Political Engagement as an Element of Social Recovery: A Qualitative Study

Recent work applying a capabilities approach to public mental health in the United States has broadened the ways in which we can conceptualize successful social functioning and recovery: “A capabilities-informed ‘social recovery’ will speak to citizenship as well as health. It will worry about what enables people to thrive, not simply survive” (1). Being positioned to value and exercise full citizenship rights and responsibilities is also an essential social component of belonging, and to participate in political decision making represents a participatory social role within both local and national contexts. Political participation may also reflect or result from meaningful participation in other valued social roles. In their creation of an outcome measure for citizenship, Rowe and colleagues (2) identified seven relevant clusters, five of which can be connected directly to political participation (legal rights, civil rights, and government and infrastructure), self-determination through political action (choices), and community empowerment (world stewardship). Although there is growing recognition of our need to broaden the concept of social recovery to account for these dimensions, little is known about the meanings associated with political participation among consumers of mental health services.

Literature on shared decision making in mental health care underscores the need for and desire on the part of consumers to become active participants in their own health care, medical decision making, and wellness behaviors (3–6). This is sometimes designated as a process of “activation” (5–7). This project expanded on the conceptual purview of “activation,” locating it within a capabilities framework to encompass participation and empowerment in social life within broader communities and transcending the health-focused or medical realm (1,8).

The purpose of this study was to explore and describe consumer attitudes toward political participation and the association between political engagement and social recovery. In particular, this project investigated activation through participation in and empowerment through political processes, with a focus on the symbolic meanings of voting and other forms of political engagement.

Methods

We received approval for this study from the Nathan S. Kline Institute for Psychiatric Research Institutional Review Board. This study used a qualitative design and a community-based participatory research model, which is a methodology that involves members of the relevant community in the research process (9,10). Consumer peer–researchers were involved in all elements of the study, including planning and design, data collection, and qualitative analysis. This study used data from seven focus groups (N=52) of self-identified consumers or past consumers of mental health services in the New York City area, conducted from September 4, 2008, to April 28, 2009. The 2008 U.S. presidential election was used as a contextual touchstone for political participation.

Participants were recruited via peer-operated advocacy, training, and service organizations. Inclusion criteria were broad and based on self-identification as a consumer or former consumer of mental health services. Participation was not paid, but lunch was provided. All focus groups were carried out by the same team, composed of an academic investigator and a peer-researcher, who is a trained discussion-group facilitator. Groups began with the informed consent procedure, and participants signed consent forms after a complete description of the study was provided to them. Participants were also asked to complete a brief demographic questionnaire.

Focus groups were conducted with the use of a discussion guide and included questions about voting, general political participation, social inclusion, and barriers to participation. The questions were designed to be dynamic and flexible, and they were introduced by the group facilitator as conversation topics rather than as rigid survey questions. Group discussions lasted from one to two hours, and they were audio recorded and transcribed. Transcripts were then coded for salient themes based on a grounded-theory approach, which is a method of qualitative analysis that allows theory to be drawn systematically from data (11). The main focus was on identifying themes relating to the relationship between political engagement and broader social functioning, inclusion, and recovery. Potential themes were written in the transcript margins and then discussed among our investigative team to identify the most salient themes.

Results

The sample included 26 men (50%) and 26 women (50%), and ages ranged from 19 to 65, with a mean age of 47. A total of 26 participants (50%) self-identified as African American or black, 13 (25%) self-identified as white or European American, and one each (2% each) as Asian American or Native American. Eight participants (15%) identified themselves as having Hispanic ethnicity, and 11 (21%) did not self-identify as belonging to any category. This breakdown is consistent with the broad diversity of racial-ethnic minority groups within public mental health in the New York City area (12).

Of major themes, two were related to the symbolic meanings of voting and political participation. The first theme was “social opportunity and difference,” and it was based on participants’ discussions of voting and political participation as symbolic of inclusion (versus exclusion) and community empowerment for members of minority groups in general, including but not limited to consumers of mental health services. For example: “I grew up to know that it was very important, my being a minority, that one way or another we had to be heard . . . . It’s one of the way[s] that our voices are heard, and that’s the only way that we could make a difference, in voting.”

This theme also included discussions of overcoming legacies of discrimination. Voting was mentioned in multiple contexts as a powerful symbol in both historical and contemporary contexts. For example, an African-American woman in her sixties described voting as symbolic of progress within the context of U.S. race relations and generational changes in social inclusion: “How my grandfather said he felt the first time he actually got to vote, even though it was scary, and then when he came up North, how he could just walk into the [polling place] and vote, and it made him feel good about himself. . . . I’ve been voting a long time, and I’ve never seen lines like [those in 2008] . . . and that maybe all the stuff that we’ve heard about ‘every vote counts,’ our vote counted and it would make a difference. Yes, it was important.” The salience of this theme was not limited to African-American participants. For example: “I’m a second-generation American. My grandparents came from Russia. . . . They came from dictatorships. The proudest day was to vote, because [in] other countries they couldn’t vote, because of discrimination against Jews or maybe just having one party. . . . It’s a responsibility that everyone who comes to America, who becomes a citizen, should vote.” Although voting was the primary focus of the study, some participants also discussed political participation beyond voting, identifying hypothetical goals of participating in local school committees or running for public office themselves.

The second theme was consumer solidarity, and it was based on participants’ descriptions of helping other consumers become involved in a wide range of social and political activities, including voting. This theme was associated most often with individuals who were themselves involved in peer-related consumer advocacy organizations and least among those who described themselves as generally uninvolved in all social activities. Helping other consumers to vote is an example of this theme: “I do what’s known as voter registration for the inpatients at [a state facility], because I strongly believe you shouldn’t lose any citizenship rights just because you have mental health issues.” Multiple participants also described participating in mental health advocacy–related public protests and demonstrations. The concept of solidarity was also expanded to the broader disability community with the discussion of a “disability voting bloc,” which would also address the concerns of those with other disability conditions, including movement, visual, hearing, and other disabilities. Participants suggested curb cuts and braille signage as potential solidarity issues that could be addressed by this hypothetical group.

Discussion

Voting and political participation have strong symbolic meaning for consumers of mental health services, and it is interlinked with concepts of social inclusion, participation, and becoming an active member of one’s community (activation), as well as helping others to participate. This is consistent with Ware and colleagues’ (8) description of social integration as connectedness and citizenship, which emphasizes maintaining reciprocal personal relationships and full rights and responsibilities of citizenship within a democratic society. There is also a strong intersectional component; in other words, individuals often described their interests as situated within multiple overlapping domains, and they act as representatives of multiple communities (13). Within our sample, the most common intersection included both consumer identification and African-American identity; other intersections addressed both consumer identification and elements of class (poverty and homelessness, for example), gender, religion, immigration, Hispanic ethnicity, advanced age, and a visual impairment.

This study had multiple limitations. Because of its qualitative nature, we were unable to gather broad, representative data about the actual voting behavior of consumers of mental health services. Our sample was also limited to individuals who self-selected to participate, and our recruitment sites were based at targeted gathering places, which are social spaces; therefore, our sample likely underrepresented individuals who are more socially isolated. Because groups were conducted in English, our sample likely underrepresented Hispanic and other migrant groups. Because the sample was small and geographically focused, there are limitations to the generalizability of this study. Large quantitative studies are needed to supplement our meaning-centered approach and to ensure increased external validity.

Conclusions

This study suggests that qualitative studies of the symbolic meanings of political participation are an important component of understanding the broader contexts of social recovery. In addition, the understanding of the lives of consumers as multidimensional, with multiple community affiliations and multiple social vulnerabilities, can help elucidate the complexity of social participation and recovery. The concepts of citizenship and connectedness, including the desire of consumers to become active participants in the shaping of communities through political action, are promising topics of future qualitative studies.