The importance of language
The language used to describe ‘service users’ (our preferred term) is perhaps more varied in mental health than in any other sector of health and social care. Most of the literature on service users comes from the context of specialist psychiatric care rather than primary care. ‘User’, ‘survivor’, ‘patient’, ‘customer’, ‘citizen’, ‘consumer’: all imply different notions of the roles and responsibilities of people with mental health problems and the relationship between services and users. Pilgrim & Rogers (1999) have described a useful four-part typology of users as consumers, survivors, providers or, perhaps most commonly, as patients.
‘Consumerism’ is a relatively new ideology within the public sector in the UK, linked to the rise of general management principles in the National Health Service in the 1980s and the development of a market economy through the introduction of an internal market. It is also linked to the growing acknowledgement of the importance of customer satisfaction, with users of health and social care as customers who can exercise an informed choice about the services they receive and, if not satisfied, take their ‘business’ elsewhere. However, as Rogers & Pilgrim point out:
many psychiatric patients do not ask for what they get – it is imposed on them. Various sections of the 1983 Mental Health Act, like its legal predecessors, are utilised to lawfully impose restraints and treatments on resentful and reluctant recipients. In such circumstances, mental patients could be construed to be consumers if being dragged off the street and force fed was a feature of being a customer in a restaurant. (Rogers & Pilgrim, 2001, p. 169)
Poverty can also limit choice, with private sector mental health services out of bounds, while, at times of crisis, the ability and motivation to obtain information about a range of services and select between them can be difficult (Rogers et al, 2001; Lester et al, 2004). For many people across the world with mental health problems, simply getting access to any kind of service, not the luxury of choosing between services, is the key issue. Choice also implies a possibility of exit from the system, a notion that is difficult to sustain in a society whose courts recognise the validity of advanced directives only when they prospectively authorise treatment, not when they are used to reject the possibility of treatment (Szasz, 2003).
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