Harnessing civil society to promote social inclusion of people with severe mental illness

The engaging and comprehensive review by Henderson et al1 outlines current barriers to social inclusion among people with severe mental illness. As with any insightful paper, this review raises several important questions. One concerns the relative roles and responsibilities of different sectors of society in promoting social inclusion in people with severe mental illness. I contend that six actors and sectors are directly implicated in this process. First are individuals with severe mental illness, who can use their agency to engage in actions that enhance social inclusion, for example joining recovery colleges or other community organizations. Second is the family, who can encourage social engagement by providing moral, practical and social support. Third are official health services, which can provide offerings such as supported employment and peer support, while empowering patients’ agency through therapeutic interventions. Fourth is the government, which can introduce or amend legislation to reduce discrimination against people with severe mental illness, while also funding anti-stigma campaigns. Fifth is business and the private sector, which can adopt socially inclusive workplace policies that provide opportunities for people with severe mental illness. The final sector is civil society, which remains under-harnessed and under-appreciated, despite much promise and innovation in this sector2. But what is civil society? A broad definition refers to “non-state not-for-profit voluntary organizations formed by people in that social sphere”, and includes faith-based organizations, civic groups, sports clubs, social clubs, outdoor groups, recreational groups, and other voluntary associations3. These are typically bottom-up, grassroots and community-led organizations, firmly rooted in local neighborhoods, which may focus on a single activity with a specific mission, or deliver a variety of programs with a broad mission. For example, faith-based organizations such as neighborhood churches may deliver multiple groups and programs, such as youth groups. Other organizations, such as sports clubs or gardening clubs, will focus on a single regular activity based on a shared interest, typically including weekly activities. Evidence presented by Henderson et al1 converges with the wider literature to indicate that involvement in these groups can be instrumental in reducing loneliness and isolation, while promoting social inclusion and sense of belonging. For example, a seminal randomized study4 involved clinical staff working with patients to identify personalized areas of interest, with staff then helping patients engage in social activities “outside the services’ resources and with members of the community at large”. Results indicated a significant increase in social networks compared to a control group, and at one- and two-year follow-up. Similarly, a review paper found that initiatives which encourage community engagement are the most effective in facilitating social network improvements, when compared to options such as social skills training5. This can include participation in groups centred on a wide variety of activities such as walking, conservation, arts and crafts. Some of these activities often have the added benefit of improving physical health, which is vitally important given the elevated risk of cardiovascular problems and obesity in this population. What is it about civil society participation that contributes to such gains? To start, participants may make diverse connections with new people beyond mental health services, which can open doors to local friendships, increased social capital, and even job opportunities. Indeed, such “weak ties” (sometimes known as bridging social capital) are known to catalyze important elements of social inclusion. However, they are frequently absent in people with severe mental illness6. This absence may be particularly severe in patients who have spent considerable time in clinic-based groups and hospital-based activities limited to interactions with staff and other patients. Moreover, such civil society groups typically revolve around a shared activity which is enjoyable and involves the acquisition of new skills, imparting a sense of accomplishment and mastery to people with severe mental illness. This means that there is intrinsic motivation to engage and return. Participation in such meaningful activities outside the mental health system, where the individual is not identified as a patient, has been recognized as instrumental in the recovery process7, and is consistent with an “all of society approach” to mental illness2. Such informal organizations can be particularly important in resource poor settings, where professional clinical coverage may be thin. Indeed, the finding that people with schizophrenia in low-income countries have better recovery than those in Western countries has been explained as partly due to wider social networks and greater community involvement among patients in the former6. Unfortunately, civil society organizations remain under-harnessed by mental health systems in Western countries. Some evidence suggests that service providers will sometimes signpost and encourage patients with depression and anxiety to use such organizations, but that this remains uncommon for people with severe mental illness8. The lingering notion that people with severe mental illness are incapable of participating meaningfully in such organizations may be involved. But such stigmatizing notions surrounding social competence have recently been disproven. For example, robust evidence indicates that people with severe mental illness can successfully work in the competitive market, belying archaic yet common beliefs that they could not work7. All this raises another question: what can service providers do to better promote the utilization of civil society organizations by people with severe mental illness? Some mental health service providers have attempted to launch similar groups within the wider mental health system, only open to patients and located within mental health facilities. These programs may be helpful in some respects, but will not contribute to social inclusion nor community integration in the same manner as participation in a civil society organization. Instead, service providers can consider three courses of action that may be helpful. First, as suggested by Henderson et al1, service providers can engage in resource mapping, liaison and collaboration with civil society organizations, with appropriate information shared with patients. The literature on religion and mental health offers useful examples of liaison and collaboration between faith-based organizations such as churches and the mental health sector, especially for minority and immigrant patients9. Some of these partnerships have included mental health education for the clergy and the congregation to ensure that the receiving environment is well-equipped to help. This could provide a useful model for similar liaison and collaboration. Second, social prescribing has much potential to help people with severe mental illness connect with civil society organizations and participate in meaningful activities therein. Such prescribing is highly person-centred, as patients express preferences that are personally meaningful, which are realized through clinical (and sometimes financial) support. However, the literature suggests that research and practice in social prescribing and mental health tends to focus on anxiety and depression8. Moreover, social prescribing is not equally available across countries. Greater efforts should be made to implement and expand social prescribing for severe mental illness. Finally, other actors are also instrumental in fostering connections with civil society. Families can play a vital role in supporting such connections, and should be encouraged and empowered to help as part of psychoeducation interventions. Moreover, the private sector may be able to offer charitable grants to initiatives and programs that attempt to connect patients with civil society organizations. All this is consistent with recent calls for an “all of society” approach, that aims to shift an excessive reliance on biomedically oriented mental health services towards a multi-pronged strategy that includes an instrumental role for civil society2. Such action is long overdue.