About this special issue

The source of this special issue of the American Journal of Psychiatric Rehabilitation reflects border crossings that are the main theme of this brief introduction. The theme comes from a postevent discussion among attendees and presenters at a 2016 symposium at Yale University titled “Recognition: Explorations in Equity, Justice, and Health Care.” The symposium was sponsored by the International Recovery and Citizenship Council (IRCC) and the Citizenship, Recovery, and Inclusive Society Partnership (CRISP). The IRCC is

a global collaborative of policy makers, healthcare providers, persons with lived experience, advocates, researchers, and other stakeholders … [that … ] focuses on bi-directional learning and the sharing of policy, service delivery, workforce, and other mental health and addictions innovations designed to promote recovery, citizenship, and healthcare system development and transformation. (IRCC charge document, 2014).

The CRISP is a European Union Horizon 2020 research and innovation project focused on knowledge exchange and dissemination, based at the University of Strathclyde. CRISP grew out of collaborative work between scholar-researchers at Strathclyde, New York University, and Yale and includes academic and professional organizations from four countries, Finland, Scotland, Germany, and the United States.

For Axel Honneth, autonomous life and positive identity depend on three forms of recognition—close relations of love & trust, legally institutionalized relations of universal respect for all persons’ autonomy and dignity, and solidarity and respect among members of a community. Returning to the 2016 symposium for a moment, a theme presented and discussed on the relevance of recognition theory (Honneth, 1994) to mental health was that the mental health field can at times be narrow and parochial, and that we need to look outside our field for ideas and frameworks that can push us forward in our thinking and practice of citizenship, recovery, and other progressive approaches (Rowe, 2016). For Axel Honneth, autonomous life and positive identity depend on three forms of recognition—close relations of love and trust, legally institutionalized relations of universal respect for all persons’ autonomy and dignity, and solidarity and respect among members of a community (1994). Recognition also speaks to recovery and citizenship at a time when behavioral health care and supports are threatened by funding cuts, discrimination, and stigma, and by conservative social notions of “pulling yourself up by your own bootstraps” that deny the resources and tools that people need to accomplish that very task, or that fail to recognize disabilities which may limit, without necessarily obliterating, people’s abilities to do so. Recognition speaks directly to equity and justice, and less directly but still importantly to health care. Not fully enunciated in discussion at the symposium but in the air, as these writers experienced it, were national and disciplinary border crossings and how far you have to walk from your mental health terrain to get there.

This brings us to the theme of this special issue. Consider the following terms: recovery, citizenship, social inclusion, capabilities, empowerment, social determinants of health and structural competence, human rights.

Recovery, or social recovery—“having a life” even if or even while coping with symptoms and constraints of mental illness (Anthony, 1993)—is being pushed back to its social roots in the Civil Rights and disability rights movements, against recovery’s tendency to overemphasize, or be interpreted as being solely about, a subjective sense of “being a person in recovery” (Davidson & Roe, 2007) and minimizing the roles of state, culture, and society in mental health reform (Hopper, 2012). Citizenship, defined as the person’s strong connection to the rights, responsibilities, roles, resources, and relationship and a sense of belonging that is validated by others (Rowe, 2015), has focused much of its efforts on helping individuals with lived experience of mental illness (albeit in group settings) but is shifting its gaze to more collective efforts, including community organizing. Social inclusion is often defined so broadly in practice as to lack teeth, if defined at all, but in recent years has been linked to the capacities of responsibility, accountability, imagination, empathy, judgment, and advocacy. These capacities, in theory, may be integrated into mental health systems of care and practice, as well as being practiced and achieved outside those systems of care (Ware, Hopper, Tugenberg, Dickey, & Fisher, 2007).

Capabilities theory, adapted from Amartya Sen’s work on alleviating poverty and deprivation in developing countries, emphasizes individual agency—the capacity to pursue one’s goals—and people’s “functionings,“—the practical choices that people can make and the personally valued endeavors they can pursue (1992). Capabilities theory argues that poverty is not merely as a lack of income but a deprivation of choice and social participation (Hopper, 2007; Sen, 1985). Brought to bear in mental health, capabilities practice may support people’s acquisition of positive social roles and undertakings (Hopper, 2007). The concept of empowerment for persons with psychiatric challenges often tends to be either broadly defined or not defined and focused on individual empowerment. Empowerment from a social work perspective, however, emphasizes collective means of empowerment, including social activism (Gutierrez, 1994) that also empowers individuals (Gutierrez, 1994), and has much to offer the mental health field in a time of border crossings. The social determinants of health are the negative impacts of poverty and social disadvantage on communicable and incommunicable disease and life expectancy. Efforts to turn public health knowledge into political action and public policy (Marmot, 2005) are slow to make their way into public mental health consciousness but are being nudged by the fact that that the early mortality of persons with mental illnesses (Parks, Svendsen, Singer, Foti, & Mauer, 2006) has indeed made its way into the consciousness of mental health practitioners and policy makers. Structural competence, influenced by attention to these deficits, is a new approach to the training of psychiatrists and other mental health professionals that shifts the focus, relatively, from individual disability, disease, the individual impact of stigma, and social difficulties that stem from individual deficits, to social, political, and economic forces that influence persons with and without mental illnesses alike, beyond the purview of diagnosis (Metzl & Hansen, 2014). Finally, the topic of human rights is making its way into mental health care (Gostin & Gable, 2009), more quickly in Europe than in the United States, burdened by the difficulty of turning legal rights into effective and actionable rights but forcing all other progressive approaches to attend to and incorporate the fact of it into care, policy, and research.

The concepts and approaches above are hardly final. Among others that deserve their own space are gender including lesbian, gay, bisexual, transgender, questioning (LGBTQ) concerns; community reentry from prison for persons with mental illnesses; intersectionality; race, racism, and undoing racism; upstream interventions with their public and direct-care attention to prevention and alleviation; peers as staff and researchers; intersectionality; and others. Here, before introducing the articles in this special issue, we offer the following ideas:

1. That an important stream of thought, attention, and action in mental health care and research is being turned toward the social aspects of mental illness and their role in supporting the meaningful and valued lives of people with mental illnesses in society.

2. That this stream represents a next step beyond integrated systems of care, which moved mental health care ahead in the 1980s by incorporating social needs as social, not mental health, needs in public systems of care.

3. That these elements are part of a movement away from, and balance to, the importance of clinical-individual approaches in mental health care.

4. That this movement toward at least the question of common cause with other groups who are disenfranchised and socially marginalized (though the stigma of mental illness does not automatically disappear in progressive social groups).

5. That the separation between mental health reform and advocacy, especially advocacy in common cause with other disenfranchised groups, is weakening, and that this suggests political action that stands partly in tension with, but may become less and less separable from, mental health reform.

Introduction to the articles in this special issue

All articles for this special issue are coauthored across borders, meaning that each has representation from international scholars and/or practitioners. The articles are divided into three sections, beginning with citizenship as described by the people. Harper and colleagues start off this issue with an article that represents what people with mental illness define as citizenship, called “Finding citizenship: What works?” Next are descriptions and findings discussing citizenship interventions or projects that are being conducted in the United States with future work being planned in Scotland. These include the second article, “Project Connect: A community intervention for individuals with mental illness” by Bromage and colleagues and the third, “Constructing community to achieve citizenship using recognition theory, recovery, and citizenship as a reflective lens: Experiences from the United States and Scotland” by Stewart and colleagues. The next set of articles are under the section “Citizenship – As Practiced by Providers.” This section starts off with an article by Miller and colleagues on the role of person-centered recovery planning in Scotland and the United States and its implications for citizenship-oriented care. Bellamy and colleagues follow with “Development of the Citizens Measure into a tool to guide clinical practice and its utility for case managers.” The last section is about citizenship in larger social contexts and the possibilities of taking citizenship and recovery-oriented care approaches full-scale in policy formation and in reforming social movements. Vasconcelos and Desviat’s article “Empowerment and recovery in the mental health field in Brazil: Socio-historical context, cross-national aspects and critical considerations,” Aldam and colleagues’ article “Lessons from a national mental health arts festival,” and Onocko Campos and colleagues’ article “Recovery, citizenship, and psychosocial rehabilitation: A dialog between Brazilian and American mental health care approaches” highlight some of the social contextual challenges to consider in the development of citizenship and recovery-oriented approaches on a larger scale.

Declaration of interest

The views in this publication are solely the responsibility of the authors. The Commission is not responsible for any use that may be made of the information it contains.