Choose, judge, and move on The tensions arising from implementing personalized care for homeless people with mental health issues in the UK
Abstract
For the last decade, the UK government has followed an agenda of “personalizing care.” Based on ethnographic material from three hostels supporting homeless people with mental health issues in central London, I analyze tensions in the everyday implementation of this policy agenda: on the one hand, using tools such as personal budgets, personalization was practiced by providing people with short-term, concrete choices—between different care workers, activities, and housing options, for instance. On the other hand, the implementation involved developing judgment around longer-term plans, centered on how to “move on” people to independent living. What I describe as personalization’s focus on positive liberty is complicated by the consequences of mental health issues and the after-effects of long-term institutionalization. As a result, choice and judgment were often in tension with each other and more substantially with the residents’ desires for maintaining support and care, linked to a different kind of “freedom in dependence.”
You can’t buy into what they want. It is about rules and the routine. She [referring to resident Kathy1] was in [the office] earlier and was messing around. I said to her: you want your medication, you want your money, please sit down. “No—money now,” Kathy said. She didn’t want to listen and I said to her, “If you want the money, you have to follow the rules.” I sent her away.
When I arrived in the staff office, Kathy, a resident I had gotten to know well, had just walked in while Harry, her support worker, was telling me about the earlier confrontation. When I saw her, Kathy seemed relaxed. She smiled at Harry through the external window of the office before marching in through the main door, heading straight to the sink. She poured herself water and sat on the “medication chair.” Harry opened a cabinet with his key and took out a paper bag with Kathy’s name on it. He emptied the bag onto the table, where two different sets of pills appeared. Two clicks later, a bright orange pill sat on the table right next to a white one. Kathy grabbed and swallowed both without looking up at us. Harry was observing Kathy, now with a thick, transparent plastic envelope in his hand containing a stack of ten-pound notes. Kathy couldn’t take her eyes off the money as Harry counted it out. “You have 70 [pounds] left. You want 10 today, don’t you?” Kathy nodded, took the money and quickly disappeared.
This procedure, what they called the “morning routine,” occurred every day at the three homeless hostels I was volunteering at during the summer of 2014 in central London (for a similar description, see Knowles 2000: 45). The hostels catered explicitly to homeless people with mental health issues and housed thirty-eight people at the time of my research; most of these residents regularly took medication. Often, they were, similar to Kathy, unable to reliably administer daily tasks like medication themselves and hence agreed to have it managed by the hostel staff in addition to their personal finances.2
In one of her earlier regular meetings with her support worker, Kathy had taken the decision—in a process I will come to call “making a judgment”—to police herself both in terms of money and medication and, as a result, her support worker Harry was strict with her in the morning: she could not have her money without taking her medication. That is what she herself had agreed on. The contract Kathy had made with herself was a strict barrier preventing her from making short-term choices in “tricky situations,” such as taking medication. Judgment—leading to reflected-upon and accountable plans for future practices, such as the long-term care plans—was put above spontaneous choice in the daily environment of the hostel. What looked like a “guardianship” arrangement usually found in care homes (e.g., where people with intellectual disability are supported)3 was quasi-institutionalized and hence regime-like across the Hostels, as I would observe during my fieldwork. The appearance of choice was upheld—in the long term, with the compact every person would deliberately enter with their social worker—while short-term, perhaps erratic or seemingly dangerous, decisions could be better controlled. At times, this control (which was seen as “teaching”) was in direct tension with the person’s immediate wishes; in the opening vignette, the spontaneous choice Kathy wanted to make—getting her money without taking her medication—went against the reflective judgments she had previously taken. Her support worker Harry saw it as his task—even against Kathy’s spontaneous will—to make her stick to her prior judgment.4
My fieldwork in London in 2014 was crucially overshadowed by the continuous playing out of this tension between different kinds of choices and judgments, short and longer term; Kathy and most of the other residents I encountered in the Hostels were making or not making decisions every day. The key backdrop for the conflicts I observed was indeed much larger, trickling down from the policy-making world: the day-to-day implementation of “personalization” policies, which had just been launched in the United Kingdom, had just started at the Hostels when I arrived. The day-to-day implementation of these high-level policies, which I will provide more (historical) context for in the following section, was what also affected Kathy in the opening vignette. Teaching judgment and enforcing it was part of every resident’s plan to progress and ultimately “move on”5 and out of the Hostels. Independence—living alone without support—was seen as the ultimate goal which “personalization” was supposed to lead to. This was as much driven by the government’s desire to provide adequate support for everyone—people experiencing homelessness or people with intellectual disabilities alike—as by debilitating budget cuts and austerity measures rippling through the whole of the UK care system (A. Daly et al. 2012; Fitzpatrick, Pawson, and Watts 2020; Macdonald and Morgan 2021). But not only were choice and judgment, both implemented under the policy umbrella of personalization, in tension; more fundamentally, personalization and its longer-term goal of “moving on” and achieving independence was in direct conflict with what Kathy and many of the other residents I encountered desired and often needed: continuous support and care. My analysis follows earlier observations by Desjarlais (1997) and Myers (2015) who in their respective studies of homeless people in Boston and disabled people in urban America find that (unconditional) freedom is often not a desirable goal to work towards.6 For many of the residents I encountered at the Hostels, their version of ideal freedom was not found in what Berlin calls “positive liberty,” but often contained more care and support leading to “freedom in dependence” (see Englund 2006; Ferguson 2015).
Before presenting and analyzing in-depth ethnographic material introducing Hostel residents Dylan, Benjamin, and Deborah, I will provide more context on the “personalization” policy agenda and its implementation in the UK. Following a brief methods section, I go into the history of “personalization” in the UK. In the empirical part, the focus is on one of the major tools of “personalization,” budget plans and their connection to enabling choice and judgment, and on one of the core goals of personalization as it was implemented in the Hostels, “moving on.” Analyzing everyday situations, tensions between different incommensurable choices and goals as well as between the overall agenda and the need and desire of residents for more care will become apparent. In the conclusion I will revert to the theorizing I began above providing alternative ways of assessing residents’ desires in relation to different kinds of freedom drawing on Berlin, Englund, and Ferguson. The empirical analysis and theorization lead me to propose the need for a focus on a different kind of freedom, in dependence, which takes residents’ desires for care seriously.
Methods and context of the Hostels
In 2012, I was conducting four months of daily fieldwork as a volunteer in three hostels that were part of a big social housing organization specifically supporting people experiencing homelessness. I had encountered the organization during prior fieldwork in London (Lenhard 2014; 2017) and arranged this fieldwork for the summer of 2012 with a (social worker) contact I met during my earlier fieldwork. My own position was that of a volunteer; every week, working directly with people across the three Hostels who were willing to participate, I organized various activities, such as cooking and gardening, in a relatively unstructured and ad-hoc manner. Most of the time I supported staff with their daily tasks and accompanied residents while they went shopping, took others to art exhibitions, the barber, the post office or simply for lunch in a fish and chip shop nearby. I helped with everyday tasks such as clearing up the breakfast utensils, and participated in workshops and administrative duties (e.g., putting the residents’ post out) across the three Hostels.
Hostels I–III were run by one of the largest homeless charities in the UK providing support and housing to thousands of people every day. Their funding derived from the usual mix of housing benefits, charitable donations, and crucially (local) government contracts (for providing different kinds of support).7 The three particular hostels I volunteered at only admitted people who had previously been homelessness but also struggled with severe mental health issues; they were part of the same residential block in central London and provided accommodation for the mid to long term (generally between two years and several decades). Altogether, thirty-eight people experiencing homelessness lived in the Hostels at the time of my research and were supported by ten project workers, four support workers (cleaners, cooks, etc.) and six night workers. While the nineteen residents at Hostel I were mixed in terms of age, gender, mental health diagnosis, and tenure in the institution, Hostel II housed fourteen elderly male residents who have been living in similar institutions for between fifteen and thirty-five years. Hostel III consisted of five apartments inhabited by the most independent residents with a high expectation of “moving on” (i.e., eventually leaving the institution and its support network altogether).
At all times, I was concerned about protecting my informants’ anonymity and security (Denzin and Lincoln 2011: 474; Lee-Treweek and Linkogle 2000). All residents and members of staff verbally consented to my research, and management of the organization agreed on my double role as volunteer and researcher. No research participant was paid. Where consent was impossible to negotiate (e.g., with people who were suffering from acute mental health problems), I refrained from collecting data. Even though I did not fully avoid contact and activities with these residents, particularly in group settings (e.g., cooking), I only engaged in more formal questioning with people who were able to clearly state their consent. Overall, I did not make any recordings and abstained from photography to keep the work as unobtrusive as possible. This article is thus based on notes I took retrospectively every day (Esterberg 2001: 73). I followed Hall (2003: 11f.) in this choice of method and procedure; he conducted a similar study in the homeless hostel environment in the UK.8
From care to choice in the UK: A brief contextualizing history
Over the centuries, Britain—and naturally other countries—have treated “poor people,” including people experiencing homelessness, in a variety of ways. They were criminalized by the Poor Laws and the 1824 Vagrancy Act (Beier 1985) or confined to then newly emerging institutions, such as the clinic (Foucault 2003), the asylum (Goffman 1991), and the workhouse (Williams 1981). In the first half of the twentieth century, care and custody started to be offered in parallel more directly, with among others the establishment of the National Health Service, the UK’s public healthcare system (G. Daly 1996). From the 1950s onward, this also triggered a rethinking of the mental health sector toward treatment (with new medications) and increasingly prevention (Jones 1993). As the system soon after came under financial pressure, driven by the oil crisis and shrinking manufacturing industry (Musterd and Ostendorf 1998), the 150,000 people with mental health issues that had been living in UK asylums in the 1950s were increasingly transferred to (semi-)private institutions, similar to the historical precursor of Hostel II. People were released from hospitals and high-support care homes, where, some argued, they became too dependent (Barton and Oliver 1997) promoting community care as the desired ideal (Shepherd 1990). The homeless population was also affected by this shift: while the Housing (Homeless Persons) Act 1977 increased the support for homeless individuals and community care was arguably a positive development (Killaspy 2006), the number of people in guest houses and hostels for homeless people tripled between 1970 and 1990 (G. Daly 1996).
Over the last thirty years, several government initiatives (e.g., The Single Homelessness Initiative and Rough Sleepers Initiative, 1990–9) further targeted the homeless sector, including a further shift toward localism (away from central government to local council oversight) and community care. “Community care” was not only about removing the state from its role as the provider of care—always also with the goal of cutting budgets further and increasing austerity (A. Daly et al. 2012; Fitzpatrick, Pawson, and Watts 2020; Lenhard 2014; Macdonald and Morgan 2021)—but also introduced new values such as “personal choice,” “empowerment,” and more recently “personalization.”9 The focus of the support process, featuring individual needs assessments, care plans, and key workers, shifted to the individual and providing flexible arrangements around their needs instead of a centralized, “one-size-fits-all” provision of services. Since the 2000s, “personalization” became a central policy buzzword. Launched with a number of Department of Health Green Papers in the mid-2000s (Department of Health 2005; 2007) and supported by initiatives by the Social Care Institute for Excellence (SCIE 2005), “personalization” was launched as the new guiding principle on the path to people’s independence and “moving on” (firstly in the health sectors, but seeping into other government silos). Following demands by, among others, disability rights groups and activists (Power, Lord, and deFranco 2013), “personalization” started as an elaboration of the development toward allowing the “client” to choose their services and fit them around their individual needs. “Paternalistic care” (SCIE 2010: 2) was to be replaced by choice in support workers and overall choice in the kind of care received. The underlying principle was focused on enabling “clients” to take care of themselves, through the planning and management of their own services. In homelessness specifically, the “Supporting People” initiative, which was launched with almost £2bn in 2003 to enable local authorities to help “vulnerable people live independently,” was one vector establishing local authority and community care—laying the groundwork for the “personalization” I encountered at Hostels I–III. Concretely, personalization—or individualized or tailored services or person-centered support—emerged as a movement to focus more on clients or users’ individual circumstances; it started with grassroots disability activists but quickly spread through social care policy (Needham 2018).10 The Care Act 2014 established one key component: personal budgets, which we will also see implemented below, across care and support services. Homelessness services, while only mandated directly from 2017 onward, started to experiment with this logic around the time my fieldwork happened (Mackie, Johnsen, and Wood 2019). What I want to fill with empirical detail from my observations at Hostels I–III is this shift.
From a theoretical perspective, the shift toward “personalization” in the UK care sector can be described through a shift to what Mol (2008) calls a “logic of choice” (see also Myers 2015). As Mol (2008) explains, choice has often overwhelmingly positive connotations: it is associated with more individual and patient freedom, more sway over one’s own life (also as a recipient of care), and more influence regarding what practices, activities, and treatments one takes part in. People who make choices are conceived of as emancipated and “in control.” But in her study of diabetes care in the Netherlands, Mol describes this kind of choice as essentially an economic one (2008: 16) making it potentially unfit, even dangerous in the medical context where a logic of care is often more suitable. With empirical material from the three Hostels, I focus in the following on how “personalization” was concretely implemented in homelessness services, and the tensions that arose associated with this implantation. How did the logic of choice, encapsulated in the “personalization agenda,” arrive at the hostels?
Everyday personalization: individual budgets and the struggle with “moving on”
In the sector of homeless care (and homeless mental health11 care even more specifically) in the UK, the “personalization agenda” had only begun to be implemented during the time of my research. In the summer of 2012, the Hostels had for the first time hired an explicit “personalization manager,” Anna, paid for out of local government budgets. Trained as a social worker, her task was, among other things, to design personalized budgets and care plans with all residents—and subsequently provide and organize the desired services and activities for and with residents. “Personalization” was a concrete attempt to continue the decades-old effort to make care specific to the individual and following the personal choice of people, often refashioned as “clients.”12
Historically, the Hostels were all always staffed twenty-four hours a day given the high (mental health) needs of many of the residents; translating the “personalization” agenda into practice hence often involved many different members of staff, like Harry who we encountered in the opening vignette. In general terms, I observed care professionals at the Hostels—key workers, carers, managers, and therapists alike—following what Mol (2008) calls a “logic of care.” I frequently observed care as a process of support, help, and pedagogy (Golightley 2014: 57), a collective effort of ongoing and interactive consolation and encouragement which included the residents (Mol 2008: 29). In this sense, care was tinkering; it was to “meticulously explore, ‘quibble,’ test, touch, adapt, adjust, pay attention to details and change them, until a suitable arrangement (material, emotional, relational) has been reached” (Winance 2010: 111). As the historical trajectory above indicates, this logic of care, however, was gradually eroded and challenged, including during the time of my fieldwork with the arrival of the “personalization” agenda: for decades deinstitutionalization was having an impact; more recently, “moving on” “community care” programs were designed to turn passive patients into active “clients.” “Personalization” was the latest step toward the logic of choice (Mol 2008: 13). What this paper is focused on are the empirical observations of how the implementation of this agenda creates tensions in the everyday work and lives of the residents and staff.
In the first section below, I analyze one of the major tools of “personalization,” individual budgets. On the one hand, staff were focused on teaching and enabling the resident to make more decisions; on an everyday basis, this materialized as a drive toward making spontaneous market choices—allowing them to select from a “menu of activities,” including spending money on the gym, a massage, psychotherapy, a TV, or a manicure for instance. Providing choice was, however, concretely accompanied and embedded by the teaching and promotion of what Lambek (2008) calls “judgment”; this involved defining and working toward longer-term goals such as independence, bodily and mental health, and, most importantly, the life skills for “moving on” into non-supported living. Tensions and conflicts arose when these two aims clashed, such as in the case of Kathy who was unwilling to stick to her previous judgment in favor of spontaneous choice, or Benjamin, a long-term resident whom I will introduce below.
In the second section, I analyze how personalization—and the personalized care plans developed as part of its implementation—are (still) focused mostly on the goal of “moving on” to more independent living and housing; resident’s desire and need for care, especially longer-term care, was often in direct tension with this goal. While staff “personalized care” by teaching residents how to budget, administer their medication mostly with the goal of “moving on,” I observed how the ability to make judgments was much more complicated for people struggling with severe mental health issues, such as schizophrenia, bipolar disorder, and depression. Ultimately, care had the potential to lead to more judgment when we observe residents such as Dylan, who lived in the more independent Hostel III. For other residents, however, care was about maintenance and management (Pilgrim and McCranie 2013) rather than about “personalized moving on.” People like Kathy or Benjamin depended on long-term care—a continuation of what Mol calls a “logic of care,” of the open-ended, needs-based process of support, which demands active involvement from the care receiver and giver (Mol 2008: 19, 29, 29). I argue in the conclusion that people like Kathy, Benjamin, or Dylan demanding care were not unfree, however; they pursued a different kind of freedom, what I call “freedom in dependence” following Englund (2006) and Ferguson (2015). This kind of freedom—conditional on delicate, complex, and time-consuming negotiations by residents and staff—can entail stability and comfort for the residents I encountered. This is a freedom unrecognized by government policy in a historical period where a logic of choice in Mol’s sense (2008) has taken over, and incommensurable with the “personalization” agenda ultimately focused on moving people on (and out), always following the underlying objective to save money.
1. A tool of personalization: Individual budgets
“It’s a tool, a philosophy.”
Anna, the personalization manager,
enthusiastically describing the new initiative.
“I went to Harlow once. They had slides. I love slides. All kinds of waterparks, actually.” Jamie smiled broadly and looked happier than I had seen him before. “Would you want to go there again?,” Anna asked him. “It’s far away,” Jamie said despondently. “But we can rent a car. It would be fun, wouldn’t it? We could get some money for this. You know, this is what ‘personalization’ pays for.” I stood with Anna and Jamie as they smoked a cigarette just outside Hostel I; he was reminiscing about the large swimming pool in Harlow he had enjoyed so much a few years ago. Jamie had been living in Hostel I for over five years. He had been diagnosed with schizophrenia as well as a physical disability that made it almost impossible to use his left arm. Jamie spent most of his days smoking, drinking coca cola, and wandering around the small front court of the hostel. Occasionally, he came into the office to chat with the staff. As I learnt from the conversation above, and on a later occasion when he spoke excitedly about going on holiday to Cornwall, Jamie didn’t like London and preferred being in the countryside. It is memories of these moments, reflections of the happiness he experienced on big waterslides or walking through high grass, that enthused him. When we went back to the office, Anna made her view on the matter clear, suggesting explicitly how Jamie’s “personalization budget” could help with creating experiences like Harlow: “You see there are moments when clients are happy and they talk about stuff they want to do. This is where ‘personalization’ is helpful.”
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Under “personalization,” individual budgets13 (paid for by the local government) are given to residents to finance activities and services. In a personal “care plan,” resident’s goals are linked to activities and adequate finance is allocated to support endeavors, which could include going to the cinema or the library, purchasing DVDs, a gym membership, yoga classes, or manicures as well as psychotherapy. This primary tool of “personalizing activities” I observed as part of the agenda’s implementation at the Hostels fits with Mol’s (2008) description of a logic of choice that I described above: staff offer residents various options from which they can choose, a circumscribed “menu” of services. These activities were mostly limited to services offered within the organization (therapy, cooking, food, art, and washing, for instance) and the community (mental health groups, job training, etc.) but was, in theory, open to more innovative activities. This is the kind of choice Jamie’s waterpark outing would fall under.
Secondly, allocating personal budgets was also supposed to devolve responsibility and inculcate longer-term thinking and planning in residents. In the past, so the argument goes, many groups and activities at the hostel were offered for free and residents’ commitment was limited. The thought was simple: if residents have to pay for activities with personal but limited budgets and are able to choose, the level of engagement and commitment would increase. It was hoped that residents would not only be able to make a spontaneous choice between options at a single point in time, but also build skills that allow them to plan, enacting what Lambek calls “judgment.” In contrast to choices, judgments are about “balance[ing] among alternate human goals … fitting one’s conduct to meet the particular context and circumstances” and to establish a personal “hierarchy of value” (Lambek 2008: 145). While choices are made among a set of commensurable, discrete, and measurable items according to an “axis of comparison” and difference (2008: 145), judgment appears in contexts without a standard of measurement and axis of comparison among incommensurable alternatives. In the life of the residents, the goals of their decisions were often unobtainable indeed: stability in the hostel, freedom and independence in a flat, the comfort of being cooked for, mental well-being, and the security of the hostel community.
Doubts among staff with regards to implementing the “personalization” agenda—and teaching residents choice and judgment—arose particularly in relation to the fact that many of the residents were often not able to take decisions, short or long term, due to their mental health issues (see also Mol 2008: 8). Invented for the adult care sector (and most advocated for by disability rights activists), the application of “personalization” was more complicated in certain sectors, such as the care of homeless people with mental health issues. Harry, a key worker supporting six residents at Hostel I, explained this further with regards to the budgets:
The money is supposed to be spent directly on the individual client but at the same time the responsibility is rolled over [to them]. This is working fine for many people, but some of our core clients can’t really cope with this pressure. They are not used to take decision.
A second problem with individual budgets under the “personalization” agenda takes us back to the opening vignette with Harry and Kathy. Leveraging medication becomes a way for staff to cope with more complicated clients. Anna, the personalization manager, that is, the person responsible for implementing the agenda, explained the conflict to me:
It [medication] frustrates them a lot. They wake up tired, put on weight; you can’t concentrate, you get tired very easily. … [Still] a lot of the clients in the mental health special units are heavily drugged-up because it costs less time than actual therapy and talk.
This [therapy] might be something the new initiative may lead to if the people on the ground can decide, [but] some are already getting sick of it but over the long term I think it is beneficial to think about it in these terms. Practically it [deciding] is a problem now.
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Tension also arose from being forced to balance choice and judgement for residents like Benjamin. Having been institutionalized in different care settings—homeless hostels, hospitals, elderly care facilities—for three decades and struggling with several mental health issues (psychosis, schizophrenia), he was barely able to communicate in a way either I or professionals would understand on a day-to-day basis, and spent most of his time sitting in one of the communal areas of the Hostels staring into the distance. He liked listening to music—but only when somebody else put it on—and went to buy two cans of ginger beer every day, which was generally his only time outside. That residents like Benjamin were driven by routines and procedures, and appeared passive and cared for, does not mean that they have to be written off as “unfree.” Choice for him was often spontaneous and enabled by support and care. He was, for instance, one of the most active participants in the art group—he enjoyed painting fairies and trees—and took part in many other activities. Constant encouragement on the part of the key workers was an important aspect of his decision process.
Benjamin did not really reach a level of independent judgment in this way, however. He was unable to plan his life or take longer-term decisions himself. He often preferred spontaneous enjoyment over plans that would improve his well-being. On the daily outings to the corner shop to get his ginger beer, for example, Benjamin frequently challenged me to hand over the thirty pence of change to him. I was warned beforehand that he would use cash to buy alcohol, however, which was not allowed in the Hostels. While Benjamin was in this sense not “planning his life” toward independence, he was able to choose when supported and cared for. Practices such as managing Benjamin’s money and medication, cooking, cleaning, and washing for him were long term and helped him to comfortably live through his solitary daily routine in contrast to the educational program which, for instance, Dylan engaged in as I will describe in the next section. In fact, the psychologist who had accompanied the Hostels for a long time, Georgina, agreed with this observation: many cases of schizophrenia, manic depression, and bipolar disorder had to be treated with efforts toward managing the chronic condition in an attempt to reach a fulfilled life, rather than focusing on “moving people on.” Particularly for the elderly inhabitants of Hostel II—some of them in their seventies and eighties—the goals of “moving on” and taking care of themselves were distant and often impracticable. In this environment, “personalization”—and the budget constraints that came with it—was a challenging reorientation for often care-desiring residents who were suddenly forced to learn how to plan and judge.
2. The goal of personalization: The tension between “moving on” and the desire for care
Deborah, just over thirty but already with over ten years’ experience living in institutional settings such as homeless hostels and hospitals, described her feelings about Hostel I and her hopes for the future in a conversation with me:
I don’t like being in hostels. I like feeling independent, like [when] I lived in my own flat and all that. I have been in hostels before. And in hospitals. My family doesn’t come here. My sister and Co. They saw me in my apartment but don’t come here. They don’t like it. I am on the list for Hostel III [the apartments] and they said I could move there in four months.
Hostel I, in which she was living at the time, was technically time-limited; moving on from there to a more independent living arrangement, such as Hostel III, should happen within two to three years. While Deborah found a refuge at Hostel I temporarily, she was pushed to change (and plan this change herself) in a way that Bowpitt et al. (2014) describe for the context of day centers: the temporary security she had achieved at Hostel I was not the focus in and of itself; it was used as a stepping stone to continue the personalized path and enable making longer-term plans to “move on.”
But in order to progress, Deborah needed to develop certain life skills deemed crucial by support workers on the person’s pathway, as Anna, the personalization manager described:
We will never send a person for failure […] You can’t send anyone to live independently if you are not sure. We try to teach them skills before they leave.
In the Hostels, care was mostly offered with specific goals in mind, defined clearly in people’s “personalization” plans. The care relationship between a support worker and a resident in this sense can be understood as a pedagogic relationship that is first of all focused on developing concrete abilities that eventually enable independence (Laidlaw 2014). As part of recent government initiatives (National Service Framework for Mental Health; “No Health Without Mental Health”), only this particular kind of care was desirable: only care that led to bettering, cure, and remedy. As Knowles (2000) describes in the context of homeless care in Canada: “The ideal—re-integratable—client serves as the model for all clients.” Translated to the Hostels, people like Deborah were supposed to be depicted and modeled as “curable” and care understood as temporary and goal-oriented, only helping Deborah develop toward “moving on” and independence.
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One afternoon in summer 2012, I was on a walk with Dylan, who had been living in one of the semi-independent apartments in Hostel III for over a year when we met. Over the weekend, Dylan—a middle-aged British man with a history of mental health issues and homelessness—had taken pictures for a photo competition, organized by a partner institution in St Pauls, for homeless people specifically. He was not quite happy with what he had taken photos of: “I didn’t push myself enough to take pictures of London. I took quirky pictures of things in the house, my bike and stuff.” We were on our way to hand in the disposable camera for the competition and decided to sit down at a nearby café afterwards. Dylan had been in different assisted living projects over the last ten years and some of them were very restrictive: “I was living on the first floor [of a hostel] and the office was on the ground floor next to the living room. Staff always knew when you went out and they asked where you went and what you were doing. I mean, that was really constraining and restrictive.” That was different at Hostel III; he liked the space and autonomy it gave him: “There is no office in my building, and I can do what I want.” He told me very excitedly about a party he had been to the previous weekend: “I know this friend from school but I am hanging out a lot with his brother now. The birthday was great—I came home very late.”
Dylan seemingly mastered many of the skills that other people in Hostels I and II, such as Benjamin, Katy, and Deborah, were lacking; he took his medication himself, prepared food, and maintained a functioning social life. He was considered a success case by hostel staff, on the verge of being able to live fully independently. At the same time, he was unsure about his own capacities: “They told me I will be here for about two years max. I think it’s actually two years minimum. I need all kinds of life skills, like just living my life, budgeting, using the tube.” Dylan was not willing to let go of the supportive environment of the hostel, which provided an important degree of organization for him: “I can go to the hostel [Hostels I and II that is] when I need anything. When I have an idea and want to do something, like going away and stuff.”
While Dylan was not “pushed through” too quickly, the goals he was supposed to reach were still clear: temporarily, his desires to be taken care of in a process of “sharing decisions” (Winter and Noom 2003) were granted and he engaged in “dialogue with the social worker” (2003: 335). This dialogue, however, was still ultimately fixed on “moving him on” within two years. The temporality of care had to be defined and be filled with “personalized goals” (teaching life skills, such as the social and organizational skills he encountered during the photo competition). There was a potential conflict looming, however, given how uncomfortable Dylan felt about the timeline and leaving all support and care behind.
***
Despite her excitement for her new role as “personalization” manager, Anna expressed doubts about the influence of what was often called “institutionalization” on the residents: “Ideally, decisions are to be taken by the people living here. But you will see some of the residents are not able to take decisions anymore. What I am positive about is the ones that have not yet been in the system for so long.” Institutionalization turned out to be one of the big hindrances for efforts such as “personalization” on the ground. “Clients” have become used to a way of life—in many cases over decades—which was very much “lived for them.” As another key worker, Carl, who had been at the Hostels for almost ten years, described: “Some of the clients have problems with their identity. All their lives people have taken decisions for them.” People were entrenched in a system of long-term care without goals, which in some cases made them passive and content with being cared for and uninterested in “moving on” and a personalization plan focused on life skills and reaching goals (Knowles 2000: 44).
Even the seemingly very dedicated Deborah was ultimately not quite sure about her dream of complete independence. She did like it in the hospital she had visited so frequently over the last decade: “They told you what to do. Here it’s different. It was kind of security there.” Others, such as a resident of Hostel II, Jake, clearly articulated how they disliked the prearranged, unchallengeable trajectory toward “moving on.” While passionately shaking his head, he explained in a conversation with me: “I can’t cook. I can’t do the laundry. I can’t do anything. I really don’t want to move anywhere.” As Desjarlais describes, based on his ethnography of Boston homeless shelters, some people “grab onto a sense of coherence, stasis, or painlessness” (1997: 112) and are content with a dependence that entailed being “glued together.”
The long-term key worker Carl, as well as the therapist Georgina, were very skeptical about the whole drive towards “moving on” for yet another reason as the latter described to me in a conversation:
I’ll be honest with you. We have a hard core of clients where it [independence] won’t happen. They are grappling with mental health problems and with medication and with institutions and all that. But [the organization] doesn’t want to hear about maintaining. It’s all about independence.
Reframing freedoms
“Personalization” is about giving people more choice and personal freedom in defining their care pathways as explicated in Mol’s (2008) logic of choice. How this was translated in the Hostels was first of all in a “menu of services,” options to choose from planned according to individualized budgets. This kind of freedom is an instantiation of what Laidlaw calls “spontaneous freedom” (2014: 173f.), the “cultivation of an open responsiveness to the sheer contingency of what might come into view” (2014: 175). In the context of the Hostels, residents were often reflexively responding to stimuli in their environment—a friend visiting, a desire to smoke, hunger for chocolate—and in many ways free to follow these impulses. “Personalization” was hence firstly implemented as expanding this kind of spontaneous freedom which has historically often been oppressed for homeless people with mental health issues, especially in environments of incarceration and confinement.
At the same time, certain spontaneous choices—negotiating the purchase of alcohol (Benjamin), receiving her “pocket money” without taking medication (Kathy)—contradicted the second aspect of how “personalization” was translated into the Hostels. Residents also had to devise individual care plans, mostly focused on the ultimate goal of “moving on.” This kind of plan required judgment from residents, in the sense of the continuous labor of deciding “among incommensurable goods” (Lambek 2010: 27) or what I term, paraphrasing Laidlaw, residents’ “reflective ability” (2014: 147ff.). In such a scenario, “we step back from and evaluate our own thoughts and desires and decide reflectively which desires we wish to have and to move us to action” (2014: 148). In the case of the Hostels, staff tried to teach residents to judge on their path to “care for themselves.” Residents like Dylan were learning to take their medication, manage their money, decide on education plans (Dylan was doing a photography degree when I left my field site behind) and acquire “life skills”; in the process they were taught to reflect on their lives, set themselves goals—he wanted to eventually move to Scotland to his family—and to start putting them into action.
Care helped residents like Dylan and Deborah to develop “life skills” and reflective capacity. “Caring professionals … seek to cultivate our minds … in the hope of making us more balanced, they give counterbalance. They encourage us to take good care of ourselves” (Mol 2008: 29; my emphasis). Regular key working sessions and constant reminders and encouragement to take part in activities, for instance, led Benjamin to participate in the art group and cookery lessons. Like in the study of London homeless day centers by Johnsen, Cloke and May (2005), staff were supposed to nurture reflective judgment as a collective effort between care worker and resident.
Reflective ability, already partly actualized in residents such as Dylan, was ultimately seen as the precondition for yet another form of freedom: “moving on” and leaving the need for care behind. The last step in the narrative, on which many practices of implementing “personalization” in the Hostels were modeled, was independence. The independence envisioned in the care environment resembled Berlin’s (1998: 219) concept of “positive liberty.”15 As he describes (1998: 203), the “true self” wishes “to be a subject, not an object; to be moved by reasons, by conscious purposes, which are [its] own, not by causes which affect [it], as it were, from the outside.” In contrast to other understandings of care, which can be on the brink of turning people into objects (Buch 2013: 641), “personalization” is supposed to foster this kind of thinking toward independence in residents. The model of making the full attainment of one conception of what it means to be free (positive liberty, in the form of independence and “moving on”) conditional upon reflective ability (in the form of judgment) seems to work at first—at least on the surface level—for people such as Dylan and Deborah. For other residents such as Benjamin, the process of care toward independence could not be fully actualized; he was in need of ongoing care in an effort to manage the chronic conditions he found himself dealing with.16 And even residents like Dylan and Deborah struggled with the “always forwards” movement toward “moving on,” especially on a timeline that wasn’t their own. Tensions arose repeatedly as I have described in depth above.
Desjarlais traced similar behavior in his classic study of a homeless mental health shelter in Chicago (1997: 183, 199; see also Knowles 2000: 113). He found that residents’ agency “proceeded crabwise … acted in terms of negation and opportunism … characterised by reactivity, indirection, contradiction, spontaneity and impermanence” (Desjarlais 1997: 203). Especially for people struggling with mental health issues and the effects of years of institutionalization, freedom is more likely to be practiced in a reflexive (direct, immediate) rather than in a reflective (considered) way. Acts of spontaneity—demanding the change to buy alcohol, refusing to take medicine—are an impulse of the moment and are often inconsistent with residents’ earlier judgments. Unable to follow their judgments or unable to judge in the first place, residents such as Benjamin or Kathy make spontaneous choices without striving (or being able to strive) for the often unobtainable independence envisioned by “personalization” and “moving on.”
***
In the past, it had been accepted in the Hostels that care could be long term. Benjamin and others were not constantly pushed toward acquiring new skills, toward managing their money and learning how to budget. They were engaged in their respective routines—waking up, sitting, watching television, doing one or the other activity—while receiving the necessary and desired support. The personalization agenda challenged this practice. While “moving on” was the defined, and reflected upon, goal for residents like Deborah and Dylan, it was still regularly challenged; residents demanded and desired more care and tension arose regularly. Government documents and advocates of “personalization” might not immediately think of choice when they see or talk to them (Liebow 1993), but it is not easy to dismiss the residents’ desire for “freedom in dependence.”
Englund (2006: 31) describes in his analysis of the survival strategies of poor families in Malawian townships how their choice of “reciprocal dyadic relationships” of debt, obligation, and loyalty enables them to reach at least partial freedom. Laidlaw (2014: 162) comments: “the obligation and security provided by specific relations of mutual dependency help secure some degree of freedom from other more coercive relationships.” Ferguson (2015) makes a parallel claim in his historical analysis of Ngoni in Southern Africa and his description of contemporary South Africans’ searching for wage labour (and in this dependency). He describes how in the 1820s neighboring groups sought out the predatory Ngoni and willingly surrendered as captives. In this process they were often integrated into the community as wives and children. Like in desired relations of wage labor today, the resulting relations between Ngoni and their voluntary subordinates were not conceived of as unfreedom or bondage (2015: 226), however. They were seen as the enabler of social membership. A “plurality of opportunities for dependence” (2015: 226) created the person as free and offered further options: “To be dependent on someone is to be able to make at least some limited claims on that person” (2015: 231).
Putting aside the vast differences between these African contexts and my own fieldwork with people experiencing homelessness in London, parallels can be drawn to illustrate what I call “freedom in dependence.” A similar situation to the one found in Malawian townships, where there are benefits of entering dependent relations such as those incurred by debt, is desired by some of the residents of the Hostels. Benjamin, Kathy, and later also Dylan and Deborah, choose more or less consciously relationships of care (helping them with cooking, washing, cleaning, choosing activities, etc.), which gave them freedom from coercive market choices and from the independence (or responsibility as Englund calls it) imposed on them by government efforts as well as prevailing social attitudes outside of the Hostels. Residents may still enact spontaneous and direct choice—and that could be a positive impact of “personalization” if kept at this. Overall, however, their behavior challenged the assumptions of what Ferguson (2015: 32) calls the “emancipatory liberal mind,” which links freedom tightly to independence and autonomy. Like Berlin’s account of “positive liberty,” Ferguson’s analysis has close parallels with the ideas extolled by “personalization,” in firstly allowing a limited degree of spontaneous choice and secondly training residents in judgment on their path to independence. In practice, however, Benjamin, Kathy, Dylan, and Deborah find comfort in stability and care, and value this security over the independence which “personalization” and “moving on” might offer. The ideal condition for them would appear to be spontaneous freedom as desired and care when necessary. This is where staff are implicitly asked to support and take delicate decisions on how far this support goes. The balance between freedom and care is subtle, and the exercise of even limited freedom within dependence can be seen as a success despite perhaps not meeting the policy goals of “personalization” and “moving on.”
Notes
1. All the names in this document are anonymized and so are other details about the person (age, country of origin, diagnosis, etc.) in order to avoid constructing traceable persona.
2. While this (extra-legal) “guardianship arrangement” was not usual for the homeless sector (unlike for social care), it was quasi-institutionalized (and consented) in Hostels I–III. The money usually came from the client’s (central government paid) disability or unemployment benefits and the daily allowance was decided upon by key worker and client together in a budget plan. This “spending money” is different from “personalization money,” which came from additional local government budgets.
3. The Hostels were explicitly not care homes (and hence not regulated as such) but were administered by a large housing charity as social housing (and regulated by the Regulator of Social Housing).
4. The Mental Capacity Act (2005) was not discussed during my fieldwork by the support workers as something that needed to be “invoked” to trigger or enforce such a “regime”; people were not seen as “incapacitated” as such. They were able to make choices but only in specific contexts, e.g., meetings with support workers. The Deprivation of Liberty Safeguards (DoLS) had not yet been put in place to counteract restrictions of freedoms, which arguably some of what I observed could come under (it only came into place several years after my fieldwork, in 2015).
5. “Move on” describes the general pathway through different homeless institutions from emergency accommodation to hostels to independent living. In the later part of this article, this development will be explored further.
6. Clara Han’s (2012) study makes a similar case for the benefits of, in her case, debt networks, which help people on the edge of absolute poverty in Chile to survive and care for each other; I refrain from further drawing on the parallels with her observations, however, given the vastly different context and setup.
7. I say crucially because this is where the link to the personalization agenda seeps in: government money started to come with new imperatives shortly before my fieldwork in the mid 2010s as I explain in the historical contextualization below.
8. Hall’s study, however, was not conducted in London and also specifically focused on young people experiencing homelessness.
9. See the Mental Capacity Act 2008 for a similar narrative in the field of mental health.
10. Personalization only reached its full force in homeless support provision with the Homelessness Reduction Act of 2017; you can find a very good (ethnographic) analysis of its frontline implementation in Reeson (2024), confirming many of the tensions I analyze in this paper.
11. Mental health is a complicated concept and the accepted European Union (2005) definition pays tribute to this: “Mental ill health includes mental health problems and strain; impaired functioning associated with distress, symptoms, and diagnosable mental health disorders, such as schizophrenia and depression.” However, I will only mention particular diagnoses where they make a difference for the observation and will stick to the term “mental health issue/problem” in the analysis below.
12. “Client” or “service user” has become the dominant term in both care studies and the actual sector of care. In order to avoid a biased connotation of emancipation, I will use the more neutral term “resident” throughout the paper.
13. These budgets are not to be confused with the “spending money” distributed in the opening vignette to Kathy but part of the institution’s budget (also paying for the “personalization worker” Anna). They are administered by the institution (in this case Hostels I–III) and decided upon with the residents (as described below).
14. This tension rightly raises a bigger question: how can the agenda of “moving on” in the homeless sector co-exist with people who are either “deemed” as lacking capacity or are over long stretches of time unable to, for example, exercise choice or judgment (even if not defined as “lacking capacity” under the Mental Capacity Act, like the residents of Hostels I–III I encountered)? For the purpose of this paper, I will leave this policy conflict to the side, however.
15. For Berlin, “positive liberty” is the “freedom which consists in being one’s own master” (1998: 203), in being “decided, not being decided for” (1998: 203). It is freedom that must be enacted by the individual—not simply the freedom from physical constraint, which Berlin dubbed “negative liberty.”
16. I am not in a position to judge whether it was purely the impact of their severe mental health issues, or partly also the influence of institutionalization and even medication, which made residents tired, inactive, and passive. Both reflection and in turn independence were, however, difficult to achieve for such individuals.
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Dr Johannes Lenhard is affiliated researcher and lecturer in Social Anthropology, Sociology, and the Judge Business School at the University of Cambridge; his monograph “Making better lives,” on fieldwork with people experiencing homelessness in Paris, was published in 2022 by Berghahn. His second monograph on the ethics of venture capital investors is under contract with Columbia University Press.
Johannes Felix Lenhard
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