Promoting Empowerment in Clinical Practice
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Empowerment can best be described as a client’s ability to be actively involved in his or her care. Empowered clients see—and believe— themselves to be capable of making decisions about their treatment, and are confident that their decisions will help them effectively manage their mental illnesses (Alegria M et al, Med Care 2008;46(3):247–256).
Empowered clients come to appointments armed with information; they ask questions and are not afraid to disagree with your prescribed treatment regimen. For clinicians, empowerment means that you work in partnership with your clients, jointly discussing and developing treatment plans, and acknowledging that your clients—not you—have ultimate authority and control over their own care (Schutt RK and Rogers ES, J Comm Psychology 2009;37(6):697–710).
Empowerment: Positives and Negatives
Client empowerment has many positive outcomes. Studies show that high levels of empowerment are significantly associated with improved self-esteem and self-efficacy. Empowered clients report greater self-confidence and independence, and increased optimism about their futures (Finfgeld DL, Adv Nurs Sci 2010;27(1):44–52). Empowered clients are more likely to follow treatment plans, stay engaged in services, and be highly satisfied with the care they receive (Jonikas JA et al, Community Mental Health J 2011;online ahead of print). Empowered clients also report fewer symptoms, and better physical and mental health.
While client empowerment promotes improved treatment outcomes, several barriers prevent clients from becoming good self-advocates (Brashers et al, Health Commun 1999;11(2):97–121). Society views clinicians as all-powerful: you spent many years in training, you are an expert in your field, so therefore, you, as a clinician know what is best for your clients. Your clients may feel that it’s wrong to ask you questions. They may fear that you’ll think that they are challenging your authority, and that you may discharge them from your care. Similarly, clinicians may hold the same attitudes: they know what’s best for their clients and are not to be questioned. Some clients may not discuss concerns with you because of their own limited knowledge about their illnesses, standard treatments, or prognoses.
In addition, family members, in an effort to protect their ill relatives, may discourage clients from advocating for their own care. “What if your doctor says ‘no’ or fires you? What if this medication doesn’t work and you become psychotic and lose your other services?” are common fears expressed by well-meaning family members who believe that client empowerment can only lead to negative consequences for their relatives.
Stigma also is a powerful barrier to empowerment (Kai J and Crosland A, Br J Gen Pract 2001;51:730–736). The negative stereotypes associated with mental illness may prevent clients from asking questions about their treatment because they don’t want to acknowledge that they have a mental illness, and don’t want to hear or think about what the future may bring. Stigma often prevents clinicians from seeing clients as individuals rather than diagnoses. It prevents mental health organizations and systems from collaborating with clients rather than controlling their care.
Enhancing Client Empowerment
There are three key components for you as a clinician to overcome these barriers and enhance client empowerment: client education, clinician communication, and enactment.
Client Education. Knowledge is power: Clients need education about their illnesses and recommended treatments to engage in successful, mutual discussions with you. Communication and problem-solving skills training also boost clients’ ability to take part in these discussions.
Research shows that participating in peer-led programs—interventions run by individuals who publicly acknowledge their own mental illnesses—improves client empowerment and promotes positive client-provider collaborations (Pickett SA et al, Community Mental Health J 2012;online ahead of print).
In peer-led programs, leaders who have “been there” and know what it’s like to live with mental illness provide needed educational and emotional support to clients. Participants receive information about the causes of mental illness and standard treatments; learn illness self-management strategies; and receive communication and problem-solving skills training.
For families, programs led by their peers teach participants how to work with their ill relatives and clinicians to set client-determined treatment goals. Available nationwide at no or low cost, some well-known peer-led programs are Building Recovery of Individual Dreams and Goals (BRIDGES), Wellness Recovery Action Planning (WRAP ), Peer-to-Peer, and Family-to-Family. (See this month’s Expert Q&A with Mary Ellen Copeland for details on WRAP .)
Clinician Communication. As a clinician, your empathy and encouragement are powerful empowerment enhancers. Even the most educated and assertive clients will be reluctant to partner with you if they feel that you are unapproachable, and don’t take their concerns and treatment goals seriously. Your conversations with clients need to convey understanding and respect. Information provided to clients should be clear. Clients may need to be encouraged to speak, and you may need to start the discussion process by asking, “What questions do you have for me?”
The University of Illinois at Chicago (UIC) National Research and Training Center on Psychiatric Disability (www.cmhsrp.uic.edu/nrtc) offers several toolkits to help facilitate your discussions with clients. While primarily designed for clients, these toolkits provide user-friendly strategies you can use to get the ball rolling. There are tools for talking about treatment plans and difficult issues such as medication compliance, and for identifying treatment goals and strategies to help clients take responsibility for achieving those goals.
Another resource is Common Ground, a web-based application created by Pat Deegan (www.patdeegan.com/commonground) that facilitates shared decision making between clinicians and clients. While in the waiting room, clients, assisted by a peer, use Common Ground to complete a one-page report that summarizes their concerns and current status. The program also links clients to information about treatment. Clients then bring their reports into their meetings with their clinicians and use the reports to develop a shared-decision treatment plan.
Enactment. No matter how educated your clients may be, how empathic you may be, and how agreeable you may both be about treatment decisions, empowerment will not work unless those shared decisions are put into practice. This means accepting clients’ choices even when those choices may go against what you might recommend. This doesn’t mean throwing caution to the wind, but rather discussing all options with clients. You need to provide honest feedback about potential negative consequences, agree to try-it-and-see, and make a shared plan for what to do if the approach fails.