Building a Client Driven System

I am very happy to participate in today’s retreat. I have been asked to introduce the discussion on the “discrimination dilemma” — specifically the problem of how the behavioral management system oppresses clients and renders the dialogue of clients and providers unbalanced.

This is considered the dominant moral dilemma of the mental health environment today — that discrimination is legally and theoretically sanctioned in our current provider-driven system.

As a trained lawyer, to me discrimination means that someone is not being treated equally because he or she belongs to a certain class of individuals who all share a specific characteristic. In the case of mental health clients, discrimination means that individuals with mental health disabilities are being treated differently from individuals without mental health disabilities — usually by someone in a position of power. We are all familiar with the prevalence of discrimination against clients with mental health disabilities — especially in the housing and employment contexts.

Today, however, we are going to spend some time talking about discrimination in the behavior management system. The provider-client relationship is an inherently discriminatory one because the provider is treating the client differently than a non-disabled individual because the client has a mental health disability. This occurs both on the one-on-one level and then is reinforced by the current system of laws.

1. Let’s first look at how discrimination manifests on the one-on-one relationship level between the provider and client

   The way that I see this — is that, in the medical model, the provider-client relationship is an imbalanced one. The provider has power over the client and this imbalance renders the client powerless and vulnerable — all because the client has a mental health disability.

   For example, some providers treat clients as if they were children or worse, as if they were incompetent. This often comes from formal training where clinicians were taught that keeping the client at a distance from them was professional, whereas blurring personal boundaries — possibly equalizing the power imbalance — was unprofessional. Providers are operating under a “best interest” standard — meaning clinical decisions are made after considering what is in the best interest of a client — often without consulting the client about which decision he or she favors and why. This can result in the client feeling stripped of personal responsibility, which in turn causes feelings of reduced self-worth and dignity. Often times these treatment decisions are being made against the client’s will at a time when the client is possibly at his or her most vulnerable, such as when a client is being hospitalized. Ultimately, the client may actually become more passive and dependent altogether.

2. Looking beyond the one on one relationship, a system of laws has been set up to reinforce this power imbalance.

   In many respects, the current system of laws has been set up to allocate power to the provider (versus the client), reinforcing this power differential — all because the client has a mental health disability.

   For example, the law allows a clinician to lock up a client in a hospital against his or her will. According to our laws, a clinician can even medicate a client against his or her will. Individuals without disabilities simply would not tolerate being treated like this. Hence, we have a system of laws sanctioning this unequal treatment.

   Now, certainly, patients’ rights laws have been enacted in order to counteract this power imbalance. The patients’ rights laws attribute some power to clients by offering them some hope of protection against the provider’s power to make forceable treatment decisions — however, in many ways these laws only serve to reinforce the overall system of power because they make it more legitimate. Providers “feel” as if the system is fair because the patients’ rights laws exist, when in fact, they really serve to reinforce the distance between the provider and the client.

I do not believe we are here today to discuss ways of completely abandoning the current system because of this inherent discrimination — but in order to seek ways to bridge the power imbalance as a system we have to face this reality in order to find meaningful solutions.