When Martin* called 911 to report gunshots, he didn’t expect to be arrested and charged with a crime. But there were no gunshots. Martin, who is homeless and has schizophrenia, was experiencing auditory hallucinations. The police arrested him for filing a false report and for methamphetamine possession. He’s one of millions of Americans with a serious mental illness (SMI)—which encompasses such conditions as schizophrenia spectrum disorder, psychotic disorder, severe bipolar disorder and major recurring depression—who is also living in poverty. Of the roughly 10 million American adults diagnosed with SMI, more than a quarter live below the poverty line, which is more than double the number in the general population living below the poverty line (Serious Mental Illness Among Adults Below the Poverty Line, SAMHSA, 2016).
In recent years, psychologists have been conducting research to better understand the link between SMI and social factors such as poverty, neighborhood composition and immigration status and to develop effective interventions. But they are not always involved with one key aspect of aiding this population: providing treatment.
“Patients at community mental health centers often go through an entire course of treatment and never encounter a clinical psychologist,” says Kim Mueser, PhD, a professor and clinical psychologist at Boston University’s Center for Psychiatric Rehabilitation. Instead, psychiatrists, social workers and case managers deliver most of the care.
But experts say because of their relevant knowledge of psychopathology, social factors and psychotherapy, psychologists with adequate specialized training can help people like Martin, who was deemed incompetent to stand trial and entered a treatment program at the Oregon State Hospital, where he received care from clinical psychologist Jessica Murakami-Brundage, PhD, and other mental health professionals. Though most of Murakami-Brundage’s patients make significant progress, the lack of sustained professional support and community resources means that many relapse soon after leaving the hospital.
Now, psychologists are studying the ways in which SMI and social determinants such as poverty and other neighborhood conditions interact and are developing novel interventions to provide more sustained care. And in August, APA approved a new postdoctoral specialty, SMI psychology, a major step toward increasing psychologists’ engagement with this population.
“If psychologists had more exposure to this population, they would really fall in love with the people and the work,” says Murakami-Brundage.
Social determinants
Over the past several decades, an extensive body of research has explored why so many people with SMI live in poverty. The “social causation” theory suggests that growing up in impoverished communities—with problems such as high crime rates, parental stress and a high likelihood of experiencing trauma—increases a person’s risk for SMI. On the other hand, the “social drift” hypothesis posits that because people with severe mental health problems often struggle with education and employment, they end up in more deprived neighborhoods and circumstances.
Some previous findings have supported the social causation theory, including a retrospective analysis of census and hospitalization data in Massachusetts that analyzed more than 34,000 patients over a seven-year period (Hudson, C.G., American Journal of Orthopsychiatry, Vol. 75, No. 1, 2005). But a recent systematic review of a broader range of evidence has called those results into question, finding mixed results and concluding that the nature of the link between poverty and SMI is still unclear (Kwok, W., International Journal of Social Psychiatry, Vol. 60, No. 8, 2014).
While researchers say it’s tough to confirm a causal link between poverty early in life and risk for SMI, most believe that poverty can both contribute to and result from such illnesses.
Now, psychologists have started to analyze the relationship in prospective studies that offer more conclusive evidence, aided in part by data from national health-care systems. One 30-year longitudinal study led by Paul Hastings, PhD, a professor at the University of California, Davis, Center for Mind and Brain, and his colleagues at the Centre for Research in Human Development at Concordia University in Montreal, looked at 3,905 Canadian families and used peer evaluations, medical records and census data to examine whether childhood neighborhood conditions and behavioral characteristics predicted a diagnosis of bipolar disorder, schizophrenia or another psychosis spectrum disorder in adulthood. Hastings and his colleagues found that children growing up in disadvantaged neighborhoods—especially those who were rated by peers as both highly aggressive and highly withdrawn—were more likely to develop an SMI later in life (Development and Psychopathology, 2019).
“Even after accounting for educational attainment, changes in socioeconomic status over time and other factors, childhood neighborhood conditions were significantly tied to the likelihood of a diagnosis,” says Hastings, adding that the observed link between neighborhood conditions and behavioral characteristics highlights an opportunity for early prevention by investing in neighborhood resources.
Other social factors, including minority status, urban living and immigration, have also been tied to SMI. A longitudinal study conducted with more than 200,000 people in Sweden linked living in urban settings with the development of a psychotic disorder (Zammit, S., et al., Archives of General Psychiatry, Vol. 67, No. 9, 2010), while other research has documented an increased risk of schizophrenia among Caribbean-born migrants and their descendants in England (Tortelli, A., et al., Social Psychiatry and Psychiatric Epidemiology, Vol. 50, No. 7, 2015) and an increased risk of psychosis among refugees in Denmark, Sweden, Norway and Canada (Brandt, L., et al., JAMA Psychiatry, 2019).
For children and teens, migrating to an unfamiliar place and living in poverty constitutes an adverse childhood experience, which research suggests may interact with a person’s genetic predisposition to mental illness to trigger the onset of an SMI (van Os, J., et al., Nature, Vol. 468, 2010).
“Many of these situations create more stress,” Mueser says, “which may be particularly problematic for individuals with an existing biological vulnerability to schizophrenia or other serious mental illnesses.”
Novel interventions
Regardless of whether poverty is a cause or an effect of SMI, or both, the effects of the two together are sobering. In the United States, around 80% of adults with SMI are unemployed, according to the nonprofit National Alliance on Mental Illness (Road to Recovery: Employment and Mental Illness, 2014), and an estimated 111,000 people with SMI are homeless (“U.S. Department of Housing and Urban Development Continuum of Care Homeless Assistance Programs Homeless Populations and Subpopulations,” 2018).
Psychologists say treating patients’ symptoms is not enough to address these intertangled problems. Addressing social factors such as homelessness, unemployment and community inclusion “is not something that happens after people get better —it’s something that actually helps people get better,” says Mark Salzer, PhD, a professor of social and behavioral sciences at Temple University and director of the Temple University Collaborative on Community Inclusion of Individuals With Psychiatric Disabilities, which designs and runs interventions to increase community engagement among people with SMI.
A landmark 1999 U.S. Supreme Court decision, Olmstead v. L.C., spurred the funding and development of innovative services by psychologists and other mental health professionals. The court ruled in favor of two women living at a state psychiatric hospital in Georgia who argued that the Americans with Disabilities Act required their state’s government to allow and support them to live in the community (“Olmstead: Community Integration for Everyone,” ADA.gov). The result was a proliferation of new policies and initiatives to comply with the new standard, including the launch of Salzer’s collaborative center in 2003.
“Inclusion—the opportunity for people with serious mental illnesses to live in the community —is a legal right. Our research shows that in almost every way, these people aren’t participating in the community like everyone else,” Salzer says. “Not only is this a violation of their rights, but it’s also not good for their health.”
Research by Salzer and others supports a recovery-oriented approach to managing SMI, showing that with proper intervention and support, many people can recover and live independently. For example, a cross-sectional survey of more than 41,000 American adults found that a third of people with a lifetime SMI had been in remission for one year or more (Salzer, M., et al., Psychiatric Services, Vol. 69, No. 5, 2018).
Most of the interventions psychologists are developing cluster around three fundamental supports that can help this population thrive: a home, a job and a friend, says Greg Townley, PhD, director of research for the Homelessness Research & Action Collaborative at Portland State University.
A crucial first step involves offering permanent supportive housing to those who need it that’s not conditional on sobriety or use of mental health services. Numerous studies have shown that the Housing First initiative, developed by psychologist Sam Tsemberis, PhD, and now with programs in more than 100 U.S. cities, can improve mental health outcomes, reduce substance misuse and decrease treatment costs (Housing First, University of Wisconsin Population Health Institute, 2019). New research by Townley and his colleagues helps explain why, finding that Housing First participants with SMI in five Canadian cities are more involved in their communities and feel an increased sense of hope and autonomy (Macnaughton, E., et al., American Journal of Psychiatric Rehabilitation, Vol. 19, No. 2, 2016).
“Once we get people indoors, that acts as a springboard for them to reconnect with services and social supports and to start developing skills that can get them on the trajectory toward recovery,” Townley says.
But people with SMI need more than just stable housing —they also need something meaningful to do. In a qualitative study of 57 young adults with SMI enrolled in vocational support programs, participants said that working improved their financial independence, social engagement, self-esteem and feelings of contributing to society (Torres Stone, R.A., et al., Psychiatric Rehabilitation Journal, Vol. 41, No. 4, 2018). Earlier research conducted in Europe reported similar benefits of vocational support among adults with psychotic disorders (Koletsi, M., et al., Social Psychiatry and Psychiatric Epidemiology, Vol. 44, No. 11, 2009).
“Returning to work is highly therapeutic for individuals with serious mental illness and contributes to their long-term economic stability,” Townley says. “We are doing a disservice by assuming people can’t work. Most people want to and should.”
One way psychologists are helping is by studying and promoting policies that can expedite the transition to a new job for those in recovery from an SMI. Rather than requiring individuals to complete extensive prevocational training, supported employment programs start by matching people with jobs based on individual skills and interests, then provide them with additional supports and training to ensure they succeed (Marshall, T., et al., Psychiatric Services, Vol. 65, No. 1, 2014). For students with SMI, supported education programs can help by offering emotional support, coaching, and training in interpersonal and time management skills (Ringeisen, H., et al., Psychiatric Rehabilitation Journal, Vol. 40, No. 2, 2017).
Salzer’s team is also looking beyond education and employment to help support patients’ efforts to participate in leisure and recreational activities in their communities. The Independence through Community Access and Navigation (ICAN) intervention helps patients engage in a range of activities in order to promote growth and independence.
More challenging but equally important is helping people with SMI develop social supports and interpersonal connections. Part of the challenge is that managing their symptoms has prevented some adults with SMI from honing social skills. Others with SMI simply fear interactions with strangers because of perceived stigma and rely heavily on traditional supports such as family members or case managers. But new research by Townley and his colleagues shows that casual relationships—such as engaging in regular conversations with a barista or a neighbor—can also be effective in fueling recovery and reducing loneliness (American Journal of Community Psychology, Vol. 52, No. 1–2, 2013; Kriegel, L.S., et al., American Journal of Orthopsychiatry, 2019).
“These are relationships where you may not even know the person’s name—but seeing them regularly leads to a sense of acceptance and becomes an important part of your daily routine,” Townley says.
Specialty training
To better prepare psychologists to assess, treat and support people with SMI, APA’s Task Force on SMI and Severe Emotional Disturbance (SED)—established in 1994 to aid psychologists working in the area—has helped create a new specialty in SMI psychology. A specialty is a defined area of psychological practice that requires a structured course of education and training to master specific skills and theoretical knowledge. The task force spent nearly a decade crafting the detailed APA Recovery to Practice curriculum, then submitted a petition for the recognition of SMI psychology as a specialty to the APA Commission for the Recognition of Specialties and Proficiencies in Professional Psychology, which recommended the petition for approval earlier this year.
The new specialty—spearheaded by the task force, APA’s Div. 18 (Psychologists in Public Service), the Div. 18 special section on SMI/SED, and the Psychosis and Schizophrenia Spectrum Special Interest Group of the Association for Behavioral and Cognitive Therapies—was recognized by the APA Council of Representatives at APA 2019 in August, thereby establishing it as APA policy.
“There’s a growing recognition that it takes additional training and skills to work well with this population,” says Murakami-Brundage, a member of the task force. “There’s already been tremendous growth in understanding the potential for recovery, but the training is lacking.”
The dearth of graduate programs, internships and postdoctoral fellowships focused on SMI psychology inspired Mary Jansen, PhD, director of Bayview Behavioral Consulting Inc. in Vancouver and a former chair of the task force, to organize the petition for the new specialty. She says trainees in SMI psychology programs will receive instruction on evidence-based interventions developed and tested specifically for this population, such as cognitive-behavioral therapy for psychosis and individual resiliency training, which teaches people skills to manage their illness. Trainees will also learn to administer assessments developed for people with SMI, including functional assessments to test a person’s capacity for communication and social skills, among others.
SMI psychology training programs will be required to operate from a recovery-oriented philosophy. The programs will also teach psychologists how to collaborate with other mental health professionals, such as psychiatrists and social workers —who may take different approaches—and how to advocate for people with SMI.
“Most providers don’t believe that people with a serious mental illness will improve or can live meaningful lives,” says Sandra Resnick, PhD, an associate professor of psychiatry at Yale University and a former chair of the APA task force. “It’s important that our training opportunities share the perspective and data that show that’s simply not true.”
The Specialty Council for SMI Psychology, which includes representatives from each of the specialty’s four organizational members and is responsible for overseeing continuing professional development and education, will be represented on the Council of Specialties in Professional Psychology, a nonprofit that supports the development and functioning of psychological specialties. The specialty council will also apply for affiliation with the American Board of Professional Psychology so that psychologists can eventually obtain board certification in the area.
“Oftentimes, people with the most significant disabilities get treatment from people with the least amount of experience,” says Resnick. “The new specialty will help us elevate the needs of this population and show psychologists that more people should be pursuing this crucial work.”
