Could citizenship be a basis for recovery?

I had a very interesting afternoon last week listening to Professor Michael Rowe from Yale School of Medicine at an event organised by the London Drug and Alcohol Policy Forum. He was talking about an approach to working with people with multiple needs — mental ill-health, substance misuse conditions, homelessness and contact with the criminal justice system — that he has been researching.

Professor Rowe started his talk by describing some outreach work that he and some colleagues had been involved with and illustrated that with the story of ‘Jim’ a rough sleeper who had mental health issues.

Jim wasn't easy to get to know, he didn't want to be in treatment, felt that any help that was on offer wouldn't work for him, and was adept at refusing or finding ways of being refused services. Through persistence and working at a pace that Jim felt comfortable with one of the outreach workers — someone with lived experience — built a relationship of trust, encouraged Jim to have his needs assessed by professionals and to start to access the systems and medications that should have supported his needs. Jim progressed to the point where he took on a tenancy.

But Jim was socially isolated and within six months was talking about returning to the streets, where he had a group of peers and status that he lacked in the wider community.

For Rowe this story was the catalyst for developing his thinking about how important community connectedness was for recovery and desistance. Funded by the local equivalent of the criminal justice system’s liaison and diversion scheme Rowe and his team developed and undertook a research project testing an approach around a concept of building the active citizenship for people with multiple and complex needs.

Over 100 people were recruited to a trial where they were randomly allocated between treatment as usual (41 people) or the Citizenship Project intervention (71 people). Rowe told me that none of the participants had been mandated into the trial by the criminal justice system, and that the range of crimes that participants had been involved in ranged from public nuisance through to in one case a charge of manslaughter.

The definition of citizenship that the research team — which included clinicians, researchers, practitioners and people with lived experience — developed is based on 5 concepts: rights, responsibilities, roles, resources and relationships. These were explored in depth by participants (now dubbed students) in the intervention arm of the trial over the course of 4 months in a series of classes some led by the research team or other experts and some developed by the students themselves.

As we might expect not everyone managed to last the course with some dropping out altogether, some participating intermittently, and others either returning to finish the course after taking a break or restarting when they felt able to commit.

The second stage for the participants was to explore and take part in what Rowe described as a Valued Role project, which allowed the individuals to put into practice some of the learning from the earlier phase. Rowe told us that one group reflected on their experience of interactions between the police and people who are street homeless and developed a session which they took to the police to help them (the police) think about that experience and how it could be improved for all parties. Another used this section of the programme to try and repair relationships with her family — by learning how to cook a Thanksgiving meal.

The final element of the trial was the use of what Rowe described as wraparound peer mentor support — which included working with the participants around goal setting, strategies for avoiding relapse, and working on their advocacy skills.

The results of the trial have been reported here, and included reduced use of substances both six months and twelve months after the end of the programme, and significantly increased quality of life, greater satisfaction with and amount of activity, and higher satisfaction with work (where the participant was in employment) than the control group.

However, they also found that participants reported increased mental ill-health (anxiety/depression) and agitation (for example tension, excitement, distractibility) at 6 months (but not 12 months) and significantly increased negative psychiatric symptoms at 12 months.

The research team have some ideas about how to reduce the negative effects by increasing the amount of peer support available to participants for longer and are seeking funding for a second trial and are also looking at ways of bringing the intervention to scale.

Meanwhile they’ve also developed a validated tool for measuring citizenship outcomes which is now being adapted for a UK context by the University of Glasgow.

Perhaps worryingly, the commissioners who were in the room with me, listening to Professor Rowe, while enthusiastic about the approach (which clearly worked with the grain of their conception of asset based recovery) were pessimistic about being able to make a case for the resources that might be needed to achieve replication of this approach in the current economic environment.