It is useful when considering the discussion of the CHIME processes to be mindful of the extent that service-users in medium-secure units, and those transitioning back into the community, might experience in their daily lives the opposite of these processes, in other words, feeling isolated (rather than having connectedness), feeling hopeless (rather than hopeful), lacking a sense of identity (rather than retaining a sense of their identity), and so forth. The following sections are based on the CHIME framework [9] and are structured in order of importance and relevance based on the interpretation of data in this study.
Connectedness
The participants frequently discussed the importance of the social elements of the sessions, as they facilitated interactions (and friendships) that otherwise would not occur. This was especially significant for those from medium-secure units, as service-users highlighted that they would probably not have got out of bed if they did not have the sessions to attend, and for some it was the only time in the week that they left the unit. It was evident from the participant observation that there was a strong element of community and connectedness amongst participants, with a welcoming and friendly culture that was very much valued, as Marty (Volunteer) suggested:
I’ve been here for a very long time, I’ve seen the change in people. They’ve made a lot of friends. They feel here they can get involved, where years ago they were very quiet, shy. They involve their self with other people, talk and communicate. Look at ‘Gerald’ for example, when he first came, he was very quiet. He never got involved. He couldn’t even touch a ball. You look at him now and he’s fantastic. He’s cheerful. He’s happy. When you see him, he shakes your hand and he gets on with people. It wouldn’t have happened if he couldn’t come here and see everyone.
This supports previous studies, highlighting the social benefits in terms of shared experiences [30, 51] with others that provide something to talk about (football) as well as an opportunity to talk and connect [16], which is deemed important in recovery [9, 11] especially for those involved in medium-secure units who might be, or feel, isolated.
An issue that comes with increased connectedness in this context, which was highlighted previously in a football project [4], was the competitive nature of football and how it could lead to violence in sessions. However, it was noted that participants frequently praised these sessions and the ‘culture’ that meant there was very little conflict, violence or “aggro that we don’t wanna see here” (Garth, Service-user). Some suggested the reason for this was the interactive, collective nature of the sessions, as staff and service-users played together and were considered, generally, to be equal, or as Jermain (Service-user) put it “on the same level, everyone is the same out on the pitch, no matter where you came from or whether you are staff or usually locked-up”. Another factor is the long-standing nature of the sessions, as they have been running, in various forms, for more than a decade, with some participants being involved for that period of time. Therefore, there is a well-established culture or habitus [52] that guides the behaviours, which is especially useful to inculcate new-comers to the sessions.
Empowerment
The nature of medium-secure units means service-users have limited empowerment, but these football sessions demonstrated that this does not always have to be the case. The data supported a number of the sub-themes of the empowerment processes that Leamy et al. [9] identified as being important for recovery, with the most recognisable being ‘maintaining good physical health and well-being’. It was reported frequently in the interview data that participants were mostly sedentary during the rest of the week, but that these sessions gave them a chance to be active. The general sedentary behaviour of service-users raises questions about other service-users who do not attend these types of sessions, and whether provision (options more appealing to personal tastes than football) should be made more readily available, especially on wards where opportunities and, therefore, choices and empowerment are extremely limited. For Jimmy (Service-user), the opportunity to be active was appreciated:
You’ll always see me running, in the game I’m running all the time, non-stop. It’s the only chance I get so I get sweating. It’s good for my heart, and my weight, ‘cause I didn’t always look like this. But it’s hard, when I’m not here, to run around at all.
Being empowered enough to be able to make a choice [53] is important for ‘regaining independence and autonomy’ [9]. Participants appreciated how service-users can choose to attend (albeit, if that is an authorised option for them), can be team captains (and choose their teammates), and can choose to attend and not actually play (for instance, there is one service-user who never plays football, but attends almost every week and in the short time gap between games will run a lap of the pitch). This empowerment and taking control of decision making transcends just those experiences of service-users in medium secure units, as participant observation made it possible to witness over time how the sessions provided a safe and familiar space for people as they progressed on their recovery journey [5], a journey that sometimes involved participants who had previously returned to the community becoming more ill and finding themselves back in secure care, but they benefitted from the on-going sessions and the connections they retained, as Greg (Service-user) explained:
I was feeling a lot better a while ago, but I had some troubles again. But you know what, I only missed like four weeks or something [of the football], and they let me keep coming, so that really helped to see the guys. Them people are my friends, it’s like coming home. Some of these guys here I’ve known through the footie for five or six years, we wouldn’t have that otherwise.
The football sessions appeared to be a useful tool for the process of regaining independence and autonomy for transitioning service-users who were out of the units or wards, as there remained a support network for them to cohere around whilst they made decisions and recovered their autonomy, for instance, choosing to attend, considering organisation and timing, making transport arrangements, and so on. The final element of the empowerment processes that were evident was how the positive and supportive culture encouraged ‘focusing on strengths’ [9]. In sessions this included supportive remarks, encouragement ‘from the side-lines’ from spectators, cheering when someone scored, and generally making people feel good about their footballing ability, which service-users reported contrasts with experiences of some of the language and interactions in clinical settings. This positivity is considered important for recovery processes and making positive changes [3], which shall be discussed in the following sections on hope and identity.
Hope and Optimism
Previous football and mental wellbeing studies, for instance, Lewis et al. [36] found via quantitative data analysis (often using the Warwick-Edinburgh Mental Wellbeing Scale) that participants felt more optimistic following involvement in such a project. The current study goes beyond this questionnaire and survey data to provide some qualitative elucidation to what this optimism or hope might actually entail, whilst providing a voice for the participants. It was evident that there were elements of being involved in the sessions that encouraged participants to feel more hopeful and optimistic about the future in terms of the short, medium and long-term. In the short term, service-users felt that they really benefitted from having something to look forward to each week, as Ricky (Service-user) outlined: “it’s the best bit of my week that’s for sure. If I’m honest, like, it’s the only good bit of the week mostly, keeps my health going. I’d come every day if they ran it”. Ryan (Staff) echoed this from a staff perspective:
These guys look forward to coming, absolutely. I can speak about the patients who I work with, and they talk about it all week, especially if they’ve had a good performance and scored some good goals. They don’t shut up about it [laughter]. They keep telling us how brilliant it is, and it gives them a real focus, and I think that gives us as staff something to work with.
In the medium term, participants appreciated how (perhaps indirectly) the sessions enabled them to see beyond their current circumstances and feel more hopeful about their own health and personal recovery. This was mainly due to the incorporation of service-users who had transitioned through the stepped process and had either moved from medium to low-secure units, or into service accommodation or back into the community, but who still attended the sessions. From spending time with the participants, and seeing these transitions occur, it was possible to see the personal relationships and communication present that gave people hope that things could change. As Jon (Service-user) stated: “It definitely gives me a bit of hope, because I see people come here that aren’t even in secure services anymore. People that I know that have got out and they’ve come back and still chat to me and that, do you know what I mean? It makes you see what you can do, like, and be better“. Hardeep (Service-user) also explained: “it gives people hope seeing others that are now back in the community. Some people that have moved on from here, they come back, and I think that’s really good, but for them its good, too, so they have somewhere familiar to come, they aren’t just on their own out there”. There was also the benefit for being optimistic moving forwards about the therapeutic relationships between staff and service-users, as Jasper (Staff) explained:
It’s beneficial for everybody involved. Even the members of staff who aren’t involved in actually playing can see their patients in a different light, because there are a lot of patients who are stuck on the ward day in, day out and they come here and they’re completely different. It’s like seeing a completely different person at times.
Almost on a weekly basis, service-user participants expressed what can be interpreted as a longer-term hope of getting well and ‘being a footballer’ or just joining a local team once they are back in the community, which shall be discussed in relation to identity in the next section.
Identity
A common theme amongst service-users was how they had played football a great deal prior to becoming ill. During the participant observation data collection there were very often discussions about the teams they had played for or the level they had reached, and it was frequently followed by a reflection of how pleased they were that these sessions were available to them to ‘recover’ that ‘old’ part of their identity, whilst providing hope that this could be enhanced further in the future. In addition to being an important element of their perception of self [16] and giving life value and meaning [54], there is potentially a benefit to their social identity in that playing football again affords them cultural capital [55], which is valued in this different ‘field’ [52] (i.e., in a football arena in the town centre) that contrasts so markedly from their usual social environment (being in a unit or on a ward) that does not value such capital, and therefore can make that person feel undervalued. Furthermore, service-users, volunteers and staff appreciated the dynamic of everyone playing together, as Sean (Service-user) stated:
The power dynamics aren’t that obvious, everyone’s on one level. I can’t praise it enough. It’s good that here I’m better than the staff [at football] and we have more of a laugh about that, whereas the rest of the time I’m just ‘Sean’ the patient.
This is in line with the more collective, solidarity-enhancing activities that have been called for by Leamy et al. [9] and McKeown et al. [30] which highlighted the benefits of flexible inter-personal relations in settings that contrast with the ‘mainstream’ mental health service settings and relations with practitioners. This significance is perhaps intensified in medium-secure units where these relations and power dynamics are especially manifest, as Onken et al. (53, p10) suggested the “interaction among characteristics of the individual (such as hope), characteristics of the environment (such as opportunities), and characteristics of the exchange between the individual and the environment (such as choice), can promote or hinder recovery”, therefore services could benefit from reflecting on service-users’ hope and identity when considering opportunities and choices.
Meaningful
Although the data suggested that this element of the recovery processes framework was discussed the least by participants, there was a strong consensus of football being meaningful and the sessions meaning a lot to them in terms of their health and ongoing recovery. Participants felt particularly strongly when asked ‘what if the sessions stopped?’. Put simply by Megan (Service-user): “If the sessions weren’t on I think I might fall back into depression. A lot of people would be lost without this, I think. I know I would”. These sentiments were echoed by staff members Lewis and Mikey: “for some of the guys who come, it’s the only physical exercise they do. It’s the only social thing they do” (Lewis, Staff); “I dread to think, mate [what would happen if the sessions stopped]. I dread to think. They say to me ‘What would I do on my own on a Tuesday?’, they all love football and want to come here” (Mikey, Staff). A functionalist perspective [56] would highlight the function of sport of being the ‘hook’ that brings people together, in order for additional benefits (such as the other CHIME recovery processes) to be enabled. The obvious limitation in a practical sense for services is that not everyone likes football and facilities might not be available, however other sports could be offered and despite the limited funding there is a growing body of evidence that is highlighting how sport can really influence people’s personal recovery, so these opportunities arguably should be made available.