Quest for client autonomy in improving long‐term mental health care

Abstract

The objective of the present study was to explore how mental health-care professionals initiate, improve, and maintain client autonomy while improving other aspects of quality of care. We studied the different ways in which they approach autonomy and the dilemmas associated with them. As a methodology, we used the insights of actor-network theory, where concepts cannot be predefined, but are formed within specific situations, and therefore, should be studied by addressing the actors involved. Data were gathered by conducting ethnographic observations of national conferences of a quality-improvement collaborative and by interviewing actors involved in the improvement practices. In a bottom-up analysis, four approaches to autonomy emerged: (i) professionals removed constraints to autonomy and passed initiative to clients; (ii) professionals made an active effort to learn and support client preferences; (iii) clients were given opportunities towards independent lifestyles; and (iv) professionals tried to 'normalize' their relationship with clients to encourage roles other than those of client. The study showed that autonomy is an important issue throughout the process of quality improvement. Articulating the different approaches to autonomy and the dilemmas in these approaches contributed to reflection on the concept and highlighted the limits of the concept within a mental health-care setting.

Determinants of the quality of care relationships in long-term care - a systematic review

“…The studies described encouragement as a determinant of the care relationship [ 5 , 8 , 9 , 14 , 17 , 21 , 26 , 27 , 29 – 34 , 36 ]. Encouraging care professionals underline the capabilities of a client, not their disabilities [ 32 ]. Especially when clients have a negative self-image or have received negative feedback from people in their environment, instilling hope, being a positive force and promoting independence were described as important [ 5 ].…”

“…Especially when clients have a negative self-image or have received negative feedback from people in their environment, instilling hope, being a positive force and promoting independence were described as important [ 5 ]. Encouragement also involves care professionals being positive and optimistic in contacts with clients [ 29 , 31 , 32 , 36 ]. Clients were encouraged by care professionals to explore their possibilities and make a contribution to the environment and others, for example helping the wellbeing of other clients [ 14 , 17 , 32 ].…”

Mutual powerlessness in client participation practices in mental health care

“…Members of the ‘Recovery‐oriented care’ project explicitly said that the strategy of clients approaching other clients was chosen partly to escape exerting power. Professionals wanted their clients to recover but did not want to take the lead 46 . As the recovery movement itself is initiated by (former) clients, the role of professionals in such a recovery framework is often unclear and debatable.…”

Governing Mental Health Care: How Power Is Exerted in and Through a Quality Improvement Collaborative

“…The desirability of this effect was sometimes discussed because it could also lead to clients failing repeatedly. Furthermore, some clients did not adopt autonomous behaviours, like those who held on to being dependent or those who claimed to have no wishes at all (Broer et al 2010b).…”

“…The analysis for this article is based in part on the results of other articles within the mental health care projects of CfB (Broer et al 2010a(Broer et al , 2010b(Broer et al , 2011.…”