GEOFFREY NELSON, JOHN LORD, AND JOANNA OCHOCKA Shifting the Paradigm in Community Mental Health: Towards Empowerment and Community Toronto, ON: University of Toronto Press, 2001, 311 pages (ISBN 0-8020-4823-4, C$65, Hardcover)
Reviewed by GEORGIANA BEAL
Although the literature has emphasized the importance of consumer involvement and partnership in mental health care for many years, the achievement of this objective remains elusive. This book, as it combines theory, practice, and research (a case study) about the processes of empowerment and integration of consumers of mental health care in a Canadian setting, delineates strategies and approaches that can be factors in fulfilling this important aim. The varying levels that need to be involved are discussed and this contributes to an understanding of the conditions that facilitate and inhibit this process. The course of empowerment is described on three levels: policy and planning, organizational, and individual. The body of the text, a study of the community of Kitchener-Waterloo, tracks the changes that occurred during the paradigm shift from the institutional-medical approach to an empowerment-integration approach in community mental health. The research, which includes the voices of consumers, yielded rich information about the change processes and outcomes at these levels, and concludes by offering an examination of why there was a less-than-complete shift to the ideals of community mental health. The explanation grows out of the assumptions and values underlying the varying levels.
As noted, the text does have important things to say; however, there are a couple of issues that need to be highlighted. The use of the word "paradigm" might create some problems for the reader. The authors argue strongly that shifting from the traditional paradigm, termed the institutional-medical approach, to an empowerment-community integration approach the paradigm shift becomes apparent. However, there is evidence that the concept of partnerships with consumers of mental health services ensuring that the client is the centre of the system, has been with us since the early '90s (Best Practices in Mental Health Reform, 1997).
Enabling and empowering consumers to take part in all aspects of care is certainly not new to many aspects of health care in general, for example in the changes around choice in childbirth and for individuals with Hiv. In mental health it is more likely that a certain set of conditions are now in place that has enabled consumers to be much more active participants in their care. For example, provincial government policy, more interactions with consumers at all levels, organizational readiness, ability of clients to have ready access to information that affects them, and the will to take action are conditions that have pushed consumer involvement. These conditions have certainly contributed to the changes we now see in mental health. Whether one can call this a paradigm shift or not is open to discussion.
Further, the term consumer/survivor does become a bit tiresome as it is used throughout the text. Judy Chamberlin (1991) argued that there are many terms people can and do use when describing clients/patients/consumers/survivors. In addition, the references in this section are dated. That being said, there is little doubt that there is still a lot of resistance to empowering consumers in this field and that there are difficulties around differentials in power. The authors are quite correct in bringing these issues forward.
The opening chapters where the authors contrast the old and new system using the notion of institutional dominance theory versus empowerment-integration are also open to critique. It is true that there is an institutional-medical approach, and that there are important issues of power imbalance. A more current literature to describe the state of affairs would have been helpful. It also might have been interesting to ask why it has been so difficult to implement these changes, beyond the fact of medical domination. …