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Empowerment is a ubiquitous concept. Everyone from mental health professionals, rights activists and life coaches to advertisers and teachers seeks to empower their clients. So pervasive is the concept, and so gilded with good feelings, that there are few who would question the value of empowerment. What is most often lacking is a useful definition, and even more, a pragmatic program of how empowerment can be achieved. In Empowerment of People with Severe Mental Illness. A Practical Guide Donald M Linhorst succeeds admirably in bringing conceptual clarity to the notion of empowerment, and in providing a set of concrete interventions to guide mental health practitioners, program managers and policy makers
The first section of the book provides a context for the achievement of empowerment, with chapters on conceptualization of empowerment, a history of pwerlessness, and an exploration of coercion. Linhorst is aware that there is a paradox in the idea that one person can empower another, quoting one author to the effect that:
"The one function anyone else cannot perform for another person is that of empowerment. Empowerment is a reflexive activity, a process capable of being initiated and sustained only by the agent or subject who seeks power or self determination" (p. 9).
Such a sentiment is consistent with many first person accounts of mental illness in which people talk about recovery beginning when they took responsibility for their lives. It is also consistent with the philosophy of recovery espoused by theorists such as Patricia Deegan. On the other hand, Linhorst argues that there are ways of providing services that are more conducive to self-initiated empowerment than others.
Linhorst explores empowerment at institutional and individual levels. Drawing on research into the concept of procedural justice, he translates the broad idea of empowerment into something concrete for everyday clinical practice. He makes the case for empowerment based on historical and continuing coercion of those with mental illness, and perhaps more importantly, by arguing that empowerment is consistent with services statements about what they want to achieve for consumers. Thus seen, empowerment is both an ethical and clinical imperative.
The fourth chapter is the pivot on which the rest of the book turns. In this chapter Linhorst sets out nine conditions of empowerment. These conditions represent an extrapolation of earlier work by Joel F Handler, whose publications focus on the implications of public policy for citizen empowerment. Linhorst outlines a comprehensive set of conditions covering everything from managed psychiatric symptoms to availability of structures and processes of participation, a supportive organizational culture, resources, and incentives. To use another term that has almost lost meaning through glib usage, Linhorst's conditions are holistic. They focus on the person as an individual, as well as on the context within which they experience distress and illness. In discussing a supportive culture, Linhorst is aware that staff of mental health services need support to change and to implement new models. Empowerment involves changes in multiple systems, all of which need to align around a central philosophy of care.
Chapter four also explores models of engagement, setting the medical model alongside recovery, rehabilitation and strengths models. Linhorst points out that the medical model is not limited to the practice of physicians, but can also extends to other disciplines, like nursing, social work and psychology. I'm not sure that there is always a clear conceptual distinction between something that is properly called a "medical" model, and a broader model of paternalistic professional dominance that might be called "professional" or even "institutional". Along with much of the literature critical of mainstream psychiatry, Linhorst calls all of this "medical", but like "empowerment", terms like "medical model" need to carefully explicated if they are to be useful as more than convenient slogans.
All four models of engagement are outlined, along with their implications for empowerment. In the final part of this chapter Linhorst explores the professional norms of the major mental health disciplines. Linhorst's own profession of social work is said align most strongly with empowerment, although Linhorst notes that this ideal is not always realized in practice. More traditional disciplines such as psychiatry are less explicitly aligned with empowerment, something also highlighted by their own critics.
Each of the next seven chapters explores a critical area of empowerment. These are: treatment planning; housing; organizational decision making; planning and policy making; employment; research and service provision. These chapters share a common structure, with an initial introduction, a summary of the nine conditions of empowerment applied to the specific area under discussion, then a detailed discussion of each condition. Linhorst uses cases studies to show how his model of empowerment can be used to analyze the functioning of a service, and to plan interventions from clinical to policy levels, that will help to achieve the goal of empowerment. Each of these chapters closes with a set of guidelines based on the preceding discussion. The format of this section of the book means that these chapters are somewhat repetitive, but there is a certain inevitability about that given that Linhorst is attempting to provide a practical guide. The big advantage is that for someone concerned with say, housing, the chapter on housing will stand alone as a guide; similarly those concerned with employment, research and other areas can find useful practical guidance in the chapter focusing on their interests.
The case studies are helpful, too, in showing examples of how empowerment does or doesn't work. They would be useful for anyone planning to audit a program in terms of empowerment, or setting up a new service committed to empowerment. A theme throughout the book is that empowerment needs committed professional staff, and can be very demanding on consumers involved in proving consultancy and other services. As part of their recovery people sometimes need to leave behind their involvement in advisory roles, making succession planning and mentorship of new consumer consultants an important aspect of an empowerment program.
In the final chapter Linhorst draws the strands of the book together with a summary of opportunities for empowerment, and limitations facing people with severe mental illness. This chapter looks forward to how empowerment can be sustained, and to the challenges that face consumers and service providers in achieving empowerment on a long term basis. Like the previous chapters, this final chapter contains many practical points which could provide a basis for continued service development.
Empowerment of People with Severe Mental Illness is a book that is driven by a philosophical commitment to empowerment, and by the insight that more than rhetoric is needed to achieve empowerment in practice. Linhorst is realistic about the limitations severe mental illness may impose on consumers. But he does not accept that mental illness provides a ready made justification for coercive or paternalistic practices. There are parallels between this work and recent work on social inclusion, and this commonality would make for a fruitful collaboration. The book is clearly written and logically organized. The reference list and index are comprehensive making the book a valuable reference work for undergraduates through to experienced clinicians and those in management and policy roles. Professionals and consumers involved in developing mental health programs will find that this book delivers on its promise to provide a practical guide.
© 2007 Tony O'Brien
Tony O'Brien is a lecturer in mental health nursing at the University of Auckland, New Zealand: [email protected]