Advancing social inclusion for people with co‐occurring mental health and substance use disorders

People with co-occurring mental health and substance use disorders tend to experience more social exclusion than those with a mental health or substance use disorder alone. The intersection of psychiatric distress and substance use often complicates clinical care and intensifies barriers to addressing social determinants of health such as housing and employment. Co-occurring mental health and substance use also strains relationships with family members and friends, and often reduces community engagement. These challenges are exacerbated by the stigma associated with this comorbidity1, and can be further compounded by unemployment, homelessness or criminal justice involvement. Integrated, evidence-based treatment that addresses both mental illness and substance use2, while promoting recovery and community connection, is essential for advancing the social inclusion of these individuals. Over the past 30 years, the field has shifted from traditional approaches to treatment, which operated in silos by separating mental health and addiction services3. In the past, clients were entering treatment either through the mental health or substance use service system, depending on which problem area was more severe or based on availability of treatment slots. This siloed approach often unnecessarily fragmented care and contributed to treatment dropout, poor long-term engagement and, ultimately, increased social isolation. While people still occasionally talk about receiving silo-based care, the field has advanced, and integrated treatment models are now offered in many contexts worldwide. These integrated approaches reduce barriers to care access, improve continuity of care, and create space for whole health recovery that includes the pursuit of meaningful life roles and social inclusion. In people with co-occurring mental health and substance use problems, stable housing is often a critical need that can reduce social isolation and support social and community engagement. Without stable housing, engagement in treatment, social services, and other aspects of community life remains limited. The Housing First model, which offers immediate access to housing without preconditions such as sobriety or treatment compliance, exemplifies a low-barrier approach that supports both stability and dignity4. In Housing First, wraparound supports are embedded, and people can benefit from psychiatric and substance use services, community outreach, and linkages to social service agencies. An overriding philosophy of this approach is that people are not punished for engaging in risky behaviors, as it is understood that these behaviors, such as substance use relapses, often occur during the recovery process. Individuals who receive Housing First have been found to maintain their housing and pursue other personal life goals, which in turn reduces social isolation. Employment is another critical component of recovery for individuals with co-occurring mental health and substance use disorders. It does not only provide financial stability, but also offers a pathway to social identity, community belonging, and self-efficacy. Individual Placement and Support (IPS) has been found to increase competitive employment outcomes and reduce reliance on emergency services among those with co-occurring disorders5. Offering clients with this comorbidity a multidisciplinary team-based care in addition to employment support has been found to be critical5. When implementing IPS for clients with co-occurring disorders, several factors should be considered. These include such things as avoiding the prescription of addictive medications, or preparing clients to address any possible prior legal involvement during the application process. An IPS staff member might assess job suitability in relation to the person’s time in recovery and level of comfort for such things as working in an environment that may expose to alcoholic beverages. Despite these challenges, ongoing employment can help individuals build social networks, develop a sense of purpose, and pursue regular peer interactions. Peer support is gaining recognition globally, with growing evidence suggesting that it offers a particularly effective means of fostering social inclusion6. For individuals with mental health and substance use disorders, a peer support specialist is defined as someone who has lived experience of both challenges and is in stable recovery. Peer support specialists bring authenticity and hope to recovery-oriented systems and the clients they support. Moreover, they serve as role models and offer suggestions based on their lived mental health and substance use recovery journeys. They can also play a proactive role in connecting clients to recovery resources by bringing them to 12-step meetings or introducing them to recovery events in the community to promote substance-free social engagement. Peer roles themselves offer valued social identities and meaningful employment opportunities. Programs such as Atmiyata in India have shown that community-based peer interventions are both feasible and culturally relevant also in low-resource settings7. Finally, the field has continued to evolve to better serve the disparate needs of individuals with co-occurring mental health and substance use problems via multi-component interventions with a goal of promoting recovery, social inclusion and community integration. These multi-component interventions often integrate many of the aforementioned approaches into one service delivery model. One such evidence-based intervention, developed specifically for people with co-occurring mental health and substance use disorders, is Maintaining Independence and Sobriety Through Systems Integration, Outreach, and Networking (MISSION)9. This intervention has been adapted for people who are also homeless, in the criminal justice system, or veterans, as these individuals tend to have high rates of social isolation. Delivered by a case manager and peer specialist team, MISSION embodies the promise of comprehensive, integrated, team-based whole health care that incorporates mental health and addiction treatment, assertive community outreach, and housing and employment support to address situational barriers to care and promote community inclusion9. The flexibility of MISSION, along with ongoing recovery planning, enhances treatment engagement, improves mental health and substance use outcomes, and promotes social inclusion, especially among individuals disengaged from traditional services. Ultimately, social inclusion is not a secondary outcome. It must be a central goal of any treatment for co-occurring mental health and substance use disorders. Evidence-based interventions must extend beyond clinical stabilization to support individuals in reclaiming roles, rights, and relationships with family and others in their communities. Systems of care that integrate services and foreground inclusion can help individuals move from surviving on the margins to thriving within communities. This is the standard of care that we must embrace if we are to fulfill the promise of dignity, equity, social inclusivity and recovery for this often marginalized population.