The freedom of belief and opinion of people with psychosis: The viewpoint of the capabilities approach

ABSTRACT

People with psychotic delusions have been mostly ignored when the freedom of belief and opinion is discussed. In this article, a view of freedom of belief and opinion based on the capabilities approach is presented, and I discuss what aspects are relevant and how these human rights can be promoted in cases of people with psychotic disorder. It is argued that although psychotic disorder may weaken many capabilities of thought and belief, it may also impart some meaningful abilities to the individual. Unbalanced power structures and nursing cultures that ignore existential considerations as well as stigmatization may weaken the person’s freedom of belief and opinion. However, this freedom can be promoted in psychiatric care through the arrangements needed for practicing religion and discussing politics, issuing appropriate medication, helping in decision-making, individualistic care and service user involvement. Further, promoting participation in civil society and the community at large as well as coworking with religious and ideological communities may promote freedom of belief and opinion more widely in society. The challenges involved with the relationships between juridical and ethical rights in the capabilities approach are discussed at the end of the article.

KEYWORDS:

• Capabilities approach
• delusions
• freedom of belief
• freedom of opinion
• psychosis

Introduction: The freedom of belief and opinion—pressured between two opposite views

The autonomy and freedom of people with psychotic disorder as well as ethical aspects of involuntary psychiatric treatment and other possible forms of force have been themes often discussed in ethics and philosophy of psychiatry as well as nursing sciences [123]. However, when it comes to the specific human rights of people with psychosis—namely, the freedom of belief and opinion¹—the discussions have been relatively few. This is interesting, since the freedom of belief and opinion are human rights protected by international human rights conventions [4]. Moreover, the World Health Organization (WHO) and the ethical principles guiding psychiatric treatment ensure that these rights pertain to psychotic people as well [5, 6]. However, understanding what these rights actually protect is anything but clear in cases where people have psychotic beliefs and opinions (in other words, delusions).

When the question has been whether a person with psychotic delusions is free to think and believe, and whether involuntary psychiatric treatment and the use of involuntary antipsychotic medication are justified, two opposite views have been presented. The so-called antipsychiatric view suggests that involuntary treatment and especially the use of involuntary antipsychotic medication violate patients’ human rights since the purpose of the treatment and the use of medication is to influence the beliefs of patients with psychosis [7, 8]. On the other hand, other debaters have claimed that psychosis is something external and alien to the individual, which has distorted his or her authentic beliefs and opinions. Thus, the purpose of involuntary treatment, medication included, is to liberate the person and return his or her freedom of belief and opinion (concerning these views, see, for example, [9, 10]).

Interestingly, the human rights theory seems not to solve the question of how the freedom of belief and opinion should fundamentally be understood, taking into account that some people hold psychotic delusions. It seems that human rights theory ignores the deep conceptual questions that the case of psychotic individuals raises. Namely, if we take the human rights theory concerning freedom of belief and opinion literally, we probably should adopt the antipsychiatric view. The reason for this would be that, in human rights conventions and human rights theory, it has been claimed that the right to hold thoughts in one’s mind should not be restricted in any situation and for any reason. Moreover, it has been claimed that thoughts can be whatsoever, which seems to mean that delusions too, can be seen as thoughts that people have a right to hold in their minds [11].

This kind of approach to the delusions and involuntary treatment has not been adopted in mental health legislation and in the practice of psychiatry because the use of involuntary treatment and involuntary antipsychotic medication are allowed in certain situations. This is wise, since the antipsychiatric view seems to be ethically problematic. Moreover, I suppose that the conclusion of “a right to hold a delusion,” based on the literal interpretation of human rights theory, is a sign of ignorance within the theory itself: people with delusions have not been taken into account when the theory was developed. Thus, it is probably not meaningful to apply these kinds of conclusions to practice.

However, the other view, which sees psychotic disorder as violating freedom of belief and opinion, is problematic as well. First, this kind of view is not recognized in juridical human rights discussion. Psychosis as a nonintentional nonsubject can violate human rights only in a certain metaphorical sense. Second, this view sees the person with psychosis as a victim who should be liberated, which may lead to ignoring the agency of the person—the agency which should be viewed as crucial when discussing the right to freedom of belief and opinion.

It seems that people with psychosis are actually left as outsiders and pressured between these two opposite views. If we adopt an antipsychiatric view, we may neglect the people’s right to treatment in an unethical way. People who resist psychiatric treatment would simply be “left with their delusions.” Is this really what we mean when we want to protect the freedom of belief and opinion? On the other hand, if we adopt the view which understands psychiatric treatment as liberation, the right to freedom of belief and opinion blends into the right to be treated and means almost nothing. So, it seems that people with psychotic delusions are left unattended to when freedom of belief and opinion is discussed, even though these rights should also be their rights. This is why we need to develop the theory concerning freedom of belief and opinion in such a direction that it can be meaningful also as a right of people with psychotic delusions. What does it protect in situations where people have psychotic delusions and what kinds of action do these rights challenge in treatment and society?

The purpose of the article and method

In this article, I present a view of freedom of belief and opinion based on the capabilities approach and discuss what aspects are relevant and how these human rights can be promoted in cases of people with psychotic disorder. The article is based on research where material from different fields (for example, discussions concerning philosophy, ethics of psychiatry, human rights theory, political philosophy, and experiences of service users) were analyzed by philosophical conceptual analysis in order to realize interdisciplinary two-way interaction in human rights theory.

The expression “two-way interaction” refers to Jonathan Glover’s idea that there must be a two-way interaction in ethics. Ethical principles guide practice, but practical dilemmas should also challenge one to develop principles as and when it is necessary. As Glover puts it, “ethical beliefs should also be revisable in the light of an empirical understanding of people and what they do” [12]. I suppose that the same idea can be applied to jurisprudence. The way in which human rights are understood must be tested, and rights should be redefined if we notice that they are not applicable in real life.

I first present how the freedom of belief and opinion as a human right is understood from the viewpoint of the capabilities approach, and what seems to matter when the challenging situation of people with psychotic delusions is considered from the capabilities approach perspective. I then proceed to discuss how freedom of the belief and opinion of people with psychotic delusions can be promoted in psychiatric treatment in communities and societies. At the end of the article, I consider the challenges of discussing human rights from the viewpoint of the capabilities approach.

The freedom of belief and opinion from the capabilities approach perspective

The capabilities approach, presented, for example, by Martha Nussbaum and Amartya Sen, is a view of human rights which emphasizes that freedom is based on different abilities and opportunities of the person. Sen argues that people are free when they are able to lead their lives in such a way that life is valuable to them [13]. According to Nussbaum, the capabilities approach is interested in what people are actually able to do and be and the real opportunities that are available to them [14]. Those who defend the capabilities approach emphasize that freedom in terms of capability is not the freedom to do something particular, but the freedom to choose. According to Nussbaum, options are freedoms [14]. Sen describes the idea as follows: “The focus of the capability approach is thus not just on what a person actually ends up doing, but also on what she is in fact able to do, whether or not she chooses to make use of that opportunity” [15].

Freedom in terms of capability can be divided into internal capabilities and external opportunities that affect each other. According to Nussbaum, internal capabilities are personality traits, intellectual and emotional capacities, states of bodily fitness and health, internalized learning, and skills of perception and movement. External opportunities or external conditions are, according to Nussbaum, social, political, and economic conditions which allow for a range of choices [14]. When it comes to freedom of belief and opinion, it might signify, in terms of capability, that the individual is capable of believing and thinking, choosing his or her convictions (at least in some sense), belonging to religious and ideological communities and living according to his or her views.

The utility of the capabilities approach is that it takes into account the diversity and vulnerability of humanity. This is why the approach has been fruitful for understanding the human rights of people in poor countries and those in richer countries who have special needs [13, 16]. When human rights are defined, we need to do it in a way that is applicable to all members of humanity, not only those who already have several abilities and opportunities for reaching their goals. Thus, the capabilities approach to human rights might have potential when the freedom of belief and opinion of people with psychosis is understood.

Thinking and believing abilities, and people with psychosis

When it comes to people with psychotic disorder, the challenge of freedom of belief and opinion is not primarily if they are allowed to hold and manifest certain beliefs or not, or whether or not they are treated involuntarily. These questions are only secondary. Primarily, the interest is in believing and thinking abilities and in the capability to choose a way of life and communities to belong to.

How psychotic disorder weakens thinking and believing abilities

Psychotic disorder may weaken an individual’s internal capabilities to enjoy and exercise his or her freedom of belief and opinion in many ways. First, delusions may influence the ability to act in reality and engage in social relationships in a meaningful way. If a person’s view of reality does not correspond to the way other people see it, it may be difficult for that person to choose a way of life in which he or she has some value [171819]. Psychosis may also influence the person’s social abilities if the person loses touch with other people who “no longer seem to be saying anything comprehensible or straightforward,” as Grant Gillet puts it [19]. Even though the person has some insight, delusions and hallucinations may be seen by the individual as temptations, which he or she tries to fight against, sometimes unsuccessfully. Gillet notes how voices that are usually “just in the background” and part of a person’s own controlled thinking, may sometimes “seem to have taken on a life of their own with urgent and desperately important messages to convey” [19]. A person may also feel powerless in relation to his or her hallucinations [20].

Second, in some cases, a person with psychotic disorder decides to carefully consider what to believe, and he or she may even refrain from creating ideas in order to avoid delusions. For example, when John Nash learned to discriminate and reject his paranoid ideas and attitudes, he rejected politically oriented thinking “as essentially a hopeless waste of intellectual effort” at the same time [21, 22]. A person with a past of religious activity and religiously oriented delusions may later think that religiosity does not suite him or her. Religion may seem like a drug which leads to the delusions.² In this sense, psychosis may in some cases prevent the person from continuing with, adopting, or developing political, ideological, or religious ideas.

Third, it has been noted that in many cases, psychosis may weaken individuals’ cognitive abilities, such as their reasoning abilities, insight into their own condition, and the ability to pay attention and concentrate [24, 25]. According to Lauri Kuosmanen [24], these cognitive impairments hamper the realization of basic human rights. However, Radden and Sadler [25] point out that these incapacities are rarely absolute and permanent.

At least some psychotic disorders are associated with feeling powerless, which can be described as apathy, insensitivity, or “being like a vegetable, not a human being,” as one of the patients interviewed by Iso-Koivisto put it. As the patient described, “My feeling is that I have nothing or that I don’t enjoy anything and I don’t have any zest for life. I just go from one place to another as if I was numb. It is not possible to read any newspapers or concentrate on anything. If you read, after a while you cannot remember what you read about”³ [23].

Gillett points out that psychosis can severely disrupt an essentially dynamic and interactive pattern of being, and the individual may face an impasse when “the world ahead is presided over by a demand and an expectation to meet it in some very limited way” [19]. Moreover, a person with psychotic depression completely lacks any energy, which Bolton and Banner [17] describe as a phenomenon “that spans the mind-body divide.” Moreover, he or she “feels despair and hopelessness, sees no point in getting up.”

How might psychotic disorder increase internal capabilities?

However, not all the consequences of psychosis are negative. Instead, in some cases, psychosis may feed certain internal capabilities of the individual. This does not mean that a person should be encouraged to experience psychosis, but it might mean that an approach that sees psychotic disorder only as something negative that has to be treated will not see other effects that psychosis may have on the individual’s life.

Psychosis may be associated with a person becoming more aware of life and feeling that his or her life has more meaning. Sihtij Kapur [26] defines psychosis as a state of aberrant salience based on the idea that dopamine has a central role in the process whereby the psychotic individual considers some events and ideas in the external world as important. When Kapur describes the experiences of psychotic individuals, he seems to suggest that some patients become able to think about and understand the world in a new way. For example, some patients with schizophrenia have said, according to Kapur, that they developed greater awareness or that their brain “awoke,” that they noticed new things or that they could put the pieces of the puzzle together. Bill Fulford and Lubomira Radoilska [27] also discuss how psychotic experiences, though significant symptoms of mental disorders, may also be regarded as a basis for problem-solving capacity and positively life enhancing. Glenn Roberts [28] found that people who had lived with delusional beliefs for a long time discovered that their life was very meaningful. Even though their quality of life was weak measured objectively, Roberts found that they considered their life almost as worthwhile as Anglicans who were deeply committed to their Christian faith. According to Roberts, his results confirm the impression “that for some there may be satisfaction in psychosis and that the formation of delusions is adaptive, a creative achievement rather than affliction.”

Psychosis may also be experienced as a positive crisis, which stimulates the person to realize how pointless his or her life has been. It is worth noting that experiencing a psychotic disorder may change a person’s view about what is valuable, and thus, psychosis may influence the way the person would like to realize his or her capabilities. Eeva Iso-Koivisto [23] reports that it is possible that a psychotic experience might lead to the person seeing more options and even increased active agency. One patient interviewed by Iso-Koivisto [23] described her psychosis as a personal crisis in relation to all kinds of “smart systems,” institutions, and society in general. Psychosis led her to consider the meaning of existence. Before, she was unable to answer questions concerning this subject and felt that everything she did was meaningful. Through psychosis, she realized for the first time that not everything she used to do was meaningful. Grant Gillett [19] points out that for many people with mental disorder, “experiences of marginalization have caused a reevaluation of the values around which their lives are organized and that distances them from an all-in conception of reason-governed action in terms of the choices regarded by most as normal rather than pathological.”

Stigmatization and unbalanced power structures as problems of the freedom of belief and opinion

Psychosis has consequences for the person’s various social roles in treatment, different communities, and society in general. According to the WHO [5], people with mental problems suffer from different forms of discrimination and face difficulties in integrating into society. Ethical guidelines for psychiatry also refer to the idea that people with psychotic disorder are in a vulnerable position and therefore need special protection (see, for example, [6], Principle 1:3). The question of a psychotic person’s limited social engagement is connected to the problem of stigmatization, which can be determined as something that reduces the psychotic person’s capabilities. It has been claimed that the stigma attached to mental illness has more influence on the patient’s future than the illness itself [16, 24]. These effects on the person’s social roles may also concern the freedom of belief and opinion.

Problems in treatment

It has been claimed that psychiatrists and mental institutions have a significant amount of power over people who are vulnerable and in a weak position in society. Lauri Kuosmanen [24] argues that unbalanced power structures reduce the freedom of psychiatric patients. John Sadler [29] notes how the use of power often becomes a goal, and how patients are left without the possibility of defending themselves: “With the power of psychiatric diagnosis, patients/clients’ lives and lifestyles are at stake. Those who may be most vulnerable—the recipients of mental health services—often have the least direct input into a construct that will have a profound impact on them.”

Jennifer Radden and John Sadler [25] note that the arrangements in psychiatric practice give unchecked power to the professional practitioner (for example, private meetings where intimate details are considered). Even though there may not be direct coercion of a patient, the structures of psychiatric care may make the patient feel that he or she is being put under pressure or being ignored. Kaltiala-Heino et al. [9] note, for example, that lengthy negotiations concerning medication may feel coercive even though the patient finally “chooses” peroral medication. Marius Romme [30] criticizes any use of a diagnosis that alienates people from their own experiences about what is going on: “it makes them a passive victim of disease; it inhibits an individual’s existing capability and potential and so impedes recovery.”

The problems of psychosurgical operations have been widely recognized from a human rights point of view. In this discussion the focus has been on the irreversibility of the treatment (see Council of Europe Committee of Ministers [31], article 28:1–2). However, from the viewpoint of the capabilities approach, it seems that the focus should not be on the fact that the effect is permanent but on what the permanent effect is, namely does this permanent effect increase capabilities? From the viewpoint of the capabilities approach, we might think that the problem is not primarily that the beliefs or thoughts of a person are irreversibly influenced by a surgery, but instead, that there is a risk of destroying the person’s ability to be a thinking, believing, and competent individual.

Some effects of antipsychotic medication can also be problematic from the viewpoint of freedom of belief and opinion. Sihtij Kapur [26] seems to think that antipsychotic medication may reduce the individual’s motivation, desires, and pleasures:

“A high salience of the objects and ideas that one loves and desires is the important force that drives humans and their social interactions. It is quite conceivable that the same mechanism (i.e., dampened salience) that takes the fire out of the symptoms also dampens the drives of life’s normal motivations, desires, and pleasures. Obviously, the effects are not symmetrical, i.e., drugs do not dampen normal saliences to the same degree they dampen aberrant saliences, yet I know of no drugs that selectively and exclusively affect one and not the other in animals.” Marius Romme and Sandra Escher [20] have pointed out that if the role of antipsychotic medication is overemphasized, the patient may become psychologically dependent on it. Even though medication may be necessary in many cases, patients should be encouraged to find more permanent ways of dealing with their disorder. They might develop a stronger agency in relation to their disorder and thus deal with it that way.

It seems that stigmatization may lead to the existential needs of people with psychosis being ignored. Wagner and King [32] noted that people with psychotic disorder considered existential questions as the most important themes when their needs were the topic of discussion. However, carers (including both formal carers such as mental health workers and informal such as family members) often regarded such questions as symptoms of the disorder or as the results of failures, for example, with the medication. They also emphasized the need for health, housing, leisure, and work, and considered existential issues as being secondary. In these cases, the diagnosis might be seen as a label that influences how carers understand the existential considerations of patients. Since having existential considerations is central to humanity, one might even ask whether people with psychosis are not seen as being fully human when their existential considerations are ignored, even though they themselves value them.

An interesting question from the viewpoint of the freedom of belief and opinion is the rules that forbid public discussions concerning religion and politics in mental health facilities and advise discussing such matters only in a private area and only with certain people. Even though the purpose of these rules might be to protect patients and create a peaceful atmosphere to assist recovery and to avoid conflicts between patients, the question remains whether patients’ needs are also being ignored in the area of freedom of belief and opinion. If discussions concerning religion and politics happen in a private area, this is problematic from the viewpoint of affiliation, expression, and the ability to voice one’s opinions through dialog, which can be seen as important capabilities in society that the person might develop in mental health facilities.

Problems in relationships, communities, and society

The marginalization and stigmatization of people with psychotic disorder may weaken their integration into society [33]. For example, people with mental health problems are slightly less likely to vote in elections than those with good mental health [34]. However, Chan and Chiu [35] observed the political activity of mental health service users in Hong Kong and noted that they were more likely involved in protest actions and had higher levels of political efficacy. However, according to Chan and Chiu, this activity did not appear to produce significantly higher electoral participation or a stronger sense of citizenship, as these aspects were still lower in the group of mental health service users.

Concerning private and family life, there may be a risk of the person with psychosis becoming more dependent on other family members. One might ask to what extent should a person with psychotic disorder take other people’s wishes into account when he or she makes choices, especially if the person is not able to live independently. In some cases, the person with psychotic disorder may follow the opinions and beliefs of family members without fully considering them. (On equal power relations, see, for example, Fulford et al. [36], pp. 480, 554.)

It has been suggested that some people are more vulnerable than others, and that people with problems are more easily influenced by others. According to Radden and Sadler [25] people with psychotic disorder are often temporarily and partially deprived of the capabilities required to defend against exploitation. Their judgement in matters concerning their immediate and long-term self-interest, their capacity to communicate their concerns and needs to others, and their perceptions of other people’s responses may be relatively weak. From the viewpoint of capabilities, the power relations in ideological and religious communities is a difficult challenge, since in order to realize one’s freedom of belief and opinion, one often needs to belong to some community where, for example, one can practice religion or politics; but some communities also may exploit their vulnerable members [37]. For example, if an individual with manic disorder wants to donate a large amount of money to a religious community, political party, or ideological group, the nursing staff has to consider whether to prevent this or not. They also have to consider whether this is a sign that the person is being exploited, or whether it is something the psychotic individual wants to do as a way of participating in some community. From the viewpoint of the capabilities approach, the central question in evaluating this might be to consider how the donation of this money will influence the psychotic individual’s options to later in life. If the person donates so much that his or her options are significantly restricted, preventing him or her from donating the money might be necessary in order to protect the person’s capabilities.

When it comes to social roles in ideological and religious communities, there may also be a tendency “not to take so seriously” the opinions and experiences of people with psychotic disorder. Even though the community may tolerate such a person, there may be a long way to go until he or she is taken seriously and supported in his or her choices (for experiences in religious communities, see Wachter [38]). It is likely that a person with psychotic disorder may easily become stuck in the role of a psychotic person in the community, which may prevent the person from adopting other roles. One aspect of stigmatization has been the undesirable effects of antipsychotic medication, which have been socially disabling [39]. If a person with psychotic disorder is displaced from social life and society by stigmatization, developing new ideas together with others, and having some influence in society and in social life may turn out to be impossible.

The deficient understanding of religious, political, and ideological questions in psychiatric treatment might relate to these wider challenges in communities and society. The question arises whether the attitudes of mental health workers might even discourage people with psychotic disorder from being politically, religiously, or ideologically active. If such discouragement is present, is being active ideologically seen as a threat to the person’s mental health and recovery? Or are society and communities also protected from “psychotic activity,” since patients who are in a passive role may be more easily tolerated in communities? Moreover, the question arises of whether ignorance of ideological themes of discussion and discouragement, if they occur, may lead to patients looking for help concerning religious and ideological issues in places and from people who may harm them.

Promoting believing and thinking capabilities in psychiatric treatment

From the viewpoint of freedom of belief and opinion in terms of capability, a challenge exists to develop treatments that support the patient’s believing and thinking capabilities, as well as to realize a way of life that he or she values. According to Nussbaum [16], good care that takes into account the particular needs of each individual, providing stimulation for the senses, imagination, and thought, constitutes a valuable form of attachment, encourages social and political affiliations, supports control over one’s political environment, promotes the capacity to engage in practical reasoning, make choices, and protects the patient’s self-respect.

Religion and politics during hospitalization

When it comes to the ethical principles guiding psychiatric treatment, the MI Principles [6] recognize that the patient has a right to treatment, which is suitable given his or her cultural background, and that the environment and living conditions in a mental health facility should be as close as possible to those found in normal life.⁴ The Explanatory Memorandum to the RCE [31] points out that the catering arrangements for a psychiatric facility should take patients’ beliefs into account.⁵ However, with respect to ethical principles, no special attention is given to the opportunity to practice one’s religion or participate in political activities during treatment. It is not even mentioned that during elections, an individual’s right to vote should be protected or that voting facilities should be arranged in mental health units. It seems that a psychotic individual’s opportunities to exercise his or her freedom of belief and opinion by voting and practicing his or her religion have not been considered to be as important as his or her opportunities to engage in leisure activities, education, consumption, and work. In this regard, there are also other opportunities that the nursing staff together with religious and ideological helpers could arrange for patients during hospitalization. For example, prayer rooms could be built, discussion groups could be held, masses and services could be organized, literature could be purchased for a hospital’s library, movies could be shown, access to the internet could be arranged as could education, just to mention a few examples.

Appropriate medication

Appropriate medication increases patients’ ability to choose a way of life they value. From the viewpoint of the capabilities approach, freedom of belief and opinion obliges actors responsible for the development of new medications to develop better treatments, which would be effective in promoting abilities that the psychotic disorder has weakened with as little risk and with as few undesirable side effects as possible. Antipsychotic medication can be considered as first aid, given in an emergency, which increases the chances of recovery, and improves any cognitive deficits connected, for example, to schizophrenia, and may make it easier for a person to give up his or her delusions [40, 38, 25]. Sihtij Kapur [26] claims that antipsychotics provide a platform for the psychological and cognitive process whereby an individual can work through his or her delusions and hallucinations. Kapur supposes that this psychological and cognitive process follows similar stages in any case where the individual gives up cherished beliefs or overcomes fears. According to Kapur, “it may involve processes of extinction, encapsulation, and belief transformation.”

However, Iso-Koivisto [23] notes that for some patients, the possibility of coming off their medication or controlling the dosage themselves signifies subjectivity and agency. Thus, from the viewpoint of capabilities, it seems important that the patient knows that he or she is not forced to use medication but that it is something that the patient can consent to. Moreover, psychiatric treatment should not be based on medication in an unbalanced way. Even if medication promotes capabilities, it does so only in part. According to Romme and Escher [20], it is important that patients with psychosis learn to talk about their experiences and deal with them so that they become leaders of their lives. They claim that this ability is supported by putting psychotic experiences into the context of people’s life problems, and treating their personal philosophy with interest and respect.

Shared self-determination

It is also important to note that a psychotic person may need help in making decisions. From the viewpoint of the capabilities approach, it is not necessarily a threat to a patient’s freedom of belief and opinion if decisions are made together. People are seen as fundamentally social, and even dependent on others. Patients interviewed in Maritta Välimäki’s study [41] reported that making decisions together was an important aspect of their self-determination. However, Nussbaum [16] emphasizes that in cases where a person is dependent on others, the person’s opportunities to choose should be supported. Also, Kuosmanen [24] states that it is important that the patient’s capability for choice is supported as much as possible “even in ostensibly minor matters.”

The idea of shared self-determination can also be recognized in the definition of autonomy presented by Widdershoven and Abma [42] when they define autonomy as moral development, which, in turn, is dialogical and practical learning. If autonomy is understood in this sense, it is crucial that a patient is able to reflect on his or her values and find a way to practically deal with his or her situation. However, the patient may need help “to develop a new and better understanding of his situation and a more adequate way of dealing with it,” as Widdershoven and Abma [42] express it.

The consumer model and individualized care

The capabilities approach focuses on the individual’s opportunity to choose and his/her ability to realize goals. Thus, it seems that the consumer model and individualized care in psychiatric treatment are also relevant topics when discussing the psychotic individual’s freedom of belief and opinion.

In the consumer model, people with psychosis are seen as consumers of mental health services who are invited to give feedback and express their opinions concerning these services. Mental health practitioners are seen as advisers, coaches, or collaborators who assist the person to achieve his or her self-defined life goals [43]. Radden and Sadler [25] note that the consumer model can be applied only partly in cases where patients suffer from psychosis, because they may be temporarily or partially deprived “of the very capabilities required for an exercise of autonomy.” However, Radden and Sadler [25] note that patients’ capabilities have too often been underestimated. According to them, one should recognize that people with psychotic disorders probably become autonomous consumers at some point in their treatment.

Moreover, one might ask whether a patient should have more options even if he or she has been sent for involuntary treatment. For example, could a patient choose the psychiatrist who treats him or her?⁶ If this kind of significant power were to be given to patients who are sent for involuntary treatment, would it make the treatment more successful, would it reduce the chances of them feeling humiliated, and would it increase their self-respect? For example, if patients were worried about how their religious beliefs or ideological thoughts would be considered during treatment, they could choose a psychiatrist whom they could trust and feel safe discussing this issue with.

Even though the consumer model seems to provide more options to people with psychosis, the need for deeper service user involvement in psychiatry has been recognized. Instead of seeing patients consuming services, which somebody else has planned for them, they could also have the power to decide what the content of these services should be. Hickey and Kipping [43] call this deeper involvement the democratization approach. Moreover, patients could have more opportunities to speak out for themselves when different psychiatric definitions are given and when further mental health research is done. Maritta Välimäki [41] describes how some patients were delighted when asked about their views on self-determination, and said that it was the first time that someone had shown an interest in what they thought. Välimäki also notes that many patients were capable of offering important insights into the concepts and definitions that are used in mental health nursing.

Nussbaum [16] points out that the important idea behind individualization is that people are not (stigmatized) “types” but rather individuals.⁷ Peele and Chodoff [44] note that general statements about what “the mentally ill need” are suspect because the mentally ill “comprise such a heterogeneous group.” Fulford, Thornton, and Graham [36] argue that different patients have different values. Mental health service users are not a homogeneous group with similar values. They are all individuals with values of their own.

However, from the viewpoint of the capabilities approach, individualized care does not mean that the treatment offered must be in line with the individual’s wishes. The focus of individualized care is not on fulfilling the individual’s dreams but on his or her agency (compare with [44]). Instead of the satisfaction of the patient, Nussbaum [16] emphasizes how important it is for the patient to have the opportunity to be active in the world even if the patient experiences some frustration. Fistein [45] also notes that people with an impaired capacity for autonomous agency would not be able to flourish in an environment where “all their wishes were respected,” since they are not always able to work out how to achieve a state of affairs that they could value or care about. Moreover, people are not always aware of the threats and risks associated with pursuing their goals. In cases where patients ask for help in reaching their religious, political, or ideological goals, the nursing staff must carefully consider whether to help or not. For example, in some cases they would have to take the need to protect the patient’s reputation and privacy into account, as well as what is good for others. These considerations were central in the case presented by Radden [46], where a hospitalized patient wanted to preach the Gospel to people around her and wanted help to do so: “Explaining this directive to me, she urged me to share her revelation with her elderly mother and her school-age daughters. I explained that I was reluctant to do so, and that whatever the truth of these messages, her loved ones would be bothered by them. She was distressed over my decision, seeing me as an agent of the devil for my failure to tell the world of her revelation—this was a message from God, she stressed, and not to be kept secret.”

Even when patients are not helped to realize their wishes and goals, it is still crucial to know what they are. In these cases, the psychiatrist is still obliged, according to Radden and Sadler [25], to understand the source of the patient’s view, “the extent to which they rest not only on discoverable empirical realities but on deeply held moral and philosophical attitudes and beliefs,” and negotiate treatments by referring to the patient’s values and perspectives. Fulford, Thornton, and Graham [36] point out that too often goals are misunderstood or are simply assumed without asking patients what they actually are.

A challenge for communities

In western societies in particular, work life gives people opportunities and influences their social roles in society. Taking this into account, states could, for example, promote opportunities for psychotic people to work part-time without, for example, the risk of losing their pensions or other economic benefits. Moreover, the state could promote a civil society where people’s opportunities and social roles would not tie so closely to their occupational status. Chan and Chiu [35] point out that policy-makers should endeavor to empower mental health service users as voters and as “survivors,” and in this way, help people to identify themselves as citizens.

In addition, good library systems serve people who are not able to buy the books themselves, and that way, further their intellectual development. Moreover, there could be various free courses where it would be possible to develop one’s thinking, such as literature and writing courses and courses in philosophy, ethics, and art. Furthermore, the state could be obliged to provide extra support for education so that people with psychotic disorder have greater opportunities to develop intellectually. The state might also be legally obliged to support different kinds of social groups and networks where people with psychotic disorder could meet and discuss their ideas.⁸ Also, the service users’ involvement in research (especially in mental health research) is a way to promote their freedom of belief and opinion by giving opportunities to influence the way in which issues are discussed and challenge the users to develop their ways of thinking [47]. These sorts of activities could be partly provided by ideological or religious communities, or by other kinds of organizations in which case the state could support them.

According to the WHO [5], religious authorities and other opinion-makers could also take part when the rights of people with mental disorder are discussed. Ideological and religious communities may recognize that people need to develop their capabilities. There may be people in these communities who give their time in order to understand individual situations. These communities may also give people something to do so that they are able to use their gifts. Moreover, communities’ active roles in promoting the freedom of belief and opinion might often go together with protecting the rights to mental health. According to Borras et al. [48], people with schizophrenia who considered religion important in their life and actively attended religious group activities were the most adherent group in psychiatric treatment. Non-adherent patients with schizophrenia were more often people who considered religion important but who were not actively involved in religious groups. From the viewpoint of mental health and capabilities, it might be worth encouraging religious patients to be socially active in their religious groups. It might be that in most religious communities, a psychotic person’s religious views develop in a more healthy direction if he or she gets feedback and has somebody to talk with about religious issues.⁹

Finally, it might be seen as a wider cultural and ethical challenge to encourage people with psychosis to participate and be more social with other members of society. People in general could act in relation to each other so that every citizen could enjoy freedom of belief and opinion, which might mean, for example, “a chance to get to know somebody better, a cue that you are welcome to participate in some activity, a suggestion that you make yourself known in some context or other where others may create social affordances for you,” as Grant Gillet [19] puts it while discussing the holistic nature of recovery where “nothing is incidental, and everything contributes to everything else, even something as minimal as becoming competent at walking the neighbour’s dog.”

Discussion

The consequences of psychotic disorder seem to be deep and holistic, and when it comes to freedom of belief and opinion, they concern both internal capabilities and external opportunities. In this article I have suggested that psychotic disorder may, on the one hand, weaken many believing and thinking capabilities, but on the other, also bring some meaningful abilities to the individual. Unbalanced power structures and nursing cultures, which ignore existential considerations, may weaken the person’s capabilities as well as add to stigmatization in communities. I also pointed out different possibilities for how the freedom of belief and opinion of people with psychotic disorder can be promoted. Arrangements in mental health facilities are needed for practicing religion and discussing politics, appropriate medication, helping in decision-making, individualistic care, and service user involvement to promote the freedom of belief and opinion in the treatment context. Promoting civil society and participation in societies and communities and co-working with religious and ideological communities may promote freedom of belief and opinion more widely in society.

Whatever the reason for a person’s weak capabilities is, with psychotic disorder, from the viewpoint of the capabilities approach, it is a sign of injustice: society has not offered the individual with psychosis access to capabilities [13, 16]. From the viewpoint of the capabilities approach, there is a collective duty to promote the thinking and believing capabilities of people with psychotic disorder [16].

However, as a point of view concerning human rights, the line between judical and ethical duties must be defined more precisely. Who and how far are people judicially responsible for protecting the freedom of belief and opinion of individuals with psychosis? Especially when we consider the freedom of belief and opinion of people with psychotic disorder more broadly in communities and society, it is not clear in which sense it can be said that communities or the society as a whole have violated these rights and in which sense they are responsible for promoting them. For example, even though it seems that stigmatization reduces freedom of belief and opinion, in most cases it would be impossible to charge somebody with stigmatizing someone else. Since stigmatization is a complex process where almost everyone is involved in one way or another, it might be regarded as a social problem, which belongs to the area of ethics rather than a legal problem. However, from the viewpoint of the capabilities approach, the state might still have a legal obligation to somehow prevent stigmatization and promote capabilities. We might also ask whether the person with psychosis has certain duties when it comes to developing their internal capabilities. Is a patient with psychosis expected to be, in a certain sense, virtuous in order to possess his or her internal capabilities? (See Kuosmanen [24], p. 5, note 1; about being a virtuous patient in the context of psychotherapy, see Waring [50]).

When the psychotic individual’s freedom of belief and opinion is discussed in terms of capability, the challenge seems to be that it is unclear what exactly should be protected by the law. It seems that capabilities are weakened because other people are suspicious, because mental health workers and others are not sufficiently virtuous, and so on. However, it is unclear how these problems could be solved by legislation. Even if there were legal solutions, the attitudes of those who follow the rules of law rather than what the law itself stipulates seem to be more crucial for psychotic individuals’ capabilities. The capabilities approach seems to have a challenge: psychotic people’s freedom of belief and opinion in terms of capability is very much an ethical question, which cannot be resolved by law. However, since freedom of belief and opinion is a legal right, it should be understood in such a way that it is possible for it to be protected by law.

Thus, it seems that realizing interdisciplinary two-way interaction in human rights theory as has been done in this research leads us to deep challenges of human rights discussions concerning the relationships between judicial and ethical rights and duties.

Notes

By “freedom of belief and opinion” I refer to the constellation of human rights that protect an individual’s thinking and believing, including freedom of religion, belief, conscience, opinion, and thought.

See, for example, the patient interviewed by Iso-Koivisto [23, p. 85], who suspected that her psychosis was influenced by a bad spiritual season. Another patient, also interviewed by Iso-Koivisto [23, p. 91], found that he started to hear voices after he had started praying for help for his emotional life.

“Se nyt on semmonen, ettei niinku oo mitään, ei mistään nauti, eikä oo mitään semmosia elämisen haluja, sitä menee semmosena puuduttetuna paikasta toiseen. Eikä mitään lehtii pysty lukemaan, ei mihinkään keskittymään, jos luet niin et muista vähän ajan päästä yhtään mitään mistä luit.” Translated by the author.

When the WHO [5] interprets MI Principles, it notes that facilities for religious practice are included in an environment that is “as close as possible to that of normal life.”.

For example, Muslim patients do not eat pork. Some patients may also be convinced vegetarians, etc.

Authors Widdershoven and Abma [42] seem to be open to something like that since they note that if it is necessary, “the care situation should be adjusted, for example when a patient does not want to be helped by a certain professional, but is open to another.” However, should the opportunity to choose one’s psychiatrist be open to all who seem capable of making such a choice?

Nussbaum discusses this in the context of people with mental impairments.

See Wagner and King [32], who note that some patients with psychotic disorder find it important to share their experiences and views in group therapy. They report that these patients’ understanding of their illness was developed in these groups; they were also better able to accept their illness, and even their self-esteem improved. However, some patients preferred to both find the information about mental disorders and reflect upon their lives by themselves.

Borras et al. [48] noted that only 36% of patients with schizophrenia discussed spiritual issues with psychiatrists even though more than two thirds of them considered spirituality to be very important in everyday life. See also Teinonen [49], who argues that individualistic spirituality may be a health risk, because a person’s own fears and feelings of guilt often influence his or her image of God. According to Teinonen, people usually need others to help them create a healthy image of God.