Citizenship and Mental Health began when a man who’d once been homeless said that he wanted to give up his apartment and return to the streets of New Haven.
Jim, said sociologist Michael Rowe, Ph.D. ’96, was a veteran who heard voices. He had initially resisted the overtures of a peer outreach worker who gradually won his trust, convinced him to get treatment for his illness, and helped him find an apartment. “Jim was the quintessential success story of outreach,” said Rowe, an associate professor of psychiatry and co-director of the Yale Program for Recovery and Community Health.
And then, one day, “his outreach worker came into our team meeting and said ‘Jim wants to live out on the street again,’ ” said Rowe. Team members were incredulous: why would Jim want to return to the pavement under the Water Street overpass? The outreach worker explained, “Because there he knew people. He felt that he belonged.” Rowe recalled: “That was a heartbreaking moment that revealed to me the limitations of what we were doing.”
That day in the mid-1990s led Rowe to launch what would become the Citizens Collaborative. Its aim was to integrate people with mental illness into communities beyond those created by the mental health system. “Even the most innovative mental health programs, in which work was more than work, went beyond the clock, and even smashed the damned clock, could not make people neighbors, community members, and citizens,” Rowe wrote. He envisioned people with mental illness walking down streets to greetings from neighbors and invitations to join in a neighborhood clean-up or take part in discussions about upcoming elections.
Rowe and colleagues created and studied citizenship programs in New Haven, funded by the National Institute of Mental Health, the Connecticut Department of Mental Health and Addiction Services, and the Melville Charitable Trust. They registered people to vote; helped clients connect with people who shared their interests, such as fellow cycling enthusiasts or stock traders; and encouraged clients to help others, for example, by serving on an advisory board.
Citizenship, as the team came to define it, comprises rights like freedom from stigma, responsibilities like knowing how to manage money, roles as parents or employees, resources like housing and religious communities, and relationships with others.
A randomized controlled study of 114 people who received mental health services showed that those who participated in a citizenship program were more satisfied with their lives and less apt to misuse alcohol and drugs.
This need to foster citizenship, said Rowe, is rooted in the deinstitutionalization of the 1960s and “came out of the success of mental health outreach work‒reaching its limit and hitting the wall.” To thrive, people with mental illness need more than just services, said Rowe. They need to “come in from the margins.”
A guide for setting up citizenship programs will be posted at medicine.yale.edu/psychiatry/prch/.