Relationship of Community Integration of Persons With Severe Mental Illness and Mental Health Service Intensity

Data from an ongoing study funded by the National Institute of Mental Health were collected from 33 individuals with severe mental illness of diverse racial-ethnic backgrounds who were treated in two publicly funded mental health clinics in Los Angeles. A total of 18 participants came from high-intensity community treatment teams, called Full Service Partnerships, that are grounded in the assertive community treatment model. These teams have low caseloads (20:1), and an in-vivo, “whatever it takes” approach. Another 15 participants came from low-service-intensity usual-care treatment teams that use a traditional office-based approach (one to four appointments per month) with medication management and case management or therapy. Data were collected from the participants between January and December 2010. After the study was described, participants provided written informed consent. The study was reviewed and approved by the institutional review boards at the University of California, Los Angeles, the University of Southern California, and the Los Angeles County Department of Mental Health Human Subjects Committee.

Participants from the two service conditions were purposively matched on primary diagnosis, Global Assessment of Functioning (GAF) score of ≤55, hospitalization, homelessness, and incarceration in the past six months. Data for this study were collected by two trained and supervised interviewers in the context of face-to-face interviews. Previous analyses using administrative data have shown that the high-service-intensity group received significantly more service hours over the first six months of treatment (8.1 hours per month for the high-intensity group, compared with 2.5 hours per month for the low-intensity group).

Physical integration was defined as the “extent to which an individual participates in activities” and “uses goods and services” in the community (2). The involvement in community activities scale, adapted from the leisure and recreation activities subscale of the Independent Living Skills Survey (10), measured the extent to which an individual participated in community activities and his or her level of satisfaction with that participation. The extent to which an individual used goods and services in both the mental health and non–mental health communities was measured with a social capital resource generator adapted for individuals with a mental illness (11).

Psychological integration was defined as the extent to which an individual perceived membership in a community and was measured in two ways. The Community Integration Measure (12) (with mental health and a non–mental health community versions) measures the sense of participation, connection, and belonging to a community. Cronbach’s alpha was .83 for the mental health community version and .93 for the non–mental health community version. The second measure, the Community Integration Rating Scale, was adapted from the Community Integration Measure (12) and asked the interviewer to use all sources of information from the interview and rate the degree to which the subject participated in, was connected to, and was accepted by the mental health and non–mental health communities. Cronbach’s alpha was .81 and .83, respectively, for the mental health and non–mental health versions.

Social integration was measured by a social network interview (13), and perceived availability of social support was measured by the short version of the Medical Outcomes Study Social Support Survey (14) (Cronbach’s α=.82).

Of the 33 participants, 18 (54%) were female and 27 (82%) were from racial-ethnic minority groups. The mean±SD age was 41±8 years. Fifteen (46%) were diagnosed as having a schizophrenia spectrum disorder, 17 (51%) as having a mood disorder, and one (3%) as having another disorder. The low- and high-service-intensity groups were equivalent on gender, age, symptom severity, psychosocial functioning, life satisfaction, quality of life, and length of time in services. No significant differences were found between the two groups in the likelihood of being homeless or incarcerated or the likelihood and length of inpatient care in the six months before services began. Homeless participants in the low-service-intensity group had been homeless for longer than those in the high-intensity group (132 days versus 32 days in the previous six months, p<.05).

In terms of physical integration, the entire sample engaged in four out of ten common community activities and were between “a little to somewhat” satisfied with their level of community activity. In regard to social capital resources, the entire sample received significantly more social capital from the non–mental health community. Regarding psychological integration, participants’ self-ratings and the ratings of interviewers indicated that they were significantly more integrated into the mental health community than the non–mental health community. Participants’ average network size was 14±4 individuals, and their average network consisted of 62% non–mental health individuals (family, non–mental health friends, and non–mental health acquaintances), and 38% mental health individuals (mental health treatment peers, service providers, and mental health acquaintances). About one-third of the average network was family, and about a quarter was friends. Participants’ average social network included about twice as many non–mental health friends as mental health friends.

Table 1 summarizes the comparisons between high- and low-service-intensity groups on physical, psychological, and social measures of integration. In regard to physical integration, no significant differences were found between the groups in their level of participation in community activities or satisfaction with involvement in community activities. However, the high-intensity group had significantly less total social capital compared with the low-intensity group. For psychological integration, the high-intensity group felt significantly more integrated than the low-intensity group into the non–mental health community. However, this self-rating was in contrast with the interviewer rating, which indicated that the low-intensity group showed higher psychological integration than the high-intensity group into the non–mental health community.

In terms of social network characteristics, the average network of the high-service-intensity group had significantly more mental health members than the average network of the low-service-intensity group, and the average network of the low-intensity group consisted of significantly more non–mental health members. Participants in the low-intensity group had significantly more family members in their network. Their networks also had a higher proportion of individuals whom they knew before their mental health treatment began, although this difference was not significant. There was no significant difference between high- and low-intensity groups on perceived social support.

These results show that the total sample rated themselves and were rated as being more psychologically integrated into the mental health community than the non–mental health community. However, their social networks were populated by more individuals from the non–mental health community, and the participants received significantly more social capital resources from the non–mental health community than from the mental health community. Although both groups felt more integrated into the mental health community, the high-service-intensity group was rated by interviewers to be less integrated than the low-intensity group into the non–mental health community. The high-intensity group also had less social capital resources than the low-intensity group. In the high-intensity group, a larger proportion of the social network was populated by members of the mental health community, whereas in the low-service-intensity group, a larger proportion was populated by members of the non–mental health community.

This study examined the level of community integration of individuals with severe mental illness into mental health and non–mental health communities by using the conceptual framework of Wong and Solomon (2) and explored the association between intensity of mental health services and community integration. An individual’s movement away from various mental health treatment modalities and toward the non–mental health or “normalized” communities has become a yardstick to measure improvement and recovery (4,8). However, our results suggest that the experience of community integration for individuals with severe mental illness is a complex phenomenon. We found support for Wong and colleagues’ (7) idea of multiple communities and Mandiberg’s (9) idea of subcultures, in that not only did the individuals in our sample have distinct communities with which they interacted, but they also experienced integration into these communities differently. For example, participants felt significantly more psychological integration into the mental health community; however, their social networks and social capital resources came more from the non–mental health community. The nature and outcome of this inconsistency require further investigation.

In addition, the social networks of the high-service-intensity group had a larger proportion of members from the mental health community, whereas the low-service-intensity group turned to the non–mental health community for its social network affiliations. Pending further investigation, this might indicate that individuals in the high-intensity group have more congruence in their sense of community belonging and the sources of their social network membership, whereas for the low-service-intensity group, there may be more dissonance between the community they identify with and the community that is the main source of social network members. However, the high-intensity group may be more vulnerable because they had significantly less social capital resources than the low-intensity group.

These findings can also be interpreted by using the normalization perspective (4,5). For example, on average, the participants’ social networks had a higher proportion of individuals from the non–mental health community, which supports the notion that social integration into the non–mental health community is possible for individuals with serious mental illness (4–6). At the same time, we found that the proportion of network members from the mental health community was significantly larger in the high-service-intensity group than in the low-service-intensity group and, therefore, that the high-intensity group was less normalized in one aspect of social integration.

Although this study advances the investigation of community integration in important ways by using comprehensive and innovative measures and by distinguishing empirically between mental health and non–mental health communities, it was limited in terms of its small sample. For example, although the high-intensity and low-intensity groups were largely comparable on clinical and functional variables, larger samples are needed to rule out the group differences that could account for these findings. The study recruited a sample of individuals with severe mental illness who were engaged in mental health services, which limits its generalizability. In addition, although this study included indicators that could support normalization and subcultures perspectives, the dynamic character of these phenomena needs to be studied by using longitudinal designs. Qualitative methodologies could also be essential to understanding the subjective experience of integration into the mental health and non–mental health communities. Such additional studies would help increase our understanding of community integration and inform development of interventions to increase levels and types of community integration for individuals with severe mental illness.

Overall, we recommend that approaches to community integration for this population recognize the challenges, opportunities, and contradictions that individuals with severe mental illness face as they navigate between non–mental health and mental health communities.

This research was supported in part by grant R01 MH 080671 from the National Institute of Mental Health to Dr. Brekke and Dr. Braslow. Dr. Gabrielian was supported in part by the Office of Academic Affiliations, Advanced Fellowship Program in Mental Illness Research and Treatment, U.S. Department of Veterans Affairs. The authors thank Briana Hedman, M.A., Kim Hopper, Ph.D., Richell Jose, B.A., Lisa Mikesell, Ph.D., Amanda Nelligan, M.A., Elizabeth Phillips, Ph.D., Eric Rice, Ph.D., and Jamie Saris Ph.D., for invaluable contributions to this research.

The authors report no competing interests.