May 15, 2012

Mental Illness Power Trip: Flashback 1981

A collection of 1981 essays shows how mental illness stigma works today. 

In early 1981, the authors of the academic journal Community Mental Health published a special issue on citizen participation in community mental health services. For many years, community mental health centers had been required to include members of the community-at-large as well as service users (“consumers”) on their governing boards. How was that working out?  Where else could ordinary citizens participate?

The editors found that citizen participation seemed to work out in theory, but it hit its limits when it came up against the power of professionals to design and deliver services. This clearly relates to two themes of mental illness stigma that persist today – a real fear of loss of personal power and control, and a false derivative belief that only experts can help.

As one author noted “Dialogue between professionals and citizens has been hampered by the pervasive view that providers are better judges of the needs of individual clients and the community than are citizens in general or consumers in particular.” 

Another author identified a “persistent pattern of deference to professional judgment that raises a question about the ability of board members to use authority independently and to hold professionals accountable.”

A third author, a governing board member, wrote: “Nine years of representing the community as President and Treasurer of a board which went through a name change from advisory to governing has left me sad, annoyed, angry, frustrated and most of all disappointed.” Although nominally in control, this writer and her fellow board members found they could not seek greater effective power over the professionals on the board because the only penalty available to federal officials was to withhold service funding from clients. Moreover, the need to identify as a “consumer” or non-consumer” was both needless and stigmatizing. “To arbitrarily divide the non-provider citizens into two groups--consumers versus non-consumers--is to continue to perpetuate the stigma of mental illness. Perhaps I am naive; I thought one of the goals of Community Mental Health was to work to eliminate the labels and to educate the community that to use mental health services was not the same as to declare in the public square that I am a syphilis carrier.”

A center director noted just how strongly professionals resisted outside control of their practices. “The consumer/professional issue … is the one causing mental health professionals to flee to private practice where they feel they have a little more control over their own destiny.”

Power struggles over health center governance were nothing compared to obstacles to consumer participation in service delivery. 

As one physician-author noted: “This objection to independent patient-run programs rests on the fundamental question of the nature of mental illness as a disabling condition. Mental health professionals view mental disability as an illness or disorder requiring treatment from experts… Although former clients may have had direct experience in the workings of the system, their views are generally discounted.”

The “angry consumer” on the panel wrote: 

The client is thus viewed by the professional in an adversary situation as the supplicant (i.e. beggar) of the system, albeit a necessary one…

When a client chooses to direct his own life, and in so doing, “complains,” therapists often view the complaints as symptoms of illness, rather than as legitimate responses to an inadequate (and perhaps threatening) situation. This view serves to deny the client his rights as a human being to disagree or dislike, and preserves the professional’s self-image as all-competent and all-knowing. Fears of inadequacy on the part of the therapist resulting from the complaints are re-directed to the client as his own feeling of anxiety and projected as failure on the part of the client to “interact” appropriately. Fear of loss of the client by the therapist is seen as the client’s failure to accept therapy. Fear of anger is viewed as a true “symptom of illness.” Clients are denied the right to be angry, an emotion which is legitimate for “normal” persons in society.

The opinions in these articles are not the rants of anti-psychiatry radicals. These articles were compiled by Dr. Charles Windle, of the National Institute of Mental Health, and authored by community mental health center administrators, consumers and professionals. 

The takeaway for people interested in working on stigma reduction is this:

Fear of loss of power/control is one component of mental illness stigma that is based on fact. With all the power on the professional’s side of the equation, non-experts are left feeling they have no valid role to play.

The articles referenced in this post can be found in Community Mental Health Journal Vol. 17(1), Spring, 1981.

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