Volume 49 Number 3 
Summer 2016

Transformative Change in Community Mental Health Interest Group

Edited by Geoffrey Nelson

Achieving Recovery through Housing and Employment: Moving Towards a Capabilities-Informed Community Mental Health System

Written by Eric Macnaughton, Wilfrid Laurier University

There’s been a lot of interest within the past several years in applying Amartya Sen’s (1999) capabilities framework to community mental health, because of its parallels and potential synergies with the recovery movement (Davidson, Ridgway, Wieland, & O’Connell, 2009; Hopper, 2007; Macleod, 2014). This article traces the development of that interest, looks at an arguably “capabilities-informed” approach to housing and support (Housing First), and then proposes that a next step forward to creating a capabilities-informed system would be to support the employment prospects of people with serious mental illness, including those who have been homeless.

The Capabilities Approach to International Development
Sen (1999) describes the capabilities approach in relation to its value in promoting the welfare of citizens in developing countries. Rather than measuring well-being materially, Sen emphasizes how a capabilities-informed approach sees material resources (e.g., income, healthcare, education) in terms of their potential conversion into socially valued “being and doings”, known within his framework as “functionings.” Thus, resources become meaningful to the extent that they support people to live meaningful lives. Equally important, Sen argues, is to address the barriers that stop people from translating those resources into actual capabilities, things like stigma, discrimination, or exclusion from the process of determining how resources are allocated.

The capabilities approach then is as much about the meaning of resources for improving lives as it is about the resources themselves; and it is as much about the process of translating opportunity into outcome as it is about the outcomes in and of themselves.

The Capabilities Approach to Community Mental Health and Recovery
Writing in the context of community mental health, Hopper and others note the similarity of the concept with the notion of recovery (Davidson et al., 2009; Hopper, 2007), and articulate the implications that the capabilities approach holds for operationalizing recovery. As an individual level process, recovery has been described by Davidson and Strauss (1992) as a process of reclaiming an active self beyond the constraints of illness. As an outcome, recovery means having a “a friend, a home, a job and a life,” as survivors of the mental health system so often remind us.

Expressing recovery in the language of capabilities, Hopper (2007) argues that an essential question is whether the resources provided by the mental health system (including the interventions offered by practitioners) are understood by people with mental illness as enabling the valued “beings and doings” that Sen talks about. In plain language, the implication is that people with mental illness will engage with and benefit from interventions that they understand to help them move towards the kinds of lives they wish to live. Most fundamentally, then, recovery is about agency and choice: about providing support in a way that enables people with mental illness to choose what those resources look like, so they have the opportunity to live the kind of lives any of us would wish to live.

Capabilities and Housing First
Sam Tsemberis describe the origins of the Housing First model in the context of his previous work as a hospital psychologist, developing a program for hard to engage street-involved people with mental illness. When asked what they wanted, the majority of them wanted “housing first” (Tsemberis, Gulcur, & Nakae, 2004). Interviews with Housing First participants conducted in the Canadian multi-site At Home/Chez Soi study affirm this, and help explain this desire, documenting how, for participants, housing represented a chance to “get my life back”. This often meant reclaiming significant relationships, or valued roles as parent, worker or artist (Polvere, Macnaughton, & Piat, 2013).

As Padgett (2007) suggests, by leading with housing we foreground “ontological security” and provide the safe space for people to reclaim selves. In contrast, by foregrounding treatment (i.e. the “treatment first” approach), we contribute to stigma and loss of self (Padgett, 2007). In Sen’s terms, Housing First works as an intervention because it is understood by participants as helping them live the kinds of lives to which they aspired.

Capabilities: A Wider View
As Sen suggests, however, even when offering valued resources, there are still significant barriers hindering people from translating these into meaningful changes in their lives. As At Home/Chez Soi and other research (Yanos, Barrow, & Tsemberis, 2004) shows people coming off the street and out of survival model get to the point where they wonder “what’s next?” One particular gap is in the area of employment, a domain where evidence-based interventions exist but are not widely implemented. In the homelessness context, providing supported employment can help participants move beyond the “what’s next?” question, and translate the resources such as housing and support into more meaningful lives in the wider community. In the broader context of the wider mental health system, Dunn, Wewiorski, and Rogers (2008) document in the words of consumers, the significance of employment to the recovery process. Despite this significance, evidence-based supported employment is rarely implemented, with one study suggesting that less than 5% of people with serious mental illness have access (Drake, Bond, & Essock, 2009).

Conclusion: Moving Towards a Capabilities-Based Mental Health System
The question arises, then, of how to move in this direction whereby our systems and interventions promote recovery in the wider sense? That is, how would we move closer to the vision Hopper articulates, guided by the capabilities framework as suggested by Sen. In too many communities, the “what’s next?” gap exists for people with serious mental illness. At the same time, we have an evidence-based intervention (IPS Supported Employment) that works, but which has not been widely implemented. As community psychologists in community mental health who value recovery, and who have a font of evidence to draw upon, let’s think more about what we can do to help.

Davidson, L., Ridgway, P., Wieland, M., & O’Connell, M. (2009). A capabilities approach to mental health transformation: a conceptual framework for the recovery era. Canadian Journal of Community Mental Health, 28(2), 35-46. doi: 10.7870/cjcmh-2009-0021

Drake, R., Bond, G., & Essock, S. (2009). Implementing evidence-based practices for people with schizophrenia. Schizophrenia Bulletin, 35(4), 704-713. doi:10.1093/schbul/sbp041

Dunn, E., Wewiorski, N., & Rogers, E. (2008). The meaning and importance of employment to people in recovery from serious mental illness: results of a qualitative study. Psychiatric Rehabilitation Journal, 32(1), 59-62. doi: 10.2975/32.1.2008.59.62

Hopper, Ki. (2007). Rethinking social recovery in schizophrenia: What a capabilities approach might offer. Social Science & Medicine, 65(5), 868-879. doi:10.1016/j.socscimed.2007.04.012

Macleod, T. (2014). The capabilities approach, transformative measurement, and housing first. Global Journal of Community Psychology Practice, 5(1), 1-10.

Padgett, D. (2007). There’s no place like (a) home: ontological security among persons with serious mental illness in the United States. Social Science & Medicine, 64(9), 1925-1936. doi:10.1016/j.socscimed.2007.02.011

Polvere, L., Macnaughton, E., & Piat, M. (2013). Participant perspectives on housing first and recovery: early findings from the At Home/Chez Soi project. Psychiatric Rehabilitation Journal, 36(2), 110-112. doi:10.1037/h0094979

Sen, A. (1999). Development as freedom. Oxford: Oxford University Press.

Tsemberis, S., Gulcur, L., & Nakae, M. (2004). Housing first, consumer choice, and harm reduction for homeless individuals with a dual diagnosis. American Journal of Public Health, 94(4), 651-656.

Yanos, P., Barrow, S., & Tsemberis, S. (2004). Community integration in the early phase of housing
among homeless persons diagnosed with severe mental illness: Successes and challenges. Community Mental Health Journal, 40(2), 133-150.