Inclusion, integration, normalization, and related concepts that refer to the full participation of people with severe mental illnesses all require some level of active assent on the part of the broader community. Yet the broad community has demonstrated little willingness to actively welcome and support them on any but an individual scale. Efforts to alter this status quo include legislation that mandates inclusion, such as the Americans With Disabilities Act; antistigma campaigns; services that support community activities, such as supported employment, housing, and education; and programs that support the physical presence of people in the community, such as assertive community treatment. These efforts have had modest success when compared with the goal of full inclusion (1).
Social inclusion is a two-way street and requires those who are excluded to want full participation in the broader community. People who are excluded want the opportunity for full inclusion, which some will choose and others will not. Forced inclusion is not what excluded populations desire. The privilege of the socially and economically excluded is the choice to take advantage of inclusion opportunities or other options available to them (2). This leaves planners, providers, and users of mental health services with the task of creating alternative ways to live full community lives. One such option is to regard people in recovery from the multiple impacts of mental illnesses as their own community and to develop that community's social, civil, cultural, and economic potential. This commentary describes some efforts to develop that option through building businesses owned and operated by people in recovery and their organizations.
In the past, community in the United States was idealized as one large society in which all racial, ethnic, nationality, religious, and ability groups contributed their uniqueness, but everyone was assimilated into the broad society, as in a “melting pot.” This was never the case. Many minority groups maintain their own identities, communities, and institutions, while also participating in the broad community and its institutions. These minority communities are “identity communities,” and because people have multiple identities (3,4) they may participate in more than one identity community. Some identity communities are geographic, such as “Chinatown,” while others, such as the deaf community, are not.
Today, community is more often described as a “patchwork quilt” or a “mosaic” than a melting pot. Most contemporary mental health interventions are designed on the basis of the older melting pot model of assimilative inclusion. A patchwork quilt model would focus on building social, civic, and economic capacity and infrastructure within the identity community of people with severe mental illnesses. In this approach, as in other identity communities, individuals could choose assimilative inclusion in the broad community, or an active life within the identity community, or they could move back and forth between the identity community and the broad community (5). These options, available only when identity communities are developed, create more ways for individuals to lead successful community lives.
The recovery perspective in mental health has led many service users to think of themselves collectively, and consumer-run organizations have increased and diversified as a result. Many consumer-run organizations have changed from principally offering advocacy and mutual support to offering peer-provided mental health services. The next step for the recovery identity community is to move beyond reactively organizing to change mental health services and to focus on daily life. This can be achieved from a community development perspective rather than a services delivery perspective. It requires acquiring skill sets that are focused on the business, leadership, civic, and community-organizing skills needed to develop and maintain functioning communities. It also requires mental health staff to gain these community development skills.
A community development approach has economic and inclusion advantages. Currently, mental health services are confounded with everyday life. Support for the everyday community lives of many service users comes from paid mental health staff. Ongoing public funding is thus required to help people maintain their everyday lives. Given current economic realities, this approach is economically unsustainable. In a functioning identity community, the foundation of support comes from the identity community's institutions and activities and the social relationships that develop, with funded mental health services occupying the same critical but more limited role that other health services occupy in people's lives. Although some public funding may be needed to support the creation of community development projects, once created such projects can be largely self-supporting, making community development economically sustainable.
In addition, community development has an economic multiplier effect. Identity community-owned stores, restaurants, housing, and entertainment venues employ identity community members. When community members patronize those businesses, the money they spend pays the salaries of the employees, who also are customers of the same businesses. This is money that community members currently spend in businesses outside the identity community, losing this multiplier benefit.
Recognizing the potential for interdependence among people with psychiatric disabilities has been discouraged in the mental health field (6). Independence, integration, and reliance on normal community supports constitute an article of faith among mental health service planners. Many providers may be concerned that encouraging development of an identity community will increase stigma, discrimination, and social exclusion. Experience and research indicate otherwise. Identity has been shown to buffer the effects of discrimination and stigma (7,8). In addition, social inclusion is rarely achieved directly but more often through fully developed identity communities (9).
Financial sustainability also plays a role. Publically funded, individually focused services are expensive when they are the foundation of the support system for people with psychiatric disabilities. On the other hand, communities create collective supports, which redound to individuals and reduce the need to rely on individual supports. In that way, the collective supports of communities are more economically sustainable, especially when they are integrated into the infrastructure of the community, such as in business and civil society institutions. Businesses are a foundation for successful identity communities. They build community infrastructure, provide jobs, contribute to the multiplier effect, develop leadership capacity, and promote skill building. Several projects have explored business development among entrepreneurs within the mental health recovery community.
Business incubators are formal organizations that assist entrepreneurs by providing one stop for business education, supports, access to capital, and space to initiate small businesses. Originally developed to assist people out of work to create their own self-employment, business incubators have also been used to assist minority, immigrant, women, and other entrepreneurs who are underrepresented among small business owners. Business incubators for entrepreneurs in recovery were developed in New York City and Madison, Wisconsin, in the early 2000s (10,11). Currently, the Burton Blatt Institute at Syracuse University and the Rise Asset Development program operated by Toronto's Center for Addiction and Mental Health (CAMH) (riseassetdevelopment.com) and the University of Toronto's Rotman School of Management operate self-employment development programs that include entrepreneurs with psychiatric disabilities (12).
At the collective level, the Italian social cooperatives developed in the aftermath of the country's deinstitutionalization policy have demonstrated the effectiveness of that collective approach to business development (13,14). CAMH in Toronto and other mental health authorities have also actively helped consumer-run organizations to begin small businesses (15). In addition, for many years mental health programs have operated small businesses to employ service users as alternatives to sheltered workshops and supported employment. These were formerly called affirmative businesses and social firms (13,14), but currently they are referred to as work integration social enterprises, or WISEs. These various approaches to business development in the mental health identity community demonstrate that businesses can be successfully operated by people with psychiatric disabilities and by consumer-run organizations and mental health programs. Together, these approaches suggest ways to shift some of the supports from mental health providers to business infrastructure within the mental health recovery identity community (16).
Of course, communities are more than businesses. Businesses are fundamental to the life of the community, however. For example, artists, musicians, comedians, and actors in the recovery community often have difficulty finding venues to display and perform their work. As a result, mental health providers often discourage these artists and performers from thinking of their talent as anything but a hobby. However, the coffee shops and restaurants that function as WISEs today, and the many more that would be created as identity community businesses, provide potential display and performance space for these artists and performers. Further, a regional or national association of these coffee shops and restaurants could provide a way for these artists and performers to get their work out more broadly. This is just one example of how a community development approach creates opportunities for successful community life that does not depend on the often withheld assent of the broader community.
Mental health credit unions
Many people with psychiatric disabilities are “unbanked” because commercial banks charge fees for depositors with low balances, further depleting any savings. This relegates those affected to rely on informal economic relationships and exploitive businesses, such as check-cashing stores. Without savings accounts, they cannot build assets and credit histories and may not achieve financial competency. This same situation often affects immigrant communities. Historically many immigrant communities have created community banks and loan societies to increase individual participation in the formal economy and to build community assets. The collective small deposits of many create a larger amount that can be leveraged to build community infrastructure. For example, community entrepreneurs who may not qualify for traditional business loans may meet the loan requirements of a community bank. The same benefits can accrue to the recovery identity community. In addition to offering personal benefits, such as the opportunity to build assets and credit histories, and community benefits, such as by providing capital for businesses, a community institution such as a bank or credit union can provide financial education to its members and provide amenities, such as representative payee services for Social Security benefits and trustee services. Mental health consumer-run organizations in New York and New Jersey are developing credit unions that offer these advantages.
A community development approach adopts a set of assumptions very different from those of traditional mental health services. It is collectively rather than individually based. It separates the supports needed for daily life from those needed to stabilize mental health conditions. It bases supports on the identity community of people in recovery rather than on mental health professionals or the broad community. It constructs a supportive community through business and civic infrastructure, often creating a multiplier effect that cycles money through the identity community and builds individual and community assets. It expands capacity-building skills and knowledge within the recovery community, and infrastructure is created through use of community development resources, thus preserving the limited public funding for mental health treatment and rehabilitation services, including services that are peer provided.
Financial constraints have often forced a reassessment of mental health services. It is important for all stakeholders to be proactive and look for ways to make supports and services financially more sustainable, given limited public resources. Service design often gets trapped in path-dependent ways: modifications to existing services are made but fundamental assumptions are preserved. This commentary suggests a different set of assumptions and provides some examples of how supports and services that are based on these assumptions might look. This approach is more financially sustainable. It opens doors for service users to live in a community with various ways of being successful and permits social and economic inclusion to become a reality.
This work was partially supported by a grant from the Columbia University Center for Homelessness Prevention Studies, which is funded by the National Institute of Mental Health.
The author reports no competing interests.