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Community Integration and Mental Health

What Is Community Integration in Mental Health?

Community integration is an approach to psychiatric care and rehabilitation that helps people develop personal, social, and vocational competency in order to live as independently as possible in their own homes and communities.

Attempts to build these competencies in clients have frequently taken place in environments that are set apart from the rest of the community, such as hospitals, day treatment programs, clinics, and residential treatment programs. These environments have an important role in psychiatric care.  But their separation from the rest of the world makes them less than ideal places to prepare for life in the community.  Community integration actually takes place in the community!

Community integration programs provide services such as case management, skills development, and education, employment and housing support, in settings that are integrated in the communities where clients live.  These programs operate under the belief that having a mental health disorder should not prevent people from fully participating in their communities, and that people living with such disorders actually do better when they have that opportunity.  

Why Community Integration Is Important: The Case for A4CIP

The Association for Community Integration Programs (A4CIP) is a nonprofit 501 (c)(3) organization that educates individuals, families, and mental health professionals about the benefits of this evidence-based treatment model as an effective alternative or supplement to treatment in settings outside of the community.

Community integration programs are an important part of the array of services available to people with mental health disorders because they:

  • Enhance meaning and purpose in client’s lives.
  • Are supportive of the basic civil rights everyone possesses: personal freedom, choice, and self-determination.
  • Are the best means to help clients gain the highest level of autonomy and independence in their lives.

Although community integration programs are uniquely effective, they often lack visibility in the marketplace of mental health services.  A4CIP was created, in part, because this empowering, integrative approach was not known to most clients and their families, or to many mental health professionals who work with them.   


Find out more about A4CIP Member organizations and what they offer

 

The Guiding Principles of Community Integration

Dr. Ross Ellenhorn (LCSW, PhD), the Co-Founder and President of A4CIP, has proposed a therapeutic and philosophical framework for community integration programs “that can keep our programs focused on the right goals for clients and the proper methods for practitioners as they enter clients’ lives.”  

In his seminal article “The Mission and Heart of the Association of Community Integration Programs: Applying Living Principles to Psychosocial Recovery,” Dr. Ellenhorn sets forth 7 Guiding Principles for Community Integration (CI) Programs:

Metabolization – Processing harmful experiences

This refers to the way clients process the world around them, taking it in and responding to it.  Clients are frequently metabolizing harmful social experiences such as ostracism, isolation, lack of support, and purposelessness, as much as or more than positive ones.  The awareness that clients suffer from the wounds of difficult social hurts informs our practice at every step.

How CI programs organize care around metabolization?

Hospitality

CI practitioners enter the homes and communities of clients as their guests.  At the same time, they are also hosts in treatment, approaching each client as a unique individual, and making sure that all clients are accepted, heard, and comfortable.

Responsiveness – Responding to events in life

We all have emotional responses to events around us, some of which are very painful, but no less real to us. People labelled as mentally ill also have such responses which are no less valid or real for having a diagnosis.

How CI programs organize care around responsiveness?

Attunement

Practitioners ask their clients “what is happening,” rather than “what is wrong” with them. They practice attuned responsiveness by working with clients in the community, reacting rapidly to their concerns in real life contexts.

Purpose – Applying purpose to recovery

People perceived to lack of purpose in their lives are always at risk of being devalued and ostracized. This is especially true for people labelled with mental illness, whose low motivation, self-defeating behaviors, or misperceptions are often seen as ingrained psychological traits. Some treatment providers confuse the lack of purpose in clients’ lives for a lack of readiness, believing they must bring their symptoms under control before taking on such purpose-driven activities as employment, education, and romantic attachments.

How CI programs organize care around purpose?

Organizational Readiness

CI programs are ready to rise to the needs of clients rather than backing off in the face of a perceived lack of readiness on the part of clients.  They develop organizational readiness to help clients achieve their aspirations in their environments of choice, such as jobs, school, and social milieus, not apart from them.  

Adaptation – Adapting to care

Many people in psychiatric care find themselves having to adapt to trying, often painful circumstances.  Sometimes what looks like maladaptive behavior is actually an understandable response to impossible circumstances given a person’s limited opportunities.

How CI programs organize care around adaptation?

Agility

CI programs possess the agility needed to adapt quickly to changes in clients’ lives and circumstances. Because they operate in the communities where clients are, they are able to make quick adjustments in treatment planning and rapidly change the intensity, focus, and locale of support.

Growth – Providing space for recovery

That famous line from the Hippocratic Oath “First do no harm” presupposes that people have a natural tendency towards healthy growth.  Clinicians who understand this see their job as providing the right conditions for change and a nurturing environment that allows a space for each individual’s natural tendency to grow.

How CI programs organize care around growth?

Fostering Learning Environments

Community integration is a way of delivering services, rather than a form of treatment.  CI programs are therefore built to be learning organizations.  They are open systems that resist a one-size-fits-all approach and emphasize the building of collaborative relationships with clients, creating the right conditions for growth.

Interconnectedness – Connecting our common experience

Experience teaches us that we cannot predict our own futures, let alone the futures of our clients.  Practitioners who expect their clients to set goals and follow a clear and direct path to rebuilding their lives are bound to be disappointed.  The only remedy is to join with clients in facing the uncertainty of life together, fostering a sense of collaboration, trust, and connection.

How CI programs organize care around interconnectedness?

Curiosity

CI practitioners appreciate the interconnectedness of people and events.  Since they cannot be certain of anyone’s future, they exercise curiosity and are open to opportunities that present themselves.  Community integration programs employ a “boots on the ground” approach that fosters such openness of mind and seizes on opportunities for clients to achieve their goals – trying a new job, going back to school, or joining a new social group.

Complexity – Working within the layers

People are complex and it is impossible to know everything about them.  This is especially true of people diagnosed with complex mental health disorders.  While it is helpful for clinicians to form hypotheses about the causes of clients suffering and behavior, we must hold these assumptions lightly.  Formal assessments and diagnoses are helpful tools for understanding, but in no way are they certain. It is just as important to grasp clients’ own understandings of their predicaments.

How CI programs organize care around complexity?

Clinical Polyphony

CI treatment is multidisciplinary. In music, polyphony is a style of combining a number of different parts, each with its own melody, in harmony together. In clinical polyphony, each member of the team, including the client, has a unique voice and point of view, that are expressed together in group treatment planning. This planning is accessible to clients who are considered the experts in their own care.


How can my organization become an A4CIP member?

 

Who Can Benefit from Community Integration?

Community integration is ideally suited to people who have been treated for a single or co-occurring psychiatric disorders and are able to live in the community when provided with support and treatment.  Ironically, many people who have been deemed appropriate for long-term hospital or residential care flourish in community integration programs and show improved recovery outcomes.  Community integration is especially beneficial for young and emerging adults who are engaged in a process of role and identity exploration and cherish hopes for a purposeful life within the community.

Community integration programs frequently help people who experience symptoms of the following disorders:

  • Mood disorders, including Depression and Bipolar Disorder
  • Anxiety and related disorders, including Obsessive Compulsive Disorder (OCD), Generalized Anxiety Disorder (GAD, Panic Disorder, and Posttraumatic Stress Disorder (PTSD)
  • Thought disorders, including Schizophrenia, Schizoaffective Disorder, and other psychotic disorders
  • Personality disorders, including Borderline, Narcissistic, Schizoid, and Dependent Personality Disorders
  • Developmental disorders, including mild developmental disabilities, learning disabilities, and Asperger Syndrome
  • Co-occurring disorders with multiple psychiatric disorders and/or Alcohol and Substance Use Disorders

Community Integration Programs and Services

Community integration is a way of providing services rather than a service itself.  However, there are particular kinds of services that lend themselves to this approach because they are of necessity based in the community or lend themselves to integration.

A look at A4CIP member organizations shows the following community integrated services most commonly represented:                                                                    

Residential Support

Clients receive supportive services to foster independent living in housing that is integrated in the community. A4CIP member organizations may offer programs for supportive housing, transitional living, sober living, group homes, or residential treatment.  Some clients live in buildings owned by the program, while others may hold a lease with private landlords in the community. CI residential programs strive to offer housing opportunities that: foster independent living; provide clients with a sense of their own living space; are located where clients have access to community resources; afford clients with a level of dignity of comfort in keeping with the standards of their community; are safe for all residents.

Case Management

A collaborative process for planning, implementing, and coordinating options and services to meet the totality of clients’ health and human service needs.  CI programs favor a multidisciplinary team approach to case management that regards the client as a member of the team and an expert on his or her own care.  The PACT (Program of Assertive Community Treatment) model of case management is a team approach used by some CI programs.<

Psychosocial Rehabilitation

Also known as psychiatric rehabilitation, it is a way of delivering services rather than a form of treatment.  Psychiatric and psychosocial rehabilitation services focus on “helping individuals develop skills and access resources needed to increase their capacity to be successful and satisfied in the living, working, learning, and social environments of their choice” (Psychosocial Rehabilitation Association). Although there is great variation in how psychiatric rehabilitation is implemented, its values and aims are compatible with those of community integration.  

Vocational Rehabilitation

A process that helps people with psychiatric and other kinds of disabilities overcome barriers to employment, education, or other useful occupations.  Not all forms of vocational rehabilitation are compatible with the principles of community integration, but the Individual Placement and Support (IPS) model of supported employment and Supported Education are two evidence-based practices embraced by many CI programs. In keeping with the principle of organizational readiness, CI programs do not offer sequestered “pre-vocational” services that make client readiness a pre-requisite for receiving employment and education services.

Psychoeducation

An evidence-based therapeutic process of providing education, information, and support to people diagnosed with mental health conditions or other illnesses to help them better understand and cope.  Psychoeducation can occur in groups or in individual psychotherapy.  It may also be provided to family and friends of clients as part of CI programs’ family support offerings.

Psychiatric Treatment

The clinical care that contributes to a person’s mental health recovery.  This might include consultations with a psychiatrist, psychotherapy, group therapy or help with medication management.  The CI model holds that these medically-oriented services should be provided in the appropriate places in the community, such as doctors’ and therapists’ offices.  While these services are provided in the most unobtrusive way possible, they can still be mobile and responsive to clients’ needs when necessary.  

Addiction Treatment and Support

The array of services that help people stop using substances and maintain sobriety. Some CI programs are set up to serve clients with psychiatric disorders, while others primarily serve those with substance use disorders. The most comprehensive programs are equipped to handle both, providing integrated treatment of co-occurring disorders.

Wellness and Mindfulness

An integrative approach that addresses the physical, emotional, mental, social, and spiritual influences that affect a person’s health and well-being.  Principles of wellness and mindfulness are incorporated in such evidence-based practices as cognitive behavior therapy and dialectical behavior therapy.

Other Services

Community Integration programs offer many other types of services, such as cognitive remediation, social integration activities, peer support, art therapy and other self-expression activities, life skills, medication support, and pastoral counseling.

How to Find a Community Integration Provider?

Careful thought must be given to what A4CIP is able to deliver in this area.  Ideally, it would be a link to an email form that users could complete to request more information on CI and CI providers in their region.  That would require the commitment of a person who could respond to inquiries by email or phone within 1 business day, which may not be feasible at the start.  Short of that, you could provide users with a downloadable list of A4CIP members, including their referral and admissions information.

 

About the Author:  Jay Boll, LMSW, is the Vice President of the A4CIP member organization Laurel House, Inc. and Editor in Chief of www.rtor.org, a gateway website for families offering resources, support, and mental health best practices.

 

Jay adapted the “7 Guiding Principles for Community Integration Programs” appearing on this page from an original article by A4CIP Co-Founder and President Ross Ellenhorn, LCSW, PhD, “The Mission and Heart of the Association of Community Integration Providers: Applying Living Principles to Psychosocial Recovery.”

 

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