Finding citizenship: What works?

Experiences of the Quality of the Interplay between Home-Living Young Adults with Serious Mental Illness and Their Social Environments

The purpose of this study is to explore the experiences of the interplay between home-living young adults in the community with a serious mental illness (SMI) and their social environment and how this experience influence their mental health and well-being in light of the theory of salutogenesis. In a qualitative study, nine young adults with SMI were interviewed. The interviews were transcribed and subjected to reflexive thematic analysis. The following three overarching themes characterized these young adults' experiences of such interplay: (1) a sense of shame and feeling less valued in society, (2) challenges in engagement and maintaining relationships, and (3) the significance of social support in one's family. Accordingly, the young adults experienced both the presence of good, constructive interplay with their social environment and deficits in this reciprocal feedback loop. Overall, this study illuminates the need for more tolerant health-promoting public attitudes to ensure that individuals with a SMI might experience better interplay by feeling that they are valued members of a nurturing society and that they can contribute to their local community. Participation in society should not be limited by one's illness or expectations of being recovered before one can fully participate in society. Experiencing social support and inclusion in society is essential to strengthen self-identity and fight against stigma, thus promoting a sense of coherence, health and well-being.

Current insights of community mental healthcare for people with severe mental illness: A scoping review

Background

For the last four decades, there has been a shift in mental healthcare toward more rehabilitation and following a more humanistic and comprehensive vision on recovery for persons with severe mental illness (SMI). Consequently, many community-based mental healthcare programs and services have been developed internationally. Currently, community mental healthcare is still under development, with a focus on further inclusion of persons with enduring mental health problems. In this review, we aim to provide a comprehensive overview of existing and upcoming community mental healthcare approaches to discover the current vision on the ingredients of community mental healthcare.

Methods

We conducted a scoping review by systematically searching four databases, supplemented with the results of Research Rabbit, a hand-search in reference lists and 10 volumes of two leading journals. We included studies on adults with SMI focusing on stimulating independent living, integrated care, recovery, and social inclusion published in English between January 2011 and December 2022 in peer-reviewed journals.

Results

The search resulted in 56 papers that met the inclusion criteria. Thematic analysis revealed ingredients in 12 areas: multidisciplinary teams; collaboration within and outside the organization; attention to several aspects of health; supporting full citizenship; attention to the recovery of daily life; collaboration with the social network; tailored support; well-trained staff; using digital technologies; housing and living environment; sustainable policies and funding; and reciprocity in relationships.

Conclusion

We found 12 areas of ingredients, including some innovative topics about reciprocity and sustainable policies and funding. There is much attention to individual ingredients for good community-based mental healthcare, but very little is known about their integration and implementation in contemporary, fragmented mental healthcare services. For future studies, we recommend more empirical research on community mental healthcare, as well as further investigation(s) from the social service perspective, and solid research on general terminology about SMI and outpatient support.

Developing and establishing the psychometric properties of the Strathclyde Citizenship Measure: A new measure for health and social care practice and research

There has been increasing interest and research attention towards citizenship-based practices and care within health and social care settings. A framework for implementing citizenship-based interventions has helped support the participation in society of persons who have experienced major life disruptions. Yet, having ways to measure the impact of citizenship 'in action' within specific socio-cultural contexts has proved challenging. We report on the development of the Strathclyde Citizenship Measure (SCM) which seeks to establish a psychometrically sound measure of citizenship that is relevant to the Scottish context. We outline the three phases of developing the SCM: (1) item generation, (2) item reduction and piloting, and (3) measure validation. Having generated items for the SCM using concept mapping techniques, we piloted it with 407 participants who completed an online survey of a 60-item version of the SCM. The aims were to assess the validity of the items and reduce the number of items using principal components analysis for the final measure. This resulted in a 39 item SCM. We then sought to establish the psychometric properties of this shorter version of the SCM through testing its reliability, convergent, concurrent and discriminant validity. The 39 item SCM was administered online to 280 Scottish residents along with additional measures including the Warwick-Edinburgh Mental Well-being Scale (WEMWBS), the Depression, Anxiety and Stress Scale (DASS21), the Sense of Belonging Instrument (SOBI-A); the Big Five Personality Inventory (Shortened Version; BFI-10) and the Personal Social Capital Scale (PSCS-16). The factor structure and dimensionality of the SCM was examined using exploratory factor analysis and it was found to be reliable and valid. This paper explores the potential for the application of the SCM across health and social care settings and identifies future work to develop citizenship tools to facilitate dialogues about citizenship across health and social care practice settings.

A Mixed Methods Study Examining Citizenship Among Youth With Mental Health Challenges

Introduction

Multiple stakeholders have recently called for greater research on the barriers to citizenship and community belonging faced by people with mental health challenges. Citizenship has been defined as a person's access to the rights, roles, responsibilities, resources and relationships that help people feel a sense of belonging. Factors that may impact citizenship include financial precarity; intersecting forms of marginalization and oppression (e.g., racism); and the mental health care people receive. Research has yet to examine experiences of citizenship among youth with mental health challenges. To address this gap, this study will examine how youth experience citizenship; predictors of citizenship; how citizenship shapes recovery; and the degree to which youth are receiving citizenship-oriented care.

Methods

The research objectives will be evaluated using a multiphase mixed methods research design. Quantitative data will be collected cross-sectionally using validated self-report questionnaires. Qualitative data will be collected using a hermeneutic phenomenological method using semi-structured interviews and focus groups.

Analyses

Multiple stepwise regression analyses will be used to determine predictors of citizenship and if of citizenship predict recovery. Pearson correlations will be computed to determine the relationship between participants' perceived desire for, and receipt of citizenship-oriented care. Phenomenological analysis will be used to analyze qualitative data. Findings will then be mixed using a weaving method in the final paper discussion section.

Conclusion

Findings from this study may support the development of citizenship-oriented healthcare in Canada.

Citizens defining citizenship: A model grounded in lived experience and its implications for research, policy and practice

Citizenship is gaining currency in health and social care internationally as a way of making sense of the lived experiences of people with major life disruptions who face exclusion, marginalisation and discrimination, but the concept is often contested, poorly defined and understood. This paper charts the development of an empirical model of citizenship within Scotland, UK. A mixed-method, community-based participatory research approach using 10 focus groups (n = 77), concept-mapping exercises (n = 45) and statement clarity and relevant ratings (n = 242) was used to develop a model of citizenship that is grounded in the lived experience of participants, which is absent from current conceptualisations of citizenship. Multidimensional scaling and hierarchical cluster analysis revealed five core domains emerging from our work: 'building relationships', 'autonomy and acceptance', 'access to services and supports', 'shared values and social roles' and 'civic rights and responsibilities' representing the personal meanings of citizenship for participants. We argue that the value of this model is that it is draws upon the personal understandings and experiences of participants who emphasised the 'banal ordinariness' of its core elements. We suggest that the model makes an original contribution by clearly illustrating the practical applicability of citizenship as a concept; thus, enhancing existing theories of citizenship. Our model highlights the interplay between the relational and structural aspects of citizenship and acknowledges the barriers that marginalised groups face in claiming their citizenship rights. It offers a call to action for policy makers and practitioners to set goals that contribute to the social inclusion of those who have experienced major life disruptions.

Microaggression and the adult stuttering experience

BACKGROUND

Microaggressions are subtle insults, invalidations, or slights that target people due to their association with a marginalized group. Microaggressive experiences have been shown to degrade quality of life and corroborate negative stereotypes towards persons with disabilities. To date, minimal research has been dedicated to exploring microaggressions within adults who stutter.

METHODS

Seven adults who stutter participated in semi-structured focus group interviews similar to Keller and Galgay's (2010) qualitative investigation of microaggressions experienced by adults with a disability. Group interviews were transcribed and analyzed using QSR NVivo software to develop themes and subthemes.

RESULTS

Eight major themes were identified within two supraordinate themes: Microaggressive Behavior (patronization, second-class status, perceived helplessness, workplace microaggression, clinical microaggression, denial of privacy) and Perception of Microaggressive Behavior (exoneration of listener, no or minimal microaggressive experience). Although patronization, second-class status, and helplessness were mentioned frequently by multiple participants, exoneration of the listener was the most frequently recurring theme.

DISCUSSION

Based on these preliminary focus group interviews, stuttering-based microaggressions broadly resemble ableist microaggressions reported by Keller and Galgay (2010). Interviewees also expressed a reluctance to identify slights related to stuttering as microaggression and often characterized these incidents as unavoidable.

Microaggressions towards people affected by mental health problems: a scoping review

AIMS

This review aims to understand the scope of the literature regarding mental health-related microaggressions towards people affected by mental health problems.

METHODS

A scoping review was conducted to explore this question. Four electronic health-oriented databases were searched alongside Google Scholar. As per scoping review principles, the inclusion criteria were developed iteratively. The results of included studies were synthesised using a basic narrative synthesis approach, utilising principles of thematic analysis and thematic synthesis where appropriate.

RESULTS

A total of 1196 records were identified, of which 17 met inclusion criteria. Of these, 12 were peer-reviewed journal articles, three were research degree theses and two were book chapters. Six included empirical studies were qualitative, four were quantitative and two employed a mixed-methods design. Within these, five qualitative studies aimed to describe the nature of mental health microaggressions experienced by people with mental health problems. Themes identified in a thematic synthesis of these five studies included stereotypes about mental illness, invalidating peoples' experience and blaming people with mental illness for their condition. The included publications informed on the perpetration of mental health microaggressions by family, friends, health professionals and social workers. In addition, two studies created scales, which were then used in cross-sectional surveys of the general public and community members to assess characteristics, such as right-wing political views, associated with endorsement of mental health microaggressions. A consensus definition of microaggressions emerged from the included studies: microaggressions are brief, everyday slights, snubs or insults, that may be subtle or ambiguous, but communicate a negative message to a target person based on their membership of a marginalised group, in this case, people affected by mental illness.

CONCLUSIONS

The study of mental health microaggressions is an emerging, heterogeneous field, embedded in the wider stigma and discrimination literature. It has been influenced by earlier work on racial microaggressions. Both can be ambiguous and contradictory, which creates difficulty defining the boundaries of the concept, but also underpins the key theoretical basis for the negative impact of microaggressions. Mental illness is a more concealable potential type of identity, so it follows that the reported perpetrators of microaggressions are largely friends, family and professionals. This has implications for intervening to reduce the impact of microaggressions. There are several challenges facing research in this area, and further work is needed to understand the impact of mental health microaggressions on people affected by mental health problems.

Stranger support: How former prisoners with mental illnesses navigate the public landscape of reentry

BACKGROUND

Prisoners with mental illnesses (MI) are released from prison into environments where they are under-treated and under-supported by our criminal justice, social service, and health systems. Public space and interactions within those spaces have been shown to have positive effects in similar populations, including individuals with MI. This qualitative study explored the role different interactions play during the course of reentry. The study aimed to understand the more everyday relational dynamics that former prisoners with MI experience in public and private spaces.

METHODS

Semi-structured interviews on both experiences of public spaces and interactions within were conducted with 36 former prisoners with MI. Go-along interviews were conducted as a follow-up to these interviews with a subsample of 11 participants in order to identify and describe public spaces and interactions within those spaces. Phenomenological analysis was used to analyze data collected.

RESULTS

Participants described an array of supportive relationships with familiar strangers fostered in public spaces. Participants also described receiving stranger support from relationships typically associated with conventional and institutional supports. This form of "stranger support" was juxtaposed against the burdens and risks of reciprocal intimate relationships.

IMPLICATIONS

Public space and public space interactions can provide support streams to counterbalance the more complex support of intimate relationships. Providers might consider the utility of familiar strangers in helping clients to navigate these sometimes risky, but potentially fruitful spaces.

'The right thing to do': Fostering social inclusion for mental health service users through acts of citizenship

The theoretical framework of citizenship is increasingly being used in mental health settings to inform practice. This exploratory qualitative study describes in more detail the acts of citizenship embedded in the everyday practices of mental health workers that promote the social inclusion of people in their care. Acts make a claim for justice when one's rights and responsibilities of citizenship are denied. Semistructured interviews were conducted with 12 participants, seven mental health clinicians and five peer support workers, recruited from a mental health facility in Connecticut, USA. Two themes are presented, breaking the rules and the right thing to do, a rights-based practice that fosters inclusion for service users. Results suggest that staff undertake hidden acts of citizenship to promote inclusion and rights of service users by responsibly subverting the rules and norms of the organization. Changes to organizational practices to make visible such inclusionary acts are required. Implications for practice and considerations of organizational change through the development of a citizenship framework to underpin practice are recommended.

Prisoner exposure to nature: Benefits for wellbeing and citizenship

The direct or indirect experience of crime can cause individuals to feel vengeful against the perpetrator(s). The prison system reflects this sentiment by creating austere environments that are dehumanizing, punitive, and hopeless. Prisons are, therefore, environments in which retribution and punishment take priority over rehabilitation. Frequently, prisoners are believed to be untreatable because of their antisocial orientation. However, several factors influence an antisocial orientation such as socioeconomic status, family of origin, and mental health. The ubiquitous nothing works misbelief has resulted in prisoner marginalization and increased recidivism because of insufficient treatment. In 2015, 10 million individuals were incarcerated worldwide with around 30 million circulating through prisons each year. The prison environment decreases prisoner life expectancy and overall health. Sadly, prisoner benefits from treatment post-incarceration dissipate after 3-6 months and many prisoners die by suicide or drug overdose. Prison overpopulation, as well as poor outcome post-incarceration, requires more effective treatment. We hypothesize that Prisoner Exposure to Nature (PEN) can transform prisons into environments that are conducive to maintaining and improving physical and mental health. In prior work we proposed the continuum Nature Exposure Sufficiency (NES) versus Nature Exposure Insufficiency (NEI). Prisons are impoverished environments that limit Nature Exposure (NE) which results in NEI. Individuals experience fluctuations in mental and physical health as a result of NEI. Numerous studies have shown that direct and indirect NE can improve mood, physical health, and facilitate connectivity with self and society. It is necessary to consider ways in which we can incorporate NE for prisoner wellbeing. Additionally, it is crucial that prison personnel and prisoners develop a therapeutic/helping relationship (i.e., alliance) that is facilitated by friendliness and warmth to foster social change and citizenship. Many prisoners experience isolation and disconnection with society upon reentry. Given that most prisoners are eventually released into the community, we are obligated not to make them worse. Hence, it is important that prisons create programs that develop citizenship to engender prisoner volition to become positive and active citizens. We focus on the prison and prisoners, however our work is relevant to all total institutions (e.g., mental hospitals, nursing homes, schools, etc.). The prison system favors punishment and mass incarceration over treatment and decarceration. The deleterious effects of incarceration are clear and it is time to implement treatments based on the principles of PEN to improve prisoner wellbeing and citizenship.

The social capitals of recovery in mental health

In this article, we examine the process of recovery in people who have undertaken treatment for mental health problems, based on interviews with 34 participants. We describe their experiences through the lens of social capital, focusing on the social networks and relationships within which they are embedded and which they utilise to give purpose and meaning to their lives. The accounts give sense of movement from relationships, institutions and networks which were provided through their engagement with services towards relationships outside the health care system which were more freely chosen and which provided a sense that they were able to achieve recognition and make a contribution. The latter included activities such as art, theatre and sport. The relationships and institutions with which they were engaged via the statutory services were described as burdensome and inappropriate, whereas those which were freely chosen appeared more emancipatory and positively constitutive of identity. We have called this latter experience one of 'intentional social capital' because the participants were deliberately choosing and orienting to these networks and were able to derive pleasure and a sense of self from them. The findings have implications for how we see the situation of people recovering from mental health problems inasmuch as professional attitudes and practices could usefully be extended to more fully recognise and encourage wider patterns of social engagement and fulfilment occurring outside the limited contribution of clinical definitions and clinical interventions.

Citizenship and Community Mental Health Care

Citizenship is an approach to supporting the social inclusion and participation in society of people with mental illnesses. It is receiving greater attention in community mental health discourse and literature in parallel with increased awareness of social determinants of health and concern over the continued marginalization of persons with mental illness in the United States. In this article, we review the definition and principles of our citizenship framework with attention to social participation and access to resources as well as rights and responsibilities that society confers on its members. We then discuss our citizenship research at both individual and social-environmental levels, including previous, current, and planned efforts. We also discuss the role of community psychology and psychologists in advancing citizenship and other themes relevant to a citizenship perspective on mental health care and persons with mental illness.