Treatment service users (TSU) project: phase two

6.5 Power and empowerment

Page last updated: March 2011

Issues of power and empowerment ran throughout most issues and themes of consumer participation in the TSU Project: Phase Two. This issue was most evident in consumer interviews (at both baseline and evaluation) which showed a fundamental lack of understanding in regards to both the concept and practice of consumer participation. After an explanation of consumer participation was given by the interviewers, consumers expressed their support. However, in many cases, the consumers lacked confidence in their ability to participate in treatment decisions. While in some cases this lack of confidence related to the individual's life experiences and treatment journey, in other cases it was clear that a sense of confidence in relation to participation was linked to feelings of powerlessness.

Staff interviewed at both baseline and evaluation were significantly less likely to believe that there was an imbalance of power within their services, with many failing to recognise the potential power dynamics and the impact of this on consumer participation. Examples put forward for perceived equal power ranged from 'consumers being able to leave services whenever they chose', therefore being in 'voluntary stay' with regard to the residential rehabilitation service, to many pharmacotherapy service staff believing that the 'close relationships' formed with consumers enabled more of an equal relationship between the staff and consumers. When power differentials were acknowledged there was a divide as to whether or not these could be challenged. Some stated communication and honesty as the key to fostering equal relationships and overcoming these challenges, but others were less confident that power differences could be overcome — implying trust, power and empowerment were too entrenched in services to be changed overnight — or even at all.

As mentioned above, while many staff (and to a lesser extent consumers) did not acknowledge great differences in power standings between staff and consumers, there were many examples where this was evident. A fundamental reality of pharmacotherapy treatment that could not be ignored when considering the impact of power on consumer participation is the issue of physical dependence. Within pharmacotherapy settings, consumers are heavily reliant on the medications provided to them by services. This factor alone does not lend itself to feelings of equality with staff by consumers, and there is the inherent threat that taking part in consumer participation could 'cost' someone access to their medication or other provisions that services provide such as take-away doses. Even within residential rehabilitation and detoxification facilities there are still similar constraints — speaking honestly about service deficits will not be looked upon favorably and could result in privileges (such as recreational time) being withdrawn and even removal from the service. While some services disagreed that this would happen, often consumers past experiences of stigma, discrimination and poor treatment meant that perceptions, not simply reality, could have a powerful effect on people's decisions to become involved in consumer participation, or not.

Many consumers seemed to be resigned to considering that changes to the way services ran would be out of their hands. Changes at the policy level were seen as too distant from the consumer experience or to input via a consumer participation process. In many interviews (at baseline and evaluation) the power imbalances were simply accepted by consumers as standard and even necessary, with many consumers believing and stating that staff knew what was better for them. In some instances staff were seen as 'peers' due to the knowledge of them being 'ex-users'. In addition to earlier discussions about 'who is a consumer' and when does someone become an 'ex-user', this issue raises another potential barrier to consumer participation. For example, if consumers consider staff (that they know to be 'ex-users') as their peers, then can these staff also reasonably represent them as consumers? Even if they are peers, first and foremost they are staff and this fact raises important questions about the potential crossing of professional boundaries and confusion of roles (i.e. can you be at once a consumer and a staff member, particularly in relation to consumer participation?). This question may be answered in the positive if you are working in a drug user organisation, but a drug treatment service is a very different context which it is argued fundamentally changes the power relationships and prevents such dual roles. This issue has also been explored in the section above on the role of staff who are ex-users and/or treatment consumers.
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The staff interviews at evaluation also indicated that they witnessed the personal empowerment of those in the consumer representative role across the course of their projects. Paradoxically, the position of consumer representative can only be effective (powerful) if the individual is still recognised as a 'peer' by the client group. Being identified as 'one of them' (a staff member) effectively robs the position of credibility and, therefore, power among its constituents. A hypothetical variation on this theme was mooted by interviewees and might be termed the 'yes man': effectively an overly compliant peer chosen by staff to act as a token consumer representative. In both instances it seems that the 'voice' of the representative must remain identifiably 'ours' to consumers in order to remain authentic and empowered — as 'us' and not 'them'. Yet this in turn appears to draw upon and reinforce the very dichotomy (of staff versus client) that consumer participation purports to challenge.

The issue above brings into question the empowerment of consumers. As mentioned previously, many consumers were quite willing to let staff make decisions regarding services and treatment. This implies that services may not be doing enough to empower their consumers to make these decisions. Indeed, some staff in evaluation acknowledged power as a central issue in developing consumer participation and indicated that they found the consumer participation project challenging, as it required them to 'let go' of control. While power and empowerment issues in treatment services cannot be addressed easily, or quickly, it is suggested that it could be more effective if large-scale changes were made within organisation structures. Changes to current practices and policies — such as core requirements to train (utilising drug user organisations) staff and consumers, and engage service consumers in meaningful levels of consumer participation — would go a long way to actualising consumer participation as a valid and highly worthwhile practice. Should this not be feasible then further research and project evaluations would be beneficial, at the very least to contribute to the limited research currently available on consumer participation and consumer representation in drug treatment settings.