Sharon Johnson, October 2019
In this Book Review, Sharon Johnson provides her perspective and insights on Healthy Ageing: A Capability Approach to Inclusive Policy and Practice by Christine Stephens & Mary Breheny. This is the first review of the books from the Critical Approaches to Health series co- edited by Kerry Chamberlain and Antonia Lyons, and published by Routledge, in association with the International Society for Critical Health Psychology. (ISCHP members receive a discount on the purchase price of books in the series.)
Healthy Ageing considers the Capability Approach in navigating the difficult topic of “ageing well”, offering broader perspectives beyond the conventional idea of physical health as the only criterion to gauge the process of growing older. Rather, an ageing population is considered a necessary burden on society, with historical, social and cultural contexts needing to be taken into account.
The Capability Approach forms part of a critical, social science perspective, and makes appropriate demands on health and care systems rather than on individuals as in the “successful ageing” paradigm. The authors argue that notions of success are embedded in oppressive neoliberal ideas of individual responsibility for health and ongoing denial of growing old. Within this frame, we seek eternal youth and try to keep control of the ageing process. There is also difficulty in including death within understandings of healthy ageing, with people failing to focus on what makes life meaningful.
Challenging the successful aging discourse, the authors of Healthy Ageing ask: ‘Why should older people be asked to evaluate the “success” of their ageing?’ and ‘Why should we comment on successful attributes at all?’ These questions point to the complexity of conducting research within the existing evaluative successful ageing discourse. The theoretical starting point for Stephens and Breheny is Amartya’s Sen (1993) Capability Approach, transcending the biomedical model and instead utilising notions of resilience and lived experiences of older people to determine the meaning of healthy ageing. This is considered a theoretical approach to social justice, a field of praxis and a framework for social change.
The Capability Approach that Stephens and Breheny propose offers an alternative construction of well-being to the dominant “successful ageing” discourse, focusing on social and environmental supports that enable people to live a life they value. The concept of quality of life as a socially constructed version of individual experience shifts the medical definition of health perspective to encompass broader aspects of well-being recognised by older people themselves. Examples are the importance of being able to engage in valued activities developed across a lifetime and a strong sense of being important within one’s social group.
Core Capability Approach concepts are outlined in the book, including: ‘functionings’, ‘capabilities’, justice and inequality, and well-being, within a systemic framework. Functionings include basic needs of food, health, literacy and social respect, which are context specific. Capabilities examine the ability to function in a particular way according to values and are linked to well-being – ‘the freedom to be and do’ (p. 23). A theory of justice values equality, linked to access to good health care with a focus on actual lives. Well-being is about control over physical, social and environmental factors which make an older person achieve desired functioning.
The Capability Approach provides a theoretical framework, taking into account the material and social situation of people’s lives, considering different culturally based values. The authors cover existing research models and theories and examine critical and social approaches which could inform a Capability Approach. For example, feminist theorists add to the critical debate on ageing by foregrounding diversity and power relations.
Most of the book is made up of chapters which address the realisation of different capabilities, with vignettes of older people explaining their life experiences to contribute to our understanding. These capabilities are: physical functioning, security, contribution, social connection, enjoyment and autonomy.
Initial stories bring to life difficulties encountered by older people:
“I’m getting unsteady, terribly unsteady…I’ve managed to get someone that comes in to help…” Freida, 81 years (physical functioning).
They end with narratives of social support:
“I’ve done things in here that I have never done before, I sing in the choir, I sing solo… I never did it before’ (Brian, 76 years).
An example of physical functioning support is a home for life housing policy in the UK, which takes into account self determination in the design of apartments for the elderly so they do not need to be institutionalised.
The book ends with a discussion of research that can include the interconnection of these capabilities. Capability Approach’s main contribution is the shift away from institutionally prescribed achievements to a focus on what people can be or do, and their freedom to achieve valued functions. As ageing is inevitable, the authors offer a refreshingly sensitive and critical approach to the meaning of what it means to be healthy as we grow older and invite all readers to examine their values around this challenging phase of life.
About the author
Sharon, Johnson, senior lecturer and supervisor at non-profit higher education Cornerstone Institute in Cape Town, South Africa, has a PhD (Psychology) from Stellenbosch University, and a post-doctoral Fellowship (2016). Her focus is on stress and burnout of teachers and trauma in schools. She has been published internationally in journals and academic books and is completing her own books on care of maltreated youth in a state institution and the development of a teacher trauma tool for schools on the violent Cape Flats, South Africa.