by Richard Brunner
In the late 1990s, I did the hardest job I hope I will ever do: advocating for the rights of patients in a psychiatric hospital in one of London’s most disadvantaged boroughs.
What made it so tough? Whilst patients were usually pleased to have someone on their side, the hierarchies of clinical power made it hard for patients to get what they wanted. These were usually modest requests – perhaps escorted time outside the hospital grounds or changes to medication. But what made it even more challenging was what happened once people were discharged from hospital. They would generally return to the same difficult circumstances that had led to their admission in the first place; care plans and advocacy made little difference. And so I would see the same people admitted over and over again. Without knowing it, I was learning about the social and environmental determinants of health.
What was missing from this painful experience was an important element of evaluation. The things that made a real difference to quality of life for the professionals that adjudicated over the lives of patients – such as having relatively secure and satisfying work, a decent income and informed choices – were not incorporated into the outcomes proposed for patients. These double standards resulted in discharged patients returning to poverty and insecurity, and subsequently to readmission.
Fifteen years on and now working in the social sciences, I learned about Amartya Sen and Martha Nussbaum’s capabilities approach. The capabilities approach judges human outcomes using a set of principles. It argues that whilst the resources we hold and the subjective wellbeing that we feel matter when judging quality of life, they are only a part of the evaluation. Rather, we should evaluate human outcomes by comparing how people actually live. Using the capabilities approach compels us to judge everyone – patients and professionals alike – on the same metric: no more double standards. Another principle, and especially important given the poor outcomes commonly experienced by people that have been in psychiatric hospital, is that nation states have a duty to uphold a minimum level of decent outcomes for all. Finally, the capabilities approach says that being able to choose what we do in life is of fundamental importance to human wellbeing.
In my study, Why do people with mental distress have poor social outcomes? Four lessons from the capabilities approach, I applied the capabilities approach to ask people with experience of being in psychiatric hospital what they had been able to do after that experience, and what they wanted to do. My interviews reinforced the problem that I had witnessed years earlier: people with experience of being in psychiatric hospital were still being judged on different metrics from those with the power to judge, and were still returning to precarious lives.
The people I interviewed experienced the mental health system and other professionals as not supporting them sufficiently to make ordinary choices, such as to have children or to change types of employment. People also experienced persistent financial insecurity due to low incomes and due to changes to disability benefits and the impact of the ‘Bedroom Tax’. I saw that fifteen years on, people were still being pushed back into the same circumstances that had led to hospitalisation, in which it was hard to say that the state had upheld decent outcomes.
How can we turn this around? The capabilities approach can free up our thinking. First, it compels us to compare lives as they are actually lived and to evaluate those lives in relation to achieving equitable outcomes for all. This is a revolution in itself, challenging the menace of double standards. Second, the capabilities approach compels systems to not only consider how to provide the support necessary to enable all people to achieve a decent quality of life, but also how to facilitate a degree of freedom in those choices. Third, it puts pressure on states, and professionals acting on behalf of those states, to consider and evaluate how they are upholding minimum standards for all citizens – especially those most vulnerable.
Whilst the application of these principles would benefit those with experience of psychiatric hospital, the capabilities approach would also assist other groups who we also know experience inequitable lives – prisoners, young people leaving care, homeless people, and many more. The capabilities approach can be used across the social sciences to support analysis of equitable outcomes for all. It can also help us to reflect on ourselves: do social scientists judge others as we would like to be judged, or do we hold double standards too?
His PhD in Sociology, completed in 2015, studied people’s experiences after being in psychiatric hospital. Prior to this he worked as Research Fellow at University of Strathclyde in the School of Education, conducting qualitative research into a variety of equality and social justice topics.
His previous career included support work with homeless people, mental health advocacy, community development work, and policy work in the statutory and third sectors with a focus on equality and diversity, disability and mental health.