Mental health service user's social and individual empowerment: Using theories of power to elucidate far-reaching strategies

Discourses of Involuntary Care in the South African Psy-Complex

In 2014, the United Nations Convention on the Rights of Disabilities adopted recommendations advising the replacement of involuntary care with supported care. This has polarised many about how best to provide for People living with Mental Conditions (PLPCs). Notwithstanding the contentions of this debate, we find on a personal discursive level that involuntary care is concealed as a self-evident and unquestionable response to the treatment of PLPCs. This can mean that policy-makers and professionals reproduce approaches to PLPCs uncritically. Considering these complexities, we used Critical Discourse Analysis (CDA) to examine what current norms surround involuntary care in the South African psy-complex, and how these are reproduced. We interviewed nine members of the South African psy-complex, including review board members, psychologists, and psychiatrists, and found several discourses maintaining current psychiatric norms. These include biomedical and techno-disciplinary discourses of treatment, clinico-legal disciplinary and danger discourses, and paternalistic discourses of institutional care. Each of these uniquely highlights the ways in which involuntary care is maintained and normalised, revealing that careful consideration is required to prevent potential human rights violations on behalf of professionals and policy-makers, regardless of whether in involuntary or support paradigms.

The role of advocacy and empowerment in shaping service development for families raising children with developmental disabilities

Introduction

Empowerment of families raising children with developmental disabilities (DDs) is essential to achieving rights‐based service development.

Methods

In this qualitative study, we investigated stakeholder perceptions on the role of advocacy and empowerment in developing caregiver interventions for families of children with DDs in a global context. Participants had experience with at least one intervention, namely the Caregiver Skills Training developed by the World Health Organization (WHO). Participants were clinicians, caregivers and researchers representing five continents, and representatives of WHO and Autism Speaks. Two focus group discussions and 25 individual interviews were conducted. Data were analysed thematically.

Results

Three themes were developed: empowerment as independence and as a right; the role and practices of advocacy; and using evidence to drive advocacy. Many professional participants defined empowerment within the realms of their expertise, focusing on caregivers' individual skills and self‐confidence. Caregivers expressed that this expert‐oriented view fails to acknowledge their intuitive knowledge and the need for community‐level empowerment. Participants discussed the challenges of advocacy in light of competing health priorities. The gap between the rights of caregivers and the availability of services, for example, evidence‐based interventions, was highlighted as problematic. Scientific evidence was identified as a key for advocacy.

Conclusion

Rights‐orientated empowerment of caregivers and advocacy may make vital contributions to service development for children with DDs in contexts worldwide.

Patient and Public Contribution

Research questions were revised based on views presented during focus group discussions. Participant feedback on preliminary themes informed the development of the interview guides.

What do speech-language pathologists describe as most important when trying to achieve client participation during aphasia rehabilitation? A qualitative focus group interview study

Purpose: The aim of this study was to investigate what speech-language pathologists describe as most important when trying to achieve client-oriented participation during aphasia rehabilitation. Method: A qualitative study including semi-structured focus group interviews with 11 speech-language pathologists. Interviews were analysed with the use of systematic text condensation. Result: Four main themes emerged from the analysis. (1) It is important to take the vulnerability of the client group into account. (2) It is important to address the client's process of realisation by navigating around unrealistic wishes and goals. (3) It is challenging to involve clients when the evidence-base for clinical practice is limited. (4) It is crucial to make therapy meaningful to the client. Conclusion: This study showed that speech-language pathologists perceived prediction of a clinical course in aphasia rehabilitation as challenging due to the vulnerable client group and the perceived need to guide the clients through the rehabilitation process. They talked about how unrealistic client goals, and the lack of a solid evidence-base to guide their clinical practice, made collaborative goal setting and treatment planning challenging. Due to these barriers, the speech-language pathologists struggled to achieve client participation, and thereby aphasia rehabilitation could not be described as fully client-oriented.

The experience of mental health service users in health system strengthening: lessons from Uganda

BACKGROUND

Mental, neurological and substance use disorders are a public health burden in Uganda. Mental health service user involvement could be an important strategy for advocacy and improving service delivery, particularly as Uganda redoubles its efforts to integrate mental health into primary health care (PHC). However, little is known on the most effective way to involve service users in mental health system strengthening.

METHODS

This was a qualitative key informant interview study. At national level, 4 interviews were conducted with national level health workers and 3 service user organization representatives. At the district level, 2 interviews were conducted with district level health workers and 5 service user organization representatives. Data were analyzed using content thematic analysis.

FINDINGS

Overall, there was low mental service user participation in health system strengthening at both national and district levels. Health system strengthening activities included policy development, implementation of programs and research. Informants mentioned several barriers to service user involvement in mental health system strengthening. These were grouped into three categories: institutional, community and individual level factors. Institutional level barriers included: limited funding to form, train and develop mental health service user groups, institutional stigma and patronage by founder members of user organizations. Community level barriers included: abject poverty and community stigma. Individual level barriers included: low levels of awareness and presence of self-stigma. Informants also recommended some strategies to enhance service user involvement.

CONCLUSION

The Uganda Ministry of Health should develop a strategy to improve service user participation in mental health system strengthening. This requires an appreciation of the importance of service users in improving service delivery. To address the barriers to service user involvement identified in this study requires concerted efforts by the Uganda Ministry of Health and the district health services, specifically with regard to attitudes of health workers, dealing with stigma at all levels, raising awareness about the rights of service users to participate in health systems strengthening activities, building capacity and financial empowerment of service user organizations.

The Experiences of Older Adults with Dual Diagnosis in an Inner Melbourne Community Mental Health Service

Less is known about the experiences of older adults (65+ years of age) with co-occurring mental health and alcohol and other drug use disorders (dual diagnosis) than is known about the experiences of their younger counterparts. This exploratory qualitative study sought to interview individuals receiving case management from an inner Melbourne community mental health service to determine their experiences of living with dual diagnosis and explore their interactions with mental health and addiction treatment, and general medical services alike. Six older adults with a dual mental health and substance disorder agreed to participate in a semi-structured interview process and provided their perspectives about living with complex mental illness and alcohol and other drug use. Several key themes emerged throughout the interview process, mirroring the notion of dual diagnosis being a complex phenomenon involving a number of interrelated factors: these include medical complexity, poor service engagement and long-term use of alcohol and other drugs. Interviews also demonstrate the challenges inherent in providing care to this cohort, with the participants frequently describing their experiences with services as being fraught with difficulty. The increased understanding of the perspectives of older adults with dual diagnosis provides the foundation for further research into this population in addition to influencing future nursing care provided to this cohort.

Developing and Translating a New Model for Teaching Empowerment Into Routine Chronic Care Management: An International Patient-Centered Project

Background:

Health professional education has been criticized for not integrating patient expertise into professional curricula to develop professional skills in patient empowerment.

Objective:

To develop and translate a new expert patient-centered model for teaching empowerment into professional education about routine chronic care management.

Methods:

Eight Finnish patients (known as expert patients), 31 students, and 11 lecturers from 4 European countries participated in a new pilot intensive educational module. Thirteen focus groups, artefacts, and an online student evaluation were analyzed using a thematic analysis and triangulated using a meta-matrix.

Results:

A patient-centered pedagogical model is presented, which describes 3 phases of empowerment: (1) preliminary work, (2) the elements of empowerment, and (3) the expected outcomes. These 3 phases were bound by 2 cross-cutting themes “time” and “enabling resources.”

Conclusion:

Patient expertise was embedded into the new module curriculum. Using an example of care planning, and Pentland and Feldman’s theory of routine organization, the results are translated into a patient-centered educational model for teaching empowerment to health profession students.

Empowerment, self and engagement in day center occupations: A longitudinal study among people with long-term mental illness

BACKGROUND

Day centers are a common form of mental health service internationally. They are aimed at enhancing occupational engagement and social relations, but there is a need to clarify the outcomes of day center programs, including the impact on important aspects of recovery such as empowerment.

AIMS

The aim of this study was to explore whether perceived empowerment changed over time among Swedish day center users and whether self-esteem, quality of life, socio-demographic data and self-reported diagnosis, type of program and level of engagement in day center occupations could predict future empowerment.

METHOD

The study involved a re-analysis of longitudinal data from 14 day centers, where measures of perceived empowerment and other individual factors were collected over a 15-month period. Non-parametric statistics were used, including Wilcoxon's signed-rank test and logistic regression analysis.

RESULTS

There were no significant changes in day center attendee empowerment scores. Self-esteem and level of engagement in day center occupations were found to be predictors of empowerment, together explaining 34% of the variation.

CONCLUSIONS

Developing empowerment in the day center context involves a complex interaction of individual, social and material factors. Potential barriers to empowerment are discussed along with considerations related to measuring empowerment as an outcome of day center programs.

Empirical and pragmatic adequacy of grounded theory: Advancing nurse empowerment theory for nurses' practice

AIMS AND OBJECTIVE

To draw on the findings of a grounded theory study aimed at exploring how power is exercised in nurse-manager relationships in the hospital setting, this paper examines the empirical and pragmatic adequacy of grounded theory as a methodology to advance the concept of empowerment in the area of nursing leadership and management.

BACKGROUND

The evidence on staff nurse empowerment has highlighted the magnitude of individual and organisational outcomes, but has not fully explicated the micro-level processes underlying how power is exercised, shared or created within the nurse-manager relationship. Although grounded theory is a widely adopted nursing research methodology, it remains less used in nursing leadership because of the dominance of quantitative approaches to research. Grounded theory methodology provides the empirical and pragmatic relevance to inform nursing practice and policy. Grounded theory is a relevant qualitative approach to use in leadership research as it provides a fine and detailed analysis of the process underlying complexity and bureaucracy.

DESIGN

Discursive paper.

METHOD

A critical examination of the empirical and pragmatic relevance of grounded theory by (Corbin & Strauss, , ) as a method for analysing and solving problems in nurses' practice is provided.

CONCLUSIONS

This paper provides evidence to support the empirical and pragmatic adequacy of grounded theory methodology. Although the application of the ontological, epistemological and methodological assumptions of grounded theory is challenging, this methodology is useful to address real-life problems in nursing practice by developing theoretical explanations of nurse empowerment, or lack thereof, in the workplace.

RELEVANCE TO CLINICAL PRACTICE

Grounded theory represents a relevant methodology to inform nursing leadership research. Grounded theory is anchored in the reality of practice. The strength of grounded theory is to provide results that can be readily applied to clinical practice and policy as they arise from problems that affect practice and that are meaningful to nurses.

Empowerment of young people who have a parent living with dementia: a social model perspective

BACKGROUND

Socially constructed disablement has marginalized young people in families where a parent has younger onset dementia (YOD). This has contributed to inadequate societal support for their complex situation. Impacts on such young people include significant involvement with mental health services for themselves. In this paper, we explored the young people's lived experiences in these families and the influencing factors to enable these young people to be included and supported within their community.

METHODS

In this qualitative research study, the social model of disability was used as the theoretical framework in conducting a thematic analysis of interviews with 12 participants.

RESULTS

Three themes emerged; invisibility highlighting the issues of marginalization; connectivity foregrounding the engagement of young people with family, friends and their social networks, and being empowered through claiming their basic human right to receive the age appropriate support they needed.

CONCLUSION

The current plight of young people living with a parent with YOD demands a fundamental shift by society in developing inclusive cross-sectorial cooperation linking service providers across youth and dementia sectors. This requires working in partnership with the service users responding to the identified needs of individual family members.

The social space of empowerment within epilepsy services: The map is not the terrain

Empowerment is now seen as an integral component of holistic practice and service design in healthcare, particularly as it relates to the improvement of quality of life for people with epilepsy. However, the literature suggests that empowerment is a neglected and poorly understood concept by service users and providers alike within epilepsy services. Conceptual ambiguity is a further impediment to its understanding and implementation. Bearing this in mind, a clear definition of empowerment is needed in order to realistically recognize, encourage, and prioritize empowerment as a service design philosophy. Therefore, this paper undertakes a concept analysis of empowerment with reference to epilepsy services. Results indicate that empowerment demands a transformation of consciousness and a readiness to act on this transformation in order to allow people to gain personal power and autonomy over their own life, including the self-management of their condition. With this in mind, a critical reflection on the 'micro' and 'macro' levels of power that exist within epilepsy services is warranted with reference to theoretical principles. In this context although the map is not the terrain, we argue that an educational intervention guided by critical social theory principles has the potential to encourage an understanding of empowerment and 'holds the key' to future advances for its implementation within epilepsy services.

Situated Motives of Lay Participants in Community Collaboratives for Children's Mental Health

Publicly funded programs in many industrialized countries increasingly require the participation of citizens. In this article, I explore the "situated motives" of family members who participated alongside professionals in implementing children's mental health programs in two communities in the United States. I conducted in-depth interviews with family members and observed monthly meetings of Community Collaboratives to assess how family members understood their participation. The inductive data analysis demonstrates that family members participated (a) as a therapeutic outlet, (b) to pay it forward, (c) to gain new skills, (d) to have a voice, and/or (e) to empower the community. I then use Giddens' concepts of "life politics" and "emancipatory politics" to explore how these accounts variously reflected lay members' orientations as consumers, empowered individuals, and/or citizen advocates. In the absence of articulated and specific objectives for family participation, these "situated motives" were salient and had implications for how policy was implemented.

Barriers to the participation of people with psychosocial disability in mental health policy development in South Africa: a qualitative study of perspectives of policy makers, professionals, religious leaders and academics

BACKGROUND

This paper outlines stakeholder views on environmental barriers that prevent people who live with psychosocial disability from participating in mental health policy development in South Africa.

METHOD

Fifty-six semi-structured interviews with national, provincial and local South African mental health stakeholders were conducted between August 2006 and August 2009. Respondents included public sector policy makers, professional regulatory council representatives, and representatives from non-profit organisations (NPOs), disabled people's organisations (DPOs), mental health interest groups, religious organisations, professional associations, universities and research institutions.

RESULTS

Respondents identified three main environmental barriers to participation in policy development: (a) stigmatization and low priority of mental health, (b) poverty, and (c) ineffective recovery and community supports.

CONCLUSION

A number of attitudes, practices and structures undermine the equal participation of South Africans with psychosocial disability in society. A human rights paradigm and multi-system approach is required to enable full social engagement by people with psychosocial disability, including their involvement in policy development.

Recovery: an international perspective

Aims– To review developments in recovery-focussed mental health services internationally.Methods– Two forms of ‘recovery’ which have been used in the literature are considered, and international examples of recovery-focussed initiatives reviews. A ‘litmus test’ for a recovery-focussed service is proposed.Results– ‘Clinical recovery’ has emerged from professional literature, focuses on sustained remission and restoration of functioning, is invariant across individuals, and has been used to establish rates of recovery. ‘Personal recovery’ has emerged from consumer narratives, focuses on living a satisfying, hopeful and contributing life even with limitations caused by the illness, varies across individuals, and the empirical evidence base relates to stages of change more than overall prevalence rates. Clinical and personal recovery are different. Two innovative, generalisable and empirically investigated examples are given of implementing a focus on personal recovery: the Collaborative Recovery Model in Australia, and Trialogues in German-speaking Europe. The role of medication is an indicator: services in which all service users are prescribed medication, in which the term ‘compliance’ is used, in which the reasoning bias is present of attributing improvement to medication and deterioration to the person, and in which contact with and discussion about the service user revolves around medication issues, are not personal recovery-focussed services.Conclusions– The term ‘Recovery’ has been used in different ways, so conceptual clarity is important. Developing a focus on personal recovery is more than a cosmetic change – it will entail fundamental shifts in the values of mental health services.

Declaration of Interest: None.

Community mental health centres: a qualitative study of professionals' experiences

This article presents findings from a qualitative study of mental health work in community mental health centres with a multiprofessional workforce and aims of active user participation in the service. User participation implies collaborative relationships and different roles than that of expert professionals and dependent patients. How do professionals working in these services experience their work and professional role? This question was explored in order to highlight important aspects of community mental health work. A group of six experienced professionals from three community mental health centres in a Norwegian city were interviewed twice. The informants highlighted the complexity of community mental health work and the need to be flexible when working to support people with mental health problems in their everyday life situation. To see the service users as people and to facilitate social interaction was important. Their work was described as 'liberating' compared to working in institutions. However, although in their experience they found that professional knowledge and skills were important in their work situation, all had experienced that this was not always acknowledged by professionals in other services.

'Wrong parents' and 'right parents': shared perspectives about citizen participation in policy implementation

Government policies, both in Europe and the U.S., increasingly mandate that community-based citizens partner with professionals to plan and implement policy-relevant programs. In the U.S., parents of children with serious emotional disturbances may participate in Community Collaboratives which are charged with implementing children's mental health policy in local communities. This qualitative study examined three Community Collaboratives and identified organizational features associated with how the groups prioritized lay involvement, among other competing goals which they legitimately could pursue. Thirty-four key informants participated in in-depth interviews. Although the overall study identified several factors which permitted greater and lesser degrees of family involvement, this paper reports on one: the symbolic meaning shared by members about lay participation in their shared perspectives about "wrong parents" and "right parents." Furthermore, two alternate types of "right parents" identified a psychologized version of parents as consumers, and a civic vision of parents as partners. Results from this study are applicable to a wide array of lay-professional partnerships. This study suggests that in order to foster lay-professional partnerships in policy initiatives, lay participants must possess additional, civic-based skills, beyond those needed in the service delivery arena. Furthermore, organizational and professional change may be required to address professional dominance. Within mental health, lack of acceptance of nationally touted recovery-based models is a significant barrier. Finally, sociological implications of developing a civic-based framework for lay-professional partnerships are discussed.

Empowerment in older psychiatric inpatients: development of the empowerment questionnaire for inpatients (EQuIP)

OBJECTIVE

To develop a questionnaire that measures levels of empowerment experienced by older adults admitted to a psychiatric ward.

DESIGN

Diverse views were sought to inform the questionnaire through a triangulation method; opinions of researchers were collected through a Delphi survey, clinical staff from different disciplines completed questionnaires, and patients participated in two focus group sessions. Once the questionnaire was developed, the authors asked patients to complete it alongside other instruments.

SETTINGS

Eight psychiatric wards of seven hospitals in and around London for people aged more than 65 years with a range of organic and functional mental health problems.

PARTICIPANTS

Eighty-seven patients with a functional psychiatric diagnosis participated in the psychometric evaluation of the instrument; 28 completed the scale twice for test-retest reliability.

MEASURES

Measures of quality of life (World Health Organisation Quality of Life - Abbreviated Version), degree of dependency (Care Dependency Scale), satisfaction with care (Psychiatric Care Satisfaction Questionnaire [PCSQ]), and psychosocial functioning (GAF) were used to evaluate psychometric properties of the empowerment questionnaire for inpatients (EQuIP).

RESULTS

The EQuIP is a measure of empowerment, which computes the subjective importance of the different aspects of psychiatric care for the individual patient. It had high internal consistency (Cronbach's alpha = 0.88) and reasonable concurrent validity (correlation with PCSQ as a measure of satisfaction with care, r(85) = 0.65, p = 0.01). High test-retest variability may signify fluidity of the construct of empowerment.

CONCLUSION

The EQuIP may be used to assess empowerment in older psychiatric inpatients.

Expanding roles within mental health legislation: an opportunity for professional growth or a missed opportunity?

This paper aims to highlight both the necessity, and the way forward for mental health nursing to integrate proposed legislative roles into practice. Argued is that community mental health nursing, historically absent from active participation within mental health law in the UK, is faced with new and demanding roles under proposed changes to the 1983 Mental Health Act of England and Wales. While supporting multidisciplinary training for such roles, the imperative of incorporating nursing specific values into consequent training programs is addressed through the offered educative framework. This framework explores the issues of power, ethics, legislative thematics and application to contemporary service structures.

Psychotherapy and mental health teams

Mental health teams in different configurations and settings are under increasing pressure to offer formal psychotherapies as well as psychologically informed management to large numbers of 'difficult' patients with severe and complex presentations. This pressure has arisen variously from consumers, governmental agencies and commissioning bodies. Although these teams are an important resource, they receive limited training, supervision or support in models of psychotherapy, especially those incorporating a relational dimension and offering a coherent 'common language'. This commonly results in impairment of collective team function, including the quality and consistency of assessments, and may result in stress, splitting and 'burn out' for team members. This situation is due in part to their burden of casework and responsibility but also to prevailing, largely symptom-based and biomedical, models of mental disorder which tend to minimize the importance of psychosocial dimensions in either aetiology or treatment. Formulating and delivering appropriate, evidence-based and robust models of psychotherapy in generic team settings represents a significantly different challenge from that posed by delivery of psychotherapy in specialist settings. Approaches to this important challenge are discussed and summarized drawing on general considerations and the limited direct research evidence, and are illustrated by a cognitive analytic therapy (CAT)-based training project.