Design and paradigm

The study employed a qualitative, exploratory, and participatory design, drawing on social constructionism theory [33], which views knowledge as co-created, integrating the factors and dynamics of both personal and social contexts. A participatory design was chosen to ensure the study’s relevance and validity, with attention to both lived experience and academic knowledge [34]. The relevance of the study was discussed with several people with lived experience, including two young adults who were members of a national advisory board on the implementation of Youth FACT in Norway. These discussions, which revealed that few had been asked about their needs and wishes for social inclusion, confirmed the necessity of this study. Additionally, a peer researcher has been involved in the research process from the planning stage to analysis and dissemination of results.

Research context

The study is part of a larger project involving promotion of social inclusion among young adults and staff in FACT, recruited from three teams in Eastern parts of Norway. All teams provided services to people in both urban and more rural areas. Two teams had been operating since 2020 and one since 2021. These teams integrated expertise from the specialist and municipal health care services and peer workers. All teams had received basic training on the FACT model and participated in professional FACT networks that provided opportunities for continued professional development.

Recruitment and participants

To recruit participants, we approached team leaders in three teams. After receiving information on the aim of the study, the team leader agreed to inform the team staff about the study, encouraging them to participate. We do not know how the staff was informed. All team members, regardless of profession or role within the teams, were eligible for participation to gain experiences from different perspectives within the teams. Eligibility required experience in working with young adults with mental illness and complex problems in a FACT setting. Those interested in participating received written information about the study and their rights, and a form of consent. Recruitment was challenging, leading to six participants. The first author contacted and scheduled interviews with people who consented to participate.

Six participants (four women and two men) participated in the study. All but one had extensive experience working with young adults with mental illness and complex problems. The participants had basic education in nursing, some with specialized training in mental health work, clinical psychology and in child and youth care work. All participants disclosed having received none to limited education about social inclusion, both in basic education and afterward.

We used the pseudonyms Emma, Helen, Robert, David, Laura and Alice for the participants.

Data collection

Data was collected from May to September 2024 through individual semi-structured interviews. This approach was selected to maximize the potential for gathering rich descriptions and a deep understanding of participants’ experiences [35]. Individual interviews were chosen to ensure credible data material, as participants were able to express their views anonymously. An interview guide was developed by the first author followed by review and discussion with other authors. This collaborative process reduced the need for pilot testing. As a result, pilot testing was not conducted.

The first author conducted the interviews. The participants chose the interview location to ensure a comfortable and safe setting for sharing their experiences. The first author also reassured them that all information would be treated confidentially, especially if they disclosed critical issues or negative experiences. Four participants were interviewed in person at their FACT teams’ headquarters and two by online video interview. The interviews took form as conversations, emphasizing the value of the participants’ experiences.

The aim was to explore the participants’ understanding of social inclusion as a concept and their views and experiences with promoting it for young adults in their teams. They were also asked about collective understanding and views on joint efforts as a team, and about perceived barriers and room for improvements. In addition, they were briefly presented with some main results from previous studies addressing the experiences of social inclusion among young adults in FACT teams [13,36], and asked to reflect on these.

The interviews were experienced as honest and open conversations. Follow-up questions were asked to clarify or deepen responses, and participants were invited to provide specific examples to illustrate their experiences. All were given the chance to provide additional statements after the interview, of which none did. The length of interviews was 50–70 minutes, with an average duration of 57 minutes, and provided rich material with acceptable information power [37]. The interviews were recorded and transcribed verbatim by the fourth author.

Analysis

We employed and followed the six phases of reflexive thematic analysis [38] as described below. This enabled us to explore the descriptions and meanings of social inclusion through emphasizing the voices of the participants, and examining their comments in relation to individual, social and structural factors reflected in their views [33,39]. A team approach was employed.

The first and fourth authors, the latter a peer researcher, thoroughly reviewed the data and discussed their initial impressions to become familiarized with the dataset (phase 1). The peer researcher initially shared her impressions and thoughts to minimize the influence of the non-peer researcher. Both authors’ initial impressions and reflections were highly similar. Following this, the first author coded the interviews (phase 2), introducing initial thoughts to all contributing authors. After this, initial themes were generated (phase 3), then further developed and reviewed with contributing authors (phase 4), and finally refined, defined and named (phase 5). Throughout these stages, the authors endeavored to exercise critical awareness to avoid biases in interpretation of the data. There were discussions with all authors during all phases of the analysis [40], and the material was read several times to re-examine initial findings. There were some movements back and forth between the different phases before writing up the results (phase 6). Three main themes were developed: [1] “It has something to do with…”, [2] “We really try”, and [3] “We could do more” with a total of six sub-themes across the three main themes.

Ethical considerations

The study was approved by the local data protection officer at Innlandet Hospital Trust (ID 22587532), following recommendations by the Regional Committee for Medical and Health Research Ethics in Norway (482463). The participants signed a consent form with information stating that the interviews were confidential, that statements would have no impact on their work life, and that they could withdraw from the study at any point. This information was repeated orally before the interviews started. Participants were told that their contributions and experiences were important, and they were given the chance to ask questions or voice concerns before participating in the study. None did. At the end of the interview, the researcher asked about the participant’s experience of the interview to ensure that no harm was inflicted. Participants rated their experiences as positive.

“It has something to do with…”

The first main theme reveals the team staff’s understanding and awareness of social inclusion in general. It encompasses two subthemes: Defining social inclusion and level of awareness, and Collective understanding and team awareness.

“We really try”

In addition to exploring how the staff defined social inclusion, participants were asked about how they understood the young adult’s social context and needs and how they worked to promote their social inclusion.

“We could do more”

The concept of social inclusion and who gets to define it

Our findings also raise questions about the practical usefulness of the concept of social inclusion in its current form, as its full potential is not being realized. Yet while the concept may be open to critique, it recognizes the inherent worth of every individual in our communities and the imperative to inequality and marginalization [3]. As such, social inclusion is a concept that deserves attention and continuous improvement.

Staff struggled to provide a working definition or understanding of social inclusion and its core facilitators going beyond work, education and activities. That said, these means are important facilitators of social inclusion in the FACT handbook [29]. Still, social inclusion is recognized as a complex problem [26] that requires more than isolated good initiatives to be effectively addressed. All staff interviewed thought their team members were aware of the importance of social inclusion, albeit with variation in the attention they gave to it. Interviewees could not recall team discussions aimed at reaching a common understanding of how they could systematically work as an interdisciplinary team to promote their patients’ social inclusion. This is an important finding, given that the FACT model clearly emphasizes social inclusion as a main goal through interdisciplinary efforts [29].

The staff reported a lack of formal education on the subject, both in their basic training and ongoing professional development, and further noted that they largely lacked systematic approaches in the teams. This supports the critique of mental health services not sufficiently including the social context in treatment (e.g., 22). However, all staff acknowledged the importance of social inclusion and employed efforts to promote it, while also calling for more practice-oriented knowledge.

One reason for the difficulties in working systematically to promote social inclusion may be the conceptual challenges of social inclusion and who gets to define it. Regarding conceptual challenges, staff observed young adults who often did not recognize their social exclusion or perceive it as problematic, suggesting differing views on social inclusion and its relevance. The staff acknowledged a need to further explore their clients’ individual needs, interests and resources and address social inclusion explicitly. Lack of clear definitions or frameworks for social inclusion is part of the problem, but the means for promoting and communicating about it follows close behind. This dilemma is in line with previous research showing that young adults in FACT teams have limited experience of service providers addressing social inclusion [13,36]. This suggests that young adults had limited influence in defining what social inclusion means to them and in determining the methods to promote it. Consequently, some individuals’ needs may be overlooked or inadequately addressed.

Additionally, there is a lack of integration of objective perspectives of social inclusion such as obtaining work or income, with subjective perspectives such as a sense of identity or perceptions of their social surroundings. Such aspects might be addressed in relation to the young adults’ mental illness, especially considering the young adults’ developmental phase. However, they should also be addressed in relation to social inclusion as these young adults often have experiences of relational traumas challenging how they interact with others, feeling labelled as worthless to society, of stigma and internalized stigma, in addition to experiencing limitations because of mental illness and complex needs [13,15,16,43,44]. Practitioners, researchers and policymakers must understand the dynamics of social inclusion for young adults with mental illness, including what society has to offer them and what they have to offer society. It is difficult to see how social inclusion can be promoted without touching upon the more subjective and existential aspects of what it means to be a human being in a modern society, nonetheless a human being challenged by complex needs.

Discussion and debate on social inclusion reveal significant challenges due to the vagueness of the term and the lack of a universally accepted definition. Social inclusion is often described in broad terms, without a clear consensus on its core components [5–7]. Such ambiguities negatively affect the creation of coherent policies, as policymakers struggle to operationalize the concepts, such as social inclusion, that they are charged with addressing, thus risking fragmentation and lack of coordination of effort [45,46]. As our results show, unclear concepts may lead to disparities in what support is offered. This study, in tandem with debates and criticism of the concept itself, raises important questions: Who gets to define social inclusion? Does the definition fit the perceived needs among the marginalized? Can strategies be devised and promoted for its successful implementation among service providers and authorities?

Further, as the definition remains unclear, difficulties in measuring social inclusion follow [47], making the effectiveness of interventions difficult to evaluate. Having accurate measures may help identify personal experiences of exclusion, enabling tailored support and resources to address specific needs. It may also empower people’s mental health literacy and clarify for them the meaning of their own inclusion (and exclusion) [48].

Acknowledging the barriers

The staff spoke of individual barriers which primarily involved psychological and emotional challenges. These barriers not only affect individuals’ self-perception and mental well-being; they also impeded their participation in societal activities, education, and employment [13,36,44,49,50]. Participants in the study highlighted issues such as a perceived lack of motivation, feelings of hopelessness, and internalized stigma. As mentioned, one staff member described how some young adults viewed their situations as hopeless. Others noted that many clients did not recognize their social exclusion or see it as problematic, which made it challenging to engage them in activities aimed at inclusion. Additionally, some clients avoided broader opportunities for education, work, or social engagement because they did not see themselves as socially marginalized, reflecting a disconnect between their self-perception and societal expectations. These barriers underline the importance of interventions that build self-esteem, challenge negative self-concepts, and foster hope and agency.

Even if our results had shown that there was a common understanding of what social inclusion is and how it can be promoted, the goal of social inclusion relies not only on the excluded individual and the providers who assist them. It also relies on social and structural conditions in communities [50–52]. In the present study, the structural barriers involved systemic limitations within the FACT service framework. Participants frequently cited limited team resources and insufficient funding at the municipal level as significant obstacles. For instance, the lack of evening activities or limited access to appropriate social arenas in the local community was mentioned as a recurring issue. Additionally, the staff’s availability was limited to daytime hours, restricting their ability to support young adults who wished to engage in evening activities.

One staff member noted that the team’s focus was often diverted by frequent crises and urgent basic needs, leaving little room for planned, long-term inclusion efforts. Additionally, economic constraints in municipalities led to the closure of community meeting places, which further restricted opportunities for young adults to practice social skills and engage in meaningful activities. These structural challenges highlight the need for increased funding, expanded team operating hours, and better resource allocation to enable more inclusive and flexible services.

Societal barriers arise from broader social dynamics, such as stigma, prejudice, and exclusion within local communities. Participants described how negative attitudes from employers and community members limited opportunities for young adults to engage socially or professionally. For example, a staff member recounted how a local gym refused access to FACT clients due to concerns about antisocial behavior, effectively excluding them from an important social arena. Additionally, staff noted that some employers were reluctant to hire individuals with limited work experience or mental health challenges. These societal barriers not only impact young adults’ ability to participate in education, employment, and community activities but also reinforce feelings of marginalization and worthlessness. Addressing these barriers requires coordinated efforts to reduce stigma, raise awareness, and foster inclusive attitudes across communities. Countering such barriers requires efforts beyond the scope of FACT teams, thus pointing to the importance of helping young adults to handle social exclusion and supporting their capacity for resilience.

While these barriers can be categorized as individual, structural, or societal, they are deeply interconnected and often reinforce one another. The staff recognized that promoting social inclusion requires efforts that extend beyond the individual and FACT teams, relying heavily on broader social and structural conditions within communities. Still, FACT has been found to form bridges between different services [53] and might have an unused potential in forming bridges with other parts of the community as well. As others point out, promoting social inclusion is a complex matter and needs to involve multiple stakeholders [26].

Implications and recommendations

Strengths and limitations

A team approach was employed in the study with a combination of lived experience, psychological and sociological knowledge. The participants provided rich descriptions pointing to an acceptable degree of information power [58], however, it is possible that the study could have been strengthened by including a larger number of participants. The low number of participants may therefore have limitations on the transferability of the results. The participants worked in teams located in semi-urban areas, indicating that the findings might not apply whole cloth in other demographic contexts. This might constrain the generalizability of the findings. In addition, we did not explore team dynamics beyond interviewee comments, available resources, or institutional policies that could affect the FACT teams. This could have provided additional insights. Another limitation in the study could be including staff perspectives only. However, we have explored service users’ perspectives elsewhere [13,36]. Discussing these different perspectives in relation to each other should be explored in further research.