Author(s): Timothy MacLeod

Abstract:

Timothy MacLeod

Transformative change to mental health systems involves transformation in how practices, policies, and research respond to the needs of individuals with psychiatric disabilities. This paper presents Amartya Sen’s capabilities approach as a promising framework for outcome measurement congruent with the aims of transformative change in mental health systems. In this paper, Sen’s capabilities approach is contrasted with therapeutic and citizenship values as well as the Housing First approach to housing. The capabilities approach is examined in detail with regard to outcome measurement. Finally, this paper shows the value added of the capabilities approach to transformative mental health.

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Proponents for transformative change in mental health systems advocate for meaningful changes to social responses for individuals with psychiatric disabilities in terms of practices, policies, and research (Nelson, Kloos, & Ornelas, in press). In this paper I will present Amartya Sen’s (1999) Capabilities Approach, a perspective concerned with the measurement of welfare and global poverty reduction, as an important methodological tool for research that pursues transformative change in mental health systems. The goal of this paper will be to contribute to the nascent literature on capabilities and mental health by articulating how Sen’s capabilities approach frames measurement and in turn how this contributes to transformative mental health. In making this case I will use Housing First, with specific reference to the Canadian At Home/Chez Soi study (Goering et al., 2011), as a concrete example of transformative mental health (Nelson, 2010). Theoretically, two arguments will be advanced: (a) that the capabilities approach synthesizes citizenship and therapeutic values and connects these values with outcome measurement (Sylvestre, Nelson, Sabloff, & Peddle, 2007; Sylvestre, unpublished manuscript) and; (b) that the capabilities approach can make several important contributions to the Housing First literature. In advancing these arguments I will start by defining and discussing citizenship and therapeutic values and relate these values to outcome measurement. I will present Housing First as an example of transformative change in community mental health that synthesizes citizenship and therapeutic values in its outcome measurement and holds a strong congruence with the capabilities approach. I will briefly define the capabilities approach and review the existing literature on the capabilities approach and mental health. I will then present this approach as it relates to measurement. Finally, I will comment on the value added of the capabilities approach to transformative mental health. 

Citizenship and Therapeutic Values
An important dimension of changing the status quo of mental health systems is the foregrounding of citizenship values in research, practice, and policy (Sylvestre, unpublished manuscript). In a content analysis of mental health and housing literature, Sylvestre et al. (2007) identify citizenship and therapeutic values as two dominant categories. Citizenship values encompass access and affordability, accountability, housing rights, and legal security of tenure. Therapeutic values encompass choice and control, quality, and community integration. In their review, the authors conclude that therapeutic values dominate the housing and mental health literature and that research focusing on how housing programs are actually delivered and experienced by tenants is needed to address this value discrepancy.

Sylvestre (unpublished manuscript), drawing on the work of Hall and Williamson (1999), has extended the conception of citizenship presented by Sylvestre et al. (2007) and presented three conceptions of citizenship. The three orientations are: (a) legal citizenship (the nature of the relationship between individuals and the state); (b) normative citizenship (the interaction of citizens with civic, political, or social organization and processes); and (c) lived citizenship (the implications of citizenship in daily life). Legal citizenship denotes the relationship of the individual to the state primarily through rights and responsibilities. Rights ensure equal treatment and equal access to participation in political and civic life. Responsibilities are less well defined. Sylvestre (unpublished manuscript) draws on Marshall (1950) to articulate three dimensions of rights: (i) civil rights – rights that are necessary for individual freedom, (ii) political rights – the right to exercise political power, and (iii) social rights – the basic provisions offered by the state to ensure a base level of social welfare and the ability of all citizens to act on their rights.  Sylvestre argues that these rights are insufficient for citizenship and that often people with psychiatric disabilities are unable to actualize these rights. People with psychiatric disabilities routinely face constraints on their political and social rights and are often withheld the resources and opportunities that constitute social rights.

Sylvestre (unpublished manuscript) presents normative citizenship as participation in civic, political and social organizations. It is characterized by a set of practices as opposed to a legal status. Normative citizenship presents “duty” as a key feature of citizenship and encompasses a notion of the “good citizen”.  Expanded conceptions of agency are likely important to people with psychiatric disabilities who may participate in social organizations like consumer run organizations that supplement traditional mental health settings. However, normative citizenship carries a particular vision of social participation that may paradoxically privilege better resourced groups and serve to mask underlying power dynamics and social inequities. This vision of social participation privileges participation in formalized public organizations as opposed to private or informal spaces. If individuals are unable to preform normative acts of citizenship they may not be seen as citizens. 

Lived citizenship, for Sylvestre (unpublished manuscript), draws on the expanded agency of normative citizenship but positions citizenship in the context of daily life and is concerned with both public and private realms.  Lived citizenship draws attention to informal social processes that often are important in how people with psychiatric disabilities negotiate experiences of discrimination and exclusion. Substantively, lived citizenship shifts participation in public life from obligation, as in normative citizenship, to access to rights and opportunities.

Sylvestre uses supportive housing and Housing First to demonstrate the implications of these orientations of citizenship for mental health research, policy, and action. Combining both citizenship and therapeutic values have important implications for understanding expanding agency and participation in civic life (i.e., the normative and lived frameworks of citizenship). It is important to tie these value orientations to outcome measurement. For example, recent work linking neighbourhood characteristics to mental health outcomes (Townley & Kloos, 2011; Townley, Miller, & Kloos, 2013) have both therapeutic and citizenship dimensions. On the one hand, this research measures the impact of environment on mental health and community integration, and is therefore aligned with therapeutic values. On the other hand, it is also aligned with citizenship values insofar as it is concerned with the physical, social, and psychological integration of individuals with psychiatric disabilities in neighbourhoods. This research utilizes outcome measurements that capture more traditional clinical measures in addition to expanding agency and civic participation.  Using frameworks of measurement that are capable of highlighting both therapeutic values (mental health outcomes, community integration) and citizenship values (participation, control, expanding agency) is important in representing the transformative aims of mental health intervention.

Outcome Measurements, Housing First, and Values
Two important tools in advancing transformative mental health are conceptualization and measurement (Wong & Solomon, 2002). Measurement is central to understanding how we classify psychiatric disability, how we frame the challenges associated with psychiatric disability, and, subsequently, how we attend to the needs of individuals who have psychiatric disabilities. Measuring the most appropriate and relevant outcomes with the correct tools is essential for transformation in mental health systems. One prominent example of transformation to mental health systems is the rise of Housing First (Nelson, 2010). Housing First has been transformational in both policy and practice domains. Additionally, Housing First foregrounds attention to outcome measurement that supports transformative change to mental health systems, as will be described in more detail below.

Housing First is an approach to housing for homeless adults with psychiatric disabilities that values consumer choice in housing and community based support with a recovery and harm-reduction approach. Participants are given immediate access to precondition-free, scattered-site housing in addition to flexible community based clinical supports provided by a different agency than the one that provides the housing (Nelson, Goering, & Tsemberis, 2012). Central to this transformational shift is the normative commitment that mental health service consumers can live independently in the community and make their own choices regarding housing and clinical service use (Carling, 1995; Tsemberis, Gulcer, & Nakae, 2004; Nelson, 2010). The intersection of citizenship and therapeutic values is strongly reflected in the approach’s goals of community integration because it values the ability of adults with psychiatric disability to fully participate in civic life and find meaningful social, physical and psychological inclusion (Carling, 1995; Wong & Solomon, 2002; Ware, Hopper, Tugenberg, Dickey & Fisher, 2007; Yanos, 2007). Increasingly, measurement of Housing First outcomes reflects both citizenship and therapeutic outcomes, often concurrently.

The typical measurements of outcomes in Housing First are largely therapeutic and comprised of emergency service utilization, incarceration, hospitalizations, and health, mental health outcomes and housing stability (Aubry, Ecker, & Jette, in press; Gaetz, Scott, & Gulliver, 2013; Rog, 2004). Housing stability marks a measurement that reflects a non-therapeutic outcome, housing tenure, but remains limited in its implication for measuring meaningful community integration or expanding agency (Kloos & Townley, 2011; Townley, Miller & Kloos, 2013; Yanos, 2007). More recent studies of Housing First have included outcome measurements more inclusive of the lived experience of citizenship. A recent trial of Housing First in Canada – At Home/Chez Soi – has tested the effectiveness of Housing First in the Canadian context (Goering et al., 2011). At Home/Chez Soi was a 5-year pragmatic, mixed methods trial of Housing First across 5 Canadian cities. Approximately 5000 participants were randomized into either a treatment condition – stratified by high or moderate needs – or treatment as usual.

This trial included outcome measurements that focus more rigorously on therapeutic and citizenship-based indicators and speak to the ability of individuals to find meaningful inclusion and participation in the community. These indicators include quantitative measurements of community integration, quality of life, independent living, recovery, meaningful activity, and housing stability and quality (Goering et al., 2011). The breakdown of outcome measurement and citizenship and therapeutic values is presented below in Table 1. This table highlights the representation of both citizenship and therapeutic values in outcome measurement and is intended as a heuristic for categorizing outcome measurements into specific dimensions of the two value orientations in a housing intervention. While At Home/Chez Soi utilizes more progressive outcome measurement of citizenship we still lack a comprehensive framework for studying citizenship in housing.

Housing First and the Capabilities Approach
The measurement of outcomes in At Home/Chez Soi, and the integration of citizenship and therapeutic values, is highly congruent with Amartya Sen’s capabilities approach, an economic framework focused on the measurement of social outcomes in global poverty reduction (Sen, 1999). The inclusion of a broad range of indicators that assess social outcomes for adults with psychiatric disabilities provides a wide and nuanced lens through which we can understand well-being. In the sections below I will introduce this approach, review the literature on psychiatric disability and capabilities, and unpack this framework as it pertains to measurement.

An Introduction to the Capabilities Approach
The capabilities approach is a model of human development advanced by both Amartya Sen (1999) and Martha Nussbaum (2000). Given that the focus of this paper is measurement and outcomes, I will consider primarily the work of Sen who has made the most substantive contributions to this domain. For a discussion of the contributions of Nussbaum, see Shinn (in press). A Nobel Prize winning economist, Sen advances a notion of human development as freedom, and has developed a rigorous mixed methods econometric framework that promotes the expansion of freedom through “capabilities”. Plainly stated, capabilities can be understood as the freedom of individuals to do and to be according to their own values given the resources available to them. It expands the definition of rights by focusing on achievements or consequences (Nussbaum, 2000).  Some examples of capabilities that may be particularly relevant to individuals with psychiatric disabilities include achieving permanent housing, finding meaningful and permanent employment, and choosing one’s mental health services.

Sen’s framework deeply engages with the philosophical roots of economic measurement. Sen argues that two philosophical frameworks – utilitarianism and deontology – have dominated debates about poverty and have guided the assessment of social outcomes. I will argue in the sections that follow that these two orientations have an affinity with citizenship and therapeutic values as presented by Sylvestre et al. (2007). Sen levies substantive critiques against both utilitarianism and deontology and introduces the capabilities approach as an alternate framework for conceptualizing and measuring poverty and assessing social outcomes. I will argue that Sylvestre’s (unpublished manuscript) citizenship framework has an affinity with the capabilities approach. By measuring and assessing capabilities – what people can actually do, coupled with the choices they have available to them (freedom) – a notion of welfare is advanced that considers both agency and social structure. Moreover, well-being is understood as multidimensional; it considers factors associated with quality of life, civic engagement, as well as traditional measures of income and access to health care. This framing is highly congruent with the At Home/Chez Soi outcome measures that consider a broad range of indicators in assessing outcomes that reflect both therapeutic and citizenship values (i.e., health and mental health, housing tenure, quality of life, community integration, independent living skills, and choice) (Goering et al., 2011).

Underpinning the capabilities approach is an orientation towards discourse ethics where Sen suggests that individuals and communities should be given opportunities for participation to identify the capabilities that have meaning in their own contexts. The capabilities approach has been developed largely in the context of global poverty reductions, an example of which is the United Nations Human Development Index  (Fukuda-Parr, 2003). The capabilities approach has emerged as a promising framework for considering the multifaceted issue of psychiatric disability and well-being in terms of measurement.

The Capabilities Approach and Mental Health
An important contribution to the development of Sen’s capabilities approach is Kukly’s (2005) use of this framework to explore welfare measurement for people with disabilities in the United Kingdom. Kukly’s shows that measuring welfare for people with disabilities is distorting because it does not account for conversion. The author shows that individuals with disabilities convert money into outcomes (i.e., housing, employment, well-being) differently than the general population because of disabling social structures.

Ware, Hopper, Tugenberg, Dickey, and Fisher (2007; 2008) have deployed the capabilities approach – drawing on both Sen and Nussbaum – towards conceptualizing quality of life and community integration for homeless adults with psychiatric disability who have achieved housing. These authors utilize the capabilities approach in analyzing qualitative data and articulating expanding agency for individuals with psychiatric disability. Similarly, Davidson, Ridgway, Wieland, and O’Connell (2009) suggest that the capabilities framework is highly compatible with the recovery approach in that both frameworks pursue transformative change in the mental health system. The broader work on civil liberties and mental health undertaken by Davidson has a strong affinity with the literature on capabilities and mental health (Davidson, 2005; Davidson, 2006; Davidson et al., 2009; Pelletier, Davidson & Roelandt, 2014). Broadly this literature holds that mental health service delivery should begin with a restoration of citizenship rights and that programs should aim to expand agency in specific social contexts.

Shinn (in press) provides a thoughtful and thoroughly researched paper that describes in great detail the capabilities approach – as advanced by both Sen and Nussbaum – which she applies to supported housing intervention to highlight the contribution of this approach. This overview provides a good synopsis of the capabilities approach that is helpful in orienting mental health practitioners. The present article builds on Shinn’s work by considering in greater detail the contributions of Sen in relation to measurement.

Sen’s Capabilities Approach and Mesausrement
An important dimension lacking from the emerging literature on the capabilities approach and mental health is the articulation of Sen’s measurement of social outcomes. In this section I will elucidate the capabilities approach’s contribution to measurement of social outcomes. In addition, I will locate therapeutic and citizenship values within Sen’s framework. Finally, I will comment on the congruence of the measurement of outcomes in At Home/Chez Soi with the capabilities approach.

The starting point for Sen’s explication of the capabilities approach is a critique of two philosophical traditions that he suggests are dominant in the econometric measurement of poverty and assessment of social outcomes. The two traditions are utilitarianism – largely associated with British philosopher Jeremy Bentham working at the turn of the 18th century – and deontology – largely associated with contemporary American philosophers John Rawls and Robert Nozick. In terms of citizenship and therapeutic values (Sylvestre et al., 2007), legal citizenship has a strong affinity with deontology, while therapeutic values and lived citizenship have an affinity with utilitarianism. In the section that follows I will clarify these affinities.

Utilitarianism holds that social outcomes ought to be assessed in terms of their consequences. Consequences should be intersubjectively observable and thus quantifiable. Income or money has been the typical unit of analysis of utilitarianism in the measurement of poverty. In assessing levels of poverty, for example, we might compare the income of individuals in addition to their consumption of various goods and services (i.e., food, clothing, housing, medicines). Therapeutic values are largely concerned with the quantitative measurement of various inputs (clinical services, housing) on mental health outcomes (observable consequences) and community integration, and therefore have an affinity with utilitarianism.

Deontology is largely concerned with rights. Deontology is a reaction to utilitarianism and holds that social outcomes should not be measured by consequences but by the rights and freedoms of individuals. Put in concrete terms, deontology holds that social outcomes should be assessed by the equality of rights to basic freedoms (ie. private property, education). It is worth noting that Rawls (1971) extends the conception of the equality of rights to a social circumstance in which inequality – social and economic – should be distributed for the greatest benefit of the most disadvantaged. This assessment of social outcome is congruent with utilitarianism in that it is concerned with broader social consequence. Deontology has a strong affinity with citizenship values (Sylvestre et al., 2007) and legal citizenship (Sylvestre, unpublished manuscript) in that these frameworks are narrowly concerned with rights. Legal citizenship, like deontology, does not consider the social consequences of rights.

Sen’s substantive critiques of both utilitarianism and deontology form the conceptual basis of the capabilities approach. Where Sylvestre et al.’s (2007) conception of citizenship and therapeutic values resemble both utilitarianism and deontology, Sylvestre’s (unpublished manuscript) three-dimensional approach to citizenship significantly extends this framework. This three-dimensional approach builds upon the earlier model of citizenship and therapeutic values.  In the section that follows, I will present Sen’s critiques of deontology and utilitarianism parallel to the expansion of citizenship values through Sylvestre’s (unpublished manuscript) citizenship framework.

Sen critiques utilitarianism on the grounds that: (a) rights and freedoms are neglected (legal citizenship); (b) non-utility information is neglected (the lived framework of citizenship – participation in community life, freedom from discrimination), and; (c) conversion is not considered (individuals convert money and resources into outcomes very differently). For Sen citizenship rights figure prominently in understanding the circumstances of poverty/disability with regard to the role of the state. In the case of people with psychiatric disabilities, for example, the legal right to housing (legal citizenship) is an important consideration neglected by utilitarian measurement (i.e., measuring housing tenure vs. legal entitlement claims). Sen critiques the narrow concern of utilitarianism with observable consequences insofar as non-utility information – often the specifics of political and social processes that encompass lived citizenship – is ignored. For example, the ability of individuals with psychiatric disabilities to participate fully in community life is not an intersubjectively observable consequence.

Finally, Sen highlights the problem of conversion with regard to utilitarianism. Individuals will convert resources into outcomes very differently. Sen cites the example of an individual with a stomach parasite who will convert a given quantity of rice into nutrition very differently than an individual without a stomach parasite (Sen, 1999). In our discussion, individuals with psychiatric disabilities might convert vocational training into stable employment very differently than members of the general population who do not face the same systemic barriers (Kuklys, 2005).

Sen’s critique of deontology is straightforward. He suggests that rights are insensitive to consequence and that non-violation of rights can exist in the context of widespread human suffering. Sen levies the example of famine where historically regions facing hunger have been net exporters of food. In these circumstances, the non-violation of rights was connected to deleterious social outcomes (widespread mortality) (Dreze, Den, & Hussain, 1995). The bottom line for Sen is that rights should be associated with social consequence. In terms of citizenship values, the right to housing does not guarantee meaningful participation and inclusion in the community in which individuals are housed. It has been shown that individuals participating in Housing First routinely face isolation (Yanos, Barrow, & Tsemberis, 2004). It is important to link citizenship rights (entitlements to housing) with consequences (meaningful social connections and roles).

The capabilities approach is a hybrid of both utilitarianism (therapeutic values) and deontology (legal citizenship) that attends to the critiques presented by Sen and outlined above. This framework synthesizes therapeutic and citizenship values such that the operation of rights becomes sensitive to consequence. I have presented a visual representation of the capabilities approach below in Figure 1. The main components of this approach are inputs, characteristics, conversion factors, actual and potential functionings, the capability set, well-being/agency, and participation. These inputs are presented in Table 2.

Inputs refer to consumable commodities (housing, education, food) while characteristics specify properties relevant to wellbeing (shelter, skill development, nutrition). Conversion factors are those factors – often social processes – that specify how inputs and their characteristics are translated into wellbeing. Actual functionings are those things that people actually do after inputs are converted into well-being (being permanently housed, finding employment, being nourished), while potential functionings refer to those things that individuals could do, but choose not to (receive psychiatric treatment, participate in vocational training, participate in addictions treatment). Capabilities – taken together as the capabilities set – are the combination of actual and potential functionings, and they denote the importance of personal values and choice. Put another way, the capabilities set is a multidimensional group of indicators that assess social outcome. Well-being is a result of actual functionings, and also reflects capabilities and freedom of choice. Agency reflects other freedoms not associated with wellbeing. Finally, participation pervades the capabilities approach. Sen does not specify a capabilities set precisely because it is a valuational exercise for individuals and communities to perform themselves and reflects the importance of choice and freedom (Sen, 1999).

Key Components of the Capabilities Approach and Measurement
In the sections above I have suggested that the capabilities approach synthesizes therapeutic and citizenship values. Where the capabilities approach has a “value added” for citizenship and therapeutic values is in terms of measurement. To this end, there are three key components of the capabilities approach that clearly connect therapeutic and citizenship values to measurement. These three key components are conversion, participation, and capabilities.
Sen builds conversion directly into the model of capabilities so as to support his critique that utilitarian measurement ignores conversion. Directing attention to the conversion of resources, like the conversion of education into capabilities such as stable employment, is important in highlighting the social processes that likely impact this conversion (Kuklys, 2005). Conversion speaks to both normative and lived citizenship which document the degree to which individuals participate in the civic organizations of the community and its daily social structures. These dimensions of citizenship are important in understanding how adults with psychiatric disabilities will or will not be able to convert something like education into stable employment. Measurement of conversion is a good fit for qualitative research that tends to better capture context, particularly social processes.

Participation, including choice, is a key facet of the capabilities model presented by Sen. Participation and choice value non-utility information – one of Sen’s substantive critiques of utilitarian measurement. Participation is highly congruent with normative and lived citizenship and highlights the importance of the ability of individuals to participate in the civic and social structures of their communities. Participation is difficult to measure but is nevertheless an important consideration in the research process. For example, Ware, Hopper, Tugenberg, Dickey, and Fisher (2007, 2008) have used the capabilities approach to specify qualitative dimensions of recovery – or capabilities - that are important to people with lived experience. Implied in this analysis is that participation is a key component of recovery. Recently, Salzer, Brusilovskiy, Prvu-Bettger and Kottsieper (2014) published a validated quantitative measure of participation termed the Temple University Community Participation Scale which measures four social domains including domestic life; interpersonal life; major life activities; and community, civic and, social life.

Capabilities are the main unit of measurement in Sen’s capabilities approach. Capabilities highlight both rights and freedoms, and consequence. As such, capabilities respond to both Sen’s critique of utilitarianism (that utilitarian measurement ignores rights and freedoms) and deontology (that deontology ignores consequence). In terms of values, capabilities encompass both therapeutic values – choice and control, quality, and community integration – and legal citizenship. Capabilities ultimately translate into a robust basket of measurement indicators that reflect therapeutic outcomes (choice and citizenship outcomes) and legal citizenship (access to housing). In practice, capabilities encompass both the normative and lived frameworks of citizenship. For example, the outcome measurements of the At Home/Chez Soi project might be considered a basket of indicators that are in line with a capabilities set in which we can observe the three oreintations of citizenship and therapeutic values. While the outcome measurements of At Home/Chez Soi might form a capabilities set it, should be noted that both robust participation in the selection of capabilities by participants and attention to conversion are not clearly built into the At Home research approach.

Transformational Mental Health Systems and the Capabilities Approach
In this paper, I have presented Amartya Sen’s capabilities approach as a hopeful approach for transformative mental health in terms of outcome measurement. I have shown how the capabilities approach incorporates Sylvestre’s (unpublished manuscript) citizenship framework and argued that the capabilities approach is congruent with outcome measures in Housing First through the At Home/ Chez Soi project. Transformation in mental health systems requires change in action, research and policy. The capabilities approach offers a powerful tool set to researchers seeking to measure outcomes relevant to individuals with psychiatric disabilities and in line with the goals of transformative mental health. In particular, the capabilities approach highlights both social and political context, as well as citizenship values. The inclusion of the participation of people with lived experience in identifying capabilities opens up meaningful dialogue regarding which outcomes hold value in their lives. The focus on conversion in the capabilities approach operationalizes normative and lived citizenship values and provides researchers with a valuable tool in illustrating the importance of social and political context in outcome measurement. Finally, capability measurement presents a robust set of indicators that encompass participation, choice and agency. 

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Author(s)

Timothy MacLeod

Timothy MacLeod, MA, is a PhD student at Wilfrid Laurier University, Waterloo, Ontario, Canada.  Email: timothymacleod@gmail.com

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