support to predict the positive development of sense of coherence among people with mental health problems	N = 107 18–80 years of age, living at home with a variety of mental health challenges	Results indicate that improving social support with special emphasis on opportunity for nurturance might provide important opportunities for increasing sense of coherence among people with mental health problems	Longitudinal survey design	Performed a multiple regression analysis, with change in SOC from baseline to follow-up as dependent variable, and social support and mental symptoms at baseline as independent variables Gives important knowledge to integrate quality in the work with social support
Lamont et al. (2017) Qualitative investigation of the role of collaborative football and walking football groups in mental health recovery (UK)	Aimed to explore the experiences of players in four collaborative football and mental health projects related to; i) the perceived benefits of participation from an individual and community perspective; ii) the key elements underlying success or otherwise of the project as defined by participants, and iii) the role played by football in both the delivery	N = 25 Service users described their mental health diagnoses as: paranoid schizophrenia (n ¼ 2), bipolar disorder (n ¼ 3), depression (n ¼ 2), borderline personality disorder (n ¼ 2); n ¼ 9 did not disclose 21 and 64 years old (86%) of whom were male	Identifies that collaborative football groups can act as a conduit for recovery. Similarly, they can be an important aspect of mental health care and identifies a number of benefits in Common with previous investigations, including promotion of a reconnection with personal history, and improved wellbeing, mutual support, social opportunity, and friendship.	Focus group/in depth interview design Four FGs (60–90 minutes) as a method of gathering data about the experiences of mental health service users and practitioners in collaborative football groups The epistemological underpinning of the study was essentialist/realist as described by Braun and Clarke (2006)	Important perspectives from service users and their view on mental health recovery Supports other research on common topic
Ljungqvist et al. (2016) Money and mental illness: A study of the relationship between poverty and serious psychological problems (SWE)	Can the addition of modest financial support for social and recreational activities have an impact on social intercourse, sense of self, symptoms, and functional level among persons with SMI?	N = 150 The age of the study participants ranged between 18 and 65. The participants were diagnosed as having a SMI by psychiatrists	The concordant results from the study of Davidson et al. and this study indicate that a social initiative in the form of modest financial improvement may lead to a better situation for persons with SMI. Reducing relative poverty seems to enable these persons to regain access to and actually make use of different public and private arenas for social exchange	Intervention study design N = 100 who were in touch with both psychiatric care and with social services directed to persons with severe psychiatric problems. For 9 months they were offered, in addition to treatment and financial support as usual, an extra allowance of 500 SEK (73 USD, 53 Euro) per month. The money presented as a contribution towards social/leisure activities at the free disposal of the participant (Comparison group N = 50)	Based on the American model of Davidson et al. developed in the early 1990s. The design was adapted to Swedish conditions – gives important insight in money support as indirect strategy for boosting social support
Muir et al. (2010) I didn’t like just sitting around all day: facilitating social and community participation among people with mental illness (Australia)	Assesses whether and how supported housing models can assist people with high levels of psychiatric disability to participate meaningfully in the community	N = 92 Service Users of supported housing Australia	Understanding whether and how individualized housing support programmes improve community participation is important to address social exclusion, loneliness, stigma and discrimination, and poor economic participation among people with high levels of psychiatric disability. The HASI Stage One evaluation found that the NGOs’ role in facilitating social and community participation could be instrumental to increasing meaningful activity among programme clients. This support was possible because of permanent social housing and active mental health case management	Longitudinal evaluation design of a supported housing model in Australia: the Housing and Accommodation Support Initiative Stage One (HASI)	Enables knowledge that can be transferable to other services
McKeown, Roy, and Spandler (2015) You’ll never walk alone: supportive social relations in a football and mental health project (UK)	Evaluation of a football and mental health project to explore participants’ experiences of supportive group social relations	N = 46 Mental health service users, majority of individuals accessing IAG were working class, white men, often unemployed and experiencing such difficulties as anxiety, depression, anger, low self-esteem, or difficulties related to drug and alcohol use	Taken together, the relative success of peer-support workers in general psychiatric services, evidence from other specialist areas (such as drug rehabilitation), appreciative service-user narratives, and the findings of this study suggest that more could be made of peer-to-peer support across mental health care. In more transformative terms, the mix of mutual support demonstrated in the IAG initiative is supportive of growing interest in the value of more relational and collectivized models of care, such as therapeutic communities, Open dialogue as alternatives to established models of care	Focus group/in depth interview design Mixed-method evaluation of IAG located in seven professional football clubs in the north–west of England Facilitated six focus groups with players who had completed the programme (40 participants in total) and one with the coaches (6 participants)	Broad perspectives from service users. Experiences gives insight in alternative mental health practices that can be important in recovery
Owczarzak et al. (2013) What is “Support” in supportive housing: client and service providers perspectives (US)	Explore how clients of supportive housing programmes conceptualize support	N = 33 Residents with a variety of mental health problems	Narratives of individualism, independence, and a “do it yourself” ethic pervaded residents’ descriptions of strategies to access welfare benefits and supportive services. These themes were embedded in concerns about coercion, choice, and privacy. Residents discussed these issues in the context of their histories of substance abuse, mental health diagnoses, HIV status, and other personal factors	In-depth orientation/design Semi-structured interviews with 23 residents and 10 service providers from nine different supportive housing programmes in Hartford, Connecticut Data analysis explored residents’ perceptions of and experiences with supportive housing programmes in the context of strategies to access resources and receive emotional, financial, and other forms of support	Perspectives that are transferable to other contexts and points out knowledge that facilitate and hinders social life
Prince et al. (2018) Nine ways that clubhouses foster interpersonal for persons with severe mental illness (US)	#1: What is it about clubhouses that promote closeness? #2: In relation to other types of mental health programmes, what lessons can be learned?	N = 20 People experiencing mental health problems, using Fountain house, New York	Nine clubhouse features that are most central in promoting interpersonal closeness. Other types of mental health programmes can integrate many of the nine features in order to combat the social isolation that can lead to relapse or other adverse consequences	Focus group study in three focus groups applying grounded theory method of analysis Internal validity (Credibility) inherent in focus group process	The clubhouse and the participants are typical of clubhouses for people with mental illness and their users
Smidl, Mitchell, and Creighton (2017) Outcomes of a therapeutic gardening programme in a mental health recovery centre (US)	#1 Do participants in a gardening programme practice personal and social responsibility? #2 How does a gardening programme promote emotional well-being? Physical well-being? Socialization and peer support?	N = 20 younger adults ages 26–49, and the remaining half were 50–72-years-old. Eleven persons were diagnosed with mood disorders, and nine with schizophrenia or schizoaffective disorder	The results of this programme evaluation support the conclusion that building and caring for a garden facilitates mental health recovery, and connects people. As found in previous research, participation varied depending upon the nature of the tasks and the unique needs and preferences of each person	Mixed method-design The project was organized in four phases throughout the course of 1 year. These phases were planning, construction of raised-bed gardens, maintenance of the gardens, and harvest. The United Way’s Outcome Logic Model was used to structure the programme evaluation (United Way of Greater Richmond & Petersburg, 2015)	Example of direct strategy of social support oriented service approach – inspiration for other services
Webber et al. (2015) Enhancing social networks: a qualitative study of health and social care practice in UK mental health services (UK)	Aimed to understand how practitioners help people recovering from psychosis to develop their social networks	(N = 124) N = 51: Sample of people recovering from an episode of psychosis who were in their first or second engagement with mental health services to participate in the study. Participants were largely between 16 and 35 years of age	Findings suggest that shifting the focus of clinicians away from deficits in the social functioning of people with psychosis (e.g. Brugha et al. 1993) to identifying assets and shared interests among them (Rapp & Goscha 2011) encourages social engagement. This study supports Perry’s (2012) findings that changes in social environments impact the social networks of people with severe mental health problems	In-depth orientation/design Qualitative study of practice in six health and social care agencies in England using combinative ethnographic methods (Baszanger & Dodier 1997). Comparative method in grounded theory (Glaser & Strauss 1967)	Cannot be generalized to the whole population of people recovering from an episode of psychosis, but creates solid base of knowledge considering focusing on social predictors in recovery
Webber (2017) A review of social participation interventions for people with mental health problems (UK)	To explore and summarize social participation models	N = 19	Nineteen interventions from 14 countries were identified, six of which were evaluated using a randomized controlled trial. They were grouped together as: individual social skills training; group skills training; supported community engagement; group-based community activities; employment interventions; and peer support interventions. Social network gains appear strongest for supported community engagement interventions, but overall, evidence was limited	Review (systematic) A systematic search of electronic databases was conducted, and social participation interventions were grouped into six categories using a modified narrative synthesis approach	Enables different features of social support oriented interventions that can inspire mental health services
Whitley et al. (2008) The active ingredient of intentional recovery communities: focus group evaluation (US)	Explore and elucidate whether components of these communities appeared to assist recovery from the point of view of consumers, and if so which were the most important factors	N = 38 Participants were openly recruited from within the recovery communities Washington DC	Almost all participants lauded the recovery communities as a significant contributor to positive change in various psychosocial domains. Three aspects of the recovery community appeared to be important in this regard. Though there is significant overlap between these themes, they are differentiated in the results for ease of comprehension. The themes are (i) the community as a place of safety, (ii) the community as a surrogate family, and (iii) the community as socialization and individual growth	Focus group/in depth interview design Four focus groups were held in total (one for each recovery community). Data were analysed according to the grounded theory approach outlined by Glaser and Strauss (1967)	Small-scale qualitative evaluation in a single setting. Important perspectives other services/communities can learn from Not generalizable

The articles we reviewed in our scope have various research designs, research contexts, and population samples. Of the entire selection of 29 studies, nine have a qualitative orientation, 13 have a quantitative orientation, and three are literature reviews (one explores social support and religion, the second seeks to clarify which form of social support actually uses meta-synthesis strategies, and the third maps social participation interventions in mental health work). Two papers are conceptual framework studies. One has a mixed-method evaluation design, and one a naturalistic case study design. Most studies were carried out in western countries except two (Malaysia and China). Details are presented in Table 1.

The understanding, integration, and concept of social support employed in each of the reviewed papers are varied. Twenty papers use the term social support as a keyword, while the other papers have different terms as keywords that are related to social support such as social interaction, social networks, social predictors, supported housing, peer support, and so on. Some papers clarify and define social support, while others do not. The most common way to conceptualize social support is by connecting it to the categories that are referred to in the introduction; social support is an advocative interpersonal process characterized by at least one party gaining social benefits (Finfgeld‐Connett 2005).

The mental health characteristics of the participants studied in this review were segregated into three main groups: (a) severe/long-term mental health problems, (b) milder/moderate mental health problems, and (c) context-specific mental health problems (for example among recent immigrants, caregivers etc.), with the dominant focus on severe long-term mental health problems.

Associations between mental health and social support

In this section, we identify two different sub-themes as the major points: (a) social support associated with mental health status (or well-being), and (b) social support in relation to the experiences of people with severe mental health problems. Both themes, although somewhat related, are different ways in which social support has an impact on mental health. The first refers to the idea that people with low social support (in terms of social network, social participation, social capital, and feelings associated with the lack of social support such as loneliness) may be more likely to experience mental health problems as social support acts as a protective element in people’s lives. The second refers to the idea that people with mental health problems can go through different paths of recovery or ‘getting well’ because they each have different levels of social resources (social support) available to them to give them the boost and support they need.

Social support, mental health status, and social support preferences

People with adequate social support are less likely to use mental health services but are more likely to get support to search for help whenever they need it, as opposed to those who have inadequate social support altogether (Andrea, Siegel, and Teo 2016). Social support is associated with mental health status, as low social support is found to be associated with the risk of developing mental health and/or addiction problems or the worsening of an already existing mental health problem (Baiden, Den Dunnen, and Fallon 2017; Stockdale et al. 2007). The association between mental health and social support was also evident in high-risk population groups such as among immigrants in Canada (Puyat 2013), or people living in socially isolated neighbourhoods (Stockdale et al. 2007). Being immigrants may be a risk factor for developing mental health problems with the added effect of low social support, which may be more prevalent among recent immigrants found in studies in Canada (Puyat 2013). This is transferable to other countries depending on the social context, culture, welfare system, and environment. The combined effect of being a recent immigrant and having low social support seems to be associated with a greater risk of developing mental health disorders (Puyat 2013). In comparison with individuals who have moderate levels of social support, individuals with low social support have greater odds of experiencing mental health disorders and this association appeared the strongest among recent immigrants.

Further, Baiden, Den Dunnen, and Fallon (2017) found that close to one in five Canadians (19.6%) had mental healthcare needs, of which 68% had their needs fully met and 32% had unmet needs. Social support was the strongest factor associated with unmet needs.

Bjornestad et al. (2017) explored the effect of friendship after the first episode of psychosis in a Norwegian context. A baseline sample of 178 individuals experiencing the first episode of psychosis were followed up for over 2 years regarding their social functioning and clinical status. The researchers longitudinally followed up on those who had recovered to those who had not. The results showed that the frequency of social interactions with friends was a significant positive predictor of clinical recovery over a period of 2 years. The study concluded that interactions with friends is a malleable factor that can be targeted for early intervention, and seems to have an overall stronger impact on recovery and functional social support effects than interactions with family.

The role of religion and spirituality seems to have received less scientific scrutiny. Smolak et al. (2013) conducted a review that focused on 43 original research studies by studying people with schizophrenia and investigating the role of religion in their recovery. Of these, 12 studies were conducted in the US, 18 were conducted in other countries. Religion seems to have indirect effects by influencing people with mental health problems to seek religious or spiritual help as a form of social support (Smolak et al. 2013). On the other hand, people’s religious beliefs seem to influence the type of social support that they may be most willing to offer to people with mental health problems such as schizophrenia (Smolak et al. 2013; Wesselmann et al. 2015).

Social support in relation to the experiences of people with severe mental health problems

Social support affects the experiences of people with mental health problems in various ways. At the baseline, the strength and quality of the social support, the social network, and social relationships tend to be lower for people with mental health problems. People with severe mental health problems tend to have fewer social relationships than others, and are more likely to experience social exclusion (Baiden, Den Dunnen, and Fallon 2017; Forrester-Jones et al. 2012). Furthermore, the social network seems to be the most important support system that impacts the general well-being of people with mental health problems (Kogstad, Mönness, and Sörensen 2013). The type of social support that people with long-term mental health problems sought varied according to the types of accommodation, thus suggesting that where people live can also affect their accessibility of the social support they need (Forrester-Jones et al. 2012). There is a positive statistical correlation between one’s social network and well-being. While the social network component is a dominant factor, another significant factor is the ‘income situation,’ that leads to discrimination between those who are engaged in some kind of work or study and those that are not, and social networks emerge as the most important support system related to recovery (Kogstad, Mönness, and Sörensen 2013). Caregivers ability to give social support is an important aspect when exploring social support.

A study from China found that caregivers of people with severe depression had an increased risk of developing depression. The caregivers with higher levels of social capital had lower risk of developing depression, and this study suggest increased focus on building social network for caregivers and patients (Sun et al. 2019).

Both traditional social support and distal support such as establishing casual ties with community members were found to be associated with the recovery process (Townley, Miller, and Kloos 2013). It appears that distal support can predict both recovery and community integration after accounting for the influence of traditional social support networks (Townley, Miller, and Kloos 2013). Traditional social support had larger standardized beta weights and accounted for the greatest variance in both community integration and recovery. However, distal support still explained a significant amount of unique variance. Having enough traditional social support is perhaps more influential in the community integration and recovery process (Townley, Miller, and Kloos 2013).

As mentioned, social support in the form of interactions with friends has a solid positive impact on the recovery of people with psychosis, as was seen when they were examined longitudinally (Bjornestad et al. 2017), and increased social support was positively associated with the quality of life in people with schizophrenia (Munikanan et al. 2017). The respondents in the study conducted by Munikanan et al. (2017), who had all experienced schizophrenia, reported that at higher levels of quality of life, they had all different types of social support available (Munikanan et al. 2017).

There are important relationships among the different types of accommodation in which people experiencing severe/long-term mental health problems live, their ages, their social networks, and the types of social support that they give and receive (Forrester-Jones et al. 2012). It is important to embrace this knowledge and to create services in ways that can facilitate social support, friendship, and enhance the quality of life for those experiencing severe mental health problems. This builds a bridge to the next theme.

Features of social support-based community mental health services

For this section, we extracted two sub-themes, namely (a) social support as the direct strategy within community mental health services (peer support, recovery communities, and clubhouse developments) and (b) social support through indirect strategies such as housing support, income support, etc., which end up enhancing social support (assessing the indirect routes that boost social support). There is a difference in needs among different individuals and groups, and it is important to address this difference. Some experience severe mental health problems, while some face milder or moderate mental health problems. Despite different types of circumstances and mental health problems, combating loneliness and excessive individualization of mental health problems stand out as crucial dimensions – thereby offering an alternative or crucial supplement to ‘traditional’ psychiatric treatment. The effect of social support, while also acknowledging that people experience a variety of mental health problems, seems to be much the same: it enhances recovery and the quality of life, and it is not diagnosis specific.

Social support as direct strategies

There is strong evidence to conclude that people who have long-term mental health problems have lesser social capital and social resources that can boost their social support (Webber and Fendt-Newlin 2017; Webber et al. 2015). This is an important reason for incorporating social support-oriented strategies in mental health work. A review (Webber and Fendt-Newlin 2017) exploring social participation interventions drew upon 19 interventions from 14 countries, 6 of which were evaluated using a randomized controlled trial. The categories of social support were grouped into individual social skills training; group skills training; supported community engagement; group-based community activities; employment interventions; and peer-support interventions. Social network gains appeared the strongest among the supported community engagement interventions, and social interventions seemed to have had a great impact on recovery (Webber and Fendt-Newlin 2017).

Clubhouse features are central to promoting interpersonal closeness in mental health work. Other types of mental health programmes can integrate many of the nine features that were listed by Prince et al. (2018), in order to combat the social isolation that can lead to a relapse or other adverse consequences. Clubhouses promote closeness through (1) work, (2) repeated interactions among members, (3) a non-judgemental environment, (4) evening and weekend activities, (5) social skills enhancement, (6) power equalization among staff and members, (7) sharing of similar experiences, (8) flexibly structured activities, (9) and staff outreach after absence. All these features can be described as closeness factors.

Results from a longitudinal survey conducted in Norway indicated that improving social support – with a special emphasis on providing opportunities for nurturance – might provide important opportunities for increasing the sense of coherence among people with a variety of mental health problems (Langeland and Wahl 2009). To be helpful to others may be important for our self-esteem, sense of purpose, and well-being. The study suggests that mental health professionals should encourage service users to use their abilities to be providers of nurturance in their relationships and their social environment. Mutuality seems like a key factor in boosting the quality of the social support experienced, and the services can facilitate the quality and development of social support.

Almost all participants in a study conducted in the US lauded recovery communities as a significant contributor to positive change in various psychosocial domains (Whitley et al. 2008). Another study from the US explored caring for a garden, and found that gardening programmes were capable of facilitating recovery from mental health problems and the development of interpersonal relationships (Smidl, Mitchell, and Creighton 2017). The results suggest that building and caring for a garden facilitates recovery from mental health problems and can create a recovery community. As indicated in other studies (Prince et al. 2018; Webber and Fendt-Newlin 2017) listing social support-oriented features, this study also suggested that the connections among people that such activities create have an important impact on the recovery process. Craft activities can also be a direct strategy to connect people and to enhance recovery. Craft as an activity can facilitate stability and routines, skills and ability, and peer support (Horghagen, Fostvedt, and Alsaker 2014)

Peer support has an important impact on building strong relationships and facilitating recovery from mental health problems (Gidugu et al. 2015; B. Karlsson et al. 2017). Practical support, role modelling, mentoring, and providing social opportunities alongside emotional support by normalizing relationships with others with similar experiences stand out as the most critical and effective aspects of a peer-support specialist’s roles (Gidugu et al. 2015).

Supportive and social relations were created and shaped in a football and mental health project in England (McKeown, Roy, and Spandler 2015). Mental health service users with a variety of mental health problems (the majority of whom were working class men) experienced being connected with others and having a meaningful individual and collective agenda. In more transformative terms, the mix of mutual support demonstrated in the initiative and project is of growing interest in the value of more relational and collectivized models of care (McKeown, Roy, and Spandler 2015). It seems like collaborative football groups can act as a conduit for recovery from mental health disorders (Lamont et al. 2017).

A study from the Netherlands (de Jong et al. 2016) explored the effects of family group conferencing in public mental health contexts and found that the resilience of clients, client systems, and neighbourhoods as perceived by several respondent groups increased after the conferences. The perceived living conditions of the main participants also improved and the same applied for the quality and quantity of social support (de Jong et al. 2016).

Social support through indirect effect within strategies

Reducing relative poverty seems to enable people that struggle with mental health problems to regain access to and actually make use of different public and private arenas for social exchange (Ljungqvist et al. 2016). Help with money matters (e.g. direct money transfers) can boost social participation, social support and recovery, according to this study.

Understanding whether and how individualized housing support programmes improve community participation is important in addressing social exclusion, loneliness, stigma, and discrimination, and poor economic participation among people experiencing long-term mental health problems. The HASI Stage One evaluation (Australia) found that the role of support programmes in facilitating social and community participation can be instrumental in increasing meaningful activities among clients. This support was possible because of permanent social housing and active mental health case management (Muir et al. 2010). A study from the UK suggested that embracing a more comprehensive understanding of the contexts of housing and neighbourhoods can address housing problems and promote recovery from mental health problems (Kloos and Shah 2009). Supportive housing programmes can also be described as a broader strategy to enable access to services and support, and to maintain housing (Owczarzak et al. 2013).

Shifting the focus of clinicians away from deficits in the social functioning of people with psychosis to identifying assets and shared interests among them is important. This encourages social engagement and improves recovery (Webber et al. 2015). One can call this both a direct (workers connecting people) and indirect (workers evolving consciousness on the effects or opportunities) strategy to boost social support. Webber et al. (2015) collected data from a range of social network enhancement activities in six diverse contexts in England. The exposure of a service-user to new ideas appeared to be a key element in the process of identifying opportunities for connecting people and improving social networks.

These findings ensure that there are both direct and indirect routes to boost social support, and that mental health practice should focus more on both ways and means to offer better treatment.

Discussion

In our discussion, we focus mainly on social support examined at different levels, and the need for the incorporation of a larger amount of social approaches and social work in mental health practice. We also attempt to highlight some of the barriers on the path of incorporating social support and social work in mental health services, based on the review of literature and additional knowledge gathered. We point out gaps in research and identify areas for further research.

How do we understand and examine social support?

This scope started out with an understanding of social support as a crucial element in recovery from mental health problems. As findings from section (a) demonstrate, we can find a variety of associations between mental health, recovery, and social support. The association between friendship and recovery from mental health problems, and beliefs/religion and understanding of mental health problems are especially strong. It is also found that social support is one of the most important aspects when a service-user reports having unmet needs. Overall, this section invites us to better understand that mental health work can evolve by focusing on relational and contextual approaches, something that gets more and more attention in evolving mental health services and communities (Giacco et al. 2017), but still seems difficult to integrate. It also enforces the understanding of social support as crucial for recovery from mental health problems and in building recovery capital.

As we can see from the findings in section (b), there are many good examples of local practices that help building supportive environments for people experiencing mental health problems. It can be initiatives in the form of clubhouses, recovery communities, football groups, peer-support initiatives, gardening programmes, etc. It seems like there is significant potential to integrate social support in mental health services in a more determined manner (McKeown, Roy, and Spandler 2015). Key aspects of social support-oriented services are related to both direct and indirect strategies of social support. Help with housing and economy are examples of indirect strategies that can boost social support. On the other hand, facilitating interpersonal relationships through activities is a key direct strategy in boosting social support. Creating arenas to build friendships, social capital and to facilitate social integration are crucial to the enhancement of the potential of mental health work and social support (Topor et al. 2011). These strategies create an opportunity for both emotional and practical social support, as well as direct and indirect social support. To enhance recovery capital at different levels, we know that psychosocial factors that facilitate social support and reintegration into society are crucial for vulnerable groups that struggle with severe mental health problems and/or substance-related disorders (Johannessen, Nordfjærn, and Geirdal 2019).

With this in mind, social support is often understood and conceptualized as an advocative interpersonal process characterized by at least one party gaining social benefits (Finfgeld‐Connett 2005). However, as the literature also demonstrates, it is equally important to enhance the quality of support as well as to enable the possibility to both receive and to give (Langeland and Wahl 2009).

Furthermore, we suggest that there are four levels in which social support should be examined in relation to mental health.

What reduces and what facilitates community integration?

First, what aspects or characteristics in social support are more significantly associated with mental health concerns? The lack of social support, context-specific mental health concerns, and severe mental health problems are connected, and this seems to reduce community integration and intensify both symptoms and suffering (Baiden, Den Dunnen, and Fallon 2017; Puyat 2013). These are challenges that are often much the same in the fields of addiction and substance abuse (Andvig, Bjørlykhaug, and Hummelvoll 2019). The quality of social support has a great impact on mental health concerns and problems. It appears that how to work more with facilitating mutual social support is a key factor (Langeland and Wahl 2009).

Second, the association between social support and mental health as co-existing phenomena deserves emphasis. We have a large body of knowledge that traces back to the association between the two, and it is a paradox that services do not work more in depth with peoples social life (Andvig, Bjørlykhaug, and Hummelvoll 2019). It is important to examine the obstacles in the path of doing so, with great detail, to work more effectively with reducing social health inequalities.

Third, the association between social support and people’s experiences of recovery capital and mental health care deserves to be examined. It appears that both the types of social support and relationships have a great impact on recovery. What kind of relationships and types of support are most important? We know that friendship has great potential in facilitating recovery from mental health problems (Bjornestad et al. 2017), but distal support also plays an important role (Townley, Miller, and Kloos 2013). How does one facilitate friendship and enforce distal ties in times of a mental health crisis? This should be examined in detail.

Fourth, social support-oriented strategies need attention in framing and implementing community mental healthcare services. The examination of services offering features that integrate social support and facilitate potential friendship, and mutual support, are a crucial area to study. It would also be of importance to explore the links between increased income/instrumental support and levels of social support and recovery even further.

Barriers in integrating features of social support in mental health

What are the most crucial barriers and why do we not work more with people’s social life in the field of mental health, when we have all this knowledge? The state of the field is perhaps a key factor in understanding why. The power structures in the field of mental health are important factors that need to be addressed. The UN has addressed the need for a revolution in mental health in the following:

“The promotion and protection of human rights in mental health is reliant upon a redistribution of power in the clinical, research and public policy settings. Decision-making power in mental health is concentrated in the hands of biomedical gatekeepers, in particular biological psychiatry backed by the pharmaceutical industry. That undermines modern principles of holistic care, governance for mental health, innovative and independent interdisciplinary research and the formulation of rights-based priorities in mental health policy.” (UN 2017) P. 6.

Life circumstances and socio-economic conditions have been given very little attention in the literature because the biomedical and individual models still have the greatest influence when it comes to understanding mental health (UN 2017). Mental health service users still experience barriers in seeking help, as well as stigma and discrimination that can often be related to structures and conditions in health care (Staiger et al. 2017). Social determinants of mental health need greater attention both in terms of conceptual understanding and in actual treatment (Allen, Balfour, Bell, & Marmot, 2014). Too much of a focus on individual faults often casts shadows on the problems in the structure; for instance, shame of seeking social assistance can be a problem (Gubrium and Lødemel 2014), and has been explored both in a Nordic and global context. Therefore, an important area of focus is the creation of features in which natural interpersonal relationships and support can play key roles. This, alongside an active social policy, might be even more important related to the ongoing pandemic, a situation that underlines our social interdependence (Saltzman, Hansel, and Bordnick 2020)

Meeting the nordic and global problems in mental health

Connected to mental health struggle there are often several social problems that needs attention. It can be difficult to enhance hope if one’s living conditions are hard (sometimes extreme) and social support-oriented features are not available. Hope is, obviously, an important dimension in recovery from mental health problems, and people struggling often depend on support from others to be their carriers of hope, and that services can see the mix of challenges in their life circumstances (Sælør et al. 2014; Sælør, Stian, and Klevan 2020). It is also difficult for caregivers to maintain good health in a system that does not provide sufficient social support. Why we see an increasing inequality in health, and especially mental health, is a crucial question.

Attempts at meeting future challenges in public mental health and mental health services need to consider the changing technological, economic, social, and political contexts (Giacco et al. 2017), and strategies for reducing inequalities in mental health need more contextual interventions. Some individuals and groups are more vulnerable than others when it comes to the potential of social connectedness, for instance immigrants and especially recent immigrants as showed in studies from Canada (Puyat 2013). The same circumstances prevail for people who experience long-term and severe mental health problems (Webber and Fendt-Newlin 2017). To reduce inequalities in mental health care and to improve recovery from mental health problems, ambitious social support-oriented policies are necessary to create a more holistic approach in mental health work. It would also be a mistake to understand our potential barriers for social connectedness and social support, without actually trying to understand how the structures in our time are affecting our ability to take care of each other and to combat the rising inequality at a global scale (Wilkinson and Pickett 2020).

Conclusions

This current review has mapped and explored essential literature related to a) various associations between mental health and social support, and b) features of social support-based community mental health services. The literature suggests that the association between mental health and social support are multifarious, and that social support is crucial for the prevention of mental health problems and the maintenance of good mental health, as well as the facilitation of recovery from mental health problems in the context of both moderate and severe mental health problems. Direct strategies can be recovery-oriented communities, clubhouses that foster interpersonal relationships, and non-traditional mental health programmes such as football and gardening programmes, etc. Indirect social interventions such as help with money matters, direct financial support, and housing support, are also features that can boost social support and enhance recovery. These strategies shows even more important during crisis such as the pandemic.

We discussed why different levels of social support should be examined. The review suggests that mental health services should focus more on the various features of social support while developing services. Despite the multifarious associations, the concept of social support seems quite rigid, and it is natural to suggest that this review does not capture all the diversity in the literature because we tend to conceptualize social support in a certain manner. Nonetheless, detailed research exploring what facilitates and hinders integrating social support features in the services, the quality of social support, especially from the perspectives of both service users and service workers, is necessary.

Limitations

The potential of missing out on important studies and literature will always be a concern. We could have relied on an even larger number of databases to gain a broader perspective. The search strategy can also be a limitation, considering the fact that different search strategies can have different impacts, and we may have missed out on some important terms in our attempt to engage with a broader scope of research (e.g., cultural components, first nation people and communities). Selection bias can always occur, although author one and two (with support from a librarian) contributed and collaborated very closely in the search and selection process. This may have had an influence on the result.

Authors information

The study was conducted as a part of the first authors PhD project “Social support and Mental Health – service users, professionals and volunteers experiences with conditions that facilitates and conditions that hinders social support” at the University of South-Eastern Norway and OsloMet – Oslo Metropolitan University

Authors’ contribution

The first two authors designed the search with support from the mentioned librarian, and author 3 and 4 contributed with essential critical reviews and comments in the whole writing process

Acknowledgments

We would like to acknowledge the academic librarian, Anne Skjæret Stenhammer, who contributed in the process of developing search strategy, recommended relevant databases, and supported the searching process with valuable knowledge.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

This work was supported by the Dam Foundation [FO187631].