ETHICS OF CARE

Critical advances in
international perspective

Edited by Marian Barnes, Tula Brannelly,

Lizzie Ward and Nicki Ward
 Ethics of care
healthcare w o r k e r s an i m p o r t a n t social resource, o r j u s t ' w o r k e r s ' o n
an i n t e r n a t i o n a l j o b m a r k e t , part o f the global m o v e m e n t o f labour?
Conclusion
T h e ethics-of-care approach t o u n d e r s t a n d i n g the moralities i n v o l v e d
i n medical m i g r a t i o n highlights the vulnerabilities o f doctors before and
after the decision t o emigrate. T h i s may offer a better c o m p r e h e n s i o n
o f m i g r a t i o n mechanisms, b e y o n d the ' p u s h / p u l l ' m o d e l . M i g r a t i o n
f r o m the o r i g i n c o u n t r y is a f o r m o f protest against the s o c i o e c o n o m i c
policies i n place, and also a manifestation o f mistrust regarding the local
p o l i t i c a l capacity t o change things i n a foreseeable f u t u r e . B u t g o i n g t o
a n o t h e r c o u n t r y does n o t a u t o m a t i c a l l y p r o v i d e a n e w citizenship or
make the m i g r a n t part o f the n e w society. N e w social rules, n e w c i v i l
rights and obligations need t o be learned, accepted a n d internalised.
So the m i g r a n t doctors are t w i c e d e p r i v e d o f t h e i r citizenship, o f their
s o c i o - p o l i t i c a l w e b , and that fact feeds existential vulnerabilities such
as insecurity, fear, i s o l a t i o n , alienation a n d marginalisation.
T h e key p o i n t i n this chapter is that doctors are a social resource
that needs t o be cared about and cared for ( T r o n t o , 2013) a n d the care
d e f i c i t o f a society s h o u l d n o t be stated i n p u r e l y e c o n o m i c terms and
covered w i t h an i m p o r t e d ' w o r k f o r c e ' . T h e specificities o f medical
practice and its c u l t u r a l e m b e d d i n g need t o be considered f r o m the
perspective n o t o n l y o f m e d i c a l m i g r a t i o n policies b u t also o f the
general E U design o f m e d i c a l e d u c a t i o n .
SEVENTEEN
Mental health service use and the
ethics of care: in pursuit of justice
Tula Brannelly
The issues of care and justice in mental health
M a n y chapters o f this b o o k have attended t o the p o t e n t i a l renewal
offered b y the ethics o f care i n various realms o f everyday life. H e r e
I use the ethics o f care to address care i n m e n t a l health services b y
d r a w i n g o n data f r o m a small qualitative research project. Justice and
care are i n t e r t w i n e d i n the ethics o f care, w h e r e a c h i e v i n g social
j u s t i c e requires r e l a t i o n a l care (Barnes and Brannelly, 2 0 0 8 ) . T w o
key aspects o f the ethics o f care make the analysis o f justice and care
possible. First, j u s t i c e requires that practices are seen so that they may
be j u d g e d ( T r o n t o , 2 0 1 3 ) . As practices associated w i t h d e t e n t i o n and
c o m p u l s i o n are ' h i d d e n ' , i n that they are largely u n k n o w n t o people
n o t c o n n e c t e d t o t h e m , to be able t o j u d g e t h e m requires that these
practices are surfaced. Second, Tronto's (1993 and 2013) phases o f care
p r o v i d e an analytical t o o l for the analysis o f research data, and also,
i m p o r t a n t l y , a p o s i t i o n f r o m w h i c h to r e n e w care. First i t is necessary
t o take a b r i e f o v e r v i e w o f the t e r r i t o r y i n w h i c h care is a t t e m p t e d i n
the c o n t e x t o f m e n t a l health. M y focus here is o n p o l i c y and practice
i n the U K and N e w Zealand, w h i c h have similar m e n t a l health policy,
legislation a n d services.
E v e r y society has responses t o care for people i n need. B u t i n the
case o f people w i t h m e n t a l health problems particular responses are
i n v o k e d that differentiate t h e m as a g r o u p f r o m others considered
'needy'. D e e p l y e n t r e n c h e d n o r m a t i v e values operate t o marginalise
people w h o experience l o n g - t e r m m e n t a l illness. Societies that value
productive, c o n s u m i n g citizens often reinforce the 'otherness' associated
w i t h m e n t a l illness. People w i t h m e n t a l illness are marginalised and
e x c l u d e d o n m a n y levels. A c k n o w l e d g i n g i n e q u a l i t y for a particular
group o f people surfaces issues related to i t , stated b y T r o n t o (2013, p 91
q u o t i n g f r o m H i r s c h m a n n , 2 0 0 2 , p 231):
 Ethics of care
For instance, i f a society repeatedly, systematically constrains
w o m e n m o r e t h a n m e n , blacks m o r e t h a n w h i t e s , lesbians
m o r e t h a n h e t e r o s e x u a l s , t h e n t h e r e is a t h e o r e t i c a l
p r e s u m p t i o n i n f a v o u r o f the c o n c l u s i o n that the society
— o r the rules, n o r m s , i n s t i t u t i o n s , practices, and values i n
q u e s t i o n i n a particular c o n t e x t w h e r e f r e e d o m is at issue
— presents a b a r r i e r t o the m o r e constrained g r o u p .
T r o n t o (2013) h i g h l i g h t s the n e e d t o pay a t t e n t i o n t o the experiences
o f particular groups i n terms o f i n e q u a l i t y and care, and reminds us that
rights, i n the t r a d i t i o n o f T . H . M a r s h a l l (1950), were never i n t e n d e d
to m e e t the needs o f people w h o are vulnerable.
People w h o use m e n t a l health services may do so v o l u n t a r i l y o r be
c o m p e l l e d t o d o so t h r o u g h legislation. C o m p u l s i o n is used w h e n
i n d i v i d u a l s are considered to m e e t c l i n i c a l c r i t e r i a f o r risk o r danger as
a result o f m e n t a l illness and d o n o t c o n c u r w i t h the n e e d f o r service
i n t e r v e n t i o n . T h e c r i t e r i a f o r t h e use o f the M e n t a l H e a l t h A c t , and
subsequent c o m p u l s i o n , are a diagnosable m e n t a l illness and risk o f
h a r m o r self-neglect, o r a risk o f h a r m towards others as assessed by
m e n t a l health clinicians (psychiatrists, nurses and social workers) w h o
are g i v e n powers u n d e r legislation. T h e n o t i o n s o f risk and m e n t a l
illness are contestable.
W h e r e a person is assessed t o f u l f i l the c r i t e r i a o f the A c t , h u m a n
rights m a y be o v e r r i d d e n , j u s t i f i e d b y the need f o r p r o t e c t i o n o f the
p e r s o n o r others. P r o t e c t i o n i n c l u d e s d e t e n t i o n a n d c o m p u l s o r y
t r e a t m e n t such as m e d i c a t i o n s , a n d also the use o f seclusion
r e s t r a i n t . W h e n a p e r s o n is d e t a i n e d , c o m p u l s i o n , restraint a n d
seclusion m a y be used, h u m a n r i g h t s are contravened ( D r e w et al,
2011) and treatment can be g i v e n w i t h o u t consent. C o m p u l s i o n can
e x t e n d f r o m the i n - p a t i e n t setting i n t o the c o m m u n i t y t h r o u g h the
use o f c o m m u n i t y treatment orders. I f h u m a n rights that constitute
the t a k e n - f o r - g r a n t e d a s c r i p t i o n o f citizenship are r e m o v e d , t h e n the
a t t r i b u t i o n o f citizenship per se is, i n practice, c o n d i t i o n a l o n m e n t a l
state as d e f i n e d b y c l i n i c a l services. I n d i v i d u a l 'rights t o ' are eclipsed
b y i n s t i t u t i o n a l ' c o n t r o l o f and ' c o n t r o l o f is o f t e n e x p e r i e n c e d
oppression ( O w e n and F l o y d , 2 0 1 0 ) .
T h e r e m a y be m a n y o p p o r t u n i t i e s f o r practices t h a t l i m i t
disempowerment experienced b y users o f m e n t a l h e a l t h services,
such as m a i n t a i n i n g levels o f c h o i c e and c o n t r o l and o f f e r i n g services
that m e e t people's preferences. Examples m a y i n c l u d e the avoidance
o f restraint, especially f o r people w h o have been subject t o previous
physical o r e m o t i o n a l abuse, and that particular treatments, such as
Mental health service use and the ethics of care
electroconvulsive therapy, are o n l y ever g i v e n w i t h consent. Practices
are o p p o r t u n i t i e s f o r e x a m i n a t i o n o f the use o f p o w e r , care, c o n t r o l and
citizenship. I have argued elsewhere that c o n s i d e r a t i o n o f a p e r m a n e n t
o r t e m p o r a r y loss o f a u t o n o m y , w h i l e r e t a i n i n g c o m m i t m e n t t o the
values o f citizenship a n d p a r t i c i p a t i o n i n care, requires a practice
g r o u n d e d i n care ethics (see Brannelly, 2 0 0 6 , 2010, 2011).
M a n y problems have been n o t e d regarding the i m p l e m e n t a t i o n o f
mental health legislation. First, the spirit o f the legislation was i n t e n d e d
to provide p r o t e c t i o n t o people i n situations o f crisis. H o w e v e r , i n
practice the use o f c o m p u l s i o n has extended i n t o l o n g - t e r m restrictions
i n far-reaching aspects o f people's lives (Rugkasa a n d B u r n s , 2 0 0 9 ) .
Second, the e x p e c t a t i o n is that people w h o are subject t o d e t e n t i o n
and c o m p u l s i o n w i l l be g i v e n p r o p e r treatment to i m p r o v e their m e n t a l
state. However, h i g h levels o f dissatisfaction w i t h services and ineffective
treatments persist. T h i r d , a l t h o u g h legislation also confers rights such
as the r i g h t t o r e v i e w o f d e t e n t i o n , f e w instances o f r e v i e w f i n d i n
favour o f the person c h a l l e n g i n g this. F o u r t h , m e n t a l health service
practices are largely ' h i d d e n ' . T h o s e u n c o n n e c t e d t o t h e m personally
o r professionally are unaware o f w h a t happens t o people subject t o
c o m p u l s i o n , yet the use o f such powers is accepted as a p u b l i c benefit.
I n a context i n w h i c h increasing aspects o f ' a b n o r m a l i t y ' are recorded
as criteria f o r m e n t a l illnesses, large p r o p o r t i o n s o f the p o p u l a t i o n meet
criteria f o r diagnosis. A recent c o m m u n i t y survey o f m e n t a l health
i n Aotearoa N e w Z e a l a n d ( A N Z ) ( O a k l e y B r o w n e , Wells and Scott,
2006) i d e n t i f i e d that 2 0 % o f the p o p u l a t i o n m e e t diagnostic c r i t e r i a
and f o r a m e n t a l illness at any one t i m e . I n this c o u n t r y w i t h a p o p u l a t i o n
o f approximately 4.5 m i l l i o n , i n 2012, 4,328 people were detained
u n d e r the M e n t a l H e a l t h A c t o n i n - p a t i e n t orders o r o n c o m m u n i t y
treatment orders and 882 people were secluded w h i l e i n care ( M i n i s t r y
o f H e a l t h , 2013, p 14). A c c o r d i n g to the H e a l t h a n d Social Care
I n f o r m a t i o n C e n t r e , i n 2013 i n E n g l a n d 2 2 , 0 0 0 people were detained
and treated u n d e r the M e n t a l H e a l t h A c t o r o n a supervised c o m m u n i t y
treatment order. I n W e s t e r n countries, about 3 % o f the p o p u l a t i o n
are diagnosed w i t h a m e n t a l illness described as 'severe and e n d u r i n g '
as o r 'serious' w i t h significant impacts o n social i n c l u s i o n and physical
health. A m o n g those w i t h a diagnosis, levels o f u n e m p l o y m e n t are as
h i g h as 80%, w i t h p o v e r t y and p o o r h o u s i n g c o m m o n . A shortened
the
life span is attributable t o psychiatric medications and p o o r physical
healthcare ( C r a i g , 2 0 0 8 ) . C o m p u l s o r y assessment and treatment is
m o r e o f t e n used w i t h already marginalised p o p u l a t i o n s such as I r i s h
and Black people i n E n g l a n d , M a o r i and Pacific peoples i n A N Z .
M a o r i constitute 1 4 % o f the p o p u l a t i o n o f A N Z , b u t 3 2 % o f seclusion
 Ethics of care
events i n v o l v e d M a o r i patients ( M i n i s t r y o f H e a l t h , 2 0 1 3 ) . Such data
questions evidence o f a collective c o m m i t m e n t t o ensure justice and
w e l l - b e i n g f o r all citizens.
Spheres o f ' h i d d e n ' w o r k r e q u i r e s c r u t i n y t o i n f o r m collective
responsibility. I n d e p e n d e n t scrutineers such as the M e n t a l H e a l t h
A c t C o m m i s s i o n i n the U K a n d O P C A T , part o f the H u m a n R i g h t s
C o m m i s s i o n , have at d i f f e r e n t times h a d a c r u c i a l role t o i n f o r m
g o v e r n i n g bodies o f h u m a n r i g h t s abuses and concerns. B u t such
s c r u t i n y is o n l y part o f w h a t is necessary f o r justice. A l s o i t is necessary
to k n o w the c o n d i t i o n s and c o n t e x t f o r the loss o f rights o f some
citizens, as this enables analysis o f w h a t can be considered p r o t e c t i o n
and care ( T r o n t o , 1993). S c r u t i n y is r e q u i r e d so that society can j u d g e
the m o r a l i t y o f these actions ( T r o n t o , 2 0 1 3 ) .
N a r r o w procedural conceptions o f justice f o c u s i n g o n the process o f
i m p l e m e n t a t i o n o f the A c t , and an individual's r i g h t t o redress t h r o u g h
reviews that consider w h e t h e r the c r i t e r i a f o r d e t e n t i o n and treatment
have been m e t , are inadequate t o a c h i e v i n g socially j u s t responses to
people e x p e r i e n c i n g severe m e n t a l health problems. Such a n a r r o w
reading o fjustice is unable t o consider w i d e r i m p l i c a t i o n s o f i n e q u a l i t y
and m a r g i n a l i s a t i o n d e r i v i n g f r o m stigmatisation and d i s c r i m i n a t i o n .
R e c o g n i t i o n o f systematic marginalisation calls f o r e x a m i n a t i o n o f the
treatment o f people w i t h m e n t a l illness f r o m a social justice perspective
that also recognises the i m p o r t a n c e o f care.
Emphasis o n interdependencies i n the ethics o f care calls f o r a
universal acceptance o f v u l n e r a b i l i t y and challenges the marginalisation
associated w i t h dependence a n d need. T h i s m a y help t o decrease
the 'otherness' associated w i t h stigmatised and discriminated-against
groups. I n e q u a l i t y i n the ethics o f care examines the p o s i t i o n i n g and
treatment o f certain groups i n society and the p a r t i c u l a r contexts i n
w h i c h certain groups are constrained ( T r o n t o , 2013, p 91). T r o n t o
(2013, p 33) suggests that u n q u e s t i o n e d protections remove p o l i t i c a l
questions f r o m p u b l i c consideration. T h e c o n d i t i o n s and contexts o f
p r o t e c t i o n are w o r t h y o f e x a m i n a t i o n i n terms o f care:
I f p r o t e c t i o n is a f o r m o f care, t h e n a set o f questions about
p r o t e c t i o n arise f r o m the standpoint o f a democratic c a r i n g
society. I f care concerns needs, w h o determines the needs
f o r protection? A n d p r o t e c t i o n is ' p r o t e c t i o n f r o m w h o m ' ?
I r i s M a r i o n Y o u n g (2003) a r g u e d that there is a great
danger i f citizens s i m p l y accept the story about t h e i r n e e d
f o r p r o t e c t i o n and d o n o t q u e s t i o n i t . ( T r o n t o , 2013, p 75)
Mental health service use and the ethics of care
T h i s q u o t a t i o n relates t o the protections r e q u i r e d f r o m the threat
f r o m t e r r o r i s m , b u t the same questions can be asked i n this c o n t e x t
o f m e n t a l health services. P r o t e c t i o n is o f t e n discussed i n relation t o
a ' p u b l i c ' threat f r o m a person ' o u t o f c o n t r o l ' o r the need to protect
a person f r o m themselves.
Barnes (2012a, p 7) h e l p f u l l y c r i t i q u e d h o w p o l i c y and practice has
c o m e t o constitute independence as 'choice and c o n t r o l ' o r dependence
as 'care and p r o t e c t i o n ' . T h i s dyadic n o t i o n o f care renders the care
receiver as either able t o choose and h a v i n g c o n t r o l , o r unable to choose
and r e q u i r i n g p r o t e c t i o n . B u t o f course, people m a y b o t h be i n need
o f care and p r o t e c t i o n a n d w a n t choice and c o n t r o l .
U n s e e n o r h i d d e n practices cannot be j u d g e d . Public e x a m i n a t i o n o f
practices regarding the use o f m e n t a l health legislation s h o u l d consider
w h e t h e r these can be u n d e r s t o o d as e m b o d y i n g care, an attempt at
care o r a lack o f care. A p p l y i n g the ethics-of-care phases as an analysis
to data that examines the concerns o f people w h o have experience o f
service use w i l l help t o answer these questions.
A small qualitative research project was u n d e r t a k e n i n E n g l a n d and
A N Z about 'acts o f citizenship' (Isin, 2 0 0 8 ) . T h i s research is part o f m y
broader c o n c e r n f o r citizenship and care that considers the experiences
o f people w i t h m e n t a l health problems i n r e l a t i o n t o citizenship as a
practice (Lewis, 1998) and status (Lister, 2 0 0 3 ; L a n o i x , 2 0 0 7 ; H a r t ,
2 0 0 9 ) , and t o u n d e r s t a n d w h a t responses i m p e d e o r sustain citizenship
(Busfield, 2 0 1 0 ) . T h e 'acts o f citizenship' research project was d r i v e n
b y a c u r i o s i t y t o k n o w w h a t people w h o have used services w o u l d
consider the m a i n issues that require change i n m e n t a l health service
p r o v i s i o n . T h i s c u r i o s i t y evolved as a response t o conversations with
m e n t a l health service users i n research and teaching.
Participants were i n v o l v e d i n the service user/survivor m o v e m e n t ,
described here as 'service user activists', a l t h o u g h some may n o t refer to
themselves as such. I have used the t e r m activist, as all participants were
engaged i n activities t o p r o m o t e change i n m e n t a l health services, f o r
example t h r o u g h governance, b e l o n g i n g t o service user organisations
and/or w o r k i n g as advocates. I n the i n t e r v i e w s , participants w e r e
asked to consider w h a t key areas o f change they t h o u g h t were r e q u i r e d
i n m e n t a l health service p r o v i s i o n . T h e r e w e r e three participants i n
E n g l a n d and six i n A N Z and they were r e c r u i t e d t h r o u g h service
user n e t w o r k s and i n t e r v i e w e d i n 2011 and 2012. T w o o f the n i n e
participants w e r e m e n . O n e p a r t i c i p a n t asked t o respond b y e - m a i l .
Pseudonyms are used f o r the research participants.
Participants d r e w o n t h e i r various roles as f a m i l y m e m b e r s , (ex)
service users, advocates, educators, researchers, campaigners, peer
 Ethics of care
service providers, m e n t a l health commissioners and n e t w o r k leaders.
T h e y w e l c o m e d the o p p o r t u n i t y t o discuss t h e i r concerns rather than
the usual requests f o r c o n s u l t a t i o n t o respond t o g o v e r n m e n t agencies.
W h i l e m e n t a l health p o l i c y prioritises easier access and greater choice
i n m e n t a l health services, participants referred to t h e i r o w n and others'
experiences o f d e t e n t i o n , c o m p u l s i o n and force and p r i o r i t i s e d these
f o r the t r a n s f o r m a t i o n o f services.
Renewing care and justice with the ethics of care
I n this presentation o f analysis, data is presented that uncovers ' h i d d e n '
practices aligned w i t h the five spheres o f care ( T r o n t o , 2013, p p 2 2 - 3 ) ,
w i t h a focus o n solidarity, trust and relational care.
Caring about.
At this first phase of care, someone or some group notices unmet caring needs.
Attentiveness.
People i n distress are o f t e n part o f care n e t w o r k s , a l t h o u g h some may
w e l l be v e r y isolated and e x c l u d e d f r o m t h e i r existing care n e t w o r k s .
Professional help is sought w h e n care w i t h i n usual n e t w o r k s cannot be
sustained. T h i s is sometimes because o n - g o i n g h i g h levels o f distress
can be v e r y d i f f i c u l t t o cope w i t h , and f a m i l y m e m b e r s may themselves
experience distress. W h a t e v e r the situation that care workers are i n v i t e d
i n t o , i t is t h e i r responsibility t o understand w h a t is w o r k i n g and w h a t
is n o t f o r the people w i t h i n the care n e t w o r k .
T h e decision to i n v i t e paid workers i n t o a care n e t w o r k is a significant
step, an i n v i t a t i o n t o j o i n w i t h ' the care that is already o c c u r r i n g .
R e c o g n i t i o n o f the needs o f all i n v o l v e d enables a n e g o t i a t i o n t o take
place. Tensions, conflicts and difference may be present here, and the
n e g o t i a t i o n needs t o be facilitated w i t h this i n m i n d . T h e voice o f the
person w h o requires p r o t e c t i o n needs t o be heard, as this may i n f o r m
the care process about w h e t h e r p r o t e c t i o n is w e l c o m e o r u n w a n t e d .
R e c o g n i t i o n o f the person's preferences, needs and strengths i n this
w a y ensures that abilities and challenges are k n o w n and that the person
is able t o c o n t r i b u t e w h e r e possible. A focus o n 'care and p r o t e c t i o n '
shifts the p o w e r away f r o m the person, and t h e i r diverse strengths,
abilities a n d needs may n o t be f u l l y u n d e r s t o o d .
T h e lead i n t o service use is o f t e n at a t i m e o f crisis w h e n people
are s t r u g g l i n g t o m a i n t a i n themselves i n t h e i r w o r l d . F i o n a discussed
w h a t she f o u n d h e l p f u l i n such a situation and w h a t she advocated f o r
o n b e h a l f o f others:
Mental health service use and the ethics of care
" t h e r e are t w o things that are really h e l p f u l — i t is great t o
have h o m e treatment teams - I h a d t o f i g h t f o r that. Also
i t is essential t o be able t o define y o u r o w n crisis and self-
refer t o crisis r e s o l u t i o n . "
Participants described t h e i r d i f f i c u l t y w i t h u n d e r s t a n d i n g the purpose
o r the i n t e n t o f the service, as they d i d n o t t h i n k that t h e i r needs o r
f a m i l y needs were u n d e r s t o o d o r valued. L i z z i e c r i t i q u e d services f o r
missing the o p p o r t u n i t y o f h e l p i n g her t o m a k e sense o f w h a t was
h a p p e n i n g f o r her:
" T h e other b i g question that they had n o idea about h e l p i n g
me t o answer was 'what's the m e a n i n g o f this distress'. T h e r e
was n o interest i n i t , they j u s t w a n t e d t o eradicate i t . "
Services d e f i n e d people b y t h e i r distress, and failed t o l i n k that distress
to o t h e r aspects o f the person's life, such as t r a u m a . N o attempts were
made t o u n d e r s t a n d h o w the person e x p e r i e n c e d t h e i r distress, o r
h o w they i n t e r p r e t e d i t . Service users w e r e considered ' d i f f i c u l t ' w h e n
they d i d n o t accept the assessment, diagnosis o r treatments o n offer.
Assessments and t r e a t m e n t plans failed to u n d e r s t a n d w h a t the person
w a n t e d f r o m the service, as they d i d n o t ask w h a t was i m p o r t a n t t o the
person. L a c k i n g insight i n t o illness was a t e r m used w h e r e people d i d
n o t see themselves as i l l , o r d i d n o t w a n t m e d i c a t i o n . W h e r e services
failed to understand needs and respond effectively t o t h e m , the p r o b l e m
was located w i t h the service user. E l l i e :
" I ' v e been called c h r o n i c , c o m p l e x , severe, u r g e n t , n o n -
c o m p l i a n t , acute, treatment-resistant, l o n g t e r m . . . . and all
by the t i m e I was 24 years o l d . "
Participants discussed a lack o f a c k n o w l e d g e m e n t o f needs at different
stages o f using services. Teresa was t o l d b y the c o m m u n i t y service
that she m e t its c r i t e r i a f o r recovery and n o l o n g e r r e q u i r e d a service,
despite h a v i n g used i t f o r over 20 years:
" A n d I have b e e n t o l d that I have recovered, that I a m n o w
w e l l , and that i f I need t o go back t o services I can b u t , y o u
k n o w , o n l y i n crisis sort o f t h i n g . A n d i t may seem daft that
someone l i k e m e , w h o has y o u k n o w , speaks u p and speaks
o u t about m e n t a l health services, i t is really h a r d t o speak
o u t about h e l p i n g and help f o r yourself."
 Ethics of care
I f services are n o t attentive t o the people w h o use services, subsequent
resources are misplaced and wasted. Also, systematic exclusion o f the
person, t h e i r experience and k n o w l e d g e is neglectful and c o m p o u n d s
distress. E n a c t i n g care becomes i m m e d i a t e l y impossible.
Caring for
Once needs are identified, someone or some group has to take responsibility to
make certain that these needs are met.
I n the ethics o f care, r e s p o n s i b i l i t y is a call t o a c t i o n based o n
needs i d e n t i f i e d t h r o u g h attentiveness. R e s p o n s i b i l i t y is therefore
f o r w a r d l o o k i n g and based i n a c t i o n . Professional responsibility may
be d i f f e r e n t l y conceptualised as d u t y o r o b l i g a t i o n , and services may
assume that families have obligations t o meet needs. Families m a y w a n t
to take some responsibility, b u t m a y n o t be factored i n t o care p r o v i s i o n
b y services. R e s p o n s i b i l i t y is a c t i o n o r i e n t a t e d and relational i n care
ethics, w h e r e o p p o r t u n i t i e s f o r responsibility are recognised.
Services m a y n o t be able t o m e e t needs considered b e y o n d their
r e m i t . Few ' o u t o f h o u r s ' services exist f o r people i n distress and crisis,
so people access hospital e m e r g e n c y departments as a place o f safety
o r w h e n i n j u r e d . A t t e n d a n c e at a health p r o v i d e r is an o p p o r t u n i t y
f o r a p o t e n t i a l l y life-saving i n t e r v e n t i o n , such as the p r e v e n t i o n o f a
suicide. H o w e v e r , participants discussed h o w stafflacked responsibility
t o p r o v i d e care. E l l i e said:
" I w o u l d say a l o t o f w o r k needs t o be done w i t h emergency
staff and police, p a r t i c u l a r l y A & E (accident and emergency)
staff t o i m p r o v e attitudes a n d decrease t h e stigma a n d
d i s c r i m i n a t i o n w h i c h leads t o some appalling m i s t r e a t m e n t
— w h i c h t h e n leads to people n o t using those services w h e n
they need to, w h i c h is q u i t e dangerous."
Participants discussed h o w p o o r attitudes prevailed, such as blame and
b e i n g made t o feel u n w e l c o m e i n services.
Care-giving
The third phase of caring requires that the actual care-giving work be done.
Competence.
I n the ethics o f care, c o m p e t e n c e relates t o the a b i l i t y t o m e e t needs
and h a v i n g the necessary resources. C o m p e t e n c e t o p r o v i d e care w h e n
people are i n distress requires a c o n n e c t i o n b e t w e e n people so that
Mental health service use and the ethics of care
distress is n o t exacerbated by isolation. Josephine spoke about her most
recent experience o f d e t e n t i o n :
" A n d distress o r k i n d o f m i n d chaos, h o w e v e r y o u w a n t t o
frame the experience, people need things that [pause] they
do n o t n e e d t o be shut o f f f r o m o t h e r h u m a n beings. I t j u s t
seems so simple t o m e . . . . So I m i g h t be a b i t k i n d o f h i g h
and n o t eat f o r three days, b u t eventually w i t h some o t h e r
k i n d o f e n c o u r a g e m e n t t o rest and be n u r t u r e d w i t h g o o d
f o o d and sleep, I ' m g o i n g to c o m e o u t o f that . . . "
Competent care r e q u i r e s a p p r o p r i a t e resources. L e g i s l a t i o n was
discussed as a w a y t o guarantee access t o l i m i t e d service p r o v i s i o n :
"One o f the c o n f l a t i o n s that happens i n this debate is
that people associate c o m p u l s o r y t r e a t m e n t w i t h reliable
services. So t h e y t h i n k i f w e d i d n ' t have that [legislation]
there, m y relative w o u l d be neglected." (Lizzie)
P e o p l e w h o ask f o r h e l p e x p e c t c o m p e t e n t services. R e s e a r c h
participants recognised that f a m i l y members d i d n o t always w a n t the
sort o f help o n o f f e r f r o m services. E l l i e reflected o n experiences o f
f a m i l y members c a r i n g f o r people i n r u r a l and r e m o t e areas w h e r e
services are inaccessible:
"Families are o f t e n d o i n g g o o d w o r k h e l p i n g t h e i r f a m i l y
and n e e d e n c o u r a g e m e n t to c o n t i n u e that a n d reinforce
that they are d o i n g w e l l . C u r r e n t l y , they t e n d t o t h i n k that
someone w i l l step i n and take c o n t r o l b u t they are n o t always
pleased w i t h the o u t c o m e w h e n people d o . "
T h e w a y that care was c u r r e n t l y b e i n g p r o v i d e d was o f t e n i g n o r e d ,
w h i c h meant that service providers d i d n o t j o i n w i t h care, b u t saw
themselves as the p r i m a r y care givers, i g n o r i n g the strengths a n d
preferences o f the care n e t w o r k (see Barnes, C h a p t e r T h r e e i n this
v o l u m e ) . Service users and care givers o f t e n w a n t t o be listened to,
reassured and t o receive practical help, w h i c h is d e m o t e d b y the service
focus o n risks, safety a n d c o n t a i n m e n t .
 Ethics of care
Care receiving
Once care work is done, there will be a response from the person, thing,
group, animal, plant or environment that has been cared for. Observing
that response and making judgements about it for example, was the care
sufficient?, successful?, complete?) is the fourth phase of care. Responsiveness.
Responsiveness requires that care providers are o p e n t o the responses
o f p e o p l e w h o use services at i n d i v i d u a l , f a m i l y and systemic levels.
M e n t a l health service user i n v o l v e m e n t is expected t o i n f o r m and
i m p r o v e service provision. Some participants acted i n senior governance
roles t o i n f o r m research f u n d i n g , p o l i c y m a k i n g and service provision as
a representative o f service user n e t w o r k s , o r i n a consultancy capacity.
B u t participants n o t e d fluctuating c o m m i t m e n t t o user i n v o l v e m e n t .
" I t is a sign o f the times as w e l l that the k i n d o f expertise
that they w a n t i n these p o w e r circles is n o t the k i n d that I
have. T h e y d o n ' t w a n t any k i n d o f service user expertise.
T h e tide has gone o u t . " (Lizzie)
A b d u l i d e n t i f i e d t h e absence o f an i n d e p e n d e n t b o d y t o hear
c o m p l a i n t s , thereby m a k i n g the process f o r change inadequate:
" W h a t is said about s u p p o r t f o r m e n t a l health and w h a t
y o u actually get is a b i g difference. I f y o u c o m p l a i n y o u
are c o m p l a i n i n g to the same t e a m therefore a waste o f t i m e
complaining. N o independent body to complain to."
Layers o f marginalisation and e x c l u s i o n , i m p l i c i t and e x p l i c i t , serve t o
delegitimise and silence o p p o s i t i o n a l voices (Barnes and B o w l , 2 0 0 1 ;
Barnes and C o t t e r e l l , 2012) and thereby b l o c k responsiveness.
Caring with
This final phase of care requires that caring needs and the ways in which they
are met need to be consistent with democratic commitments to justice, equality
and freedom for all. Solidarity.
T r o n t o s (2013) w e l c o m e a d d i t i o n o f s o l i d a r i t y b y ' c a r i n g w i t h '
builds o n Sevenhuijsen's (1998) a c k n o w l e d g e m e n t o f the i m p o r t a n c e
o f trust. T h e ethics o f care acknowledges past injustices. U n d e r s t a n d i n g
constructions o f people w h o experience madness has a l o n g history.
Foucault (1964) discussed the b i r t h o f the asylum as a response t o h o w
people w i t h m e n t a l health problems were r e m o v e d f r o m prisons as
they w e r e t h o u g h t i n f e r i o r , Szasz (1960) c r i t i q u e d psychiatry f o r a lack
Mental health service use and the ethics of care
o f u n d e r s t a n d i n g about the 'problems o f l i v i n g ' and G o f f m a n (1961)
e x a m i n e d the impacts o f i n s t i t u t i o n s o n the experience o f madness.
T h e otherness associated w i t h madness is materialised t h r o u g h the
operationalisation o f a b n o r m a l i t y i n psychiatry. L i z z i e c o m m e n t e d
about the denial o f h u m a n status:
" T h e w a y people get a r o u n d this is t o , i n a subtle way,
is t o deny h u m a n status t o people that are b e i n g treated
differently . . . W e live i n a democratic society . . . and people
haven't g o t t o the p o i n t w h e r e they are ready t o say people
w i t h m a j o r m e n t a l health problems need t o be treated j u s t
l i k e us . . . "
Service users/survivors have called f o r apologies f r o m the i n s t i t u t i o n s
that have treated people w i t h brutality. Josephine h a d been a 'listener'
to people w h o had been abused i n asylums. Participants p o n d e r e d w h y
change had n o t o c c u r r e d despite the considerable efforts o f service
u s e r / s u r v i v o r m o v e m e n t s , a n t i - p s y c h i a t r y m o v e m e n t s a n d recent
a c k n o w l e d g e m e n t s o f social exclusions, stigma a n d d i s c r i m i n a t i o n s .
Lizzie reflected o n the successes o f the s u r v i v o r m o v e m e n t :
" I t h i n k y o u can, i f y o u l o o k at the w o m e n ' s m o v e m e n t ,
the gay l i b e r a t i o n m o v e m e n t and the M a o r i renaissance
m o v e m e n t and the c i v i l rights m o v e m e n t , they have made
m o r e gains t h a n w e [ s u r v i v o r m o v e m e n t ] have, and that
saddens m e . . . T h e b i g issue that got people o u t i n the 1970s
was f o r c e d t r e a t m e n t and there is m o r e f o r c e d treatment
g o i n g o n n o w , a n d services have m o r e j u r i s d i c t i o n . . . So
that, c o m p u l s o r y t r e a t m e n t , has g o t t o be the h o t issue -
that is the issue that is s t o p p i n g services d e v e l o p i n g , i t is
the b o u l d e r i n the m i d d l e o f the road t o achieve a recovery
o r i e n t a t e d service."
A d d r e s s i n g t h e e n d u r i n g nature o f c o m p u l s i o n w o u l d i n d i c a t e a
significant shift i n the willingness o f services t o a c k n o w l e d g e previous
harms that service users have e n c o u n t e r e d , and o p e n a discussion
about the possibility o f r e v i e w o f the use o f c o m p u l s i o n . Solidarity,
rather t h a n p a r t i c i p a t i o n , b e t w e e n services a n d service users t o develop
services that m e e t needs c o u l d p r o v i d e a w a y o f t h i n k i n g a b o u t h o w
t o orientate partnerships f o r real change.
T h i s ethics o f care analysis reveals actions that a t t e m p t e d t o shut
d o w n and m i n i m i s e the voices o f people w h o experience distress, and
 Ethics of care
a lack o f skilled i n t e r v e n t i o n t o help people recover. Despite concerted
efforts t o raise p u b l i c awareness and challenge d i s c r i m i n a t i o n , and to
u n c o v e r the realities o f the m e n t a l health system, those w h o live w i t h
m e n t a l illness feel that l i t t l e has changed i n terms o f the p o s i t i o n i n g
a n d treatment o f people i n t h e i r situation. W i t h the i n t r o d u c t i o n o f
c o m m u n i t y - b a s e d c o m p u l s i o n , c o n t r o l has been e x t e n d e d rather than
t e m p e r e d , and rights are n o t available to people w h o are c o m p e l l e d to
use services. Systematic marginalisation and exclusion are experienced,
j u s t i f i e d b y p o o r l y c o n s t r u c t e d and heavily c r i t i q u e d f r a m e w o r k s o f
illness and over-exaggeration o r i l l - c o n s i d e r e d responses t o risk. Yet
people w h o are i n need require a response, and at times that response
m a y i n c l u d e c o n t r o l . Procedural rights are necessary t o ensure p r o p e r
t r e a t m e n t i n the w a y that c o n t r o l is exercised, b u t are inadequate
f o r access to redress and cannot address the f u n d a m e n t a l injustices
experienced b y those l i v i n g w i t h severe m e n t a l illness. W h a t is required
is care that is g u i d e d b y T r o n t o s i n t e g r i t y o f care i n o r d e r t o p r o v i d e
p r o t e c t i o n w h e n i t is absolutely required, b u t that this s h o u l d be j u d g e d
w i t h care. Justice requires care.
T h e i n t e g r i t y o f care is p o t e n t i a l l y transformative as a g u i d e f o r
practice a n d as a c r i t i q u e o f c a r i n g practices, as i t provides specific
critiques o f practices b e t w e e n p e o p l e that achieve o r i m p e d e the aims
o f care. I t reinstates the dynamics o f relationships as central t o c a r i n g
practices b e t w e e n all o f the people i n v o l v e d . E a c h one o f the elements
o f the i n t e g r i t y o f care has transformative p o t e n t i a l . Attentiveness
requires all o f the actors i n v o l v e d t o state t h e i r needs, b u t services
rarely state w h a t t h e i r needs are i n a g i v e n situation, such as the need
t o m a i n t a i n a person's safety a n d therefore l i m i t t h e i r f r e e d o m . Such
a statement o f need m a y w e l l crystallise the i n t e n t o f services t o use
force, f o r example. R e s p o n s i b i l i t y t o meet needs w o u l d m e a n that
services were unable t o j u s t i f y n o t m e e t i n g needs as a l i m i t a t i o n o f
t h e i r service boundary. C o m p e t e n c e w o u l d mean that the (lack of)
necessary resources to provide care was clearly stated, a level o f advocacy
that most practitioners w o u l d w e l c o m e . Responsiveness ensures that
there is a service user's perspective about care. Finally, s o l i d a r i t y w o u l d
pave the w a y f o r a m e a n i n g f u l renewal o f governance and leadership
i n a partnership b e t w e e n people w h o p r o v i d e services and those w h o
use t h e m .
A n ethics o f care has a central p o l i t i c a l a r g u m e n t f o r equality. People
w h o experience mental health problems o f t e n do so as a consequence o f
life events, such as trauma and interpersonal violence, o f t e n c o m p l i c a t e d
b y poverty, a lack o f o p p o r t u n i t i e s and m a t e r i a l and social resources.
I d e n t i f y i n g needs, f i n d i n g the r i g h t responses, w i t h a responsibility t o
Mental health service use and the ethics of care
create and sustain change is transformative. D e t a i l e d k n o w l e d g e o f lived
experiences is necessary t o understand w h a t responses are r e q u i r e d .
T h i s c o m p l e x , situated k n o w l e d g e provides d i r e c t i o n f o r responses t o
alleviate inequality. E v e r y d a y experiences are about everyday life and
are n o t restricted t o p a r t i c u l a r services, so i t is necessary f o r a societal
responsibility t o alleviate inequality, b e y o n d a response that is l i m i t e d
t o health and social services.
O n e societal responsibility is to consider h o w people w h o d e p e n d
o n others are v a l u e d . T r o n t o recognises that dependency has l o n g
been l i n k e d t o a p a t h o l o g y o f the i n d i v i d u a l , a n d therefore w h e t h e r
that person is an (in)adequate c i t i z e n (2013, p 150). H e a l t h and social
services reflect and c o n s t r u c t societal n o r m s regarding social w o r t h . I n
m e n t a l health discourses, dependence and independence are e m b e d d e d
i n the n o t i o n s o f (lack of) self-reliance and resilience, and close self-
surveillance o f health behaviours such as adequate sleep, decreasing
anxieties and healthy eating. L i t t l e o r n o a t t e n t i o n is g i v e n t o the
adversity that people face. Services emphasise decreasing personal risks
f o r service users and e n c o u r a g i n g the use o f m e d i c a t i o n f o r the c o n t r o l
o f symptoms. Emphasis o n risk management and medications obscures
w h a t service users actually n e e d f r o m services i n o r d e r t o deal w i t h
poverty, u n e m p l o y m e n t , d i s r u p t e d e d u c a t i o n o r practical help. Care
is broader t h a n c l i n i c a l services that a i m t o decrease the s y m p t o m s o f
m e n t a l illness. M u l t i p l e and v a r i e d services are r e q u i r e d that respond
to the c o m p l e x and situated l i v e d experiences o f service users. I n times
o f austerity a n d rationalisation, there is a t e n d e n c y t o assume that t o
receive any service is f o r t u n a t e , and c l i n i c a l services are f a v o u r e d over
c o m m u n i t y services f o r f u n d i n g . T h i s creates a s i t u a t i o n w h e r e m a n y
people do n o t receive the care that they require, and are also faced
w i t h services that are c o l o u r e d b y the p o t e n t i a l f o r c o m p u l s o r y a c t i o n
against t h e m . L i m i t i n g the o p t i o n s f o r care b y p r i o r i t i s i n g c l i n i c a l
services m a y lead to a p r o v i s i o n o f services that are n o t e x p e r i e n c e d as
care. A s s u m i n g that all care is g o o d may ' a l l o w ourselves to be m i s l e d
b y the ways i n w h i c h care f u n c t i o n s discursively t o obscure injustices'
( T r o n t o , 2013, p 24).
Transformations in mental health services
Justice m a y be u n d e r s t o o d here t o describe the level o f acceptance a n d
challenge that occurs w i t h i n o u r societies t o r e f o r m o r make change.
T r o n t o (2013) suggests that the ethics o f care takes central stage i n
the a r t i c u l a t i o n o f m o r a l i t y and the achievement o f care. Justice m a y
be possible b y surfacing the m o r a l i t y o f the p o l i t i c s o f m e n t a l health
 Ethics of care
service p r o v i s i o n , and the various f o r m s o f challenge f r o m s u r v i v o r
movements, antipsychiatry, a n t i - d i s c r i m i n a t o r y practices and f e m i n i s m .
T h e ethics o f care is a challenge t o the c u r r e n t accepted moralities that
enable practices that perpetuate injustices. G i v e n the past injustices i n
psychiatry, equality can be a t t e m p t e d o n l y w i t h r e c o g n i t i o n o f these
past injustices. Unless there is a w a y to articulate these issues, t h e n
inequality w i l l continue.
T a k i n g these factors i n t o consideration p r o m p t s the question o f w h a t
k i n d o f c a r i n g practices and i n s t i t u t i o n s are r e q u i r e d ( T r o n t o , 2010).
Service p r o v i s i o n is i n f l u e n c e d b y p o l i t i c s , p o l i c y a n d professional
domains o f practice. Participants were u n e q u i v o c a l a b o u t the role o f
c o m p u l s i o n , describing i t as 'the b o u l d e r i n the r o a d ' that prevented
recovery-based services, that added t o rather than h e l p e d t o alleviate
distress. T h i s made l i f e unnecessarily m u c h harder t h a n i t needed
to be. Desirable services, p r o v i d e d b y people w h o u n d e r s t o o d t h e i r
e x p e r i e n c e , h a d the aims o f h e l p i n g people t o enable themselves
t o decrease t h e i r distress. Legislative r i g h t s r e i n f o r c e d p o w e r and
incapacity, w h e n humanness and c o n n e c t i o n was w a n t e d , a l o n g w i t h
a sense o f h o p e and practical help that attended t o the social problems
o f p o o r h o u s i n g and u n e m p l o y m e n t that people faced. R e m o v i n g the
focus o n abnormality, c h a l l e n g i n g stigma and d i s c r i m i n a t i o n that stops
people accessing resources, and p r o v i d i n g the sorts o f help that w o u l d
solve social n e e d w o u l d go a l o n g w a y i n a c h i e v i n g justice.
EIGHTEEN
Conclusion: renewal and
transformation - the importance of
an ethics of care
Marian Barnes, Tula Brannelly, Lizzie Ward andNicki Ward
I n the i n t r o d u c t i o n t o this c o l l e c t i o n w e h i g h l i g h t e d the value o f the
ethics o f care n o t o n l y i n enabling a c r i t i q u e o f p o l i c y and practice,
but as a w a y o f t r a n s f o r m i n g this. H e r e w e offer f u r t h e r reflections
d r a w i n g o n the specific c o n t r i b u t i o n s made b y chapter authors. T h e
ethics o f care is a w a y o f t h i n k i n g about p o l i t i c s , social practices and
the everyday-life considerations o f people i n diverse circumstances. I t
provides a perspective that connects values — the things that ' m a t t e r ' t o
people (Sayer, 2 0 1 1 ) , the practical help and s u p p o r t they need w h e n
times are hard, the relationships t h r o u g h w h i c h they feel recognised and
v a l u e d and the p o l i t i c a l p r i o r i t i e s that g o v e r n p u b l i c decision m a k i n g .
W e w r i t e this at a t i m e w h e n c o n f i d e n c e i n d e m o c r a t i c systems is at a
l o w ebb. People are frustrated at the apparent lack o f p o l i t i c a l w i l l t o
address concerns a b o u t inequality, adequate health services, fair and
equal rights, decent e m p l o y m e n t rights and a l i v i n g wage. Despite the
f a l l - o u t f r o m the 2008 f i n a n c i a l crisis, the supremacy o f market values
remains largely unquestioned. E n d u r i n g inequalities and injustice reach
b e y o n d the local and national t o the global. D i s i l l u s i o n m e n t w i t h the
p o l i t i c a l establishment's willingness to c o n f r o n t injustice u n d e r m i n e s
confidence i n democracy.
W h a t can the ethics o f care c o n t r i b u t e i n this situation? Care is
part o f everyone's everyday lives; the issues that care raises about h o w
w e live together, w h a t w e t h i n k is g o o d o r ' r i g h t ' , a n d h o w w e take
responsibility f o r the allocation o f resources t o meet basic h u m a n needs
are e n d u r i n g ones. Care is p o l i t i c a l . Questions a b o u t w h o cares f o r
w h o m have l o n g b e e n recognised b y feminists as p o l i t i c a l as w e l l as
personal issues. As d e m o g r a p h i c shifts and global m o b i l i t y f o r e g r o u n d
questions o f w h o cares f o r an ageing p o p u l a t i o n , w e c o n f r o n t the
dangers o f i n t e r g e n e r a t i o n a l c o n f l i c t . T h i s c o n f l i c t , and the broader
debates about 'fairness' and 'deservedness' i n r e l a t i o n t o welfare, are
constructed w i t h i n ' c o m m o n sense' neoliberal assumptions about the