Mental Illness, Criminality, and Citizenship Revisited
======================================================

* Michael Rowe
* Jean-François Pelletier

In a 2000 editorial in *The Journal*, Rowe and Baranoski1 introduced the concept of citizenship as a theoretical framework for developing programatic and policy initiatives aimed at the community integration of persons with mental illness and criminal justice histories. Rowe and colleagues defined citizenship as a strong connection to the rights, responsibilities, roles, resources, and relationships—the five Rs—that society offers to its members through public and social institutions and associational community life.2,–,4 The earlier editorial helped focus understanding of citizenship in regard to the target group and its potential application in practice, thus providing a partial template for the work. Thus, the authors of this editorial would like to review the key elements of this research over the past decade, and also contemplate future efforts.

Rowe first identified citizenship in the 1990s as a way of thinking about community integration in regard to people who are homeless with mental illnesses.5 Soon, though, it became clear to Rowe and Baranoski that citizenship, with its five Rs, had a special relevance to persons with mental illness and criminal justice charges or previous incarceration, for three overarching reasons. First, programs including but not limited to jail diversion that help to redirect people from criminal to mental health systems provide a much-needed service to such persons and are important elements of comprehensive mental health systems of care. They are not, however, intended to be, nor do they function as, mechanisms to support the community integration of those persons.

Second, people with mental illness often run afoul of the law, not out of *mens rea*, but because of behavior related to symptoms of their mental illness, their lack of social skills, or the exigencies of poverty including homelessness. Many times, their “criminal conduct” involves an element of trying to make contact with their fellow citizens, or reflects an understanding that doing so is a social expectation they share with others. One example used in the 2000 editorial is of a man lecturing, loudly and in your face, on Jungian psychology at a bus stop, in an overreach at making contact with his fellow citizens. Another is that of a woman, homeless and with a mental illness, who is arrested for trespassing on private property in the act of working (collecting redeemable bottles left in the trash) and improving the environment (by recycling).1

The point of these examples was and is not to gainsay the impact of psychiatric disorders on these and other persons. It is also not to say that acting like a good citizen is preeminent in such individuals' minds at the time of their actions, anymore than it is for most people when they pay their taxes or mow their lawns, even though these acts can be said, severally, to involve neighborliness, conformity to community norms, and support for maintenance of the social contract. In addition, the authors of this editorial do not see a need to argue what is already known, that people with mental illnesses living in poverty have a special vulnerability to arrest and incarceration. Rather, Rowe and Baranoski argued then and we do now that, for many individuals with mental illness, behaviors that lead to arrest on low-level charges may include the intention to conform to, or reflect an element of, normative cultural expectations of social actors. If this is so, then interventions that support people's normative social behavior and help them to modify non-normative behavior may help them to become community members and citizens. Citizenship includes more positive elements than the ability to conform and has so included in our application of it, but normative behavior is part of “making it” as a citizen.

The next question, then, was one of application. How does one translate the theory of citizenship into practice to help the target group? Rowe *et al*.3 began by developing a four-month intervention with three components. First, classes were taught by a project director with advocacy, not clinical, experience and by community members, peer mentors and sometimes participants (students) themselves. Topics ranged from rights and responsibilities of clients of mental health and criminal justice systems, public speaking, to intimate relationships. Second were valued role projects in which students combined life experience and class learning to give back to the community, while demonstrating to themselves and others their ability to fulfill socially valued roles. An example is a valued-role project in which students met with police cadets to teach them about the experience of having a mental illness and being approached by a police officer on the street. Third was wraparound peer mentor support, in which persons with mental illness and, in most, criminal justice histories, acted as guides, counselors, and advocates to students.

With state and private funding, the next step was to conduct a randomized, controlled trial comparing outcomes for participants receiving the citizenship intervention, along with usual public mental health services, to those receiving public mental health services alone. Quantitative results of baseline and 6- and 12-month interviews showed significantly reduced alcohol and drug use and significantly increased quality of life for citizenship compared with control group participants. Criminal charges decreased significantly for both intervention and control groups.6 Qualitative inquiry showed that the citizenship intervention, initially designed as a sort of pass-through, supportive setting to help people move from the margins of their communities toward greater participation and sense of belonging, became, in fact, a new subcommunity for participants that supported its members' citizenship efforts in the community and society at large.3

So there was something to show for the collective efforts to link abstract theorizing about citizenship to the challenges of community integration for the target group. Not all was rosy, however. In addition to positive findings, a 6-month follow-up revealed that intervention participants had significantly increased anxiety, and a 12-month follow-up revealed a moderately significant increase in negative symptoms, compared with control group participants.7 These findings suggested the need for postintervention support, perhaps through a combination of graduates' continued support by a peer mentor. In addition, it was uncertain whether the theoretical framework captured all the essential domains required to support individuals' full community membership. It could be claimed, after all, only that a “best effort” had been made to translate the core elements of the five R's into practice. What was needed, now, was to measure empirically the concept of citizenship. Doing so might help enhance the original citizenship intervention by providing data to target citizenship strengths and deficiencies; provide data for development of an individual citizenship counseling tool for use in peer or other counseling and support; and provide a means of measuring baseline and follow-up citizenship status of the target group.

NIMH funding supported implementation of a community-based, peer-informed participatory study,8 using concept-mapping-factor analytic methods9 to develop an individual measure of citizenship. This study drew on the concept of “off-timedness,”10 in which people return to normative society after a period of being removed from it—as with a first-break psychiatric hospitalization or overseas military duty—and have difficulty adjusting to normative life.

A central hypothesis of this study was that persons who have experienced such significant life disruptions would have both common and different experiences of citizenship according to the nature of the disruption and that there would be both common and different experiences of citizenship across disrupted groups. By testing this hypothesis, the research team proposed to identify common elements of citizenship and the community integration and inclusion associated with it. The team would also be able to identify areas of citizenship support for persons with mental illness in general, especially those with the dual burden of criminal charges.

Over the course of this citizenship research, some colleagues have criticized the use of citizenship as an applied theoretical framework on the grounds that citizenship is too narrowly associated, in practice, with the political and legal elements of being a citizen.11 The research team believed that a more multifaceted view of citizenship would emerge from this study, including those facets related to civic participation.12

Research methods involved, first, generating citizenship items in separate focus groups with persons with serious mental illness (SMI), persons with SMI with criminal justice charges, persons with serious medical illnesses, persons with combinations of these life disruptions, and persons who had not experienced any of these disruptions. Using these items, concept-mapping sessions were conducted. In these sessions, individuals belonging to each of the target groups categorized citizenship items by perceived similarity and then ranked items according to importance and the degree to which the item was present in their lives. Concept-mapping software and analysis of its findings ultimately led to designation of seven domains of citizenship: personal responsibilities, government, caring for self and others, civil rights, legal rights, choices, and world stewardship. Participants had indeed conceptualized citizenship broadly with both legal-political and social-participation elements.13

Using the seven domains, the team developed a 45-item outcome measure for which initial validation procedures have been conducted through administration of the measure with clients of our local public mental health center. While the team is in the early stages of comparing citizenship scores by group, it has already identified that persons with SMI and criminal justice histories scored lower than all other groups on six of the seven citizenship domains, excluding care of self and others.

With intervention findings and a measure of citizenship, the team is now in a position to enhance the intervention and test the results, using the citizenship measure along with other clinical and community outcomes measures. Successful outcome of this study would have major implications for practice and policy regarding the up to 50 percent of persons receiving public mental health services and having criminal justice involvement and substance use disorders14 and to the public health burden and costs associated with care for this large group.

In the meantime, citizenship work has begun to go international. Colleagues in Canada, France, Denmark, and Australia are beginning to use the framework and have expressed interest in using the new measure. Efforts in Canada, where provincial courts and the criminal justice system have become the system of social well-being of last resort for many, are especially intriguing. Homelessness, mental illness and alcohol abuse and drugs are common denominators of criminalization in Canada as in the United States. For many persons with mental illness in Canada, the police are the front door to the treatment system. In addition, with inadequate community mental health services and long waiting lists for treatment, family members sometimes choose to take legal action against a member for a putative criminal offense, hoping a judge will require a hospital to admit the person.15 Internationally, consumers and advocacy groups have come together to raise awareness about the fact that people with mental disorders are exposed to a wide range of human rights violations, including when they are in jails or prisons.16,17

In parallel with increased attention to the citizenship status and human rights of persons with mental illness, both globalization and the increasing internal diversity of contemporary liberal democracies are forcing a redefinition of the concept of citizenship. Through this development, the field is beginning to see relatively more attention given to vulnerable and marginalized groups18 and to the concept of international citizenship.19 In addition, virtual social networks are being used to create new communities without geographic boundaries, and the notions of interconnectedness and social relations are evolving. Finally, economic and social forces of globalization pose both opportunities and challenges that have particular application to vulnerable groups. We wonder what we would have to say about these forces and their impact on our citizenship work for persons with mental illness and criminal justice histories, were we to revisit this topic once again in this journal a decade from now.

## Footnotes

*   Disclosures of financial or other potential conflicts of interest: None.

*   © 2012 American Academy of Psychiatry and the Law

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