Presentation of study results reflects the theoretically informed, yet inductive analytical process described above. We show how the analytical questions intended to specify capacities and occasions were answered, and we lay out the theory of capacity development for social integration.
What capacities are needed for connectedness and citizenship?
The following capacities are suggested by the data.
• Responsibility is the ability to act in ways that reflect consideration and respect for others.
• Accountability is being answerable to others for the consequences of one's actions in the context of a given set of social or moral standards.
• Imagination is the ability to form ideas and images in the mind and know they are mental creations.
• Empathy is the ability to envision, understand, or identify with others' points of view.
• Judgment is the ability to form sound opinions and sensible decisions in the absence of complete information.
• Advocacy is the ability to argue articulately for a position orally or in writing.
The relative salience of social, emotional, cognitive, and moral dimensions varies across capacities. Empathy, for example, is prominently social and emotional. Cognitive and emotional dimensions are especially salient in advocacy. In responsibility and accountability, social and moral dimensions come most quickly to the fore. A major advantage of the capacity construct and the larger capabilities approach is that they highlight the moral dimension of agency, thus allowing moral experience, or "what really matters" (
44 ), to be introduced into the discourses on social integration following psychiatric disability and the meaning of recovery from mental illness.
What do occasions for building capacities look like?
To address this question, five types of occasions were identified. Occasions are defined as structured mechanisms of change leading to capacity development. Here, mechanisms of change are embedded in microexchanges between mental health providers and users of care. In each type of occasion, change is directed at building capacity for connectedness or citizenship. The five types of occasions represented—contradiction, reinterpretation, rehearsal, raising expectations, and confrontation—are those most salient in the study data.
Contradiction. Mr. M, who was an interviewee, described being evicted from a homeless shelter because of repeated rule infractions. He was angry about the eviction. However, his anger was tempered—and complicated—by the fact that although shelter staff had instigated the move, they had also found him a new placement, helped him pack his things, and driven him to his new residence. Mr. M was impressed but also confused: "I couldn't just call them jerks!" he exclaimed. "True, they kicked me out, but look what they also did for me!" This seemingly contradictory juxtaposition of callousness and concern triggered a shift in both perspective and behavior for M. "I remember it really clearly," he said. "I got to the new place, and when I walked through the door I said to myself, 'This is my chance to do things differently.' And I did. It started there. I started being accountable to people."
Reinterpretation. Reinterpretation is occasioned by encounters with new meanings of a familiar idea. In the following interview excerpt, Ms. S recounts an experience of being asked to "call in" to the halfway house where she was staying. In the course of the interaction, she encounters a new meaning of "call in." Though calling in had been previously experienced as an infringement on her independence, in the interaction depicted below Ms. S was presented with the fact that calling in can also signify consideration for others. Learning and acting on this new meaning, Ms. S subsequently became more "responsible."
"I remember the first time they asked me to call in when I went somewhere. It was like, 'Call in? You ain't my mother! I ain't callin' you. It's my business where I go and what I do!' And she [staff person] was like, 'But we worry about you!' And I said, 'Nobody worries about me, so don't even go there. I'm just here for a place to live until I can get through school and get my own apartment.' And she was like, 'Well if that's all you're doing here, you could go back and sit on a ward and do that.' And I was like, 'Wait a minute, what do you mean?'"
Rehearsal. Enactment is essential to capacity. Hence a third capacity-building mechanism is rehearsal. By rehearsal, we mean executing a developing capacity in a learning environment, with the expectation of feedback. The psychiatric rehabilitation program participating in this study enables participants to rehearse being students by using an adult education model of practice. The community-based psychosis treatment center organizes theater workshops led by professional actors who stage rehearsals of emotional and imaginative capacities—empathy in the form of adopting multiple perspectives on a situation, for example. By creating a "living-learning" environment for the practice of reciprocal relationships, the therapeutic community we visited functions continuously as a "rehearsal stage" for connectedness and citizenship in the larger social world (Dickey B, Ware NC, unpublished manuscript). Rehearsal may usefully be contrasted with practice, cited above as a means of skill development. As a capacity-building mechanism, rehearsing creates experience.
Raising expectations. In a fourth example, we see increased sociability brought about through a subtle raising of expectations. During a study interview, Mr. R referred to a "turning point" after which he became more open to connecting with others. As Mr. R described it, conditions for the change were created by Ms. T, a mental health practitioner who was consistently respectful and "nice" to Mr. R. When he returned her greetings with "go to hell," she simply smiled. When he hung up on her telephone calls, she proceeded as if nothing had happened, inquiring after his well-being as usual. Then, one day, Ms. T's congeniality cooled. "She stopped talking to me," Mr. R reported. "She stopped saying 'hi,' asking me how I was doing." Mr. R found he missed the "attention." The pull of the connection he had come to expect outweighed the urge to remain interpersonally distant. Tentatively, he "tested the waters," as he put it—initiating greetings, being the first to "say hi." "And that's how it started," Mr. R concluded. "Little by little. Talking. Then the conversations started getting longer and longer. Next thing you know, I was in her therapy groups."
By exhibiting warmth and respect, Ms. T modeled an alternative to Mr. R's characteristic rudeness and expressions of anger. By pulling back at a certain point, she signaled that his usual demeanor was no longer acceptable, in effect "changing the rules" of interaction between them and setting a higher standard. The new standard required that respect be warranted or "earned" through socially acceptable behavior. Mr. R promptly responded, becoming more considerate and respectful—"nicer"—and more connected to others.
Confrontation. The last mechanism we term "confrontation." By confrontation we mean deliberate challenges to actions that fail to meet accepted standards. Confronting unacceptable actions on the part of individuals with severe mental illness sets an expectation of accountability. It assumes capacity, reinforces connectedness, and communicates that how one acts affects others—that in social interactions, something real is at stake. This is aptly illustrated in the following interview excerpt, in which a staff person at the participating therapeutic community describes her response to a resident who "faked" an injury to escape work responsibilities.
"My first thought was I want him punished. But because I felt that way I realized the worst thing I could do was talk to him at the time. So I wrote him a note about how it felt to be lied to, and how it felt to realize that he was a dishonest person, and that our trust was broken, and that that was going to have lasting consequences. The consequences that arise from people's actions are natural, and as a natural consequence of his lying to people, I'm not gonna trust him. And that's going to be really hard for us to work around."
Not every capacity-building occasion produces immediate change, as the remainder of this anecdote makes clear. The staff person's attempt to communicate a lesson in the interpersonal consequences of dishonesty initially went unheeded—her note was interpreted and dismissed as simply a "list of complaints." Subsequent attempts, at least one of which involved third-party mediation, led to an understanding of the grievance (note: a form of empathy) on the part of the resident. Eventually, the relationship was, if not strengthened, at least returned to its original state.
A theory of capacity building for social integration
Having laid out the building blocks of the theory—capacity, occasion, mechanism—we come now to the task of assembling them into a proposition, as follows:
• Individuals with psychiatric disabilities bring preexisting capacities to the development process. Existing capacities expand, and new ones take root, through exposure to occasions for growth. Occasions present challenges and may be simple or complex, that is, made up either of single interactions or of orchestrated sequences arranged in order of increasing difficulty. As challenges are mastered via mechanisms—contradiction, reinterpretation, confrontation—competency is affirmed. A sense of possibility emerges, and with it, aspiration. Together, aspiration and a sense of possibility fuel engagement with new, more challenging occasions. Capacity builds and expands into agency in an iterative, open-ended process.
This process is depicted schematically in
Figure 2 .
Occasions for capacity development share a number of characteristics. They assume that capacity development is possible and will take place. Practitioners act accordingly by setting expectations for performance and insisting that the expectations be met. They also allow for the possibility of failure and, when it occurs, find constructive ways of responding. Constructive responses examine failure and place it in perspective but also allow the consequences to unfold. Genuine actions and events are characterized by the fact that something significant is at stake.
The development process is expected to be neither uniform across capacities nor steady in pace. Slippage, stalling, and temporary reversals will occur. Unexpected obstacles will crop up. Challenges will be declined. An adequate theory must account for such contingencies, as the representation we offer attempts to do.