Empowering vulnerable populations:

An example of empowering people with mental illness through treatment planning

Donald M. Linhorst, PhD, MSW Professor and Director School of Social Work Saint Louis University October 2, 2012

PRESENTATION DERIVED FROM:

My 15 years of experience as a social worker My research on empowerment Linhorst, D. M. (2006). Empowering People with Severe Mental Illness. New York: Oxford University Press

PRESENTATION OVERVIEW
Empowerment and treatment planning defined Components of empowerment Conditions for empowerment through treatment planning Guidelines for mental health staff and consumers
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EMPOWERMENT DEFINED
Empowerment is the meaningful participation of people with mental illness in decision making and activities that give them increased power, control, or influence over important areas of their lives. (Linhorst, 2006, p. 9)
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TREATMENT PLANNING DEFINED

Treatment planning is the process by which the needs, strengths, and problems of people with mental illness are assessed, treatment goals are established, and treatment and rehabilitation activities are identified to facilitate goal achievement.
(Linhorst, 2006, p. 88)

COMPONENTS OF TREATMENT PLANNING

Strengths, problems and/or obstacles Long-term and short-term goals Treatment and rehabilitation interventions to help meet goals Reassess, reformulate goals and interventions, and reassess Format and components of treatment plans will vary, often guided by population and accreditation standards
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EMPOWERMENT

COMPONENTS OF EMPOWERMENT
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Empowerment involves holding power, control, and influence

Holding final decision making power is most empowering. However, empowerment exists on a continuum, and it can occur in some instances through a sharing of power.

Empowerment is situational
Empowerment is specific to particular activities at a specific point in time. Individuals can be empowered in one activity but not another Empowerment can increase or decease as circumstances change.

Empowerment can refer to a process

Any process that prepares people to participate more effectively in an activity that increases their power, control, or influence can be considered empowering.

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Empowerment can refer to an outcome

Empowerment outcomes
Are the consequences or results of empowerment processes Can be short-term or long-term Can be subjective or objective

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One cannot empower another

People must empower themselves. However, others play a critical role in providing individuals with supportive relationships, resources, decision making opportunities, and other things many people need to empower themselves.
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EMPOWERMENT

CONDITIONS FOR EMPOWERING MENTAL HEALTH CONSUMERS

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Managed Mental Health Symptoms

The consumers symptoms are managed to the degree necessary to meaningfully participate in a specific activity.

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Managed Mental Health Symptoms and Treatment Planning

Symptoms can limit
insight into the mental illness ability to focus ability to process information ability to consider options ability to make informed choices ability to understand consequences

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Managed Mental Health Symptoms and Treatment Planning

Addressing the condition
Treat symptoms and provide consumers with tools to manage symptoms Involve consumers in as many treatment decisions as possible as it is rare that symptoms prevent people from making any decisions As symptoms subside, increase the role consumers play in treatment planning
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Participation Skills
The consumer possesses the skills required to meaningfully participate in a particular activity.

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Participation Skills and Treatment Planning

Identify and express needs and goals Weigh options for goals and activities Cognitively link services and interventions with goal achievement Resolve conflicts with staff if they arise during treatment planning

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Participation Skills and Treatment Planning

Addressing the condition
Provide skills training as needed Promote use of advocates at treatment planning sessions if consumers lack the skills to meaningfully participate

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Psychological Readiness
The consumer has the psychological readiness, that is, confidence, motivation, willingness to meaningfully participate in a particular activity.

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Psychological Readiness and Treatment Planning

Lack of psychological readiness can be associated with
Past failed attempts to improve themselves Fear of change Lack of knowledge of themselves and the possibilities that exist for them Clinical depression

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Psychological Readiness and Treatment Planning

Addressing the condition
Must first assess the reasons associated with the lack of readiness; may need to:
Treat symptoms of depression Development of supportive relationships between case managers and consumers Create opportunities for small successes Use motivational interviewing

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Mutual Trust and Respect

The consumer and the persons with whom he or she is interacting have the necessary level of mutual trust and respect to meaningfully participate together in a particular activity.

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Mutual Trust and Respect and Treatment Planning

Lack of trust and respect can be reflected in clinician paternalism Consumers may not want to participate in treatment planning unless they believe clinicians respect their right to participate and have their best interests in mind Development can be more difficult with consumers from cultural, racial, or ethnic backgrounds different from staff
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Mutual Trust and Respect and Treatment Planning

Addressing the condition
Partnerships based on egalitarian relationships that respect and appreciate the different strengths each bring to the decision making process Establish positive relationships, which can carry over to treatment planning Clinician self-disclosure Reinforce and celebrate accomplishments Clarify expectations of both parties in the treatment planning process
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Reciprocal Concrete Incentives

Concrete incentives exist for both the consumer and persons with whom he or she is interacting to meaningfully participate together in a particular activity.

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Reciprocal Concrete Incentives and Treatment Planning

Concrete incentives for consumers to meaningfully participate
Can lead to subjective feelings of empowerment Are most likely to have goals and interventions in the plan that reflect their preferences Need clinicians expertise to assist them to identify the most helpful interventions If coerced into treatment, plan can provide a roadmap to ending coercion

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Reciprocal Concrete Incentives and Treatment Planning

Concrete incentives for clinicians to meaningfully engage consumers

Consumer involvement in treatment planning increases the likelihood that their clients will have favorable outcomes Consumers possess information about their disability, strengths, and goals that clinicians need to develop an individualized treatment plan that is most appropriate for their clients
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Availability of Choices
The consumer has choices he or she values and sufficient information about those choices to make informed decisions about a particular activity.

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Availability of Choices and Treatment Planning

Consumers should have a range of choices
Across service types (e.g., medication, housing, and employment) Within service types (e.g., choices of types and location of housing)

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Availability of Choices and Treatment Planning

Factors limiting service choices
Under funding of public mental health services Emphasis on medication at the cost of other treatment and rehabilitation options Poor coverage of mental health services by private insurance companies Not having health insurance or being under insured Managed care restrictions on treatment Legal or informal sources of coercion
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Availability of Choices and Treatment Planning

Addressing the condition
Political advocacy at the local, state, and national levels to increase mental health services Updating staff on service options Staff and consumers taking the initiative to create new services to fill gaps

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Participation Structures and Processes

The consumer has structures and processes through which to meaningfully participate in a particular activity.

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Participation Structures and Processes and Treatment Planning

Basic treatment planning structures
Treatment teams Case managers

Family involvement
Should be involved when they have a genuine, constructive interest, And when the consumer agrees to it
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Participation Structures and Processes and Treatment Planning

Key processes
Consumers present when writing treatment plans Individualizing treatment goals Breaking down broad goals into smaller, more concrete goals Adapting decision making to consumers abilities

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Participation Structures and Processes and Treatment Planning

Key processes
(continued)

Having an agreed upon process for resolving consumer and staff differences Involving consumer advocates when needed to ensure consumers preferences are identified Modifying the process when consumers are experiencing severe symptoms, are deemed incompetent, or are coerced into treatment
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Access to Resources
The consumer has access to the resources needed to meaningfully participate in a particular activity.

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Access to Resources and Treatment Planning

Client resources
Advocates to participate in the planning process when needed Mediation process for resolving differences between consumers and staff Logistical resources (e.g., transportation, child care) Adequate time to participate at a time that is convenient to the consumer
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Access to Resources and Treatment Planning

Staff resources
Staff training to realize the potential of consumers to direct their own treatment to understand why some consumers may choose not to participate and how to address it to develop the skills to meaningfully engage consumers in the treatment planning process Staff time to meaningfully engage consumers in the treatment planning process

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Supportive Culture
The culture in which the consumer is interacting in a particular activity is supportive of shared participation.

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Supportive Culture and Treatment Planning

A culture is supportive when
Stigma, discrimination, and paternalism are minimized within the mental health organization Consumers are viewed as capable of making meaningful decisions and caring for themselves

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Supportive Culture and Treatment Planning

Addressing the condition
Mental health organizations adopt recovery models and psychiatric rehabilitation approaches Leaders create mission and vision statements that reflect the recovery and strengths perspectives Administrators model these perspectives for staff in their interactions with consumers
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Supportive Culture and Treatment Planning

Addressing the condition
(continued)

Staff receive extensive training, technical assistance, and opportunities to discuss treatment planning Administrators develop systems to evaluate consumer participation and staff competencies related to treatment planning Administrators establish caseload sizes at reasonable levels so that staff have the time to meaningfully engage their clients in treatment planning
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GUIDELINES FOR MENTAL HEALTH STAFF

Recognize the important contributions mental health consumers make to treatment planning Teach skills needed by consumers to meaningfully participate Develop trusting and respectful relationships to promote meaningful participation Adapt the treatment planning process for consumers from diverse backgrounds
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GUIDELINES FOR MENTAL HEALTH STAFF (continued)

Have mechanisms to resolve conflicts that invariably arise during treatment planning Include consumer advocates in treatment planning when needed Ensure adequate time for treatment planning Develop an organizational culture that supports meaningful participation Include family members in treatment planning when consumers agree to it
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GUIDELINES FOR MENTAL HEALTH CONSUMERS

First and foremost, exercise your right to meaningfully participate in treatment planning Request, and in some instances demand, meaningful choices Ask for advocates if you believe they can help you make better decisions Carefully consider the suggestions offered by staff for goals and treatment activities
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GUIDELINES FOR MENTAL HEALTH CONSUMERS (continued)

If experiencing active symptoms that interfere with your ability to participate, ask to meet at another time Ask for more time to complete the treatment plan if you feel rushed Seek information that assists you in making choices about goals and treatment activities

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CONCLUSIONS
Consciously look for opportunities to empower vulnerable consumers Be aware of the conditions for empowerment, and seek ways to ensure they are met The benefits of empowerment are extensive, for consumers, social service organizations, and the public at large.
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CONTACT INFORMATION
Donald M. Linhorst, PhD, MSW
linhorsd@slu.edu 314.977.2745 School of Social Work, Saint Louis University, 3550 Lindell Blvd., St. Louis, Missouri, 63103

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