Guest editorial

Citation

MacIntyre, G., Hamer, H., Reis, G. and Bellamy, C. (2023), "Guest editorial", Journal of Public Mental Health, Vol. 22 No. 3, pp. 93-97. https://doi.org/10.1108/JPMH-09-2023-162

Equity and inclusion: people, power and politics – the potential of citizenship to transform mental health

This issue, Equity and inclusion: people, power, and politics – the potential of “citizenship” to transform mental health, has been produced to mark the 10th anniversary of the International Recovery and Citizenship Collective (IRCC) that envisioned a world where people thrive, connect to their communities and live meaningful lives. The IRCC brings together academics, policymakers, practitioners, community members, advocates and people with lived experience who want to transform and make meaningful, significant changes in mental health, community, citizenship and recovery. The IRCC aims to inform policy and practice by providing a more holistic, collective and solution-focused lens through which to understand the experiences of communities that have been marginalised, stigmatised and socially excluded often because of their mental illness, substance use, incarceration and homelessness “status”. Citizenship in this context is defined as the strength of an individual’s connection to the 5Rs – rights, roles, relationships, resources and responsibilities, and a sense of belonging (Rowe et al., 2001).

The IRCC represents a shift from an individual, medicalised approach that focuses on the absence of clinical symptoms to one which understands the importance of structural and political barriers to inclusion and belonging (Rowe and Davidson, 2016). Hoffman (2004) contends that models of citizenship are a “momentum concept” rather than regarded as static concepts such as patriarchy or violence that are barriers to emancipation and inclusive citizenship. Whereas momentum concepts, such as freedom and equality, are part of the human condition, citizenship requires constant re-working to provide social justice for the marginalised and oppressed. Members of the IRCC have continued this momentum by developing and testing citizenship across the USA (Rowe et al., 2012; Rowe, 2015), Scotland (MacIntyre et al., 2021; Cogan et al., 2022) and has been translated in Canada (Pelletier et al., 2015), Norway (Nesse et al., 2022), New Zealand (Hamer, 2017) and Spain (Eiroa-Orosa and Rowe, 2017; Eiroa-Orosa, 2023), emphasising the relational aspects of citizenship that contribute to recovery and promote a sense of connectedness and belonging. Members of the IRCC, in their work, have argued that to achieve a sense of citizenship, people must undertake valued social roles and have their contributions valued and recognised by others (Stewart et al., 2017), and must have access to resources and support to enable them to do this.

These scholars have emphasised the collective nature of citizenship and have advocated for the right to social participation for those who have been marginalised and excluded, promoting a sense of solidarity and common cause (Quinn et al., 2020; Reis et al., 2022). This suggests that citizenship is action-focused, a form of active practice (Lister, 1997, 2007) that can challenge unequal power differentials and promote new alliances and relationships. An essential part of this action-focused approach is peer support, a valuable tool that can enhance citizenship by promoting social integration and a sense of belonging. Indeed, according to Bellamy et al. (2017), peer support can positively impact levels of hope, empowerment and quality of life, reduce hospitalisation and decrease recidivism.

This issue aims to bring together a series of articles that shed light on the relationship between citizenship, recovery, mental health, substance use and disability. Bringing these contributions together creates the opportunity for bidirectional learning and sharing policy, service delivery, workforce and other mental health and addictions innovations designed to promote, develop and transform the health and well-being system of care through recovery and citizenship strategies. Taking a citizenship-focused approach allows us to consider lived experiences in the broader social context, which is reflected in the papers presented here. By shifting our attention from deficit-focused approaches to mental health, we can understand the strengths and contributions that individuals make to their local communities, helping foster a sense of belonging, hope and recovery. The articles in this issue (and in earlier preview edition) come from international, multi-disciplinary perspectives (people in recovery, psychology, psychiatry, social work, sociology and political science) that consider how aspects of citizenship can promote a sense of belonging for those with lived experience of exclusion and marginalisation as a result of mental health problems, addiction or disability as well as exploring the barriers and discrimination faced. This collection of papers is an international effort with representation from Brazil, Canada, Lithuanian, Spain, Hong Kong and the USA. We hope it will shed new light on debated constructs of community and belonging and terms such as citizenship and recovery.

The selected articles showcase theoretical and methodological innovation where lived experience and peer research have been central components of the work, highlighting the value of different forms of knowledge and challenging previous epistemic injustices (Fricker, 2007) where the most marginalised voices have been excluded. Indeed, throughout the process, from commissioning the special issue to peer review and editing, peer research and lived experience have featured significantly, which has been a genuinely collaborative effort. The special issue is particularly timely given the growing interest in citizenship-informed approaches from researchers, policymakers and health and social care services and systems. This issue presents a number of key themes and provides an opportunity to critically reflect on contemporary developments and debates across a range of settings.

Before introducing the articles in this special issue, we want to highlight an earlier edition of the journal, where we were able to showcase two articles for the Special Issue:

www.emerald.com/insight/publication/issn/1746-5729/vol/22/iss/1

We chose these because both offer the reader insight into the concept of citizenship and how it can be applied in the field of public mental health by promoting the inclusion of groups who tend to be ignored and excluded. In the first article, entitled “Meeting in the middle: experiences of citizenship in community-engaged psychosis research”, Ben-David and colleagues come together as academics and people with lived experience to research citizenship and community participation collaboratively. The paper explores the structural barriers to this kind of participation while highlighting the benefits and rewards of such work.

The second paper previewed was entitled “Making the case for citizenship-oriented mental healthcare for youth in Canada”, a viewpoint article by Jordan and others, based on their vast experience working in young people’s mental health. It examines the various ways the concept of citizenship can be applied to young people’s mental health in Canada. Jordan et al. provide an example of this Generation Squeeze. This key Canadian third-sector organisation has successfully lobbied governments to address issues such as climate change, childcare and housing costs. Other ways of promoting citizenship for young people in Canada are described, including adapting and delivering citizenship-based interventions to meet the needs of younger people and connecting those in care to civic-related organisations.

Citizenship, recovery, lived experience and peer support

The first theme we wish to highlight is the benefits and challenges of peer support, and we have selected two articles focusing on developing peer support in Brazil across two different settings. Both articles were written by academics alongside peer support workers who have lived experience of mental health problems or substance use. A paper entitled “Peer Support in Brazil: Experiences and Strategies of Inclusion, Empowerment, and Citizenship” presents six Brazilian peer support experiences in the Southeast and South regions led by Webster et al. These areas represent the country in many aspects, although they are among the wealthiest in Brazil. The positive outcomes of the implementation of the peer support strategy reported suggest that other areas of the country may benefit from this strategy. However, further investigation is needed to confirm this hypothesis. They conclude that peer support and lived experience leadership can help to advance Brazilian Psychiatric Reform by reducing stigma and promoting empowerment, autonomy and activism.

In a second paper from Brazilian authors entitled “The Belo Horizonte’s harm reducers as a possible and practical peer-support experience”, by Viera and colleagues, harm reducers are co-authors with academics and mental health professionals. The article describes the harm reducers’ life experiences, the impact of this experience on their work and the lives of users of mental health services. The finding emphasises the activism of the harm reducers and suggests that they exercise active citizenship, encouraging and empowering others to do the same. It is argued that harm reducers exhibit key features of active peer support, suggesting that a recovery-oriented, citizenship-focused model of care and support is possible in Belo Horizonte, Brazil.

Citizenship and mental health systems

Our second strand of papers considers citizenship within mental health systems. We present two papers that consider how a citizenship-focused lens can change practice with a shift towards more holistic, recovery-focused care and support. In a paper entitled “Citizenship as mental health: A study protocol for a randomized trial of awareness interventions for mental health professionals”, Eiroa Orosa and colleagues discuss the relationship between mental health and citizenship to support professionals in understanding mental health in the context of social rights and responsibilities to move towards rights-based practice. The study conceptualises citizenship across service users, families and professional organisations. This will lead to the development of an awareness-raising intervention. The project’s intended results justify citizenship as a lens through which to understand mental health at national and international levels. The authors believe that it is essential to carry out projects in close collaboration with stakeholders to ensure social impact.

“The Recovering Citizenship Learning Collaborative: a system-wide Intervention to increase citizenship practices and outcomes” by Flanagan et al. also focuses on systems-level change. Flanagan and colleagues describe the Recovering Citizenship Learning Collaborative as a training, consultation and implementation community of practice for 13 local mental health authorities and two state hospitals in Connecticut, USA. The view of the group is that recovery occurs in the context of people’s lives, in their communities and society and this approach has been implemented across the local health authority in partnership with people with lived experience and an academic partner to support system change and improve citizenship-oriented care and outcomes. The authors shared lessons learned, such as the importance of assessing organisational readiness for change, addressing leadership investment and attention to systemic barriers and offering tools to promote structure and accountability to build the foundation for improved citizenship practices and client outcomes at the multi-agency system level.

Citizenship, recovery and community

In our final theme, we have selected articles highlighting the importance of community in enhancing a sense of connectedness and belonging (or not), thus promoting a sense of citizenship among those individuals who have experienced mental health problems or disability. Conversely, when those with disabilities or mental health problems are unable to access community participation on the same basis as others, this can act as a barrier to citizenship (Cogan et al., 2022). In the first of two papers entitled “Community knowledge and attitudes towards recovering citizenship and mental illness: A telephone survey approach”, Wong and colleagues present findings from a study that used a telephone survey to assess the views of people in the community in Hong Kong on the concepts of recovery and citizenship. The authors used a questionnaire comprised of the Mental Health Knowledge Schedule, the Short Form-Community Attitudes Towards Mental Illness and questions on attitudes towards Recovering Citizenship, including the 5Rs (discussed earlier). The findings showed that people in Hong Kong had a good knowledge of mental illness, recognition of recovery from mental illness and a sympathetic view towards people in recovery. However, they argue that this can be further improved. They suggest several ways to do this, including awareness-raising programs and disseminating the concept of recovering citizenship. They conclude by suggesting that having people in recovery take up valued roles in the community could facilitate the acceptance of social inclusion.

In the final article entitled “People and places: the potential of city events to facilitate the inclusion of people with disabilities in community life”, Sumskiene and colleagues collected data from four Lithuanian communities by drawing ecological maps and conducting interviews with community members with disabilities (35) and without disabilities (24) on the process of relocation of people with disabilities into communities. The aim was to explore the symbolic meanings of physical places and social spaces for community members with and without disabilities in these communities. Based on the work of Brofenbrenner (1968), the study found that disabled and non-disabled people often interacted physically but rarely socially. The authors pointed to the potential of city events and festivals to promote inclusion in communities but argue that participation in the events alone will not promote community-based citizenship. Instead, disabled people must have the opportunity to participate in decision-making. They conclude that policymakers must consider ways to promote this and suggest a range of options, including participation in community councils, the provision of accessible information and the implementation of an inclusive community vision.

In bringing these papers together, we aim to present themes and issues that highlight the potential of citizenship as a conceptual framework, a model of practice and a way of being, to create real change. The papers here challenge exclusion in the form of epistemic injustice by bringing together new alliances of academics, policymakers, practitioners and people with lived experience. These groups have worked together and carried out research in meaningful partnerships, and the outcomes of their endeavours are presented here. We hope that the evidence presented can begin to have an impact on how we understand mental health and illness as well as on the systems that have been put in place to offer support and on outcomes for individuals who experienced mental health problems, substance use, disability and other forms of exclusion and marginalisation. We hope this issue inspires key stakeholders in health and social care, families and people with lived experience by validating history, culture and values. Moreover, we hope it can be considered a call to action for those individuals and groups, advocacy organisations, activists and academics looking for ways to transform society.