Archived Information

**Enhancing Personal Empowerment of People with Psychiatric
Disabilities**

Patrick W. Corrigan, Psy.D.

Dr. Corrigan is Professor of Psychiatry and Executive Director,
University of Chicago Center for Psychiatric Rehabilitation,
Tinley Park, Illinois.

For most of recorded history, people with psychiatric disabilities have
struggled with maintaining personal power over their lives. The
centuries-old battle against stigma is the best example of this
struggle. The ancient Greeks first gave voice to the concept of stigma
noting that those who were marked with mental illness were often
shunned, locked up or, on rare occasions, put to death (Simon, 1992).
During the Middle Ages, people with mental illness were viewed as living
examples of the weakness of humankind, what goes wrong when people are
unable to remain morally strong (Mora, 1992). This kind of attitude led
families to hide away those with psychiatric disabilities from public
view. Not until the 18th century did asylums and treatment centers
emerge for mental illness. Before that time, those with serious and
persistent mental illness were often locked up with criminals. Although
the struggle for personal power has vastly improved during the last
century, people with mental illness still encounter stigma and
disempowerment. The recently released report by President George W.
Bush's New Freedom Commission for Mental Health (2003) issues a clarion
call for practices that facilitate consumer empowerment.

The goals of this paper are threefold:

1\. Provide a working definition of empowerment as applied to the lives
of people with psychiatric disabilities.

2\. Identify community and service systems barriers to empowerment.

3\. Describe guidelines and other system enhancements that facilitate
personal empowerment.

"There is no medicine like hope, no incentive so great, and no tonic so
powerful as expectation of something tomorrow."

> O.S. Marden
>
> 1850-1924

Understanding Personal Empowerment

Empowerment has been defined as personal control over all domains of
life, not just mental health care but also decisions related to such
important areas as vocation, residence and relationships (McLean, 1995;
Rappaport, 1987; Segal, Silverman & Temkin, 1995). This is especially
important in societies that stigmatize persons with psychiatric
disabilities. Western cultures, for example, seem to rob these persons
of authority over treatment plans and life decisions (Brockington, Hall,
Levings & Murphy, 1993; Link, Cullen, Frank & Wozniak, 1987). Research
on the construct of empowerment leads to a better understanding of
effective services and their impact on quality of life (Corrigan &
Garman, 1997). Rosenfield (1992), for example, found a measure of
consumer empowerment correlated with quality of life. Rogers,
Chamberlin, Ellison and Crean (1997) completed a more comprehensive
series of studies on mental health consumer empowerment with their
Empowerment Scale. Items for the Empowerment Scale were first identified
by a panel of 10 leaders in the consumer movement and then validated by
participants in six self-help programs. An unpublished analysis of 261
responses to the scale, conducted by Rogers et al. (1997), yielded seven
factors that describe the construct:

• self-efficacy,

• powerlessness,

• self-esteem,

• effecting change,

• optimism/control over future,

• righteous anger and

• group/community action.

These factors are intercorrelated and seem to correspond with two
superordinate factors that describe the impact of empowerment on persons
with schizophrenia and on their community (Corrigan, Faber, Rashid &
Leary, 1999). These are:

• The impact of empowerment on the self is such that, despite societal
stigma, empowered consumers endorse positive attitudes about themselves.
They have good self-esteem, believe themselves to be self-efficacious
and are optimistic about the future.

• The impact of empowerment on the community is manifested by the
consumer's desire to affect his or her stigmatizing community. Consumers
believe they have some power within society, are interested in affecting
change and wish to promote community action.

Readers may note that terms like empowerment and disempowerment are
frequently interchanged in the remainder of this article. In part, this
interchange represents empowerment as a continuum (Corrigan, Faber et
al., 1999; Rogers et al., 1997). At the positive end of the continuum
are people with psychiatric disability who, despite their disability,
have positive self-esteem and are not significantly encumbered by a
stigmatizing community. At the negative end are people who report being
unable to overcome all the pessimistic expectations about mental
illness. One might think that a paper about empowerment would be
presented in the affirmative voice (e.g., What might people with mental
illness, service providers and the community at large do to promote
personal power?). Unfortunately, much of the research and literature on
empowerment looks at the negative impact of its absence (What happens
when a person with mental illness is disempowered?) (Corrigan & Garman,
1997; Rapp, Shera & Kisthardt, 1993). Hence, I have chosen to intertwine
what is known about disempowerment with what is the vision of
empowerment to address the themes of this article.

Barriers to Empowerment

Stigma is the societal embodiment of disempowerment; it promotes
expectations in both the public at large and individual consumers that
people with mental illness are incapable of the responsibilities
commensurate with living independently. Results of two factor analyses
on more than 2,000 English and American participants revealed three
common themes to stereotypic attitudes about mental illness that endorse
this assertion (Brockington et al., 1993; Taylor & Dear, 1981):

• Fear and Exclusion. Persons with severe mental illness should be
feared because they are dangerous. As a result, they should be kept out
of the community and housed in institutions.

• Authoritarianism. Persons with severe mental illness are
irresponsible; life decisions should be made for them by others.

• Benevolence. Persons with severe mental illness are childlike and need
to be cared for.

These kinds of widespread attitudes have two effects on the power of
persons with mental illness. First, they rob people of the opportunities
that are central to recovery and a quality life (e.g., good jobs,
comfortable income, nice housing and good friends). Perhaps of equal
concern are the effects that stigma has on some people with mental
illness. People living with serious mental illness who are immersed in a
culture that endorses psychiatric stigma begin to believe this stigma
and question their own capabilities for independent living (Wahl, 1995).
Because self-stigma has such an insidious impact, its effects on
empowerment are examined first.

Some people experience stigma as a private shame that diminishes the
person's self-esteem (Corrigan, 1998; Corrigan & Watson, 2002). This
kind of shame leads to self-doubt about whether the person is able to
live independently, hold a job, earn a livelihood or find a life mate.
Even though they may have mastered their symptoms and disabilities,
people with mental illness must also overcome stigmatizing reminders
that they still have a disability or are not useful members of society.
One recent study showed the breadth of discrimination experienced by
mental health consumers (Wahl, 1999). The majority of 1,300 respondents
reported discouragement, hurt, anger and lowered self-esteem as a result
of their experiences. An earlier study by Link (1982) showed the loss of
self-esteem that results from stigma also has practical consequences.
Participants in their study reported that being publicly labeled with a
psychiatric illness had a negative impact on work and income.

Activities That Facilitate Empowerment

Research has yet to examine strategies for overcoming self-stigma, but
several candidates show promise (Corrigan & Watson, in press).
Internalizing the kind of messages embodied in recovery may help to
diminish self-stigma. Cognitive restructuring may also prove useful in
helping people learn to challenge stigmatizing views they may hold of
themselves (Corrigan, 1998; Haaga & Davison, 1991). Alternatively,
self-stigma will diminish as a person's sense of empowerment improves.
Seven sets of strategies have some empirical support for facilitating
empowerment of people with mental illness (Corrigan & Lundin, 2001).
Each of these is discussed more fully in the remainder of this article.

Empowerment may be construed narrowly in terms of control over the
services that help people deal with their disabilities (e.g., problems
related to mental illness). It may also be understood more broadly in
terms of command over all spheres of one's life, such as succeeding at
work, in relationships, during play, spiritually and in as many other
domains as possible. Table 1 lists seven strategies that facilitate
empowerment. These are loosely ordered from those that should now be
obviously accepted by the mental health system --- they represent the
base of empowerment approaches (like issues about collaboration and
consumer satisfaction) --- to those that are visionary and need to be
more widely accepted and disseminated, such as consumer operated
services and participatory action research.

Table 1: Seven Ways to Foster Empowerment.

> NOTE: These are arrayed from those that minimally foster empowerment
> to those that more fully enhance personal empowerment.
>
> 1\. From Noncompliance to Collaboration
>
> A change in perspective from expecting consumers to passively comply
> with treatment to making care-plans that are user-friendly.
>
> 2\. Consumer Satisfaction and Other Input on Services
>
> At the absolute minimum, programs that empower participants need to be
> satisfactory to those participants. Moreover, these programs need to
> obtain input from consumers to ensure that program design reflects
> their interests.
>
> 3\. Lodges and Clubhouses
>
> For more than three decades, the mental health system has supported
> treatment programs that were largely operated by persons with mental
> illness. Lodges are residential programs in this mold; clubhouses are
> social and work programs.
>
> 4\. Supported Housing and Employment
>
> Instead of the consumer going to the professional, the best treatment
> occurs when the professional travels to the consumer and all the
> places in which consumers need assistance. Provision of services in
> the person\'s home or community is the hallmark of Assertive Community
> Treatment (or ACT). Services in real-world job sites is supported
> employment.
>
> 5\. Consumers as Providers
>
> Many persons with mental illness are deciding to return to school,
> obtain necessary credentials, and assume jobs in the mental health
> system as providers. In this way, they can change the system from the
> inside.
>
> 6\. Self-Help, Mutual Assistance and Other Consumer-Operated Services
>
> There is almost a 50-year history of programs developed by persons
> with mental illness to help peers. These programs provide places where
> people can provide and receive help from individuals with similar
> concerns.
>
> 7\. Participatory Action Research
>
> Much of the current research on psychiatric disability and
> rehabilitation reflects the perspective of the existing mental health
> system. Persons with mental illness must be equal partners in the
> research enterprise for future studies to represent the differing
> interests of consumers.

1\. From Noncompliance to Collaboration

Many mental health providers must drastically reconceive their viewpoint
about the consumer's relationship with treatment for empowerment to
occur (Fenton, Blyler & Heinssen, 1997; Ruesch & Corrigan, 2002). The
old notion was that persons with mental illness should comply with all
aspects of treatment: Professionals knew best; anything that strayed
from the prescribed treatment program represented unclear thinking due
to the illness. Failure to comply was indicative of unconscious
motivations to resist health. Mandatory treatments and a coercive system
rested on these assumptions. Research evidence seemed to clearly support
these conclusions. Depending on the study, anywhere between two-thirds
and three-quarters of persons did not take their psychiatric medications
as prescribed. More than half of all participants in rehabilitation and
similar psychosocial programs did not complete the treatment plan as
agreed (Cramer & Rosenbeck, 1998). These data suggest resistance is
rampant and significantly undermines treatment of serious psychiatric
illness.

Considered another way, however, these data might be perceived to yield
completely different conclusions. Rather than 66 to 75 percent of
persons taking their medication incorrectly, perhaps two-thirds to
three-quarters of all mental health providers are prescribing drugs
poorly. Lack of compliance may not represent resistance by a person with
psychosis as much as meager treatment by the mental health team. Equally
sobering statistics suggest that more than 70 percent of all persons who
are prescribed any kind of medicine (not just psychoactive drugs) do not
take it the way the doctor ordered (Rogers & Bullman, 1995). Clearly,
incorrect use of medication is not solely a problem of persons with
mental illness.

Rather than expecting persons to passively comply with care --- be it
psychiatric care or general medical treatment --- what is needed is more
enlightened practice that calls for collaboration between providers and
consumers. An equal partnership occurs when each party learns from the
other: Providers learn about the nature of specific symptoms and
corresponding disabilities from the person challenged by these problems;
consumers learn the range of treatments and services that address these
problems. How do providers and consumers foster a collaborative working
relationship? More than a decade ago, we wrote a paper that outlined
strategies for answering this question (Corrigan, Liberman & Engel,
1990), which are summarized in Table 2. As outlined in our earlier
paper, these strategies have some empirical support for fostering the
collaboration among providers and consumers.

Table 2: Barriers to Collaboration and Ways to Overcome Them

> Barriers Ways to Overcome Barriers
>
> TREATMENT TECHNIQUES
>
> Nasty side effects of medication
>
> · Use new generation of medications that reduce side effects.
>
> · Use low-dose medication strategies.
>
> · Educate consumer to side effects and teach self-tracking strategies.
>
> Complex treatment plans
>
> · Engage consumers in central role in designing treatment plan.
>
> · Use simple language.
>
> · Clearly explain steps of treatment.
>
> · Begin simply and slowly; add more complex steps gradually.
>
> Long-term treatment
>
> · Regularly assess goals and relevance of treatments to these goals.
>
> · Provide treatment holidays.
>
> · Consider place-train options.
>
> TREATMENT DELIVERY SYSTEM
>
> Depressing and dingy atmosphere of clinics
>
> · Improve clinic decor and ambience.
>
> · Offer coffee and refreshments.
>
> · Require all staff (including clerks) to be courteous and respectful.
>
> · Move most services to the consumer's home or other setting.
>
> Long waits at clinics
>
> · Maintain realistic schedules.
>
> · Send reminders to consumers.
>
> PROVIDER-CONSUMER RELATIONSHIPS
>
> Provider's poor interpersonal style and lack of interest in consumer
> feedback.
>
> · Alert administrators about poor provider style.
>
> · Educate providers about the importance of "collaborative" roles.
>
> · Educate providers about the need for consumer satisfaction.
>
> · Pair provider with mentor for remediation.
>
> FAMILY-CONSUMER CHARACTERISTICS
>
> Lack of knowledge of or unrealistic expectations about treatment.
>
> · Educate consumers and family members to treatment options.
>
> · Provide opportunities for consumers and family members to share
> concerns.
>
> Adapted from Corrigan, Liberman & Engel (1990).

2\. Consumer Satisfaction and Other Input on Services

One of the assumptions of empowerment and collaboration is that
treatment teams will design interventions and programs that are pleasing
to participants. Hence, assessing consumer satisfaction is a minimal
requirement for establishing programs that empower consumers (Corrigan,
1990; Dickey & Sederer, 2001). Although one might think this to be a
straightforward process, assessing consumer satisfaction is more
difficult in actuality. Hence, some rules for developing a useful
consumer satisfaction scale are provided. Unfortunately, concern with
consumer empowerment frequently ends with the assessment phase. Programs
collect data on satisfaction but subsequently fail to use it in
improving services. A second important part of this process is to
consider ways to use information from satisfaction evaluations to
further improve the setting.

What goes into a consumer satisfaction scale? When evaluating consumer
satisfaction, satisfaction scales should consider four categories or
domains: the service environment, the service providers, specific
interventions and preparation for autonomy (Corrigan, 1990; LeBow,
1982). What is the quality of the service environment? Are the rooms
pleasant, including the decor, lighting, furniture and temperature? If
food is provided, is it tasty and plentiful? How are the service
providers? Are they knowledgeable and competent in their specific jobs?
Are they approachable, respectful and friendly? Can the consumer
interact with them informally? How useful are specific interventions
themselves? Do they provide the consumer with the needed skills? Do they
help the consumer better understand his or her goals? Do they provide
the resources and support needed for goals? Is the service preparing the
consumer for autonomy? After finishing the program, is the consumer
better able to live independently? Is he or she more hopeful about the
future?

Unfortunately, this approach to assessing satisfaction can lead to
"halo" or "devil" effects (Corrigan & Jakus, 1993a,b). Halo effects
occur when the consumer rates everything as satisfactory: The program
was great, the staff were great, the food was great, the building was
great, everything was great. Research has shown that halo effects are
very common in consumer satisfaction studies. Although some services may
indeed be satisfactory, rating everything highly does not help to
identify those components that need to be changed. Service providers
would not know where to put their efforts in improving services. Devil
effects are provided by people who are angry with the program. They rate
all components as highly dissatisfactory. The program was poor, the
staff was lousy, the food was rotten, the building was dingy, everything
really stunk. Like the halo effect, rating everything alike (in this
case, poorly) does not help providers focus on specific aspects of the
program.

To avoid this problem, consumers may be encouraged to compare a specific
program to another similar service in which the person has been involved
in the past (Corrigan & Jakus, 1993b). For example a counselor might
request the following from a client:

"Currently, you are participating in the Opportunities Program on
Supported Employment. Tell me another similar program you have
participated in the past. Write it here
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_. Now answer the following questions by
comparing your experience in Opportunities with this other program."

Research has shown this kind of comparative approach yields to better
differentiation among components of a program (Corrigan & Jakus,
1993a,b).

Having input on services. The full benefit of evaluating consumer
satisfaction will only be realized when providers use the results from
these evaluations to actually change services. Unfortunately, this kind
of program improvement is frequently done without consumer input.
Instead, treatment providers take the findings and decide how to improve
program aspects on their own. This kind of approach fails to promote
empowerment. The preferred way to handle findings from satisfaction
evaluations would be to involve participants in focus groups where they
discuss their concerns about aspects of the program and, more
importantly, provide recommendations for ways that the program might
improve (Rogers & Palmer-Erbs, 1994).

There are two essential roles to fill in these kinds of focus groups:
the leader and participating members (Morgan, Krueger & King, 1998). The
best leaders for these groups are other consumers who are trained to
facilitate these kinds of groups. Although traditional service providers
may have skills for running discussion groups like these, members might
be hesitant to speak freely because they believe the provider will be
biased in favor of the established program. Many consumers are able to
lead these groups after one hour of training. We do not have the space
here to consider the skills for a focus group leader; the interested
reader should consider such resources as Bernard Bass's and R.M
Stogdill's Handbook of Leadership (1990).

Focus groups should comprise six to eight members. A good mix of people
with different opinions should be invited to the focus group. Include
consumers at both ends of the scale --- persons who are fully satisfied
with the program and those who are highly critical --- as well as
individuals in the middle. In this way, a polite contrast of opinions is
possible. Prior to the meeting, leaders should develop a series of
questions to guide the discussion. These questions should be based on
the results of the consumer satisfaction evaluation.

3\. Lodges and Clubhouses

Consumers have obtained further control of the mental health system and
their world in two kinds of programs: lodges and clubhouses. In both
settings, people with mental illness have equal authority to that of the
professional staff in operating the program. Lodges were started in the
1960s by George Fairweather as residential and work communities for
persons recently transferred from long-term hospitals. Clubhouses
spontaneously emerged in New York City as a meeting place for people
recently discharged from the state hospital. Both of these models
represent consumer dissatisfaction with the way mental health providers
acted towards persons with mental illness. This dissatisfaction led to a
philosophy that clearly echoes the importance of empowerment.

The Fairweather Lodge: Living and working together. The lodge is made up
of persons with psychiatric disabilities who live and work together
(Fairweather, 1969). Typically, lodges form real-world businesses to
maintain themselves (e.g., janitorial services, bulk mailing, copy
centers, or temp agencies). Sometimes, lodges hire non-disabled people
who demonstrate expertise in areas needed to maintain the business. They
may also seek professional help to serve as "consultants" to lodge
members, to provide assistance in those psychiatric and rehabilitation
strategies needed to help members manage their symptoms and
disabilities.

The lodge program is built on several principles that clearly reflect
the spirit of personal empowerment (Fairweather, 1969). These principles
have been divided into two sets:

• those that help the consumer fill the role of lodge member (living and
working with peers); and

• those that help the lodge develop norms which make it a thriving
community (or what Fairweather called "a social subsystem").

People are more willing to embrace a role when they have a stake in it.
In other words, living and working with others has to satisfy what the
person wants and needs in his or her life now. This means the person
needs to have autonomy in his or her role within the lodge. At the
minimum, a person's role needs to be voluntary. People cannot be
court-ordered to a lodge or sent against their will. In addition, people
need the right to self-determination: namely, the opportunity to decide
for one's self how to meet his or her responsibilities in the lodge
community.

It is the nature of interaction that there be some hierarchy among
social roles. Some people need to be supervising others to make sure all
needs of the lodge are met. Another principle of lodge programs is that
all members have the opportunity to be promoted to leadership jobs and
thereby experience the benefits, as well as the demands, of different
roles throughout the hierarchy. At the same time, all roles within the
lodge must be filled. In this way, the community is assured that all
tasks of the lodge are covered.

There is an interesting contradiction between the goals of autonomy and
the demands of operating a residential and work community. How does the
lodge balance each person's right to self-determination with the
community's need to get all its work done? The second set of principles
suggests development of community norms that seek this balance. One of
the major rules of the Fairweather Lodge is "Members are encouraged to
do things as a group" (Fairweather, 1969). Proponents of the lodge
program believe that its strength lies in sharing both good times and
tough decisions among all members. Group discussion is central to the
empowerment and personal growth experienced in this setting.
Unfortunately, a second principle of the lodge recognizes that this
group must be limited in size. The community can only serve a small
number of people in order to meet their work and home needs
satisfactorily. This can be a sobering thought for some lodge members;
namely, that their community is closed to many others like themselves
who are also in need (Corrigan & Garman, 1997).

The success of the community occurs in a complicated balance between
norms. On one hand, the norms of the program must correspond with those
of the larger society in which the lodge finds itself. Basing lodge
rules on those in the larger society makes sense because these are the
rules with which community members are likely to already be familiar.
For example, "respect privacy" and "do not steal" should be two familiar
rules to most Americans and therefore be incorporated into the norms of
lodges in the United States. The lodge also needs to develop norms that
reflect the unique character of its community. For example, the prime
rule, "Members are encouraged to do things as a group," is not reflected
in Western society as a whole. However, proponents of the lodge program
believe this kind of norm is essential for the unique atmosphere needed
to develop a community of living and working peers. In like manner, each
community needs to consider as a group what other particular rules it
will adopt to meet the individual needs of its members.

The Fountain House: A clubhouse for persons with mental illness. During
the years after the end of World War II, many people were released from
Rockland State Hospital, located outside of New York City, with no
community connections. In order to survive, they would meet on the steps
of the New York Public Library to provide one another with resources and
support. Soon, the group gained notoriety and other persons released
from Rockland joined them in this makeshift society they called WANA: We
Are Not Alone. In 1948, the group bought a building through the generous
donations of a Jewish women's philanthropic group. The building had a
fountain in the back yard; hence its name, Fountain House. It was built
around a fundamental philosophy:

"Men and women with mental illness have the right to a life which
includes access to meaningful, gainful employment; a decent place to
live; a community of support; the opportunities for education and
recreation offered by the communities in which they live; and the chance
to be needed, wanted and expected somewhere everyday" (International
Center for Clubhouse Development, 1948).

Several values characterize the clubhouse. In some ways, these
principles overlap with the lodge model; in other ways, they reflect the
special charm of social clubhouses (Macias, Barreira, Alden & Boyd,
2001). Persons belonging to the clubhouse are members rather than
consumers. They have equal power with the professional staff hired to
support clubhouse activities, not only in daily operations but also in
decisions about budgetary issues. With membership comes responsibility.
All members are expected to contribute to some aspect of the clubhouse's
operations. Clubhouses are designed so that each member is essential for
efficient operation. The fully collaborative nature of staff and
consumer leads to all members being considered co-providers.

Clubhouses are open every day of the year. Unlike mental health centers,
which typically close for holidays, clubhouses are open for their
members to celebrate. Clubhouses also provide a wide variety of
opportunities, including housing, education, social support, recreation
and vocational training and placement. Services are never pressed upon
members. Rather, they are used as the individual sees fit. Clubhouses
operate according to a work-ordered day with normal 9 to 5 schedules
(Besancon & Zipple, 1995). Each day, members (consumers and staff alike)
decide among a variety of work units that comprise the necessary tasks
to keep the clubhouse running effectively. Work activities at Fountain
House have included horticulture, thrift shop, snack bar and dining
room, clerical work, education, and research. Participation in this kind
of activity reacquaints members with the demands of the work world as
well as its many benefits.

4\. Supported Housing and Employment

Even though lodge and clubhouse programs have many values that promote
empowerment, they still require consumers to go outside their home
"turf" to receive services. Programs of Assertive Community Treatment
(PACT) turned the service world upside down (Bond, McGrew & Fekette,
1995; Mueser, Bond, Drake & Resnick, 1998; Stein & Test, 1980). Instead
of demanding that consumers go out of their way to the offices of
providers, why not bring services to the consumers where they need it,
such as in their homes or anywhere that the consumers might deem
necessary for resources and support? PACT proponents believe the entire
range of services --- medications, psychotherapy, skills training, money
management and the rest --- can be and should be provided in the
person's home or community. A variation of this idea is supported
employment, where a job coach provides services alongside the consumer
at his or her place of work (Bond, Drake, Mueser & Becker, 1997; Drake
et al., 1999).

PACT and supported employment facilitate empowerment in several ways.
First, these programs are consumer-centered. Services are defined by the
needs of the consumer, not by the provider. Although this may seem
obvious now, this value was revolutionary when first proposed. In the
past, treatment plans reflected what was best for the consumer AND the
provider. Hence, a person would not be referred to an independent
housing program if it were outside the case manager's district. A
consumer would not begin competitive work until the agency had an
available job coach. Consumer-centered services remind the provider that
it is up to the agency to find the necessary resources and supports to
help consumers achieve their goals on their timeline.

PACT and supported employment are also strengths-oriented (Rapp, 1998).
This view differs from the disease model that dominates traditional
services. Proponents of the disease viewpoint believe that people are
defined by their symptoms and other weaknesses that need to be fixed
through treatment. The strengths model recognizes that people are
described by their skills, not their shortcomings. Awareness of these
skills is essential; these are the tools that people use to accomplish
their goals. Providers who are consumer-centered make interventions as
convenient and efficient as possible. Hence, PACT is comprehensive and
cross-sectional. That is to say, it provides services across all domains
of need: housing, finances, family, health care, spiritual matters and
recreation.

PACT and supported employment are also longitudinal. By this we mean
that the needed service is provided by a single team as long as the
person needs it. In the past, mental health providers used to have the
bad habit of ending services at times not convenient for the consumer.
Today, PACT and supported employment continue as the person changes
homes or moves in and out of institutions. Sometimes, services are
provided indefinitely. Mental health systems of the past had the unwise
practice of discontinuing community services for those individuals who
had to be hospitalized because of short-term psychiatric emergencies.
Unfortunately, these people had to start over with a new team when
released a few weeks later. The PACT and supported employment team
continue to offer support and resources even while the person is
hospitalized or involved in the criminal justice system (Bond, Drake,
Mueser & Becker, 1997; Mueser, Bond, Drake & Resnick, 1998).

Effective PACT and supported employment is accessible and available.
This means services are provided in places that are convenient to the
consumer, typically in his or her home or place of work. Moreover,
service is provided at times that make sense to the consumer. The
provider does not ask the person to stay home from work so that the
provider may come to the consumer's apartment to discuss shopping.
Instead, the provider comes in the evening when the person is home from
work and has eaten dinner.

5\. Consumers as Providers

What better way to influence the system that provides services than for
people with mental illness to assume jobs as providers in these
services? In this spirit, consumers have filled almost every conceivable
position in the mental health system (Mowbray, Moxley, Jasper & Howell,
1997; Solomon & Draine, 2001). Consumers have become job coaches, they
have worked on assertive community treatment teams and they have run
support groups. Consumers have also worked at all the professional
levels that comprise the treatment team, as psychiatrists,
psychologists, social workers and psychiatric nurses. Several well-known
consumer advocates have cut their teeth as mental health professionals.
Daniel Fisher is a psychiatrist; Fred Frese is a psychologist. Each of
these gentlemen has gone through more than 20 years of struggling with
the psychiatric disabilities resulting from schizophrenia.

Having consumers as mental health providers yields several significant
benefits for the individual consumer as well as for people with mental
illness in general. At the broadest level, consumers as providers
challenge stigmatizing notions about people with mental illness. Public
understanding of consumers reaches beyond the simple idea that they are
psychiatric diagnoses. Despite their disabilities --- or perhaps because
of them --- people with mental illness are able to support peers with
mental illness by providing them with knowledge about psychiatric
symptoms, skills to deal with these symptoms and resources to meet their
goals. These abilities challenge the notion that people with mental
illness are incompetent.

Consumers assume roles that traditional providers frequently will not do
or are not able to do well. Many jobs related to supported employment
and programs of assertive community treatment require long hours and
travel into places that are less than desirable. Most people are not
willing to meet these challenges unless they have experienced the same
struggles. There are some tasks that only consumers can provide. One of
these is the "I've been there too" kind of support. Those in the throes
of depression or anxiety receive immeasurable benefits by hearing from a
peer who has been in the same situation, survived the challenge and
thrived to become a mental health provider. There is one last aspect to
consumers becoming providers which must be highlighted: Providing help
to others reaps significant benefits for the helper. This is the
principle of mutual help that is discussed more in the next section.

6\. Self-Help, Mutual Assistance and Other Consumer-Operated Services

Consumer-operated services differ from the earlier service model in that
they are entirely developed, operated and provided by and for people
with mental illness (Davidson et al., 1999; Solomon & Draine, 2001).
Consumer-operated services are not just another form of clinical
treatment (Luke, Roberts & Rappaport, 1994). Clinical treatment reflects
a medical model: People seek out services to resolve symptoms (Corrigan
& Penn, 1997). Clinical treatment features a hierarchy between healer
and person in clinical settings; healers have some special power that
they use to help patients resolve problems. The relationship between
healer and patient is expected to end when symptoms remit.
Consumer-operated programs have been likened more to communities with
life-long histories (Maton, Leventhal, Madara & Julien, 1989) or to
grassroots information and support systems (Meisen, Gleason & Embree,
1991). Mental illness may be the common experience that draws people to
consumer-operated services. But unlike traditional clinical treatment,
this is not where the impact of consumer-operated services ends.
Consumer-operated services place an extraordinary value on peer support,
hope and recovery (Van Tosh & Del Vecchio, 2000). Consumer-operated
services seek to provide safe settings where a person can find the
necessary understanding and recognition that society at large is not
able to give. In the ideal, there is no hierarchy of roles in
consumer-operated programs; members are peers benefiting from
interactions with equals. There are no limits placed on the amount of
time a person can be involved in a program. Depending on personal needs,
some members come and go from consumer-operated programs, while others
may stay connected for years (Durman, 1976; Luke et al., 1994).

Types of Consumer-Operated Services. Three kinds of programs comprise
the consumer-operated services: consumer-run drop-in centers; peer
support programs; and education and advocacy programs.

Consumer-run drop-in programs provide an open venue for consumers to
receive a variety of services as needed in a specific location that is
open at set times during the day and week. Individuals participate in
drop-in activities on a voluntary, at-will and non-coercive basis.
Service components parallel the gamut of traditional mental health
activities and may include assistance with entitlements, medication
education, clothing, bus or transportation passes and moving.

Peer support programs are typically individual or group-based assistance
and encouragement organized around a worldview or 12-step approach that
is consistent with empowerment and recovery. Peer support programs, like
drop-in centers, may tackle a broad range of work, housing, health and
relationship goals that are needed by participating consumers.

Education and advocacy programs operate under the belief that consumers
with knowledge about mental illness and psychiatric services are best
able to address their own disabilities as well as to fix what is wrong
with the mental health system. Education and advocacy programs use
well-defined curricula to teach consumers this kind of information,
usually in short-term classroom settings. The education and advocacy
program model also relies on peer support to accomplish its goals
(Corrigan & Lundin, 2001).

7\. Participatory Action Research

The purpose of research is to discover what kind of outcomes result from
providing a specific intervention program (for example, Programs of
Assertive Community Treatment) in a certain way (e.g., using a team of
providers instead of individual case managers) with a specific group of
consumers (e.g., persons with mental illness recently released from
prison). Research is meant to answer questions about programs.
Traditionally, this kind of research is completed by academic experts,
people with many years of education leading up to a doctorate in social
science or medicine and working as a professor in a university. There is
widespread belief that social science requires many years of study in
statistics and research methodology and can, hence, only be completed by
these kinds of experts.

Many consumers believe that this kind of "scientist as expert" view
actually causes problems of its own and diminishes empowerment (Rogers &
Palmer-Erbs, 1994). They describe a "blame the victim" mentality that
permeates much research. According to this mentality, traditional
research shows how persons with serious mental illness lack skills, lack
work histories, lack motivation, lack family ties, and so on (Rapp et
al., 1993). It is these person-centered deficits that account for all
the individual's problems and hence should be the focus of research and
services.

This point may be better understood if we consider how research in other
disabilities --- blindness for example --- has developed over time
(Whyte, 1991). As the result of forceful input from persons who are
blind, researchers realized that teaching people how to live with their
impairment is not enough. We also need to change the environment so that
those who are blind can get around more easily. Research in this area
led to Braille in elevators, crosswalks that beep, and better use of dog
guides. This kind of research is only going to be accomplished when
people with disabilities are full partners.

Participatory Action Research (PAR) describes how researchers and
consumers become partners in studying mental illness and appropriate
treatment (Rogers & Palmer-Erbs, 1994). PAR calls for a significant
change in the roles of consumers and professionals, calling for
consumers to actively investigate research hypotheses themselves and
enlist trained researchers as consultants to their projects. The goal of
PAR is to advance research that supports the fundamental assertions of
consumer empowerment. Instead of asking typical research questions
(e.g., How does the consumer fit into society?), PAR examines questions
such as: What must society provide in terms of resources and
accommodations in order to enable the consumer to also be one of
society's resources?

Participatory Action Research is no longer a pipe dream. Many federally
funded research efforts have incorporated the priorities of PAR into
their guidelines. For example, several large-scale projects funded by
the U.S. Substance Abuse and Mental Health Services Administration
(SAMHSA) require a consumer advisory panel to have an active partnership
in planning and implementing its research projects. As a result, most
decisions that govern the projects are made through a sometimes tortuous
exchange between the consumers on the project and the science
investigators. The result is a research project that represents the best
interests and insights of consumer empowerment.

Summary

When President George W. Bush released the final report of the New
Freedom Commission on Mental Health in 2003, the commission's charge was
to evaluate the state of the American mental health system and propose a
guiding vision for the years to come. Central to its message was the
idea of empowerment; that a successful service system must rest on
personal decision making by the individual who is to benefit from
services. The commissioners also noted that evidence-based practices are
essential for America to enjoy a high-quality care system. This article
contains a review of seven evidence-based approaches promoting
individual empowerment for consumers of mental health services. With the
charge of the president's commission and the continuing research and
development that its report will hopefully generate, empowerment and the
greater achievement of life goals for people with mental illness will
only blossom.

Please send all correspondence to:

Patrick Corrigan

University of Chicago Center for Psychiatric Rehabilitation

7230 Arbor Drive

Tinley Park, IL 60477

Telephone (V): (708) 614-4770

Fax: (708) 614-4780

E-mail: p-corrigan@uchicago.edu

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