Book reviews

This is a book about the power of language to a€ect profoundly the roles and relationships of people who use mental health services and the people who provide them. The assumptions and implications of language, according to Perkins and Repper, have created a mental healthcare system beset by implicit contradictions and power imbalances which inevitably reduce the e€ectiveness of available services. It is remarkable, and remarkably hopeful, that two clinicians, one a clinical psychologist and the other a nurse who is currently studying health sciences research, wrote this book. The authors' comprehension of the complexity and political consequences of relationships within the mental health system is a major strength. Their concepts are presented with a view to the three `decision-making groups' that comprise the system: people who experience mental health problems (`users'); providers of `formal and informal treatment, care and support'; and society and its public organizations, such as the police and justice system. Their knowledge of user issues is reasonably thorough and models an open and sensitive approach to inclusion and user rights. The dilemmas examined in Choice or Control are extensive and informative. They include the following. (1) De®nitions. How needs should be de®ned and by whom; the di€erentiation between health and social issues; mental and physical illness and their interrelationship; disability; `madness'; roles; treatment interests; empowerment; prioritization of care as an ethical and political judgement; guidelines for diagnosis, duration, disability (2) Mental health and society. Public demands; rights of the individual vs. rights of society for comfort and safety. (3) Family needs. Lack of recognition and appreciation; potential con ̄icts in professional relationships with family and with user ± con®dentiality and power. (4) Evaluation. evidence-based care; identi®cation of treatment e€ectiveness; responsibility; accountability (5) Treatment issues. Prioritization of mental health care; diagnosis as a criterion for care; assessment and care planning models; amount of care provided ± from over-provision to nonprovision; cure and the `normalization' process; relationship between duration of hospitalization and relapse; treatment vs. punishment; enforced treatment and the length of enforced treatment; the right to refuse treatment; user involvement in care planning; social issues as a form of treatment, especially employment, housing and social relationships (6) Clinician attitudes. Disregard of user views generally; clinicians' beliefs about treatment needs vs. users' wishes; pragmatic care vs. the traditional cure/symptom relief approach; threat of alternative (user-run) services to mainstream clinicians; reluctance to work with dicult clients; non-compliance viewed as irrational and pathological; need for power and recognition of professional expertise; doing with vs. doing for. The premise of the book is that the language of mental health care re ̄ects the very real inequities of power that dictate the functional parameters of the mental health system. This language of power permeates all aspects of the system, thus the need for this book. Perkins and Repper emphasize the centrality of users in a system that is supposed to care for them. The fundamental questions the book raises in relation to each dilemma examined are `who makes the choices?' and `who is in control?' Not surprisingly the answer is inevitably the clinician (de®ned as a psychiatrist, clinical psychologist, nurse, occupational therapist, social worker or other therapists). Were users `allowed' to be involved in Book reviews