Social Workers Warn Current Systems Entrench Poverty and Trauma for People With Psychosis

An new article published in Social Work in Mental Health outlines the persistent systemic and structural social injustices faced by people who experience symptoms of schizophrenia-spectrum conditions. The authors, led by Shannon M. Blajeski of Portland State University, also call both for the National Association of Social Work to implement specific guidelines for working with people that experience symptoms of schizophrenia-spectrum conditions and a promotion of intervention research among their colleagues.

They write:

“Individuals living with schizophrenia-spectrum conditions are faced with a myriad of social injustices, in addition to experiencing the clinical effects of illness, These include dependence on a limited system of public welfare and treatment as a result of failed social policies following deinstitutionalization, historical discrimination and public stigma, poverty, social isolation, increased incarceration, and disproportionate rates of suicide and chronic health issues.”

This paper calls attention to the historical marginalization of people that experience psychosis, including the trauma of institutionalization, the failures of deinstitutionalization, and the cycle of poverty and disability experienced by many service users. The authors also explore social work’s contributions to treating people with schizophrenia-spectrum conditions, as well as what the field can do to improve.

Drawing on co-author Jordan DeVylder’s 2015 paper for the American Academy of Social Work and Social Welfare, the goal of the current work is to alert the field of social work to the historic and systemic injustices faced by individuals with schizophrenia-spectrum conditions. The authors also seek to explore both how social workers have historically supported people with schizophrenia-spectrum conditions and current social worker training specific to working with people with a serious mental “illness.”

The Failure of Deinstitutionalization

The authors contend that people labeled with schizophrenia are routinely subjected to coercive practices, social exclusion, and rights violations that are normalized as care in the public mental health system. Not only are all these issues associated and intertwined with each other, they are also compounded by historic and ongoing budget cuts to public mental health and the public welfare systems.

During the 1960s and 1970s, most individuals with schizophrenia-spectrum conditions lived in psychiatric institutions. The Community Mental Health Act of 1963 was developed to integrate those living in institutions back into their communities. However, this legislation lacked specific guidance on what support was needed in the community for this reintegration process. This lack of guidance was accompanied by local laws that forbade the placement of clinics and housing for people with mental health issues and followed by Reagan-era budget cuts to the little community resources that were available.

The Poverty-Disability Cycle

Poor planning around the Community Mental Health Act of 1963 and the erosion of community resources and support resulted in high rates of homelessness, housing insecurity, unemployment, and poverty for people living with symptoms of schizophrenia-spectrum conditions. This led many people with schizophrenia-spectrum symptoms to become dependent on social security as a primary source of income. As social security benefits typically require younger recipients to be “disabled,” a label most often given by medical doctors and psychiatrists, this system forces the people caught up in it to submit to a medical model of their psychological distress.

The authors note that people diagnosed with a serious mental “illness” are the largest group of “disabled” social security benefit recipients. This group is also the most likely to start receiving these benefits at a young age, which can trap them in a poverty-disability cycle.

The authors explain:

“The acquisition of Social Security income is inextricably tied to the medical model of disability, which may have a negative influence on individuals’ confidence and opportunity to later move into the labor market. This often leads to a focus on acquiring disability benefits in treatment settings rather than on career-building or employment. This is detrimental to young adults with psychosis in particular because their developmental phase of searching for employment or pursuing higher education is thus replaced by periods of disability.”

Lack of employment and further isolation from community not only makes those with schizophrenia-spectrum conditions dependent on the biomedical model of mental illness and disability, it also further ostracizes and isolates them—increasing their risk for suicide. Suicidality increases further when lack of employment and community integration is compounded by exclusionary and prejudiced practices such as sanism, racism, and the trauma of living with symptoms of schizophrenia-spectrum conditions.

“Unfortunately, although psychotic disorders and PTSD are often comorbid, people who have experienced a psychotic episode are rarely treated for the trauma [and racism] they endured at its peak by social service providers…Black and Latinx individuals experiencing psychosis are more likely to endure the use of physical restraints in emergency settings and African Americans are overrepresented in hospitalizations…Moreover, marginalized groups and those from lower social economic classes are more apt to receive pharmacological treatment rather than therapy, are often prescribed older, first-generation antipsychotics instead of modern medications, tend to spend longer periods in treatment (including hospital readmissions), and face disproportionate rates of incarceration before receiving appropriate care.”

Social Work and Schizophrenia

Given that individuals with schizophrenia-spectrum conditions encounter trauma at every turn in the mental health care system, it is imperative that social workers are equipped with the knowledge and skills to support them. This is particularly true when working with people from marginalized groups with schizophrenia-spectrum conditions.

Social work historically has sought to—and continues to—support individuals with schizophrenia-spectrum conditions. This support is exemplified by the field’s development of community-based services and interventions such as the Assertive Community Treatment model, the Strengths-model, and the Clubhouse Model of Psychosocial Rehabilitation, as well as its support of peer-led models like Open Dialogue.

However, the authors contend that despite social work’s historical commitment to helping people with serious mental “illness,” many social workers are ill-prepared to support individuals with schizophrenia-spectrum conditions and are at risk of harming and/or further traumatizing them.

To begin to remedy these shortcomings, the authors call for:

1. A specification of practice guidelines for working with individuals with schizophrenia-spectrum conditions at the National Association of Social Work level.
2. A promotion of intervention research among social work scholars, to build upon, and revitalize social work’s historical contributions to models of care for those with schizophrenia-spectrum conditions.

The authors conclude:

“Individuals with schizophrenia-spectrum conditions have long-suffered the negative effects of marginalization, and the roots of historical injustices persist as negative life outcomes for this population. As a field of social work, we should build upon our historic contributions to supporting this vulnerable population, and take organized action to improve MSW practice training for the future workforce.”

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Blajeski, S. M., Bornheimer, L. A., Wojtalik, J. A., Studer, L., Ben-David, S., Turner, P. R., … & DeVylder, J. E. (2025). Addressing injustices toward individuals with schizophrenia-spectrum conditions: a call to action for social work practice. Social Work in Mental Health, 1-22. (Link)