EMPOWERMENT AND PEER SUPPORT: STRUCTURE AND PROCESS OF SELF-HELP IN A CONSUMER-RUN CENTER FOR INDIVIDUALS WITH MENTAL ILLNESS

EMPOWERMENT AND PEER SUPPORT: STRUCTURE AND PROCESS OF SELF-HELP IN A CONSUMER-RUN CENTER FOR INDIVIDUALS WITH MENTAL ILLNESS

Personal empowerment is a guiding philosophy of many mental health service programs, but there has been little empirical research on the empowerment process in these programs. The authors examine social processes and consumer orientations within a self-help drop-in center for individuals with psychiatric disabilities, using intensive interviews and focus groups. They investigate motives for consumer involvement, bases for program retention, and processes of participant change. Motives for involvement in the center were primarily instrumental, whereas the bases of retention were more often maintaining social support and developing self-esteem. Participants valued the center’s nonstigmatizing environment and its supportive consumer staff. Some used the opportunity to become a staff member to move into a more normalized social role; all seemed to derive benefits from helping peers. There were indications of some staff members adopting a more authoritarian posture, but participants repeatedly lauded most staff for their supportive orientation. The authors conclude that the ‘‘helper/therapy’’ process was a key to successful empowerment. �C 2009 Wiley Periodicals, Inc.

This project was funded by the Center for Mental Health Services, SAMHSA Grant No. UDISM52352. We are grateful for the research assistance of Jillian Doucette, Robin Myers, and Kathy Norman, and for the comments of the anonymous reviewers. Correspondence to: Russell Schutt, Department of Sociology, University of Massachusetts-Boston, 100 Morrissey Blvd., Boston, MA 02125. E-mail: russell.schutt@umb.edu

JOURNAL OF COMMUNITY PSYCHOLOGY, Vol. 37, No. 6, 697–710 (2009)

Published online in Wiley InterScience (www.interscience.wiley.com).

& 2009 Wiley Periodicals, Inc. DOI: 10.1002/jcop.20325

Consumer empowerment is an essential goal for the postinstitutional mental health service system (Substance Abuse and Mental Health Services Administration [SAMHSA], 2009). In contrast to the dependence and passivity that hospital-based care allows—even encourages, success as a community resident requires independent decision-making and self-directed action. However, achieving the goal of empower- ment requires that consumers in community settings overcome the effects of stigma, poverty, and social isolation that reinforce cognitive deficits, emotional insecurities, and social difficulties. For those attempting to manage serious and chronic mental illness, becoming empowered is not simply a matter of ‘‘location, location, location.’’

By increasing the ability of mental health service consumers to manage their own affairs and giving them responsibility for treatment decisions, the empowerment movement focuses attention on the need to improve community functioning within the context of normalizing treatment. Yet despite growing recognition of the potential for persons with serious mental illness to take action on behalf of themselves and others (Nelson, Ochocka, Janzen, & Trainor, 2006), the means for developing this potential are not well understood. Peer support groups have become widely accepted as a key component of the empowerment process, but a relatively small fraction of persons with serious mental illness participates in them and little research has been completed about their effectiveness (Brown, Shepherd, Wituk, & Meissen, 2007; Davidson et al., 1999).

We investigated a consumer-run program for mental health service recipients designed to facilitate consumer empowerment, which was located in a large Midwestern city. The Empowerment Center was one of eight consumer-run programs studied in a national project funded by SAMHSA. A national group of researchers, consumers, and other experts developed a list of philosophical and operational principles underpinning consumer-run programs and then created a working definition of such programs with administrative, structural, and procedural criteria (Johnsen, Teague, & McDonel Herr, 2005). Researchers visited each program and conducted a fidelity assessment to ensure that these sites were in fact adhering to a generally accepted definition of a consumer- run program. The Empowerment Center on which we focused conformed to the operational definition developed and thus can be considered representative of consumer-operated programs; it was also similar to many such drop-in programs in its array of services and their accessibility (Minth, 2005).

In this article, we examine the motives for Center involvement, the bases for program retention, and the process of participant change. Our analysis highlights the benefits that consumers appeared to reap from the empowerment approach and the difficulties that they encountered in developing a sense of community. Our conclusions explicate the process of consumer empowerment and suggest facilitators and barriers to its success.

THE PROCESS OF EMPOWERMENT

We follow Rappaport (1995) in conceptualizing empowerment as having structural and psychological dimensions and as describing both a process as well as an outcome of that process (and see Perkins & Zimmerman, 1995). As a structural process, empowerment in mental health treatment means engaging mental health service consumers and staff in relatively egalitarian, personal relationships and using group process and consumer involvement to develop service plans and make treatment decisions (Rosenfield, 1992).

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Other authors concur and define empowerment in the mental health setting as involving shared decision making, having the power to act freely, having authority and control over one’s treatment, and being able to advocate on one’s own behalf (Hollander & Offerman, 1990; Ralph, 2000; Salzer, 1997).

As a psychological process, empowerment involves developing self-efficacy, self- esteem, and optimism about the future (Corrigan, Faber, Rashid, & Leary, 1999; Perkins & Zimmerman, 1995). The goals of both structural and psychological empowerment processes are to develop community living skills, rather than to treat psychiatric symptomatology, and to shift the locus of control for service decisions to the consumer (Rappaport, 1987, p. 122).

SOCIAL ISOLATION AND PEER SUPPORT

Social isolation itself is a disempowering phenomenon often associated with chronic mental illness and its exacerbation can contribute to the continuation or worsening of psychiatric symptoms (Link, Cullen, Frank, & Wozniak, 1987; Sharfstein, 2005). Yet professional attempts to reduce social isolation through medication or professionally run programs can reinforce segregation from the larger community (Hogarty & Wieland, 2005), whereas simply discharging inpatients to community settings without proactive efforts to decrease social isolation can result in very minimal patterns of social interaction—‘‘virtual relations’’ with TV characters and ‘‘venturing forth’’ simply to have casual contact with people in settings like stores and parks (Beal et al., 2005; Liberman & Silbert, 2005).

Peer support can help to overcome social isolation with a process that is consistent with the goal of empowerment: gaining experience in a valued role as a helper and helping to build a sense of community (Davidson et al., 1999). Peer support can be defined as ‘‘social emotional support, frequently coupled with instrumental support, that is mutually offered or provided by persons having a mental health condition to others sharing a similar mental health condition to bring about a desired social or personal change’’ (Solomon, 2004, p. 393; and see Mead, Hilton, & Curtis, p. 2001). Social support provides resources for effective functioning and a foundation for coping with stress and loss (Mirowsky & Ross, 1986; Rosenfield & Wenzel, 1997). Some authors (e.g., Randall & Salem, 2005; Solomon, 2004) have attempted to articulate the ‘‘active ingredients’’ of self- and mutual help. Such programs, according to these authors, can provide a venue where experiential knowledge can be shared; where role models of recovery are present; and where social support and valued organizational roles are available. In addition, such programs provide a sense of connection, belonging, and community that is often lacking for individuals receiving services in the mental health system (Randall & Salem, 2005). In a comprehensive review of self-help and consumer-operated programs to date, Campbell (2005) examined several studies of self-help programs for mental health clients which, taken together, suggest that self- help and peer support programs can promote empowerment and recovery (Dumont & Jones, 2002; Van Tosh & delVecchio, 2000), increase social support, functioning, and activities (Forquer & Knight, 2001; Yanos, Primavera, & Knight, 2001).

However, the processes by which these outcomes are effected are not well understood. Many peer support programs have focused on developing supportive structures within or in collaboration with the formal mental health system (Beal et al., 2005). Therapeutic communities emphasize peer support processes involving intense

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engagement of staff who are neither clinicians nor consumers (Rapaport, 1960). The Boston McKinney Project attempted to develop supportive consumer-run group homes within the mental health system, but with minimal direction from mental health staff (Ware et al., 1992). By contrast, self-help groups and consumer-run programs— ‘‘Consumer/Survivor Initiatives’’—like the center that we studied, are operated exclusively by and for people with a history of mental illness (Nelson et al., 2006).

Research provides some evidence that self-help groups improve consumer social support and social networks, personal empowerment, and use of traditional mental health services, but the design of most of this research has been weak (Campbell, 2005; Nelson et al., 2006; Solomon, 2004). Brown et al. (2007) found benefits of participation in consumer-run organizations based on retrospective self-report. Based on cross- sectional research, Davidson et al. (1999) reported greater social integration among mutual support participants: more voluntary relations, more valued social roles, and more life-enriching activities. Ochocka, Nelson, Janzen, and Trainor (2006) found that new members who became active participants in Ontario consumer/survivor initiatives (CSIs) reported fewer psychiatric symptoms, more social support, more sustained employment, income, education, and/or training compared to those who were inactive. Corrigan’s (2006) survey of consumers found that participation in peer support programs in the past 4 months explained only a small portion of the variance in individual empowerment.

Two studies using more rigorous designs found some evidence for beneficial effects of participation in peer support groups. Rogers et al. (2007) used a rigorous multisite longitudinal design to study outcomes among consumers assigned randomly to traditional or consumer-operated services. Their intention-to-treat analysis found no effect of type of service, but consumers who were more involved in peer support experienced some gains in personal empowerment and some individual sites had positive effects. Roth and Crane-Ross (2002) tested a causal model of empowerment’s effects using a two-question self-report measure. They found that empowerment had only an indirect effect on symptoms and self-reported quality of life and no association at all with clinician-rated functioning. In conjunction with the results of research using less rigorous methodology, these findings suggest that there may be some positive benefits of peer support groups, but these effects may occur only for some participants and may be due to only some of the features that comprise peer support programs.

Several qualitative investigations have helped to identify potentially beneficial features of consumer/survivor initiatives. In their research in Ontario, Ochocka et al. (2006) emphasized the value of a safe, welcoming environment, social opportunities with peers, and having an alternative worldview with a purpose. Solomon (2004) highlighted the importance of an experiential learning process, the use of a mutual benefit approach, offering natural social supports, making participation voluntary, and maintaining primary control of the service by individuals with psychiatric disorders. Salzer and Shear’s (2002) qualitative study of peer support specialists indicated benefits from facilitating others’ recovery and thus gaining interpersonal competence, facilitating one’s own recovery and thus acquiring personally relevant knowledge, gaining social approval, experiencing professional growth, and facilitating community integration.

These processes are consistent with expectations of the ‘‘helper/therapy principle’’ (Brown et al., 2007) and related theorizing by Nelson et al. (2006) about the ‘‘power reversal’’ process and by Mead et al. (2001) about the importance of managing conflict and developing shared responsibility. Our research involved an intensive investigation of these processes.

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METHOD

We used qualitative methods including intensive interviews and focus groups to improve understanding of the processes by which self-help programs may facilitate personal empowerment and decrease social isolation. Eleven clients were selected for interviews on an availability basis, after referral by the program director and completion of a consent form; 15 others participated in one of two focus groups. Questions asked in the focus groups were similar to those in the interviews, but questions about personal background were omitted. The focus groups provided an opportunity for dialogue within the group to enrich participants’ comments and identify commonalities in sentiments (Schutt, 2009, p. 345). One focus group included only the consumer-staff members, who meet regularly and so develop a somewhat collective orientation that could best be captured in a focus group. The other focus group included Empowerment Center participants who were available at a designated time, but could otherwise not be scheduled for an individual interview. All participants agreed to participate after seeing a flyer announcing a ‘‘study of the Empowerment Center.’’

The interview schedule posed 16 questions about motivations for joining the Empowerment Center, experiences at the Center, and use of other services (the focus group schedule included 10 of these questions). Coding was conducted by two graduate research assistants who met frequently with the first author and established coding reliability through coding the same interviews. The coders first developed categories based on the questions and then by discovering additional categories that were not anticipated explicitly by the questions (Strauss & Corbin, 1990, pp. 62–72). Using the constant comparative method, the coders checked new interview material with the codes that had already been formulated, adding new codes as needed until the point of saturation was achieved (Bowen, 2008). All interviews were fully coded in this way and cross-checked. The NVivo qualitative analysis program was used to facilitate the coding process and data retrieval (Bazeley, 2007). The final detailed list of codes (‘‘nodes’’ in NVivo) included 81 distinct categories, from which 10 basic themes were indentified (Hesse-Biber & Leavy, 2006, p. 352).

All procedures were approved by the Boston University Institutional Review Board for the Protection of Human Subjects.

The median age of the interviewees was 40. Eight were men. Most respondents were high school graduates; four who had not finished high school and one who had some schooling beyond high school.

We focus first on the bases of attraction of the Center and then on the processes through which engagement was maintained and participants came to feel empowered. We give special attention to the role of consumer staff in the Center—the role that most explicitly embodies the ‘‘helper/therapy principle’’—and to the Center’s value for coping with mental illness. We conclude by identifying some of the strains in the operation of the Center due to its need to operate on the boundary between the formal mental health service system and community-based groups.

The Setting

The Center is a consumer-operated drop-in center with four components: a peer-run Drop-In Center, Community- and Facility-Based Self-Help Groups, Individual Peer Support, and a Friendship Warmline. At the time of our investigation, it was a joint

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program of a consumer advocacy group and the city’s largest mental health services provider and received funding from the city. It was located near the city’s center in renovated space in the basement of a large home that was converted for the Drop-In Center.

The center was governed by a Board of Directors, 60% of whom were consumers of mental health services. Both the fulltime Executive Director and the Associate Director were individuals with a mental illness and the 18 parttime workers were themselves consumers of center services. The Center maintained connections with other service providers throughout the metropolitan area and solicited programmatic advice from a community advisory board that included representatives of universities, religious organizations, and other community organizations in addition to private and public mental health service providers.

An internal study of EC service use indicated that on average, individuals came to the Center three times per week for one year and on an average day approximately 40–60 different individuals came to the Center. The participants were predominately male (70%) and African American (60%). All participants had a mental illness and an estimated 60% had a dual diagnosis of substance abuse; a large percentage was homeless.

The peer-run Drop-In Center operated 7 days a week, 365 days a year. It was the only drop-in center in the city available to people with mental illness and provided a clean, safe, tolerant, and drug- and alcohol-free environment with participatory decision-making. The explicit goal of the center was to provide opportunities for consumers to create an empowering, nonhierarchical environment in which self-help and mutual assistance would flourish and consumers would develop skills and competencies through exposure to their peers. Support groups and educational programs were offered on mental illness, wellness, and other more specific interests. Meals, social activities, clothes-washing facilities, showers, public transportation vouchers, and other amenities were available. The Center provided access to computers and self-help books as well as resources about social services and assistance for locating permanent housing. The Center also hosted self-help groups like Alcoholics Anonymous (AA) and Narcotics Anonymous (NA).

Findings

Participants’ comments about their experience with the Center focused on motives for joining, the process of developing social relations, managing mental illness, and helping others.

Motives for joining.. Consumers reported coming to the Empowerment Center because it offered benefits that were unavailable elsewhere in the shelter or mental health systems: a safe place of refuge during the day and an opportunity to relax, ‘‘I was looking for somewhere to be in the daytime, instead of sittin’ in the house. It was like a safe haven to come for me, during the days.’’

Many participants had been attracted by more tangible resources available at the Center. From providing hot meals, showers, laundry facilities, bus tickets, and movies to help with finding a job or a place to live and securing help with medications or mental health services, the participants recalled with enthusiasm the resources they had found at the Center: ‘‘Man, I think it was a blessing!’’ ‘‘It changed my life, it changed me.’’

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Many participants reported that they continued to benefit from instrumental help provided by the Center. A course in living skills and regular art therapy sessions helped some develop their own capacities. ‘‘It’s VERY helpful. You learn a lot.’’

All the interviewees attributed their interest in the Center to the safe environment and/or instrumental help it provided. In addition to these explicit reasons, interviewees’ comments about their subsequent experiences suggest that developing social relations with people who cared about them and would try to help them was an important implicit motive.

Developing social relations. Although the bases of attraction to the Center were largely instrumental, social bonds and a supportive atmosphere were often the bases for retention.

ywhen I walked in that first time, that day when I went in, I got somethin’ to drink, everybody just… said ‘‘Hi, how are you?’’ just bein’ real friendly, which, eased me being nervous and then, um, and I noticed people will, people here will help out each other whenever they need it.

Talkin’ to [the Center director]—I call her ‘‘Mom’’—she was very instrumental in me, uh, gettin’ myself cleaned up. [She] helped me get on the right path and I’ve lived the longest time that I ever had clean in my life! But, uh, I’ve sort of, kind of developed a bond not only to [the Center director] but to this place, because I felt like if it wasn’t for the Center, I’d never even had those two years [of sobriety].

Interaction with others at the Center helped participants put their own problems in perspective and helped them feel accepted in spite of their problems. Simply having the opportunity to talk with others about their problems was highlighted by some respondents, while others said that having an environment in which other people had mental illnesses made them feel that ‘‘everything was all right.’’

One Sunday night, when I was really down in the dumps and depressed, and I, I couldn’t shake it, y it made ALL the difference to have a place you know that… it might not be the greatest, but it was still safe, and you could come here, and be yourself, and just chill out.

Valuable social connections occurred while participants played cards together and engaged in ‘‘heated discussions’’ about what they were going through.

Staff played an important role in creating this supportive environment. Participants praised staff for caring about them and helping to create a sense of inclusion in the group. Participants also appreciated the value of rules maintained by staff—such as not allowing sleeping or disruptive behaviors—that kept participants engaged with others. Organized social activities also provided incentives that kept many participants returning to the Center: ‘‘the different meetings. ythey have the outings and like field trips and things like that. So, that kept me comin’.’’

Resources provided by the Center for instrumental purposes had an additional implicit benefit of creating a sense of social inclusion: ‘‘yyou can go to the library and

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anything you want in the library, you know… they got it. You know, computers, things of that nature. Things that make you feel, you know… like you’re a part, part of bein’ here.’’

In addition to highlighting the importance of social support processes, these comments suggest that different participants were most appreciative of different types of social support. Some were most appreciative of the instrumental value of social support, some appreciated the generally supportive social atmosphere and others responded favorably to staff-initiated structured social activities.

Managing mental illness. Stigma was a common theme in the lives of Center participants and several found in the Center a place of refuge from it.

I liked it for one reason. The people that work here are mentally disturbed, also. They’re manic depressives and stuff, and I like bein’ around that. I don’t like bein’ around people that are just normal. They treat you like you’re a patient and treat you like shit. I don’t like that. So I [like] being around these people and they treat you like yourself.

I just thought it was a neat idea that they had a place for mentally ill people that was run by mentally ill people.

Participants who reported a high level of alienation from regular mental health service providers found the Empowerment Center to be a less judgmental alternative—one that did not focus on mental illness.

They don’t push you around. They treat you like yourself. ..You go into a mental hospital, they don’t treat you like a person, they treat you like a damned patient, crazy. That’s how all hospitals treated me all my life. y I’ll never go inside another one, ‘cause I know how they treat you. They don’t treat you with your problem, they treat you like you’re crazy. And I don’t like that. I hate that.

Consumer staff members described their approach in terms that reflected a commitment to treating participants with basic dignity, without stigma.

Other participants used the Empowerment Center as a source of support for involvement in treatment. The Center had helped these participants to understand mental illness as a health problem that they were not responsible for and that could be treated, like other illnesses. It was ‘‘OK’’ to have a mental illness, ‘‘as long as I’m dealing with it.’’

I take my medication every day. I take it mornin’ and night, you know? yUh, it’s nothin’ really to be ashamed of because I didn’t have anything to do with it. yAnd, I do what I gotta do to maintain it and function like a normal person, if you know what a normal person is. So I’m just normal, you know?

Although appreciation for the Center’s nonstigmatizing environment was wide- spread, participants’ comments about mental illness suggested that this environment was used to support two different approaches to mental illness: some emphasized that the Center environment allowed them to see themselves as normal; others stressed

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that the Center helped them to maintain their medication regimen. In both cases, the result was a feeling of less helplessness and more self-control.

Helping others—the helper-therapy principle. Learning how to help others—how to maintain social interaction with others despite mental health-related difficulties—was a critical aspect of the empowerment process.

It helps me when I focus on helping somebody else. I don’t tend to key in on what’s goin’ on with me all the time. And that depression doesn’t keep bein’ as tough. You know, I’m helpin’ somebody andy when you’re doin’ something to help somebody, it usually says a little accomplishment. yall these different personalities. y my real purpose of being here is to try to help people.

Although this sentiment was shared by many participants, those who became staff members described more intense engagement in helping others.

It [being on the staff] gave me a sense of responsibility. So y if I see a guy sleepin’, or slobberin’, or somethin’, I’ll go check and make sure he’s okay. You know? ‘Cause sometimes, you know, they aren’t always sleepin’. They could be in like ay a light comayfrom the fact they’re not takin’ medication. So it gave me somethin’ to y look forward to. I would come to work and, ‘‘maybe I can help somebody today. Or maybe I can have some information where I can say hey they’re hirin’ over here today.’’ You know, I can kick somethin’ off, ‘cause I’ve looked in the paper. Certain things that give me, like I said, responsibility.

Many comments like this illustrated the helper-therapy principle, as participants improved their understanding of their own problems by helping others.

Traditional organizational roles. As in any social service organization, participants reported problems in the orientations of some staff members (Lipsky, 1980; Schutt, 1986). The most common complaint was that some staff let ‘‘authority go to their head.’’ ‘‘Some of ‘em, I don’t even think they know they’re doin’ it. They’re just, they let authority go to their head. ‘Oh, I’ve got a job. I’ve got to enforce this.’ You know?’’

Despite reports like these, participants praised most staff for avoiding the demeaning orientations toward Center users that they had experienced in the regular mental health system.

It’s not like goin’ to a regular y mental health center yThey’re just regular workers, and they treat you the way they want to treat you. yThis place don’t do that. They treat you, everybody treats you, everybody acts the same way.

The Center thus was able to prevent the common tendency of social service staff to adopt dismissive attitudes toward clients as a means of reducing work-related frustrations (Lipsky, 1980).

Developing community. A sense of community and group commitment among Center participants emerged from these diverse processes.

I’m really crazy about this place. You know? I don’t know what I’d do without it. I guess I’ve become somewhat of a barnacle, you know? I’ve attached myself

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to it. y, without the Center, I don’t know… I don’t know where I’d be at right now, to tell you the truth… that’s sincere, straight from the heart.

Participants emphasized repeatedly their appreciation of staff efforts to solve problems—‘‘and USUALLY it works’’—and to engage participants even when it took a ‘‘little bit of push’’: ‘‘They WANT you involved here.’’

yeven though it is a drop-in center to other people, it’s like most of our home, because we have to be here. You know, everybody sticks together like a family here, too. And that, that’s the, the best thing about it. yyou know, everybody get a chance to be a leader and a follower.

The sense of belonging that resulted from these interactions, of being with others who care—of ‘‘community’’—seemed to be the Center’s most valued benefit and its most distinctive achievement.

CONCLUSIONS

Mental health services must be judged in part by how well they create structures and norms in community settings that enable the process of personal empowerment to occur among the consumers served. It is not until consumers of mental health services feel empowered to take action in their own interests and are able to maintain supportive relations with others that mental health services can be said to function adequately in community settings.

We have focused attention in this article on a unique peer support, consumer-run program that provides a structure in which empowerment processes can be studied and empowerment goals can be achieved. Participants’ comments suggest that the Center has been relatively successful in achieving the goal of empowering homeless consumers of mental health services. Although most consumers first participated in the Center for strictly instrumental reasons, they soon found themselves engaged by other participants, including consumer-staff, in activities that increased their feelings of self- efficacy and deepened the availability of social support.

The empowerment process at the Center seems best understood with the concept of the ‘‘helper/therapy principle.’’ Participants learned from others how to meet the needs of people in situations similar to their own and then taught others how to meet their own needs in the same ways. Through this process of learning and sharing, Center participants developed a sense of their own capacities and strengthened their bonds with others. From being socially isolated individuals with psychiatric disabilities and co-occurring substance abuse, Center participants began to identify with a larger, functional social group and to gain a sense of community. Although this transforma- tion was neither immediate nor inevitable, the interviews revealed evidence of its frequent occurrence. This achievement is all the more notable because it occurred without the ideological unity or fixed routines that help to explain the success of other attempts at building intentional communities (Kanter, 1972; Vaisey, 2007).

The strong attachment expressed for the Center does indicate the potential for a type of ‘‘reinstitutionalization’’ in the community if participants come to rely only on each other for support and feel it unnecessary to seek greater community engagement.

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Because we conducted only a cross-sectional study of the Center participants, we do not know how many made a further transition into stable residential settings or more normative community activities. We suspect that some pressure from the formal mental health service system or planned efforts to move the consumer-staff into more regular employment roles could be a necessary disturbance that would prevent a long- term process of equilibrium in which the goal of reintegration into the larger community is only partially achieved.

We also found some evidence of strains in the ongoing operation of the Center. Empowering individuals has the potential to undermine the development of community (Riger, 1993). Socialization to the role of being a peer supporter and training about different types of serious mental illness that may affect other consumers can help consumer-staff avoid reverting to the culturally sanctioned role of authoritarian management (Schutt & Garrett, 1992, p. 37). But the fact that there were few indications of staff adopting such a role suggests that the process of social engagement with Center participants largely kept this contrary process under control.

Several methodological limitations must be considered when evaluating the strength of support for our conclusions. Our reliance on retrospective self-reports about motives and processes means that our analysis reveals only how participants made sense of their experiences at the Center. Although this perspective is essential for understanding empowerment processes—even, arguably, the most important per- spective on these processes—ongoing ethnographic research on these social processes or quantitative investigation of participants’ backgrounds and outcomes could result in attributing greater importance to self-selection for being a center participant or less significance to the apparent gains in participant functioning. Our research design also did not allow us to make a systematic assessment of the extent to which particular types of participants benefitted more or less from their Center experience. The Center served largely poor, African American men, many of whom were homeless, substance abusing, unemployed, and not highly educated. Whether this model of peer support services would have similar effects with a different constituency must be determined.

It is also important to recognize the difference between our definition of empowerment and the construct suggested by those who view empowerment as involving community action and attempts to effect change (Corrigan et al., 1999; Perkins & Zimmerman, 1995). The Empowerment Center that we studied did not have a goal of community action and there was no evidence in our interviews or focus groups that Center participants were seeking to effect change in the mental health system through political action. Our conclusions about empowerment processes thus cannot be assumed to apply to efforts with this different goal. However, the existence and operation of the Center as a consumer-oriented alternative itself effected a significant change in the local mental health service system. Our findings also have direct relevance to more activist approaches because the processes we studied would be a necessary foundation for more ambitious efforts to involve participants in collective action.

Susan Estroff (1981) characterized the traditional mental health service system as involving a process of ‘‘making it crazy’’ by disempowering participants and requiring those clients who can return to community-based roles to separate from other consumers. The Empowerment Center that we studied provides an alternative approach to community-based mental health care for the most disenfranchised segment of consumers. By emphasizing the value of helping peers, the Center provided a structure in which meaningful empowerment processes could occur. Our research should help to improve understanding of this process.

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REFERENCES

Bazeley, P. (2007). Qualitative data analysis with NVivo. Thousand Oaks, CA: Sage.

Beal, G. (1999). The constitution of community: How individuals diagnosed with schizophrenia and their friends achieved community. Psychiatry: Interpersonal and Biological Processes, 62, 173–186.

Beal, G., Veldhorst, G., McGrath, J., Guruge, S., Grewal, P., DiNunzio, R., et al. (2005). Constituting community: Creating a place for oneself. Psychiatry, 68, 199–211.

Bowen, G.A. (2008). Naturalistic inquiry and the saturation concept: A research note. Qualitative Research, 8, 137–152.

Brown, L.D., Shepherd, M.D., Wituk, S.A., & Meissen, G. (2007). How settings change people: Applying behavior setting theory to consumer-run organizations. Journal of Community Psychology, 35, 399–416.

Campbell, J. (2005). The historical and philosophical development of peer-run support programs. In: S. Clay, B. Schell, P.W. Corrigan, & R.O. Ralph (Eds.), On our own, together: Peer programs for people with mental illness (pp. 17–64). Nashville, TN: Vanderbilt University Press.

Corrigan, P.W. (2006). Impact of consumer-operated services on empowerment and recovery of people with psychiatric disabilities. Psychiatric Services, 57, 1493–1496.

Corrigan, P.W., Faber, D., Rashid, F., & Leary, M. (1999). The construct validity of empowerment among consumers of mental health services. Schizophrenia Research, 38, 77–84.

Davidson, L., Chinman, M., Kloos, B., Weingarten, R., Stayner, D., & Tebes, J.K. (1999). Peer support among individuals with severe mental illness: A review of the evidence. Clinical Psychology: Science and Practice, 6, 165–187.

Dumont, J., & Jones, K. (2002). Findings from a consumer/survivor defined alternative to psychiatric hospitalization. Outlook, 3, 4–6.

Estroff, S.E. (1981). Making it crazy. Berkeley: University of California Press.

Forquer, S., & Knight, E. (2001). Managed care: Recovery enhancer or inhibitor? Psychiatric Services, 52, 25–26.

Hesse-Biber, S.N., & Leavy, P. (2006). The practice of qualitative research. Thousand Oaks, CA: Sage.

Hogarty, G.E., & Wieland, M. (2005). Weak ties and schizophrenia: Promise and problems. Psychiatry, 68, 230–235.

Hollander, E.P., & Offermann, L.R. (1990). Power and leadership in organizations: Relationships in transition. American Psychologist, 45, 179–189.

Johnsen, M., Teague, G., & McDonel Herr, B. (2005). Common ingredients as a fidelity measure for peer run programs. In S. Clay (Ed.), On our own together: Peer programs for people with mental illness (pp. 213–238). Nashville, TN: Vanderbilt University Press.

Kanter, R.M. (1972). Commitment and community: Communes and utopias in sociological perspective. Cambridge: Harvard University Press.

Liberman, R.P., & Silbert, K. (2005). Community re-entry: Development of life skills. Psychiatry, 68, 220–229.

Link, B.G., Cullen, F.T., Frank, J., & Wozniak, J.F. (1987). The social rejection of former mental patients: Understanding why labels matter. American Journal of Sociology, 92, 1461–1500.

Lipsky, M. (1980). Street-level bureaucracy: Dilemmas of the individual in public services. New York: Russell Sage Foundation.

Mead, S., Hilton, D., & Curtis, L. (2001). Peer support: A theoretical perspective. Psychiatric Rehabilitation Journal, 25, 134–141.

708 � Journal of Community Psychology, August 2009

Journal of Community Psychology DOI: 10.1002/jcop

Minth, H. (2005). The St. Louis Empowerment Center. In: S. Clay (Ed.), On our own together: Peer programs for people with mental illness (pp. 108–122). Nashville, TN: Vanderbilt University Press.

Mirowsky, J., & Ross, C. (1986). Social patterns of distress. Annual Review of Sociology, 12, 23–45.

Nelson, G., Ochocka, J., Janzen, R., & Trainor, J. (2006). A longitudinal study of mental health consumer/survivor initiatives: Part 1—literature review and overview of the study. Journal of Community Psychology, 34, 247–260.

Ochocka, J., Nelson, G., Janzen, R., & Trainor, J. (2006). A longitudinal study of mental health consumer/survivor initiatives: Part 3—A qualitative study of impacts of participation on new members. Journal of Community Psychology, 34, 273–283.

Perkins, D.D., & Zimmerman, M.A. (1995). Empowerment theory, research, and application. American Journal of Community Psychology, 23, 569–580.

Ralph, R.O. (2000). Recovery. Psychiatric Rehabilitation Skills, 4, 480–517.

Randall, K.W., & Salem, D.A. (2005). Mutual-help groups and recovery: The influence of settings on participants’ experience of recovery. In: R.O. Ralph & P.W. Corrigan (Eds.), Recovery in mental illness: Broadening our understanding of wellness, (pp. 173–205). Washington, DC: American Psychological Association.

Rapaport, R. (1960). Community as doctor. London: Tavistock.

Rappaport, J. (1987). Terms of empowerment/exemplars of prevention: Toward a theory for community psychology. American Journal of Community Psychology, 15, 121–148.

Rappaport, J. (1995). Empowerment meets narrative: Listening to stories and creating settings. American Journal of Community Psychology, 23, 795–808.

Riger, S. (1993). What’s wrong with empowerment? American Journal of Community Psychology, 21, 279–293.

Rogers, E.S., Teague, G.B., Lichenstein, C., Campbell, J., Lyass, A., Chen, R., et al. (2007). Effects of participation in consumer-operated service programs on both personal and organizationally mediated empowerment: Results of multisite study. Journal of Rehabilita- tion Research & Development, 44, 785–799.

Rosenfield, S. (1992). Factors contributing to the subjective quality of life of the chronic mentally ill. Journal of Health and Social Behavior, 33, 299–315.

Rosenfield, S., & Wenzel, S. (1997). Social networks and chronic mental illness: A test of four perspectives. Social Problems, 44, 200–216.

Roth, D., & Crane-Ross, D. (2002). Impact of services, met needs, and service empowerment on consumer outcomes. Mental Health Services Research, 4, 43–56.

Salzer, M.S. (1997). Consumer empowerment in mental health organization: Concept, benefits, and impediments. Administration and Policy in Mental Health, 24, 425–434.

Salzer, M.S., & Shear, S.L. (2002). Identifying consumer-provider benefits in evaluations of consumer-delivered services. Psychiatric Rehabilitation Journal, 25, 281–288.

Schutt, R.K. (1986). Organization in a changing environment: Unionization of welfare employees. Albany, NY: SUNY Press.

Schutt, R.K. (2009). Investigating the social world: The process and practice of research (6th ed.). Thousand Oaks, CA: Sage/Pine Forge Press.

Schutt, R.K., & Garrett, G.R. (1992). Responding to the homeless: Policy and practice. New York: Plenum.

Sharfstein, S.S. (2005). The healing power of relationships. Psychiatry, 68, 212–213.

Solomon, P. (2004). Peer support/peer provided services underlying processes, benefits, and critical elements. Psychiatric Rehabilitation Journal, 27, 392–401.

Strauss, A., & Corbin, J. (1990). Basics of qualitative research: Grounded theory procedures and techniques. Newbury Park, CA: Sage.

Structure and Process of Self-Help in a Consumer-Run Center � 709

Journal of Community Psychology DOI: 10.1002/jcop

Substance Abuse and Mental Health Services Administration (SAMHSA). (2009). National consensus statement on mental health recovery. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration. Retrieved June 10, 2009, from http://www.samhsa.gov/pubs/mhc/MHC_NCrecovery.htm

Vaisey, S. (2007). Structure, culture, and community: The search for belonging in 50 urban communes. American Sociological Review, 72, 851–873.

Van Tosh, L., & del Vecchio, P. (2000). Consumer/survivor-operated self-help programs: A technical report. Rockville, MD: U.S. Center for Mental Health Services.

Ware, N., Desjarlais, R.R., AvRuskin, T.L., Breslau, J., Good, B.J., & Goldfinger, S.M. (1992). Empowerment and the transition to housing for persons who are homeless and mentally ill: An anthropological perspective. New England Journal of Public Policy, 8, 297–314.

Yanos, P.T., Primavera, L.H., & Knight, E.L. (2001). Consumer-run service participation, recovery of social functioning, and the mediating role of psychological factors. Psychiatric Services, 52, 493–500.

Zimmerman, M.A., Israel, B.A., Schulz, A., & Checkoway, B. (1992). Further explorations in empowerment theory: An empirical analysis of psychological empowerment. American Journal of Community Psychology, 20, 707–728.

710 � Journal of Community Psychology, August 2009

Journal of Community Psychology DOI: 10.1002/jcop


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