Good Intentions Overruled: A Critique of Empowerment in the Routine Organization of Mental Health Services

Contemporary private corporations and public agencies have been quick to embrace the latest management fads, such as liberation management and business process re-engineering. Opponents of these trends argue that they are merely euphemisms for downsizing. Supporters insist that new and innovative management practices produce positive ripple effects, including employee empowerment, customer satisfaction, and better services.

As these management principles and practices take hold, administrative barriers are abolished, hierarchies are flattened, and people are empowered. Many mental health agencies are starting their own re-engineering processes, quality assurance initiatives, and empowerment programs. Although these developments are certainly a step in the right direction, are they producing true forms of empowerment for mental health consumers and practitioners alike? In Good Intentions Overruled, Elizabeth Townsend critically examines the issue of empowerment and recommends a myriad of ways in which to create a more humane mental health system.

Townsend is an academician, writer, and researcher from eastern Canada, professionally trained in occupational therapy, adult education, and sociology. She offers an eclectic lens for viewing the role of power in the everyday delivery of mental health services. While she writes primarily from an occupational therapist's perspective, she diligently includes the perspectives of other mental health professions. The intended audience includes sociologists, adult educators, mental health professionals, occupational therapists, consumers, and, ideally, managers who will put the concepts into practice.

Townsend's introductory chapter outlines her theoretical influences, research methodology, personal biases, and ethical considerations. Data for this book were collected from the author's detailed field research with seven occupational therapists at six day programs across Atlantic Canada. Her theories about the destructive forces of power in organizations are based on the "institutional ethnography" developed by sociologist Dorothy Smith. The author is primarily interested in exposing the hidden, often invisible, forces controlling the delivery of community mental health services. Moreover, she values the role of participatory forms of research and management.

The next six chapters focus on the specific areas of practice and service delivery where empowerment principles are either subverted or ignored by the controlling forces, coordinating functions, and management systems of the mental health industry. These chapters constitute the core of the author's research results. Particularly, Townsend examines how the mental health system categorizes patients, focuses on the individual at the expense of collective action, discourages participatory decision making, provides room only for simulated learning experiences, suppresses risk taking, and promotes the exclusion of individual patients from constructive opportunities in everyday life. Some readers may argue that she neglects the forces of managed care. However, all of these hidden processes undermine the noble intentions of dedicated professionals and thus sustain the marginalization and stigmatization of mental health consumers.

In the concluding chapter, which is the most important one, the author outlines how the mental health system can change to produce a truly robust form of empowerment. To some, her recommendations may be overly idealistic and far-fetched; nevertheless, they are interesting.

Her chief recommendation focuses on the need for the mental health system to classify patients as clients, persons, or residents rather than as cases. This semantic play may be an obvious step, but it does represent the beginning stage of transformation.

Townsend's other recommendations for change are far more radical. She suggests that clients become more involved in the decision process within organizations and partners in the design, implementation, and evaluation of programs. She contends that empowerment can truly come about only when organizations encourage collective forms of action and proactively challenge harsh welfare policies that were myopically developed to reduce the redistributive role of government in people's lives.

Finally, she says that professionals in the field need more substantial educational preparation about public policy and economic development and that they must be willing to "reduce the cycle of referrals among professional psychiatric services." Although some professionals may balk at the recommendation to reduce referrals, given the need for integrated treatment modalities, supporters of managed behavioral health care will applaud the idea.

Carl Cohen (1) has argued that psychiatrists and others in the field urgently need to develop multiple strategies to attack such corrosive forces in society as poverty, racial discrimination, joblessness, and powerlessness. Good Intentions Overruled lends itself to this approach. Although scholarly in tone and structure, it gives professionals and consumers some constructive strategies for creating an empowered mental health system.

One can only hope that managers, too, will read this book and apply the recommendations. Townsend's ideas represent something more than just a new management fad. Even if managers do not implement her recommendations, at least they will have been exposed to empowerment approaches and practices.

Mr. Provost is affiliated with the Concord-Assabet Family and Adolescent Services in Acton, Massachusetts.