Relationship of Community Integration of Persons With Severe Mental Illness and Mental Health Service Intensity Rohini Pahwa, Ph.D. Elizabeth Bromley, M.D., Ph.D. Benjamin Brekke, B.S. Sonya Gabrielian, M.D., M.P.H. Joel T. Braslow, M.D., Ph.D. John S. Brekke, Ph.D.
Objective: Community integration is integral to recovery for individuals with severe mental illness. This study explored the integration of individuals with severe mental illness into mental health and non–mental health communities and associations with mental health service intensity. Methods: Thirty-three ethnically diverse participants with severe mental illness were categorized in highintensity (N518) or low-intensity (N515) mental health service groups. Community integration was assessed with measures of involvement in community activities, social capital resources, social support, social network maps, and subjective integration. Results: Although participants rated themselves as being more Dr. Pahwa, Mr. Brekke, and Dr. Brekke are with the School of Social Work, University of Southern California, Los Angeles (e-mail: [email protected]). Dr. Bromley is with the Semel Institute Center for Health Services and Society, Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles (UCLA), and the Desert Pacific Mental Illness Research, Education and Clinical Center, West Los Angeles Veterans Affairs (VA) Healthcare Center. Dr. Gabrielian is with the Department of Psychiatry, VA Healthcare Center, Greater Los Angeles, and the Department of Psychiatry, UCLA School of Medicine. Dr. Braslow is with the Department of Psychiatry and the Department of History, UCLA. 822
integrated into the mental health community, their social networks and social capital were primarily derived from the non–mental health community. The high-intensity group had a higher proportion of members from the mental health community in their networks and had less overall social capital resources than the low-intensity group. Conclusions: The findings suggest opportunities and possible incongruities in the experience of community integration. (Psychiatric Services 65:822–825, 2014; doi: 10.1176/appi.ps.201300233)
C
ommunity integration has been recognized as an essential component of recovery, an important outcome of mental health treatment, and a challenge for individuals with severe mental illness (1). It has been suggested that individuals with severe mental illness are better off when they are integrated into the general (that is, non–mental health) community. However, little work has been done to understand community integration for this population or how mental health services may influence community integration (2). This study examined integration into the mental health and non–mental health communities in a sample of community-dwelling individuals with severe mental illness and explored the relationship between PSYCHIATRIC SERVICES
intensity of mental health services and community integration. Community integration of individuals with severe mental illness has typically been associated with physical integration (3); however, multiple dimensions of integration are now considered. Wong and Solomon (2) proposed three dimensions of community integration: physical, psychological, and social. This model of community integration includes participation in the physical community, a sense of belonging and acceptance, and social integration (2). In addition, there are two valueoriented perspectives on community integration of individuals with mental illness: normalization and subculture. Normalization, a traditional goal of integration (4,5), postulates that individuals with mental illness belong in the non–mental health community and that this is an indicator of recovery (6). However, individuals with a mental illness who live in the non–mental health community can be isolated, and moving them away from their mental health community may isolate them further (7). In this regard, Mandiberg (8,9) has discussed the concept of a mental health subculture. The subculture perspective suggests that being a member of the mental health subculture can be a source of identity and support and a buffer against stigma and that this membership does not preclude integration into the non–mental health community (8). Unfortunately, there has
' ps.psychiatryonline.org ' June 2014 Vol. 65 No. 6
been little empirical investigation of these two facets of community integration of individuals with severe mental illness. This study advances research on community integration in three ways. First, we defined and operationalized community integration using Wong and Solomon’s theoretical model. Second, we expanded previous research by examining integration into both mental health and non–mental health communities using the normalization and subcultures perspectives. Third, we investigated the association of community integration with mental health service intensity. The aims of the study were to examine community integration of individuals with severe mental illness and to explore the relationship between mental health service intensity and community integration for this population.
Methods Data from an ongoing study funded by the National Institute of Mental Health were collected from 33 individuals with severe mental illness of diverse racial-ethnic backgrounds who were treated in two publicly funded mental health clinics in Los Angeles. A total of 18 participants came from high-intensity community treatment teams, called Full Service Partnerships, that are grounded in the assertive community treatment model. These teams have low caseloads (20:1), and an in-vivo, “whatever it takes” approach. Another 15 participants came from low-serviceintensity usual-care treatment teams that use a traditional office-based approach (one to four appointments per month) with medication management and case management or therapy. Data were collected from the participants between January and December 2010. After the study was described, participants provided written informed consent. The study was reviewed and approved by the institutional review boards at the University of California, Los Angeles, the University of Southern California, and the Los Angeles County Department of Mental Health Human Subjects Committee. Participants from the two service conditions were purposively matched on primary diagnosis, Global Assessment of Functioning (GAF) score of #55, hospitalization, homelessness, and PSYCHIATRIC SERVICES
incarceration in the past six months. Data for this study were collected by two trained and supervised interviewers in the context of face-to-face interviews. Previous analyses using administrative data have shown that the high-serviceintensity group received significantly more service hours over the first six months of treatment (8.1 hours per month for the high-intensity group, compared with 2.5 hours per month for the low-intensity group). Physical integration was defined as the “extent to which an individual participates in activities” and “uses goods and services” in the community (2). The involvement in community activities scale, adapted from the leisure and recreation activities subscale of the Independent Living Skills Survey (10), measured the extent to which an individual participated in community activities and his or her level of satisfaction with that participation. The extent to which an individual used goods and services in both the mental health and non–mental health communities was measured with a social capital resource generator adapted for individuals with a mental illness (11). Psychological integration was defined as the extent to which an individual perceived membership in a community and was measured in two ways. The Community Integration Measure (12) (with mental health and a non– mental health community versions) measures the sense of participation, connection, and belonging to a community. Cronbach’s alpha was .83 for the mental health community version and .93 for the non–mental health community version. The second measure, the Community Integration Rating Scale, was adapted from the Community Integration Measure (12) and asked the interviewer to use all sources of information from the interview and rate the degree to which the subject participated in, was connected to, and was accepted by the mental health and non–mental health communities. Cronbach’s alpha was .81 and .83, respectively, for the mental health and non–mental health versions. Social integration was measured by a social network interview (13), and perceived availability of social support was measured by the short version of the Medical Outcomes Study
' ps.psychiatryonline.org ' June 2014 Vol. 65 No. 6
Social Support Survey (14) (Cronbach’s a5.82).
Results Of the 33 participants, 18 (54%) were female and 27 (82%) were from racialethnic minority groups. The mean6SD age was 4168 years. Fifteen (46%) were diagnosed as having a schizophrenia spectrum disorder, 17 (51%) as having a mood disorder, and one (3%) as having another disorder. The low- and high-service-intensity groups were equivalent on gender, age, symptom severity, psychosocial functioning, life satisfaction, quality of life, and length of time in services. No significant differences were found between the two groups in the likelihood of being homeless or incarcerated or the likelihood and length of inpatient care in the six months before services began. Homeless participants in the low-service-intensity group had been homeless for longer than those in the high-intensity group (132 days versus 32 days in the previous six months, p,.05). In terms of physical integration, the entire sample engaged in four out of ten common community activities and were between “a little to somewhat” satisfied with their level of community activity. In regard to social capital resources, the entire sample received significantly more social capital from the non–mental health community. Regarding psychological integration, participants’ self-ratings and the ratings of interviewers indicated that they were significantly more integrated into the mental health community than the non–mental health community. Participants’ average network size was 1464 individuals, and their average network consisted of 62% non–mental health individuals (family, non–mental health friends, and non–mental health acquaintances), and 38% mental health individuals (mental health treatment peers, service providers, and mental health acquaintances). About one-third of the average network was family, and about a quarter was friends. Participants’ average social network included about twice as many non–mental health friends as mental health friends. Table 1 summarizes the comparisons between high- and low-service-intensity groups on physical, psychological, and 823
Table 1
Measures of community integration for 33 participants with severe mental illness, by intensity of mental health services
Measure Physical integration Community activities N of community activitiesb Satisfaction with level of activityc Social capitald Total social capital resources From mental health sources From non–mental health sources Psychological integration Self-rated integratione Mental health community Non–mental health community Interviewer-rated integrationf Mental health community Non–mental health community Social integration Social network Network size Proportion of members from mental health community Proportion of members who are family Proportion of members who are friends Proportion of members who are case workers Proportion of members known before mental health treatment Social supportg
High intensity (N518)
Low intensity (N515)
M
M
SD
4.50 2.17
2.12 1.34
SD
4.13 1.47
ta
1.92 –.52 1.30 –1.51
20.56 6.38 24.40 3.50 7.67 8.82 9.93 7.98 19.61 10.23 25.33 13.50
2.19* .77 1.38
41.83 39.11
6.30 37.67 8.01 –1.67† 8.86 31.80 11.26 –2.09*
11.53 6.94
2.06 10.53 2.25 8.67
1.96 –1.40 2.22 2.18*
14.95
5.08 13.00
3.62 –1.24
.50 .25 .27 .09 .31 15.00
.20 .12 .16 .05
.25 .45 .22 .07
.19 .43 3.96 14.33
.16 –3.78** .19 3.61** .16 –.82 .06 –1.54 .19 4.39
1.82† –.46
a
df531 Scale ranges from 0 to 10. c Possible scores range from 0 to 4, with higher scores indicating more satisfaction. d Possible scores range from 0 to 84, with higher scores indicting more social capital resources. Total social capital resources is not an arithmetic mean of mental health and non–mental health social capital resources because of the presence of an “other” category. e Possible scores range from 10 to 50, with higher scores indicating greater perceived integration. f Possible scores range from 3 to 15, with higher scores indicating greater perceived integration. g Possible scores range from 4 to 20, with higher scores indicating greater perceived social support. * p5.05, **p5.01 †p5.10 b
social measures of integration. In regard to physical integration, no significant differences were found between the groups in their level of participation in community activities or satisfaction with involvement in community activities. However, the high-intensity group had significantly less total social capital compared with the low-intensity group. For psychological integration, the high-intensity group felt significantly more integrated than the low-intensity group into the non–mental health community. However, this self-rating was in contrast with the interviewer rating, which indicated that the low-intensity group showed higher psychological in824
tegration than the high-intensity group into the non–mental health community. In terms of social network characteristics, the average network of the high-service-intensity group had significantly more mental health members than the average network of the low-service-intensity group, and the average network of the low-intensity group consisted of significantly more non–mental health members. Participants in the low-intensity group had significantly more family members in their network. Their networks also had a higher proportion of individuals whom they knew before their mental health treatment began, although this PSYCHIATRIC SERVICES
difference was not significant. There was no significant difference between high- and low-intensity groups on perceived social support. These results show that the total sample rated themselves and were rated as being more psychologically integrated into the mental health community than the non–mental health community. However, their social networks were populated by more individuals from the non–mental health community, and the participants received significantly more social capital resources from the non–mental health community than from the mental health community. Although both groups felt more integrated into the mental health community, the high-service-intensity group was rated by interviewers to be less integrated than the low-intensity group into the non–mental health community. The high-intensity group also had less social capital resources than the low-intensity group. In the highintensity group, a larger proportion of the social network was populated by members of the mental health community, whereas in the low-service-intensity group, a larger proportion was populated by members of the non–mental health community.
Discussion This study examined the level of community integration of individuals with severe mental illness into mental health and non–mental health communities by using the conceptual framework of Wong and Solomon (2) and explored the association between intensity of mental health services and community integration. An individual’s movement away from various mental health treatment modalities and toward the non–mental health or “normalized” communities has become a yardstick to measure improvement and recovery (4,8). However, our results suggest that the experience of community integration for individuals with severe mental illness is a complex phenomenon. We found support for Wong and colleagues’ (7) idea of multiple communities and Mandiberg’s (9) idea of subcultures, in that not only did the individuals in our sample have distinct communities with which they interacted, but they also experienced integration into these communities differently. For example,
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participants felt significantly more psychological integration into the mental health community; however, their social networks and social capital resources came more from the non–mental health community. The nature and outcome of this inconsistency require further investigation. In addition, the social networks of the high-service-intensity group had a larger proportion of members from the mental health community, whereas the low-service-intensity group turned to the non–mental health community for its social network affiliations. Pending further investigation, this might indicate that individuals in the high-intensity group have more congruence in their sense of community belonging and the sources of their social network membership, whereas for the low-serviceintensity group, there may be more dissonance between the community they identify with and the community that is the main source of social network members. However, the high-intensity group may be more vulnerable because they had significantly less social capital resources than the low-intensity group. These findings can also be interpreted by using the normalization perspective (4,5). For example, on average, the participants’ social networks had a higher proportion of individuals from the non– mental health community, which supports the notion that social integration into the non–mental health community is possible for individuals with serious mental illness (4–6). At the same time, we found that the proportion of network members from the mental health community was significantly larger in the high-service-intensity group than in the low-service-intensity group and, therefore, that the high-intensity group was less normalized in one aspect of social integration. Although this study advances the investigation of community integration in important ways by using comprehensive and innovative measures and by distinguishing empirically between mental health and non–mental health communities, it was limited in
PSYCHIATRIC SERVICES
terms of its small sample. For example, although the high-intensity and low-intensity groups were largely comparable on clinical and functional variables, larger samples are needed to rule out the group differences that could account for these findings. The study recruited a sample of individuals with severe mental illness who were engaged in mental health services, which limits its generalizability. In addition, although this study included indicators that could support normalization and subcultures perspectives, the dynamic character of these phenomena needs to be studied by using longitudinal designs. Qualitative methodologies could also be essential to understanding the subjective experience of integration into the mental health and non–mental health communities. Such additional studies would help increase our understanding of community integration and inform development of interventions to increase levels and types of community integration for individuals with severe mental illness.
Conclusions Overall, we recommend that approaches to community integration for this population recognize the challenges, opportunities, and contradictions that individuals with severe mental illness face as they navigate between non–mental health and mental health communities. Acknowledgments and disclosures This research was supported in part by grant R01 MH 080671 from the National Institute of Mental Health to Dr. Brekke and Dr. Braslow. Dr. Gabrielian was supported in part by the Office of Academic Affiliations, Advanced Fellowship Program in Mental Illness Research and Treatment, U.S. Department of Veterans Affairs. The authors thank Briana Hedman, M.A., Kim Hopper, Ph.D., Richell Jose, B.A., Lisa Mikesell, Ph.D., Amanda Nelligan, M.A., Elizabeth Phillips, Ph.D., Eric Rice, Ph.D., and Jamie Saris Ph.D., for invaluable contributions to this research. The authors report no competing interests.
References 1. Townley G, Kloos B, Wright PA: Understanding the experience of place: expanding
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methods to conceptualize and measure community integration of persons with serious mental illness. Health and Place 15:520– 531, 2009 2. Wong YL, Solomon PL: Community integration of persons with psychiatric disabilities in supportive independent housing: a conceptual model and methodological considerations. Mental Health Services Research 4:13–28, 2002 3. Segal SP, Aviram U: The Mentally Ill in Community-Based Sheltered Care: A Study of Community Care and Social Integration. New York, Wiley, 1978 4. Wolfensberger W: Social role valorization: a proposed new term for the principle of normalization. Journal of Intellectual and Developmental Disability 49:435–440, 2011 5. Wolfensberger W, Tullman S: A brief outline of the principle of normalization. Rehabilitation Psychology 27:131–145, 1982 6. Bond GR, Salyers MP, Rollins AL, et al: How evidence-based practices contribute to community integration. Community Mental Health Journal 40:569–588, 2004 7. Wong YLI, Sands RG, Solomon PL: Conceptualizing community: the experience of mental health consumers. Qualitative Health Research 20:654–667, 2010 8. Mandiberg JM: The sword of reform has two sharp edges: normalcy, normalization, and the destruction of the social group. New Directions for Mental Health Services 1999:31–44, 1999 9. Mandiberg JM: The failure of social inclusion: an alternative approach through community development. Psychiatric Services 63:458–460, 2012 10. Wallace CJ, Liberman RP, Tauber R, et al: The Independent Living Skills Survey: a comprehensive measure of the community functioning of severely and persistently mentally ill individuals. Schizophrenia Bulletin 26:631–658, 2000 11. Van Der Gaag M, Webber M: Measurement of individual social capital; in Textbook of Social Capital and Health. Edited by Kawachi I, Subramaniam SV, Kim D. New York, Springer, 2008 12. McColl MA, Davies D, Carlson P, et al: The Community Integration Measure: development and preliminary validation. Archives of Physical Medicine and Rehabilitation 82:429–434, 2001 13. Rice E: The positive role of social networks and social networking technology in the condom-using behaviors of homeless young people. Public Health Reports 125:588–595, 2010 14. Sherbourne CD, Stewart AL: The MOS Social Support Survey. Social Science and Medicine 32:705–714, 1991
825
Objective: Community integration is integral to recovery for individuals with severe mental illness. This study explored the integration of individuals with severe mental illness into mental health and non–mental health communities and associations with mental health service intensity. Methods: Thirty-three ethnically diverse participants with severe mental illness were categorized in highintensity (N518) or low-intensity (N515) mental health service groups. Community integration was assessed with measures of involvement in community activities, social capital resources, social support, social network maps, and subjective integration. Results: Although participants rated themselves as being more Dr. Pahwa, Mr. Brekke, and Dr. Brekke are with the School of Social Work, University of Southern California, Los Angeles (e-mail: [email protected]). Dr. Bromley is with the Semel Institute Center for Health Services and Society, Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles (UCLA), and the Desert Pacific Mental Illness Research, Education and Clinical Center, West Los Angeles Veterans Affairs (VA) Healthcare Center. Dr. Gabrielian is with the Department of Psychiatry, VA Healthcare Center, Greater Los Angeles, and the Department of Psychiatry, UCLA School of Medicine. Dr. Braslow is with the Department of Psychiatry and the Department of History, UCLA. 822
integrated into the mental health community, their social networks and social capital were primarily derived from the non–mental health community. The high-intensity group had a higher proportion of members from the mental health community in their networks and had less overall social capital resources than the low-intensity group. Conclusions: The findings suggest opportunities and possible incongruities in the experience of community integration. (Psychiatric Services 65:822–825, 2014; doi: 10.1176/appi.ps.201300233)
C
ommunity integration has been recognized as an essential component of recovery, an important outcome of mental health treatment, and a challenge for individuals with severe mental illness (1). It has been suggested that individuals with severe mental illness are better off when they are integrated into the general (that is, non–mental health) community. However, little work has been done to understand community integration for this population or how mental health services may influence community integration (2). This study examined integration into the mental health and non–mental health communities in a sample of community-dwelling individuals with severe mental illness and explored the relationship between PSYCHIATRIC SERVICES
intensity of mental health services and community integration. Community integration of individuals with severe mental illness has typically been associated with physical integration (3); however, multiple dimensions of integration are now considered. Wong and Solomon (2) proposed three dimensions of community integration: physical, psychological, and social. This model of community integration includes participation in the physical community, a sense of belonging and acceptance, and social integration (2). In addition, there are two valueoriented perspectives on community integration of individuals with mental illness: normalization and subculture. Normalization, a traditional goal of integration (4,5), postulates that individuals with mental illness belong in the non–mental health community and that this is an indicator of recovery (6). However, individuals with a mental illness who live in the non–mental health community can be isolated, and moving them away from their mental health community may isolate them further (7). In this regard, Mandiberg (8,9) has discussed the concept of a mental health subculture. The subculture perspective suggests that being a member of the mental health subculture can be a source of identity and support and a buffer against stigma and that this membership does not preclude integration into the non–mental health community (8). Unfortunately, there has
' ps.psychiatryonline.org ' June 2014 Vol. 65 No. 6
been little empirical investigation of these two facets of community integration of individuals with severe mental illness. This study advances research on community integration in three ways. First, we defined and operationalized community integration using Wong and Solomon’s theoretical model. Second, we expanded previous research by examining integration into both mental health and non–mental health communities using the normalization and subcultures perspectives. Third, we investigated the association of community integration with mental health service intensity. The aims of the study were to examine community integration of individuals with severe mental illness and to explore the relationship between mental health service intensity and community integration for this population.
Methods Data from an ongoing study funded by the National Institute of Mental Health were collected from 33 individuals with severe mental illness of diverse racial-ethnic backgrounds who were treated in two publicly funded mental health clinics in Los Angeles. A total of 18 participants came from high-intensity community treatment teams, called Full Service Partnerships, that are grounded in the assertive community treatment model. These teams have low caseloads (20:1), and an in-vivo, “whatever it takes” approach. Another 15 participants came from low-serviceintensity usual-care treatment teams that use a traditional office-based approach (one to four appointments per month) with medication management and case management or therapy. Data were collected from the participants between January and December 2010. After the study was described, participants provided written informed consent. The study was reviewed and approved by the institutional review boards at the University of California, Los Angeles, the University of Southern California, and the Los Angeles County Department of Mental Health Human Subjects Committee. Participants from the two service conditions were purposively matched on primary diagnosis, Global Assessment of Functioning (GAF) score of #55, hospitalization, homelessness, and PSYCHIATRIC SERVICES
incarceration in the past six months. Data for this study were collected by two trained and supervised interviewers in the context of face-to-face interviews. Previous analyses using administrative data have shown that the high-serviceintensity group received significantly more service hours over the first six months of treatment (8.1 hours per month for the high-intensity group, compared with 2.5 hours per month for the low-intensity group). Physical integration was defined as the “extent to which an individual participates in activities” and “uses goods and services” in the community (2). The involvement in community activities scale, adapted from the leisure and recreation activities subscale of the Independent Living Skills Survey (10), measured the extent to which an individual participated in community activities and his or her level of satisfaction with that participation. The extent to which an individual used goods and services in both the mental health and non–mental health communities was measured with a social capital resource generator adapted for individuals with a mental illness (11). Psychological integration was defined as the extent to which an individual perceived membership in a community and was measured in two ways. The Community Integration Measure (12) (with mental health and a non– mental health community versions) measures the sense of participation, connection, and belonging to a community. Cronbach’s alpha was .83 for the mental health community version and .93 for the non–mental health community version. The second measure, the Community Integration Rating Scale, was adapted from the Community Integration Measure (12) and asked the interviewer to use all sources of information from the interview and rate the degree to which the subject participated in, was connected to, and was accepted by the mental health and non–mental health communities. Cronbach’s alpha was .81 and .83, respectively, for the mental health and non–mental health versions. Social integration was measured by a social network interview (13), and perceived availability of social support was measured by the short version of the Medical Outcomes Study
' ps.psychiatryonline.org ' June 2014 Vol. 65 No. 6
Social Support Survey (14) (Cronbach’s a5.82).
Results Of the 33 participants, 18 (54%) were female and 27 (82%) were from racialethnic minority groups. The mean6SD age was 4168 years. Fifteen (46%) were diagnosed as having a schizophrenia spectrum disorder, 17 (51%) as having a mood disorder, and one (3%) as having another disorder. The low- and high-service-intensity groups were equivalent on gender, age, symptom severity, psychosocial functioning, life satisfaction, quality of life, and length of time in services. No significant differences were found between the two groups in the likelihood of being homeless or incarcerated or the likelihood and length of inpatient care in the six months before services began. Homeless participants in the low-service-intensity group had been homeless for longer than those in the high-intensity group (132 days versus 32 days in the previous six months, p,.05). In terms of physical integration, the entire sample engaged in four out of ten common community activities and were between “a little to somewhat” satisfied with their level of community activity. In regard to social capital resources, the entire sample received significantly more social capital from the non–mental health community. Regarding psychological integration, participants’ self-ratings and the ratings of interviewers indicated that they were significantly more integrated into the mental health community than the non–mental health community. Participants’ average network size was 1464 individuals, and their average network consisted of 62% non–mental health individuals (family, non–mental health friends, and non–mental health acquaintances), and 38% mental health individuals (mental health treatment peers, service providers, and mental health acquaintances). About one-third of the average network was family, and about a quarter was friends. Participants’ average social network included about twice as many non–mental health friends as mental health friends. Table 1 summarizes the comparisons between high- and low-service-intensity groups on physical, psychological, and 823
Table 1
Measures of community integration for 33 participants with severe mental illness, by intensity of mental health services
Measure Physical integration Community activities N of community activitiesb Satisfaction with level of activityc Social capitald Total social capital resources From mental health sources From non–mental health sources Psychological integration Self-rated integratione Mental health community Non–mental health community Interviewer-rated integrationf Mental health community Non–mental health community Social integration Social network Network size Proportion of members from mental health community Proportion of members who are family Proportion of members who are friends Proportion of members who are case workers Proportion of members known before mental health treatment Social supportg
High intensity (N518)
Low intensity (N515)
M
M
SD
4.50 2.17
2.12 1.34
SD
4.13 1.47
ta
1.92 –.52 1.30 –1.51
20.56 6.38 24.40 3.50 7.67 8.82 9.93 7.98 19.61 10.23 25.33 13.50
2.19* .77 1.38
41.83 39.11
6.30 37.67 8.01 –1.67† 8.86 31.80 11.26 –2.09*
11.53 6.94
2.06 10.53 2.25 8.67
1.96 –1.40 2.22 2.18*
14.95
5.08 13.00
3.62 –1.24
.50 .25 .27 .09 .31 15.00
.20 .12 .16 .05
.25 .45 .22 .07
.19 .43 3.96 14.33
.16 –3.78** .19 3.61** .16 –.82 .06 –1.54 .19 4.39
1.82† –.46
a
df531 Scale ranges from 0 to 10. c Possible scores range from 0 to 4, with higher scores indicating more satisfaction. d Possible scores range from 0 to 84, with higher scores indicting more social capital resources. Total social capital resources is not an arithmetic mean of mental health and non–mental health social capital resources because of the presence of an “other” category. e Possible scores range from 10 to 50, with higher scores indicating greater perceived integration. f Possible scores range from 3 to 15, with higher scores indicating greater perceived integration. g Possible scores range from 4 to 20, with higher scores indicating greater perceived social support. * p5.05, **p5.01 †p5.10 b
social measures of integration. In regard to physical integration, no significant differences were found between the groups in their level of participation in community activities or satisfaction with involvement in community activities. However, the high-intensity group had significantly less total social capital compared with the low-intensity group. For psychological integration, the high-intensity group felt significantly more integrated than the low-intensity group into the non–mental health community. However, this self-rating was in contrast with the interviewer rating, which indicated that the low-intensity group showed higher psychological in824
tegration than the high-intensity group into the non–mental health community. In terms of social network characteristics, the average network of the high-service-intensity group had significantly more mental health members than the average network of the low-service-intensity group, and the average network of the low-intensity group consisted of significantly more non–mental health members. Participants in the low-intensity group had significantly more family members in their network. Their networks also had a higher proportion of individuals whom they knew before their mental health treatment began, although this PSYCHIATRIC SERVICES
difference was not significant. There was no significant difference between high- and low-intensity groups on perceived social support. These results show that the total sample rated themselves and were rated as being more psychologically integrated into the mental health community than the non–mental health community. However, their social networks were populated by more individuals from the non–mental health community, and the participants received significantly more social capital resources from the non–mental health community than from the mental health community. Although both groups felt more integrated into the mental health community, the high-service-intensity group was rated by interviewers to be less integrated than the low-intensity group into the non–mental health community. The high-intensity group also had less social capital resources than the low-intensity group. In the highintensity group, a larger proportion of the social network was populated by members of the mental health community, whereas in the low-service-intensity group, a larger proportion was populated by members of the non–mental health community.
Discussion This study examined the level of community integration of individuals with severe mental illness into mental health and non–mental health communities by using the conceptual framework of Wong and Solomon (2) and explored the association between intensity of mental health services and community integration. An individual’s movement away from various mental health treatment modalities and toward the non–mental health or “normalized” communities has become a yardstick to measure improvement and recovery (4,8). However, our results suggest that the experience of community integration for individuals with severe mental illness is a complex phenomenon. We found support for Wong and colleagues’ (7) idea of multiple communities and Mandiberg’s (9) idea of subcultures, in that not only did the individuals in our sample have distinct communities with which they interacted, but they also experienced integration into these communities differently. For example,
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participants felt significantly more psychological integration into the mental health community; however, their social networks and social capital resources came more from the non–mental health community. The nature and outcome of this inconsistency require further investigation. In addition, the social networks of the high-service-intensity group had a larger proportion of members from the mental health community, whereas the low-service-intensity group turned to the non–mental health community for its social network affiliations. Pending further investigation, this might indicate that individuals in the high-intensity group have more congruence in their sense of community belonging and the sources of their social network membership, whereas for the low-serviceintensity group, there may be more dissonance between the community they identify with and the community that is the main source of social network members. However, the high-intensity group may be more vulnerable because they had significantly less social capital resources than the low-intensity group. These findings can also be interpreted by using the normalization perspective (4,5). For example, on average, the participants’ social networks had a higher proportion of individuals from the non– mental health community, which supports the notion that social integration into the non–mental health community is possible for individuals with serious mental illness (4–6). At the same time, we found that the proportion of network members from the mental health community was significantly larger in the high-service-intensity group than in the low-service-intensity group and, therefore, that the high-intensity group was less normalized in one aspect of social integration. Although this study advances the investigation of community integration in important ways by using comprehensive and innovative measures and by distinguishing empirically between mental health and non–mental health communities, it was limited in
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terms of its small sample. For example, although the high-intensity and low-intensity groups were largely comparable on clinical and functional variables, larger samples are needed to rule out the group differences that could account for these findings. The study recruited a sample of individuals with severe mental illness who were engaged in mental health services, which limits its generalizability. In addition, although this study included indicators that could support normalization and subcultures perspectives, the dynamic character of these phenomena needs to be studied by using longitudinal designs. Qualitative methodologies could also be essential to understanding the subjective experience of integration into the mental health and non–mental health communities. Such additional studies would help increase our understanding of community integration and inform development of interventions to increase levels and types of community integration for individuals with severe mental illness.
Conclusions Overall, we recommend that approaches to community integration for this population recognize the challenges, opportunities, and contradictions that individuals with severe mental illness face as they navigate between non–mental health and mental health communities. Acknowledgments and disclosures This research was supported in part by grant R01 MH 080671 from the National Institute of Mental Health to Dr. Brekke and Dr. Braslow. Dr. Gabrielian was supported in part by the Office of Academic Affiliations, Advanced Fellowship Program in Mental Illness Research and Treatment, U.S. Department of Veterans Affairs. The authors thank Briana Hedman, M.A., Kim Hopper, Ph.D., Richell Jose, B.A., Lisa Mikesell, Ph.D., Amanda Nelligan, M.A., Elizabeth Phillips, Ph.D., Eric Rice, Ph.D., and Jamie Saris Ph.D., for invaluable contributions to this research. The authors report no competing interests.
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