A note on terminology. We use the word participant rather than patient because patient, in the context of severe persistent mental illness, has accumulated stigma and now functions as an identity label rather than a description of a role. Participant is an ordinary word, used across many settings, that describes what someone is doing rather than who they are.
The Puzzle of Sustained Underperformance
One of the enduring questions in mental health care is why decades of scientific advances, billions of dollars in public investment, and the efforts of countless dedicated professionals have not consistently produced better outcomes for many people living with serious mental illness. The intuitive explanation is that resources are insufficient. From a systems perspective, however, the country has already invested heavily. Most of the components that recovery requires are in place somewhere. Effective medications exist. Evidence-based psychotherapies are widely available. Rehabilitation programs, housing supports, peer services, case management, vocational opportunities, and community resources have all expanded considerably over the past several decades.
The shortfall, then, may not be a problem of components. It may be a problem of how those components relate to one another. Funding streams remain fragmented. Programs are compartmentalized. Research and practice often operate in separate spheres. Housing is disconnected from treatment, vocational opportunity is disconnected from rehabilitation, and clinical intervention is disconnected from ordinary community participation. Providers frequently do excellent work within their own domains, yet the system as a whole struggles to generate forward motion. The result is not a lack of effort. It is a lack of acceleration.
The Flywheel as a Different Way of Thinking About Recovery
The business literature describes a phenomenon known as the flywheel effect. A flywheel is heavy, and at the start it turns slowly. Each push contributes a small amount of momentum, but the rotations themselves begin to carry energy forward, and over time the wheel becomes increasingly self-sustaining. The principle is that the relationships among the components matter as much as the components themselves. Each successful rotation supplies the energy for the next.
Recovery from serious mental illness may operate according to similar principles. Clinical services contribute to stability. Stability supports participation in daily life. Participation creates the conditions for social connection. Social connection produces motivation and hope. Motivation, in turn, improves engagement with treatment, and better engagement leads to better outcomes. Better outcomes attract public confidence and continued investment, which then strengthens the services that started the loop. When these elements operate in isolation, progress is fragile and easily lost. When they reinforce one another, recovery begins to accumulate.
This way of thinking may help explain why mental health systems so often experience chronic resource strain. When funding is directed primarily toward crisis response rather than toward the conditions that make sustained recovery possible, emergency rooms, inpatient units, law enforcement, and forensic systems become progressively more burdened. Resources are consumed managing failure rather than accelerating success. The challenge, in other words, is not only clinical. It is organizational, social, and economic at the same time.
An Instance That Works: The ASC Flywheel
ASC has been operating for more than four decades on principles consistent with this view. From the beginning, we have built our programs around what we believe to be the central question in serious mental illness care. Do the people we serve actually want what we are offering? When they do, adherence becomes possible. When they don’t, no amount of clinical expertise will keep them in treatment. This is why we have always prioritized what we call highly desirable services, and it is why the ASC model has produced sustained outcomes where many other approaches have struggled.
What Participants and Families Actually Want
For most of the modern era of schizophrenia treatment, the field has organized itself around positive symptoms such as hallucinations, delusions, and disorganized thought. There are good reasons for this. Positive symptoms drive crises and hospitalizations, and they remain the public face of the illness. They are not, however, what participants and their families tend to identify as most important to address.
A growing literature supports this. When asked, people living with schizophrenia tend to give higher priority to relief from depressive and negative symptoms (the withdrawal, the lost motivation, the inability to take pleasure in things) than to reduction of positive symptoms (Moritz et al., 2017). A recent paper by Strauss and colleagues makes this finding more specific. They asked outpatients with schizophrenia, along with their family members or caregivers, to rate which negative symptom domains mattered most across several dimensions of life: treatment goals, daily distress, social functioning, work functioning, and quality of life. Both groups identified the same three domains: anhedonia, avolition, and asociality (Strauss et al., 2026). These were rated consistently higher than blunted affect or reduced speech. The level of improvement that participants reported as meaningful was modest rather than dramatic.
Caregivers in the Strauss study placed particular emphasis on asociality. The authors attributed this to family members’ direct exposure to the symptom in daily life. They are the ones who notice when a family member stops coming to gatherings, or pulls away from conversation at the dinner table. Participants themselves weighted avolition most heavily. The two perspectives looked at the same illness from different positions, but the overall message was consistent. What people most want help with is the disengagement that schizophrenia produces, in its various forms.
This reframing matters for system design. If the symptoms most important to participants and families are the social and motivational ones, then the services that matter most are those that address them. Such symptoms do not respond particularly well to medication. To the degree they respond at all, they respond to social experience. A system organized around positive-symptom suppression alone will continue to miss what participants and families say matters most.
Why Socialization Is the Hinge
This is where the design of ASC programs becomes important. The home-like settings, the gardens and animals, the shared kitchens, the daily rhythms, the art rooms, and the peer interaction are not features we have added to make the place feel pleasant. They are clinically active. They give the people in our programs something to do, somewhere to belong, and a reason to stay. What we are creating, when this works, is sustained social experience. Participants spend their days in conversation, shared tasks, and ordinary roles inside a community of peers and staff. This happens to be the same symptom domain that participants and their families tell researchers they care most about. We have organized our programs around it on purpose.
Socialization is the hinge of the entire flywheel. It acts directly on the negative symptoms that participants and their families have identified as most important. At the same time, it makes adherence to everything else realistic. Participants who are socially engaged tend to stay in treatment. They keep their appointments. They participate in discussions about their medication. They put up with the side effects long enough to settle on a regimen that works. They stay in therapy long enough for CBT and motivational interviewing to be useful. Participants who are not socially engaged tend to drop out, sooner or later.
The point here is straightforward. People do not maintain treatment relationships in environments they want to leave. They do maintain them in environments where they want to stay. Most of what we do at ASC follows from this.
Agency, Work, and the Problem of Earned Experience
There is a deeper layer underneath the argument about social engagement that deserves its own attention. Engagement matters because of what it makes possible, and what it makes possible at the deepest level is a sense of self-efficacy, of personal achievement, and of gratification taken from work that someone has chosen and accomplished. These experiences are largely absent from the lives of many of the people we serve. Days are often organized for them. They wait to be told what activity will happen next, what group to attend, where to live, what medication to take. Even within well-designed programs, participants frequently find themselves in the position of asking for what they need, rather than working toward it and earning it.
This matters clinically. Recovery is not the same as being managed well. A person can be stable, adherent, and present in every group on the schedule, and still be living a life in which nothing they do feels like their own. The ordinary mechanisms by which adults build a sense of competence and worth, working toward goals, contributing to a household, earning the resources that make small choices possible, are mechanisms that most participants have limited access to. The environments and treatments most participants encounter do not empower them to participate actively in earning, and therefore valuing, their own circumstances.
Poverty makes this worse. Participants typically arrive in our programs with very little, and the financial situation that surrounds severe persistent mental illness offers few avenues out. Residential programs cannot realistically employ their participants in any substantial way. The roles available are limited, the funding does not support meaningful wages, and the regulatory environment makes ordinary employment relationships difficult to establish. Working for the things one wants, which is among the most reliable routes to self-efficacy in ordinary adult life, is mostly unavailable. This is not a failing of any particular program. It is a structural feature of how this kind of care is organized and funded. But it has clinical consequences, and any honest account of the field has to name them.
Within these constraints, we work to create as many opportunities for genuine agency as the structure allows. Participants take real roles in the daily operation of the household. They cook, they care for animals, they tend gardens, they make decisions about how their environment looks and feels. They mentor newer participants. They join in shaping the rhythm of program life rather than receiving it as something handed down. These are not large freedoms by ordinary standards, but for people who have spent long stretches of life in settings where every decision was made for them, they are substantial. The difference between a participant who waits for the next activity to begin and a participant who is responsible for some small piece of how the day actually unfolds is a difference that shows up in adherence, in mood, and in long-term trajectory.
This is also where the flywheel framing pushes back against a common assumption in the field. Care has often been thought of as something delivered to a person, and recovery as something that follows from receiving enough of it. The flywheel does not work this way. A flywheel turns because energy is being added to it from inside the system, including from the participants themselves. Without agency, achievement, and the gratification that comes from earning some part of one’s own circumstances, there is no internal source of momentum. The wheel can be pushed from the outside indefinitely without ever beginning to turn on its own.
The Flywheel at Work
With agency in the picture, the full loop becomes clearer. Highly desirable services bring participants into engagement. Engagement creates the kind of sustained social experience that does something about anhedonia, avolition, and asociality, the symptoms participants and families have told us they care most about. Within that social experience, participants take on real roles, contribute to the life of the program, and accumulate the small daily achievements that build a sense of competence. Together these support adherence, and adherence allows the other evidence-based interventions, both pharmacological and psychosocial, to actually do their work. The outcomes that result are visible to the counties that fund care: fewer hospitalizations, fewer crisis interventions, longer periods of stability. As that pattern builds over time, the counties continue to fund and expand what we do, which lets us reinvest in the environments that started the whole sequence.
None of this can be shortcut. Environment by itself does not improve symptoms directly. It works through social engagement, and social engagement is what addresses the symptom domain participants tell us matters most. That, in turn, is what makes adherence possible. Adherence is what lets the rest of the treatment deliver its effects. If any one of these intermediate steps is missing, the wheel does not turn.
A Longer Loop: Visibility and Community
There is a second loop running alongside the first, on a slower timescale. As the people we serve become visible to their neighbors as residents and community members rather than as institutional cases, stigma diminishes. When stigma is lower, families stay more involved in care, qualified staff are easier to recruit and retain, new sites can be licensed and opened with less neighborhood resistance, and participants are more likely to maintain their community tenure over the long term. These outcomes feed back into the strength of the program, producing more of the visible normalcy that lowered stigma to begin with. Community-based models in Norway and Italy have shown for years that when care is continuous, locally embedded, and acceptable to the people in it, both clinical outcomes and system costs improve (Leckey, 2011; Insel, 2022).
Why This Is Hard to Replicate
What makes the ASC model difficult to replicate is largely not a question of capital. Buildings can be built, and protocols can be adopted by anyone willing to put in the work. The harder things to copy are less tangible. They include the design discipline that keeps services genuinely desirable rather than only adequate, the staff culture that views adherence as something earned through engagement rather than demanded through pressure, the clinical judgment that knows when more autonomy is appropriate and when it is not, the multi-decade county relationships built on a track record with difficult cases, and the community familiarity that allows neighbors, families, and referring clinicians to understand what ASC actually is. None of these accrues quickly.
Implications for the Larger System
As Dr. Insel and others have argued, the principal challenge in mental health care today is no longer the absence of effective treatments. The problem is how to deliver them reliably, at scale (Insel, 2022). The flywheel framing suggests one reason this has proven so difficult. When components of care are organized in isolation, even excellent ones, they do not generate the cumulative momentum that recovery requires. The system spends heavily but produces fragmented results, and participants who would otherwise have recovered remain trapped in cycles of crisis.
A system that generates momentum produces benefits across every level. Participants experience greater engagement and opportunity. Staff find greater purpose, and turnover declines. Communities depend less heavily on emergency services. Public investment yields stronger returns. Research becomes easier because successful programs create the stability that innovation and evaluation require. Success, in this configuration, begins to build on success.
Perhaps the future of mental health care does not lie in finding a single breakthrough intervention. It may lie instead in designing systems where the interventions we already have strengthen one another. The question is not whether treatment works. The question is whether we have organized treatment, community resources, social opportunities, and economic investment in such a way that recovery can gain momentum. ASC offers one example of what this can look like in practice. The flywheel turns slowly at first, but once it is turning, it produces something that no isolated intervention can match.
References
Deegan, P. E., & Drake, R. E. (2006). Shared decision making and medication management in the recovery process. Psychiatric Services, 57(11), 1636–1639.
Insel, T. R. (2022). Healing: Our path from mental illness to mental health. Penguin Press.
Leckey, J. (2011). The therapeutic effectiveness of creative activities on mental well-being: A systematic review of the literature. Journal of Psychiatric and Mental Health Nursing, 18(6), 501–509.
Moritz, S., Schröder, J., Klein, J. P., Lincoln, T. M., Andreou, C., Fischer, A., & Arlt, S. (2017). Effects of online intervention for depression on mood and positive symptoms in schizophrenia. Schizophrenia Research, 175, 216–222.
Strauss, G. P., Zhang, Z., Arnold, L. E., Hutcheson, A. L., Barolette, J. T., Luck, J. E., Carter, Z. A., Knippenberg, A. R., Allen, D. N., & Kirkpatrick, B. (2026). Subjective perceptions of negative symptoms among outpatients with schizophrenia and their relatives or caregivers: Definitions, importance, measurement, and desired improvement. Schizophrenia Research, 295, 61–71.