Empowering People with Mental Illness within Health Services

As a result of anti-discriminatory legislation, campaigns and initiatives, a number of mental health services and individuals are now adopting more empowering attitudes and practices towards people with mental health problems. However discrimination and disempowerment remains prevalent within many organisations. This article explores ways in which people with mental illness can be further empowered, with particular reference to mental health care provision. Discussion and recommendations are underpinned by a four-tier framework of empowerment, which incorporates issues relating to the individual, the organisation, the service user and society.


Introduction
As a result of anti-discriminatory legislation, campaigns and initiatives, a number of mental health services and individuals are now adopting more empowering attitudes and practices towards people with mental health problems. However discrimination and disempowerment remains prevalent within many organisations. This article explores ways in which people with mental illness can be further empowered, with particular reference to mental health care provision. Discussion and recommendations are underpinned by a four-tier framework of empowerment, which incorporates issues relating to the individual, the organisation, the service user and society.
Many individuals and organisations have highlighted the disempowering attitudes and behaviours towards people with mental illness which exist in society. These may occur within health [1][2][3], education [4], the workplace [5,6] or society at large [7]. The term 'disempowerment' refers to taking away power from an individual [8], thus leaving them feeling helpless, without control over their lives and less likely to succeed. It has been posited that this is a result of widespread discrimination [9], which includes unhelpful misconceptions and negative beliefs and behaviours towards people with mental illness, which result in stigmatisation and the disempowerment of this group of people.
A number of measures have been taken to address this issue. Anti-discrimination legislation which inhibits discrimination and promotes empowerment of people with mental illness is and has been in place for a number of years. This includes The National Service Framework for Mental health [10], The Equality Act [11] and The Mental Health (Discrimination) Act [12]. Several organisations and campaigns have contributed to positive change by reducing stigma and discrimination and promoting more empowering behaviours towards people with mental illness, for example, Time to Change [13], The Mental Health Foundation [14] and Mind [15].
However, although these initiatives have resulted in the adoption of more positive and empowering attitudes towards people with mental illness by some, discrimination and disempowerment

Neeru Aggarwal
Teacher of Psychology and Psychotherapist, UK Department of Neurobiology, Huahzong towards people with individuals with mental health problems still remains widespread [16,17]. This article explores ways in which empowerment can be implemented, within mental health services specifically. This is with reference to the literature and the author's experiences of working within mental health.

Discussion and Recommendations
The following discussion is with reference to a four-tier model, which conceptualises and discusses empowerment at four different dimensions [18]. The first is the individual level of empowerment, which refers to how much belief a person has that they have control and influence over their own lives, and how able they are to exert this influence. For empowerment to be possible at this level, the individual needs to possess skills and qualities, such as self-esteem, the confidence to communicate their views and wishes, and mental capacity. In order to maximise empowerment at this level, it is helpful for mental health professionals take an active role in supporting these skills. The following issues are important: The treatment of and attitudes towards the individual are crucial for empowerment at this level, in that they can influence communication of needs, wishes and wants. In order to maintain self-esteem, trust and enable the person to feel comfortable to disclose their feelings, choices and wishes, the establishment of a good therapeutic relationship is crucial. In order to attain this, it is important to be respectful, non-judgemental and avoid making the person feel inadequate in any way. Molkenthin [19] refers to the necessity of establishing a relationship in which the individual feels accepted as a person of worth, and feels free to Acta Psychopathologica ISSN 2469-6676 express them-selves without fear of being rejected. Gilburt et al. [20] discuss the importance of the absence of coercion, and the presence of cultural sensitivity and good communication on part of the mental health professional, whereas Modic and Zveltz [21] highlight the importance of empathy, trust, safety and a sense of connection between the service user and the mental health professional.
In addition, a willingness to share power with service users and accept their expertise is essential [22]. This is integral for a trusting, 'equal' relationship and to create an empowering environment. It is important for the individual to know and believe that their views will be taken on board and their choices and decisions respected, and for this to be explicitly communicated, not only in written literature about the service but in person by mental health professionals. This will help to bring about self-efficacy or the belief that one has the ability to influence the services provided for them.
Where mental capacity is lacking, reference should be made to the Mental Capacity Act [23] which protects the rights of people with mental illness. In this instance, appointment of and support from an independent mental capacity advocate might be helpful and appropriate.
The second dimension of empowerment is the organisational/ professional level. This specifically relates to the way that organisations and professionals treat the person with mental illness. Here, empowerment relates to the extent to which care professionals are willing to support service users to empower themselves. It includes their readiness to communicate with and consult with individuals and how empowering their attitudes and behaviours are. It may involve professionals examining and perhaps revising their practices; considering whether these are demeaning, whether they reinforce traditional stereotypes, and if they help to sustain patterns of inequality and power.
The Social Model of Disability suggests that problems arise from society's restrictive attitudes about mental illness, and from the way that other people perceive people with mental health problems. These prejudices which are not always conscious make it extremely difficult for individuals with mental illness to assert their rights. They include beliefs that people with mental illness lack competence and are not in the best position to make their own choices and decisions, which can leave individual service users feeling very disempowered.
Mental health care professionals need to be willing to collaborate and work in partnership with mental health service users and put aside beliefs that the professional knows best [24]. It is important that professionals move away from seeing the person with mental illness solely in terms of their illness and deficits and are willing and able to embrace their expertise and assets [25]. Listening to and taking on board the comments, views and wishes of individuals with mental illness are extremely important. This is not only essential in order for the person to have influence and control over what is happening to them, but to establish the correct diagnosis and a treatment plan which meets their needs, and with which they are happy to co-operate with. It goes without saying that imposing a treatment plan on someone can be counter-productive. It may not beneficial for the individual and they may not be willing to adhere it. Ultimately, failing to listen to the individual may lead to incorrect diagnosis and an inappropriate care plan.
It is important to encourage active involvement of the person with mental illness at all stages of contact, from consultation, through to diagnosis, treatment, and after care. Checking in regularly with the individual for their views and feelings about different issues is appropriate. It is helpful to explain the options available, so that service users can make their own informed choices. Again, a willingness to work in partnership with the individual is essential, as is a willingness to respect the choices and decisions of service users [26].
An issue which may arise and cause a dilemma for mental health professionals is a conflict between autonomy and safety. It is important to resolve and manage risk effectively, and in a way which maximises rather minimises empowerment of the individual. Sometimes there is a tendency to be overly protective and in the process discourage the person from doing things they wish to do. It is important to try to find ways for individuals to fulfil their own goals by providing appropriate support to manage their illness.
People with mental illness should be provided with the information and support they need to understand and effectively self-manage their mental health [27]. The Recovery Model points to the importance of building resilience. This model does not stipulate the need to eliminate the symptoms of mental illness and provide a complete cure, which may or may not be possible, but it is about professionals being able to see past the person's illness and support them to move forward with their lives, achieve their goals and engage in things which are meaningful for them. It may not be possible to control the symptoms of their illness, but the person can still have control over their lives [28].
The third level of the empowerment model is: 'The service-user power level of empowerment.' It refers to service users' actual achievement of desired change, power or control and includes components such as consultation, information, and choice having a voice, autonomy, participation and involvement in decision making, control, influence and power. It is important to note that participation, involvement and decision making needs to extend beyond the care plan to involvement in the management and development of services and policies, which may entail inviting service users to meetings and working groups and supporting userled initiatives. In order to avoid being tokenistic and superficial, empowerment needs to be reinforced at all levels within service systems and it is not satisfactory for service providers to obtain individual or collective feedback from service users and then use their discretion about whether to use it or ignore it. This could be very disempowering. In some instances there may be a need for organisational change, i.e., changes in the decision making processes within services; in the relationships between service providers and service users; in service planning and monitoring; and in the recruitment and training of staff. considers the structured patterns of prejudice within society or more specifically mental health organisations. It involves challenging the existence of these divisions which disempower groups of people, such as those with mental illness, by allocating them low status and power. It relates to the achievement of social inclusion, equality of opportunity and equal rights and involves social and political changes and freedom from discrimination in the wider society. Components of this dimension include equality in relation to life opportunities and quality of care. At this level, there is a need to ensure that existing national and in-house legislation and policies which highlight the importance of service user empowerment, choice and involvement in decision making are implemented within mental health services. Unfortunately although these exist, they do not always change people's behaviour.
In conclusion, the article has summarised ways in which mental health professionals and organisations can empower service users, with reference to a four-tier framework of empowerment. Although progress has been made over the last few decades, there is still a need for more work in this area, in order to develop positive and empowering attitudes and behaviours towards people with mental illness.