Centering Agency and Choice in Moving Toward Social Justice in Mental Health: Reflections on Childhood Maltreatment, Psychiatric Symptoms, and Homelessness

The report by Widom and colleagues in this issue (1) is based in an exceptional longitudinal study designed to examine the adult life course of children exposed to legally recorded maltreatment. Since the 1980s, this study has made profound contributions to what we know about the impact of childhood maltreatment in multiple domains (2, 3). About 25 years ago (4), Widom reviewed past contributions and envisioned themes for subsequent work. A prominent future theme would be the investigation of causal pathways by which social determinants (and inequities in them) shape health across the life course after childhood experience of maltreatment. Our comment pertains to both the specific causal pathway examined in this report and to the broader theme within which it is situated.

We begin by drawing attention to a novel feature in this report: the use of prospective follow-up data to disentangle a potential causal pathway from child maltreatment to adult homelessness. Then, with respect to social determinants, we take a broader view, proposing that in mental health research, we need to engage more with theories of social justice and human rights. These theories give deeper meaning, and when applied in conjunction with studies of social determinants of mental health, they offer a path forward to mitigate social inequities.

The study led by Widom began in 1986. The researchers identified 907 children ages 0–11 years who had legal records of maltreatment during 1967–1971, and for comparison 667 children who did not, with the two groups approximately matched on social class. The sample was first recruited for assessment in early adulthood; 76% participated. After that they conducted three subsequent follow-ups, with about half of these 76% retained in the last follow-up 2009–2010.

The causal pathway examined in this paper is one in which childhood maltreatment increases risk of psychiatric symptoms in early adulthood, which in turn increases risk of homelessness in later adulthood. In other words, psychiatric symptoms “mediate” subsequent risk of homelessness. An analysis using structural equation models supports the presence of this pathway. The authors use the multiple follow-ups of maltreated children during adulthood for their analysis. Their data are to our knowledge the best available for the purpose. Crucially, the first assessment included lay diagnostic interviews (DIS-III-R), and the first assessment as well as subsequent follow-ups included past year homelessness. Thus, the paper represents a welcome effort to discern pathways from child experience to adult homelessness within a life course perspective.

Readers also need to be aware of the paper’s limitations. For example, there was substantial attrition over the follow-ups. This and several other potential sources of bias have been investigated in previous papers (5), and to some degree in this one, and do not appear likely to account for the findings. Other limitations include imprecise measures of past year homelessness. Our main concern, however, pertains to the method used for analysis of mediation. The structural analysis the authors use to evaluate mediation was elaborated in seminal papers (6) during the early 21st century. Since then, new methods have been developed and widely adopted for mediation analyses in epidemiology. From our perspective, these newer approaches are better suited to the question about mediation posed by the authors because they require more explicit statements and evaluations of the underlying assumptions of the mediation model (7). Yet the findings are highly plausible, and we recognize that methods for mediation analysis vary somewhat across disciplines.

As recognized early on by Widom (4), results such as these are also complementary, indeed integral, to advancing our understanding the social determinants of mental health across the life course. It is now widely acknowledged that the conditions in which individuals live are crucial in shaping illness and health, including mental health (8). A recent review showed how key social determinants are associated—causally, authors propose—with mental health outcomes (9). These social determinants, such as socioeconomic disadvantage, early life adversity, migration, discrimination, and sex-based inequities, among others, are unevenly distributed across populations, reflecting deep social inequities.

Yet in our view, we have a responsibility in mental health to go beyond describing social inequities and how they emerge across the life course. While “equity” is a valuable concept, it falls short of capturing the complexity of the challenges in this field. We advocate for a framework that also incorporates human agency and choice allowing us to better define fairness, recognize injustices, and most importantly, chart a path toward justice in mental health. This framework must draw upon social justice theories being applied in other fields, such as health and social development. Notably, these theories have received scant attention in mental health. Two of the factors contributing to this gap bear mention here. First, existing general theories cannot be directly applied in the mental health field; they require substantial adaptations to account for the social complexities surrounding the designation of mental ill-health (10). Second, human agency and choice have been historically denied to those diagnosed with severe mental health disorders. These factors make it all the more essential to center human dignity and rights by engaging with social justice theories.

As a starting point, we propose building upon a highly developed and widely used framework called the capabilities approach (CA), which has had a major impact in the fields of development, human rights, and public health (8, 11, 12). A distinct feature of CA is that it highlights agency and choice as essential to justice. A fundamental goal of CA is to expand the “freedoms” of people to live their lives in ways they find meaningful. As Nussbaum puts it, the capabilities approach “is focused on choice or freedom, holding that the crucial good societies should be promoting for their people is a set of opportunities, or substantial freedoms, which people then may or may not exercise in action: the choice is theirs” (13, pp. 18). She points to the difference between fasting and starving. The effect may be the same from a nutritional perspective, but the capabilities are different, because the former involves choice and the latter does not.

In applying CA to the mental health field, we have to contend with ambiguities in differentiating agency and choice. In what sense can we say that a person with severe anorexia nervosa chooses to starve? Nonetheless, the field has evolved in the 21st century with the increasing orientation toward recovery and early intervention, and with the growth of survivor-led movements such as Mad Studies. The latter tend to emphasize lived experience and first-person knowledge and promote a transdisciplinary perspective that is broader than the biomedical model (14). Further, normative instruments such as the UN convention of the rights of persons with disabilities (15) have made it increasingly clear that a framework such as the CA, where choice and agency are central, is urgently needed. Our challenge is to adapt it to the complexities we face.

Widom and colleagues’ results underscore the need for this adaptation by elaborating the interrelationships between childhood maltreatment, psychiatric symptoms, and homelessness. The fundamental rights of children stipulated in the UN Convention on the Rights of the Child already include safety from maltreatment, participation in decision-making, and provision of other rights such as education (16). Previous authors have suggested that combining human rights-based approaches and epidemiologic research is an effective way to promote these rights (17), and the World Health Organization has suggested the same for mental health services (18). We believe, however, that we also need to take the further step of integrating mental health into theories of social justice and vice versa.

Nascent applications articulated in mental health indicate the promise of CA and explore the role of freedom to exercise agency and choice in recovery, policies, and services (19–21). These applications have underscored three key points. First, the concept of recovery must be expanded to ensure that people with mental ill health have the conditions to not just survive, but to thrive. This requires safeguarding fundamental rights—such as access to housing, health care, and education—and enabling capabilities that allow individuals to flourish in the community. Second, policies must reflect this broadened understanding to make structural change possible. Finally, practice innovations informed by this framework have to operationalize agency, choice, freedoms, dignity, and rights in day-to-day work. Then we need to find ways to evaluate whether these theories are applicable and beneficial in practice. While current scholarship articulating the CA in the mental health field has not arrived at a full resolution, their work lays a foundation for doing so. It is now time for the mental health field writ large to dedicate time and resources to build on this work and chart the paths toward social justice.