Psychiatric Quarterly, Vol. 73, No.

3, Fall 2002 ( C 2002)

EMPOWERMENT AND SERIOUS MENTAL ILLNESS: TREATMENT PARTNERSHIPS AND COMMUNITY OPPORTUNITIES
Patrick W. Corrigan, Psy.D.

The health goals of persons with serious mental illness are greatly improved when their personal power is advanced. Two targets of empowerment are discussed in this paper: treatment partnerships and community opportunities. Strategies that enhance treatment partnerships include provider endorsement of recovery rather than promoting an approach that suggests poor prognoses, treatment plans that are collaborative rather than unilateral decision making that is perceived as coercive, and treatment services provided in the persons community rather than geographically or psychological distant institutions. Approaches that focus on the person and treatment relationship are not sufcient however. Stigma and discrimination are signicant barriers to the kind of community opportunities that are necessary to help people attain life goals. Communities that substitute stigmatizing attitudes and discriminatory behaviors with realistic views of mental illness are more likely to provide the kind of reasonable accommodations that some people need for work and independent living opportunities.
KEY WORDS: consumer empowerment; stigma; serious mental illness.

Center for Psychiatric Rehabilitation, University of Chicago. Address correspondence to Patrick Corrigan, University of Chicago Center for Psychiatric Rehabilitation, 7230 Arbor Drive, Tinley Park, IL 60477; e-mail: p-corrigan@ uchicago.edu; www.ucpsychrehab.org. 217
0033-2720/02/0900-0217/0
C

2002 Human Sciences Press, Inc.

218

PSYCHIATRIC QUARTERLY

For almost all of recorded history, people with such serious mental illnesses as schizophrenia, bipolar disorder, and major depression have struggled with maintaining personal power over their lives. The ancient Greeks rst 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 (1). During the Middle Ages, persons with mental illness were viewed as living examples of the weakness of humankind, what goes wrong when people are unable to remain morally strong (2). This kind of attitude led to hiding away those with psychiatric disabilities in the familys closet. Not until the 18th century did asylums and treatment centers arise 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; two sources of disempowerment are the focus of this paper. (1) Treatment providers who endorse disempowering notions about mental illness are likely to undermine collaborative relationships with persons who consume their services. (2) Communities that promote stigma will fail to provide the rights and opportunities to which all adults are entitled. This paper reviews these sources of disempowerment and ways to overcome them. A model that describes how empowerment leads to improved outcomes is provided in Figure 1.

THE GOALS OF MENTAL HEALTH SERVICES What are the goals of programs that serve persons with serious mental illness? The answer to this question is essential to understand how empowerment affects the health of people with these disorders. First, treatment programs seek to decrease psychiatric symptoms so persons can obtain some relief from the various symptoms that may plague them; e.g., dysphoria, anhedonia, agitation, confusion, and rage. Stateof-the-art practice guidelines instruct providers to mix supportive psychotherapy, symptom monitoring, medication management, and skills training to help people obtain symptom relief (35). Many professionals and advocates believe that this kind of treatment package requires a mutually respectful and optimistic collaboration between consumers of psychiatric services and their providers. According to this view, consumers who are empowered in these collaborative relationships will benet more from treatment and be more successful in controlling their symptoms.

PATRICK W. CORRIGAN

219

FIGURE 1. A heuristic model of how empowerment leads to improved mental health outcomes in persons with psychiatric disabilities.

Symptom relief is by no means where service for people with serious mental illness ends. According to the DSM-IV, the key to what makes any mental illness serious is a signicant portion of time since the onset of the disorder where one or more major areas of functioning work, independent living, and self careis markedly below expected levels (3). It is this kind of persistent disabilities that make mental illnesses severe. Rehabilitation counselors seek a two-tiered approach towards remediating these disabilities (6,7): (1) helping consumers learn the necessary skills to overcome their disabilities (a treatmentbased approach similar to symptom remediation), and (2) changing the environment so persons can obtain reasonable accommodations that support them at work and home. In terms of the latter, communities that endorse the stigma of mental illness are not going to support an individuals right to self-determination in his or her community; the right to determine the kind of job they should pursue, the neighborhood they will live in, and the people with whom they will consort (8). Problems posed by this kind of stigma and discrimination require

220

PSYCHIATRIC QUARTERLY

public action to provide persons with serious mental illness the kind of opportunities needed to overcome their disabilities. Readers may notice that terms like empowerment and disempowerment are frequently interchanged in this paper. In part, this interchange represents empowerment as a continuum (9,10). At the positive end of the continum is the person with serious mental illness who, despite their disability, has positive self-esteem and is not signicantly encumbered by a stigmatizing community. At the negative end, is the person who reports being unable to overcome all the pessimistic expectations about mental illness. One might think that a paper about empowerment, health, and mental illness would be presented in the afrmative voice; 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 (11,12). Hence, I have chosen to intertwine what is known about disempowerment with what is the vision of empowerment to address the two themes of this paper: treatment partnerships and community opportunities.

THE EFFECTS OF EMPOWERMENT ON TREATMENT PARTNERSHIPS Clinical trials and effectiveness research have identied several pharmacological and psychosocial treatments for remediating symptoms and helping persons attain goals that are blocked by psychiatric disabilities. As suggested in Figure 1, many believe a partnership with the treatment team is central to these interventions; a mutual exchange between practitioners (who are expert in the interventions that improve symptoms and disabilities) and consumers (who are expert in their disability and life goals). Unfortunately, several barriers that result from disempowerment undermine this partnership; some of these are reviewed here. These are contrasted to ways that promote personal empowerment. Focus on Recovery, Not Poor Prognosis The traditional prognosis for serious mental illness had been poor. Kraepelin (13) voiced the most notable of these ideas; i.e., persons with schizophrenia and other serious mental illnesses will inevitably experience a progressive downhill course, ending up demented and

PATRICK W. CORRIGAN

221

incompetent. The impact this has on treatment is insidious; why try valiant interventions if the person is going to eventually end up on a back ward? Longitudinal research, however, fails to support Kraepelins assertion. For example, researchers in Vermont and Switzerland followed several hundred adults with severe mental illness for thirty years or more to nd out how mental illness impacted the long-term course of the disorder (14). If Kraepelin was right, the majority of these people should end up on the back wards of state hospitals. Instead, research discovered that between half to almost two thirds of the samples no longer required hospitalization, were able to work in some capacity, and lived comfortably with family or friends; they recovered. Recovery signals a revolution in mental health services. It clearly reinstates hope and potential in the life course of a person with severe mental illness. Unfortunately, the practices and perspectives of mental health practitioners often lag behind innovative ideas (15). For example, research has shown that well-trained professionals from most mental health disciplines subscribe to stereotypes about mental illness (1620). Many providers endorse the pessimistic notion that persons with serious mental illness are doomed to poor outcomes. Hence, an essential process for promoting empowerment is changing attitudes among health care providers. Replace Coercive Treatment with Collaboration Many persons with serious mental illness experience treatment programs as coercive, forcing patients to comply with an intervention which they either do not fully understand or, which they do not believe to be benecial (10,11,21). Perceived coercion may occur for several reasons. Confusing or complex treatment regimens may be misunderstood, leading to mistaken assumptions that practitioners are making unilateral decisions without the consumers participation. Treatment regimens for chronic disorders, that seem to continue indeterminably, are often experienced as coercive (22). Concerns about violence by persons with serious mental illness often lead to recommendations for mandatory inpatient and outpatient interventions (23). Social psychologists have dened reactance as the common response to perceived coercion; namely, persons behave contrary to the intent of a threat (2426). For example, consumers who believe medications are forced on them may decide not to comply with their prescription. Researchers have argued that this kind of reactance may be a central reason why persons with mental illness do not comply with

222

PSYCHIATRIC QUARTERLY

medication and other treatment regimens (22,27). Actually, the term compliance used in the previous sentence also promotes attitudes of disempowerment in its own right. The notion of compliance perpetuates the misconception that adherence derives primarily from patient motivation or resistance; the clinician is to overcome resistance and take the lead in inuencing this behavior. Rather than viewing the consumer as a passive receptacle for treatment, clinicians must partner with them to design treatment programs that meet the persons goals. In an earlier paper, we specied strategies that foster this collaboration (28). We divided this list into strategies that facilitate clinician-consumer relationships, those that make the treatment delivery system more pleasing to consumers, and approaches that make the treatment techniques themselves less aversive.

Service in the Community Not Institutions During the rst half of the 20th century, services were typically provided in institutions that were removed from the consumers community. This practice, in part, developed out of the notion of asylum, a place where persons with mental illness can escape the demands of everyday living to recoup their strengths and abilities (29). Despite this noble intent, sending people away to hospitals was soon identied as the prototype of disempowerment. Mental health advocates realized that quality of life was rooted in fully experiencing the opportunties and problems of ones neighborhood (30,31). Practitioners followed the lead by calling for community-based treatment of mental illness. A small step towards this goal was achieved in 1963 when John Kennedy signed the Community Mental Health Centers Act. The intent of the act was to move inpatient, outpatient, and emergency care services to the neighborhoods from which consumers hail. A major leap in community-based services that empower people with serious mental illness was demonstrated in the 1970s research program of Stein and Test (32). They advanced the notion of communitybased care by removing services from centrally located centers and bringing them to the consumers themselves. Stein and Test surmised that the impact of medication management, skills training, and support would be greatly improved when provided in the persons home, workplace or other meaningful setting, real places where personal goals are intimately experienced. A recent review of more than 75 studies that have examined the impact of Stein and Tests Assertive

PATRICK W. CORRIGAN

223

Community Treatment (ACT) show the intervention has moderate to good effects on hospitalization, housing stability, symptoms, and quality of life (33). The spirit of community-based interventions has further expanded with the integration of consumer-operated services into this armamentarium (34). STIGMA AND THE LOSS OF COMMUNITY OPPORTUNITIES Stigma is the societal embodiment of disempowerment (see Figure 1); it promotes expectations in both the public at large and many individual consumers that people with serious mental illness are incapable of the responsibilities commensurate with living independently. Results of two factor analyses on more than 2000 English and Americans revealed three common themes to stereotypic attitudes about mental illness that endorse this assertion (35,36). (1) 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. (2) Authoritarianism: persons with severe mental illness are irresponsible; life decisions should be made for them by others. (3) Benevolence: persons with severe mental illness are childlike and need to be cared for. These kind 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 which stigma has on some people with mental illness. People living with serious mental illness who are immersed in a culture that endorses psychiatric stigma (37) begin to believe this stigma and question their own capabilities for independent living. Because selfstigma has such an insidious impact, its effects on empowerment are examined rst. The Effects of Self Stigma Some people experience stigma as a private shame that diminishes the persons self-esteem (38,39). This kind of shame leads to self-doubt about whether the person is able to live independently, hold jobs, earn a livelihood, or nd life mates. Even though they may have mastered their symptoms and disabilities, persons with mental illness must also overcome stigmatizing reminders that they fail to recover or are

224

PSYCHIATRIC QUARTERLY

not useful members of society. One recent study showed the breadth of discrimination experienced by mental health consumers (40). The majority of 1300 respondents reported discouragement, hurt, anger, and lowered self-esteem as a result of their experiences. An earlier study by Bruce Link (41) 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. Research is yet to examine strategies for overcoming self-stigma, but several candidates show promise (39). 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 of themselves (38,42). Ultimately, selfstigma will change when common stigmatizing attitudes of the public are stopped.

Societal Stigma and the Loss of Opportunities As we stated earlier in this paper, one of the central goals of mental health service is to help persons overcome the disabilities that prevent them from achieving life goals. In part, this means helping persons take advantage of the opportunities available to most adults in their community; good jobs, safe housing, reasonable income, and diverse friends. Unfortunately, research shows that stigma steals these opportunities from persons labeled mentally ill. Citizens are less likely to hire persons who are labeled mentally ill (4346), less likely to lease them apartments (4749), and more likely to falsely press charges for violent crimes (50,51). This kind of injustice requires community change. Social psychologists have identied three ways to change stigmatizing attitudes and discriminatory behaviors in the general public: protest, education, and contact (8). Protest seeks to suppress stigmatizing attitudes of mental illness and behaviors that promote these attitudes through appeals to moral indignation. Shame on you for thinking about mental illness in a disrespectful way. Unfortunately, research suggests protest has little effect on negative attitudes about mental illness (52). This does not, however, mean protest yields no benets as far as discrimination is concerned. Businesses that are the object of protest because of stigmatizing media representations (e.g., an advertisement that says, We must be NUTS to sell cars so cheaply!) may cease these ads rather than face economic boycotts (37).

PATRICK W. CORRIGAN

225

Several research studies have examined the effects of education on stigmatizing attitudes and discriminatory behavior (5256). Typically, education programs contrast key myths about mental illness with corresponding facts. These studies show signicant changes in attitudes but little effects on behavior. Contact seems to yield better effects. Contact challenges public attitudes about mental illness through direct interactions among the general public and persons who have these disorders. Myths are directly challenged when members of the general population experience persons with mental illness as no different than the rest of the population. Two recent studies have shown that contact yields greater improvements in attitude change than education; contact also facilitates helping behaviors (52,53). Consider the implications of contact for empowerment; this research suggests one of the greatest resources for challenging the stereotypes that undermine opportunities is the person with mental illness.

CONCLUSIONS Persons with mental illness, who experience personal power over their immediate life decisions, seem to demonstrate better mental health outcomes. Making sense of the path between empowerment and mental health began with description of the goals of mental health treatment. Two goals were distinguished: providing relief from the painful symptoms of serious mental illness and attaining life goals that are blocked by psychiatric disabilities. Attitudes and behaviors that foster disempowerment will block attainment of these goals; conversely, strategies that promote empowerment and challenge stigma facilitate health goals. Several strategies were identied that seem to promote empowering treatments and treatment partnerships. Providers that adopt an attitude of recovery encourage an optimistic approach towards dealing with symptoms and disabilities. This kind of approach is further facilitated when providers work collaboratively with consumers, being vigilant to such issues as the quality of consumer-clinician relationships, the treatment system ambience, and the perception that specic techniques are perceived to be coercive. The treatment partnership is also augmented by providing services in the persons community, rather than some geographically or psychologically distant institution. The impact of empowerment does not end there. Health goals, especially related to those that are diminished by disabilities, are

226

PSYCHIATRIC QUARTERLY

facilitated when the stigma and discrimination that have been used to describe these disabilities are challenged. Hence, persons who replace self-stigmatizing attitudes with positive expectations about work and independent living goals will be more successful in pursuit of those goals. Moreover, communities that replace the myths of mental illness with accurate information will be more apt to provide the kind of reasonable accommodations that people need to successfully attain work and independent living opportunities. We have only just begun to outline and test the hypotheses outlined in this paper. It is up to future research to determine the veracity of these assertions and to amend them as more is learned. REFERENCES
1. Simon B: The perception of ingroup and outgroup homogeneity: Reintroducing the intergroup context. In: Stroebe W, Hewstone M, eds., European Review of Social Psychology, Vol. 3. Chichester, England, John Wiley & Sons, 130, 1992. 2. Mora G: Stigma during the medieval and renaissance periods. In: Fink PJ, Tasman A, eds., Stigma and Mental Illness. Washington, DC, American Psychiatric Press, 41 57, 1992. 3. American Psychiatric Association: Practice guideline for the treatment of patients with bipolar disorder. American Journal of Psychiatry 151:12, 1994. 4. American Psychiatric Association: Practice guideline for the treatment of patients with schizophrenia. American Journal of Psychiatry 154:4, 1997. 5. American Psychiatric Association: Practice guideline for the treatment of patients with major depressive disorder. American Journal of Psychiatry 157:4, 2000. 6. Anthony WA, Liberman RP: Principles and practice of psychiatric rehabilitation. In: Liberman RP, ed., Handbook of Psychiatric Rehabilitation. New York, Macmillan Publishing Company, 1992. 7. Corrigan PW, Rao D, Lam C: Psychiatric rehabilitation. In: Chan F, ed., Case Management Desk Reference. Lake Zurich, IL, Vocational Consultants Press, 527 564, 1999. 8. Corrigan PW, Penn DL: Lessons from social psychology on discrediting psychiatric stigma. American Psychologist 54:765776, 1999. 9. Corrigan PW, Faber D, Rahid F, et al: The construct validity of empowerment among consumers of mental health services. Schizophrenia Research 38:7784, 1999. 10. Rogers ES, Chamberlin J, Ellison ML, et al: A consumer-constructed scale to measure empowerment among users of mental health services. Psychiatric Services 48:1042 1047, 1997. 11. Corrigan PW, Garman AN: Some considerations for research on consumer empowerment and psychosocial interventions. Psychiatric Services 48:347352, 1997. 12. Rapp CA, Shera W, Kisthardt W: Research strategies for consumer empowerment of people with severe mental illness. Social Work 38:727735, 1993. 13. Kraepelin E: Dementia Praecox and Paraphrenis. Translated by Barclay RM. Edited by Robertson GM. Edinburgh, E&S Livingstone, 1919. 14. Harding CM: Course types in schizophrenia: An analysis of European and American studies. Schizophrenia Bulletin 4:633642, 1988.

PATRICK W. CORRIGAN

227

15. Backer T, Liberman R, Kuehnel T: Dissemination and adoption of innovative psychosocial intervention. Journal of Consulting and Clinical Psychology 54:111 118, 1986. 16. Keane M: Contemporary beliefs about mental illness among medical students: Implications for education and practice. Academic Psychiatry 14:172177, 1990. 17. Lyons M, Ziviani J: Stereotypes, stigma and mental illness: Learning from eldwork experiences. American Journal of Occupational Therapy 49:10021008, 1995. 18. Mirabi M, Weinman ML, Magnetti SM, et al: Professional attitudes toward the chronic mentally ill. Hospital and Community Psychology 36:404405, 1985. 19. Page S: Social responsiveness toward mental patients: The general public and others. Canadian Journal of Psychiatry 25:242246, 1980. 20. Scott DJ, Philip AE: Attitudes of psychiatric nurses to treatment and patients. British Journal of Medical Psychology 58:169173, 1985. 21. Rappaport J: Terms of empowerment/exemplars of prevention: Toward a theory for community psychology. American Journal of Community Psychology 15:121148, 1987. 22. Fogarty JS: Reactance theory and patient noncompliance. Social Science and Medicine 45:12771288, 1997. 23. Munetz MR (ed.): Can Mandatory Treatment be Therapeutic? San Franciso, JoseyBass Publishers, 1997. 24. Brehm JW: A Theory of Psychological Reactance. New York, Academic Press, 1966. 25. Brehm SS, Brehm JW: Psychological Reactance: A Theory of Freedom and Control. New York, Academic Press, 1981. 26. Dowd ET, Wallbrown F, Sanders D, et al: Psychological reactance and its relationship to normal personality variables. Cognitive Therapy and Research 18:601612, 1994. 27. Rogers A, Day JC, Williams B, et al: The meaning and management of neuroleptic medication: A study of patients with a diagnosis of schizophrenia. Social Science and Medicine 47:13131323, 1998. 28. Corrigan PW, Liberman RP, Engel JD: From noncompliance to collaboration in the treatment of schizophrenia. Hospital and Community Psychiatry 41:12031211, 1990. 29. Colp R: History of psychology. In Kaplan HI, Sadock BJ, eds., Comprehensive Textbook of Psychiatry, Vol. 2, 6th ed. Baltimore, Williams & Wilkins, 27772800, 1995. 30. Beers CW: A Mind That Found Itself: An Autobiography. New York, Longmans, Green, & Co, 1908. 31. Chamberlin J: On Our Own: Patient-Controlled Alternatives to the Mental Health System. New York, McGraw-Hill, 1978. 32. Stein LI, Test MA: Alternative to mental hospital treatment: I. Conceptual model, treatment program, and clinical evaluation. Archive of General Psychiatry 37:392 397, 1980. 33. Mueser KT, Bond GR, Drake RE, et al: Models of community care: A review of research on case management. Schizophrenia Bulletin 24:3774, 1998. 34. Davidson L, Chinman M, Kloos B, et al: Peer support among individuals with severe mental illness: A review of the evidence. Clinical Psychology: Science and Practice 6(2):165187, 1999. 35. Brockington IF, Hall P, Levings J, et al: The communitys tolerance of the mentally ill. British Journal of Psychiatry 192:9399, 1993. 36. Taylor SM, Dear MJ: Scaling community attitudes toward the mentally ill. Schizophrenia Bulletin 7:225240, 1980.

228

PSYCHIATRIC QUARTERLY

37. Wahl OF: Media Madness: Public Images of Mental Illness. New Brunswick, NJ, Rutgers University Press, 1995. 38. Corrigan PW: The impact of stigma on severe mental illness. Cognitive and Behavioral Practice 5:201222, 1998. 39. Corrigan PW, Watson AC: The paradox of self-stigma and mental illness. Clinical Psychology: Science and Practice, in press. 40. Wahl OF: Mental health consumers experience of stigma. Schizophrenia Bulletin 25:467478, 1999. 41. Link B: Mental patient status, work and income: An examination of the effects of a psychiatric label. American Sociological Review 47:202215, 1982. 42. Haaga DA, Davison GC: Cognitive change methods. In: Kanfer FH, Goldstein AP, eds., Helping People Change: A Textbook of Methods, 4th ed. New York, Pergamon Press, 248304, 1991. 43. Bordieri J, Drehmer D: Hiring decisions for disabled workers: Looking at the cause. Journal of Applied Social Psychology 16:197208, 1986. 44. Farina A, Felner RD: Employment interviewer reactions to former mental patients. Journal of Abnormal Psychology 82:268272, 1973. 45. Olshansky S, Grob S, Ekdahl M: Survey of employment experiences of patients discharged from three state mental hospitals during the period 19511953. Mental Hygiene 44:510522, 1960. 46. Link BG: Understanding labeling effects in the area of mental disorders: An assessment of the effects of expectations of rejection. American Sociological Review 52:96112, 1987. 47. Page S: Effects of the mental illness label in attempts to obtain accommodation. Canadian Journal of Behavioral Sciences 9:8590, 1977. 48. Page S: Psychiatric stigma: Two studies of behavior when the chips are down. Canadian Journal of Mental Health 2:1319, 1983. 49. Page S: Effects of the mental illness label in 1993: Acceptance and rejection in the community. Journal of Health and Social Policy 7:6168, 1995. 50. Sosowsky L: Explaining the increased arrest rate among mental patients: A cautionary note. American Journal of Psychiatry 12:16021604, 1980. 51. Steadman HJ: Critical reassessing the accuracy of public perceptions of the dangerousness of the mentally ill. Journal of Health and Social Behavior 22:310 316, 1981. 52. Corrigan PW, River LP, Lundin RK, et al: Three strategies for changing attributions about severe mental illness. Schizophrenia Bulletin 27:187196, 2001. 53. Corrigan PW, Rowan D, Green A, et al: Challenging two mental illness stigmas: Personal responsibility and dangerousness. Schizophrenia Bulletin, in press. 54. Holmes EP, Corrigan PW, Williams P, et al: Changing public attitudes about schizophrenia. Schizophrenia Bulletin 25:447456, 1999. 55. Penn DL, Guynan K, Daily T, et al: Dispelling the stigma of schizophrenia: What sort of information is best? Schizophrenia Bulletin 20:567578, 1994. 56. Penn DL, Kommana S, Manseld M, et al: Dispelling the stigma of schizophrenia: II. The impact of information on dangerousness. Schizophrenia Bulletin 25:437446, 1999.