A meta-synthesis of qualitative studies on citizenship and mental health

Abstract

Background:

Citizenship, as conceptualized by Rowe and colleagues, emphasizes the significance of relationships and community membership, encapsulated by the ‘5 Rs’ – rights, responsibilities, roles, resources, and relationships.

Methods:

A meta-synthesis of 20 qualitative studies on citizenship and mental health was conducted.

Results:

We identified four central themes: Autonomy and Empowerment, Social Inclusion and Relationships, Social Exclusion, and Non-Relational Resources and Supports. Service users’ experiences illuminate the challenges of achieving full citizenship, negotiating societal norms, and accessing non-relational resources.

Conclusions:

This synthesis contributes to our understanding of Citizenship and its relationship with mental health, highlighting its role in fostering social inclusion and empowerment as well as informing potential implications for mental health interventions and policies.

Introduction

Since its inception in the late 1990s, Citizenship, as defined by Rowe and colleagues (Rowe and Baranoski 2000, Rowe et al. 2001), has emerged as a crucial theoretical framework applied to promote social inclusion and participation within mental health contexts. The term ‘Citizenship’ carries diverse meanings in both research and everyday language. These descriptions are critically framed by the inclusion of individuals in their social landscapes, whether that be their neighborhood, community, or society at large. Philosophers such as Aristotle, dating back to the fourth century BC, have pondered the importance of citizenship, arguing that true citizenship involves active participation in the politics of one’s community (Rowe 2015). This discussion of ‘politics’ refers to the integral workings of community life, including civic engagement and social interactions. Building on this historical perspective, Aristotle and other philosophers contend that an individual’s membership in the ‘city’ is fundamentally shaped by their social nature. This perspective underscores the interconnectedness of human beings within the societal fabric.

While citizenship is commonly associated with legal rights and national identity, Rowe and colleagues (Rowe and Baranoski 2000, Rowe et al. 2001, Rowe and Pelletier, 2012a) define the concept as an individual’s relationships and membership within their community. Specifically, Citizenship is defined as a robust connection to the ‘5 Rs’ comprising rights, responsibilities, roles, resources, relationships, and a sense of belonging (Rowe 2015). One’s strength of relationship to these ‘5 Rs’ can be understood as the gauge between full citizenship and social marginalization. Unfortunately, when membership in society as we define it is mediated by social inclusion not everyone finds themselves belonging. Namely, those who experience mental health challenges or other life disruptions often also experience strained relationships and become excluded from a comprehensive sense of citizenship. This model shares similarities with other social models of recovery, such as relational or family recovery (e.g. Wyder et al. 2022), which also emphasize the importance of connectedness. However, the citizenship model places greater emphasis on civic engagement and societal participation.

The theory of Citizenship began to formalize through observations made by homelessness outreach workers in New Haven, Connecticut. Over time outreach workers noticed the limitations of their scope when they found that the individuals who they assisted off of the streets and into homes were experiencing a sense of ’second-class citizenship’. This second-class citizenship, also called ‘program citizenship’ was characterized by a dependance on mental health staff and other program resources (Rowe 1999). Individuals were now housed, but they expressed feelings of isolation in their new homes and a loss of the social networks that they had developed during their time on the streets or in shelters (Rowe et al. 2001). It was through this outreach work and observations that professionals and researchers alike identified the importance of social inclusion to reach a sense of first-class citizenship (Rowe and Pelletier, 2012b).

From this theoretical foundation emerged various citizenship interventions and studies geared towards the application of the citizenship framework. The first iteration of these was called Citizens which aimed to facilitate the community integration of individuals transitioning from homelessness into housing (Rowe et al. 2001). Community members, businesses and social service providers were all recruited to connect homeless persons who were entering housing to the larger community network and assist them in acquiring valued roles in their communities. Citizens was followed by the Citizens Project, also called the Citizens Intervention which involved a group intervention with wraparound peer support for people who experienced co-occurring mental health challenges and substance use disorders, many of whom also had criminal justice histories (Rowe et al. 2009). The next step for Citizenship was to test the utility of the intervention which was implemented using a randomized controlled trial design comparing the intervention alongside usual public health services to the public services alone (Rowe et al. 2007). The intervention proved useful, which encouraged an individual measure for citizenship to be constructed. This measure was validated using concept mapping methods, and data were collected in collaboration with men and women diagnosed with mental health challenges (Rowe et al. 2012). Having constructed and implemented the citizenship intervention and measure, researchers began to expand the scope of citizenship, applying it to various contexts and populations outside of New Haven.

In recent decades, researchers from around the world have embraced the Citizenship framework, adapting it to diverse communities and occasionally clinical settings for the purpose of supporting the social inclusion and full community membership of individuals with mental health challenges. From its utility in Clown Therapy in Brazil (De et al. 2019) to Musical Intervention programs in the United States, the concept of Citizenship has been explored and intermittently reported upon for the past 20 years (Kriegel et al. 2022). However, what is currently missing in the literature is a comprehensive overview of existing Citizenship literature aimed at enabling us to observe its evolution and subsequent utility. Better understanding and dissemination of Citizenship and its practical applications at both individual and community levels will support the greater goal of targeted public health efforts in the field of mental health.

Building on the CHIP (Context, How, Issues, Population) framework for developing research questions (Shaw 2010), we aim to provide a comprehensive analysis of the existing qualitative literature analyzing aspects of Citizenship related to Michael Rowe and colleagues’ theoretical framework. Our objective is to consolidate the research to gain a deeper understanding of how the Citizenship framework has evolved over time and socio-cultural contexts. We will conduct a meta-synthesis of qualitative studies, identifying and presenting pivotal themes that reflect the most salient elements of the lived experience of mental health challenges and community-based recovery within the context of the Citizenship framework.

Method

This study adhered to the current Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement (Page et al. 2021) to ensure a transparent approach to the systematic review and meta-synthesis process.

Eligibility criteria

To maintain conceptual consistency, only articles that explicitly referenced Rowe’s Citizenship theoretical framework were considered for inclusion in this meta-synthesis, unless the article mentioned the 5 Rs or Michael Rowe had authorship. To ensure academic rigor and reliability, the review was limited to peer-reviewed journal articles. A quality appraisal of the selected articles was conducted using the Critical Appraisal Skills Programme (CASP) Checklist For Qualitative Research (Critical Appraisal Skills Programme 2024).

Search strategy

The search strategy consisted of two parts. It began with examining the works authored by Michael Rowe, the primary author and architect of the Citizenship theoretical framework. Beginning with his contributions, which involved both primary and collaborative authorship, we took a snowballing approach to identify other Citizenship literature. The second part involved a systematic search of two electronic databases: Scopus, and Medline. We used the search terms ‘Citizenship’ or its components: ‘rights’, ‘responsibilities’, ‘roles’, ‘resources’, and ‘relationships’, along with ‘Mental Health’ and ‘mental illness’. Restrictions were set such that searchable years were limited to 2000–2023 and the language was limited to English. A single reviewer autonomously screened each record, utilizing the ASReview Lab software – a tool tailored for systematic reviews. The sources were last consulted on October 30th, 2023. A PRISMA (Page et al. 2021) flow chart presenting a detailed account of the search strategy can be found in Figure 1.

Figure 1. PRISMA flow diagram of the study selection process.

Qualitative meta-synthesis

We followed methodological practices for qualitative meta-analytic research, outlined by Levitt (2018). Details regarding aims, participant demographics, data collection methods, approaches to analysis, and key findings about each of the included qualitative studies can be found as supplementary material.

Data collection

As outlined above, the primary aim of this qualitative synthesis was to identify the core components of lived experience of mental health challenges and community-based recovery within the context of the Citizenship framework (Rowe 2015). Our data collection specifically targeted information obtained directly from mental health service users, peer support workers, and professionals. The findings of the included articles report themes and experiences discussed or encountered by these groups when examined through the lens of the Citizenship framework.

Data synthesis

Eighty-seven primary themes were identified and transformed into initial research units. If the same theme was repeated in another text, it was marked as present for that study using the categories already created. Categories and occurrences were introduced in a spreadsheet. These units were subsequently organized into nine thematic categories. The categories were formed by comparing the research units to one another to identify similarities and differences within the context of the study question. The nine categories initially identified were autonomy, empowerment, active forms of social inclusion, relationships, active forms of social exclusion, passive forms of social exclusion, external resources, structural barriers, and finally, rules and norms in society. Ultimately, four central themes were distilled from the initial nine to consolidate findings and streamline results. These themes were developed by the first author and discussed with the second author.

This analysis led to the identification of four overarching and conceptually significant themes: Relationships and Autonomy, Social Inclusion and Relationships, Social Exclusion, and Non-Relational Resources and Supports. Original themes, occurrence and proportion of identified themes can be seen in table 1. A comprehensive account of each identified theme is described in the results and discussion section.

Table 1. Occurrence and proportion of themes

Results

Characteristics of included studies

As shown in Figure 1, the initial selection process identified 1,274 records. After removing duplicates, 998 records were screened, excluding 870 based on titles. The remaining 128 records were screened through abstracts, excluding 47. Finally, 81 full-text articles were assessed and 20 were selected for the qualitative meta-synthesis. We excluded just one qualitative study (Mutschler et al. 2019) because although the theoretical framework of Citizenship is mentioned, its results are not focused on that framework but on the implementation aspects of a social intervention project. We then applied a systematic qualitative meta-synthesis approach to the qualitative data drawn from the 20 selected studies.

The selected articles spanned across the publication period of 2012–2023. Included studies were collected from five countries including New Zealand, Norway, Scotland (UK), Spain, and the United States. These studies involved a total of 683 participants and diverse populations, including individuals with lived experience of mental health challenges and co-occurring substance use disorders, as well as professionals involved in their care. Data collection methods varied, including interviews, focus groups, and surveys. Analytic techniques employed included thematic, narrative and phenomenological approaches.

Identified themes

Autonomy and empowerment

Autonomy and Empowerment emerged as the first central theme in our analysis of the lived experiences of mental health service users. Defined by one’s ability to possess and navigate the rights and responsibilities of being an independent and autonomous member of society, this theme includes one’s ability to make and actualize goals, define their purpose, utilize their skills and care for themselves as well as others. For many, it represented a significant barrier to achieving full membership in the community. While it is expected that relationships and support constitute core elements of life in the community and full citizenship, participants often found themselves having to rely on others in ways they did not want to, just to live what they described as a ‘normal life’. In a study conducted by Ponce and colleagues (2012), focus groups were conducted with individuals experiencing mental health challenges, histories of criminal justice charges, and homelessness. The participants described how access to opportunities was often intertwined with an inevitable dependency on others. When discussing securing housing, one participant said:

‘… they need a second signature and nobody wants to do that because they might not want to risk it because they don’t know if you have made that change yet and they don’t want to risk it because it might jeopardize them’.

Participants across studies described mental health conditions and life disruptions not only infringing upon their autonomy but also a sense of personal identity, in some cases completely supplanting it with whatever diagnosis or life disruption they faced. In one study by Stewart and colleagues (2017), which explored the usefulness of citizenship in explaining constructions of community, one participant discussed how the Citizenship Project addressed their sense of self:

‘Citizens Project is like a Harbor, like a shining peace from the sea for all of those lost souls. It helped me regain a piece of the man I thought I lost. It brought back my self-confidence, my hunger for life’.

Similarly, another participant noted:

‘Sometimes I forget that I have a mental illness. I don’t forget in terms of my frailties, but I forget the label. If you dare to forget then something will remind you… but [I think] do I have to be a service user all the time? Can I do other things as well? Just doing ordinary things such as going to work, or shopping at the supermarket … acting like an ordinary person’. (Hamer et al. 2017).

Social inclusion and relationships

The most prevalent themes reported by participants across multiple studies highlight the significance of social inclusion and relationships. This makes sense when we consider Citizenship to be a tool for social inclusion, although it also reflects the impact of mental health challenges on relationships. In this context, the theme is defined as an individual’s capacity to connect with others in their communities while fostering trusting, reciprocal, and respectful relationships. Social inclusion encompasses a range of interactions, from casual encounters with community members as passersby in public spaces to deliberate efforts to cultivate close relationships with family members and friends. From the data gathered, we identified four main styles of social inclusion and relationships: 1) Large Scale Social Interactions: These interactions involve a general sense of inclusion and positive social recognition. This style represents a passive form of inclusion where individuals may feel acknowledged in their community without deeper engagement. For instance, feeling recognized as part of a larger community can offer a sense of belonging, but it may lack meaningful connections; 2) Intermediate Level Interactions: This category encompasses relationships with passersby in public spaces, indicating a level of engagement that goes beyond mere acquaintanceship. While these interactions provide a degree of social connection, they still fall under a passive from of inclusion because they do not foster deeper relationships; 3) Intimate Relationships: This style involves cultivating close, supportive networks with family and friends, reflecting active social inclusion that necessitates intentional efforts to maintain and nurture these connections. Active engagement with family members demonstrates how deliberate efforts can foster supportive and meaningful relationships; 4) Programmed Inclusion: This category includes relationships formed through structured initiatives, such as those within the Citizens Project and other peer-led support groups. These relationships are characterized by intentional involvement and participation, where participants actively engage in programs designed to promote social connections. This emphasis on purposeful engagement underscores the critical role of structured support in fostering active inclusion, enabling individuals to build meaningful relationships and exercise their citizenship within the community.

Among the twenty studies included in this qualitative meta-synthesis, fifteen provided in-depth insights into the significance of one or more of these four styles of social inclusion and relationships. In one article presenting findings on community integration experiences, a participant highlighted the extent to which their community integration efforts were focused on their family.

‘I am reacquainting with relatives which is the hugest benefit …. I wish they were more back in my life but we are making contact and the contact has all been very, very helpful and warm and inviting and loving …. I’m shedding a little at a time the role of the black sheep of the family’. (Harper et al. 2017)

Another service user, describing her and her husband’s role as school cleaners shares in a focus group the importance of more distant relationships saying, ‘We’re the school cleaners, and the kids will say “There’s the cleaners - Hi cleaners.” [It’s] feeling and being included’. (Hamer et al. 2017).

Social exclusion

Similar to the recurring theme of social inclusion, social exclusion emerges as a significant and pervasive concern expressed by service users. In this context, social exclusion can be best characterized as the challenge faced by service users to ‘fit in’ with mainstream society. It is defined by a profound sense of isolation and marginalization from both internal and external factors, including examples such as assaults on one’s dignity and the persistent feelings of being in an inescapable ‘hole’. Much like social inclusion, social exclusion can be expressed in both active and passive forms. Passive social exclusion often manifests via societal rules and norms, making it challenging for individuals to navigate these expectations. These norms encompass conventional societal standards and expectations governing ‘normal’ behavior and identity. For those dealing with mental health challenges, conforming to these norms can be particularly difficult, contributing to their experiences of social exclusion. A participant from one study described her perspectives about these expectations, ‘Who gets to say what is normal? (I am an) expressive, creative person who has spent my entire life not put in a box. Act normal, for whom? Heaven help me from normal!’ (Hamer et al. 2014). Other individuals described their experiences with more active forms of exclusion where individuals are deliberately excluded or labeled based on past actions or their psychiatric diagnosis. One participant shared:

‘It’s more important how others perceive you, how they think of you, where they pigeon hole you, what box they fit you into. So you can think you’re a good citizen but other people because you did something 20 years ago still categorize you as dodgy’. (Cogan et al. 2021).

Non-relational resources and support systems

The final theme generated by our analysis underscores the significance of non-relational resources and support systems. These systems – such as legal rights, economic support, housing, and financial assistance – are considered to be universally accessible, regardless of personal relationships or social bonds. However, individuals with mental health challenges and their care providers identified several barriers that restricted their access to these systems.

Several articles delve into the exploration of these resources as they pertain to mental health service users. In a mixed-method study conducted by Harper and colleagues (2018), the authors investigated the experience of utilizing financial services among people with mental health challenges. The findings of this study revealed that, on the whole, financial services ‘do not work well’ with individuals with mental health challenges. They found that service users often struggle with the associated fees, encounter difficulties in saving money, and frequently find themselves burdened by substantial arrears and debt. One participant states:

‘[I had] one bank account while I was working and I was trying to get my-self together. It was … the year my mom died and I wanted to show that I could be responsible. I don’t know how that account got messed up… if it was overdrawn or what… I closed [it] then I went to [name of bank]. At that time my Social Security check was getting direct deposit into it and then my son had them cash a check that wasn’t no good. My next bank account was [name of bank]. I screwed that [up] because I was getting high’. (Harper et al. 2018).

Other arenas such as housing and work were discussed among participants as being significant barriers to their life in the community. Many participants described it being difficult to find housing because of their mental health record or criminal histories. For the same reasons participants found that finding jobs seemed to be a challenge even when they were qualified for the work. One participant says, ‘I couldn’t get hired at McDonalds. They told me I was so-called ‘over experienced’ or ‘overqualified.’ What do you mean about “over qualified?” But yet, someone who graduates from college, you got that person to work’. (Rowe 2015).

While non-relational resources, such as legal rights and housing, are theoretically independent of personal relationships, it is important to address underlying relational dynamics that can influence access to these resources. For instance, gatekeepers, like bank officers or landlords, can impose barriers based on stereotypes surrounding mental health challenges. It is critical to acknowledge how a lack of support by people such as gatekeepers in navigating complex systems can further hinder access. We have chosen to discuss non-relational resources separately due to their pervasive presence in participants’ experiences, underscoring the intricate interplay between relational aspects and the accessibility of these resources.

Discussion

This qualitative meta-synthesis provides a comprehensive overview of the relevant qualitative literature on Citizenship and mental health, shedding light on its evolution, significance, and impact on the lives of individuals with lived experience of mental health challenges. Our findings highlight the central themes of autonomy, social inclusion, social exclusion, and non-relational resources and support within the context of the Citizenship framework. These themes underscore the multifaceted experiences of mental health service users as they navigate the complexities of societal integration.

Our findings align with Dell et al.’s (2021) ecological model, which views recovery as a shift from a negative identity state to one of psychological well-being. This transformation requires supportive social conditions, autonomy and personal responsibility, roles and relationships that facilitate experiences of belonging, and self-acceptance. Building on this, social exclusion is increasingly understood as a multidimensional process that goes beyond economic deprivation, encompassing the denial of rights, and civic participation (Cedeño 2023). While a large part of the social inclusion literature focus on subjective experiences of connection and belonging (Haslam et al. 2024), there is a growing recognition of the need to examine broader structural factors that influence political and economic participation (Wise and Sainsbury 2007, Lühr et al. 2022). This understanding of social inclusion aligns with the Citizenship framework’s emphasis on full participation in community life, highlighting the need to transform mental health care systems by redefining social integration objectives.

It is important to acknowledge the limitations of this study. The absence of primary data collection means that our analysis is entirely dependent on the quality and scope of the existing studies included in the meta-synthesis. Additionally, while four major themes have been identified for analytical purposes, it is important to acknowledge the overlap between them and the bidirectional relationship between mental health challenges and the other subjects highlighted. As one participant emphasized when discussing housing, ‘Housing is such a problem. Where are we going to sleep at night? You give me meds to sleep, but I’m not going to take them because I have to watch over where I sleep’. (Clayton et al. 2020), illustrating how a lack of stable housing exacerbates both safety concerns and mental health struggles. However, this interconnection underscores the significance of the Citizenship framework, which serves as both a holistic lens for understanding the impact of mental health challenges and an intervention that provides a sustainable approach to addressing the diverse harms experienced by community members.

Looking ahead, there are several promising avenues for future research. First and foremost, a continued focus on the practical applications of the Citizenship framework within mental health settings is necessary. Involving individuals with lived experience and mental health professionals in research and intervention design remains pivotal. Policy evaluation through a Citizenship lens can inform necessary changes in mental health policies and legislation to better support social inclusion and participation. Lastly, exploring ways to integrate quantitative and qualitative results can offer a more holistic understanding of citizenship and the lived experiences of individuals experiencing mental health challenges. Therefore, further validations of the Citizenship measure should be pursued. Cultural adaptations following the methodology outlined by Rowe and colleagues (2012), would enhance the measure’s utility by allowing for a broader scope of application.