Original Article: Empowerment

Empowerment: A Three- session Intervention David Goldberg & Frances Campbell

During organisational uncertainty a child guidance clinic developed a three-session intervention based on the concept o f 'empowerment', A link is made between clinical practice and political philosophy, and consequences for clients and organisations are described.

Keywords: Empowerment; child mental health; power

introduction

Over the last 15 years radical changes in British society have influenced both the context and delivery of child mental health services (Parry-Jones. 1994). There is increasing disparity of resources between the rich and the poor (Rowntree Foundation, 1994) while political phil- osophy has focused on individual responsibilit) at the expense of social communality (Elston, 1991 ; Rose, 1992). Clients and professionals share the predicament of more responsibility but greater material and ideological restric- tions. At the centre of this conflict is the concept of individual responsibility : each person being responsible for determining his or her own future with a right to be considered as a free-acting individual. Self-determination leads to active citizenship and. by implication. to full mental health. This political concept is compatible with many psychological theories (e.g. cognitive-behaviour and systemic therapies). which assume that the more a person feels in control of his or her own feelings. beliefs and actions. the greater is their mental well-being. Thus, the more a person takes responsibility for his or her own future the more likely he or she will be healthy. The corollary is that the more the professional hands over responsibility to the client. the more likely that health is forthcoming. This issue can be encapsulated in the term 'empowerment'. the use of which suggests that power can pass from professional to client. to the latter's benefit.

The setting

Battersea Child Guidance Clinic is a multidisciplinary team including child psychotherapists. psychiatrists. social workers and a therapeutic teacher. The prevailing ortho- doxy over many years had been psychoanalytically based. Mith varying interests in family and cognitive- behavioural therapies. Since the demise of the inner London Education Authority in 1990, the management system had become increasingly complex and overlapped

with other local mental health services. The staff a t the three Child Guidance Clinics in the borough felt criticised for being inaccessible (with long waiting lists) and for being preoccupied with long-term work to the exclusion of other types of work. An impending borough-wide review and reorganisation led to a need to demonstrate efficiency.

Three-session intervention

The three-session intervention was based on this concept of 'empowerment': that the more clients feel in control of their situation, the better their mental health. They may take power by doing what they think is best, i.e. using solutions that they think may work. These solutions, or use of power, are more likely to be effective if they know the limits of legitimate power, gain legitimisation or authorisation from those seen as more powerful than themselves, and do not attempt to influence that over which they have no power.

The following structure was devised :

1. Clients were phoned or sent individualised letters. We aimed to stress friendliness, state what we knew about the referral, discuss the aim of the meeting and ask the clients to invite whoever (including any professional) they felt could help them find a way forward. We tried to speak to referrers beforehand but would not speak to any other professional without a discussion with the client.

2. Three sessions were offered for the clients to work out the best way forward. No elaborate explanations were given. We implied, but unless asked did not say explicitly, that further child guidance involvement would be offered if appropriate. As much as possible of the structure of the meeting was determined by the client, including the length of the session and the timing of the second and third meetings. (For instance, one set of parents decided to keep

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Original Article : Empowerment

the last two sessions in the ‘ bank’ to use when they needed them.)

3. The focus of the meeting was on what the parents and children believed was the best way forward. They were asked to generate options for the future and to debate the ‘pros and cons’ of each. Solutions were questioned but all solutions were taken seriously, however apparently ludicrous. The clients were asked to think about the consequences of any solution. Who was responsible for which part of the solutions was discussed. This prompted clients to examine the limits to their power; professionals the limits of their interventions; and both the role and responsibilities of other professionals.

4. Two professionals from different disciplines met the clients. The lead professional (i.e. the person taking responsibility for the work) introduced the session and structured it. The other adviser stressed the differences in his or her view and tended to ask questions or add information that generated or legitimised the solution chosen by the clients, e.g. he or she sometimes questioned the expert advice suggested by the first therapist. Dis- cussion of the difference in view between the two therapists was found to stimulate discussion by the clients of the alternatives open to them.

5. At the end of the session the solutions desired by the clients were written down and distributed to the referrer and others in the network. Often a letter was written to enforce the conclusion.

Questioning was used to stimulate the generation of the client’s solutions, inspired by:

1. Solution-focused therapy, focusing on such ques- tions as ‘How would you know that you had found the solution?’ and ‘What is the first step towards the solution?’ (de Shazer, 1985).

2. Brief motivation interviewing. This has been de- veloped in work with people who are alcohol-dependant. The method aims to help patients articulate for themselves the reasons for concerns and the arguments for change. Different sets of strategies (menus of questioning) are used, depending on the person’s readiness to change (Rollnick, Heather & Bell, 1992).

3. Interventive interviewing. Questions are designed to test hypotheses about the client’s view of change (Tomm, 1987).

4. Cognitive-behavioural strategies. Fundamental principles are followed such as the use of realistic targets and debating and testing maladaptive thinking. Many of the solutions suggested by clients can be considered in this framework, e.g. self-instruction training, etc. (e.g. Trower, Casey & Dryden, 1988).

We found it was helpful to make a clear distinction

between our personal and our professional views. Wel- coming the clients was as informal as possible. This was in marked contrast to the introductions, which were for- malised. Introductions included job title, professional role and task as well as details of any connections with outside agencies. This allowed the professionals to ask questions from two viewpoints and state two opinions: the personal and the professional (Haber, 1994; Real, 1990). This encouraged the clients to follow their own solution while welcoming a debate with the therapists as experts. As a professional, the therapist could introduce information about the service or about children’s problems in general. Furthermore, the therapist may want to ask questions and comment on the interactions in the room. There may be a sense of negotiations taking place between equals rather than instructions being issued.

Clarification of who has the authority to do what, with whom is stressed from the start. Expression of areas of hopelessness may enable clients to focus on areas in which they and others have authority (Bennett & Bennett, 1983). Throughout the session, the two therapists may use hypotheses that link the power relationships to the presenting problem or solution (Haley, 1976). An attempt was made to follow a simple rule: just as parents are responsible for their children, the parents should control negotiations with other professionals. Therefore no offer was made to speak to other professionals except if authorised by the clients.

Conflicting views of the way forward presented in two ways: when parents disagreed and when the therapist’s view of what the child was saying conflicted with the parent’s views. In the first instance, the child was excluded and the professionals explored the dilemma of which parent does what, exploring the difference until a hint of resolution was noted. In the second circumstance, the therapist articulated the child’s view in a debate with the parent. The lead therapist claimed to speak for the child while the other took the parent’s view, thus articulating the two sides of the dilemma.

Theconsequences

Over a period of 11 months there were 20 referrals. Four families did not attend their first appointment, comparable to the clinic ‘drop out’ rate of 18%. The age range of the children was from 4 to 14 years, with a gender ratio of 14: 6 boys : girls, again similar to the clinic referral popu- lation. Self-referrals were preferred in the first 3 months of the study but later there were no specific selection criteria. Five clients were seen once, three twice, three on three and five on four or more occasions. Despite the initial intention of limiting the number of meetings to three, a quarter of cases had longer contact. In each instance, a joint task had been negotiated so that an end to contact was assumed. The first interview lasted until acceptable solutions became evident, usually between one and a half hours and two hours. Subsequent meetings were timed to last no longer than one hour.

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Original Article : Empowerment

The spontaneously expressed views of the clients at the closure of contact varied widely: six found the meetings prompted change. two others found the meetings helpful and three said they \+ere not helped. In the remaining cases the response was less clear. although three appeared to appreciate the involvement of the clinic. On follow-up, three families. whose members had expressed a range of responses to our intervention. were being seen by other services within our agency.

Many of the initial meetings tended to follow a similar pattern. Clients appeared relieved by the idea that they had been offered a limited number of sessions. This was against the prediction that clients would feel deprived of an open-ended senice. As we asked questions about what they thought \+as the best way forward. there was often increasing anxiet) in the room. which was felt by the professional asking most questions. At the start many of the clients said they did not know what to do. As the discussion evolved there vvas usually a rush of suggestions associated with increasing excitement. Clients usually left the first session expressing a mixture of anxiety about putting their suggestions into practice and pride. The therapists were often left feeling more connected with their clients than usual but concerned that they might have missed clinically important material. What happened in the second and third session was not predictable from the first session.

The feedback from clients. referrers and managers varied :

I . Cliildren and [heir parents were often wary at first but became increasingly enthusiastic. This obserbation is similar to Wheeler’s (1995) description of the intro- duction of solution-focus therapy in a child mental health setting. Clients appear to welcome validation of their view of the world. enjoy the sessions and thank us to an embarrassing extent. Many find original solutions which. to our surprise. work. For example, the woman who mobilised seven agencies as her child was not sleeping. said that she had decided the way forward for herself. She chose to begin with a brief temper tantrum herself, which silenced her child. and then began a simple programme in which she left the bedroom in a slow step-wise fashion. This strategy had worked so well that at the next meeting she and her daughter looked rested and played spon- taneously.

2. As [lierupists we were concerned that we were not acting in our usual professional role : no formal psjchiatric formulation or social assessment was made. We did not ask questions unless immediately relevant to the solutions suggested by clients. Clients frequently revealed a huge amount when. instead of directly questioning them. we asked general questions such as ‘I wonder why that is so?’ When alerted to a significant psychiatric disorder (e.g. the management of which was beyond the capabilities of the adults) u e reverted to conventional professional roles. If any clients had sought such an assessment as part of their solution we would have discussed it further. However. a

risk remained that specific psychiatric and social path- ology was overlooked because of the absence of systematic enquiry.

3. District social service colleagues. Concern had been expressed that we would not speak to the social worker of a client until after speaking to the client in person. One case highlighted unresolved issues. A mother referred herself for help for her 10-year-old child, who described how he was upset by the arguments between his divorced parents, who both demanded custody. The boy’s name was on the Child Protection Register after investigation following the father reporting that the mother had hit the boy. The mother saw the way forward as independent professionals talking with the boy. The boy wanted the judge to decide as soon as possible about where he should live and future access arrangements. Furthermore, he did not want to discuss his problem with anybody as he had experience of his statements being used by professionals to decide his fate. He wanted his parents not to involve him in their arguments. One of the therapists put this view to the mother, who accepted it. The therapist stated that this view should be put to all the adults.

The social worker was informed the next day and agreed to the plan. However, after further discussion, the Social Service Department thought this plan was not in the best interests of the child. The proposed meeting was cancelled. This raised the issue of who had what authority over the child or, in this case, could the allocated social worker of a registered child constrain the solution chosen by the parents. Four weeks later there was a request from the Social Service Department for us to follow up on the original plan.

4. School and other non-statutory agencies. The sol- ution followed by the family may not suit other pro- fessionals. One adolescent supported by her mother came up with numerous ideas about how to survive in the classroom without being expelled. One solution was to smile at the teacher who irritated her instead of being ‘lippy’. In order to keep up this smile she would imagine this teacher with a pig’s snout. At the next visit she proudly reported that, when asked by another teacher why she was so much better in class, she had told the teacher of this strategy. She described the teacher as being indignant and calling us a t child guidance ‘infantile’.

Other examples were more serious. In a number of cases, families had attended reluctantly, having been told that they had a problem by an outside agency. One black British 13-year-old was referred by his tutor, who was unfortunately unable to accept the grandmother’s in- vitation to come to our first meeting. The tutor wrote that the boy’s disruptiveness a t school was related to his poor relationship with his grandmother and grief over his mother’s death. At the meeting the warm relationship between the grandmother and the boy was evident. We discussed the boy’s difficulty a t school, the inter-genera- tional conflicts and loyalties in light of the family’s

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0ri.qinal Article : Empowerment

migration, and the death of the mother. The grandmother wanted to find out more from the school. We offered to meet them again, this time maybe at the school, if and when the grandmother thought we could be of assistance. A few days later the tutor telephoned, concerned that we had not taken the problem seriously. (In our usual practice in such cases we would have arranged the first or second meeting at the school using professional power to decide the way forward rather than support the grandmother directly in her solution.)

5. Child mental health services. The management within health and social services expressed interest in both the philosophy and ‘package’ to meet the growing waiting list. Cost effectiveness was limited by the amount of professional time; two professionals were thought to be needed to stimulate debate rather than instruction. (Ad- ministratively, the three-session invention may cause problems as the presenting clinical problem is not clarified and may not be recorded accurately.)

Conclusion

This paper was written not to advocate a specific approach to treatment, but to stimulate discussion about how clinical practice is, and should be, adapted to the changing social and political environment (Rose, 1985). We suggest that recognition of the prevalent political philosophy as it influences clinical practice can help therapists in meeting the needs of clients who are constrained by the same philosophy.

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