From: bc17@ukc.ac.uk Date: Fri, 17 Mar 95 02:39:34 +0000 October, 1994 What makes empowerment so difficult? Brian Campbell Introduction Users of mental health services are now asserting their rights to participate in the decision making process affecting them. They are asking to be valued as people first, able to lead active lives and make positive contributions to society. Although attempts at having a more powerful voice in their lives go back to the late 19th century, the greatest advances in empowerment have been made since the 1970s. Following the lead of feminist, black and gay rights groups to gain more power, mental health users are developing a philosophy and direction toward empowerment. Measuring empowerment is difficult. There is no yardstick that can show us relative levels of power or lack of power. Empowerment carries varying definitions. Rappaport (1987, 2) states, "Empowerment is not only an individual psychological construct but is also organisational, political, sociological, economic and spiritual". Chamberlin (1990, 330) defines it more simply in terms of a "rejection of the role of passive service recipient and a stronger voice in mental health matters, generally". Morgan (1993, 190) discusses empowerment in terms of the "ability to gain information in an understandable format". Beresford and Croft (1993, 131) state, "This process empowerment) enables us to make the connection between our private troubles and public policy. It makes possible the journey from our own personal needs to influencing and changing attitudes, values, policy and practice". Ramon (1991,17) defines empowerment as, "the need to give power to people with disabilities and, for them to take it". I will define empowerment as a process whereby a disadvantaged or vulnerable class seeks equality of power within existing social frameworks. A number of conditions combine to establish and maintain people in less powerful positions than others. I will examine some of these conditions from the viewpoints of ideology and power (ideological barriers), service design and delivery (systemic barriers) and vulnerability (personal barriers) and how they affect people who have experienced mental health problems. It is important to note that these factors be viewed in relation to one another, as they interact, to create and maintain social inequalities. Ideological Barriers to Empowerment Ideological barriers to empowerment represent the influences of ideology and the distribution of power within society and how they affect the perception and treatment of people. The view that people with mental health problems are ill maintains an ideology of hopelessness and helplessness. Physicians and other professionals usually see these conditions from the viewpoint of an illness model that implies, "peoples troubles cannot be caused by conflicting personal needs, opinions, social aspirations, values, and so forth" (Szasz 1970, 13). Research efforts, primarily funded by pharmaceutical companies with vested financial interests in the illness model, continue to look for biological roots of peoples problems, emphasising genetic and organic factors while ignoring social or personal origins. Szasz (1972, 12) states, "While medical diagnoses are the names of genuine diseases, psychiatric diagnoses are stigmatizing labels. Psychiatric illness is a myth, psychiatric intervention is a type of social action, and involuntary psychiatric therapy is not treatment but torture". The link between ideology and professional treatment has been identified by a number of authors. Marshal (1990, 26) describes how psychiatry, pinned its hopes on the medical model most in its endeavours to gain recognition and how psychology has lent credibility to the diagnostic model. Farber (1990, 292-293) describes how the disease model implies that people with mental health problems are fundamentally unworthy or defective: "(1) their lives are lacking in authentic meaning or significance; (2) they are unworthy of being loved; and (3) they are incapable of judging what is in their own best interests (they are objects, not subjects). He goes on to say, As long as people continue to grant the experts the power to define them as mentally ill, as ontologically defective, there will be perpetuated a dialectic of domination and dependency". The public view of the mental health patient reinforces the illness model and negative ideology. Entrenched in our language, the mad, lunatic, crazy and neurotic are viewed as different, dangerous, irresponsible and unpredictable. Because they may be dangerous to themselves or others they are often controlled and segregated from normal society. Bean and Mounser (1993, 113) summarise social ideology in the following: "Not being responsible for their actions they (mental health patients) can easily be regarded as forfeiting their basic rights unless or until they return to an accepted level of responsibility. Lacking responsibility they are also seen as lacking other qualities which demand citizenship. As a social group they command little political power, and rarely need to be taken seriously - by this we mean that their demands can be regarded as the outcome of their mental condition and their claims easily side-stepped. They lack the appeal and the power to operate a successful pressure group. All to often others must act in their stead". Farber (1990, 287) states that "mental illness is a cultural artifact, the end result of a particular kind of highly structured dialogue between socially empowered experts and socially disenfranchised, psychiatrically stigmatised individuals". Being black or female compounds the effects of ideology as cultural and gender stereotyping reinforce the heavy stigma already placed on people with mental health problems. Francis, David, Johnson and Sashidharan (1989, 483) describe the black experience as: "They are more likely than their counterparts to have been brought to hospitals against their wishes (i.e. compulsorily admitted, usually through the police under sections of the mental health legislation) and, in most cases, seen as requiring coercion and seclusion within hospitals. Black patients are also more likely than white patients to be forcibly treated, detained in secure facilities such as locked wards, regional secure units and special hospitals. On average their treatment is more heavily reliant on medication or other physical methods". Women who have experienced the psychiatric system suffer similar disempowering effects due to gender stereotyping. Once burned at the stake as witches, women who experience problems are still oppressed. Szasz (1972, 193-195) has likened the witches of the middle ages "(the scapegoats of the clergy) to the involuntary mental patients of today (the scapegoats of psychiatry)". Terms like neurotic and hysteric were primarily ascribed to women and are still used by some professionals today. Women who are assertive, non-compliant or challenging can be labelled as having borderline personality disorder. Degrading labels identify the individual to others and themselves as being hopeless and untreatable. They can become the marker for years of abusive treatment. Tranquillisers, neuroleptics and antidepressants have been used as tools of social control and are more likely to be given to women than men. Valium was known as mothers little helper in the sixties and seventies. Prozac is well on its way to becoming sisters little helper in the nineties. Astin (1991, 12) says, "Historically, femininity has been seen as a pathology in itself. Madness is ascribed by those holding patriarchal power. But not only is a woman labelled, but disempowered on the grounds that because she is ill she cannot help herself". Reed and Wallcraft (1992, 10) assert that women are put in a particularly powerless position by the failure of mental health services to acknowledge their needs and rights. Women who have been sexually molested in hospitals have either not been believed or not taken seriously. Little has been done to address the issue of safety for women. The treatment, labelling and dismissal of women and their experiences in an oppressive patriarchal mental health system all serve to maintain disempowerement. The language of psychiatry and psychology serve and sustain the ideological barriers to empowerment. Medical terminology mystifies and labels peoples circumstances. Terms like Schizophrenia, rarely understood by the general public, cater to disempowering ideology. Symptoms, not individuals, become predominant as identity and power is lost to diagnostic criteria. "The labels sometimes attached to this client group both obscure the nature of the difficulty and have serious consequences in terms of devaluing the individual" (Lavender and Holloway 1988). Systemic Barriers to Empowerment Systemic barriers to empowerment support and strengthen ideology. Until the latter half of this century, individuals with mental health problems in western culture were isolated from the rest of society in institutions. Institutionalisation became popular in the late nineteenth century and continued until the 1960s. Asylums were created to in response to the ideology that people with mental health problems are dangerous and unpredictable and should, therefore, be segregated from society. Few ever came out of an asylum after being admitted. The 1960s saw major reductions in residential treatment with the advent of deinstitutionalisation. Community based services replaced asylums and hospitals as the dominant method of managing people who experience mental health problems. Baldwin (1991, 27) asserts that community care was "established, primarily, to reduce costs and had little to do with the quality of services for consumers". In between the asylums and community services are district or general hospitals that only "manage symptoms and are drug-centred in their treatment approach" (Butler 1993, 2). Insulin shock, ice baths and psychosurgery are relics of the past, yet hospital and some community based treatments still promote the use of electroconvulsive therapy, physical restraint and seclusion. Neuroleptic and hypnotic medications serve as passive yet powerful agents of community restraint and social disempowerment as their actions are designed to promote passivity and conformity. It has been argued that community based services have replaced asylums and hospitals as a more acceptable and economical agent of disempowerment. Farber (1990, 285) contends that "any psychiatric, psychological or other professional treatment undermines the individuals capacity for change and is simply a method of maintaining social control". Allen (1992, 255) has the following observation on community treatment: "There is an unspoken assumption by its adherents that the therapeutic community must be a good thing. To question whether it follows any guiding principles of empowerment - let alone whether it rehabilitates clients - is a topic close to heresy!" Community services retain the imbalances of power inherent in institutional settings. Management is hierarchical and service providers are usually recruited from traditional nursing and social work professions. "Planning and management of services has continued to reflect the medical ethos of the model: community care in short was derived from a medical model" (Baldwin 1993, 8). Allen (1992, 254), commenting on his own experiences as a community housing project manager describes staff as "healthy and omnipotent" and residents as "disempowered and necessarily ill who's lack of formal power is contradictory to the notion that they take more responsibility for their lives". Diminished legal rights contribute to disempowerment. They can be abrogated when a person is considered mentally ill. If a person is deemed by a physician or social worker to be dangerous to themselves or others they may be forcibly detained and treated. Nowhere else in society can a person be held or be subjected to invasive trearment for what they might do. The rights to privacy, consent to treatment, access to medical records and the ability to bring criminal and civil action are all compromised under the legislative practices of many western countries. Bean and Mounser (1993, 114) say that "physicians can do almost anything to a patient as they are armed with a view that they have a duty and an obligation to provide treatment and are supported by an ideology which refers to treatment as always being in the patients best interests and (is) buttressed by a view that psychiatry offers a humanitarian service". Personal Barriers to Empowerment Most people with mental health problems have been labelled, institutionalised and medicated. Some have been forcibly detained, restrained and treated against their will. Asserting or even imagining a right to power is difficult under these circumstances. People who have been institutionalised may become disadvantaged due to the highly structured nature of institutional (and sometimes community) life. They have been told when to wake up, when to eat, when to take their medications and how to spend their money. Social skills are underdeveloped as people have not had the usual experiences of engaging others in society. Mental health problems can become apparent in adolescence and interruptions in formal education and skill development may occur. Social position is compromised. Many have been unable to work due to the personal limitations of coping in a society that misunderstands them. Others have encountered employers who are unable or unwilling to deal with the challenges of employing someone with a perceived, potentially dangerous disability. Harp (1994, 84) reports employment rates of only 10 to 30 percent for people discharged from psychiatric hospital wards. "They feel resigned to a life of unemployment or a series of dead-end jobs, in which they are disinterested and/or for which they are overqualified" (Cohen 1986, cited in Harp 1994, 88). Unemployment and reliance on social services perpetuates dependence and a lack of power. Fear of losing permanent housing and income benefits is a concern to many who wish to return to work. Should they be unsuccessful in their attempts, social benefits may be interrupted or terminated. Powerful medications (neuroleptics, antidepressants and benzodiazepines) are often given to people with mental health problems. The actions, side effects or addictive natures of these drugs can impair an individuals ability to concentrate, relate or perform. Employment, education, social position and life skills are the essence of power. If they are absent, an individual will be unable to attain or exercise any significant amount of power within society. Personal barriers to empowerment can stem from many of the same conditions that lead people to seek help in the first place. Drawing on the experience and knowledge of Cindy, a psychiatric survivor, I will discuss how an adult, abused as a child and seeking help for consequent mental health problems can be an example of this. The abused child may attempt to avoid feeling powerless in a number of ways. One way is to be good. The reasoning is, by being good the abuse will stop. The child has then exercised a degree of power over their situation. Another way is to control herself. If she can't control the events in her life, she can control herself. Control can be exercised over emotions and actions. Self control may take the form of controlling food intake, overachieving, self-harm or addictive behaviours. It can carry on to adulthood with the individual mistaking her coping mechanisms for real power. She may believe she has power when she does not. She may not realise they she is being marginalised within the mental health system as this realisation may demonstrate to her how powerless she really is and bring back the childhood experience. Interacting with professionals who are unaware of or choose to ignore these conditions may perpetuate the lack of power. They may mistake the individuals needs and how they are attempting to assert them within a behavioural paradigm. The individual continues their behaviour as this is all they know yet is repeatedly dismissed or disciplined for their actions. An empathetic environment where professionals are proactive to the needs and powerlessness of their clients is required to acknowledge and address these issues. An essential part of the empowerment process is the recognition and ability to through work through the feelings as well as the facts of powerlessness. Conclusion I have outlined some of the conditions that combine to create and sustain the conditions that make empowerment difficult for people with mental health problems. The disadvantaged and vulnerable do not have easy access to the resources that would allow them to accomplish the task of empowerment. Any attempts to change ideologies and systems will require a commitment by providers, legislative authorities and the general public to value and respect those who are different. To accomplish this, in a society that views people with mental health problems as helpless, hopeless and dangerous, coupled with a patriarchal medical system dominated by the belief that mental health problems are biological in nature, may prove to be impossible. References Allen P. (1992) User Involvement in a Therapeutic Community, Therapeutic Communities: 13, 4, p. 255. Astin J. (1991) Women & Madness, Misogony or Mental Illness?, Asylum: 5, 3, p 12. Baldwin S. 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