Coordinated Specialty Care (CSC) programs for young people experiencing early psychosis often promise to help them get back into life through work, school, and social connections. A new qualitative study describes what that actually looks like on the ground, beyond job programs and family meetings.
In a paper published in the Community Mental Health Journal, Elizabeth C. Thomas of Temple University and colleagues surveyed and interviewed leaders of CSC programs across the United States to map how they support community participation in everyday life.
“Coordinated Specialty Care (CSC) programs for young adults with early psychosis aim to promote community participation; however, research on practices beyond those focused on employment, education, and family relationships is limited,” the authors write.
“Many express a desire to engage in other aspects of community life, including the arts, spirituality/religion, sports, civic engagement, and friend and intimate relationships. … Understanding the factors influencing the implementation of community participation practices within CSCs is an essential next step.”
The study offers rare detail on what programs are doing, what gets in the way, and how community life is framed as a form of “medical necessity” for people with experiences of psychosis. The participants treat participation in ordinary community life as central to “recovery,” not as an afterthought to symptom management. The paper also exposes the gap between rights-based aspirations for inclusion and the uneven realities inside U.S. early psychosis services.
Thomas and colleagues ground their work in a growing literature that treats community participation as a health issue. Drawing on previous research, they note that “community participation is regarded as a ‘medical necessity’ due to its strong links with positive physical, cognitive, and mental health outcomes.”
In the United States, CSC has become the dominant early intervention model for psychosis, combining psychiatry, psychotherapy, family services, and supported education and employment in multi-disciplinary teams. These programs are supposed to offer “developmentally appropriate” support that helps young people build lives in their communities. Yet little is known about how CSC programs actually support those broader forms of participation in practice.
The study is part of a larger mixed-methods project on community participation in CSC. First, the research team convened an advisory group of young adults with early psychosis, family members, and professionals, who used a modified Delphi process to generate a list of potential “community participation practices” for CSC programs.
Using that list, the researchers conducted a national online survey between February and April 2023. They recruited 30 CSC senior leaders (program directors or team members with broad oversight) through a national listserv and other professional channels. The survey asked whether their programs were implementing each of the identified practices and collected basic background information.
For the qualitative component, which is the focus of this article, the team used purposive sampling to invite survey respondents to in-depth interviews. Eleven leaders, each representing a different CSC program in seven states, agreed to participate. Most were women with more than 6 years of experience in their roles and worked in social work or case management.
The qualitative data come entirely from program leaders, not from young people, family members, or peer staff themselves.
Across these 11 sites, every program reported using more than one community-participation strategy, but none used all 10 practices under study. One program implemented two practices, two implemented four, two implemented five, two implemented seven, two implemented eight, and two implemented nine. No programs implemented three, six, or all ten practices.
One set of efforts focused on shared decision-making. Four programs had some form of committee or workgroup that brought together staff and current or former clients to “review and discuss programmatic efforts around promoting community participation.” In three cases, community participation was a standing topic within existing groups, such as “a young adult leadership council or alumni group.” Another program described a “behavioral health advisory committee” that included both clients and staff, although “it was unclear the degree to which this committee focused explicitly on community participation beyond the behavioral health system.” Two more programs reported that community participation was discussed in routine staff meetings, but because this did not align with the advisory group’s original definition, those examples were not counted as full implementations of the practice.
Programs also tried to build bridges to ordinary community organizations. Four sites described “engaging in active outreach to mainstream community organizations.” Leaders said outreach helped them “identify opportunities for participation and reduce barriers to participation.” One director described connecting with a local “restaurateur” to pilot “a series of cooking classes for clients.”
For 10 of the programs, this meant connecting with mainstream organizations accessible to anyone, regardless of mental health status. That included gyms, public transport programs, educational programs and exam prep courses, volunteer organizations, libraries, religious groups, housing assistance programs, employment resources, community youth groups like LGBTQ support groups, and museums. Three programs also met with clients outside program settings, such as parks, cafés, and while walking. Two programs emphasized staff who specialized in this work.
Nine programs went further, describing how they routinely delivered services in community settings rather than inside clinics. Staff accompanied clients as they moved through their neighborhoods and worked toward goals. One interviewee said this:
“It’ll also be going out, and maybe they’re doing employment searches…we’ll just go out and meet downtown, and we’ll just walk from place to place, and we’ll be outside where nobody can see us. But we’ll be supporting them as they go in and ask for applications, or if somebody’s hiring. We’ll go to the Y.M.C.A. or a fitness club if that’s what they’re wanting.”
Three of those nine also described holding sessions in public spaces “such as coffee shops or restaurants, for the purpose of providing CSC services,” noting that “It’s not uncommon for us to do a session in the park with them or to take them to the library. And those are the individual sessions.”
Six programs said they designed activities to help clients participate on their own, or with friends and family, rather than relying on staff. One site did this by explicitly emphasizing that support was time-limited:
“We really encourage everybody that we are not a permanent program. We are a up to 2 years, and at some point you’ll be graduated and you’ll get sick of us, which is great…But what we wanna make sure is going on is that you have those people that are gonna be around forever like your parents or your wife or husband…and we want them to be involved with us from the very get go…we’re really gonna encourage [family members] to be [supporting clients] instead of us, even if we’re happy to help out…So really making sure that they realize that we’re trying to build that independence and that creation of a support network around them.”
Three of the six described encouraging outings and events to “rebuild a damaged family relationship or communication challenges.” Another focused on helping clients “expand [their] social circles” and deepen relationships with acquaintances, while one program highlighted a peer specialist who helped a client navigate public transportation independently.
Mutual support among clients was another theme. Nine programs “endorsed implementing at least some program activities routinely in community-based settings” where clients could support one another. Some organized group outings, like “going to the beach, Frisbee golfing,” or informal mentorship in which “somebody…took on the role of mentor…he would offer to give people rides home…they would meet…to go play video games or go play golf.”
Five of the nine also “described holding ongoing groups based on shared interests in community participation.” One leader said:
“We have a rotation of groups that occur at [program] all the time…the groups are driven by participants on what their interests are…engaging around anime, engaging around photography, they did mural tours so they walked the city in different areas of the neighborhoods and talked about the murals and what they meant to them. We have chess club and writing…group and art group. There’s cooking group…whatever a young person’s passion is there’s probably space at [program] to create or to engage with other people who are interested in the same thing.”
In eight programs, interviewees described “self-disclosure of community participation experiences by staff with clients.” Seven said staff “often share their personal experiences with community events and activities, including success stories and challenges related to community participation.” In three programs, leaders saw this kind of self-disclosure as “the primary responsibility of peer specialists on the team,” noting that “inherently, that’s his role to share his experiences.”
A subset of sites “reported implementing programmatic supports across three specific domains of community participation (i.e., spirituality/religion, dating/intimate relationships, and civic engagement).” Four provided supports “focused on spirituality and religion,” nine “addressed dating and intimate relationships,” and five “offered supports related to civic engagement.”
Sometimes this began with intake questions that “assess[ed] interests and needs in these areas…to inform treatment planning.” In other cases, staff responded when clients raised these concerns over time. One director described their approach to spirituality and religion:
“So that’s something that they’re expressing interest in pursuing is strengthening their spirituality or finding a church or something then we’re happy to explore with them. We can tell them either, ‘Hey, I know that there’s these ones or…we can look up how to find them or go through with how to access those different things, and maybe find reviews or have a conversation of…do you know what your spirituality is – you have a chosen religion?”
Dating and relationships often showed up in groups. Six programs “incorporated dating and intimate relationships into ongoing groups.” One offered “a healthy relationships series,” with groups “6 and 8 weeks long” that “talked about intimate partner violence and other ways to identify…is this a safe and healthy relationship for me? Is this not? If it’s not, what can we do? How can I get help? How can I get out of it? Civic engagement supports four programs, including help with “registering to vote and getting involved in volunteer activities and advocacy efforts.”
Interviewees noted that the broader “political, economic, or social climate” shaped outreach and partnerships with mainstream organizations. “Client motivation and interest” were described as essential for efforts like advisory committees and peer mutual support, and “perceptions about effectiveness or acceptability” influenced whether committees, outreach, and independent participation took root.
Programs that did not implement these practices told a different story. They “frequently cited barriers such as insufficient staffing and limited resources.” Leaders described environmental and structural obstacles, including “the political, economic, or social climate (e.g., stigma) and the physical environment surrounding the program (e.g., rural setting),” which limited outreach, connections with mainstream organizations, and even staff self-disclosure.
They also pointed to “client issues (e.g., low motivation, interference from symptoms, lack of personal resources)” as barriers to serving on committees or engaging in independent participation. Finally, some practices never got off the ground because of “lack of perceived acceptability,” which hampered “program activities occurring in community-based settings.”
In their view, the goal of CSC is to provide precise support as clients learn how and where to engage with their communities, rather than leaving them to “go it alone” amid confusion and stigma, concerns that echo broader work on community-led mental health research.
They argue that many of these efforts could be deepened and made more explicitly about participation, not just treatment access. Advisory bodies, for instance, could function as committees “specifically dedicated to identifying and addressing barriers to community participation, ensuring a broader focus beyond clinical recovery.” Outreach, which many programs now use to educate communities about early psychosis and CSC services, could also introduce organizations to the value of participation “for everyone, including clients with early psychosis,” and build pathways into volunteering, recreation, job training, and college support. Sessions already held in cafés, libraries, gyms, and recreation centers could be used for guided practice in “initiating social interactions or navigating public spaces,” or in “overcoming anxiety related to group activities,” so that people come away better able to use these places independently. This mirrors arguments about community inclusion and the social determinants of mental health.
The authors suggest workarounds such as designating “community inclusion specialists,” “advocating for the medical necessity of community participation programming with funders,” relying on community rather than clinic-based resources, involving people with lived experience in anti-discrimination efforts, and adopting “empowerment-focused approaches” that help young people pursue “personally meaningful goals.”
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Thomas, E. C., Shern, D., Slanzi, C. M., Surratt, Z., Bertolami, N., & Salzer, M. S. (2025). Implementation of Community Participation Practices in Coordinated Specialty Care: Insights from a Qualitative Study. Community Mental Health Journal. https://doi.org/10.1007/s10597-025-01554-w