Journal of Psychiatric and Mental Health Nursing, 2009, 16, 285–292

User involvement in community mental health

services – principles and practices
M. BORG1 phd, B. KARLSSON1 phd & H. S. KIM2 phd
1
Associate Professor and 2Professor, Department of Health Sciences, Buskerud University College, Norway

Correspondence: BORG M., KARLSSON B. & KIM H. S. (2009) Journal of Psychiatric and Mental
M. Borg Health Nursing 16, 285–292
Buskerud University College User involvement in community mental health services – principles and practices
Department of Health Sciences
Box 235 Although user involvement has been the vision of mental health care for the last decades,
3601 Kongsberg
there are indications of this vision remaining as rhetoric rather than reality in many clinical
Norway
settings. The objective of this paper is to raise some fundamental questions associated with
E-mail: marit.borg@hibu.no
user involvement. Four challenges are examined: assumptions about the nature of the
problems, the power of defining ‘true knowledge’, the power domination in service provi-
sion and community mental health care as an accommodating arena for maximizing the
service user role. Finally, some strategies are suggested in order to overcome barriers
towards realizing the intentions of user involvement.

Keywords: citizenship, community care, mental health, patient rights, recovery

Accepted for publication: 16 October 2008

I found him so balanced in a way . . . didn’t have all
kinds of programs of his own that we had to go through.
I could talk about anything . . . everyday life, things that
were important to me, not necessarily problems . . . I
was the one who decided what to talk about.
One voice appropriate for setting the agenda for the
present paper: taking the user perspective involves interest
and awareness of the service user’s daily problems – and
mental healthcare professionals being available without
predetermined agendas or programmes. The stance of user
perspective has been prominent in mental health policy and
practice in most Western countries for the past decades,
with numerous policy documents, books and papers being
written and many providers embracing it in their strategic
planning. Furthermore, we have seen the upcoming of a
rich variety of constructs which carry significant amounts
of allusive and persuasive language, like user participation,
user empowerment, quality standards for user involve-
ment, user controlled services, user-focused and collabora-
tive research, user councils, to mention some. Although
user involvement in mental health services and partnership
between service users and professionals has been the vision
and intention in the practice of mental health care for the
last decades, there are evidences indicating that this vision
remains as a rhetoric rather than a reality in many clinical
settings (see e.g. Edwards & Staniszewska 2000, Rose
2003, Hansen et al. 2004, McCabe 2004, Beresford 2005,
Graham et al. 2005). The historical background that
shaped the modern mental health care still plagues the
notion of professional ‘control’, resulting both from the
pathologicalization and medicalization of mental health
problems and from the persisting concept of deviance that
underpins the meaning of mental health problems. Within
this pervasive milieu, the notion of user involvement
continues to remain a rhetoric.
In mental health nursing, the concept of user involvement
has a critical significance as mental health nursing is increas-
ingly practised in community settings, shifting away from
inpatient settings. Community mental health nursing, prac-
tised in either an independent or a team mode, demands
nurses to approach service users in the everyday context
rather than in the institutional context, thus making user
involvement a key orientation in practice. However, user
involvement initiatives that have been put into place at
national, regional and local levels from the policy man-
dates seem to have had a minimal effect on mental

© 2009 Blackwell Publishing 285

M. Borg et al.
healthcare professionals’ practice in general as well as that
of nurses.
The aims of this paper are to raise some fundamental
questions associated with user involvement in community
mental health services, present some central challenges
associated with user involvement in relation to community
mental health practice and discuss ways of overcoming bar-
riers towards realizing the intentions of user involvement.
Different concepts – different meanings?
Strengthening the user perspective and user involvement in
mental health services has been a key part of policymaking
in many countries, and also has been encouraged by World
Health Organization (WHO) in order to establish services
that are better tailored to people’s needs and used more
appropriately. The WHO Mental Action Plan for Europe of
2005 acknowledges that a lack of empowerment of users
and carers and poor advocacy will hinder the delivery of care
(European Commission 2005). In Norway a central inten-
tion in the 10-year national initiative to restructure mental
health services (Norwegian Ministry of Social & Health
Affairs 1997) is to promote user participation and ensure
that service users’ opinions are to be taken into account in
decision-making for individualized planning processes. Citi-
zenship rights are emphasized in the process of receiving
services while the society in general is viewed to have the
overall responsibility of meeting the needs of its citizens.
However, user perspective and user involvement is not a
single concept, but encompasses meanings at several levels.
The following concepts are frequently used to suggest dif-
ferent levels of user activities in practice: user involvement,
user participation, user perspective, user control and user
empowerment. These terms, in common use, seem to refer
to somewhat different ideas regarding users’ roles in receiv-
ing as well as developing mental health services. For
example, a simple examination of words suggests ‘partici-
pation’ to be less engaging and influencing than ‘control’
and ‘empowerment’, while ‘involvement’ to be somewhat
passive and non-committal, and ‘perspective’ to be all
encompassing. However, the differences among the terms
are subtle, and scholars and practitioners often use the
terms interchangeably. In the context of this paper, we find
the differentiation used in a Norwegian report about user
participation helpful (The Directorate of Health and Social
Welfare 2006). Here ‘user’ is referred to as a person who is
in need of or makes use of mental health services, and the
concept ‘user perspective’ is given an overall meaning,
entailing various levels of user involvement such as:
• participation as an individual user of services in her or
his assessment, planning and decision-making thr-
ough the rights for information and to offer opinions;
286
• being a representative of service users mandated by a
group to represent collective user interests in policy
development, service design and evaluation, training
programme design and general quality insurance;
In addition, the following two points can be added to
enrich the role of service users at individual, system
and political levels:
• being an influencer in focus groups or through indi-
vidual interviews by providing personal opinions
regarding evaluations and service improvements;
• being an influencer as board members, planners or
professionals providing inputs from work-related or
user-expertise and experiences.
Such policy statements are not only evident in the docu-
ments from the central government but also typically pro-
posed in local health enterprises and municipalities, where
service user participation is mandated as the right of hav-
ing choices, viewed as the fundamental citizenship rights,
required in order to understand people’s mental health
problems and promoted as essential to recovery. In this
paper, we thus use the term, user perspective, to refer to the
general orientation and the mode of actions that uphold the
centrality of users in the provision of mental health services.
The philosophy of the user perspective
The concept of user perspective in mental health care is
founded upon two philosophical foundations, which are
post-modern in nature: (1) existential, phenomenological
philosophy as an ontology; and (2) critical philosophy of
the postmodernism for the practice philosophy. This is an
approach that is counter to the dominance of medicaliza-
tion and control in health care in general and mental health
care in particular.
The ontology of illness and illness experiences has been
historically tied to the objectification of disease and illness in
modern medicine in general as well as in mental health care.
The general medicalization began to be most aggressively
advocated and accepted in the 1980s in the culture of
biomedical advances and economic politics (Hafferty 2006),
and the medicalization of psychiatry and mental health has
evolved into the culture of DSM and pharmaceutics in the
recent decades (Leifer 2001, Nye 2003, Conrad 2005,
Mayes & Horwitz 2005). Although Foucault’s critique of
mental illness (Foucault 1967) and Szasz’s objection to
medicalization of mental illness (Szasz 1960, 1961) pro-
vided the early objections to ‘treating’ mental illness for
control, medicalization in the more recent decades became
more firmly grounded on scientific development and
economic rationality. With the advent of the concept of
diagnosis as the central starting point for medical care,
including mental health care and the facade of therapeutic
© 2009 Blackwell Publishing

success, the person who is experiencing the distress or
problems is objectified only as the situ of the problem. As a
result, a person whose subjective being and life in context
make him or her a unique individual often became lost
behind the label of a disease or a diagnosis (Barker et al.
1998). Objectification of the situation of being sick thus
became equated with being diagnosed, and the person was
often met as diagnoses rather than as an individual having
problems in given contexts. The philosophy of existential
phenomenology (Heidegger 1962, Merleau-Ponty 1962) is
a critical posture to shift this objectification of health
problems to subjectification of experiences. In existential
phenomenology, the focus is the subjective meaning of
experiences rather than the experiences themselves as objec-
tified incidences. Human beings’ existence and experiences
are viewed to be intrinsically and totally fused within the
context and subjectivity. Thus, mental health problems are
lived in everyday contexts, experienced within the mean-
ings gained subjectively. Therefore, the user perspective
embraces the philosophy of existential phenomenology as
the ontology of illness experiences, and signifies the critical
nature of subjective experiences and their meanings of
mental health problems to both the individuals themselves
and professional practitioners.
Critical philosophy (Habermas 1971) is the second phi-
losophy that undergirds the user perspective specifically in
relation to practice philosophy. Mental health care has
been historically and continues to be entrenched with
power-inequality between the professionals and users. This
comes from the traditional concept of medical power, and
the acceptance of mental health problems as deviance
requiring control and as conditions in which human
decision-making abilities are often thought to be less than
intact. Domination and control emanating from power
differentials are viewed to be the sources of alienation and
distorted views of situations. Thus, critical philosophy that
calls for equalization, mutual understanding and sharing as
the fundamental bases for human relationships is embraced
in the user perspective so that the rights of users are pro-
tected and the voices of users have equal weights in their
care. Critical philosophy is oriented to correcting domina-
tion, distortions and distrust not only at individual levels
but also at systematic levels. The dominant medical/
pathological culture and control orientation are the sources
for delimiting the contribution of users in their own care
both at individual–practitioner relationships and in domi-
nant practice patterns in general. The user perspective
founded upon critical philosophy shifts the power from the
professionals to the users especially in making user voices
heard and user choices to be upheld. In a similar argument,
Stickley (2006) advocates critical realism as the basis upon
which service users can usurp the power of control in their
© 2009 Blackwell Publishing
User involvement in mental health services
mental health care not within the traditional hierarchy of
power but through emancipatory action projects outside
the existing power structures.
The challenges of the user perspective and
practice implications
Encompassing a user perspective involves empowerment,
emancipation, and regulating the relationship between
service users and professionals and between service users
and various administrative and management levels.
Four challenges are examined in relation to their practice
implications.
Challenge 1. Assumptions about the nature of the
problems within the objectivity/subjectivity debate
How is it decided what the concrete mental health problem
presented by a service user is about? An issue to give some
reflection and consideration in discussing the user perspec-
tive is the presence of opposing key assumptions about the
nature of problems experienced by service users. There are
two issues regarding the nature of mental health ‘problems’
presented by service users for services: one is associated
with the frames by which the problems are viewed and
determined for their significances, and the other is regard-
ing the attribution of labels. When a service user comes in
contact with a mental health professional for service, it is
through a discourse between the service user and the pro-
fessional practitioner a determination of mental health
problems gets formulated. As Mishler (1984) noted in his
study of medial discourse, two voices, the service user’s
voice of everyday life and the professional’s voice of medi-
cine, often tend to clash and do not meet to reconcile
different perspectives from which two parties see problems.
This often results in the medical professionals remaining
within the frames of biomedicine, including causality ori-
entation, primacy to objectification of symptoms, and
control. The mental health problem determinations there-
fore tend not to reflect the service user’s everyday life
concerns and personal meanings of experiences. In addi-
tion, findings in recovery studies (Breier & Strauss 1984,
Topor 2001, Mezzina et al. 2006, Borg 2007, Davidson &
Roe 2007) reveal the importance of understanding mental
distress within the context of the person’s everyday life,
which moves us beyond the simple assertion that mental
illness is a brain disease. Life contexts as opposed to illness
contexts offer insight into how people can live full and
rewarding lives despite the ongoing presence of health
problems. It also discloses the impact of everyday life
resources and simple trivialities on improvement, like living
conditions, income, employment situations and social
interactions outside treatment settings. These are central to
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M. Borg et al.
processes of recovery and cannot be seen as lying outside
the scope of clinical practice.
Determining diagnoses and giving ‘medical’ labels to
mental health problems have become the general protocols
for mental health care with the acceptance of the DMS
system during the past several decades. However, the dilem-
mas with labelling are highly present in all areas of mental
health services, including the community services. Various
problems associated with diagnosing and diagnoses have
been highlighted throughout the history of psychiatry. Psy-
chiatric diagnosis has been challenged as faulty from several
perspectives, including the reification problem, application
of standardization and averages, and being blamed for
creating more problems than it has solved. One fundamental
criticism is that pathological discourses rarely consider the
person’s life circumstances, and where problems and symp-
toms are then identified in individualistic, inherent and
internal ways (Read 2004, Beresford 2005). Similar issues
were raised by Basaglia (1987) who criticized mental health-
care systems for having a main interest in illness entities
rather than in the person experiencing the mental distress
and daily life consequences. Larsen (2004) calls for a set of
explanations rather than a single dominating one, in order
to value individual experiences. Larsen argues for appreci-
ating the person as someone who in attempting to under-
stand her or his situation, also draws on resources from the
cultural repertoire that makes sense, such as attributing an
importance to what the voices actually represents and means
for the person.
The challenge, therefore, is in how to reconcile the dif-
ferences between the professionals’ perspectives of mental
health problems and the service users’ experiences within
their life contexts, in order to align mental health care with
the ‘true’ problems. Upholding the user perspective in the
determination of mental health problems means not only
for the professional practitioners to expand their visions of
mental health problems beyond the ‘biomedicine’, but also
to share the power of determination and labelling with
service users.
Challenge 2. The power of defining ‘true knowledge’
Our assumption is that true knowledge is context-
determined and value-dependent. Michel Foucault (1967,
1973) has through his works, in different ways, discussed
the relation between science, knowledge and power. Fou-
cault uses the term discourse. He developed the idea of
discourse by situating it historically, culturally and socially.
Foucault poses a difficult dilemma for science by asking the
question: is it possible to establish ‘true knowledge’ when
the concept of truth itself has had many complex and
variable meanings? He claims that all ideas and under-
288
standings are historically, culturally and socially specific,
but that some concepts and ideas has become so widely
accepted that they are taken as true. In ‘Madness and
Civilisation’ (Foucault 1967), he identified the emergence
of the concept of reason and its contrast to irrationality, in
the events and social processes which created the asylums.
He argued that the ‘insane’ were defined, identified and
incarcerated in the buildings of the former leper colonies as
part of the system which constructed social orders of
modern rational principles. Without the emergence of sci-
entific knowledge and rational explanations of the world,
he argued, there would have been no mental illness as we
understand it today. It would have not been appropriate to
define forms of behaviour as rational or irrational or as
normal or abnormal in the first place. The creation of
‘madness’ or ‘insanity’, like constructions of science, was
the complex institutional product of opposition between
reason and unreason at the heart of modernity.
Foucault’s perspectives of power and knowledge bring
to our attention that in the fields of specialized knowledge,
our actions are governed by the constituents of the power
structures themselves (Foucault 1973). It means that under-
standing within the fields of knowledge is manufactured
within their discourses. In mental health services, ‘true
knowledge’ is typically associated with having specialist
knowledge, thus allowing professionals to have unique
power and control. The psychiatrist for instance has power
to diagnose a condition, and because the person belongs to
this specialist discourse, their word is considered authori-
tative and ‘true’. Bråten (1973) describes the professional
knowledge hegemonies as model-power – a power built on
monopolizing and hegemony over certain worldviews.
In the context of model-power, the user perspective is
threatened.
Voices both inside and outside mental health services are
challenging the failure to pay attention to alternative
understandings of mental distress, raising vital questions as
to how psychiatry can continue to dominate the epistemol-
ogy of mental health problems when there are well-argued
challenges to this from a service user perspective and the
recovery literature (Deegan 1990, Beresford 2005, Borg
2007). In recent years, there has been an expansion in
social approaches to mental health issues as a reaction
towards the medical illness models. New networks and
expanding multidisciplinary and service user literature urge
a need to take into account social and material as well as
individual factors and forces involved in the formulations
and experiences of mental health problems (Wilson &
Beresford 2002, Beresford 2005, Mezzina et al. 2006).
Still, many practice cultures find it hard to implement user-
based or socially oriented knowledge as they are not on the
golden standard list of evidence-based practice (EBP).
© 2009 Blackwell Publishing

Neither are they particularly promoted in the discourse of
the New Public Management (NPM) reforms with unitary
management, organizational loyalty, and new types of
control and reporting systems visualizing health care as
processes and outcomes. Johannessen (2004) claims that
the effect of the interaction between the NPM reforms in
Norwegian mental health care and EBP is a central precon-
dition for understanding how knowledge traditions and
work practices in mental health care are currently chang-
ing. In the eyes of many clinicians, new formal modes of
rationality have had a great impact on practice, threatening
the very nature of therapeutic relations as well as the pros-
pects of creating contexts and opportunities for user
involvement on a substantial level.
A reminder of the Italian psychiatrist and reformer Basa-
glia in the 1980s may be in place: ‘When people’s problems
or troubles are not viewed within the context of everyday
life and are not recognized as the focus of considerable
efforts or as influenced by difficult situations or conflicts,
they simply become reduced to an illness entity’ (Basaglia
1987). As opposed to professional knowledge domains,
service users’ knowledge gives attention to everyday life
situations and how mental distress affects their lives – often
on a very concrete level. They may well talk about pursuing
interests, making your home neat and pleasant, being with
friends, and in general being occupied with meaningful
activities were described as helpful:
It’s important to have things to do that give meaning. I
go for walks a lot in the area here, maybe start the day
by turning on the PC, and then take a turn tidying. For
me it is important to have 1–3 things to do that are
good. Situations of doing nothing promote illness for
people with serious mental illness. I need some on-going
projects . . . those are good things. (by an informant in
recovery study, Borg 2007)
User knowledge is rich in what professionals as well as
researches may see as trivialities; it is substantial and
detailed, and contributes to establish and justify knowledge
in concrete human life contexts. Such knowledge encom-
passes the competence and skills of dealing with voices and
of living with side effects of medicine, the strategies devel-
oped in order to keep a job, or to live on a limited monthly
budget. The systemization of user experiences through
qualitative research represents an important contribution
to give validity to this knowledge as well as to develop new
methodologies for eliciting such knowledge. Knowledge
from the service users’ perspective of their experiences of
mental distress points to the reformulation of the concept
of mental illness from that of chronic debilitating disease
resulting in dependence to that encompassing recovery as
its trajectory. As knowledge elicited from recent qualitative
studies reveal (Borg 2007):
© 2009 Blackwell Publishing
User involvement in mental health services
• processes of recovery means ‘taking back control and
getting on with one’s life’, and managing most things
most of the time;
• recovery is not about cure nor necessarily about
symptom relief, but rather about learning to live with
and finding ways of overcoming barriers;
• recovery is considered a dynamic and social process,
incorporating individual as well as environmental
perspectives and the relationships between the two.
User knowledge does not rank high on the evidence
hierarchy of knowledge. The explanations for this may well
be found in the challenges mentioned earlier, but may also
well be found in the dominant understanding of what
knowledge is. We have a situation with a knowledge hierar-
chy or evidence-hierarchy as Martinsen (2005) puts it,
where evidence-based medicine or practice has been
accepted and instituted as the major mode of knowledge
base guiding practice. Although EBM has provided valuable
knowledge for practise, there remain major problems in
the power imbalance between sciences and other ways of
knowledge acquisition, when EBM is claimed to be on the
top of the hierarchy of scientific knowledge, developed
mostly through clinically controlled trials and statistical
analysis. As Marthinsen states, it is highly problematic when
it appears to put ‘professional judgment’ aside and is pre-
sented and used in ways which are apparently blind to
power issues. Knowledge hierarchy is a power hierarchy. In
this hierarchy of evidence, user knowledge does not really
count much.
Challenge 3. Power domination in service
provision – the power of double messages:
mentalism and microaggressions
Concepts like mentalism and microaggressions are men-
tioned by service users as examples of what makes it dif-
ficult to realize a mental health service characterized by
user perspective and user involvement (Chamberlain 1978,
Deegan 1990, 1997). Mentalism refers to the oppression of
people who have been diagnosed with psychiatric disorders.
It is typically about being placed in a sick role, with expec-
tations of compliance to the treatment orders and doing all
they can to work with the professionals on their premises.
The implications of the sick role for user involvement are
to accept, rather than challenge the imbalance of power
between professional experts and service user. Mentalism
has similarities with other ‘isms’ such as racism (the oppres-
sion of racial minorities), sexism (the oppression of women),
heterosexism (the oppression of gay men and lesbians),
class-based oppression (the oppression of people based on
the socio-economic class they were born into) and able-ism
(the oppression of people with disabilities). Like all forms of
289
M. Borg et al.
oppression, mentalism occurs at cultural, systemic, interper-
sonal and personal levels (Chamberlain 1978).
Microaggressions refer to ‘the things you experience
every day that then add up and take their toll’, as the
psychiatrist Alvin Poussaint puts it (Sparks 2002). It is a
domination of a special kind in which a person is subjected
to disrespectful and humiliating communications daily or
several times a day, and receives messages that he or she is
different, dangerous, a nut case, a ticking bomb, a chronic
schizophrenic or a dual diagnosis. Such microaggressions
have a cumulative effect. The negative stereotypes inside
and outside services, the labelling of people as treatment
resistant and non-compliant, and the sensational media
stories carry rhetoric messages creating barriers towards
user participation and collaborative practices. This form of
practice is often entrenched within the ongoing scene of
mental health services as ‘experienced’ dominations that
occur in a systematic way. Service users within both the
service system and their social environment experience
such microaggressions that freeze their intentions and will-
ingness for user involvement.
Challenge 4. Deinstitutionalization and community
mental health care – accommodating arena for
maximizing the service user role?
The idea of deinstitutionalization was to give individuals
who need help and support for mental health problems a
basically normal life as a citizen – a life beyond symptoms
and deviance. Learning from history, of Barton (1959)
and what he called institutional neurosis, identified as an
illness that struck persons who remained in psychiatric
institutions for many years; and from Goffman’s (1961)
well-known investigations of the ‘total institutions’, the
objective of deinstitutionalization was to provide alterna-
tive, accessible and available community practises. In other
words, one would expect that these new locally based
arenas had developed to become appropriate for strength-
ening the user perspective and the overall quality of life for
users. Deinstitutionalization has been successful in some
instances regarding these intentions, although there are
many failed stories especially in relation to user involve-
ment. The continuing referents to service users and their
care in the community mental health services sector with
vocabularies such as ‘psychiatric homes’ or ‘psychiatric
daycentre’ or with expressions like ‘our neighbour is a
psychiatric patient’ revert the service users of community
services back to ‘psychiatric’ arena. The label of ‘psychiat-
ric’ patients is retained within the community services
sector, not allowing them to be simply people. A double
message exists in which on one hand citizens’ lives are
made psychiatric with an inherent conception of depen-
290
dency, and on the other hand the objective of user per-
spective is to be upheld for self-determination and active
involvement. The major approach should encompass then
that the concept ‘psychiatric’ should be reserved to the
medical discipline and context for disease orientation, and
not be referred to in relation to services and systems aimed
at citizenship and community living. The major approach
in deinstitutionalization and community services needs to
incorporate the rights and responsibilities of independent
citizens as the primary orientation.
An example of housing, a key issue in community
mental health services, offers an insight to this double
message. Looking back to earlier days, the ‘home’ of indi-
viduals with long-term mental health problems was often
the psychiatric hospital, characterized by Goffman (1961)
as a ‘total institution’, where individuals carried out all
their daily activities with the same people and under the
same authority. The institution was both home and work,
and daily routines were set and often rigidly enforced by
caretakers. Following deinstitutionalization, a variety of
services and programmes for accommodation has devel-
oped. When it comes to places to live, board and care
homes, supervised apartments, and supported housing, to
name a few, all represent efforts to relocate people within
the community. Nevertheless, these programmes may bring
as much associations to institutions as they do to people’s
homes, with a dominant presence of control systems,
rules and regulations, and service values for what consti-
tutes avenues towards recovery above those of the service
users.
Conclusion
There is a paucity of evidence that records the effects of
initiatives and programmes that have been put into place to
improve user involvement in mental health care in general
and community mental health care in particular. Although
there are anecdotal evidences of their effectiveness, it is
difficult to garner their effects in changing the practice in a
fundamental way. Hansen et al. (2004) report a prevailing
tendency of mental healthcare professionals as individuals
and as teams to overestimate service users’ needs in
comparison with service users themselves in patient care
planning after the introduction of the user involvement
initiatives, suggesting the continuing undercurrent of
medical paternalism in practice. On the other hand,
both the nurses, as reported in the study by Anthony &
Crawford (2000), and the service users, as reported by
Lammers & Happell (2003), seem to uphold the value of
user involvement in mental health care. However, the
results of these three studies also point to the need to find
ways to deal with the rhetoric-reality gap and to examine
© 2009 Blackwell Publishing

various facets that impede the introduction and success of
user involvement initiatives. We offer a few key approaches
that need our attention in order to overcome barriers
towards realizing the intentions of user involvement.
First, analysing the rhetoric-reality gap: How is the situ-
ation today? The field of community mental health is char-
acterized by rhetoric, in the sophist meaning, in speeches
and policy documents, with a rich variety of local slogans,
a typical ‘art of arguing clearly, specifically and convinc-
ingly’ about the importance and value of user participation.
While the value of user involvement is espoused strongly at
the systems levels from WHO, nations and healthcare insti-
tutions, the actual institutionalization into the system of
practice is often lacking. However, there are evidences
of professionals working strategically on strengthening
the users’ involvement on different levels. In addition,
many examples of helpful helpers and helpful arenas are
described in narratives of recovery. Furthermore, there are
user-run services, ‘experts by experience’ working in train-
ing and services, and user monitored recovery programmes,
which need to be systematically monitored and examined
for their models and effects.
There continues to be the need to critically assess the
relation between knowledge and power in mental health.
From the perspective of Foucault, the key questions would
be: ‘In what way does the knowledge production in mental
health create new “subjects” of inquiry and in what way
does it identify what is normal and abnormal in relation to
such notions as being insane, having pain or even being a
user?’ and ‘In what ways are mental health professionals,
as social agents of knowledge and knowledge production,
involved in activities that reinforce the powerlessness of the
users in their practice guided by the traditional distinctions
regarding rational/irrational and normal/abnormal?’. In
that sense, the discussion about mental health as science
could be seen as a sophisticated new way of getting social
control of the users and the power to define what knowl-
edge is valid.
Second, we need to understand why there is a gap.
Transformation in services involves insecurity for both
stakeholders and professionals of what they may lose on
various levels as well as concern about new demands put
on them. Changes requiring more user involvement may
well be seen as a risky business with a lot of time-
consuming and chaotic ‘mess’. Transforming the roles of
professionals and service users towards partnership and a
relationship open for negotiations and equalizing their
knowledge bases when it comes to effectiveness and out-
comes involves major changes in philosophies, attitudes
and daily practice as well as reviewing the local truths and
traditions. Stakeholders may question whether or not the
user perspective actually makes a difference.
© 2009 Blackwell Publishing
User involvement in mental health services
A critical issue is also that many service users are not
accustomed or comfortable with all aspects of user involve-
ment. Although everyone wants to be treated respectfully
and have a choice, not all feel oppressed by a biological
practice model, not all feel the need to fight, quite a few are
rather pleased with services and not all are ready to be
involved as user representatives. Opting for a status quo or
dependency by users can come from an institutionalized
long-term oppression at societal levels as well as from the
preferences based on indifference and convenience. These
are not easily changeable at either the system or individual
levels. Freire’s critical pedagogy for the oppressed (Freire
2000) provides processes through which service users as
well as professionals can be transformed to embrace and
practice genuine forms of user involvement in mental
health care.
Third, practitioners’ work with this rhetoric-reality gap
– In order to talk about ‘real user perspective’, we believe
there is an urgent need to put the power inequality between
professionals and users on the agenda at a more concrete
level. Facing up with the everyday life implications of user
involvement may help us beyond the rhetoric, for instance,
by awareness and working against mentalism and micro-
aggressions within the healthcare practices. There is a need
for self-examination by professional practitioners in their
use of microaggressive language in discourses and in the
uses of various symbols in the practice arena that are
mentalism-oriented such as pens and mugs with psychotro-
pic drug names on them, or that suggest power differentials
such as doors labelled segregating staff from service users.
Service users need adequate and appropriate resources to
participate, may be training, information, welcomed on
equal level as opposed to tokenism. Realizing user involve-
ment means to put assumptions and attitudes on the table
and being willing to have uncomfortable discussions. Pro-
fessionals and service users need to be working together on
this in the context of everyday life practises as opposed to
making more policy statements.
Community mental health nurses are situated logisti-
cally in this arena of developing successful user involve-
ment initiatives by being the first-line contacts with service
users and their families, as the transformation must occur
at the ground level, that is, at the practice level. Transfor-
mation through self-emancipation and user emancipation
needs to occur through dialogical processes, critique and
empowerment.
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