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Explore: Power to Empower lies Beyond Binaries


There is a fundamental contradiction at the heart of mental health services between care and control, risk and recovery. On our PROMISE journey we have grappled with our understanding of these binary dilemmas. To help our staff explore these seemingly binary issues we have used a range of techniques. The use of metaphor and images in a story format (Navigating Rocky Waters) has been most rewarding and engaging. Staff have different thinking styles and thus we used a mix of logic and rationality based exploration using facts and figures (quantitative workstream) as well as a feeling and intuition based approach (qualitative research study). We laid out a net as wide as possible to acknowledge and collate differing views, however as our understanding of the issues grew, we created bite size chunks for further detailed exploration. In this brief article we share our evolving insights from the exploration phase that might help organizations who are setting out on this journey. Although the insights are overlapping, there are subtle differences, adequate grasp at various levels, from the end user to the board, will help to reframe these black and white scenarios into shades of grey and ash.


Board briefing



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Frontline insight



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Patient’s journey



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Power to Empower


Power is not a binary position, the contours of the landscape dictate how it ebbs and flows. Power-play occurs in every relationship, whether it be in the one between the board and the frontline of an organization or within the patient professional duo. Leaders often believe that power flows from their positional advantage, but leaders are only powerful if followers follow. When it comes to power related cultural change and changing the nature of day to day interactions at the frontline, leadership have to be aware of the need to role model and live the change they are proposing. Dictating from the top is a futile exercise, as the balance of power lies in the accumulated inertia of what we call culture. The goal has to be to win hearts and minds so the frontline feel empowered to take the initiative and take ownership of the organizational journey.



If such power is invested in the frontline they then will have the influence and attributes to empower patients. Traditionally, in the patient professional relationship, the one with the clinical experience and theoretical knowledge holds all the aces, i.e. the professional. The patient’s experiential knowledge is often undervalued and sometimes disregarded. When power is skewed in this fashion it can result in patients trying to assert themselves in an unhelpful way, as they inherently feel ‘done unto’. These power struggles which often play out in the form of coercive practice stemming from professional concern for the patient, can so easily be avoided by ‘doing with’ rather than ‘doing to’. In order to work together and come to a consensus, professionals need to be able to see things from the patient’s perspective i.e. understand their values and priorities, attitudes to illness and risk. If knowledge gives rise to power, then surely an increase in the available knowledge bank will increase the power to improve outcomes. Since hope, agency and self-belief are such vital ingredients of recovery this approach of combining power is not summative but multiplicative. Unfortunately the cultural inertia in this relationship is such that either the professional unconsciously takes a paternalist role or the patient a subservient one. The opportunities lost from not utilising the combined power that lies in a partnership are immense. There is a strong case for the frontline to redress this balance by transferring the power they have inherited from the top, thus empowering patients to identify their values, needs and goals. How to do so is the question and in PROMISE therein lies the answer.


PROMISE is a paradigm of coproducing an alternative discourse in Mental Health Care.