Book reviews -- Return to Community: Building Support Systems for People with Psychiatric Disabilities by Paul J. Carling

Return to Community: Building Support Systems for People with Psychiatric Disabilities. By Paul J. Carling. New York: Guilford Press. 1994. 348 pp. Cloth $40.00, paper $18.95.

In Return to Community: Building Support Systems for People with Psychiatric Disabilities, Carling sets out a comprehensive and well-organized treatment of a very timely topic. Section I presents a brief overview of the way people with psychiatric disabilities have been viewed and treated in society over the past 40 years and presents useful recent statistics. Carling issues a call to action and sets forth the basic ideas of a model for change. This overview brings the reader up to speed on the current state of affairs for this population by reviewing historical antecedents. Thus, Carling makes the book accessible to those who have not followed the debate closely but does not bore those who have. His readable and concise review helps to frame the issues discussed in later chapters.

In his call to action, detailed in chapter 2, Carling sets forth his most compelling material. Carling draws clear distinctions between the current state-of-the-art model, which he calls the comprehensive community support systems model, and the model that has grown out of the community-integration movement, the framework for support. The community-support-systems model, which is predominant in the United States, focuses on the professional caregiver and the need for professionally based services over the long haul. Emphasis is placed on the formal service-delivery system and the central role of professional mental health personnel as the primary deliverers of these services. The philosophy that undergirds this model, Carling argues, is residual, stressing the incapacities of the "client" and the implied dependence on the professional caregiver.

The framework for support model, on the other hand, is a self-help model that has been widely adopted in Canada. The focus of this model is on empowerment, enabling people with psychiatric disabilities to take control of their own lives through the development of relationships with friends, family, and community. This model reduces the control of the professional community and places it into the hands of the individual. The model encourages the control of services by consumers of services. It also depends heavily on the willingness and ability of the community to integrate the person into community life. Carling identifies stigma as the primary obstacle to this integration and suggests ways that stigma can be overcome.

In section II, Carling discusses ways in which those with psychiatric disabilities and professionals who work with them can organize for community change. He suggests the development of groups consisting primarily of mental health consumers working within communities to educate, facilitate, and network for change. A chapter is devoted to strategies, that is, how to develop a mission statement for the group, how to address community concerns, how to assess where the community is in terms of its views of the mentally ill, and whom to involve. Although this section does not go into depth on any of these issues, it is a useful overview that directs the reader to other more detailed sources.

In section III, Carling addresses how community integration might be achieved. The section begins with a discussion of how established systems might be revamped. he discussion is considerably enhanced by the use of examples showing how states and localities can develop service principles and adapt community-support services to focus on the concept of community integration of persons with psychiatric disabilities. The examples function both as illustrations showing how concepts are put into action and as encouragement that this can actually be done.

As a social work educator, I was particularly interested in the section discussing changes within higher-education programs that can enhance community integration of persons with psychiatric disabilities. Carling states correctly that mental-health-related courses in higher education have focused on pathology and treatment issues as opposed to taking a holistic view of the needs of the person. Curriculum content on community-support systems and community integration for persons with psychiatric disabilities is still sparse, although it is perhaps covered more fully in social work than it is in other disciplines as a result of social work's emphasis on systems theory. Carling makes valuable suggestions for correcting this imbalance, again using some examples of where this has been done.

The last three chapters in this section are devoted to discussions of housing, employment, and social integration. In the areas of housing and employment, the issues of access and development are stressed. The focus is on practical areas--getting down to the basics in working with landlords, "decongregating" current residential facilities, working with employers, and creating employment opportunities. Again, the author makes generous use of case examples. The section ends with a fine chapter on social integration, which Carling recognizes as the most critical element in the return to the community. Social isolation and loneliness are examined, and suggestions are made on how to facilitate contacts and promote peer-support networks. Consistent with his self-help focus, however, Carling resists the temptation to assign all these tasks to the professional helper and stresses that mental health consumers must take on this responsibility themselves.

In what seems to be an acknowledgment that many professionals in the mental health field will find the concept of self-help difficult to implement, Carling devotes section IV to discussions on sharing power with consumers and involving families as partners. By examining strategies, discussing implications, and reviewing resources, these chapters remind the reader of the main point: True return to the community can be realized only if consumers are empowered as partners who are valued as community members and supported by the community structure.

As a professor teaching social welfare policy and a part-time clinical therapist practicing in a small-town mental health outpatient clinic, I found Carling's book insightful, readable, and on target. I work in a state that has not made the strides in the mental health field that Carling's home state of Vermont has, and the new self-help approach to community integration for those with psychiatric disabilities has yet to appear widely here. Carling's book strikes a chord as a call to action to improve the lives of a population that for too long has been victimizied by the very system that is supposed to serve it.

Copyright Family Service America Nov 1995
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