Silence and Surveillance:Mental Illness, Evidence-Based Practice,

and a Foucaultian Lens

Anna Scheyett

ABSTRACT. Evidence-based practice (EBP) has had a significantimpact on aspects of social work practice in mental health. It is importantfor social work to consider EBPs and their implications, particularlyaround the dynamics of power and potential for coercion and oppres-sion. This paper uses a post-modern lens to examine EBPs and explorethe dominant discourses of science and mental illness that are its founda-tion. Specifically, it uses the work of Michel Foucault to explore threemajor thematic fields: silenced voice; moral fault; and power and knowl-edge; and concludes with a discussion of the implications for socialwork research and practice. [Article copies available for a fee from TheHaworth Document Delivery Service: 1-800-HAWORTH. E-mail address:<docdelivery@haworthpress.com> Website: <http://www.HaworthPress.com>© 2006 by The Haworth Press, Inc. All rights reserved.]

KEYWORDS. Mental illness, evidence-based practice, post-modern-ism, Foucault, consumer, social work research

Anna Scheyett, MSW, LCSW,CASWCM, is Clinical Assistant Professor, Schoolof Social Work, University of North Carolina at Chapel Hill, 301 Pittsboro Street,Chapel Hill, NC 27599-3550 (Email: amscheye@email.unc.edu).

The author would like to thank Dr. Leslie Bella for her guidance and support in thedevelopment of this paper.

Journal of Progressive Human Services, Vol. 17(1) 2006Available online at http://www.haworthpress.com/web/JPRO

2006 by The Haworth Press, Inc. All rights reserved.doi:10.1300/J059v17n01_05 71

In essence, Foucault says that if you think you understandmadness–just think again by looking at its history. Histories of in-stitutions and treatments have now disclosed extreme varieties ofengagement with this problem–each extreme being broadcast inits time with the same reassuring confidence. What evidence isthere that our understanding of these phenomena has improved,that present-day certainties are more reliable than those in thepast?

(Still & Velody, 1992)

INTRODUCTION

Over the past ten years, evidence-based practice (EBP) has had asignificant impact in some areas of social work (Gambrill, 1999) andthe field of mental health (Tanenbaum, 2003). EBP is derived fromevidence-based medicine, and both share at their foundation “the con-scientious, explicit, and judicious use of the current best evidencein making decisions about the care of individual patients (Sackett,Rosenberg, & Muir-Gray, 1996). To be considered ” evidence-based”a practice must have been established as effective through scientific re-search according to set criteria (Mullen, 2002) involving a hierarchicalranking of evidence, with randomized controlled trials ranked highest,typically followed by well-designed non-randomized trials, cohort orcase-control trials, multiple time series trials, and finally descriptivestudies and case reports (Ganju, 2001).

One EBP project that has had a pronounced impact on mental healthservices in the U.S. is the Evidence-Based Care for Persons with Seri-ous Mental Illness (EBP/SMI) initiative. Led by investigators from theNew Hampshire-Dartmouth Psychiatric Research Center, and fundedby the Robert Wood Johnson Foundation and the U.S. Substance Abuseand Mental Health Services Administration (SAMHSA), this initia-tive aimed to identify, from the literature, EBPs for adults with seri-ous mental illnesses (SMI). Using a hierarchical rubric like the onediscussed above, the initiative identified six evidence-based practices:(1) medication guidelines; (2) illness management; (3) assertive com-munity treatment; (4) family psychoeducation; (5) supported employ-ment; and (6) integrated substance abuse and mental health treatment(i.e., dual diagnosis services) (Calhoun, 2002). Since research has dem-onstrated that the majority of services received by people with SMI are

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not evidence based (Lehman, Steinwachs, & Co-Investigators, 1998),the initiative also had the goal of developing and disseminating train-ing materials based on these EBPs to mental health care providers(Calhoun, 2002). Subsequent actions have included SAMHSA fundedpilot sites and toolkits for planning and implementing these EBPs in theU.S.; other countries are looking at these EBPs with interest.

Given the alacrity with which some social workers have adoptedEBPs in general, and the EBP/SMI initiative in particular, I believe it isimportant for social workers to consider these practices and their impli-cations thoughtfully. Reducing the painful symptoms of SMI is a goalof the EBP/SMI initiative, and these outcomes do occur. The challengefor us as social workers is to ask “At what cost?” In this paper I explorethis question by stepping outside the positivist paradigm and askingwhat can be learned about the dynamics of power in mental health “bestpractices” from a different frame. Using a post-modern lens to examinethe dominant discourses of science and of mental illness that engen-dered EBP/SMI, what do we see, and can these observations help us associal workers create processes that better meet the wants and needs ofindividuals labeled with mental illnesses? 1

For this project I utilize some of the concepts developed by MichelFoucault in Madness and Civilization (1965) and in his later works toinform my analysis of EBP/SMI. I also draw from the comments of anumber of consumers who have been participants in dialogues andfocus groups on EBP that I have facilitated over the past two years(Scheyett & Childers, submitted for publication; Scheyett & McCarthy,2004) The paper uses a Foucaultian lens to explore EBPs and concludeswith a discussion of the implications of these explorations for socialwork research and practice.

EVIDENCE-BASED PRACTICES THROUGHA FOUCAULTIAN LENS

In Madness and Civilization (1965) and in his later works such asPower/Knowledge (1980) Foucault offers dramatically nontraditionalreadings of the history of the treatment of mental illness, the history ofconfinement, and the nature of power. He examines the dynamic ofrepressive power in the relationship between Madness2 and Reason,and how this dynamic forms the unrecognized foundation of modernmental health treatment and research. In this article I examine theEBP/SMI initiative using some of Foucault’s concepts, specifically the

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concepts of silenced voice, moral fault, and the relationships of powerand knowledge.

Silenced Voice

Foucault identifies the development of the internment houses of themid-seventeenth century as the moment in which Madness was silenced(Rose, 1992). Here, and in subsequent “moral” treatment, Foucaultholds that Madness lost its voice, “it was deprived of its language; andalthough one continued to speak of it, it became impossible for it tospeak for itself” (Foucault, 1976, p. 69). In losing its voice and place,Madness also lost its meaning. Its language was seen as involutionaland self-referential, with no possible meaning for the world of Reason.The dialogue between Madness and Reason was thus silenced, and “thelanguage of psychiatry, which is a monologue of reason about madness,has been established only upon the basis of such a silence.” (Foucault,1965, pp. x-xi).

The EBP/SMI process would, at first glance, seem to be an effort torekindle a dialogue between Madness and Reason. Throughout theinitiative there is discussion of the importance of consensual values,of including consumers and their families in program development andtreatment decisions (Drake et al., 2001), and including them in theEBP/SMI project itself (Calhoun, 2002). However, on closer examina-tion, the initiative can also be seen as yet another monologue of Reason,stripping the voice of Madness of meaning and power. This can be seenin the establishment of the research questions and research processesinforming EBPs, and the resultant EBP interventions.

Silence and Research

EBP is based in positivist research, which is driven by inquiry; thusit is essential to consider whose voice asks the questions. Are the out-comes studied in EBP research those of value to the consumer or to themental health system? For example, in ACT research the most com-monly examined outcome is days of hospitalization (Bond, McGrew, &Fekete, 1995), but though this results in lower system costs there is noindication that this outcome is the one of most importance to consum-ers. A consumer/advocate discussed this lack of consumer voice in de-fining EBP outcomes by saying “I am concerned that the definition ofsuccess [in EBP research] is generated by constructs and hypotheses,and may miss what consumers consider to be success (Scheyett &

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Childers, submitted for publication). I would argue that the voice of theconsumer is seldom if ever present in the genesis of the positivistresearch question. This occurs, at least in part, because in research con-sumers are the Other, the objects to be studied. Dialogue betweenresearchers and consumers, between the researcher and the object ofresearch, between Reason and the Other within the discourse of science,does not occur because dialogue requires two entities that recognizeeach other’s commonalities and humanity, while an Other can havenothing of value to say. The silence of Madness is imposed by the struc-ture of the research upon which EBP is built.

Silence echoes in the research process as it does in the researchquestioning. At their foundation, EBPs are based in a hierarchy thatdoes not acknowledge the validity of consumer voice–qualitative stud-ies, interviews, first person accounts are not considered “evidence” andare ignored. Knowledge creation based in the direct voice of the con-sumer, considering positionality and contextuality, is prohibited, de-spite a body of literature on the possibility of rigor and trustworthinessin qualitative studies (Rodwell, 1998). I would argue that without thisconsumer voice in the research process there is no possibility for creat-ing a knowledge-based system that facilitates consumer agency, auton-omy, and the potential for recovery. For example, had there been aconsideration of the consumer literature on the trauma of coercion andlack of privacy and autonomy in treatment in its analysis, then ACTmay not have been seen as a benign and effective intervention (Deegan,1997; Watts & Priebe, 2002). Consumer voice, and research methodswhich privilege consumer voice, are essential if “evidence” is to reflectthe reality and meaning of consumers’ lives; as one consumer stated“If we continue to use the definition that it [research] works only if youuse a randomized controlled trial, we lose.” (Scheyett & Childers,submitted for publication).

Silence and Intervention

The six specific EBP/SMI interventions are also filled with thesilenced voices of consumers. Foucault states that Madness “is judgedonly by its acts; it is not accused of intentions, nor are its secrets to befathomed. Madness is responsible only for that part of itself which isvisible.” (Foucault, 1965, p. 250). In the EBP/SMI initiative there islittle focus on meaning and subjective experience; practices emphasizeskills and behaviors, work and education, with little acknowledgmentof or attention to the existential challenges and subjective struggles

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consumers may face. Nowhere in the EBP/SMI interventions is coun-seling provided to explore these important life questions. A consumerdescribed this as a process where “What we’ve done is taken awayeverybody’s ability to struggle with and figure out why . . . ” (K.T., per-sonal communication, 2003). Another consumer described the empti-ness beneath surface EBP successes by saying, “A person who receiveservices from an ACT team and make no community disturbances is agood outcome–they are quiet, perhaps leading a life of desperate isola-tion, but considered a success.” (Scheyett & Childers, submitted forpublication). The EBP/SMI researchers themselves acknowledge thatin interventions such as illness management there is a paucity of explo-ration of outcomes such as hope, meaning, and purpose (Mueser et al.,2002). Nowhere in the actual services of the EBP/SMI is there thespace, essential for recovery, where consumers can voice and grapplewith the meaning of their experience.

The EBP/SMI practice of medication management, which focuseson algorithms to determine which medications should be given to a psy-chiatric patient, (Gilbert, Altshuler, Rago et al., 1998; Mellman, et al.,2001) is a specific arena where consumer voice is conspicuously si-lenced. Much emphasis is given to “medication compliance,” to beinggood, obedient, and taking medication as told to by the psychiatrist.Non-compliance is implicitly seen as transgression, willful disobedi-ence, rather than as assertion of autonomy and a clear communicationfrom the consumer about his/her dissatisfaction with the effects of themedication. The physician, guided by research-based standardized in-struments, is the judge of adequacy of response and tolerability of sideeffects (Mellman et al., 2001); the individual experiencing the effects isrendered invisible and silent while the provider’s voice is privileged.There is no opportunity for the practitioner to explore the meaning oftaking medication for the consumer, no chance for the consumer to ar-ticulate his/her story and tell of medication’s impact on the individual’ssense of self and identity (Rodwell, 1998). Given this, consumers’ con-cern about the dehumanizing effects of guidelines is understandable,and the reassurance of “consideration of the individual” (Mellman et al.,2001) rings hollow in a dynamic where the consumer is neither trulyseen nor heard.

Illness management is an EBP designed to help consumers cooperatewith professional treatment and increase skills in symptom manage-ment and relapse prevention (Herz, Lamberti, Mintz et al., 2000), lifecoping skills (Hogarty, Greenwald, Ulrich et al., 1997), and medicationcompliance (Cramer & Rosenheck, 1999), all by means of increasing

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insight into their SMI, and providing education, training, and behavioraltailoring (Mueser et al., 2002). Here both the individual’s voice and thatof other consumers is de-privileged in comparison with the professional’sknowledge. Illness management is a professional service, “conductedin the context of a therapeutic relationship in which the teacher . . . isresponsible for the overall treatment of the individual’s psychiatricdisorder.” (Mueser et al., 2002, p. 1273). Thus illness management ishierarchically structured, with the provider imparting wisdom to theconsumer in the context of a larger relationship within a structure wherethe provider is “responsible” or in charge of treatment. Though illnessmanagement includes “respecting patients’ rights to make decisionsabout their own treatment” (p. 1274), one must ask if a consumer cantruly voice his/her wishes within this larger dynamic of responsibilityand power. In addition, when writing of illness management, research-ers are careful to distinguish it from “illness self-management,” whichis peer-facilitated and helps people learn to cope and take care of them-selves by connecting with others who have had similar experiences. Thedialogic intervention of peer-to-peer support, of consumer voice speak-ing its experience and wisdom to another, is not included because “rig-orous controlled research evaluating the effects of these programs hasnot been completed” (Mueser et al., 2002, p. 1273); this simply high-lights the fact that the consumer voice in peer support is not valuedenough to be equally researched in EBP-acceptable ways. It should benoted, however, that a body of literature on the effectiveness of peerservices and supports does exist, which includes both qualitative andquantitative studies (Scheyett, 2000); extensive research has also beendone on consumer-operated programs (Campbell & Leaver, 2003). Thisprivileging of professional, disciplinary knowledge over the situatedknowledge of the consumer is also seen in the family psychoeducationEBP, where professional experts provide support, skill training, and in-formation regarding mental illness (Dixon et al., 2001); consumers arenot co-leaders who can provide insights and information to familiesbased on their life experiences in this EBP model.

Similar to illness management, the EBPs assertive communitytreatment (ACT) and integrated dual diagnosis services (which oftenuses ACT as a part of the intervention) are grounded in a structurewhere providers are “responsible” for consumers and their voice is priv-ileged over consumer voice (Drake et al., 2001). ACT is an intensiveservice where a provider team assumes “responsibility” for a con-sumer around the clock in their community settings (Burns & Santos,1995; Phillips et al., 2001). A core principle of ACT is that “the team is

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assertive in engaging individuals in treatment and monitoring theirprogress” (Phillips et al., 2001, p. 773, emphasis mine), whether theconsumer wishes to be engaged or not. The consumer’s ability to voicehis/her wishes and choices is silenced in the larger paternalistic struc-ture of ACT-team-knows-best, which provides services whether theconsumer wants them or not.

Questions can also be raised about consumer voice and choice inthe EBP supported employment (Bond et al., 1999, 2001). Supportedemployment programs use a rapid job search, individualized to thestrengths, work experience, and preferences of consumers (Abrams,DonAroma, & Karan, 1997), and support services for employment areclosely integrated with mental health services. I would argue thatthough the strengths and preferences focus may allow consumer voice,within the mental health system’s paternalistic structure it may be diffi-cult for consumers to truly express their wishes, and they may againexperience silenced voice, now in a vocational arena. The fact thatprimary concerns about supported employment include low payingunskilled jobs and short retention times (Bond et al., 2001) raises thequestion of whether consumers really prefer and choose these menialjobs, or whether they acquiesce silently to professional suggestion andthen leave the work site as quickly as feasible.

In summary, recovery, the putative goal of the EBP/SMI initiative,is an individualized journey towards purpose and meaning. However,mental health services based in the EBP/SMI initiative may create iatro-genic barriers in this journey. In both its epistemology and its practices,the EBP/SMI initiative silences consumer voice and thus precludes ex-ploration of the issues of meaning and existence essential to recovery.

Moral Fault

In his history of Madness, Foucault posits that the classical era’s con-finement of Madness shifted during the nineteenth century, and Mad-ness was seen ultimately as “the psychological effect of a moral fault”(Foucault, 1965, p. 158). With the assumption of moral flaw, Madnessalso became burdened with guilt, with responsibility for its actions, andwith conscience. No longer were the physical chains of the internmenthouses necessary, Madness was (and is) contained in the psychic chainsof a treatment that is “moral sadism” (Foucault, 1976). The punitivetreatment entails work, surveillance, and the admission of guilt andwrong and return to reason.

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Work, as a central component of the treatment of Madness, serves anumber of functions. It is to some extent productive, but its most impor-tant functions are as symbolic participation in the world of Reason andas punishment/treatment. Surveillance also plays an essential role intreatment, with constant watchfulness by professionals making a con-tinual demand for conforming behavior. Under constant surveillance,what Peter (2000) and others have called the “normalizing gaze,”Madness learns to behave always as if the normalizing gaze was upon it,and to restrain itself. In this surveillance, the observer’s power “insertsitself into [the individuals’] actions and attitudes, their discourses,learning processes, and everyday lives.” (Foucault, 1980a, p. 39). In thisinternalized process of moral and social rehabilitation, Madness mustlearn to see itself as mad, express remorse for wrong behaviors andthinking, and return to the world of Reason (Gordon, 1992).

Echoes of Foucault’s concepts of work, surveillance, and thelanguage of moral fault thread their way through the EBP/SMI. Work isthe core of the supported employment EBP (Bond et al., 2001). It is seenas both productive and therapeutic (what Foucault might call disciplin-ary); not only does work increase consumers’ resources, but studieshave shown that it improves self-esteem and controls symptoms (Bondet al., 2001)–the structure of labor is good discipline, providing organi-zation and promoting a return to Reason. Though not overtly articu-lated, the emphasis on work in the EBP/SMI raises questions aboututilizing work as a moral treatment, a way of redeeming consumers andmaking them more “worthy” in the eyes of the community, earningback a position lost by the flaw of mental illness. Work becomes a sym-bolic act that signifies consumers as productive citizens, with all themoral connotations implicit in that phrase.

The dynamics of surveillance can also be seen in the EBP/SMI,justified by the consumer’s flaw of lack of insight. The EBP AssertiveCommunity Treatment (ACT), which can also be a part of the integrateddual diagnosis EBP (Mercer-McFadden, Drake, Brown et al., 1997),has been referred to as a “hospital without walls” (Swartz, 1995), and anumber of consumer groups have raised concerns about its aggressivepursuit of consumers in the community (Fischer & Ahern, 2000). TheACT team defines itself as entirely responsible for its consumers, deliv-ering medications, teaching skills, managing money, and ensuring at-tendance at all appointments (Phillips et al., 2001), thus enclosing themin a structure of surveillance and power. ACT can be seen as the ulti-mate surveillance in the Foucaultian sense, a surveillance that can enterone’s home, speak with one’s neighbors and associates, even control

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one’s money, housing, and medications, all outside the institutionalsetting. One consumer discussed the impact of ACT’s surveillanceby saying “so many professionals could take over somebody’s life–swallow them up until they disappear” (E.C. personal communication,2004). This pursuit and surveillance is also seen in supported employ-ment, where practitioners provide job coaching on site (Bond et al.,2001); consumers must “behave” at work and cannot escape the watch-ful eye of the professional. Even family psychoeducation can be seen ashaving an element of surveillance, with family members trained byprofessionals to watch for signs of relapse and non-compliance. Thissurveillance also extends forward in time, as many EBPs–ACT, sup-ported employment, dual diagnosis–are of long-term or indefiniteduration. Consumers may never know if or when they will be freed fromthe watchful eye of the system.

Moral fault is implicit in much of the focus on medications in theEBP/SMI initiative. In the medication management EBP, the languageused for individuals whose symptoms are not reduced by medication is“treatment resistant” (Kane, Honigfeld, Singer et al., 1997; Mellmanet al., 2001). This language suggests that the consumer is somehow fight-ing against and is at fault for the lack of improvement he/she experiences.Consumers who do not take their medication are “non-compliant,” with“poor insight” into their illness, in other words, flawed and disobedient.

The illness management EBP works to help people collaboratewith providers, to take the skills and structures providers give, anduse them to return to stability–a process akin to what Foucault refersto as the “exterior Cogito” of the physician structuring the flawedself of the weak and wrong-headed patient (Foucault, 1965). Part of ill-ness management involves the consumer accepting his/her illness in aprocess often referred to as “developing insight,” reminiscent of theconfessions of guilt in Madness and remorseful cooperation with thenineteenth century physician required in the asylum. Aggressive andcoercive efforts are used in this process of “acceptance.” For example,the integrated dual diagnosis EBPs (Drake, Essock et al., 2001; Mueseret al., 2002) includes “motivational interviewing” (an interventionwhere professionals “persuade” consumers to comply with treatmentusing strategies some see as verbal double-binds and manipulation),and coercive efforts such as payeeships and involuntary outpatientcommitment.

The EBP/SMI initiative reinforces the sense of moral fault under-pinning SMI, using the flaws of lack of cooperation, compliance, andinsight as justification for the coercion of surveillance and labor.

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Interestingly, this sense of moral fault is diffused beyond consumers topractitioners not willing to engage in EBPs. Throughout the EBP/SMIthere is an emphasis on “fidelity” to the models (Calhoun, 2002), a needto keep faith with the interventions and not wander astray. It has beennoted in the literature that proponents of EBP in general argue that it isunethical not to support EBP (Gupta, 2003) and that pursuit of EBP isequivalent to pursuit of health for patients (Miettinen, 2003). Thus,those practitioners who question EBP are impugned as both unethicaland unfaithful to patients and to research–serious moral flaws indeed.

Power and Knowledge

For Foucault, power and knowledge are inextricably intertwined(Foucault, 1980a; Gordon, 1992). In Western society, science is privi-leged as the true source of knowledge, giving it tremendous power.Foucault views this privileging of science as a form of repression, andasks “which speaking, discoursing subjects–which subjects of experi-ence and knowledge–do you then want to diminish when you say:‘I who conduct this discourse am conducting a scientific discourse andI am a scientist’?” (Foucault, 1980b, p. 85). Thus there is tremendouspower in claiming the knowledge of scientific evidence-based practicessuch as the EBP/SMI initiative. Holding the knowledge of best practicescreates a hierarchy of power, with wise researchers and providers whoknow what is best bestowing their disciplinary knowledge (and thus thepossibility of recovery) upon consumers and their families. The recipi-ents (such as families receiving EBP psychoeducation, or consumersreceiving EBP illness management) can only accept this knowledgewithout question; their experience and views are rendered powerless bythe authoritative stance of knowledge. This knowledge supports thewielding of power within mental health systems; the coercive powerthat can be used in ACT or any other EBP is justified because the re-search evidence has shown it to be effective. However, the values, para-digms, and assumptions behind this power are not examined becausethe knowledge justification makes them “right,” “obvious,” and “true.”However, from a recovery perspective, as one consumer stated “Unlesswe have a shared set of values and paradigms, no amount of EBP willmake a difference.” (Scheyett & Childers, submitted for publication).

Power uses knowledge for its own political purposes as can be seenin the EBP/SMI initiative. Following the logic of EBP, any practice thatdoes not meet the EBP criteria is not best, is flawed, and is viewed aswrong or untrustworthy. Implicit here is that the source of the flaw, the

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problem in the mental health system that limits recovery potential,is poor practices and flawed individuals. Nowhere in the EBP/SMI arethe larger political and structural issues that exacerbate or induce SMIexamined and challenged. Structural issues that create barriers to imple-mentation of EBPs are addressed, but larger issues such as poverty,discrimination, stigma, and violence are not examined. For example,the difficulty consumers may face when attempting to find employmentis defined as a lack of work skills, not the stigma and discrimination per-petrated by employers and other community members (Link, Cullen,Mirotznik, & Struening, 1992). Foucault demonstrated that in the clas-sical era the state used its power to create a system whereby medicalknowledge labeled and confined individuals for what were ultimatelyeconomic and political (rather than medical) reasons. Concerned indi-viduals might wonder if EBPs are a modern example of this same dy-namic, of political self-protection at a systems level. Concerned socialworkers must be aware that if we focus exclusively at the individuallevel and do not acknowledge and address the structural barriers andoppressions facing consumers, we allow and support their perpetuation(Dominelli, 1988; Ife, 1997; Morell, 1996).

As a final comment, it is ironic to note that despite the demand forrigorous research as the standard for practices, evidence-based medi-cine in general (of which EBP is a part) has no solid evidence base-nobroad-based and rigorous studies have demonstrated that having practi-tioners provide services in an evidence-based medicine system im-proves patient outcomes (Miles, Grey, Polychronis, Price, & Melchiorri,2003). Here the power inherent in the privileged position of researchcreates a knowledge “reality” called EBP, even though this knowledgeis (by EBP’s own standard) deficient and this knowledge reality isimposed upon de-privileged and much less powerful consumers.

CONCLUSIONS AND RECOMMENDATIONS

In examining the EBP/SMI initiative using some of the concepts ofFoucault, significant issues emerge, issues of discounted and silencedconsumer voice, of surveillance in a hospital without walls, of moralflaw in both SMI and its treatment, and of repression. Because of theseissues, the EBP/SMI initiative can inhibit, rather than promote, recov-ery. However, before moving to a discussion of possible social workresponses, I believe it is important to acknowledge both the limitationsof Foucault’s concepts, and the productive aspects of EBP.

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Limitations

Foucault has been criticized both for distorting history and forromanticizing Madness (Erevelles, 2002; Gelb, 2000; Merquoir, 1986).In his work the suffering of mental illness is the suffering of exclusion.Little attention is paid to the fear and pain caused by symptoms of men-tal illnesses themselves, and to providers’ desires to relieve that painaside from any motives of social control. In addition, in Foucault’spresentation Madness never has the possibility of self-agency; it is apassive victim of confinement, treatment, and repression. I would arguethat the archeology of the history of the consumer rights movement andthe establishment of legislation such as the Americans with DisabilitiesAct demonstrate the falsity of this view (Sayce, 2000). To both deny thepossibility of alleviation of suffering through mental health treatmentand to deny the power that consumers have exerted over the state is tolimit the discourse of mental illness within a frame of victim/oppressor.

Similarly, limiting a view of the EBP/SMI initiative to repression de-nies its potential for productive, positive effects. With implementationof EBPs the possibility of individual professional’s capricious use oftreatment is lessened. In addition, ensuring that consumer receive ser-vices that have been deemed “best” validates their legitimate claim forsupport; as one consumer noted it says, in effect “We deserve the best.”(Scheyett & Childers, submitted for publication). EBPs are provided ina community setting–and although surveillance continues this setting atleast provides the possibility for contact and beginning communicationbetween consumers and individuals not labeled SMI. The language ofthe EBP/SMI acknowledges the possibility of recovery, and its mentionof consumer involvement in program planning and service plan devel-opment contain hints of openness to dialogue. As I stated at the begin-ning of this article, though there are benefits to EBPs, as social workerswe must look at the issues of silence, moral fault, power/knowledge,and ask “At what cost?”

Foucault’s view, though perhaps distorted, serves as a magnifyingglass, highlighting the very real issues of repression and power thatmight otherwise be overlooked if we remain within a positivist para-digm. I would argue that in an eagerness to embrace EBPs, many socialworkers and mental health professionals have not carefully scrutinizedits costs, which can be very high. EBPS, as they exist currently, may de-crease symptoms and improve some outcomes, but do so in a way thatcan be oppressive, paternalistic, stifling, and that may ultimately lessenchances for recovery (rather than simple stabilization).

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Recommendations

Social work is an action-based and a value-based discipline (Mullaly,2002). As such, we cannot simply point out the problems of silence,repression, and moral blame within the EBP/SMI, we cannot merely say“The cost is too high!” We must also act. Foucault has long been criti-cized for being anti-humanist and callous to the realities of suffering,and for feeling no need to engage in or provide recommendations foraction (Erevelles, 2002; Gelb, 2000). However, he does offer one pow-erful idea useful as a tool for criticism and for action, that of “subjugatedknowledge.” By this term Foucault refers to “a whole set of knowledgesthat have been disqualified as inadequate . . . located low down on thehierarchy, beneath the required level of cognition of scientificity.”(Foucault, 1980b, p. 82). By re-voicing subjugated knowledge andmoving it forward in action we are able to criticize and change the domi-nant discourse. Foucault’s strategy was to use subjugated knowledgeto look back and explore the struggles in history, in a process he referredto as genealogy (Foucault, 1980b). I propose that social work strive toopen a space for the subjugated, situated knowledge of consumers anduse this to look forward and explore recovery in a process we canconsider one of generativity.

How are we to begin this process? Broadly speaking, I believe thiswill require three important shifts: (1) from silencing consumers tolistening to consumer voice; (2) from viewing consumers as morallyflawed to seeing consumers as full and equal partners; and (3) fromlinking power and disciplinary knowledge to linking power to the situ-ated and subjugated knowledge of consumers. Social work itself mustre-begin communication with consumers and reopen the dialoguebetween Madness and Reason that has been silenced for so long. Thismeans that we must be willing to listen to consumer voices, to put asidethe specialized language of our discipline and the privileged position ofour knowledge. We must also give up the power stance of “us and them”and move beyond what one consumer described as “the battle lines[that] were always drawn–you were sick, they were well” (Cloutier,1994, p. 31), towards true mutualism and connection. Dialogue cannotoccur in the traditional social spaces we have created for consumers,spaces of coercion and control in treatment. We need new venues thatare safe for dialogue, that are as equal as possible so that we may listen,partner, and act on the situated knowledge of consumers. Glimmersof this activity can be seen in dialogue projects that bring consum-ers together with others to engage and work towards greater mutual

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understanding, but these efforts are nascent (Bluebird, 1995; Scheyett &Kim, 2004). Another potential place for partnership is with the con-sumer/survivor movement. There is a rich history in this movement,and real power in current consumer groups (National Mental HealthConsumers’ Self-Help Clearing House, n.d.) Social workers need toconnect here and to encourage additional dialogue in a radical humanistprocess of subjective joining and understanding (Howe, 1987).

Specifically, how can this occur? How can social workers listen toand partner with consumers in order to raise situated/subjugated knowl-edge and experience, and de-privilege the current structures of EBPs?To do this, I believe social work efforts must focus in two domains.First, social workers must engage in the long-term process of creatingnew research and practice structures grounded in and driven by theknowledge and lived experience of consumers. Second, social workersmust engage with consumers in the here and now to recontextualize themental health services they provide, connecting the personal, political,and clinical. Only through this two-pronged approach can social workattend to both current consumer needs and long-term system reform; adual role conceptualized by Mullaly (2002) as both challenging oppres-sion and “tending to the wounded,” those who are currently harmed bythe oppressive system.

Research

The creation of new practice structures grounded in consumer know-ledge requires consumer-driven research/knowledge generation. In anarticle titled From Lab Rat to Researcher, Campbell and colleagues(Campbell, Ralph, & Glover, 1993) describe a continuum of possibleroles for consumers in research, from “lab rat/object” to “respondent” to“consultant” to “partner” to “independent researcher” to full “stake-holder” in the research and dissemination process. For social work tosupport empowered research roles (e.g., consultant, partner, independentresearcher) for consumers, and to support the operationalization ofconsumer research findings in practice, it is useful for us to be guided bythe concepts of consumer voice, partnership, and power in situatedknowledge.

In order to support consumer voice, social workers must be involvedin supporting the development of a consumer-defined research agenda.Consumers have not had full opportunity to voice their own questionsand define the outcomes that are important to them, to question thedominant discourse and articulate their views and needs. Only when

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the research questions belong to consumers can the evidence theresearch produces be meaningful and the practices it engenders benon-oppressive. In addition, answers to consumer-defined researchquestions should be found through techniques that do not silence ordenigrate consumer voice. This means that social workers and consum-ers will have to work together to de-privilege traditional positivistresearch strategies, advocate for the legitimacy of non-positivist ap-proaches (e.g., narrative, constructivist, dialogic) (Guba & Lincoln,2004; Rodwell, 1998; Rosenwald & Ochberg, 1994) and partner in thecreation of new research approaches, all with the goal of elevating con-sumer voice and giving authority to the situated/subjugated knowledgeof consumer experience.

Beyond listening to consumer voice, social work research shouldengage consumers as full research partners, co-creating knowledgethrough approaches such as participatory action research (Fisher, 2002;Nelson, Ochocka, Griffin, & Lord, 1998; Ristock & Pennell, 1996) orthe hermeneutic circle of constructivist research (Rodwell, 1998). Inaddition to this partnership, however, is another important role forsocial work, that of facilitating and supporting independent consumerresearch, creating a power/knowledge nexus in the situated knowledgeof consumers’ lived experience (Griffiths, Jorm, & Christensen, 2004).By sharing the knowledge and research skills of social work, we canfacilitate consumers’ empowerment to own the research process andgenerate relevant practice knowledge to meet their goals and needs.Finally, if the knowledge generated in these research processes is to beemancipatory, it cannot be hoarded by a privileged few. New knowl-edge creates new power, and thus should be widely disseminated. Newpractices, interventions, strategies to promote recovery identified byresearch should be shared not merely with providers, but with consum-ers and their families as well, discussed in a language accessible to all(rather than the specialized voice of science) and diffused throughoutthe community.

Practice

Through the generation of new practice knowledge in the researchprocess discussed above, new emancipatory actions that social workerscan engage in may be identified. However, today’s social workers areleft with the question of what to do in the here and now, when the expec-tation is that they will practice from an EBP framework. I would suggestthat by broadening and contextualizing the dialogue with consumers,

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again using the concepts of voice, partnership, and power in situatedknowledge, social workers can use what may be helpful about EBPswhile avoiding (at least some) of its oppressive effects.

To illustrate, let us take the EBP of illness management. The goal ofthe illness management EBP is to help people reduce their symptoms ofmental illness and cope more effectively with their symptoms (Mueseret al., 2002); the assumption is that by doing this consumers will prog-ress in their recovery. In a traditional illness management intervention,the professional would assess the consumer’s deficits, and then provideskills that “have been shown by science” to work to address the deficits.This would include teaching the consumer cognitive-behavioral strate-gies for coping with symptoms, helping him/her develop strategies toremember to take medication and come to appointments, and teachinghim/her about mental illness, signs of relapse, and how to get help. Theapproach is hierarchical, assumes that SMI is something to simply bemanaged, and that the reason symptoms are problematic are because theconsumer is deficient in the skills needed to manage them.

Consumers, on the other hand, may have very different views andneeds. Being truly heard and understood is important to the recovery pro-cess; one consumer expressed this by saying “There again it comes downto does this counselor really, really understand?” (Scheyett, submitted forpublication). Consumers may also experience the illness managementteaching and behavioral tailoring of the provider “expert” as paternalisticand controlling. A consumer expressed his/her frustration with this pater-nalism by saying “I’m tired of people telling me how to run my life . . . [I]want some control and some respect . . . They treat you like a child; I’m24 years old.” (Scheyett, submitted for publication).

A more anti-oppressive intervention would take a very different,collaborative social work approach (see, for example, Poulin et al.,2000). A social worker would begin by establishing a relationship andcontext of meaning for the work with the consumer (Brun & Rapp,2001). This would involve listening intently to the consumer’s voice andstory, engaging in dialogue with the consumer around what s/he wantsfrom the relationship, what resources and strengths the s/he brings to thework, what “recovery” means and would look like to him/ her, and whats/he sees as short and longer-term goals (DeJong & Miller, 1995). Oneconsumer who reported that s/he had experienced such a relationshipwith a mental health provider described it by saying that what wasthe most important was “the mutuality–I never felt talked down to.”(Scheyett, submitted for publication).

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During this initial process a consumer could, for example, identify agoal of having more meaningful relationships, and see the distraction ofhearing voices and “feeling like people think I’m odd” as barriers to thisgoal. This would be followed by partnering with the consumer to iden-tify a range of resources, strengths, and situated knowledge that can beused to help the consumer reach his/her goal (Rapp, 1998). These couldinclude the consumer’s prior experiences and learning (e.g., “Could wethink about good relationships you’ve had in the past–how did thosehappen?”), conversations with other consumers who have had similarexperiences (e.g., going to a peer support group and raising this issue inthe discussion), and practices identified in the research as helpful inreaching the consumer’s goal (e.g., medication adherence strategies tohelp reduce the voices). Here, rather than an expert telling the consumerwhat works, the consumer and social worker partner to co-generatea range of options, and can then discuss the pros and cons of eachgrounded in the consumer’s knowledge of self and experience. As aconsumer stated “If you want to know what works–ask me” (Scheyett,submitted for publication). The advantages and limitations of an EBPsuch as the medication compliance strategies of illness management canbe discussed, just as the advantages and limitations of advice from afamily member or another consumer can be discussed. After full explo-ration of all options, with an EBP being only one option, the consumercan make an informed choice, and give truly informed consent to anintervention strategy.

The process outlined above is essential, but it must be emphasizedthat it is by itself insufficient for practice. It is important that the dia-logue between social worker and consumer include discussion of theexternal barriers the consumer faces in reaching his/her goals. Thesebarriers include stigma and discrimination against people with mentalillnesses (Dickerson, Sommerville, Origoni, Ringel, & Parente, 2002;Wahl, 1999), disability structures that ensure people will remain inpoverty (Dobelstein, 1992), and the wide-spread de-privileging ofconsumer voice discussed throughout this paper. Without this conver-sation, the unspoken message that the causes of the consumer’s prob-lems are due to internal flaws remains. If these structural barriers areacknowledged and discussed, and if the consumer is encouraged to con-nect with peers and dialogue in this consciousness-raising process, thenthe self-eroding effects of societal “blame the victim” can be reducedand the chances for recovery maximized.

Social work is a profession that focuses on empowerment andopposes oppression. However, in our work with consumers, in our

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eagerness to be anti-oppressive, I fear that social work may rush into“consumer-driven” research and practice initiatives without having firstdone the hard work of divesting itself of privilege and establishing truedialogue and shared language with consumers. This process takes time,takes work, and must be revisited continually. Perhaps ultimately whatsocial work needs is to shift from establishing “best practices” to creat-ing “best processes”(Anthony, 2003), to shift from searching for “whatto do” to fix things to learning “how to be” to work together, to groundour work in the voices of consumers and their situated knowledge, topartner with consumers in both research and practice. Only after wehave learned this, after the discourse of science and the heretoforesilenced discourse of consumer experience are metamorphosed into adiscourse of valued voice, can we begin to work together towards waysof consumer recovery.

NOTES

1. Throughout the paper I use the term “consumer” to refer to individuals with SMI.This term is preferred by some individuals, while other terms with varied connotations,such as “survivor”, “ex-patient” or “ex-inmate” are preferred by others. I choose to useconsumer because it is used in the EBP/SMI literature, but intend no disrespect to themeanings inherent in the other terms.

2. Throughout this article I use the term “madness” when referring to Foucault’soeuvre, rather than the more contemporary “SMI” or “mental illness” in order to moreaccurately reflect his text.

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