Community, Public Policy, and Recovery from Mental Illness: Emerging Research and Initiatives

Abstract

This commentary examines the roles that communities and public policies play in the definition and processes of recovery for adults with mental illness. Policy, clinical, and consumer definitions of recovery are reviewed, which highlight the importance of communities and policies for recovery. This commentary then presents a framework for the relationships between community-level factors, policies, and downstream mental health outcomes, focusing on macroeconomic, housing, and healthcare policies; adverse exposures such as crime victimization; and neighborhood characteristics such as social capital. Initiatives that address community contexts to improve mental health outcomes are currently underway. Common characteristics of such initiatives and select examples are discussed. This commentary concludes with a discussion of providers’, consumers’, and other stakeholders’ roles in shaping policy reform and community change to facilitate recovery.

Introduction

Recovery is a ubiquitous, influential concept in mental health policies and services. The Substance Abuse and Mental Health Services Administration (SAMHSA) defines recovery from mental illness as a “process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential”.¹ Braslow notes “three broad categories of meaning from the recovery literature: recovery as a mental health outcome; recovery as a subjective, ineffable experience; and recovery as a system of values meant to animate mental health delivery systems and clinical care”.² Health policy and services perspectives have focused on symptom reduction and reorganizing mental health systems to become more recovery-oriented, while consumers’ views on recovery often include community participation, inclusion, belonging, and well-being.^3,4 This expanded vision suggests a recovery framework that considers communities and policies that may facilitate or inhibit recovery.⁵

This commentary examines the role of communities—places, contexts, relationships—and public policies in the definition and advancement of recovery from mental illness for adults. Although the authors are aware of the importance of recovery as a concept for individuals with substance use disorders and for children, adolescents, and transitional-age youth, we felt those topics warranted a separate discussion tailored to those groups.^6–8 This paper begins by outlining the concepts of both recovery and community and then reviews evidence on the influence of public policies and community contextual factors on outcomes for people with mental illness. Lastly, this paper considers emerging community-level interventions and discusses potential roles for mental health providers and other stakeholders in community coalition-building and community action.

I. Individual vs. Collective Definitions of Recovery

While a pervasive concept, there is no universally accepted definition of recovery. This commentary recognizes that, for some, recovery is an ongoing process, while for others it involves the achievement of functional goals or symptom reduction⁹. Definitions can differ depending on discipline and perspective, such as clinical, policy, advocacy, and personal/individual. These definitions reflect diversity in values and perspectives: advocacy and political views, perceived importance of mental health services, domains of experience deemed to promote recovery, and individual versus collective views on achieving and maintaining recovery. This section will begin with a frequently cited individualistic definition of recovery and highlight alternate definitions that emphasize the roles of community and relationships.

The 2003 New Freedom Commission on Mental Health was a pivotal document that adopted recovery as the core principle of federal mental health policy.¹⁰ The New Freedom Commission defines recovery as “the process in which people are able to live, work, learn, and participate fully in their communities. For some individuals, recovery is the ability to live a fulfilling and productive life despite a disability. For others, recovery implies the reduction or complete remission of symptoms”[page 5].¹⁰ Michael Hogan, Chair of the Commission, comments on recovery as an assertion of consumer “self-awareness and a sense of empowerment” [page 1469].¹¹ In the New Freedom Commission’s definition, individuals define their own recovery and direct the means toward its achievement.

In contrast, collective definitions acknowledge that recovery is facilitated, obstructed, or otherwise influenced by contexts. If recovery means the ability “to live, work, learn, and participate fully in one’s community,” as in the New Freedom Commission’s definition above, its realization will differ depending on one’s community, including what resources are available.¹⁰ A community with fewer educational, employment, social, and other opportunities may impede individuals’ recoveries as compared to communities with greater resources. For example, SAMHSA’s 2004 definition of recovery emphasizes community as one of four dimensions of recovery, stating “communities have strengths and resources that serve as a foundation for recovery” [page 7].^1,12 SAMHSA further asserts, “Communities have responsibilities to provide opportunities and resources to address discrimination and to foster social inclusion and recovery” [page 7].¹ The importance of social networks and community supports to facilitate recovery is echoed in other advocacy, research, and international definitions of recovery.^9,13–15 Whereas clinical definitions of recovery typically focus on reduction of symptoms and disability, consumer definitions often focus on the social dimensions of recovery, such as inclusion, integration, connectedness, and meaningful relationships.^3,4

Similarly, social science insights from medical anthropology and disability studies emphasize individuals’ interrelationship with their social contexts. The social model of disability, the capabilities approach to recovery, and studies of structural stigma describe how social and institutional structures and processes can influence recovery.^16–18 These frameworks explain the means by which social, cultural, and political responses to those with mental illness can reduce opportunities for recovery and social participation.^19,20 Using these frameworks, scholars have traced the ways that biomedical and legal institutions are complicit in stigmatizing people with mental illnesses.^21,22 Hopper writes, “If disability’s social reality – the viable identities and real prospects available to afflicted persons – is determined as much by the rules and resources applied to difference as by any underlying impairment, then restoration and repair become social projects not merely treatment regimens. They require interventions into common meaning-making as well as material provisions of housing and work. Such socio-cultural accommodations enlarge the realm of the possible and transform the meaning of injury.”¹⁶

Definitions of recovery emerging from the lived experiences of consumers of mental health services and allies have important political roots.²³ For many, recovery carries political meanings focused on redefining mental illness, changing cultural attitudes about people with mental illness, and altering service delivery. This paper does not aim to represent all recovery meanings and intentionally approaches recovery through a social-ecological lens, focusing on multi-sector and policy contributors to individuals’ well-being and resilience. Consistent with previously described collective definitions of recovery, consumer definitions prioritize social, community, and political contexts to realizing recovery goals. Hence, it is important to have a clear framework for these determinants of mental health and recovery.

II. Defining Community and Community-level Determinants of Mental Health

Community has been broadly conceptualized in three ways: 1) spatial or geographic units, 2) units of patterned social interaction, and 3) symbolic units of collective identity.²⁴ Community, therefore, can refer to shared spaces (e.g., counties, neighborhoods) or shared activities and identities (e.g., culture, occupation, sexual orientation, or gender identity). Community contributions to health are intuitively accepted areas of research and intervention in public health and clinical practice in other medical specialties. Notable examples include food deserts and obesity, air quality and asthma, and neighborhood chronic stressors (e.g., violence) and hypertension^25–27.

The Model for Analysis of Population Health and Health Disparities by the Centers for Population Health and Health Disparities of the National Institutes of Health provides a framework for understanding the influence of community on mental health outcomes and disparities (Figure 1).²⁸ The model describes three categories of biological-environmental determinants of health disparities based on their spheres of influence relative to the individual. Distal determinants exert their influence on health at the population level, intermediate determinants at the interpersonal level, and proximal determinants at the biological level. Distal determinants include social conditions and politics, such as racial discrimination, prejudice, poverty, public policy, and stigma, as well as institutional contexts such as political, economic, and healthcare systems. Intermediate factors include physical contexts (e.g., parks, housing quality, neighborhood safety), social contexts, and relationships (e.g., social integration, social supports). Proximal determinants include individual-level demographics, risk behaviors, and biology. Lastly the model describes biologic-environment interactions among all three levels, illustrating that factors can act at multiple levels (e.g., mental health stigma affecting economic opportunities, relationships, and biological stress processes). As a result of these interactions, the effects of a given determinant on mental health outcomes are not uniform across populations and individuals, but differ due to factors such as local culture and resources. As such, the mental health effects of certain community-level factors may be greater for vulnerable populations.

Figure 1.

Model for Analysis of Population Health and Health Disparities, Centers for Population Health and Health Disparities of the National Institutes of Health

Figure reproduced with permission from Warnecke RB, Oh A, Breen N, et al.: Approaching health disparities from a population perspective: the National Institutes of Health Centers for Population Health and Health Disparities. American Journal of Public Health 98: 1608–1615, 2008. Copyright The American Public Health Association.

III. Community-level Factors Impacting Mental Health

The next questions are whether and to what extent community-level factors affect mental health and recovery. The following discussion focuses on distal and intermediate-level community determinants. This section is not meant to be comprehensive but rather illustrative of examples of community-level determinants that are the subject of emerging research, initiatives, and public policies. Individual-level determinants of health (proximal factors) also play an important role in recovery, but are not the focus of this commentary.

Macroeconomic Events and Economic Policies

There has been a great deal of research on the relationship between social class and its proxies (e.g., income) on health.²⁹ A recent analysis of US mortality records from 1999 to 2014 showed a 14.6- and 10.1-year life expectancy gap, for men and women respectively, between the 1% of the population with highest income and the 1% with lowest income.³⁰ Mental illness has been found to be bi-directionally related to income.³¹ A population-based prospective study showed that people with incomes less than $20,000 had increased lifetime odds of having psychosis (odds ratio of 4.28) and bipolar disorder (2.56) compared to people with incomes greater than $70,000.³¹ This relationship between income and mental health is complex, involving upstream macroeconomic policies, the influence of mental illness on employment and earning potential, the effects of class and income on the ability to purchase goods and services, and opportunities to alter intermediate and proximal determinants through higher income (e.g., purchasing housing in environmentally greener neighborhoods).

Two distal determinants of note are the Great Recession of 2008 and the availability of Supplemental Security Income (SSI) for disabled adults. Macroeconomic events, such as the Great Recession, have population-level effects on unemployment, income, debt, perceived financial security, and other factors. These in turn have downstream impacts on health and even mortality, with effects that may persist for years even after employment is regained.³² A stark example of the effect of the Great Recession was described in a 2014 study that compared trends in the incidence of suicides from before (2001–2007) and after (2008–2010) the recession in Europe, Canada, and the United States.³³ The authors estimated that the Great Recession was associated with 10,000 “economic suicides,” with suicide incidence markedly increased in all regions from 2008–2010. Similar findings are seen in studies using other methods and in a recent systematic review.^34–36 In other words, recession and population-level decrements in economic opportunities are associated with worsened mental health, increased prevalence of mental illness, and higher incidence of suicides and suicidal behavior.³⁶

A second example of an economic distal determinant on mental health is SSI for adults with disabilities. SSI is a cash benefit, totaling up to $8,830.84 annually for individuals (as of 2017) depending on an asset-based sliding scale. In 2013, SSI was the sole source of income for over one-third (35.4%) of adult recipients.³⁷ A substantial proportion of SSI recipients still have total family incomes below the federal poverty threshold (41.9%), and most have incomes below 125% of the federal poverty level (54.2%).³⁷ SSI and other public cash assistance programs are important financial safety nets for many adults with mental illness, lifting some above the federal poverty level, albeit in some cases at only subsistence levels.

To our knowledge, no prospective study has measured the mental health status of individuals before and after the receipt of SSI financial payments. In 2015 a Swedish study examined participants with serious mental illness concurrently receiving both safety net mental health and social services, and government cash assistance benefits.³⁸ The non-randomized, prospective study had two groups: one (n = 100) received a monthly additional cash allowance of $73 for 9 months, while another (n = 38) received no cash assistance. Both groups received treatments and social services as usual. After the 9-month intervention and 7 months of follow-up, there were no significant mental health changes for the group who did not receive the allowance. The group that did receive the allowance had significant improvements in perceived quality of life and social networks, and statistically significant (but clinically modest) decreases in depression and anxiety symptom severity.³⁸ The causal relationship between enhancing income and improved mental health is supported by a large cluster-randomized study of an unconditional cash transfer program in Kenya (n = 1960, $20 monthly cash transfers), which showed 24 percent lower odds of depression among cash recipients compared to individuals in control communities who did not receive payments.³⁹

Housing Policy and Homelessness

According to the National Epidemiological Survey on Alcohol and Related Conditions, people with mental health disorders have a substantially higher risk of homelessness compared to the general population, and people who are homeless are unusually likely to have mental health issues.⁴⁰ In 2010, the last year this national diagnostic data was reported, nearly half (46%) of over 400,000 sheltered homeless adults self-reported having serious mental illness and/or a chronic substance use disorder.⁴¹ Broadly speaking, mental health services research has put forward two evidence-based Housing First (housing not contingent on pre-placement sobriety \ or adherence to mental health treatment) models for people who are chronically homeless with serious mental illness. The first is the scatter-site model which involves rapid placement in low-density housing, supported by outreach-based mental health services such as Assertive Community Treatment teams⁴². The second model consists of housing placement in congregate settings with on-site mental health and other services^43,44. Numerous studies have found both models to be effective at decreasing mental health symptoms and improving quality of life, functional status, substance use outcomes, and retention in permanent housing.^44–48 The Department of Housing and Urban Development and Veterans Affairs Supported Housing (HUD-VASH) program adopts elements of both models above. HUD-VASH has been shown to increase days housed, social contacts and the availability of emotional support, and satisfaction with relationships^49,50. These findings suggest a causal link between specialized housing services and positive mental health outcomes for people who are homeless with serious mental illness.

Looking distally, the effects of housing policy on homelessness and mental health outcomes are seen in the juxtaposition of two urban communities. New York City has the largest and Los Angeles County the second largest number of people who are homeless in the country, 73,523 and 43,854 respectively.⁵¹ Nearly 3 in 4 individuals experiencing homelessness in Los Angeles County are unsheltered, that is living in “places not meant for human habitation” (e.g., streets, parks).⁵¹ By contrast, only 3.9% of people who are homeless in New York City are unsheltered.⁵¹ This is due to multiple factors, but follows a New York State Supreme Court decision in the 1979 case of Callahan v. Carey and subsequent follow-up litigation, which established a “right to shelter” in New York City.⁵² The effect of this ruling can be seen in the growth of homeless shelter beds from roughly 11,000 in 1983 to over 60,000 in 2016.⁵³

Two examples of distal civic initiatives in New York and Los Angeles to improve the outcomes of individuals who are homeless with serious mental illness are the New York/New York (NY/NYIII) supported housing system and the Los Angeles County Department of Health Services’ Housing for Health program. The NY/NYIII system is the largest locally funded permanent supported housing network in the country and includes housing specifically for people with serious mental illness and substance use disorders.⁵⁴ Studies of NY/NYIII residents with substance use disorders have shown improved outcomes (decreased odds of using stimulants or opiates in the past 30 days after 1 year of being housed), particularly for those living in residences with high fidelity to Housing First principles.⁵⁵ NY/NYIII housing has also been shown to lead to significant changes in public service utilization, specifically decreased emergency and acute hospital service use and decreased incarcerations.⁵⁶ Newly approved Los Angeles ballot initiatives Measures H and HHH will finance permanent supported housing to benefit the unsheltered homeless population.^57,58 The Los Angeles County Department of Health Services’ Housing for Health program is an emerging initiative that uses public-private partnerships to subsidize permanent supported housing and services for individuals with chronic health conditions, including serious mental illness.⁵⁹ Preliminary results, 1-year pre- and post-placement in Housing for Health permanent supportive housing, show a 76% reduction in medical hospitalizations and a 68% reduction in emergency room visits.⁶⁰

Healthcare Policy

At the distal level, healthcare policy has far-reaching effects on mental health beyond access to treatment. Increasing access to health insurance coverage can promote recovery. This is supported by findings from Oregon and Massachusetts that showed, respectively, that health insurance expansions lowered depression rates and improved self-reported mental health.^61,62 The Oregon Medicaid study showed that 2 years of health insurance access resulted in a 30% relative reduction in depression prevalence.⁶¹ Possessing health insurance likely improves mental health outcomes through pathways other than simply more treatment, such as by decreasing the financial and psychological stress of anticipated healthcare costs.⁶¹ Relevant policy examples include health insurance expansion via the Affordable Care Act and the Mental Health Parity and Addiction Equity Act.

Additionally, coordination, integration, or co-location of mental health services within primary care or other settings has the potential to enhance recovery by increasing treatment access.⁶³ Relevant examples include incentivizes to implement collaborative care models, the creation of behavioral health homes, and mandated models such as mental health diversion courts and assisted outpatient treatment.^64–67 A recent randomized controlled trial compared behavioral health home services (a collaboration between a community mental health center and a Federally Qualified Health Center) to usual care and showed significant improvements in quality of care (improved cardiometabolic care, increased use of preventive services) and clinical outcomes (improved blood pressure control and health-related quality of life) in the behavioral health home group after 12 months.⁶⁸

Disparities in Exposure and Vulnerability

Turning to intermediate community-level determinants, mental health consumers experience disparities in their exposure to adverse factors such as food insecurity and housing/employment discrimination, which impact mental health.^69,70 One important adverse exposure is violence. Multiple studies have shown that people with serious mental illness are at higher risk of crime victimization.^71–76 This is in contrast to media representations that disproportionately depict people with mental illness as being violent and dangerous⁷⁷. A study of 936 randomly selected consumers of 16 Chicago outpatient, residential, and day treatment programs found that they were 11 times more likely to be a victim of a violent crime in the past year than the general population.⁷¹ More than a quarter of people with serious mental illness self-reported being a victim of a violent crime in the past year.⁷¹ A more recent study followed 951 consumers for a year after a hospital discharge and found that 43% were the victim of violence during that period.⁷⁶ Exposure to victimization, in many forms, has been shown to be associated with greater depressive, anxiety, cognitive, and psychotic symptom severity in people with schizophrenia and schizoaffective disorder.⁷⁸

Going further, a recent study focused on a predominantly low-income, city-dwelling sample (n = 615, 95% African American) and used an evidence-supported survey to measure participants’ perceptions of neighborhood disorder (e.g., physical disorder as reflected by vandalism, social disorder reflected by crime). The study found that perceived neighborhood disorder predicted posttraumatic stress disorder (PTSD) symptomatology, even when controlling for individuals’ childhood and adult trauma exposure. In other words, individuals developed PTSD symptoms when exposed to adverse social and physical environments. These findings are supported by other research that showed similar associations between adverse neighborhood environments (e.g., population density, household deprivation, urbanicity) and increased incidence of psychosis, mood disorders, anxiety, and substance use.^79–82 The Moving to Opportunity study showed that these adverse neighborhood effects on the mental health of adults can be reversed⁸³. The study randomized some families to receive Section 8 housing vouchers and assistance to move to “low-poverty” neighborhoods. Parents within families that moved to those neighborhoods reported significantly decreased emotional distress and depressive symptoms after 3 years, compared to parents that remained in “high-poverty” neighborhoods. The study authors theorized that this could be due to decreased neighborhood disorder and greater availability of health and social resources in “low-poverty” neighborhoods. However, the study’s findings were mixed for children, with improved depression and conduct disorder in girls, but greater rates of depression, PTSD, and conduct disorder in boys⁸⁴.

Social Capital, Collective Efficacy, and Social Cohesion

Neighborhood disadvantage has been shown to be associated with higher prevalence of mental illness, but neighborhood social capital in the forms of collective efficacy and social cohesion can positively contribute to mental health and can even be protective in the face of adverse exposures described above.⁸⁵ Social cohesion can be thought of as the level of interconnectedness in the relationships among people in a community, whereas collective efficacy is a “group’s shared belief in its conjoint capacity to intervene on a problem or issues based on shared norms and behaviors.”^86,87 The Project on Human Development in Chicago Neighborhoods (PHDCN) was a longitudinal study conducted from 1994 to 2002 that examined how neighborhood characteristics influenced individuals’ behavioral health and social outcomes.⁸⁸ One PHDCN study on depression in women who had experienced intimate partner violence found protective mental health effects of neighborhood supportive mechanisms, particularly collective efficacy and social cohesion.⁸⁷ The authors stated that this may be the result of decreased stress owing to increased social supports, enhanced feelings of control, and lower mistrust of others.⁸⁹ Neighborhood social capital has also been shown to be protective of mental health after exposure to natural disasters (e.g., Hurricane Sandy), life-threatening violence, and discrimination based on immigrant status and race.^90–93

IV. Emerging Initiatives and Policies Impacting Community-level Determinants of Mental Health

New policies, public health initiatives, and service delivery models are intervening on intermediate and distal determinants to facilitate individuals’ mental health and recovery. Some of these changes are prompted by payment rules that acknowledge socioeconomic influences on health outcomes.^94,95 Generally, such upstream strategies have four qualities in common: they 1) address both health and social needs, 2) decrease community-level inequities in health and social opportunities, 3) incorporate cross-sector partnerships, and 4) promote community-wide values around mental wellness and recovery. These upstream initiatives recognize that community-level determinants can obstruct individuals’ recovery, and they attempt to rectify systemic factors known to perpetuate social and health inequities.

Across medical specialties and public health, upstream strategies are already underway with initiatives that fall under the rubrics of health equity, health-in-all-policies, and the social determinants of health.^94,96–106 Examples of such initiatives, both public and private, include the United Kingdom’s social impact bond “trailblazer” projects, Center for Medicare & Medicaid Innovation Accountable Health Communities, Centers for Disease Control Community Transformation Grants, The California Endowment’s Building Healthy Communities initiative, and the Robert Wood Johnson Foundation’s Culture of Health.^94,107–110 These strategies have the potential to improve mental health by supporting existing community programs to address social needs, creating incentives for the formation of new networks of care, improving the built environment, and creating shared values around recovery.

Two examples of distal policies that aim to address intermediate determinants of recovery are Social Security Act Section 1915(i) Home and Community-based Services (HCBS) and California’s Mental Health Services Act (MHSA).^100,103 Section 1915(i) created an optional Medicaid benefit for services that address social determinants of health that were previously excluded from healthcare.¹⁰³ New York State incorporates HCBS designed for at-risk people with serious mental illness to directly fund services including supported employment, supported housing, peer specialists, transportation, and education supports.⁹⁶ In California, the MHSA annually funds more than $1.8 billion of new, recovery-oriented mental health programs through a one-percent tax on personal incomes above $1 million.¹⁰⁰ Recovery language and goals pervade the MHSA, and the act serves as a platform to increase access to recovery-oriented services and generate statewide values for mental health promotion.

County and city governments are also fertile ground for promoting community-oriented strategies that focus on distal- and intermediate-level determinants like neighborhood safety, shared community values for mental health, and social capital. The Los Angeles County Department of Mental Health’s Health Neighborhoods is a county-wide initiative to improve service coordination among faith-based organizations, social services, mental health, public health, substance use treatment, and other community-based organizations in 11 under-resourced neighborhoods.^111,112 Health Neighborhoods leverage community strengths and partnerships to address intermediate and distal determinants through projects to decrease interpersonal and family violence, promote community safety, and build collective efficacy. At the city level, New York City’s ThriveNYC initiative is an $850 million multi-program initiative that introduces a mental health mission across more than 20 city agencies, from transportation to public parks.¹¹³ ThriveNYC emphasizes multi-sector partnerships, community capacity building, and shared values to address mental health and social needs. One ThriveNYC program is the Connections to Care program, a $30 million public-private partnership to integrate mental health services into community-based programs that serve low-income neighborhoods.

Large-scale, federally-funded, multi-sector programs to address mental health and social needs have been attempted before with mixed results. As one example, the $35-million Collaborative Initiative to Help End Chronic Homelessness (CICH) combined evidence-based models (Assertive Community Treatment, Housing First) with multi-sector partnerships among housing, supportive services, primary care, mental health, and substance use treatment services.¹¹⁴ Compared to usual care, individuals receiving intervention services spent significantly more days housed, fewer days in jail, and received more healthcare and case management visits. No significant differences were seen, however, in physical or mental health-related quality of life, substance use, or measures of community adjustment.¹¹⁴ Also, the results of the Moving to Opportunity study, discussed above, differed among sub-groups (parents, boys, girls).⁸³

The examples of CICH and the Moving to Opportunity Study illustrate that despite evidence-based and emerging interventions, many questions remain. Which distal and intermediate determinants should be prioritized for intervention to yield improved mental health and quality of life? What service delivery models are optimal, and for whom? By what combination of social (e.g., number of days housed) and health (e.g., substance use) metrics should success be defined? How can outcomes for sub-groups be supported within highly complex interventions? It is clear, however, that there is a high individual and societal cost of failing to act on the “cumulative disadvantage” of early disparities in distal and intermediate determinants, which contributes to a cascade of health and social problems that compound throughout the lifespan.¹¹⁵

A growing line of research has the potential to answer the questions above and inform new initiatives by measuring the magnitude and duration of the influence of distal and intermediate determinants on individual- and population-level outcomes.¹¹⁵ This new generation of research integrates multiple modalities, from precision medicine to ethnography to population-level secondary data, to understand the mechanisms by which these determinants act on individuals’ mental health and to characterize biological-environmental interactions among the full constellation of determinants.¹¹⁶ New research also seeks to understand how to engage non-healthcare sectors to achieve these goals and provide new models for multi-sector partnership and community capacity-building.^117,118

Policymakers, community leaders, healthcare providers, business leaders, consumers, advocates, and other stakeholders have opportunities to facilitate positive mental health by examining policy, social, and physical environments. Drawing on the four qualities common to the strategies described above, programs can be supported that create shared, multi-sector responsibilities to care for people with serious mental illness by concurrently addressing social and treatment needs. Additionally, policymakers can incentivize services that enhance communities’ capacities and assets to support individuals’ mental health outcomes, social integration, and quality of life.

V. Addressing Community and Policy Contexts for Recovery

Mental health providers can focus on community contexts for recovery through clinical practice, advocacy, political activity, education, and research. To be effective, clinicians may need to understand consumers’ social/community contexts and how these may impact their recovery. This could entail the use of systematic screening tools for social determinants of mental health and recovery.¹¹⁹ Such screening could then be linked to interventions on risk factors, such as social isolation, which are known to obstruct recovery. Following research and policy examples described above, systems of care may consider adopting multi-sector collaborative care approaches for mental illness and building coalitions that more efficiently address upstream determinants. They may do this, for example, by including social services and community-based organizations within healthcare networks and increasing providers’ expertise in systems-based practice, which is defined by the Accreditation Council of Graduate Medical Education (ACGME) as “awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care.”^{94,97,111–113,120–122}

Consumers, family members, providers, and others have the opportunity to support public policies that address distal and intermediate barriers to individuals’ recoveries. Stakeholders may look to consumer leaders and mental health advocacy organizations, such as Mental Health America and the National Alliance on Mental Illness, for information on emerging policies relevant to maximizing recovery.^15,123 Consumers and providers may also consider avenues for political engagement (e.g., voting, contacting legislators and other elected officials), as advocacy and the exercise of political rights have been described as important components of recovery for some^124,125.

Providers and other stakeholders have the ability to improve access to mental health services and address distal determinants by working to decrease stigma and increase public acceptance of those living with mental illness. Mental health educators, medical schools, graduate schools, and the ACGME have the opportunity to ensure that professional training programs increase awareness of systems-level issues in mental health treatment, adopt model curricula (e.g., systems-based practice, structural competence), and create incentives for providers to choose careers serving under-resourced communities.^{121,126–128}

Science has identified distal and intermediate community-level determinants like neighborhood safety, collective efficacy, and employment opportunities that can serve as intervention targets. Moreover, mental health research has provided templates for evidence-based, multi-sector, multidisciplinary interventions to address mental health and social needs, such as the scatter-site and congregate permanent supported housing models described above. Despite this, people with serious mental illness rarely have access to a broad array of effective services, in part because of failures to implement multi-system interventions and to assure their availability and acceptability. Mental health researchers have the opportunity to work closely with policymakers and health system administrators to address this important science-to-service gap¹²⁹.

Involvement of providers and consumers in research on recovery interventions is an important area for growth. Community-partnered research approaches are designed to advance science while promoting community voice, consumer and community leadership development, and social justice in research.^118,130,131 A relevant example is Community Partners in Care (CPIC), a Los Angeles-based community-partnered participatory research study with community and consumer co-leadership in all phases.¹²⁰ CPIC included 95 programs in five sectors: social/community services (e.g., hair salons, exercise clubs, senior centers), outpatient primary care, outpatient mental health, substance use treatment services, and homeless services. Programs were randomized to two approaches to implementing expanded collaborative care networks for depression: expert training for individual programs versus multi-sector coalitions to collaborate in training and implementation. CPIC provided evidence for the superior effectiveness of the coalition approach in improving participant outcomes, relative to trainings for individual programs. CPIC and other community-partnered research showcase the importance of diverse community and consumer voices in the science of recovery.

The preceding sections describe how policy, institutional, and interpersonal environments can either enhance or obstruct journeys to recovery. Underfunding of effective mental health care; fragmentation at the level of policy, reimbursement, and clinical services; and the legacy of deinstitutionalization and mass incarceration have reflected and reinforced stigma about people with serious mental illnesses. In response, many communities have chosen to make dramatic public investments in mental health infrastructure, as New York City has done with the nearly $1 billion investment in ThriveNYC and as California and the City of Los Angeles have done through the success of ballot initiatives like Measure H in March 2017, Measure HHH in November 2016, and the Mental Health Services Act in 2006. Moreover, windows of opportunity emerge to implement wide-ranging policy innovations to improve outcomes¹³². The initiatives described in section IV will unfold in the context of emerging federal health policy shifts. The effects of new healthcare policies on mental health outcomes, multi-sector initiatives, and recovery warrant vigilance and concurrent study. Mental health advocacy organizations, consumers, families, providers, researchers, and other stakeholders should consider ways to translate hard-earned knowledge into shared values and policy imperatives for the well-being of people with mental illness.

Conclusion

Communities can contribute to positive mental health. Box 1 summarizes some ways for mental health stakeholders to take action on community and policy-level determinants of recovery and positive mental health. This commentary urges a broad examination of the aspects of community life that contribute to mental health. As outlined above, consumer definitions, research, emerging initiatives, and innovative policies suggest the importance of distal and intermediate determinants to positive mental health. Complicating individualistic frameworks of recovery, this commentary urges the development of collective responsibility for mental health and an examination of the community experiences and structural environments of people with serious mental illness. Further dialogue and culture change is needed to impel broader public policy reform and intentional efforts at community change and capacity-building. Following emerging policies, such reforms can build on community assets, strengthen coalition-building across healthcare and social/community sectors, and attend to issues of equity.

Box 1. Summary of Considerations for the Mental Health Provider: Taking Action on Community and Policy Determinants of Recovery and Positive Mental Health.

1. Mental health providers engage in systems-based practice

2. Mental health educators provide training in systems-based practice and social determinants of mental health

3. Mental health leaders create and support formal research and policymaking roles for consumer and community member input

4. Mental health researchers conduct research to better understand how social determinants affect individuals’ mental health outcomes

5. Mental health researchers develop new evidence-based, multi-sector models of care to address health and social needs, in partnership with communities

6. Mental health policymakers create incentives for trainees to enter careers in public-sector/community mental health

7. Mental health policymakers, researchers, and other stakeholders support new policies and initiatives that include the following qualities, in line with existing local, state, national, and international programs:

   1. Address both health and social needs for those with serious mental illness and substance use disorders

   2. Decrease community-level inequities in health and social opportunities

   3. Promote multi-sector partnerships with healthcare systems

   4. Promote collective efficacy and responsibility for mental health recovery

Addressing upstream determinants at community and policy levels is challenged by domains of influence and funding streams that are often far outside of healthcare, but this is starting to change. Policies, programs, and service delivery models are emerging across the country that address upstream inequities in health and social opportunities, include cross-sector partnerships, and create shared values around mental health and recovery.

In accordance with a public health perspective on recovery, “the limits of the clinical encounter do not represent the end of the story of how to address social determinants but the beginning.”¹³³ A new generation of mental health research and policies has the potential to change the trajectory of entire communities. To understand what would improve recovery, the field must listen to communities. To effect change, the field must have the courage to follow communities’ agendas.