Learning Objectives
By the end of this section, you will be able to:
- Identify circumstances where client representation is required for clients with a mental health problem
- Describe the issues relating to a client who has diminished responsibility
- Outline ways to encourage the empowerment for clients with a mental health problem
- Identify situations when the empowerment approach would be used in providing care to a client with a mental health problem
Client representation entails that the mental health nurse put aside their own bias and provide culturally sensitive care to each client. Effective client representation means increasing the comfort of the client, protecting their rights, and including the client and family in the assessment and creation of a plan of care. Clients may enter mental health services through a variety of situations, including the justice system. Nurses and other mental health professionals work to create a feeling of empowerment through various avenues and protections.
Client Representation
In legal terms, client representation means to consult with the client regarding the client’s objectives, how the client wants to proceed, and then take the action approved by the client (American Bar Association, 2024). Mental health nurses can participate in this role. Nurses are empowered by self-awareness, which can transfer to advocacy. Mental health nurses who speak as representatives for their clients are called to take every opportunity to understand the lived experience of those in their care.
When the client enters the care environment following an interruption in their equilibrium, it is important for them to be treated with respect and appropriate decisions made regarding their treatment plan. Sometimes, significant others may be available to express the concerns of a client who is unable to express their own needs and assist with establishing an acceptable plan of care. Other times, health-care facilities have recognized the need for client representatives to serve as a liaison between clients and family members and health-care workers, advocating for the rights of the client.
The Criminal Justice System
Studies indicate that 18 percent of the general U.S. population lives with mental illness and that approximately 37 percent to 44 percent of those in jails or prisons have mental illness. The Substance Abuse and Mental Health Services Administration (SAMHSA, 2022) describes an overrepresentation of individuals with mental health conditions in the criminal justice system. In an effort to divert these clients, Mental Health America (MHA) has suggested that timely and accurate screening and evaluation can successfully result in the placement of individuals with mental health concerns in the appropriate care setting, avoiding falling into the criminal justice system (MHA, 2023). Another suggestion includes allowing access to a mental health professional for those who do find themselves in the criminal justice system, leading to appropriate assessment and treatment for adults and adolescents.
Link to Learning
Watch this video The Portrayal of Mental Illness in the Media while thinking about the various views of mental illness portrayed in media.
The Americans with Disabilities Act
It is important for nurses to understand that mental health issues can be considered disabilities under federal law. The Americans with Disabilities Act (ADA) is the civil rights law ensuring that persons with disabilities receive protections from discrimination with respect to employment, public services and accommodations, transportation, and other aspects of daily living. Physical and mental diagnoses that limit participation in activities of daily living (ADL) are considered to be disabilities under this law. Such disabilities include impairments or limitations in basic activities like eating, sleeping, physical movement, thinking, concentrating, communicating, and emotional or thought regulation, especially as these impact public social and workplace interactions (ADA National Network, 2018; Spriggle, 2017). It is also important to note that mental health challenges can exacerbate physical disabilities that individuals may have.
Diminished Responsibility
Reduced liability for a criminal act on the part of a defendant who has been proven to have certain alterations in thought processes is called diminished responsibility (Johnston, 2024). It provides a mitigating defense when the mental health disease is not severe enough to excuse criminal responsibility completely. In certain circumstances, the diminished responsibility defense replaces, and is a lesser version, of an insanity plea; the individual often will receive a sentence for a lesser crime, for example, manslaughter instead of murder.
Nurses’ Response to Clients with Diminished Responsibility
A court conviction for a lesser charge by reason of diminished responsibility is brought due to finding of the defendant’s inability to comprehend the legal aspects of the situation. Examples of mental health conditions that may support a finding of diminished responsibility include:
- neurodevelopment disorders
- psychotic disorders
- bipolar disorders
- depressive disorders
- trauma and stress-related disorders
- neurocognitive disorders (Missouri State Public Defender, 2016)
Nursing care for clients with these diagnoses requires interventions to address alterations in thought processes and sensory perception, such as presenting reality, safely confronting delusions, and monitoring mood and risk for harmful behaviors. Medications and collaborative care will be essential for these clients. In addition, communication and coping skills will be included in client and family education.
Nonjudgmental care is a professional standard even when a client has been accused or convicted of a crime. Hammarström et al. (2019) found that nurses’ identity as caring professionals was challenged in these situations. Nurses reported feeling frustrated, while also wanting to be open to the client’s experience and condition. These researchers suggest that nurses utilize strategies of reflection and basic self-care, look at their roles realistically, and strive for ethical practice (Hammarström et al., 2019).
Lehrer (2021) addressed the problem from a trauma-informed care perspective and acknowledged that a compassionate connection is necessary in the therapeutic relationship. Lehrer calls for nursing competence in communication, assessment, and a commitment to the human right of unbiased health care.
Empowerment
Empowered individuals are able to mobilize existing resources to accomplish goals. The World Health Organization (WHO, 2024) calls for the empowerment of communities, which means assisting people to take action toward improving their own health. This action requires development of personal skills for members of these communities through health promotion education (WHO, 2024).
Individuals can learn to take control of their lives and make decisions that affect their well-being. In other words, nurses can help clients to become more empowered. Assisting mental health clients to gain self-confidence, self-esteem, and self-awareness can result in clients experiencing empowerment in different areas of life, such as career, finances, health, and relationships. With empowerment, clients enhance communication, build trust, and maintain boundaries, which can improve relationships.
Empowerment in Mental Health Care
According to the Directorate-General for Health & Consumers (2010) of the World Health Organization, “Empowerment is not a destination, but a journey” (p. 1). Empowerment involves people learning to adopt self-reliance, participating in decisions, possessing dignity and respect for others, feeling a sense of belonging, and contributing to a wider community. Self-determination and autonomy are included in this process.
Link to Learning
Review this document from the World Health Organization titled User Empowerment in Mental Health to better understand worldwide efforts to empower the caregivers in mental health as well as the recipients of mental health care. This document addresses perspectives and taking action at societal, service, education, and individual levels.
Differentiating Between Empowerment and Enablement
It is important to recognize the difference between empowerment and enablement in efforts to assist clients. Empowering someone helps them change their behavior on their own. Nurses can empower clients by guiding them to resources and teaching them life skills. Empowerment will give them the power to make and live with their own choices (BRC Healthcare, 2021). When a person attempts to make life easier for an individual that leads to negative consequences, it is called enablement. Enabling someone reinforces negative behaviors. Some examples of enabling are ignoring or tolerating negative behaviors, providing excessive monetary assistance, covering or making excuses, doing work for them, denying there is a problem, and failing to follow through with established consequences. When nurses empower in place of enable, they give mental health clients the ability to confidently assess their options, make choices that align with their values, and live by their choices.
Link to Learning
Read the article Are you empowering or enabling? to understand the differences between empowering and enabling and to more effectively help mental health clients.
The Empowerment Approach in Mental Health Care
The overall process of empowering clients in mental health care entails the following: helping to restore hope and respect, enabling clients to reclaim their life, helping them to feel connected, recognizing and helping them recognize their rights, following client preferences for learning skills, moving from secrecy to transparency, and assisting with self-initiated growth and change.
Dimensions of Empowerment
Empowerment is the process of taking control and responsibility for one’s own actions. Four dimensions identified in this process include:
- self-reliance
- participation in decisions
- dignity and respect
- belonging and contributing to a wider community (Directorate-General for Health & Consumers, 2010)
Many clients experience powerlessness; the process of empowerment can assist them in gaining control of their life, resulting in increased self-esteem (Directorate-General for Health & Consumers, 2010). Learning to trust in one’s ability to take care of self and collaborating with supportive others creates an environment wherein clients’ well-being is protected and enhanced.
Empowerment and Relationships
Nursing practice is relationship-based. The nurse-client relationship is based upon shared decision-making, empathy, and effective communication. Molina-Mula and Gallo-Estrada (2020) state that nurses should strive to preserve the client’s values in health care and respect the client’s experience. This is the meaning of person-centered care, which promotes client autonomy (Molina-Mula and Gallo-Estrada, 2020). Empowerment helps clients experience strong, healthy relationships in their personal lives. With empowerment, individuals have more confidence and are more able to build trusting relationships. Empowerment promotes stability in relationships and enhances problem-solving skills due to the individual’s comfort in representing their own interests.