Hello and welcome. I'm Alexia Wolfe, Executive Director of the Delaware Behavioral Health Consortium, and SMI's Social Determinants of Care expert for SMI Advisor. I'm so pleased that you're joining us for today's SMI Advisor webinar, Community Inclusion as a Medical Necessity, Strategies for Clinicians. Next slide. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers you need to care for your patients. Next slide. Today's webinar has been designated for one AMA PRA Category 1 Credit for Physicians, one Continuing Education Credit for Psychologists, one Continuing Education Credit for Social Workers. Credit for participating in today's webinar will be available until June 11, 2024. Next slide. Slides from the presentation today are available to download in the webinar chat. Select the link to view. Next slide. Captioning for today's presentation is available. Click Show Captions at the bottom of your screen to enable. Click the arrow and select View Full Transcript to open captions in a side window. Next slide. Please feel free to submit your questions throughout the presentation by typing them into the question area found in the lower portion of your control panel. We'll reserve 10 to 15 minutes at the end of the presentation for Q&A. Next slide. By participating in this activity, you agree to the terms and conditions for APA activities, including the APA participation policy, privacy policy, and terms of use. This includes the use of AI assistance to transcribe and summarize the content of this activity. And now I'd like to introduce you to the faculty for today's webinar, Dr. Mark Salzer. Mark Salzer, PhD, is a professor and former department chair in the College of Public Health at Temple University. He has also been the principal investigator and director of the Temple University RRTC on Community Living and Participation for People with Serious Mental Illness, a rehabilitation research and training center. Dr. Salzer, thank you for leading today's webinar. Thank you, Alexia, and it's great to be here with everybody today to talk about community inclusion, which is a topic I'm pretty excited about. The goal of today's conversation is for me to describe what community inclusion is and why it's important. I'll be discussing some of the fundamentals for promoting community inclusion, including addressing or commenting on some of the barriers and challenges faced by individuals with serious mental illnesses in participating more in the community in ways that are desired. And the last thing I'll do is I'll talk about some strategies that clinicians can use to promote community inclusion of individuals with serious mental illnesses. I'd like to start this topic actually with a quote from somebody whose work I really admire, Charlie Rapp, who's a professor emeritus of social work at the University of Kansas. Charlie's really well known for strengths-based case management approaches, and he was giving a presentation once in Australia and said, people with serious mental illnesses don't need more referrals to mental health services. They need referrals to life and community. It's important to understand that Charlie wasn't suggesting that people with serious mental illnesses don't need referrals to mental health services. He was actually acknowledging that we do a pretty good job of supporting people in getting access to medications and therapies and healthcare services. I mean, I guess we can always do better. But his main point is we don't spend enough time thinking about what people with serious mental illnesses want to do with their lives and how they want to be connected to community. And that's really what community inclusion is all about from my perspective. One way that I like to describe community inclusion is actually to compare it to other ways that people exist in the world and in society. I'd like to start with the top right-hand quadrant. We see a circle where there are blue people in that circle. Those blue people are intended to represent individuals who do not experience disabilities. All of those individuals are in that circle, which represents participation of some sort. People who are working, going to school, dating, parenting, leisure, recreation, voting, volunteering, going to church, synagogue, mosque, friendship, family relationships. The blue people are participating in this top left-hand quadrant. We see on the outside there are figures that represent people who experience disabilities. Those people on the outside, people who experience disabilities, are not participating. They're not in that circle with the blue people. This represents exclusion of some sort. The top right-hand quadrant, we see two circles. One circle has the blue people in it. They're working, going to school, dating, parenting, friendships, family relationships. We see a separate circle where people with disabilities are represented in that circle. That represents segregation. Examples of segregation in mental health services would be things like separate housing or residential programs just for people with serious mental illnesses. Sheltered workshops or other types of employment that are just for people with mental health issues. Leisure programs and recreational programs that are just for people with mental health issues. These are examples of segregation, not inclusion, which is what we think is important and what is important for health and wellness of people in recovery as well. Finally, I'm going to go to the bottom right-hand quadrant, the one that says inclusion. We see one circle, again, representing participation of some sort. We see blue people in that circle. And we see the figures that represent individuals with disabilities in there as well. This is what inclusion is all about. It's people with and without disabilities who are participating in the same types of settings and environments, doing similar but not necessarily the same things. And that's really what inclusion is all about. Some of the key principles of inclusion are that people, all people, with or without disabilities are valued for their uniquenesses and what they can contribute in these environments. Everyone has opportunities to participate like everybody else and utilize their uniquenesses in that particular environment. And the last principle is that the environment is a welcoming and embracing environment. The environment, the work environment, the educational environment, the social environment, the leisure and recreational environment, the faith environment is saying to people who experience disabilities, we want you here. You are important. You make us stronger as a community, a stronger workplace, a stronger educational environment. And, again, this is what inclusion is all about. A couple of times already I've mentioned that people with disabilities, the concept of inclusion is actually really well known in the broader disability community. It's been around for about 70 years or so at this point in the physical disability community, the sensory disability community, the intellectual and developmental disability community. This is the driving concept in those communities, in disability services, rehabilitation services. This concept is a little bit newer for us in behavioral health and mental health services. And I'm thrilled, again, to be able to share information about why inclusion, why this orientation is so critical to the health and wellness of people with serious mental illnesses. Another concept I want to make sure that you're aware of is the concept of participation or community participation. What I mean by that is I mean all of these areas. When I talk about community participation, I'm not only thinking about employment and housing and maybe family relationships or other social relationships, which many of our services do focus on those areas, as well as housing, but I'm also talking about educational opportunities and participation in post-secondary educational settings, certificate programs, learning about things that people are interested in. I'm talking about intimate relationships involving dating and marriage and how we support people in that way. Supporting parenting, spirituality and religion, engagement in faith communities, civic engagement like voting and volunteering. The fact of the matter is that all of these areas of participation are areas where people with serious mental illnesses are not participating as much as the general population. We have indications that all of these areas are important to people with serious mental illnesses like they are to people who do not have serious mental illnesses. All of these areas have been demonstrated to be associated with positive health outcomes, positive physical health outcomes, positive cognitive health outcomes, and positive mental health and wellness. So much so that I've come to call the promotion of community inclusion and participation a medical necessity. Partly based on social determinants of health thinking, but also based on other research and thinking that's out there that I'll be covering in this presentation in just a little bit. So what do I mean when I use this term community inclusion or a related concept of community integration? I'm referring to this as the opportunity that people with serious mental illnesses have to live in the community and be valued for one's uniquenesses and abilities like everybody else. So a key concept is opportunity, supporting people if they desire to work, supporting people in working. If they desire to go to school, and many people do, supporting them in that way. Supporting dating, supporting parenting, supporting leisure recreation, supporting faith interests. That is what community inclusion is all about. As a result of those opportunities and supports, we hope to see increased participation in all of those areas. So supporting community inclusion and opportunities leads to increased community participation. One thing I like about the concepts of community integration and community inclusion is that these are legal rights. And they're actually identified as legal rights in many countries around the world, including the United States, based on the Americans with Disabilities Act that was passed in 1990. That actually talked about the concept of community integration and that people with disabilities should have the opportunity to essentially live in the community like everybody else and have a right to live in the community. The Americans with Disabilities Act was specifically applied to people with serious mental illnesses as a result of a very well-known Supreme Court decision referred to as the Olmstead decision. And many of you are hopefully aware of this. The Olmstead decision was a court case brought by two women, Elaine Curtis and Lois Wilson, who were in a psychiatric institution in Georgia. Lois and Elaine claimed, with support from their mental health providers at the institution, their psychiatrists, their psychologists, their social workers, their nursing staff, that they could live in the community if they had the proper supports. And because they were being unnecessarily confined in a psychiatric institution in violation of the Americans with Disabilities Act, the Supreme Court found in their favor and concluded that unnecessary institutionalization is a form of discrimination prohibited by the Americans with Disabilities Act. This Supreme Court decision was as big as any other civil rights-oriented court decision that has happened. It set off a flurry of policy initiatives, including the President's New Freedom Initiative and the President's New Freedom Commission report that has really influenced mental health services for people with serious mental illnesses across the country. The concept of recovery was mentioned as a driving mission of mental health services in the President's New Freedom Commission report. Things like peer support services played a big role in the report as well. And many other initiatives have also occurred as a result of this. But as we'll talk about a little bit later, these initiatives and the OMSA decision really have not adequately led to enough people with serious mental illnesses really doing the things that they want to do in the community like everybody else. We absolutely need to do more to promote the health of people with serious mental illnesses by supporting their participation. I also like to point out that community inclusion is identified as a human rights issue as well, based on the statements from the Convention on the Rights of Persons with Disabilities that was adopted by the United Nations General Assembly, where they declared that nations must promote full and effective participation and inclusion in society, including competitive employment and participation in the economic, political, social, cultural, recreational activities of their communities. So this is a huge issue. It is a rights issue and something for us to pay a lot of attention to. As Alexia mentioned, I've been doing work in this area for a long time, for about 20 years. Initially, I used to talk about community inclusion as a rights issue and say, let's go, let's promote rights. And our provider colleagues would say, you know, yeah, that sounds great. And then they would go ahead and continue to do the things that they've been doing in the past. About 10 or 15 years ago, I started pulling together information about the importance of inclusion and participation that not only recognizes that these are legal and human rights issues, but these are also health care issues. That lack of participation, and I mentioned before, people with serious mental illnesses are not participating in all of the areas that I've mentioned before as much as they would like. And they actually have some of the lowest participation rates of any disability group that's out there. Not only is it a rights issue, it is a medical necessity. It is associated with positive physical, cognitive, and mental health and wellness benefits. My colleague Rick Barron and I have really described this and brought together the evidence base supporting this statement, along with a description of the fundamentals, the practices that are required of us in order to promote community inclusion of individuals with serious mental illnesses. One of the things that we include in this document as part of the theoretical or conceptual support for the importance of community inclusion and participation is this framework right here. This is called the International Classification of Functioning, Disability, and Health. If I was with you in an audience, I would ask you to raise your hand if you're familiar with this framework that's sometimes called the ICF framework that was developed by the World Health Organization in the early 2000s. By the way, this is not a mental health-specific framework. This is a cross-disorder or disease framework. If I were to ask you that question, about 10% of Americans are familiar with this framework. When I ask that question internationally, about 50% of people will raise their hands, 50% of people in the mental health community. One important part of this framework or what this framework really describes is, first of all, that health consists of lots of different components. One component is described as body function and structure. This is probably the traditional perspective of health. I think I have my laser pointer here. I'm circling body function and structure. This would be kind of a traditional perspective on health. How is my liver functioning? My kidneys? My heart? My lungs? What are my blood levels like? And any symptoms or issues related to that. People with serious mental illnesses, these might be things like hallucinations and delusions and executive functioning issues, depression, all of those kinds of things. Mania would all fit within body function and structure. And targeting body function and structure with interventions is addressing one aspect of health for people with serious mental illnesses and individuals with other disorders or disease. But the ICF framework and the World Health Organization also identified two other aspects of health that are critically important for us to address in healthcare. One, they described as activity. This refers to someone's ability to execute a specific task or action. Oftentimes we think about this in terms of activities of daily living or instrumental activities of daily living. Grooming, bathing, dressing, paying bills, doing things that are important to be able to work or go to school or those kinds of things. I also typically include skills, like social skills, interpersonal skills, problem-solving skills, as examples of activities or specific tasks or action. According to this framework, if somebody isn't able to or doesn't execute these tasks or actions in a sufficient way, that also means they don't have full health. The last dimension of health, the World Health Organization referred to as participation. This refers to people's opportunities to move around in their community, which is referred to as community mobility or mobility. And it also refers to involvement in a social situation. What did the World Health Organization think about in terms of involvement in a social situation? This refers to going to work, the ability to go to work, go to school, dating, parenting, leisure, recreation, voting, volunteering, going to church, synagogue, or mosque, voting, volunteering, friendships, family relationships, all of that participation is viewed as important for people and is viewed as an aspect of health. The last important thing to know about this ICF framework is that it didn't or it doesn't accept a traditional perspective that in order to get to participation, we need to fully eliminate body function and structural issues, which means that people can still be symptomatic in some way and still participate, where some providers actually think that symptoms need to be fully removed through treatment in some way in order for somebody to work on their ADLs or IDLs or to participate successfully in the community. It also recognizes that people don't need to have fully functional activities of daily living as well, that it recognizes that people can participate even when grooming isn't perfect or dressing or those kinds of things. Obviously, we're not talking about people going to work naked or those kinds of things, but people don't need to be perfectly dressed or groomed to be able to participate in the community like everybody else. The ICF framework also suggests that participation can actually benefit ADLs, IDLs, and body function and structure, that people who are going to work, going to school, dating, parenting, these kinds of things actually can have positive impacts on physical health, cognitive health, and mental health and wellness. And let me try to show you very briefly some of the data and some of the thinking related to this. First of all, physical activity or engagement in community participation is associated with enhanced physical activity, people who are moving around more. And my colleagues and I at Temple University have done some research to really demonstrate that people who are participating more in the community are more physically active than people with serious mental illnesses who are not participating in the community. We know that this is an important issue for people with serious mental illnesses because there's evidence indicating that people with serious mental illnesses spend about 75 to 90% of their days engaged in what's called sedentary behavior. And this is much higher than the general population, by the way. Sedentary behavior refers to what probably many of you are doing right now, many of us. I'm also doing this too. It refers to sitting down and lying down primarily. Sedentary behavior is recognized to be bad for health. Physical activity, even if it's not going to the gym or jogging or working out, any physical activity beyond sedentary behavior, even if it's a light walk or moving around, getting up and going some other place and sitting back down is better than sedentary behavior. When we have programs and services that support sedentary behavior, that is not bad for health. And all of these are some of the outcomes that have been identified by the CDC as physical benefits associated with enhanced physical activity, not sitting down, not lying around. It's good for sleep, it's good for anxiety, but it also reduces blood pressure, good for heart health, cancer prevention, produces healthy weight, bone strength, balance and coordination. All of these are critical aspects of physical health that can be enhanced by increased community participation. Like many of you, I've done a lot of work in the schizophrenia area over the decades at this point. Gosh, that was hard to say that. One of the things that I learned in working in the schizophrenia area is the idea that some of the executive functioning and memory deficits or impairments that we see experienced by people with schizophrenia, schizoaffective disorder or other psychotic disorders is plausibly or likely a result of the disease process associated with these particular conditions. For many years, I used to think, yep, that's the case. There's this physical underpinning that we're still looking to identify, but this is probably some type of disease process. In the process of looking at community participation though, I started identifying some research that recognized that there are other factors related to participation that are associated with cognitive abilities for people in the general population and likely are associated with cognitive abilities of people with psychotic disorders that many of us work with. One of those areas is research that's looked at the importance of physical activity. There's a lot of research that suggests that people who are engaged in lower levels of sedentary behavior actually have enhanced working memory, executive functioning, other cognitive benefits associated with increased physical activity. It's been pretty well documented in the general population. There are some individuals who are doing some research with people diagnosed with schizophrenia, but it's a very promising suggestion that physical activity, including physical activities associated with supporting people getting out of the house to go out and do things that are meaningful to them may enhance people's cognitive abilities beyond cognitive remediation or medication impacts or other kinds of things. There's research, especially with older adults, suggesting that social isolation is associated with cognitive decline. We know people with serious mental illnesses have smaller social networks and report being more lonely and isolated than the general population. The suggestion or the implication of this is that addressing social isolation may have positive impacts on cognitive abilities of people we work with. Two other areas that I won't be able to go into a lot of detail with is one has to do with poverty. And we know that many of the people that we're working with with serious mental illnesses live in poverty. There's some fascinating research suggesting that poverty impedes cognitive functioning. And it really suggests that focusing on employment, on income in some way, shape or form could also have impacts on some of the cognitive issues that we see with people that we're working with. And I'll refer you to some work by Elder Shafir and his colleagues in this particular area. The last area that I'll mention briefly is that being in or being exposed to more stimulating environments, not just sitting in one's apartment or home or in a program somewhere that doesn't have a lot of environmental stimulation, that being in areas with more novel and stimulating environments, including work environments, school environments, faith environments, other social environments, that this can also have an impact on cognitive functioning as well. So that's why we talk about community inclusion and participation as being associated with positive cognitive benefits as well. And then there are ample mental health benefits associated with participation as well. One thing I'd like us all to recognize, and I think all of us really do, is that regardless of the diagnosis of the individuals that we work with, schizophrenia, schizoaffective disorder, bipolar disorder, major depression, that regardless of the diagnosis, we know that people with serious mental illnesses experience high rates of depression. In some of the research, my colleagues and I have done at Temple University, we've identified that in one sample of 300 individuals with serious mental illnesses, 64% of those individuals met the Hopkins Symptom Checklist cutoff for depression. In some other recent research that we publish, we've identified that 41% of individuals with serious mental illnesses are severely lonely, not just lonely, but severely lonely. And there are all sorts of negative outcomes associated with such high levels of loneliness as well. So it's really critical for us to pay attention to these two areas. And we've conducted some research indicating that supporting participation, that individuals with serious mental illnesses who are participating more in areas that are meaningful or important to them is associated with decreased depression and decreased levels of loneliness. Some of the evidence-based supporting this statement come out of positive psychology. We know that there's a lot of research out there looking at what makes anybody happy in the community. Family and friendships, the wider and deeper, the better the happiness or the greater the happiness. Marriage is associated with happiness. And that's for many people. Having meaning in life, a belief in something bigger than yourself is associated with greater happiness. And having goals that we're working for and find enjoyable are associated with happiness. All of these are areas that people with serious mental illnesses are not engaged in as much as people in the general population, and likely is an explanation for why we see such high levels of depression among individuals that we work with. We also have identified factors that make people unhappy. Poor health makes people unhappy. And we know the physical health comorbidities experienced by people with serious mental illnesses are much higher than the general population. And that by itself is associated with unhappiness. Separation and lack of social contact, isolation and loneliness is associated with unhappiness. And I've already mentioned that people with serious mental illnesses experience these at much higher levels than the general population. And finally, unemployment is associated with unhappiness in the general population. We know that people with serious mental illnesses have among the highest or possibly the highest unemployment rate. Oftentimes, it's been identified that about 75 to maybe 85% of people with serious mental illnesses are unemployed. This is routinely viewed or found to be associated with greater unhappiness in the general population. And it's clear that it's likely associated with some of the unhappiness and depression that we see among people with serious mental illnesses as well. Finally, my colleagues and I have done a lot of research, again, looking at the association between increased participation and all of these areas. And we've actually found that people with serious mental illnesses who are participating more, as I mentioned before, have greater physical activity. They have enhanced cognitive functioning. Getting out of the house to go do something is associated with greater happiness and less loneliness. And greater participation, as I've mentioned before, is associated with lower levels of depression. So all of this is really attempting in a very short period of time to try to support your thinking or recognition that community inclusion and participation is not only a nice thing, it's not only for fun or to keep people occupied, it's not only a legal and human rights issue, it is a medical necessity. It is critical for us to pay attention to these issues and really support people in doing more things that they wanna do in the community. So what are some things that clinicians can do to promote inclusion and participation? One of the things that I like to describe, and I'll do this very briefly, probably in five minutes, this is actually a presentation that I typically do in about an hour and a half, is to describe the fundamentals for promoting community inclusion and participation. And again, here's that document called Well Together that really describes the evidence base, again, behind the statement that community inclusion is a medical necessity, as well as the evidence base and the theories and frameworks that underlie these fundamentals that I'm going to describe very briefly. There are actually three sets of fundamentals that we describe. The first set has to do with knowledge and beliefs related to people with serious mental illnesses. The first fundamental is the understanding that community inclusion is important. It's not something we do at the end of treatment, or it's not something that's just a frivolous fun or something like this. This is critically important to the health of people with serious mental illnesses. That's fundamental number one. Fundamental number two is the community inclusion applies to everyone. I first started talking about this when I would talk to some of our colleagues who would say, Mark, that sounds well and good, but really only applies to about 15 or 20% of the people that I work with. And my colleagues and I pulled together the evidence, including the evidence that's been used to support the idea that recovery is real and possible for everyone with serious mental illnesses. The same research underlies the claim that community inclusion really applies to everyone. And we can't do a good job predicting who is ready to work, who's ready to go to school, who's ready for a relationship, that the best predictor of readiness is somebody saying, I wanna do that. That's what fundamental number two is all about. Fundamental number three is the idea that in order for us to effectively promote community inclusion, we need to see individuals with serious mental illnesses as people like everybody else, and not simply as patients. And what that means is when we talk about individuals that we work with, we can't just focus on symptoms and hospitalizations and homelessness and incarceration and impairments and deficits and medication and treatment. We also need to recognize that this is a person like everybody else who has hopes, dreams, and desires like everybody else. And if that's the first picture that comes to our head or first story or schema that we have about people with serious mental illnesses, we will be more likely to effectively promote community inclusion. So if you're interested in these fundamentals or any of the other ones, feel free to reach out to me and I'd be happy to talk with you more about them. The next set of fundamentals have to do with specific practices related to promoting community inclusion and participation. The first or fundamental number four is that we need to promote self-determination, people having choices about the things that they do in their lives, and we need to promote dignity of risk, which is a concept that's very well-known in the broader disability community, especially the intellectual and developmental disability community, but less well-known in mental health. And dignity of risk refers to the opportunities that people with serious mental illnesses have to make decisions and have choices that affect their own lives, even if those choices turn out to be mistakes, right? Something they don't get the job or they get fired from the job or they don't successfully complete a course at a college or university, supporting somebody in pursuing those activities, that level of participation, even if we believe that they might not be successful is an example of promoting dignity of risk. Oftentimes when I talk about dignity of risk, there'll be one of our colleagues who's in the back of the room who kind of crosses their arms and says, oh, Mr. Ivory Tower, I have no idea who you've worked with or what kind of population you work with, but the people I work with are sick. They're so sick that they can't do these things. Let me tell you, does that mean that the person that I'm working with who decides to strip off all their clothes in the middle of the winter and go run down a major highway, that that's okay, that that's what dignity of risk is all about? And I'll usually pause, catch my breath and say, no, that's not what we're talking about with dignity of risk. We're talking about, we're not talking about somebody making choices that could dramatically or significantly affect their own health and wellness or the health and wellness of others. We're talking about the dignity of risk that is associated with the 99.5% of other decisions that people with serious mental illnesses wanna make and that that's critical for us to support people in making decisions in their own lives. So I look forward at some point to be able to talk with you more about that in the future. We need to support people in multiple domains of participation, not just employment, not just housing, not just social relationships or leisure and recreational programs. We need to support people in all those areas that I mentioned before. Fundamental number six, we need to support people to participate not in programs within our agencies that only include people, other people with serious mental illnesses. We need to support people to participate out in the community in ways that all of us like to participate in the community. The participation for people with serious mental illnesses from an inclusion standpoint should look like participation that any of us are engaged in. Finally, fundamental number seven basically describes all of the evidence-based practices associated with promoting community inclusion and participation that already exist, and make sure that we're aware of these and utilize these in our practices. The final set of fundamentals, nine through 11, have to do with the importance of paying attention to the environment. The first one, fundamental number nine, refers to specifically the social model of disability, which is a perspective, an orientation, that again, has been widely accepted in the broader disability community for about 60 or 70 years at this point, but is a little newer to us in behavioral health and mental health in particular. The way I'd like to describe it, and actually you see there's a person with his fingers crossing each other on the bottom, that's related to social model of disability. The way I like to describe it is in this way. I have my left hand up there. This left hand represents Mark. Let's say Mark has been diagnosed with schizophrenia. From this perspective, Mark's diagnosis of schizophrenia is what makes Mark disabled. This is why Mark doesn't work and go to school, probably shouldn't be dating or maintain custody of his children. This is why Mark has difficulties in social relationships. This is why his functioning in those areas are low. From this perspective, again, referred to as the individual model of disability, or some people refer to it as the medical model of disability, we reduce the disability by somehow fixing Mark in some way. In mental health, we fix Mark by prescribing medications, making sure Mark takes his medications, provide cognitive remediation, social skills training, problem-solving training, therapies of different sorts, get Mark to his healthcare providers. This is how we address disability by fixing Mark. The broader disability community said, no, that is not where my lack of participation in employment and education, all these other areas comes from. My lack of participation comes from a poor fit between me, the left hand on top, and the environment, the work environment, the educational environment, the social environment, the dating environment, social welfare environment, that this lack of fit between the person and the environment is what results in the experience of an impairment, the experience of a disability. This is why I don't work. This is why I don't go to school. The broader disability community has been really incredibly successful, not completely successful, in raising awareness about these environmental barriers, the lack of curb cuts, the lack of ramps, the physical environment issues that limit participation. And they've been able to address those issues in order to create somewhat of an overlap between Mark and the environment that reduces the experience of disability that people have. From this perspective, you can reduce disability by fixing Mark, creating a little bit of an overlap, addressing the environment to create some of the overlap, or addressing both, which hopefully will maximize the reduction of the experience of disability. What are those major environmental barriers that people with serious mental illnesses experience? Poverty is a major barrier to participation and inclusion. Access to transportation and services are major barriers. A last critically important barrier is the experience of stigma, or better said, prejudice and discrimination. We all know stigma or prejudice and discrimination is bad, but we don't know, I think sometimes, how bad it is. It is keeping people from working and going to school and dating and parenting and social relationships. I know we're doing things about addressing stigma, but unfortunately, the research suggests that we're not doing enough. That stigma, there's some evidence that stigma towards depression has reduced a little bit over the years, but that prejudice and discrimination to people with bipolar disorder, schizophrenia, other types of conditions has plausibly increased over the years. This is a critical barrier to community inclusion and participation and something we need to pay attention to. I'm gonna quickly mention fundamentals 10 and 11. Fundamental number 10 is to make sure we're using non-mental health, non-social services to promote inclusion and supports, making sure we go to mainstream employment opportunities and educational opportunities. We don't just need to look within mental health services for the solutions for promoting community inclusion participation. And finally, fundamental number 11 has to do with creating welcoming and embracing environments. The example of what a welcoming and embracing environment that I like to usually offer is this story that I actually saw on CNN. I think it was 2019 at this point. It was about a four-year-old autistic boy named Brayson, and he was on a plane with his parents flying from San Diego to Houston. And Brayson had been on flights before and had done generally pretty well. But on this particular flight, Brayson, things just weren't right for Brayson. He wasn't sitting in his chair to be buckled in. He was moving around the cabin while the flight was in the air. He was lying, here you see Brayson lying in the middle of the aisle. There's a sense that possibly the vibrations helped to comfort Brayson. And he was making his way up to first class and was kicking chairs and doing different things up there. Thank goodness, this was a flight that was welcoming and embracing of Brayson's uniquenesses. Nobody was there to fix Brayson or to make him stop all of the things that he was doing that we might typically view as symptoms or impairments or deficits. The environment supported Brayson. The flight attendants allowed Brayson to sit on his mother's lap for takeoff and to lie in the middle of the aisle instead of bringing around the cart with sodas and those little biscuits that they offer. The folks in first class who probably paid, who knows, 400, $500 more a ticket to sit up there, they were reading to Brayson. They were showing pictures on their phones. They were talking to Brayson. Thank goodness this was a welcoming and embracing environment for Brayson and his family. This is an example of welcoming and embracing environments. So what can we do as clinicians to support people with serious mental illnesses around community inclusion? The first recommendation that I like to offer is to work with people and develop truly person-centered treatment plans, not treatment plans that are just about addressing symptoms and taking medications and participating in therapies, but asking people, what do you want to do in your life? And building a treatment plan around that. I want to work. I want to go to school. I want to date. I want to go to church, synagogue, or mosque. And including these participation goals in treatment plans because this is what people oftentimes want in their lives. And they might be more willing to take medications or participate in therapy or do other things if they know that we're listening to what they ultimately want in their lives. And they see a connection between what we can offer and what they want in their lives. And finally, we need to encourage, this is not finally, the other thing related to developing person-centered plans is to really encourage participation. One of the tools that my colleagues and I have developed to identify participation interests is something called the Temple University Community Participation Measure. This is a measure that basically asks people, I'm not going to be able to go into this in a lot of detail, but it asks people, what are you doing in a number of different areas related to work and education and leisure and those kinds of things? Is this activity important to you? And do you do this activity enough, not enough, or too much? So this could be one strategy that we could use to identify what are people currently doing and what would they like to do? One reason I've been a big fan of this measure is when we first created it, I was not sure that people with serious mental illnesses could complete it. And we've since done some research demonstrating that pretty good evidence of reliability and validity with this instrument. But the main reason I like to pay attention to it is that when we first started using it, I would ask my staff when they came back, how is this going? I was anxious. Again, I didn't know how it would work. And my research staff would say the people, the person I talked to, they love this measure. And I'm like, what are you talking about? Nobody loves our research tool. I said, why do they love it? They said they liked this because nobody ever asked them these things. And that is heartbreaking to me. It's critically important for us to pay attention to these things. The second thing we can do as clinicians is we can connect people to services and resources that promote community inclusion and participation. Not only resources within behavioral health and social welfare services, but mainstream resources that are available to people. This is not uncommon in healthcare. In the United Kingdom, they talk about something called social prescribing, which is very similar to promoting community inclusion and participation. In Canada and Japan, they actually prescribe nature walks for people with serious mental illnesses and other mental health conditions. That the idea of being out in nature, engaged in leisure and recreational activities is not just a frivolous, fun thing that people do, but that this is healthcare. Addressing these kinds of things is healthcare. It's not less than other ways that we treat people. And finally, assisting people and connecting to these resources. And finally, the last thing that we can do is to advocate for clients in all of these areas, to address those environmental barriers, poverty, access to transportation, other resources, and especially prejudice and discrimination. We are not doing enough at this point. May is Mental Health Awareness Month. October is Recovery Month. October 11th is International Recovery Day. This is not enough for addressing prejudice and discrimination. All of our disciplines, psychiatry, nursing, social work, psychology, occupational therapy, recreational therapy, all of our disciplines promote advocacy as part of our competencies. We're supposed to be learning these things in our educational programs. And if we're really practicing to the full scope of our abilities, we should be incorporating these in our practices instead of just focusing on other areas of our training. And again, here are some of the advocacy targets. And again, the last thing related to advocacy is to address stigma. I've already mentioned that prejudice and discrimination is rampant in the general population. It is also rampant among all of us, among mental health providers as well. That Well Together document describes that. So I'm gonna leave you with the featured resource, the Well Together document. And there's the website where you can access it. And then here are the references, some of the references that I referred to today. And I'm going to thank you all for your time and pass it back to Alexia. Well, thank you for such an interesting presentation, Dr. Salzer. And before we shift into Q&A, I want to take a moment and let you know that SMI Advisor is accessible from your mobile device. Use the SMI Advisor app to access resources, education, and upcoming events, complete mental health rating scales, and even submit questions directly to our team of SMI experts. You can download the app now at smiadvisor.org backslash app. And Dr. Salzer, one question I'd like to lead off with is, is a focus on inclusion relevant and important for those transitioning from homelessness, incarceration, or hospitalizations? Yeah, thank you, Alexia. That's a great question. So absolutely, there's actually a good indication, especially in the housing area, that there's a recognition, especially from housing first approaches, that we're able to successfully support people who are unhoused to live in independent housing or housing with other individuals somewhat successfully. But there's a concern, a growing concern, about isolation and loneliness that people experience that oftentimes lead people to start using again or not engage in services. And there's really been a suggestion in the literature to focus more on community inclusion as a way of enhancing community tenure. We've also done work with people who are leaving jails and prisons with serious mental illnesses. And we've identified that people who, six months out of jail and prison, have some of the lowest participation of anybody that we've gathered data from who experienced a serious mental illness. And there's a suggestion similar to the housing data that supporting people in participating in the community might decrease the likelihood of recidivism or hospitalization or homelessness that folks might experience. And same with folks who are leaving institutional care or long-term hospitalizations as well. Thank you for that. And we have some great questions and observations coming in on the chat. One of them is that there's still a long way to go for non-disabled people to accept and respect disabled people, people with disabilities, depending on one's preferred terminology. And this includes institutional disablism, and using words like lame. Any thoughts on that, our participant is asking? Yeah, the only thought is I completely agree. And sometimes people will ask me why I work in this particular area with people with serious mental illnesses. And part of it is it's not a competition between different groups, but I do think that to a certain extent, it's still somewhat acceptable to treat people with serious mental illnesses particularly poorly. We at least understand, or many of us do understand that discriminating, having prejudice towards other disability groups is not acceptable, but to a certain extent, it seems acceptable to treat people with serious mental illnesses poorly. Thank you. Another question about a great topic from a care manager who says that they have a client who's in a psychosocial rehab program, and it sounds like is developing an intimate relationship with someone else in the program. The client's father is expressing concerns, and it seems there may be concerns about the participant giving the client guidance regarding things like utilizing medication. Do you have any advice on ways this person can support and advocate for the client and also try to protect the person? A great topic, really interested in your thoughts on that. Yeah, it is a great topic, important topic. Any topic related to intimacy is critically important. It's something that we're not often comfortable with talking about in mental health services. I can't do it justice in two minutes to really respond to that one. All I'll say though is that, yeah, it's critically important to talk about these issues, think through these kind of challenging situations. Obviously, we do want to prevent people from experiencing harm related to any relationships they might have with anybody. But there's also a certain degree of risk like everyone else that's associated with community inclusion. Many of us, not me, I'm in a great relationship with my partner, but some of us might not have great intimate relationships or we haven't had them in the past. And we need to recognize that there is risk in these kinds of things. But I'm not throwing my hands up and saying, oh, that's okay. I'm just saying we need to think through the solutions to this situation with that in mind and figure out how we can support this person pursuing something that just like all of us, about 70% of people with serious mental illnesses say that intimacy, intimate relationships are important to them. We know intimacy is associated with positive health outcomes as well. Well, thank you. And with that, we do have to wrap up our Q&A for now, but thank you for all of the great questions coming in and that dialogue. If there are any topics covered in this webinar that you'd like to discuss with colleagues in the mental health field, you can post a question or comment on SMI Advisors Discussion Board. This is an easy way to network and share ideas with other clinicians who participate in this webinar. If you have questions about this webinar or any other topic related to evidence-based care for SMI, you can get an answer within one business day from one of SMI Advisors National Experts on SMI. This service is available to all mental health clinicians, peer support specialists, administrators, and anyone else in the mental health field who works with individuals who have SMI. It is a completely free and confidential service. Next slide. SMI Advisor offers more evidence-based guidance on recovery, such as the podcast, Personal Perspectives on Care and Recovery. This podcast episode talks about cultural influences, the impact of diagnoses, the role and impact of peer support, therapeutic alliance, engagement in care, recovery supports, family involvement, and much more. Access this resource by clicking on the link in the chat or by downloading the slides. Next slide. To claim credit for participating in today's webinar, you need to meet the requisite attendance threshold for your profession. After the webinar ends, please click continue to complete the program evaluation. The system then verifies your attendance for credit claim. This may take up to one hour and can vary based on local, regional, and national web traffic and usage of the Zoom platform. Next slide. Please join us next week on April 18th as Dr. Imogen Bell presents virtual reality treatments for serious mental illness. Again, this free webinar will be April 18th from 4 to 5 p.m. That's Eastern time on Thursday. Thank you so much for joining us. And until next time, take care. Thank you.

Dr. Mark Salzer

Temple University

community inclusion

serious mental illnesses

self-determination

dignity of risk

environmental barriers

poverty

stigma

mental health outcomes