International Journal of Law and Psychiatry 34 (2011) 303–308

Contents lists available at ScienceDirect

International Journal of Law and Psychiatry

Citizenship, mental illness, and the criminal justice system

Michael Rowe ⁎, Madelon BaranoskiYale School of Medicine, Department of Psychiatry, New Haven, CT, USA

⁎ Corresponding author.E-mail address: Michael.Rowe@yale.edu (M. Rowe).

0160-2527/$ – see front matter © 2011 Elsevier Ltd. Aldoi:10.1016/j.ijlp.2011.07.010

a b s t r a c t

a r t i c l e i n f o

Available online 29 July 2011

Keywords:CitizenshipMental illnessCriminal justiceHomelessness

The concept of citizenship in regard to persons with mental illness has gained increasing attention in recentyears, but little empirical research has been conducted on this topic. In addition, little research or conceptualwriting has been done on the topic of criminal justice in regard to citizenship for people withmental illness, inspite of the high incidence of criminal charges and incarceration among this group. We review our work on anapplied theoretical framework of citizenship, including its origins in mental health outreach work to peoplewho are homeless and in a jail diversion program. We then suggest the contribution the framework can maketo the intersecting issues of mental illness, its criminalization in the U.S., and the goal of communityintegration for people with mental illness.

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© 2011 Elsevier Ltd. All rights reserved.

1. Introduction

Two main theoretical models of citizenship—T.H. Marshall's legal,political, and social rights for individuals balanced with militaryservices, payment of taxes, and other service obligations to the state(Marshall, 1964), and the Tocquevillian/Durkheimian model ofsolidarity and general exchange through civic participation, volun-teerism, and other means (Durkheim, 1933; Tocqueville, 2000)—provide a grounding for contemporary scholarship and research. Theconcept of citizenship in regard to persons with mental illness hasgained increasing, if still modest, attention in the U.S. and interna-tionally. Ware et al. have employed it in qualitative research on socialintegration for persons with psychiatric disorders, defining socialintegration as a process through which persons with mental illnessesdevelop their capacities for connectedness and citizenship. In turn,social connectedness involves building and maintaining reciprocalrelationships, while citizenship involves the rights and privileges, andthe corresponding responsibilities, which members of democraticsocieties enjoy (Ware, Hopper, Tugenberg, Dickey, & Fisher, 2007).Rowe et al. define citizenship as a measure of the strength of people'sconnections to the rights, responsibilities, roles, resources, andrelationships available to them through public and social institutionsand “associational” life in their neighborhoods and local communities.Citizenship, in their approach, is a response to “program citizenship,”in which persons with mental illness have strong dependence onmental health staff and systems to maintain their community tenure(McKnight, 1987; Rowe, 1999). Crabtree and Chong situate citizen-ship at the heart of a dialogue between individuals and the state.Mental illness, which afflicts a significant part of the population over

people's life spans, is central to the health of a democratic society andgovernment has a contractual obligation to provide mental healthassistance to its members (Crabtree & Chong, 2000). Morrow insertscitizenship into tensions between advocacy for mental health reformand the drive toward cost containment, arguing that opportunitiesmust be created for the participation of mental health care recipientsin this debate (Morrow, 2004). McCabe et al. call for efforts to enhancethe “cultural citizenship “of persons with mental illness and otherswho are socially excluded. For them, the arts provide a means offacilitating “voice” and social participation to persons with mentalillness and other socially excluded groups (McCabe, Summerton, &Parr, 2007). Chan and Chiu view citizenship in terms of politicalparticipation, contending that voting is a powerful means forfacilitating the citizenship of users of mental health services (Chan& Chiu, 2007). Prior links theories of citizenship and human rights toresponses to the stigma of mental illness and to access to housing,employment, and family life (Prior, 2007). There is a dearth ofempirical research on the concept of citizenship in regard to personswith mental illnesses, however, and no validated measures have beendeveloped.

A gap in research and literature on citizenship for persons withmental illness is the lack of attention to the criminal justice system'spresence, for many, in their lives. This is surprising for two reasons.First, the criminal justice system has become, to a large degree, the defacto asylum system for people with mental illness. As many as 16% ofthe 1,175,000 federal and state prison inmates in the U.S. have adocumentedmental illness (President's New Freedom Commission onMental Health, 2003), and once involved in the criminal justicesystem, persons with psychiatric disabilities are vulnerable to longerprison terms for misbehavior related to their behavioral disabilities(Hopper, Jost, Hay, Welber, & Haugland, 1997). Second, the criminaljustice system marks a dramatic point at which individual actionsmeet the protective powers of the state, that is, the criminal justice

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system is a mediator of the relationship between the person andsociety (Rowe & Baranoski, 2000). Yet with the exception of Uggens etal., who have applied the concept of citizenship as full participation insociety to the civic reintegration of discharged criminal offenders(Uggen, Manza, & Thompson, 2006), and of our own work, we are notaware of any conceptual or research efforts that link mental illness,citizenship, and criminal justice involvement. We take up this themehere, drawing in part on our previous writing on the topic (Rowe,1999; Rowe, Bellamy, Baranoski, Wieland, O'Connell, Benedict,Davidson, Buchanan & Sells, 2007, 2009; Rowe & Baranoski, 2000),to review the origins of our work in practice and theory, our researchto address the intersection of the three domains above and suggestfurther applied theoretical efforts related to community integration,acceptance, and contributions of persons with mental illness andcriminal justice histories.

2. Development and application of a theoretical framework ofcitizenship

Our research on citizenship emerged from our observations of twosuccessful forms of mental health intervention that, simultaneouswith their success, exemplified the gaps, or failures, in mental healthsystems of care. We take up each of these in turn.

2.1. System failure #1: a house is not a home

The first author was director, from 1994 to 2000, of an interagencymental health outreach team under the aegis of a large public-fundedcommunity mental health center in New Haven, Connecticut. TheNewHaven project was one of 18 initiated across the country throughthe federal ACCESS (Access to Community Care and Effective Servicesand Supports) project, a nine state research demonstration designedto test the effectiveness of systems integration strategies for servicesto mentally ill homeless persons (Randolph, 1995). New HavenACCESS provided, directly or through referral, clinical and rehabilita-tive services including mental health and substance abuse treatmentand access to entitlements, work, and housing, to persons who werehomeless with mental illnesses and were not engaged in traditionaloffice-based treatment. A key case management goal was to placeclients in one of various forms of housing—from structured residentialprograms to independent apartments—with use of a client supportfund and referral to programs available through the local managedmental health service system and area property owners. Once housed,clients generally continued to receive clinical and support servicesfrom the ACCESS project or from treatment teams at themental healthcenter's main clinic.

As this work progressed, the first-named author began to see theencounters of homeless people and outreach workers not only asclinical encounters but as social encounters taking place at thephysical, psychological, and social margins of society. These encoun-ters involve transactions regarding instrumental factors such asservices and supports and expressive factors including identity andsocial status. People who are homeless engage in identity transactionswith outreach workers that pose the prospective choice of sheddingtheir “homeless identity” and building new identities as members ofthe “housed community.” In shedding their homeless identity,however, people risk earning only a marginal form of communitylife characterized by dependence on mental health staff, substandardhousing in poverty-stricken areas, and lack of positive social identitiesand relationships (Rowe, 1999).

This risk became clear to us as we began to help clients move intotheir new apartments, only to find that some wanted to return to thestreets upon finding themselves at sea in the lonely world ofapartment living, without friends or social support structures beyondthe mental health system. Placing clients in community housing, welearned, fell far short of providing them a stable home and positive

identity as community members. Many had functioned on the streetsfor years with little help from case managers, only to find that socialmarginality and isolation left them dependent on their paid helpersfor social contact once they entered housing. For a number ofhomeless individuals, then, outreach and other mental healthprograms offered substandard housing and social isolation in placeof emergency shelters and homeless companions in misery, andsecond class or “program” citizenship in place of the noncitizenship ofhomelessness (Rowe, 1999; Uggen et al., 2006).

If work with people who are homeless with mental illnesses canhelp them move out of homelessness, we reasoned, only theirinstrumental and expressive relationships to their communities andthe larger society can grant them the effective status of first classcitizenship. We adopted a definition of citizenship, noted above, as ameasure of the strength of people's connections to the rights,responsibilities, roles, resources, and relationships available to peoplethrough public and social institutions and through “associational” lifein their neighborhoods and local communities (McKnight, 1987;Rowe, 1999). Full citizenship, we argue, requires not only that peoplehave access to participation in society, but that they perceive others aswelcoming and valuing their participation. A similar goal is highlight-ed in both the 2003 New Freedom Commission's emphasis onaddressing discrimination (President's New Freedom Commission onMental Health, 2003) and the 2005 Federal Action Agenda's assertionthat “[a] keystone of the transformation process will be the protectionand respect of the rights of adults with serious mental illnesses.”(Substance Abuse and Mental Health Services Administration, 2005,p.1).

To achieve the goal of full membership in society, people musthave effective rights and corresponding responsibilities as membersof society. They also must attend to both the instrumental aspects ofcitizenship—acquiring practical knowledge and skills for gainingaccess to opportunities and resources—and the affective aspects—experiencing membership in a community by developing relation-ships and roles in it. Achievement of the five Rs, however, may beespecially problematic for people with serious mental illness who areburdened, in addition, with poverty and homelessness, and for many,with co-occurring substance use disorders and criminal justicehistories (Rowe, 1999; Uggen et al., 2006).

2.2. System failure #2: a system is not a community

We undertook a three-year community-level intervention withprivate foundation funding. Citizens involved building a coalition ofpeople who were or had been homeless, mental health providers ofservices, and community leaders for the purpose of advancing the twomain objectives of educating the public about the needs of people whoare homeless and taking practical steps to facilitate their efforts tomove from homelessness into housing. While the project sponsoredsome positive outcomes including a bookwritten by people whowerehomeless (Mattison, Benedict, & TwoBears, 2000) and a leadershipproject aimed at giving these persons a greater voice in thegovernance of agencies that were funded to serve them (Rowe,Benedict, & Falzer, 2003), we concluded that the citizenship approachshould now shift its focus to an individual's efforts to become a full-fledged community member and citizen.

The timing of this change in focus proved to be fortuitous, as thesecond-named author, Director of the Jail Diversion Project for thesame public mental health center that hosted the homeless outreachproject, had been reflecting on a related form of mental health systemfailure. Jail diversion programs were developed to reduce incarcera-tion rates for persons with psychiatric disorders who commit low-level offenses by diverting them from the criminal justice to themental health system (Steadman, Morris, & Dennis, 1995). Diversionis accomplished through clinician and client negotiations with courtpersonnel to have charges dropped or stayed in exchange for the

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client's agreement to engage in mental health treatment, and relatedapproaches (Draine & Solomon, 1999; Frisman, Lin, Sturges, Levinson,Baranoski, & Pollard, 2006; Rowe et al., 2003). Outcome studies haveshown mixed results, with some showing a decrease in substanceabuse (Cosden et al., 2003) and arrests (Lamberti, Weisman,Schwarzkopf, Price, Ashton & Trompeter, 2001; Steadman, Deane,Borum, & Morrissey, 2000), others showing similar or no differencesbetween those who were or were not diverted (Frisman et al., 2006),and others still showing high rates of criminal recidivism after initiallysuccessful diversion (Hoff, Baranoski, Buchanan, Zonana, & Rosenheck,1999).

Beyond these findings, the second-named author observed thatmany arrests of persons with mental illness for petty crimes involvedwhat could be regarded as attempts, oftenmisguided or inappropriate,to contribute to society. Consider three scenarios (details modified toprotect confidentiality): awoman is arrested for trespassing onprivateproperty in order to retrieve redeemable cans placed with other trash,aman is arrested at a bus stop for standing too close to others lecturingloudly on Freud and Jung, and another man is arrested for disorderlyconduct after urinating near the entrance to a supermarket. Eachperson was referred to the jail diversion program at the public mentalhealth center in New Haven. This represented a more enlightenedoutcome than that of locking them up for petty crimes related to theirmental illness, or homelessness, or both. For each, the treatment goalwas to stabilize their symptomswith hope that this would act, directlyor indirectly, to reduce their petty criminal behavior. Yet in each case,two implicit issues were disregarded by both criminal justice andmental health systems.

First, these three individuals were making, or saw themselves asneeding to make, a contribution to society that neither the mentalhealth nor the criminal justice system had any expectation of theirmaking. The woman arrested for trespass was working for a living, arole we associate with responsible citizenship. (She was alsorecycling.) The man arrested at the bus stop was not deliberatelydisrupting public order, but was trying to make social contact with hisfellow citizens. The man arrested at the supermarket saw himself as a“member” of that establishment and contended that he was movingaway from the store entrance when he lost control of his bladder. “Iwould never do that in my store,” he said. (We note that some jaildiversions clients are arrested for more serious crimes such aspossession or sale of drugs.)

Second, the logic of “diversion” involves the recognition thatpersons with mental illness often run afoul of the law not out of mensrea but out of difficulty negotiating an acceptable niche for themselvesin society. Yet in implementing programs based on this recognition,we divert individuals from one system to another, redefiningcriminals as mental patients but leaving them little room to definethemselves as people who can make positive contributions to society(Rowe & Baranoski, 2000).

The second-named author came to a conclusion similar to that ofthe first: behavioral health system as currently structured canmanagepatients' symptoms but cannot help them to become sociallyintegrated within their communities. The two agreed that thecitizenship theoretical framework offered the potential to begin toaddress this disjuncture. Timing was also fortuitous in that the stateauthority for mental health services, the Connecticut Department ofMental Health and Addiction Services, was funding new or, in the NewHaven case, enhanced jail diversion programs.

2.3. The Citizens Project

The authors, with other colleagues, drew on the citizenshiptheoretical framework to develop a program, the Citizens Project,geared toward addressing and enhancing the key elements ofcitizenship for persons with mental illness and criminal justicerecords. This five-month program, not including post-graduation

formal and informal contacts with Peer Mentors and staff, includes agroup component with classes followed by valued role projects, andwraparound Peer Mentor support.

2.3.1. Group component: classes and valued rolesInformation on the program is distributed to clinicians, posted at

the Connecticut Mental Health Center, and provided to local agenciesand consumer groups. Following screening for membership in thetarget population of persons with mental illness (about three-quarters of participants have co-occurring substance use disorders),and for risk factors such as violence (current risk assessment, not ahistory of violence in and of itself, determines acceptance), partici-pants meet with the Project Director, who orients them to theprogram, and with a Peer Mentor, and are given a date to begin.

The primary objectives of the group component are to: (1) enhancestudents' (participants') knowledge of and skills needed for gainingaccess to community resources, (2) enhance their ability to establishsupportive social networks with members of their local community,(3) give them an opportunity to work individually and as a grouptoward the achievement of expressed goals, (4) become part of anetwork of relationships based on mutual trust and shared interests,and (5) help them demonstrate to themselves and the communitytheir ability to take on valued roles in society. Students receivestipends for participation.

2.3.1.1. Course. The course shares similarities with social rehabilitationand social skills programs but also embodies an emphasis on bothgroup support and community contacts. Students are treated asindividuals with unique strengths and skills who are capable ofexercising rights, roles, and responsibilities and developing personalidentities as valued members of society. The Project Director, withhelp from an assistant, Peer Mentors, and community and studentpresenters, facilitates twice-weekly two-hour classes. In keeping withthe community orientation of the program, the group component isheld at a local church that hosts a soup kitchen. Students developgroup rules and norms and help shape the content of the classesthrough requests for outside speakers. The Project Director invitesstudents to talk about personal experiences, interests, and skills andencourages discussions and expressions of support among them.

Each class, as well as each meeting of the valued role project thatfollows the course, begins with a “What's up?” discussion. Studentstalk about their activities during the preceding week, including butnot limited to their struggles and successes in recovery frombehavioral health disorders, efforts to find or maintain housing,educational goals, and many others. There is an informational“community check-in” tone to these discussions. Students use“What's up?” time to problem-solve, learn about trust and trustwor-thiness, empathize with others and learn to be tolerant of differences,and criticize each other constructively while learning to acceptcriticism themselves.

Following “What's Up?” there is a recap of the last class and anoverview of the current one. Classes involve both didactic presentationsand class exercises that stress application of knowledge and skills.Outside speakers from area agencies, businesses, churches, and othersources teachmany classes,while the Project Director and PeerMentorsteach others. The curriculum covers a wide range of topics includingcitizenship, community, and neighborhood; developing appropriateself-advocacy and assertiveness skills; negotiating the criminal justicesystem including rights and responsibilities; problem solving; theAmericanswithDisabilitiesAct; public speaking; entitlementprograms;housing, jobs, and education; community integration including knowl-edge of and how to gain access to community events and opportunities;confronting the temptation to sabotage success and stress; angermanagement; healthy alternatives to drug and alcohol use; legal issuesincluding family and child, consumer, benefits and employment, anddisability law; WRAP (The Wellness Recovery Action Plan); (Mead &

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Copeland, 2000) HIV/AIDS prevention; and relationship buildingincluding intimate relationships.

The course is the most highly structured component of theintervention. Its focus on living in the community, practical skills fordaily living, and students' interaction with outside speakers distin-guish it, students say, from other groups they have attended.

2.3.1.2. Valued role projects. The classes teach, and the valued roleprojects give students the opportunity to put their learning into actionas well as to work on developing positive social networks and nichesoutside the behavioral health system. Following the “What's up?”discussion, students work with a group facilitator to plan andcomplete an education-focused project in the community thatembodies the goal of establishing meaningful social roles forthemselves as contributing members of society. Projects haveincluded group efforts such as meeting with police cadets to talkabout students' experiences of dealing with police officers on thestreet, and individual projects such as, for one student whosecolleagues found him deficient in this quality, a study of empathythat included teaching a class on the topic. Valued role projects givestudents the opportunity to step outside of the relatively closedsystem of relationships they have developed in treatment settings andinto the larger community.

The Project Director, her assistant, and Peer Mentors work witheach cohort to create a setting in which students are accepted for whothey are and for their unique contributions to the group. Thecurriculum for the group component is modified based on a givencohort's needs and interests. Each group develops its own groundrules and holds all students responsible for their actions, thusenhancing their sense of ownership of a program that develops andpursues collective goals.

2.3.2. Wraparound Peer Mentor supportThe Peer Mentor component offers ongoing mentorship, counsel-

ing, and support to students as they make their way through thegroup component and, sometimes, after they leave the intervention.Peer Mentors support students by helping them identify goals and setpriorities for achieving them, sharing their own perspectives andcoping strategies, and advocating for their access to social services,employment, education, and housing. Peer Mentors have cumulativeknowledge and experience as people who have dealt with the burdenof living with behavioral health disorders, the stigma related to thesedisorders, and the social disenfranchisement that comes with havingcriminal backgrounds. Mentors appear to combine the functions ofcase manager with consumer experience, role model, and “paidfriend” in a distinctive way that facilitates relationships which are lessformal than those of case managers with their clients but more formalthan in friendship.

Peer Mentors complete an eight module training course thatincludes information about the student population and such topics asconfidentiality, setting boundaries and goals for themselves and theirassigned students, respecting their choices, safety policies, andavailable local resources for participants. The Project Director meetsweekly with Mentors to review their individual work and supportthem in their work and their own recovery processes.

Following graduation at City Hall in New Haven with family,friends, and, often, clinicians or case managers, some graduatesmaintain contact with their Peer Mentors and the Project Directorfollowing graduation. They may also drop in for a weekly pizza lunchfor students or visit a class to talk about their experiences and teachone of the classes. A number of students have moved on to becomeparticipants of a citizenship-based “leadership project,” which trainshomeless and formerly homeless persons to sit on the boards andaction committees of agencies that provide services to homelesspeople (Rowe et al., 2003). Others have successfully completed high-school equivalency or other educational programs. Others still have

gone on to part- or full-time work. To date, we have not been able toconduct research onparticipants' long-termoccupational, community,and behavioral health or criminal justice status.

From 2001 to 2003 we conducted a randomized controlled trialof the Citizens Project that compared clinical and community out-comes for persons with mental illnesses and criminal justice chargeswho were receiving either jail diversion treatment as usual or jaildiversion plus our experimental intervention. Findings from thestudy, which included a total of 114 participants in both conditions,with baseline and two follow-up interviews, were that the citizensintervention (experimental) group had significantly lower levels ofalcohol use across 6 and 12 month follow-up periods compared tothose in the standard services group, and that intervention partici-pants showed decreasing levels of alcohol use across follow-upperiods and standard services group participants showed increasinglevels of alcohol use across follow-up periods (Rowe et al., 2007). Inaddition, unpublished results show that experimental group partic-ipants significantly increased quality of life compared to currentservices participants.

These quantitative findings are encouraging, if not overwhelm-ingly. Our qualitative and observational findings from this study andfrom our decade of workwith the Citizens Project are, we think, at leastequally noteworthy. We will briefly review five themes: (1) theprogram as a sub-community; (2) the “value added” of class topicsbeyond their direct focus; (3) “What's up?” as an exercise incommunity building that replicates itself over time; (4) the positivevalue of confronting disappointing outcomes of personal and groupefforts; and (5) the importance of being a student and graduating.

2.3.2.1. The Citizens Project as a sub-community. A contradiction at theheart of the Citizens Project, at least in its early years, is that thecitizenship framework, which began as a critique and response to thelimitation of mental health programs in regard to communityintegration and inclusion of persons with mental illnesses, putmuch of its efforts into developing… ‘a program’. This program, it istrue, stretches the meaning of social service interventions and is notlinked formally with mental health treatment, yet it retains some oftheir trappings. In addition, while the Citizens Project does not provideindividual treatment, it began with an individualistic focus: if ourefforts to build a community coalition through Citizens, while nobleand making some headway, privileged the macro-level of system andcommunity change over helping individuals, the Citizens Projectwould be explicitly focused on helping people “make it” in thecommunity.

What we have found, however, is that, within individual cohortsand over time, the project has become a mini-community that issimultaneously a haven, a training ground for participation in thelarger community, and a part of that community. The program is asupportive, if sometimes challenging, intervention for most students.Many admit to being intimidated at first, but most are able to connectwith others eventually because of their shared experiences aroundmental illness, substance use, and criminal justice contacts. Inaddition, most participants come to the project without consistentsocial support systems, and the program appears to facilitate thedevelopment of a mini-community of peers that support each other intheir individual attempts to connect with the community at large.

2.3.2.2. The value added of individual classes: the case of public speaking.Individual class topics, we have learned, often have an impact beyondtheir particular focus. Public speaking may be the best example of thisphenomenon. While it may seem questionable to devote three ormore two-hour classes to this topic for an intervention (the CitizensProject) that is not primarily focused on advocacy or publicpresentation, reflection on the challenge of public speaking suggeststhe reason for the powerful impact it has had on students: to give asuccessful public speech and benefit from it personally, the speaker

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must chose a topic of interest to him or others or both, consider pointsto be made with supporting examples, shape these points into acoherent form and to conform to a specified time limit, practice his orher speech, stand up in front of a group of peers and deliver it, listen toand learn from audience member critiques, and apply lessons learnedfrom the experience and the critiques to future speeches or otherendeavors that draw on similar requirements and skills. Publicspeaking also helps participants get to know one another, to give aswell as take constructive criticism, and to prepare for employment,housing, and other interviews. These and other classes may alsocontribute to the development of trust relationships within the groupand to what the Project Director has identified as a tendency of moreisolated participants to open up to their peers over time.

2.3.2.3. “What's up?”. “What's Up” developed in response to a need togive students in the valued role projects a chance to talk about whatwas happening in their lives and to help them transition into thebusiness at hand, which involved a much less structured approachthan the course they had just completed. As the valued role groupworkingwith this exercise, a new cohort of students, working close byin the same building, heard about it and wanted a “What's up?” oftheir own. The decision to bring the two groups together at thebeginning of each of their separate sessions, prompted by efficiency,had unexpected benefits, as “veteran” students mentored andsocialized newcomers to the project and its emerging culture andexpectations, giving new cohort members permission to begintrusting and developing relationships with one another.

Veteran students and, eventually, new cohort members, take turnleading “What's up?”, learning and practicing group facilitation andleadership skills in the process. Key elements of “What's up?” include(1) confidentiality; (2) giving each student the opportunity to speakwithout interruption and not limiting content of an individual'scontribution, yet encouraging expression of aspects of the person's lifein addition to mental illness or addiction issues; (3) keeping the focuson oneself and one's reactions to and engagement in the events andsituations people describe (no “war stories” that everyone has heardand that tend to both glamorize and depersonalize addictions andcriminal activity); (4) no cross talking, that is, listening to feedbackwithout responding and thus deflecting it; and (5) participating bygiving one's own, and responding to others', “What's up?” Throughthis process, students learn to speak about and listen to importantpersonal issues, practice the group and individual social skillsinvolved in doing so, and strengthening their “mini-community”through participation.

“What's Up?” also provides the vehicle by which students discussand put into practice the Five R's: students are encouraged to exercisetheir Rights as related to their personal lives and members of society.Through their discussions and the modeling of behavior, they learnthat they have a right to their feelings and opinions and to theexpectation of being treated with respect and dignity. Through theirdiscussions and their actions, students learn personal responsibilityand the responsibilities of others. Roles are examined and explored viamany actual and possible scenarios and through making decisions onwhich roles to pursue. Students share resources of information andcommunity contacts with each other. Finally, they learn and activelypractice skills that help the students to create and maintain a varietyof relationships.

2.3.2.4. The upside of disappointment in social life. While most cohortscomplete their valued role projects successfully, participants some-times feel their community audience did not respond as favorably orquickly as they had hoped—did not donate as generously to a fooddrive project as anticipated, for example. Such experiences, however,also become a source of group support and learning about thefrustrations of translating personal growth into positive action andacceptance in the social world.

2.3.2.5. The importance of being a student. Education, as we havelearned from this and other studies and interventions, is important tostudents, in part because so many of them have not done well informal schooling and see themselves as being at a disadvantage in lifebecause of this deficit. A recurring theme among participants who talkabout the importance of the program is that graduation from theCitizens Project is the first major project they have completed as anadult. Being a student, then, and making one's way through thecitizens process, is a valued role in itself.

3. Discussion and conclusion

Until recently, our research on citizenship for persons with mentalillness has involved the application of theory based on our bestunderstanding of what is involved in moving from the marginalizedposition of program citizenship to full citizenship. Currently, we areconducting NIMH-funded community-based participatory research(Israel, 2005) using concept mapping techniques (Trochim & Kane,2005). In this research we are eliciting from persons with mentalillness, along with Veterans returning from overseas duty, personswith criminal justice histories, persons with experience of a seriousmedical illness, persons with experience of more than one of theseforms of life disruption that results in a sense of “off timedness” inrelation to the normative world (Asbring, 2001; Devins, Bezjak, Mah,Loblaw, & Gotowiec, 2006; MacLean & Elder, 2007; Pickett, Cook, &Cohler, 1994), and those without experience of these disruptions—their understanding of and experiences of citizenship and socialexclusion. Gathering the “tome, being a citizenmeans…” responses ofindividuals from these groups will enable us to identify common anddifferent experiences of disruption across groups and to pinpointthose aspects of citizenship that are of most concern to people withmental illnesses.

Given the findings from the concept mapping process, we will beable to identify items for an instrument designed to measure the“citizenship status” of people with mental illness, based on items,elements, and concepts that their peers have designated as being atthe core of how they conceive citizenship and all that it points toregarding agency and community inclusion. Ultimately, we hope todevelop and test interventions geared toward enhancing thecitizenship of persons with mental illness, including those withcriminal justice histories. Presumably, such interventions and ap-proaches will draw on some of the intervention elements we havealready employed in the Citizens Project, but will also, we hope, bemore finely attuned to the expressed needs of its intendedbeneficiaries.

There has been recognition that mental health planners, admin-istrators, clinicians and clinical programs need to form partnershipswith the police, public prosecutors, judges, and policy makers toaddress the criminal justice issues of people with mental illness. Onesuch effort is jail diversion programs. Another is mental health courts,still controversial “specialty court” initiatives aimed at responding tothe needs of persons with mental illnesses in the criminal justicesystem (Steadman, Davidson, & Brown, 2001).We need to continue toextend the capacity of mental health systems of care to providetreatment and of mental health-criminal justice system collaborationsto attend to the circumstances and needs of this group. At the macro-level, we need to address the socioeconomic problems of homeless-ness, poverty, and lack of opportunity in the lives of persons receivingpublic mental health services. In addition, as we have argued in thispaper, we need to address the issues of social inclusion andcommunity membership of people at the margins. The citizenshipframework and the Citizens Project represent one such approach.Others are needed, consistent with the long-promised and long-thwarted goal of providing a full life in the community for personswith mental illness, including those additionally burdened withcriminal justice problems. Some of these persons, given well

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functioning jail diversions programs in place in their local mentalhealth systems of care, may be able to avoid prolonged contact withthe criminal justice system. Those who do not, including those whosecrimes merit incarceration, also need the opportunity to claim, orreclaim, a life as contributing community members and citizens, andas people who, in addition to being members of society, belong tothemselves and not the systems that have been designed to fix them.

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