The Capability Approach An Introduction Capability Seminar Center to Study Recovery in Social Contex

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The Capability Approach An IntroductionCapabil
ity Seminar Center to Study Recovery in Social
ContextsNovember 28th, 2007
Kim Hopper Kris Jones Sophie Mitra Mary Jane
Alexander
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Rethinking Public Mental HealthA Fresh Paradigm
for the Recovery Project Why?
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Public Mental Health Vision Statements

• 1961 . . . progress in helping and healing
  mentally ill persons . . . has been and remains
  arduous, slow, and uneven
• Recommend radical reconstruction of the
  present system . . .
• 2003 . . . our mental health service
  delivery system is in shambles
• Recommend fundamental transformation of the
  nation's approach to mental health careThis
  transformation must ensure that mental health
  services and supports actively facilitate
  recovery, and build resilience to face life's
  challenges.
• 2005 Mission maximizing access to appropriate
  and effective mental health services.
• 2007 NYS citizens with psychiatric disability
  live on roughly a par with the 123rd ranked
  nation. The US overall ranks 8th

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Mental and Substance Use Conditions

• Limit peoples access to
• Health and Life
• Personal Security in public, institutional and
  personal spaces
• Stable and sustainable housing
• Participation in civic life, valued relationships
  and roles

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Health Life People with Severe Mental Illness
are at Higher Risk for Serious Medical Conditions
than Other Medicaid Enrollees
In a multi-state study, people with SMI who
lived in the community died 25-32 years before
their age-matched peers
Colton CW, Manderscheid RW (2006). Preventing
Chronic Disease 3(2) A42
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Health and Life Mental Illness and Substance Use
account for the most years of life lost due to
premature mortality and disability for women,
and were 2nd only to heart disease for men.
Mental Illness Substance Use account for 20 of
total Difor 15, Alcohol Use for 4, and Drug Use
for 1 of total Disability Adjusted Life Years
(DALYs) in developed economies like the United
States
Total DALYs Accounted for by Each Illness
Category
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Social and participatory freedom Severe Mental
Illness affects key life domains - home, school,
work and the ability to initiate and maintain
close relationships and a broader social life.
About half of adults with Major Depression
experience severe or very severe impairment at
home, in close relationships and in their social
lives. Adolescents experience similar
limitations.
Role Impairment among adults adolescents with
a Major Depressive episode in the prior year

• Source NSDUH 2004 RWJ

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Personal Security in public spaces Roughly one
quarter of people with Severe Mental Illness are
Crime Victims compared to 2 of the general
population.
The risk for being the victim of a violent crime
is 12x greater for people with SMI compared to
other urban poor people. Among those with SMI,
women are at much higher risk (16x) than men
(8.5x).
Source Teplin et al., 2005
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Personal Security in private and institutional
spaces People with Severe Mental Illness are more
likely to experience all types of Trauma than the
General Population, and subsequently to develop
PTSD. Physical and sexual abuse are particularly
common among people with SMI, and they are
re-traumatized in institutions.
Sources Kessler, 1995 Mueser et al., 1998
Gearon, 2003
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Personal security and Participation
IncarcerationPeople with Severe Mental Illness
are incarcerated at high rates, disrupting their
ability to maintain stable housing, personal
relationships and employment.

• 50-60 of Jail and Prison Inmates Have Any Mental
  Illness, and 11 Have Severe Mental Illness.
• 51 of state inmates with mental health problems
  were convicted of nonviolent offences, primarily
  drug and property offenses.
• 34 of state inmates and 24 of federal inmates
  receive treatment after admission to prison.
• State inmates with mental illness are more likely
  to be with rule violations especially verbal
  assault than those without (53 v 43). They are
  2x as likely to be injured in a fight. Individual
  states data show a significantly
  disproportionate presence of these inmates in
  segregation, the harshest form of confinement.

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Participation Housing instability People with
Severe Mental Illness are at high risk for
becoming and remaining homeless and
disaffiliated, severely limiting their access to
participation in civil life and in personal
relationships

• 18-22 of those in shelters have severe mental
  illness.
• People with SMI are 4x as likely to be admitted
  to a shelter as the general population.
• Substance abuse heightens the risk for becoming
  homeless in general, BUT among shelter users who
  abuse substances, those with a severe mental
  illness stay homeless longer.

Sources Lehman and Cordray, 1993 Culhane 1997
1998 1999 Draine, Salzer, Culhane, 2002 Caton,
et al., 1994
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Parenting A Center project aims to understand
the Interplay of Capacity, Resources, Policy and
Competing Social Goods on the Freedom to Parent

• Women with mental illness are at least as likely
  to give birth to children as other US women.
• Homelessness is a major predictor of mother-child
  separations, with extended family often providing
  care for the children of these invisible
  mothers.
• How do the housing options open to these mothers
  affect family separations?
• How does their determination to parent affect
• the definition of their well being (avoiding
  stress, prioritizing treatment over parenting,
  treatment in residential programs for single
  adults)?
• other, competing social goods (reducing shelter
  populations, rapid permanent placement for
  children, risk management, interests of the
  extended family in the children)?

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A Capabilities Approach to Public Mental Health
will include

• Social justice
• how resources are distributed and rules
  formulated to ensure effective respectful
  treatment, and rightful return to lives worth
  living
• Participation
• Key translational principle (empowerment in
  action)
• Cultivation of citizens
• Ultimate goal of coordinated treatment and support

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The Capability Approach What is it?

• A broad normative (value-informed) framework for
  the evaluation of individual well-being and
  social arrangements.
• A hybrid framework, used in a variety of fields
  development, welfare economics, social policy and
  political philosophy.

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The Capability Approach Where does it come from?

• Economics
• Welfare economics
• Development economics

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What is the focus of economics?

• The allocation of scarce resources among
  alternative uses to satisfy human wants.

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Key issues in economics

• Scarcity the pervasive economic problem
• What to produce?
• How to produce?
• For whom to produce?

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• . Two branches of economics
• Microeconomics
• Macroeconomics
• . Two types of economic studies
• Positive studies
• Normative studies

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The capability approach developed as a critique
of traditional

• Welfare economics
• Development economics

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• Development as Freedom

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Core concepts (1)

• Functioning as activity, achievement.

For instance Parenting Contact with children
Custody Functional literacy, library/internet
access Civic life registered to vote, religious
affiliation Working options paid and
volunteer Independent housing Social life
friends activities outside of mental health
staff and programs Engagement with self-help
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Core concepts (2)

• Capability as practical opportunity, ability
  to achieve.
• Achievements vs. Freedoms.

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Example

• A woman is starving.
• What might be the reasons for her to be starving?
  
• Analyze this situation in the context of
  functioning(s) and capabilities.

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Capabilities Approach
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Other concepts

• Standard of living Measure of personal
  well-being
• Well-being Personal well-being and well-being
  experienced due to concern over personal
  well-being of others
• Agency Well being and ability to act for goals
  that matter

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Public Policy and Action

• Public policy and action play important roles
• In supporting capabilities directly (e.g. through
  specific service provision)
• In providing an environment where capabilities
  can flourish (e.g. political freedom, economic
  growth).

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Apply the U.N. Human Development Index to Public
Mental Health
For NYS SMI UNHDI .603 or, roughly, Morocco
Sources Colton and Manderscheid 2006 Sentell
and Shumway 2003 NYS OTDA www.otda.state.ny.us/di
rectives/2006/INF/06-INF-3320Attachment.pdf
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Mental Illness as Capabilities Deprivation

• In the international development model, poverty
  deprives individuals of the freedom to
  participate fully in the life of a country. But
  income is not the solution.
• In the public mental health model, mental illness
  deprives individuals of the freedom to
  participate fully. But symptom control is not the
  solution.

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Making it real practical examples of
participation in mental health practice . . .

• Therapeutic partnerships
• Citizenship and social integration
• Personal projects/life commitments

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Therapeutic partnerships rethinking who decides

• Installing participation as the working premise
  of decision-making in treatment (research)
  settings.
• Shared decision-making in medication management
• Psychiatric advance directives

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Citizenship and social integration ensuring the
basic securities needed to exercise citizenship

• Functional literacy, access to libraries and
  Internet
• Opportunities and support for parenting
• Opportunities for socialization
• Access to labor market
• Statutory protections (e.g. ADA)
• Confronting stigma

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Individual life commitments

• Importance of getting far enough along to stake
  out singular projects of individualized lives
• Not illness career but life course
• Impetus comes largely from consumer/survivor
  /ex-patient movement
• How managing an illness fits into a life, rather
  than the other way around