Connecting Theory to Practice: Karl Barth, Capability Theory and Psychiatric Social
Work
John B. Thompson1
Abstract This paper explores linkages between theory and practice in psychiatric social work,
specifically between Karl Barth’s theology of social justice, Martha Nussbaum’s capability
theory, and an innovative component in psychiatric services called the decision support center.
The decision support center is itself a multi-component system that not only aims at improving
and enhancing medication consultations, but, in so doing, also serves broader sociopolitical ends.
Four congruent themes in Barth and Nussbaum’s theories are discussed and applied.
Key Words mental illness; social work; Karl Barth; capability theory; psychiatry
Introduction
The many treatment modalities for mental health disorders (e.g. counseling, case management
and psychiatry) not only serve to alleviate the psychological suffering of those afflicted, they
also serve broader theological and sociopolitical ends. Mental health treatments, and theological
and sociopolitical ideas, need not be thought of as distinct or separate, however, but as
continuous and interrelated. In other words, theories, whether theological or sociopolitical, need
not be far removed from concrete practice. This paper is an attempt to build bridges between
theory and practice: to ask what a new practice in psychiatric social work—the Decision Support
1
J. B. Thompson
Doctoral student
University of Kansas School of Social Welfare
1545 Lilac Lane
Twente Hall
Lawrence, KS 66044-3184
Email: johnyt@ku.edu
Telephone: 512-636-0942
Center—(Deegan et al., 2008) ‘looks like’ when viewed through a theological lens that focuses
on social justice. Doing this will include bridging three disciplines: theology, philosophy, and
social work (the latter focused specifically on the decision support center (DSC) which involves
psychiatrists, clients, peer support specialists and case managers).
As theoretical thinking has developed for mental health treatment, broader ideas have
emerged that extend the purview beyond the individual and medical pathology. The psychiatric
recovery paradigm, the strengths perspective and shared decision making in particular have
reshaped the theoretical landscape in mental health thinking in recent times. These ideas,
without jettisoning the medical model, offer a different view of what it means to live a life with a
mental disorder. The recovery paradigm offers a holistic perspective that calls for client
empowerment in the iterative process of self-directed development, with or without psychiatric
medication (Deegan, 2010). The strengths perspective continues to (re)orient thinking away
from mere pathology, refocusing instead on the internal and external aspects and resources in
clients’ lives that can be mobilized for positive healing, change and growth according to each
persons hopes, dreams and aspirations (Rapp & Goscha, 2006). More recently, shared decision
making has offered specific contributions to the way we think of the dyadic communication
between psychiatrist and client, suggesting that the goal of client well-being, particularly related
to the complex choices involved in taking psychotropic drugs, is best served when both clients
and physicians are considered ‘experts’ in the psychiatric consultation (Deegan, 2010).
Taken together, these significant contributions to mental health theory have helped to
bring about important changes in mental health practice. Perhaps more importantly, these
changes in thinking have positively broadened our thinking about what ‘treatment’ means:
people recovering from mental illness now have many more options beyond traditional mental
health services which they may utilize in their recovery process. These include supported
education, supported employment, and a variety of self-help groups and consumer-run
organizations. These developments in recovery resources not only support the medical notion of
disease cure, but also support human development (often despite ongoing symptoms of mental
illness) in the existential, social and political spheres. Thus, thinking in the mental health field
has developed beyond just physical, individualistic, pathology-based ideas (which clearly have
their place), and now incorporates as well these broader needs for people to participate in their
communities.
Though the aforementioned theoretical developments are positive, they also tend to
represent a view from the individual outward. They have served to expand existing medical
model thinking beyond the limited scope of physiology, neurochemistry and personal
psychology to include various interpersonal relationships, family dynamics, employment,
education, and even notions of social and political participation as integral to the recovery
process (Ware, 2008). Without attempting to diminish this standpoint, the present article will
offer a different view of mental health treatment. This is a view from the perspectives of
theology and political philosophy, specifically regarding social justice. Though different, this
view is not inconsistent with the strengths perspective, shared decision making or the recovery
paradigm—in fact, it assumes them, but places them under a different umbrella, that of Karl
Barth’s Christian theology, and Martha Nussbaum’s capability theory, both of which propose
their own ideas about social justice (Deschner, 1972; Stout, 2006; Gollwitzer, 1976; Nussbaum,
2000) . Thinking about mental health this way is simply a different way of framing the same
information. Instead of asking what are the elements involved in the treatment and recovery
from mental illness, this question asks how mental health theory and practice fit within a larger
theological and sociopolitical design aimed at maximizing the real opportunities for citizens to
choose their own life courses, based on their own preferences and values.
Thinking of psychiatric practices from the perspective of social justice and theology is a
task best done in reference to particular thinkers, as opposed to merely making broad
generalizations about spirituality and/or religion. This permits a degree of depth and specificity
that otherwise remains hidden. So for this work I have selected Karl Barth, a 20th century
theologian in the Protestant Christian tradition, and Martha Nussbaum, a contemporary
philosopher who generated (as did Amartya Sen) the capability theory of social justice. The aim
here is not to proselytize or to suggest that only Barth’s theology is consistent with social justice:
surely many religious and spiritual traditions are also consistent in their own ways (as are other
Christian thinkers and Christian traditions). The aim is to look at psychiatric practices from a
different vantage point—to ‘step out’ and abstract from the concreteness of practice and ask how
psychiatry (the DSC in particular) lines up with several key themes in Barth’s and Nussbaum’s
ideas about social justice. The question is, does psychiatric social work serve as a means to
specific social justice ends? How? And how (if at all) is the DSC serving to make things better
for psychiatric clients in this regard?
My thesis is that the DSC does serve specific social justice ends as it positively enhances
the possibilities of freedom and responsibility for people with psychiatric disabilities. But the
goal is also the journey: in order to arrive at this thesis I will first describe four key themes in
Barth’s theology of social justice, along with brief arguments demonstrating their consistency
with four similar themes in Nussbaum’s capability theory. It would be possible to make
connections between psychiatry and Barth directly, but since his ideas are broadly consistent
with Nussbaum’s, and since Nussbaum’s tend to provide more detail than Barth’s (though not
linked to any particular spiritual or religious tradition), it simply makes a better bridge to use
both (and in so doing, a bridge is also constructed between Christian and secular views of social
justice). A second reason for putting the two together stems from Nussbaum’s justification for
the capability theory. In addition to an appeal to shared intuitions, she states that there is an
“overlapping consensus” (Nussbaum, 2000, p. 5) such that people from many different religious
and philosophical traditions would find her theory plausible. This paper is, in part, a response to
that challenge in the sense that, if I am correct, then Christian thought (at least as represented by
Barth) is consistent with capability theory as one specific example of an overlapping consensus.
In order to undertake an interdisciplinary endeavor such as this, a certain amount of detail
and thoroughness must be sacrificed. Doing justice to Barth or Nussbaum alone would require
summary material spanning at least the length of this entire paper. However, it seems worth the
effort to connect disciplines that usually focus quite precisely only within their own fields.
Hopefully this will have its own rewards. What follows includes two primary sections: first I’ll
briefly summarize Barth’s and Nussbaum’s general projects, then describe four specific themes
in Barth’s theology of social justice and explain how they relate to four themes in Nussbaum’s
capability theory. The second section will consist of an explanation of how psychiatry and the
DSC ‘look’ when viewed through these four paired themes.
Barth’s Theological Perspective
Karl Barth (1886-1968) was a Swiss theologian who wrote voluminously within the Protestant
Christian tradition. He is known as the “theologian of freedom,” due to his theological emphasis
on freedom beginning with his idea of God as the “one who loves in freedom” (Green, 1989).
According to Barth, God freely chose to create and redeem humanity by way of the election of
Jesus, the Christ, who was present at creation, who is with people as God incarnate, and who
died and rose for the sake of human justification and sanctification. This reality of God is not
knowable by way of any natural, or human, means (e.g. rationalism, science, emotional
experiences) but must be known via revelation. Revelation comes in three forms: Jesus Christ,
the Bible (record of Jesus), and the church (preaching). These are the sources of his general
theology (e.g. doctrine of God, sin, salvation) and also of Barth’s ideas about social justice
(these, and Barth’s experiences as a pastor) (Gollwitzer, 1961; Busch, 2004).
In 1911 Barth accepted his second pastoral call to a working class church in the parish of
Sefanwil, Switzerland. It was by observing and engaging with the concrete socioeconomic
struggles of his parishioners that he began to formulate his theology of social justice (Green,
1989). His early social justice formulation was also heavily influenced by socialist thought. He
not only considered his parishioners’ needs, but took action preaching about social justice, and
organizing strikes and labor unions. Barth states “Jesus is the movement for social justice, and
the movement for social justice is Jesus in the present” (Barth, 1911, p. 99). The social justice
movement, on Barth’s understanding, is the continuation of the spiritual power that began with
Jesus in ancient times. Despite the parallels between Jesus’ teaching and social justice, he denied
any equation of theology and socialism (or any other philosophical perspective). “From one
standpoint or another, every idea or life-form will sooner or later prove a threat to humanity”
(Barth, 1911, p. 260). Barth instead understood the movement for social justice (and the Social
Democrat party at the time) as sharing common ground with theology. An ‘inner connection”
exists between the Word of God made flesh and the ideas of social democracy. Thus, the
sociopolitical ideology always remains only an association with theology, always dependent
upon the Word of God for validation.
Barth looked to Jesus’ own social status and teaching to generate his social justice
theology (Gollwitzer, 1976). Jesus Christ, like the Social Democrats in Barth’s time, wanted a
“movement from below” with attention to, and solidarity with, the working classes, who are
dependent upon the owners, those in power. Jesus himself came from the most humble of
beginnings and was a worker (carpenter). He associated himself with the lowest of social classes,
including fishermen, tax collectors and prostitutes. He spoke not as a philanthropist from on
high, but as one from among the people, as one with the people and for the people. Jesus
preached about the Kingdom of God (KOG) not as an otherworldly heaven that ‘good’ people
supposedly earn, but as “the spirit that transforms matter” in this world (Barth, 1911, p. 106).
The Word became flesh, and not the other way around. In sum, Barth saw the Jesus who healed
the sick, preached about faith, hope and love, and taught his followers to clothe the naked, feed
the hungry, visit the imprisoned, and welcome the stranger, as a clear advocate for social justice.
“What Jesus has to bring us are not ideas, but a way of life” (p. 101).
Nussbaum’s Capability Theory
Capability theory is a particular approach to social justice that fits within the larger scope of a
liberal egalitarian political perspective (e.g. John Rawls’s Theory of Justice) (Nussbaum, 2000).
It is comprised of basic principles and ideas that have been designed to undergird the
constitutions of nations and to provide guidelines for social and economic policy. An emerging
development in political philosophy itself (ten to twenty years old) it has only recently been
applied more specifically to a other fields of study, including education, computer science,
women’s studies and now psychiatry (see e.g. Anand, 2005; Florian, 2008; Johnstone, 2007) . In
order to determine the status or well being of people within a nation (or otherwise) there must be
some measure or idea about just what the good will be. In contrast to utilitarian, libertarian, and
even resource theories (e.g. that measure goods as GDP), capability theory focuses on what
individual people are actually able to do and be in their lives.
Overlapping Themes in Barth’s Social Justice Theology and Nussbaum’s Capability
Theory
I have identified four themes in Barth’s theology that seem most relevant to the capability theory
of social justice: the value of humanity, freedom, responsibility and pragmatism. This section
will consist of brief descriptions of each of Barth’s themes, followed by a comparison with
similar themes in Nussbaum’s capability theory. Barth’s first theme is the value and dignity of
humanity. For Barth, the value of humanity is rooted first of all in God’s free decision to create
all that is: the universe, the Earth and its creatures, including human beings. Moreover, Barth
radically reconstructed John Calvin’s doctrine of election. In contrast to Calvin’s ‘double
predestination,’ Barth understood that all persons are elect in Jesus Christ.
In Christ, God chooses humanity in divine loving freedom. Jesus Christ is the elect
human being, not only as an individual person but above all as the representative, the
head, the personification of all humanity. That is to say, all humanity – and precisely all
sinful humanity – is chosen, elect, predestined by God in Jesus Christ. (Green, 1991, p.
31)
In other words, the value of humanity derives from God’s choice not only to create humans, but
also to offer reconciliation to Godself via the election of Jesus Christ. The valuing of humanity is
thus evident in the free choice to create humans, then in the offer of redemption by the grace of
self-sacrificial atonement and spiritual empowerment. This is Barth’s Christologically-centered
valuing of humanity.
In his essay The Christian Community and the Civil Community (1946), Barth discusses
the relationship between the church and the civil/political community, which also exemplifies the
value of human beings. Following the just mentioned Christological valuing, this point of value
regards the call of the disciples of Christ to take concrete action in the world. Barth imagines the
relationship between God, the church, and the civil/political community as a center circle (God)
with two concentric circles around it. The first concentric circle represents the church; the second
circle the civil/political community, or state. The role of the church is to promote the ideals of
the Kingdom of God in the civil community (while maintaining a distinct boundary between
itself and the state). The civil community is supposed to safeguard the lives and freedom of
individuals via legislative, administrative and judicial functions. “The inevitable consequence is
that in the political sphere the church will always and in all circumstances be interested primarily
in human beings and not in some abstract cause or other…” (Barth, 1946, p. 283). Whether the
cause is nationalism, the progress of civilization or culture, or the ongoing development of the
human race, the church must maintain its focus on the significance of human life and human
dignity. “Since God himself became human, real human beings are the measure of everything…”
(p. 283). Even the lowest classes of human beings in every society must be valued and
recognized by the church for attention, imitating Jesus’ own mission to seek and save the lost.
…Casting all false impartiality aside – the church must concentrate first on the lower and
lowest levels of human society. The poor, the socially and economically weak and
threatened, will always be the object of its primary and particular concern, and it will
always insist on the state’s special responsibility for these weaker members of society.
(Barth, 1946, p. 284)
The church is thus called to awareness and action on behalf of all who find themselves in need
whether due to exploitation, oppression, marginalization, poverty or illness. There is a trajectory
in this thought toward human development and maturity. Each person should aspire “…to be an
adult citizen, and he can only want his fellow citizens to live as adult human beings” (Barth,
1946, p. 284). The task of the church is to bring about (to the extent possible) the Kingdom of
God on Earth. “Their concern is with humanity. From the very start they are ‘humanists’” (p.
259). The status quo of human life that tends to be characterized by hostile competition in the
struggle for various desired ends should be supplanted by loving concern, especially for the most
vulnerable in the human population. The church should take an active role, promoting in the state
policies that support life, freedom, peace and joy based on human dignity and worth as people
who are loved by God. “Human beings are those whom God loved, for whom Jesus died and
rose again, and for whom he will come again as Judge and Redeemer” (p. 261). Barth rejects all
theocratic leanings in carrying out this mission for the church, instead stating that the church
should seek to maintain a positive relationship with the state, sharing its hope for the Kingdom of
God. Thus for Barth, the Christian life must be a political life, and the church must actively
participate in social affairs, promoting peace, justice and hope. “It will always choose the
movement from which it can expect the greatest measure of social justice (leaving all other
considerations on one side)” (p. 284).
The value and dignity of human life is also a clear starting point for the capability theory.
Martha Nussbaum (2000) states that capability theory should be “…informed by an intuitive idea
of a life that is worthy of the dignity of the human being” (p. 5). Similar to Barth’s statement that
a human life should be directed toward maturity as a human being, as one who develops the
cognitive and emotional—or relational—capacities necessary to participate in civil society, and
possibly the church, Nussbaum (drawing on Marx and Aristotle) also desires that life for humans
is not stunted or suppressed to the point that a person cannot develop in a truly human way.
The core idea is that of the human being as a dignified free being who shapes his or her
own life in cooperation and reciprocity with others, rather than being passively shaped or
pushed around by the world in the manner of a “flock” or “herd” animal. A life that is
really human is one that is shaped throughout by these human powers of practical reason
and sociability. (Nussbaum, 2000, p. 72)
The origin of the value of human life is obviously different for Barth than for Nussbaum, but
they overlap in their focus on the value of human life, and the idea that this value requires life to
be lived in a manner that reflects that value, namely in a way that permits maturation as a
person—the ability to “…develop and exercise one’s human powers” (Nussbaum, 2000, p. 72).
Nussbaum’s approach (referencing Kant) requires that each person is a bearer of value who is
treated as an end and not merely a means to some other end. Anything less renders some people
as mere objects for the use of others’ ends—a definition of exploitation.
The second theme in Barth’s theology is freedom. The church is the fellowship of people
who are called by grace and the Spirit of God to live freely.
Translated into political terms, this means that the church affirms, as the basic right
which every citizen must be guaranteed by the state, the freedom to carry out his
decisions in the politically lawful sphere, according to his own insight and choice, and
therefore independently, and the freedom to live in certain spheres (the family, culture,
art, science, faith), safeguarded but not regulated by law [my ital.]. (Barth, 1946, p. 284)
Here Barth indicates what each individual person should be able to do in the civil society,
namely to “carry out his decisions.” This implies that within the civil society conditions will be
such that an individual has the ability to make a decision in the first place. Decision making, at
least the kind that could reasonably considered independent and “according to his own insight
and choice,” will involve the real possibility of obtaining necessary information and/or
education, leaving one’s house and traveling, possibly organizing and gathering in groups, the
possibility of owning property and materials, participating in various business transactions,
thinking clearly, not being unduly influenced or exploited by business, government or any other
organization, among many other factors. Moreover, “Independent” decisions are by definition
uncoerced. In other words, the individual must be able to choose what he or she does in life
according to his or her own “insight,” or values, preferences and aspirations. Barth indicates a
number of particular areas or “spheres” in which the individual should have liberty to make
choices. It seems that the list is not intended to be exhaustive as items such as “family, culture,
art, science, faith” are broad enough to cast a wide net of possible lifestyles and identities.
Freedom in the civil sphere thus entails state-sanctioned rights and privileges as entitlements of
citizens.
Nussbaum’s theme corresponding to Barth’s understanding of freedom is simply the idea
of capability itself. She states that “…the best approach to this idea of a basic social minimum is
provided by an approach that focuses on human capabilities, that is, what people are actually
able to do and to be…” (Nussbaum, 2000, p. 5). People should be free to reflect upon and design
and carry out their own plans in life according to their own ends. Each person as an end implies a
high level of free agency and freedom from sanction or coercion from the state or any other
source. Individual flourishing means that people will have the ability to make important choices
in their lives, to have the capacity for meaningful affiliations and to develop their various
capacities. Nussbaum is much more specific in her explanation of capability than is Barth about
his idea of freedom. Nussbaum specifies capabilities even further than Amartya Sen by offering
a specific list of ten capabilities that are considered necessary for living life in a truly human
way. For the sake of brevity I will not repeat all ten capabilities here, but generally speaking
Nussbaum includes such positive things as being able to develop one’s own conception of the
good based on an adequate opportunity for education, to participate in social and political
activities, and to find recreational outlets and play. She also includes capabilities of emotional
expression and the ability to form relationships: to care for others and to be cared about. Also
included are negative aspects such as the freedom from dying early and from being malnourished
or otherwise rendered unhealthy due to violence or the lack of medical care or access to adequate
shelter.
Barth’s third theme is responsibility. Freedom, in Barthian thought, should not be equated
with libertinism. There are not unlimited choices within the realm of liberty, whether
theologically speaking or as pertains to civil society: in both cases some choices, identities and
ways of being tend to lead to captivity and/or catastrophy. Theologically, this is the rejected
realm of sin that includes such things as vengeance, oppression, greed, idolatry and the like. In
political terms Barth’s point is to insist that citizens not only have entitlements, but also
responsibilities and duties. “It follows that the church will never understand and interpret
political freedom and the basic law which the state must guarantee to the individual citizen other
than in the sense of the basic duty of responsibility which is required of him” (Barth, 1946, p.
285). Barth criticizes certain human rights schemes for acknowledging only the entitlements of
citizens and not their responsibilities to the community. “The citizen is responsible in the whole
sphere of his freedom, political and non-political alike” (p. 285). The community as a whole, and
indeed each individual person, is responsible for maintaining freedom, both for the whole, and
for each individual. For Barth there is a balance to be maintained between the interest of the
community and the interests of the individual. Either extreme leads to abuses and injustices, so
neither radical collectivism nor radical individualism are acceptable political options.
Barth’s conception of the responsibilities of citizens is that they are to each other, with
special attention to differences in individual need. For instance, arbitrary restrictions by law or
convention that are based on religion, race, class or gender distinctions should be recognized and
dismantled. The role of the church in this regard should be to “…stand for their equality before
the law that unites and binds them all, for their equality in working together to establish and
carry out the law, and for their equality in the limitation and preservation of human life…”
(Barth, 1946, p. 285)
Nussbaum would agree with Barth that equality is an essential aspect of capability or
freedom. “…[D]iscrimination on the basis of race, religion, sex, national origin, caste, or
ethnicity is taken to be itself a failure of associational capability, a type of indignity or
humiliation” (Nussbaum, 2000, p. 74). However, she does not go as far as Barth in prescribing
responsibility per se as a correlate of capability or freedom. It seems, however, that a certain
level of civic duty is implied, at least in a minimal sense, even if it only involves refraining from
participating in activities that discriminate, exploit or oppress others. Otherwise, Nussbaum’s
explicit commitment to political liberalism prescribes no particular action for any citizen, but
instead assumes that at least the vast majority of citizens will have goals, desires and aspirations.
Capability theory states that social and political conditions should be set such that people have a
real opportunity to pursue their individual ends in a truly human way. The overlap with Barth in
this case is less pronounced, but Barth and Nussbaum both require the individual to choose, and
to take action in order to bring about any desired end. For Nussbaum (and Sen) choice signifies
the distinction between capability and function. Capability refers to the real possibility one may
have to do or to be something. Function refers to the actual carrying out, or doing or being that
something. The former is prescribed, whereas the latter must remain an unenforced possibility—
a possibility that requires the individual (and not some other oppressive power) to make a choice
and act. “Where adult citizens are concerned, capability, not functioning, is the appropriate
political goal” (Nussbaum, 2000, p. 87). The former indicates an entitlement—a right or
sociopolitical condition that is protected and enforced by the state. The latter is left to individual
choice. For Barth, the sociopolitical conditions for freedom are consistent with Nussbaum’s in
that the real possibility for an individual to do and be something must obtain as a statesanctioned right. His notion of responsibility does not prescribe or enforce any particular
functioning for any individual, but it does contain a further, more socially conservative element,
the notion that the individual has not only entitlements, but also duties.
The fourth congruent theme between Barth and Nussbaum is that both are broadly
pragmatic. I say broadly because I don’t intend to commit either one formally to pragmatism as a
meta-philosophy (though both seem to fit the bill in many ways), but to make the weaker point
that they both seem to line up with pragmatism in several ways that they also line up with each
other. The consistencies between Barth and Nussbaum in this regard are also consistent with (at
least) two of John Dewey’s key pragmatist themes: particularism and democratic deliberation.
I’ll deal with each of these briefly in turn.
By particularism I mean the pragmatic idea that within a broad theoretical and/or
theological framework that is intended to undergird constitutions (in Nussbaum’s case) or
instruct the church (in Barth’s), each particular group or society must generate their own specific
sociopolitical structures, organizations and laws according to their own history, culture and
values. This is captured by Nussbaum’s concept of multiple realizability. With regard to her list
of ten capabilities Nussbam states “…the list remains open-ended and humble; it can always be
contested and remade” (Nussbaum, 2000, p. 77). Each concept, such as the role of literacy in
human functioning, will have to be interpreted and reinterpreted over time and in different
places. “Part of the idea of the list is its multiple realizability: its members can be more
concretely specified in accordance with local beliefs and circumstances. It is thus designed to
leave room for a reasonable pluralism in specification” (p.77).
Barth is even less concerned with the specific political structures and organizations of the
state so long as they maintain a separation of powers, and “…so far as they belong together
under a constitutional system of government that is equally valid for and binding on them all…”
(Barth, 1946, p. 266). The church’s role in promoting social justice in the civil society remains a
constant, while otherwise avoiding any theocratic admixture with any state institution. The role
of the state is “…the safeguarding of both the external, relative and provisional freedom of the
individuals and the external and relative peace of their community and to that extent the
safeguarding of the external, relative and provisional humanity of their life both as individuals
and as a community” (p. 267) So long as these general characteristics and functions of the state
obtain, Barth leaves the details up to each particular nation or community, and makes no further
statement about it.
In the same sense that both Barth and Nussbaum embrace particularism, they also line up
in their proposed method that should be used to determine which particular laws or institutions
should be established: democratic deliberation. Nussbaum states, “…each of the central
capabilities will need more precise determination as citizens work toward a consensus for
political purposes” (Nussbaum, 2000, p. 77). She goes on to say that this process will have to
take place within each constitutional tradition and will evolve over time through interpretation
and deliberation. “[W]e should view any given version of the list as a proposal put forward in a
Socratic fashion, to be tested against the most secure of our intuitions as we attempt to arrive at a
type of reflective equilibrium for political purposes” (p.77). Likewise, Barth commits his adult
citizens to ongoing, active political engagement in all social and political arenas. “The church
sees itself established and nourished by the free Word of God…” “By a process of analogy, it has
to risk attributing a positive and constructive meaning to the free human word in the political
sphere” (Barth, 1946, p. 286). To be sure, it would be temporally impossible for Barth to be
suggesting the promotion of a list of capabilities, or even Rawls’s two principles of justice. But,
to the extent that his theological principles of social justice are in accord with those of
Nussbaum’s, there exists a conceptual overlap not only with the principles themselves, but also
with the notion that both thinkers require people to figure out for themselves the details by way
of free, public deliberation. Barth states, “[t]he distinguishing mark of the good is that it presses
forward to the light of day. Where freedom and responsibility in the service of the state are one,
whatever is said and done must be said and done before the ears and eyes of all…” (Barth, 1946,
p. 286)
Social Justice and Psychiatry
There are several important implications of thinking about psychiatric social work from a social
justice perspective. First, from a theological point of view there is a clear call to Christians to be
aware of and to take action on behalf of people who are socially, politically and/or economically
vulnerable or disadvantaged in any way: this includes people with mental illness who, because of
their psychiatric disadvantages, are often not able to translate existing capabilities into
functionings to the same extent as people who do not experience mental illness. Mental illnesses
are medical disorders in the sense that they disrupt biological and psychological functioning in
individuals. However, they are also social, political and economic disorders in the sense that they
disrupt an individual’s ability to participate in freedoms and responsibilities as citizens in
society. Left untreated (and sometimes despite treatment), people suffering from psychiatric
disorders, particularly the most egregious and intractable ones such as schizophrenia, are unable
to reasonably do what they want, and be who they want. Without professional and/or peer
support, these individuals tend to fall victim to predators, physical disease, violence,
unemployment, substance abuse, incarceration, homelessness and early death (RachBeisel et al.,
1999; Daly, 2006).
Barth’s theology also includes a warrant or justification for this engagement of the church
in civil society, which is rooted in his Christology. The Spirit of God empowers the church not to
act merely on behalf of its own interests, but for the interests of people who need advocacy and
assistance. Anything less denies the value and dignity of humanity and renders the church
apostate (Barth, 1946). The church may take action directly, or by advocating on behalf of—or
with—people for whom conditions of freedom do not obtain, such as those with mental illness.
Linking Barth’s conceptions of social justice with Nussbaum’s adds a level of detail and
specificity that can be instrumental in actually carrying out this charge. With capability theory
there is a more direct way to assess a person’s freedom: the list of ten capabilities can be
consulted in order to determine whether a person is actually free to do and be certain things, such
as having control over his or her environment by participating in politics, or the ability to own
property and find employment that pays a living wage. In this way the capability theory serves as
a bridge between Barth’s more abstract theological constructions and the more concrete needs of
individual people in the civil sphere. In the case of mental illness the DSC becomes one vehicle
for translating theologically informed social justice ideas into real world differences in the lives
of those who suffer from psychiatric disorders.
Viewing psychiatry from this social justice perspective provides a broader view of the
goals of treatment. The medical model focuses on diagnosis, treatment of symptoms, and the
hope for an eventual cure to mental disease. The medical treatment of mental disorders, viewed
from Barth’s and Nussbaum’s perspectives, does itself serve the ends of social justice: mental
disorders are antithetical to freedom, responsibility and capability, to the extent that they prevent
a person from engaging in cognitive, emotional and social functioning: they often prevent people
from being able to live full human lives. So when psychiatric interventions (i.e. drug therapies)
provide relief of symptoms, they are at once treating a mental health disorder, but also enabling a
person to have increased life choices again. For example, Nussbaum’s list of capabilities
includes “senses, imagination and thought” (capability #4). This means that a person should be
able to “…imagine, think and reason – and to do these things in a “truly human” way, a way
informed and cultivated by an adequate education…” (Nussbaum, 2000). A person experiencing
the hallucinations and delusions of schizophrenia is inhibited from thinking and reasoning
normally and is therefore not able to develop various mathematical, scientific, or other literacies
as part of an educational and vocational process. Psychiatric medications, to the extent that they
work properly for a client, can be said to not only positively alter neurochemical processes and
restore cognitive functioning, but they also make it possible for a person to “…use imagination
and thought in connection with experiencing and producing self-expressive works and events of
one’s own choice, religious, literary, musical, and so forth” (Nussbaum, 2000, p. 74). The
capability theory thus provides answers to questions about what kinds of capabilities are
generally desirable for all citizens in the public arena beyond just restoring cognitive and
emotional functioning from a medical perspective. Nussbaum does not assert that people with
mental illnesses are in any way less than human, or that people who still experience some
symptoms in their recovery process do not have dignity. On the contrary, the basic minimum of
capabilities speaks to the value of each individual person, and the obligation of the community to
provide real opportunities—to the extent possible—for those in need.
The capability theory, and Barth’s theology of social justice are, however, not theories of
psychiatric treatment: they have been designed to undergird state constitutions and social policy.
If we take Barth and Nussbaum seriously, then people with psychiatric disorders, because of
their vulnerable condition in society, appear instantly on our ‘radar.’ This puts psychiatric social
work (including psychiatry) within the purview of social justice as well, and therefore politicizes
it. Operating with the values of social justice, particularly with Barth’s theological warrant,
means that psychiatric treatment for vulnerable populations is not something that can be left as
an optional service just for those privileged enough to afford proper care. With the capability
theory there is a set minimum of what people—especially vulnerable populations—should be
able to do with their lives (given that it is medically or otherwise possible). Since psychiatric
disorders inhibit these life possibilities, everyone should have access to adequate psychiatry.
Neither Barth nor Nussbaum specify exactly what policies and institutions should provide for
such things as psychiatric care of citizens—these details must be established via democratic
deliberation for each particular civil society and culture. Viewing psychiatry from the
overlapping perspectives of Barth and Nussbaum places it within a theological and sociopolitical
value base that prescribes not what medical treatments should be administered, but who should
have access to them, namely everyone who has a mental illness. To the extent that vulnerable
populations do not have access to proper psychiatric care, Barth and Nussbaum’s ideas offer a
critique of relevant social policies and institutions because they are not functioning in a just
manner.
The focus on what people are actually able to do and be also requires an ongoing critique
of psychiatry itself, the evaluative criteria being freedom as capability. As helpful as psychiatric
medications have proven to be, there are still many barriers to achieving positive treatment
outcomes. For instance, approximately 50% of clients who are prescribed psychotropic
medications often do not take them as prescribed, or at all (Zygmunt, 2002). There are various
reasons for this, including side effects, lack of funds to purchase medications, and failure to
connect the use of medications to clients’ goals and values. This is where the decision support
center (DSC) and psychiatric social work play an increasingly significant, and overarching role.
The DSC is a recent development in psychiatric social work that functions as one component of
the array of services offered to people with mental illnesses. The DSC aims at improving the
interactions between prescribers and clients by further activating both in the typical 10-20 minute
consultation. It is first of all a physical space, a separate room in the psychiatric facility (e.g.
community mental health center), that contains several computer terminals and a small library of
information for clients about medications and recovery (Deegan et al., 2008; Deegan, 2010).
Trained peer support persons work with clients in order to assist them in finding the information
they need and in using the new Common Ground software. The software is really the centerpiece
of the DSC: it permits the user to set treatment goals, to track how they are doing, to report
symptoms, side effects and other information relevant to their consultation, and to state what
they would like to discuss with the psychiatrist, in accord with their own values and goals. This
is all fully integrated with case management services and is completed approximately one halfhour prior to a client’s appointment with the prescriber. The prescriber receives a printed
summary of the client’s information and goals just before the visit. The intervention has been
designed to enhance the usual psychiatric consultation in such way that improvements take place
in diagnostics, medication adherence, symptom management and overall recovery from mental
illness. This intervention is consistent with good medical practice, but also of social justice for
clients, a social work value (NASW, 2011). Following positive results of interviews with clients
and physicians about using the DSC (Deegan et al., 2008), further research is being conducted
now to determine the effectiveness of the DSC in achieving its goals.
If successful, the DSC will serve both the freedom/entitlement aspect of social justice,
and the responsibility/choice aspect, according to Barth and Nussbaum (respectively). Access to
high quality psychiatric services for all who need them is an entitlement when thinking from the
capability social justice perspective. But equally important on Barth’s account is responsibility.
Responsibility first applies to the people who do not suffer from mental illness. They should set
conditions such that people with mental illness have access to psychiatric services such as
supported work and education, case management, psychotherapy and the DSC). To the extent
that they are able, responsibility also falls on the client. Recovery from mental illness usually
requires a person to take responsibility for their illness. This can mean many things, but will
likely include appearing for service appointments, taking agreed upon medications (if any) as
prescribed, engaging in supportive activities such as counseling or participating in a consumerrun organization. Nussbaum does not require responsibility explicitly, but the translation of
capabilities into functionings requires, in this case, that clients choose to take advantage of
various services and medicines as part of their recovery process. In this sense they are choosing
to have the capacity, and also choosing to make the possibilities of their capacity into realities in
various ways (just like everyone else, according to their real ability to function as their treatment
success permits). A person who has successfully recovered from mental illness would also be
considered (just like anyone else) responsible for engaging in social and political discourse in
order to ensure justice for vulnerable populations generally, and, one would hope, for people
with mental illness in particular. Thus, freedom and responsibility apply equally to all, as they
are able.
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