empowerment in mental health practice: behavioural means … · empowerment in mental health...

EMPOWERMENT IN MENTAL HEALTH

PRACTICE: Behavioural Means of

Client Empowerment

By: Courtney Brennan

April 2011

2 C. BRENNAN - EMPOWERMENT

LEADERSHIP in MENTAL HEALTH OT COMPENDIUM

Health professionals are powerful. Each carries with them a power exercised unconsciously

over others as a result of their designation, their knowledge-base, and their status. But in addition to

this contextual power, individuals in dominant positions have a tendency to display certain

dominance behaviours through their nonverbal communication, though the relationship between

these behaviours and dominance is unclear (Knapp & Hall, 2002). What’s interesting is how these

dominance behaviours can affect the behaviour of others. For example, B.F. Skinner and Erich

Fromm once attended a symposium together, where Skinner found himself in a disagreement with

Fromm and opted to use his behavioural theories to make his point:

On a scrap of paper I wrote ‘Watch Fromm’s left hand. I am going to shape a chopping

motion’ and passed it down the table to [Halleck Hoffman]. Fromm was sitting directly across

from the table and speaking mainly to me. I turned my chair slightly so that I could see him

out of the corner of my eye. He gesticulated a great deal as he talked, and whenever his left

hand came up, I looked straight at him. If he brought the hand down, I nodded and smiled.

Within five minutes he was chopping the air so vigorously that his wristwatch kept slipping

out over his hand. William Lederer had seen my note, and he whispered to Halleck. The note

came back with an addendum: ‘Let’s see you extinguish it.’ I stopped looking directly across

the table, but the chopping went on for a long time. (Skinner, 1983, pp. 54)

This quote from Skinner readily demonstrates the concept of pervasively influencing the

behaviour of others through dominance behaviours and positive reinforcement. This demonstration

raises questions on how individuals in positions of power can exert that power non-verbally over

others, and this can potentially influence the actions of others.

Powerlessness is a result of another individual exercising power-over another individual and

presents as alienation, disenfranchisement from resources, rights, and privileges, and potentially

learned helplessness (Clark & Krupa, 2000). Because health professionals take a powerful



leadership role in mental health practice, mental health clients may be especially vulnerable to the

effects of the power imbalance created by that role, compounded by the awareness of the

designation of ‘health professional’, altering their behaviour and increasing their sense of

powerlessness. However this powerlessness is the antithesis of the goal of current mental health

practice, a field attempting to embody the idea of empowerment, the increase of the holistic strength

of individuals and communities through developing confidence in one’s capacities (Townsend,

2000). However the actual practice of empowerment in mental health is often met with tension and

undermined by organizational process and objectification of the client. In order to challenge the

routine organization of power within mental health practice, Townsend (1998) recommends that

“With awareness of their participating in ruling institutions, professionals might reduce their

dominance and become translators, transmitters, facilitators, and activists who work with and on

behalf of the people they want to help.” This quote calls for action on the part of professionals to

take responsibility over their own dominance and demonstrate an individualized commitment to the

empowerment philosophy they are attempting to embody. As such, this paper will examine concrete

changes in objective behaviours professionals can analyze and adjust accordingly to increase their

client’s sense of empowerment during therapist-client discussions.

When looking objectively at human interaction, an examination from the behavioural frame of

reference is necessary. The behavioural frame of reference looks at how behaviours are formed by

observable environmental responses and the use of reinforcement and punishment to influence

behaviours in terms of intensity, duration, and frequency (Firor et al., 2009). This perspective

emphasizes an individual’s behaviours as they are objectively observable and can be manipulated

directly, facilitating research and objective assessments and outcomes. Clinician behaviour during

client interactions is an important area of practice health professionals have direct control over and

can improve and adjust with self-awareness and reflection. In taking this perspective, I hope to



examine how to adjust objective clinician behaviours to influence the behaviour of clients to enable

empowerment.

An understanding of occupation is key to this topic as occupational therapy presents as a unique

health profession, as it often resembles and is based on empowerment education, and occupational

therapists may enable empowerment by helping people to feel more powerful and to act with greater

power in everything from self-care to work hardening programmes, or through guidance in

occupations such as meeting attendance, public speaking, film making, or advocating for change in

disability benefits (Townsend, 2000). As such, occupational therapists working in mental health

settings are well positioned to be leaders in the empowerment of their clients, and should take it

upon themselves to meet this challenge.

For my paper I intend to investigate tangible and concrete methods of increasing a client’s sense

of empowerment. As such, this topic will fit well with the compendium’s chapter on Considering

Power and Empowerment. My objective is to investigate the various non-verbal behaviours implying

dominance and power, as well as avoidance and dependence. This will be obtained through a review

of non-verbal communication literature. Following this investigation, my second objective is to

examine how these behaviours can be applied in clinical practice to influence behaviour, namely by

decreasing dominance behaviours in clinicians to foster empowerment in clients.

Many self-help books praise the endless power of exhibiting dominant behaviours in persuasion,

conflict management, and debate, however the relationship between nonverbal dominance

behaviours and power status is less clear cut than it is made out to be due to the complexity of the

constructs and alternating use of concepts like dominance, power, and status (Knapp & Hall, 2002).

In personality research, the DISC (Dominance, Influence, Steadiness, & Compliance) model has been

translated into a formal standardized assessment measure of dominance in personality (See

Appendix A; Chapman, 2011). This assessment can be used to provide professionals with a general



understanding of how dominance influences their individual behaviour. In addition to the personality

psychology realm, behavioural psychologists, organizational behaviourists, and evolutionary

psychologists have conducted a great deal of research on human interaction paradigms and

dominance/avoidance behaviours exhibited in social interactions. From this research, there have

been several key behaviours associated with social dominance and power in human interaction, as

shown in Table 1.

Table 1: Common Dominance Behaviours

Voice Speak clearer, louder, and more well-articulated

Touch

Relaxed & expansive postures

Initiating touch

Gaze

Increased gaze is associated with credibility and dominance

High status people are looked at, and look more while talking than listening

Timing Waiting time increases for dominant people

Dominant people talk more and interrupt more

(Knapp & Hall, 2002).

Because lacking power implies increased dependence on others, those who lack power are

especially sensitive to how other people evaluate them and encounter more constraints and

interference (Keltner, Gruenfeld, & Anderson, 2003). This suggests that clients in mental health

settings may be more attuned to dominance behaviours and react more strongly to them.

Additionally, this information demonstrates the need for mental health workers to be educated about

dominance behaviours and how they manifest in everyday interactions, potentially through staff

education sessions (See Appendix B). Mental health clients have been noted to demonstrate

decreased duration of eye contact, increased downward gaze, and lack body language, which may

lead to negative evaluations in daily social interactions and signal a lack of power (Tickle-Degnen &



Rosenthal, 1992). Lacking power means a person not only has less access to resources, material

and otherwise, but also is more subject to social threats and punishments, creating the type of

negative, threatening context that would activate the avoidance system (Smith & Bargh, 2008).

These findings demonstrate that individuals with mental illness are often pathologically powerless in

their actions, and this affects how the world reacts to them, furthering their lack of power. As such, it

is important as clinicians to make strides to return that power to our clients by enabling them to

participate in their care and experience empowerment. Table 2 shows attributes of empowerment as

described by mental health services consumers, outlining key actions that give them a sense of

empowerment.

Table 2

(Rogers, Chamberlin, Langer Ellison, & Crean, 1997)

When looking for potential applications of nonverbal communication to the concept of

empowerment, there was no direct research to establish this connection. The book Empowerment

Overruled by Elizabeth Townsend (1998) provided some guidance in terms of how empowerment



should manifest through collaborative decision making, facilitated risk taking, and empowerment

education, and highlighted the importance of reducing dominance of the clinician, but had no

mention of directly observable dominance behaviours. As such, by comparing and categorizing

nonverbal behaviours as facilitating different components of consumer-identified attributes

empowerment, I identified a few potential categories of concrete means of potentially fulfilling

empowerment: Decrease Objectification, Reduce Exclusivity, Monitor Dominance, and Reinforce

Power Use (See Appendix C).

In terms of decreasing objectification, the institutional processes of assessment, diagnosis, and

medication largely objectify the individual as a broken item requiring repair. The individual is lost in

these processes as they are labelled and shuffled around between professionals. A concrete means

of avoiding this pitfall includes using person-first language and referring to the consumers of the

mental health system as Clients, Members, Consumers, or Residents to decrease the client’s

potential sense of objectification (Townsend, 1998). Additionally, inviting participation to involve

client in collaborative decision-making & practicing in a client-centred manner helps to empower the

individual as a director of their own care and remind them of their rights as a person.

Reducing the exclusiveness afforded to professionals by access to knowledge and resources

enables clients to further direct their care. By sharing privileges, eating areas, washrooms, library

materials, educational opportunities, and chores, implicit dominance relayed by context and position

is decreased by an equalization of physical forms of power. Additional resources can also be

provided to equalize interactions further, for example providing clients with a notebook to make their

own notes while you make documentation notes enable them to keep track of the decisions made

during sessions and equalizes visually manifested power imbalances.

The theme of monitoring clinician dominance behaviours also became apparent through the

literature, looking at ways to increase the client’s positive self-image and reduce stigma by acting



towards them in a way that is not overbearing and powerful, but instead as equals. Avoiding

inequality in seating and positioning may play a role in this realm through ensuring the clinician

doesn’t stand over the seated client or positions themselves in a higher plan or in a seat of

prominence, such as that at the head of a table. By enabling the client to take a position of power,

this may have affects on their behaviour in terms of increasing assertiveness. Additionally, Knapp

and Hall (2002) spoke to the importance of avoid dominant timing patterns, in terms of making a

client wait for your presence. Being waited for signals power and dominance, as well as disrespect

and unimportance of the client’s issues, so practicing punctuality may prevent the client from

sensing the clinician as being powerful over them and additionally like their issues are not worth the

clinicians time. Furthermore, in conversation, avoiding interrupting and allowing silence for the client

to interject is key to the empowerment process, as interrupting and dominating conversation are very

dominant behaviours. Providing clients with the time to express their opinions and ideas without

being interrupted enables them to participate more fully in their decision making and may help them

to come out of their shell and open up.

Finally, reinforcing the client’s use of powerful behaviours through nonverbal communication

may be a key means of objective empowerment. This can be done through displaying positive

feedback cues in response to client demonstrating empowerment, or dominant behaviours. These

positive feedback behaviours may include smiling, nodding, providing eye contact, as well as verbal

cues to alert the client to their use of these behaviours, and how they help to improve

communication skills as well as portrayed competence, a reoccurring theme in the consumer-

identified empowerment attributes. Additionally, the clinician must monitor their use of negative

feedback cues in response to client behaviours, avoiding forceful gestures, standing over the client,

and making unconscious negative facial displays (ex., frowns) in response to the client seeking

empowerment opportunities and demonstrating dominance behaviours, as this may undermine the



empowerment the client feels and reverse progress that has been made. Furthermore, sharing

knowledge with the client of these tactics may play a role in their empowerment education, as

dominance behaviours the clinician utilizes may be incorporated into the client’s behavioural

repertoire with facilitated reflection.

While these categories of objective empowerment are not directly based in research, there

have been studies to demonstrate the nonverbal benefits of control. Research has found that

participants assigned control over resources expressed their true attitudes, experienced more

positive and less negative emotion, were more likely to perceive rewards (ex. that their partner liked

them), and were less likely to perceive threats (ex. that their partner felt anger toward them)

(Anderson & Berdahl, 2002). Most of these effects were mediated by the sense of power, suggesting

that subjective feelings of power are an important component in the effects of power. That is,

through empowerment clients would be better situated to participate actively in therapy processes.

By incorporating these behavioural changes and organizational adjustments, there is the potential

for greater empowerment among clients, and as such, greater participation in the therapy process.

Further research is necessary to determine the explicit effects of these empowerment strategies;

however the benefit of the strategies suggested is that, due to their non-verbal nature, they are

neither time nor resource intensive and merely require greater reflection on the part of the clinician

regarding their behaviour and whether they are truly ‘talking the talk and walking the walk’ of client

empowerment.

A key component of acting as a change agent is the ability to monitor and modify one’s

progress to assess change and outcome in this area or based on experience. Rogers, Chamberlin,

Langer Ellison, & Crean (1997) have psychometrically tested the Empowerment Scale (see Appendix

D) for use with consumers, which analyzes attributes such as having access to

information/resources, having a range of options to make choices, learning skills, increasing positive



self-image, and changing other’s perceptions of competency on a 4 point Likert-scale ranging from

strongly disagree to strongly agree . Utilizing a measure of empowerment such as this one will inform

clinicians as to whether their clients feel empowered, and whether they need to adjust and modify

their practice to improve this state. Utilizing an assessment tool such as this one enables clinicians

to quantify their empowerment practices and gain objective data on the changes in client

empowerment they are potentially fostering.

In summary, it is important for clinicians to realize that mental health clients are pathologically

disempowered and this is reflected in their demeanour and non-verbal communication. Additionally,

as professionals placed in dominant positions with a specialization in enabling occupation,

occupational therapists hold a unique position to lead a paradigm shift of empowerment within

mental health contexts. Though clinicians have the best intentions for client empowerment,

organizational constraints often limit the actions of those with the best intentions and create

unbalanced power dynamics preventing client empowerment. As such, the onus of empowerment is

on us as clinicians to take necessary measures to offset these unbalanced power dynamics and

empower clients through our own behaviour. It is not enough to merely intend on empowering

clients, but it is necessary to literally ‘walk the walk’ of empowerment by making conscious

behavioural adjustments to foster the best intentions of clinicians, while reinforcing the behavioural

changes of our clients that are leading them to be more assertive, appear more competent, and feel

able to make a difference in their own lives.

Reflecting on the process of this paper, I found I discovered more objective means of

empowerment than I expected, and far more input from the perspective of the client regarding

empowerment than I thought would exist. I initially chose this topic because I find I personally often

manifest a number of dominant behaviours in my own social interactions, and as someone of

imposing stature, tend to be viewed as dominant in interactions even if I make an attempt not to be.



I wanted to explore this area of practice because I realize the importance of empowerment in mental

health settings and I wanted to find concrete measures I could take to downplay my own nonverbal

dominance and encourage the empowerment of the client. Initially as I approached this paper I

assumed I would be looking at means of directly altering my own nonverbal behaviours, but as I

researched nonverbal communication I realized that what was more important was empowering the

client to demonstrate dominance behaviours of their own through positive reinforcement of their

nonverbal behaviours. As opposed to adjusting my own non-verbal dominance practices being the

focus, I had to modify my plan to additionally include a reinforcement component for the client’s

empowered behaviours, which I was not expecting. I feel that putting the tips I established into

practice would require a great deal of conscious cognition over my own behaviour, which is not an

area I’m strong in, but I feel that the process of writing up this paper and having to find all of the

ways myself will benefit my future practice greatly and enable me to lead others in the field of mental

health to empower their clients through their actions as well as their words.



References

Anderson, C. & Berdahl, J. L. (2002). The experience of power: Examining the effects of power on

approach and inhibition tendencies. Journal of Personality and Social Psychology, 83(6), 1362-

1377. doi: 10.1037/0022-3514.83.6.1362

Chapman, A. (2011). DISC: DISC basic personality types model. Retrieved from

http://www.businessballs.com/personalitystylesmodels.htm#DISC personality systems

Clark, C. C. & Krupa, T. (2002). Reflections on empowerment in community mental health: Giving

shape to an elusive idea. Psychiatric Rehabilitation Journal, 25(4), 341-349.

Firor, E., Perras, E., Zimmerman, K., McCarthy, K., & Kronk, P. (2009). Frames of reference used in

occupational therapy. In K. Jacobs & L. Jacobs (Eds.), Quick reference dictionary for

occupational therapy (5th ed.)(pp. 312-314). Thorofare, NJ: SLACK Inc.

Keltner, D., Gruenfeld, D. H., & Anderson, C. (2003). Power, approach, and inhibition. Psychology

Reviews, 110(2). 256-284. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/12747524

Knapp, M. L. & Hall, J. A. (2002). Nonverbal communication in human interaction. (5th edition).

Toronto, ON: Nelson Thomson Learning.

Rogers, E., Chamberlin, J., Langer Ellison, M., & Crean, T. (1997). A consumer-constructed scale to

measure empowerment among users of mental health services. Psychiatric Services 48,

1042-1047.

Skinner, B. F. (1985). A matter of consequence. New York, NY: New York University Press.

http://psycnet.apa.org/doi/10.1037/0022-3514.83.6.1362

http://www.businessballs.com/personalitystylesmodels.htm#DISC personality systems

http://www.ncbi.nlm.nih.gov/pubmed/12747524



Smith, P. K., & Bargh, J. A. (2008). Nonconscious effects of power on basic approach and avoidance

tendencies. Social Cognition, 26(1): 1-24. Retrieved from

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2435045/

Tickle-Degnen, L., & Rosenthal, R. (1992). Nonverbal aspects of therapeutic rapport. In R. S.

Feldman (Ed.). Applications of nonverbal behavioural theories and research. Hillsdale, NJ:

Lawrence Erlbaum Associates Inc.

Townsend, E. (1998). Good intentions overruled: A critique of empowerment in the routine

organization of mental health services. Toronto, ON: University of Toronto Press.

Townsend, E. (2001). Enabling empowerment: Using simulations versus real occupations. Canadian

Journal of Occupational Therapy, 63(2), 114-128.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2435045/



Appendix A

(Chapman, 2011)



Appendix B

(Rogers, Chamberlin, Langer Ellison, & Crean, 1997)

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