Taking the Concept of Citizenship in Mental Health across Countries. Reflections on Transferring Principles and Practice to Different Sociocultural Contexts

Abstract

Transferring principles and practices to different sociocultural and professional contexts in the field of mental health can be very complex. Previous research on public health policy points to difficulties in different areas such as the understanding the new concepts, their applicability in different health systems, and suitable approaches to its effective implementation. The purpose of this article is to describe and analyze the process of transferring the concept of Citizenship, from its United States origins in mental health outreach work with persons who are homeless to Catalonia, Spain. We define Citizenship as promoting the rights, responsibilities, roles, resources and relationships of persons with mental illnesses, along with a sense of belonging that is validated by other citizens. The process of this transition involves embedding Citizenship in the mental health “first-person” (internationally known as Consumer/Survivor/Peer) movement in Catalonia. The paper includes a discussion of the concept of transference, including a case example of the adoption of the concept of mental health recovery in different countries. Following this, we describe the United States Citizenship model and key elements of its development. We then turn to Spain and the evolution of its mental health system, and then to Catalonia for a brief case history of transference of the principles and practices of Citizenship to that region. The “take home message” of this work is that concepts being brought from one sociocultural and national context to another, must focus on contextualization in the ‘adoptee’s’ practices, including the balance between personal involvement and professional rigor, the involvement of key actors, and ongoing evaluation of actions taken.

Full text

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METHODS
published: 21 June 2017
doi: 10.3389/fpsyg.2017.01020
Edited by:
Alemka Tomicic,
Diego Portales University, Chile
Reviewed by:
Guido Veronese,
University of Milano-Bicocca, Italy
Patricia Neves Guimaraes,
Unimontes, Brazil
*Correspondence:
Francisco José Eiroa-Orosa
feiroa@ub.edu;
fjeiroa@gmail.com
Specialty section:
This article was submitted to
Clinical and Health Psychology,
a section of the journal
Frontiers in Psychology
Received: 10 March 2017
Accepted: 02 June 2017
Published: 21 June 2017
Citation:
Eiroa-Orosa FJ and Rowe M (2017)
Taking the Concept of Citizenship in
Mental Health across Countries.
Reflections on Transferring Principles
and Practice to Different Sociocultural
Contexts. Front. Psychol. 8:1020.
doi: 10.3389/fpsyg.2017.01020
Taking the Concept of Citizenship in
Mental Health across Countries.
Reflections on Transferring
Principles and Practice to Different
Sociocultural Contexts
Francisco José Eiroa-Orosa1,2*and Michael Rowe1
1Yale Program for Recovery and Community Health, Department of Psychiatry, Yale School of Medicine, Yale University,
New Haven, CT, United States, 2Section of Personality, Evaluation and Psychological Treatment, Department of Clinical
Psychology and Psychobiology, Institute of Neurosciences, School of Psychology, University of Barcelona, Barcelona, Spain
Transferring principles and practices to different sociocultural and professional contexts
in the field of mental health can be very complex. Previous research on public health
policy points to difficulties in different areas such as the understanding the new
concepts, their applicability in different health systems, and suitable approaches to
its effective implementation. The purpose of this article is to describe and analyze
the process of transferring the concept of Citizenship, from its United States origins
in mental health outreach work with persons who are homeless to Catalonia, Spain.
We define Citizenship as promoting the rights, responsibilities, roles, resources and
relationships of persons with mental illnesses, along with a sense of belonging that is
validated by other citizens. The process of this transition involves embedding Citizenship
in the mental health “first-person” (internationally known as Consumer/Survivor/Peer)
movement in Catalonia. The paper includes a discussion of the concept of transference,
including a case example of the adoption of the concept of mental health recovery
in different countries. Following this, we describe the United States Citizenship model
and key elements of its development. We then turn to Spain and the evolution of its
mental health system, and then to Catalonia for a brief case history of transference of
the principles and practices of Citizenship to that region. The “take home message” of
this work is that concepts being brought from one sociocultural and national context
to another, must focus on contextualization in the ‘adoptee’s’ practices, including the
balance between personal involvement and professional rigor, the involvement of key
actors, and ongoing evaluation of actions taken.
Keywords: transference, citizenship, public mental health, user involvement, recovery, mental health reform,
Catalonia
INTRODUCTION: PRINCIPLES AND PRACTICE TRANSFER
BETWEEN CONTEXTS AND REGIONS
Transferring innovative principles and practices to different sociocultural contexts has often
been analyzed from the policy transfer and mobility perspectives, i.e., the scientific study of the
implementation of public policies in places not of their origin (Stone, 2012;Cook, 2015). Similar
methods have been employed to study the transfer of health systems strengthening strategies
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Eiroa-Orosa and Rowe Taking Citizenship across Countries
(El-Jardali et al., 2014), general (Simms, 2010) and mental
health reform toward patient-centered services (Hickie et al.,
2014). Previous research points to difficulties during the process
of transference in areas such as the understanding of novel
concepts, their applicability in a different environment, and
the most suitable strategies and approaches to their effective
implementation (Tervonen-Gonçalves and Lehto, 2004;Simms,
2010). In addition, resistance to and lack of motivation for change
often confronts systems reformers who introduce novel concepts
in different settings (Saraceno et al., 2007;Makhashvili and van
Voren, 2013).
Less discussed in the literature and practice of adapting
innovations to different sociocultural settings is the distinction
between ‘top down’ administrative-directed change (Tervonen-
Gonçalves and Lehto, 2004) and ‘bottom up’ or street-level
change (Rowe et al., 1998) seen in cross-national transformation
(Ovuga et al., 2007). When we talk about bottom-up approaches,
we talk of processes in which users or practitioners have initiated
actions to try to promote change. When we talk about top-
down approaches, we refer to actions in which policymakers
or health managers have initiated change. These approaches
include differences in the motivation for change that the
diverse actors have, and in the ways and directions in which
change occurs. Processes by which policymakers and managers
decide to borrow health concepts, practices, and policies of
another, usually more developed, country have little to do
with processes by which citizen and professional mobilizations
occur. Top-down changes are guided by the interests of policy-
makers and managers, which do not always coincide with
collective aspirations, while bottom-up transformations must be
promoted and accepted by service users and practitioners. For
example, the profound influence of Paulo Freire’s Pedagogy of
the Oppressed on the internationalization of the empowerment
concept, can be understood from the critical insights that
professionals borrowed for their own work. Particularly, that
inequalities in access to health and education services had
their origin in social inequalities and could be changed
through collective action (Campbell, 2014). On the other hand,
psychiatric deinstitutionalization can be understood as a top-
down transformation. While stakeholders’ protests may have
brought the need into public view, the ‘heavy lifted’ was done by
administrators whose distance from the issues in play may partly
explain some of its failures, including the increase of the homeless
population with mental disorders (Lamb, 1984) and the failures
of its implementation in non-Western Contexts (Shek and Pietilä,
2016).
Another case example relevant to our theme is the
implementation and transference of the Recovery model,
essentially adopted by the Clinton administration in the United
States in 1999 with the Surgeon General’s Report on Mental
Health (Davidson et al., 2006). The recovery model emphasizes
the participation of consumers and their families in service
planning and the promotion of recovery not as a clinical fact or
occurrence but as a process of change through which individuals
improve their health and wellness, live self-directed lives, and
strive to reach their full potential (Substance Abuse and Mental
Health Services Administration, 2012). The introduction of this
model in the United States has had a clear impact on the
policy and practice of mental health care. Perhaps its signal
accomplishment and characteristic is to advocate for and support
the participation of service users as “peer specialists” or “peer
mentors” for persons with mental health disorders, and for their
participation in systems reform (Davidson, 2016).
The transfer of the recovery concept and its derived practices
soon spread to the rest of the Anglo-Saxon world, especially the
United Kingdom, New Zealand, Australia, and Canada, as well
as other developed countries (Ramon et al., 2007). Although
to our knowledge there is no specific literature that analyzes
the strategy of transfer of the movement toward Recovery as
a public policy, we know that the consumer movement was
strongly involved in protesting current practice and advocacy
for change, along with academic, researchers, policy makers,
and practitioners. The advocacy activities carried out by these
groups and their ability to connect internationally contributed
mightily to its dissemination and adoption around the world.
Small-scale implementation strategies have included “top-down”
activities such as training and organizational change activities for
professionals (Mabe et al., 2016), sometimes provided by people
with lived experience of mental disorder (e.g., Simpson, 2002),
and bottom-up participatory processes such as involving service
users in the design of Recovery-in-Action initiatives (Park et al.,
2014).
Although the international expansion of the Recovery
movement has been instrumental in deepening the processes
of extension of community rehabilitation practices that, in
retrospect, could have enhanced the process and outcome
of psychiatric deinstitutionalization, the “colonization” of its
vocabulary by policymakers has been criticized, even leading to
movements such as Recovery in the Bin. Service users in the
recovery movement, and others, have accused policy makers of
harnessing the values of empowerment and mutual support that
are part of the recovery movement and message to cut services
and blame people for their mental ailments (Thomas, 2016). For
these reasons, critical analyses aiming to support the autonomy,
empowerment, and full citizenship of people with mental health
problems remain a topic of discussion.
The purpose of this article is to describe and analyze the
preliminary process of transferring the concept of Citizenship,
a novel approach to the social inclusion and community
membership of people with mental health problems, from the
United States to other countries. We employ a case example
of a Citizenship project developed in Catalonia, Spain as what
we hope we will also serve as an instructive example of the
challenges and possibilities for dissemination of the Citizenship
model internationally.
CITIZENSHIP: A NOVEL APPROACH TO
MENTAL HEALTH
Citizenship, involves the strength of people’s connections to the
rights, responsibilities, roles, resources and relationships that
society offers to people through public and social institutions
(Rowe et al., 2001), and a sense of belonging as full, participating
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members in society that is validated by one’s fellow citizens
(Rowe, 2015). The strengths and limitations of outreach work,
including the finding that helping people find housing does not,
in itself, lead to their community integration or full membership,
led a group of scholars and practitioners based at Yale to develop
the theoretical framework of Citizenship (Rowe and Pelletier,
2012). Although the Citizenship framework was developed
during the period of the Recovery movement (Slade et al., 2014),
and analyses show that higher levels of Recovery are usually
found in persons who are better able to exercise their rights as
full citizens (Pelletier et al., 2015), the two approaches evolved
independently.
The first Citizenship intervention was the Citizens Project,
implemented at the Yale Program for Recovery and Community
Health. The concept of Citizenship (Rowe et al., 2001) was used
as a framework (Rowe et al., 2009) for opening up opportunities
for social participation to members of stigmatized groups. In
this program, rather than viewing individuals with mental
illness as problems to be addressed through the intervention
of others, participants are “students” and “citizens.” Hence,
they are viewed as experts on many of their own problems
and difficulties, on identifying solutions to them, and who are
capable of learning not only how to maintain themselves stably
in their communities but to see themselves as and take actions to
become valued members of their communities. Citizens Project
participants are persons with mental illnesses including, for
many, the dual disorder of substance misuse, and previous
criminal charges. A randomized clinical trial comparing the
Citizenship intervention to usual care for the target group
showed that it successfully reduced alcohol and other substance
use, and increased quality of life for participants (Clayton
et al., 2013). Following this study, participatory action research
methods including peers (service users) as researchers were
employed to develop an individual measure of Citizenship (Rowe
et al., 2012) with seven dimensions of Citizenship—Personal
Responsibilities, Government and Infrastructure, Caring for
Others in Community, Civil Rights, Legal Rights, Choices and
Stewardship. This measure has also been validated for use with
persons with mental illness receiving public care (O’Connell et al.,
2017).
The use of Citizenship as a psychosocial intervention rooted
in collaborative work with and among people affected by mental
health problems is related to other similar conceptualizations.
A meeting point between all these conceptualizations is that
Citizenship should be thought as negotiated and enacted rather
than given (Stevenson et al., 2015). For example, Barnes et al.
(2004) link Citizenship with the dynamics of membership and its
legitimacy. They show how the entitlements associated with the
category citizen are embedded in the dynamics of inclusion and
exclusion of rights. Continuing with the idea of Citizenship as the
legitimation of rights entitlement, and adding a transformative
dimension, Renedo and Marston (2015) developed the concept
of participatory Citizenship in the context of patient and
public involvement in the healthcare system. They propose a
dynamic view of Citizenship comprising the participation of
different actors in negotiating and acting on their rights and
responsibilities as health service users and drivers of change.
Similarly to our conceptualization of Citizenship, the idea of
agency as opposed to prescribed interventions has emerged as an
argument against pathological approaches to trauma and distress
(Veronese et al., 2015). Specifically, there are lines of research that
may help us understand how the structure and protocols used by
mental health institutions subvert the agency of social inclusion
of their clients (Watson, 2012). In general, the conceptualization
of agency on which our view of Citizenship is based is systemic,
with individual actions understood within the broad contexts
and power relations (Diewald, 2007;Stetsenko, 2007), rather
than Bandura’s (1977) conceptualization of individual beliefs of
self-efficacy and Rotter’s (1954) notion of locus of control.
Our Citizenship framework is now being adapted for use in
other countries and sociocultural contexts. Current Citizenship
research and practice is being undertaken in Quebec (Canada),
Scotland (United Kingdom) and more recently, Catalonia
(Spain). After contextualizing our work within the Spanish
mental health system evolution, we will discuss some of the
implications of transferring the concept of Citizenship in mental
health to the latter territory.
THE SPANISH CASE OF MENTAL
HEALTH SYSTEM EVOLUTION AND
STAKEHOLDERS’ INVOLVEMENT
Spain has had some differences with respect to other Western
European countries in terms of the implementation of the
last two major waves of mental health care reform, namely
deinstitutionalization and recovery. Due to the duration of
Franco’s fascist dictatorship, the deinstitutionalization of the
psychiatric system did not begin until the 1980s, when alternative
resources to the great psychiatric hospitals and cooperation with
primary care began to be developed (Vázquez-Barquero and
García, 1999). The evolution of structural changes in the Spanish
Public Mental Health system has been marked by the division of
Spanish psychiatry into two major professional associations: The
Spanish Society of Psychiatry (Sociedad Española de Psiquiatría,
SEP, biologically oriented) and The Spanish Association of
Neuropsychiatry (Asociación Española de Neuropsiquiatría, AEN,
community and psychotherapy-oriented). While the latter has
worked together with other professional bodies (e.g., the Spanish
Federation of Psychosocial Rehabilitation, Federación Española
de Rehabilitación Psicosocial in Spanish, FEARP) and consumer-
led (relatives and more recently, “first-person” consumers’) to
support the implementation of community-based resources, the
former has always had an ambiguous role marked by its conflicts
of interest with the pharmaceutical industry (Escobar, 2009).
The arrival of the Recovery movement to Spain has been
limited to community rehabilitation services and its extension to
other care settings occurred only recently through specific and
somewhat isolated projects. In 2005, for example, the European-
wide EMILIA (acronym for Empowerment of Mental Illness
Service Users: Life Long Learning, Integration and Action) project
(Ramon et al., 2011) was one of the first to systematize joint
training actions between professionals, users and their families.
This project, together with community-oriented professional
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bodies such as the AEN and FEARP, served as an outpost of the
Recovery movement in Spain. However, the arrival of the crisis
in 2008 and the cuts in funding for public health that entailed
led to a total withdrawal of funding for this type of projects, as
the Spanish public mental health system retreated to “survival”
funding for mental health care. Based on preliminary results
of focus groups carried out as part of this Citizenship transfer
project (see ‘Methodological Implications’ section), mental health
professionals agree that in recent years they have barely been
able to provide minimum services to users, who must endure
long waiting lists for care. Many professionals say that this was
not the time to implement “any kind of novelty,” as they are
simply overwhelmed. Over the same time period there has been
an intense media debate on the influence of the pharmaceutical
industry, as the primary care protocols for the treatment of
the increased anxiety-depressive symptoms reported in these
services, caused by the economic difficulties of the population
(Gili et al., 2013), have mainly involved use of antidepressants and
anxiolytics.
An exception to the shortage of mental health care resources
has been the incorporation of individualized monitoring
programs (Programas de Seguimiento Individualizados, PSIs)
staffed by professionals who provide care in community
environments. Although these practitioners are not fully trained
in Recovery principles, many of them are familiar with its
practices. Furthermore, elements derived from other orientations
such as Community Assertive Treatment share some principles
with those of Recovery. Yet, as mentioned above, the Recovery
approach has had a very narrow scope for practice, being confined
to community rehabilitation services. The implementation of
Recovery principles in places which are more difficult to influence
such as hospitalization services, is still almost non-existent in
Spain.
An ominous event regarding the potential to implement the
Citizenship framework in Spain was the attempt to introduce
“special security measures” for people diagnosed with mental
disorders in the Spanish Penal Code by the conservative
government that took office in late 2011. This 2013 bill
produced an immediate and massive reaction from mental
health advocacy groups. The campaign against the bill revived
old synergies among groups that had been relatively inactive
for a few years, giving additional support to the first-person
(consumers/survivors/peer) movement. In Spain, this movement
is formed by associations that operate in diverse contexts, from
activism and policy reform to leisure and art. The Spanish
Federation of Relatives of Persons with Mental Illness changed
its name to “Confederation Mental Health Spain,”1intending to
integrate first-person organizations within the same structure.
However, many organizations believed that the best approach was
to construct differentiated spaces for families and those who have
lived the experience themselves. A first-person federation already
existed in Andalusia since 2009 and a new one was created in
Catalonia in 2014. Less populated communities such as Asturias,
Balearic Islands, Canary Islands, Madrid, Navarra, or Valencia
1http://consaludmental.org/
have active associations. A negotiation to create a Spanish-wide
federation is in process.
Andalusia and Catalonia are territories especially active in
the progressive approaches to mental health care and supports
because of (1) having federations that exercise the institutional
representation of people with lived experience of mental
disorders (“In first person,”2En primera persona in Spanish,
and “Voices,” Veus3in Catalan, respectively), independently
of relative’s and users’ associations’ federations (Andalusian
Federation of Relatives and People with Mental Illness4, and
Mental Health Catalonia5), and 2) having territory-specific anti-
stigma campaigns. The executive boards of these campaigns
are formed by relatives’ and users’ first-person federations, and
by representatives of public and private mental health service
providers and local governments. The Andalusian campaign
is called 1 de cada 46(“one in four,” referring to the fact
that 25% of the world’s population will suffer from a mental
disorder during their lifetimes) and the Catalan, “Obertament”7
(“openly”). In addition to its activities to prevent stigma, the
“1 de cada 4” campaign has translated materials and openly
supports the implementation of the Recovery paradigm in the
Andalusian public mental health care system. Obertament, for
its part, trains first-person activists to carry most of their
activities, and is designing a campaign to educate and influence
health care professionals. In the case of Catalonia, as a result
of the collaboration of both federations, a project has recently
been launched (Activa’t per la salut mental,8literally “get
involved in mental health”) which aims to promote the recovery
model through information, psychoeducation, empowerment
and mutual support spaces.
Having reappeared under the threat of hardening of the penal
code for persons diagnosed with a mental health disorder, the
“first-person” movement made the struggle for rights a core
objective of its work. At the same time, the institutional anti-
stigma “1decada4” and Obertament campaigns, and the relatives’
movement also supported prioritizing defense of the rights of
people diagnosed with mental health problems.
FROM BIG CONCEPTS TO DAILY WORK
WITHIN THE CATALAN MENTAL HEALTH
NETWORK
Figure 1 shows the structure of the Catalan mental health
network. As can be seen at the top of the figure, there
are three main political representation groups. The local
administration promotes executive (centered in the health
system) and comprehensive (coordinated with other departments
such as work or justice) mental health plans. Additionally, the
2http://enprimerapersona.org/
3http://veus.cat/
4http://feafesandalucia.org/
5http://www.salutmental.org/
6http://www.1decada4.es/
7http://obertament.org/
8http://activatperlasalutmental.org/
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FIGURE 1 | Principal Mental Health Stakeholders in Catalonia. ∗The Catalan Psychiatry and Mental Health Society is related to the Spanish Society of Psychiatry, of
neurobiological orientation, although it is not an organic part of it. ∗∗ The Association of Mental Health Professionals is the local branch of the Spanish Association of
Neuropsychiatry, with psychotherapeutic and community orientation, and admits the participation of psychologists, nurses, social workers, educators and other
professionals. It has recently begun to welcome the debate on the affiliation of service users.
city of Barcelona has launched its first local mental health
plan. In collaboration with these administrations, users’ and
relatives’ representatives collaborate with service providers in the
governance of the Obertament campaign against stigma.
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At the bottom of the figure we see the three groups receiving
messages from the Obertament campaign, and the remainder
of activities involving the implementation and improvement
of mental health services and societal wellbeing provided by
users’ and relatives’ federations, local administration and service
providers. Their messages are obviously not always univocal.
While unorganized service users, families and society in general
receive these messages in passively, it is important to note
that mental health professionals have complex organizational
structures independent of the service providers’ representation
structures. In addition to the professional colleges of all direct
care professions, there are specific professional associations in
the cases of psychiatry, clinical psychology and mental health
nursing. In Catalonia, there are two associations of psychiatry
with different philosophical orientations regarding mental
health intervention. The Catalan Association of Mental Health
Professionals, as the local branch of the Spanish Association
of Neuropsychiatry. The latter accepts the participation of
psychologists, nurses, social workers, educators and other direct
care professionals, as well as service users and their relatives. The
Catalan Society of Psychiatry and Mental Health, without being
a local headquarters of the Spanish Society of Psychiatry, shares
some of its scientific values, framed in a biomedical vision of
mental disorders. In addition, the Catalan Congress of Mental
Health Foundation, which emerged from the organization of an
annual congress, brings together different professionals with a
focus on human rights.
In this context, and inspired by the model of Citizenship
originated in New Haven, the first author of this article
began his journey as an agent of change of the Catalan
Mental Health system in mid-2015. In the first place, his
positioning regarding participation in participative spaces both
for professionals and service users was considered important. As
an academic and certified psychotherapist, he contacted some
of the aforementioned professional bodies, which showed some
interest and invited him to give lectures to explain the project in
public, with the understanding that more concrete activities must
follow. Examples of these are training and educational activities,
the design of which will be developed at the same time as the
project itself. As a former mental health service user, the first
author initiated activist training for the Obertament campaign
in Barcelona. The involvement of the “first-person” associations
in this campaign facilitated his contact with the self-managed
movement, where he was recognized as a first-person participant
like others, a fact that facilitated the process. In addition, his
recognition and inclusion as a mental health academic provided a
source of additional human capital, and he soon became involved
in tasks where his academic skills were useful.
As we have said before, the struggle for the rights of people
diagnosed with a mental disorder is a key objective of the first-
person mental health movement. Thus, a key strategic action for
incorporating Citizenship into the spectrum of mental health in
Catalonia was participation in a campaign to reduce or eliminate
mechanical restraints in mental health units.
The other two strategic actions that have been considered
appropriate to foster within the present project and that match
the objectives of other users’, families,’ and professionals’ groups,
are training and hiring peer support staff and carrying out
awareness activities and training for professionals. In this regard,
some of the associations within the Veus federation already
provide training to moderators of mutual support groups and
perform different awareness-raising activities for mental health
professionals, including a yearly lecture series for all mental
health trainees in Catalonia. It is understood that these activities
must be enhanced to make them accessible to all professionals,
regardless of their or their institutions,’ philosophical and practice
orientation. In a context of partial implementation of the
recovery approach, the incorporation of peer-support staff only
makes sense if mental health professionals are motivated to
accept staff with lived experience of a mental disorder. As such,
we hope to learn not only from the successes but also the
challenges of countries such as the United States that has been
implementing recovery-oriented policies for the last two decades
(Davidson, 2016). Finally, people offering peer support need to be
able to conduct other activities, such as helping people navigate
the mental health system including psychiatric hospitals.
Methodological Implications
Our project to transfer practices and approaches based on
Citizenship is built on strong personal and professional
involvement and a strategy with concrete objectives. Hence,
although it has the strength of close collaboration and personal
involvement within the main stakeholders involved, it is
critical that we also maintain scientific rigor in evaluating all
interventions carried out through this initiative.
In general terms, starting from the theoretical elaboration of
the sociocultural dynamics of well-being and distress, our project
aims to promote Citizenship practices through continuous
training of professionals and users of mental health services and
their relatives. This initiative will benefit from the experience of
the Yale program, but must also attend to the characteristics and
priorities of local stakeholders. Figure 2 shows a representation
of a proposed cycle of development of our transference project
within a complex mental health system. The three columns
represent sets of tasks that are repeated cyclically: preparation,
involvement, and evaluation of the results. The three states of
activity boxes reflect current and ongoing work.
In the first stage, international models and allies were
sought. In this phase, the first author met the second, a senior
academic director of the Yale Citizens Project. Once funding and
ethical approval were obtained (University of Barcelona’s ethics
approval reference IRB3099), focus groups were held with local
stakeholders. Fifteen focus groups including 70 mental health
professionals, 40 service users and 10 relatives were conducted.
Our choice of strategic actions was supported by the preliminary
results of these focus groups obtained through thematic analysis
(Braun and Clarke, 2006). These results show how speaking
about Citizenship and its most intuitive components, rights and
responsibilities, implies a change that can be facilitated by user
participation in the design and implementation of interventions.
Table 1 shows selected quotes from interviewees supporting the
need for self-determination, one of the main themes arising from
the analysis.
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FIGURE 2 | Proposed cycle of development of a transference project within a mental health system.
Once this exploratory phase was completed, needs assessments
were carried out and valid measurement instruments were
designed to evaluate activities of mutual support and training of
professionals. The proper evaluation of these activities has been a
source of arduous discussions. The use of controlled experimental
designs entails the exclusion of some users and professionals
from training activities, due to their disagreement with the fact
of starting a process in which they may end up in a control group.
Therefore, we have decided to evaluate all our activities, where
possible, through wait-list-controlled randomized experimental
designs. Thus, all participants complete a baseline evaluation.
Only half of these (selected randomly) have immediate access
to the training activity. Nevertheless, once the first follow-up
has been carried (approximately 1 month after the activity is
completed) the second half can be involved in the activity.
Wait-list-controlled randomized experimental designs allow
for two very important flexibility features. The first is the
possibility of randomizing individuals or blocks, as in some
cases activities must be offered to whole clinical teams or
service user groups, but in others, individual participation is
more appropriate. The second is that it is not necessary to
wait until all the participants have been included to carry
out the randomization. Rather, blocks of participants based on
natural groupings may be included until the capacity of two
training activities is completed. Thus, an activity will take place
immediately after enrollment and randomization and the same
activity will take place a month later, for participants who were
randomized “out” at baseline. This also allows for evaluation of
possible biased expectations on the part of different participant
groups since, once the activity has been carried out, the changes
in the evaluation measures should be identical both in the first
group that carried out the activity and among the members of the
waiting list group.
The final project phase includes an intense activity to interact
with a diverse range of health managers and policy makers with
the intention of proposing profound organizational changes.
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TABLE 1 | Quotations related to self-determination themes.
Service users “For me being a citizen means being able to
express myself freely and without any fear: To be
able to use my principles and my ideas and
express my needs, feelings. . . ”.
“In my process one of the most important
moments, the one I remember with most
affection, it is when a friend, who had never been
diagnosed, told me that he had also had a bad
moment and told me how he bounced forward
doing things with his friends, keeping himself
alive. Feeling that someone understands you as
an equal.”
Relatives of service users “So, for you to be able to make decisions about
your own life you should be totally autonomous,
right? Because making decisions about your own
life when you depend on another person is a bit
relative.”
“So, I think that the tendency now is to try to
make the person who has the disorder have their
own autonomy, their own life, dispose, make, and
have their own rights.”
Mental health professionals “I believe that the human right that is least
protected is the right to decide. I think the
professionals still decide for them: in an office, in
the white coat, we inform the decision ... But we
do not have direct contact with the person.”
“Talking about a decision, about their life, they ask
you: “How do you see it?” Or “I’ll talk to my
mother to see what she thinks” or “I’ll talk to my
psychiatrist to see what she thinks.” “No, no,
but ... What do you want?” I think we have to
work this issue a lot, from empowerment, right?”
This phase, however, only makes sense if at the same time,
we are offering stakeholders’ feedback, in the form of scientific
evaluation of their activities, and carrying out training and
awareness activities.
Engagement and Implications of
Strategic Activities
All the tasks described above involve the professional and
personal involvement of many people, beyond professionals
and volunteers involved in these changes. They also involve
the resolution of complex conflicts and the careful choice of
allies. In our case, as university faculty, doing such a job
involves maintaining the balance between the requirements of
an academic institution and the objectives of the first-person
movement. The former is focused on finding meaningful results
from rigorous evaluation and publication in prestigious peer-
reviewed journals. The latter is focused on physical presence,
personal relationships, and constancy in the struggle, a militancy
that must go beyond standard professional commitment, as the
potential interpersonal conflicts that can occur in the context
of these struggles are often related to intimate and sometimes
traumatic experiences.
Despite the prioritization of implementation projects
including training and awareness activities facilitated by funding
that had been absent during the 1st years of crisis, the need to
build bridges with local policy makers is a key activity. Of the
three projects mentioned (mechanical restraint reduction, peer
support and training/awareness activities for professionals), the
reduction of mechanical restraints requires the greatest amount
of collaboration with, and support from policy makers, including
meetings and spaces where all voices, including those of both
service users and professionals, will be heard. Thus, following
a series of meetings with the director of the Executive Plan of
Mental Health and Addictions in 2016, this project has been
finally articulated through the Service of the Promotion of
Patient Safety of the Government of Catalonia’s Department
of Health, which also includes the reduction of mechanical
restraints in minors and older adults in different restrictive
contexts. Recently, the Veus Federation of mental health entities
in first person appeared before the Health Commission of the
Parliament of Catalonia (2017) to explain this project, which
aims to eliminate mechanical restraints in all mental health care
facilities in Catalonia before 2025. The first author of this article
elaborated a collection of arguments in favor of the elimination
of these coercive practices that was delivered to the deputies of
the commission (Eiroa-Orosa, 2017).
The second strategic action that would benefit from
institutional support is peer support training and
implementation, involving funding to make this work possible
and the institutional commitment this funding would represent
for subsequent recruitment of trainees. A plan for peer support
incorporation in the mental health workforce is included in
the Executive Mental Health Plan Working Groups for the
period 2017–2020. However, given the experience of the EMILIA
project, which has advocated to establish peer support training
for a decade, it has been considered important to develop actions
without explicit institutional support. As such, workshops
have been developed with the collaboration of relatives and
professionals for the training of “mutual support technicians,” in
collaboration with the Mar University Hospital. Furthermore,
the Veus federation, of which EMILIA is part, supports the
development of self-managed spaces for peer support training.
Regarding the third strategic action—training and awareness-
raising activities—practitioner associations in charge of training
residents in psychiatry, forensic medicine, clinical psychology
and nursing (see Figure 1), have included these activities in
response to advocacy by the federations of Catalan relatives’
and service user associations. Additionally, funding has been
achieved by the Veus federation and its associations to offer a
training activity called: “Beyond Recovery: toward a rights-based
mental health care.” This activity will be offered to mental health
professionals regardless of their level of experience, orientation or
place of work.
While this prioritization of activities has been undertaken
with consideration of the interests of key stakeholders, the
adequacy of the Citizenship framework has become evident. In all
these strategic actions, the importance of the main components
of citizenship—rights, responsibilities, roles, resources and
relationships—is incorporated to show that full recovery is not
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possible if people are not considered full citizens with the right
to choose their own way. The aim is to enhance the rights
of people with mental health disorders through increasing the
responsibility they have over their lives, allowing them to take
on meaningful roles and helping them gain access to resources
that will enable them to be full and valued members of their
communities and society in conditions of equality.
Although the differences between the systems of support
for people with mental health problems between the United
States and European countries with a public health system go
beyond the scope of this article, we consider it fundamental to
discuss the implications that these differences may have on a
process of conceptual and practice transfer. The existence of a
purely public and universal system of health care in a country
such as Spain ensures that all residents in the territory receive
adequate attention, with a life expectancy of 83 compared to
79 in the United States (Kontis et al., 2017). This said, the
possibilities of innovation in a highly bureaucratized system
in serious financial crisis, as is the case in Spain, are lower.
This applies, for example, to arduous efforts to hire mutual
support (peer) staff, with innovation filtered through many layers
of bureaucratic prioritizing and decision making. In addition,
the forums in which such decisions are made, depend on the
ideological orientation of political power and the ability of
policymakers to release budget allocations.
One of the characteristics that facilitated the emergence of
the movement toward recovery in the United States was the
increase in funding made available from the closing of state
hospitals, though by no means the automatic transfer of it to
community services. Even so, mental health activists and reform-
minded mental health professionals had the opportunity to lobby
for the use of these resources for community mental health
care. In Spain, reformist professionals carried out the process of
deinstitutionalization with the approval of the health authorities.
Furthermore, in the 1990s the Spanish relatives’ movement
began to manage a part of the psychosocial rehabilitation services.
However, the first-person movement so far has not reached a
level of management capacity comparable to that of the Anglo-
Saxon countries. For this reason, and probably also because of
the prejudices about the capacity of people with mental health
problems, their voices have largely been absent when service
planning decisions are made. The project of transferring models
such as citizenship, we argue, will only take root if the efforts and
results of our evaluations are made available for debate in public
spaces with full participation and empowerment of all interest
groups, including those with lived experience of mental illness.
TAKE-HOME MESSAGE
The beginning of the transference of a concept such as
Citizenship from Connecticut in the United States to Catalonia
in Spain, involves the work of academics and activists but also
that of many others who have long advocated for the rights
of people diagnosed with mental disorders. The creation of
different synergies among first-person, relatives’ and professional
organizations has been important in planning strategic actions
for a successful transfer process. We think that a former service
user being one of the main advocates for and actors in this
initiative is important, as indicated by a growing body of
literature on the contributions of mental health professionals who
have experienced mental illness (Richards et al., 2016;Spaulding,
2016).
This initiative involves four key (groups of) actors—
users, families, professionals and policy makers. Although the
involvement of the first author is greater with the first and third
group, he constantly attends meetings and provides as much
as possible feedback and personal implication to the other two
actors. Acting otherwise would limit the Citizenship movement
to only one of the actors in this process and therefore, would have
insignificant impact on the lives of users.
The overlap of Citizenship efforts with the incomplete
implementation of recovery-based care in Spain has at times
made it difficult for us to identify ways in which this project
supports citizenship, or recovery, or both. In any case, both
movements are dedicated to transforming the understanding,
care of and support for people with mental health diagnoses to
assure that they are the leading actors in their own recovery
processes, and in their achieving full citizenship. We are
convinced that both fostering Recovery and Citizenship practices
are desirable. However, with an eye to criticisms of Recovery
discussed earlier, this transfer process is not intended to be an
exercise in neocolonialism. Our intention is not to implement an
idea coming from an institution (Yale) whose prestige has obvious
connotations, but to benefit from the evaluation possibilities that
the process has had in a resource-rich context. The fact that
the project has been initiated in a prestigious institution with
access to resources and carrying a certain imprimatur, facilitates
the justification and legitimacy of transfer. The use of focus
groups with the groups involved as the first research tool and
the professional and professional involvement of the principal
investigator of the United States project, help to support the
academic viability of the project in the Spanish context.
We are aware that many innovations do not occur through
participatory processes such as we describe here. Our main
objective is that innovations such as the Citizens Project can reach
the maximum number of practitioners, with adaptation as needed
for different contexts. Doing so might facilitate the extension of
these concepts not only to the psychosocial rehabilitation sector,
but also to other mental health care sectors that must promote
and safeguard the dignity and agency of their users.
AUTHOR CONTRIBUTIONS
Both authors wrote and reviewed the whole paper. The content’s
responsibility is shared.
FUNDING
This project has received funding from the European Union’s
Framework Programme for Research and Innovation Horizon
2020 (2014–2020) under the Marie Sklodowska-Curie Grant
Agreement No 654808.
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Conflict of Interest Statement: The authors declare that the research was
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