Empowerment Exhaustion

[CN: brief mention of self harm, anorexia, alcoholism]

Empowerment as a social service model holds that….well, it holds a lot of mostly-overlapping things actually. A handful of the places I’ve worked with have had empowerment models, which get summarized into catchphrases like “the client is the expert on what’s going on with them” and “we provide information; we don’t tell clients what to do.”

And I can almost hear the grumbling over here, so let me make a defense.

Lots of people who end up needing social services haven’t got many feelings of control over their lives. A feeling that you have control over your life (i.e. internal locus of control) is associated with lots of excellent mental health outcomes (Maltby, Day, McAskill, 2007)*. Empowerment might be teaching the client to have a sense of control and choice in their lives, which is a powerful lesson.

Empowerment models meet the client where they are. If Jimmy shows up in our office because a teacher reported that he was self-harming, and our response is that nobody should ever self harm ever again, well then Jimmy can reasonably conclude that we aren’t helpful or interested in why he self-harms, and proceed to dismiss us.

While we continue to suggest that he just stop doing that, Jimmy can go on his merry way ignoring us. We’ve missed the opportunity to reduce the harm to Jimmy at all (is he using clean razors? does he care for his cuts?) or figure out why Jimmy is using self-injury as a coping mechanism (is he depressed? are there interpersonal problems going on? Can we help with any of that?).

The empowerment model avoids pattern-matching to everyone else who tells the client what they should have done/aren’t smart enough to do/should be doing next. If Bob the Alcoholic shows up because his wife pressured him into seeing a substance abuse counselor and the counselor says something that sounds like “You drink too much!”…well.

Now the counselor just sounds like Bob’s wife. And Bob’s wife has been bugging him about drinking too much for a while—he’s gotten practice at ignoring people who say that! Besides, now it seems like the counselor is on his wife’s side, and people are not all that calm and thoughtful when they feel as though they’re being ganged up on. Feeling as though you and your therapist are on the same side is the best predictor of immediate outcome and roughly 8% percent of the outcome four years later.

You’ll notice that in both Bob and Jimmy’s cases, the client-as-expert framing isn’t meant to cause the conversation to stop when the client says they’re happy with the current state of affairs. (So, not: “The client says she’s happy getting high every afternoon—guess I’d better pack it in then!”) But instead, it assumes that the client is doing the current behavior because it feels adaptive…and might currently be adaptive.

A personal example: for most of the time I’ve had an eating disorder, up until a few years ago, eating a whole meal caused me to be panicky and anxious, unable to focus or sit still to work. At this point in recovery, I was able to usually force myself to do it, deal with being panicky for a while, and then go about my normal life. But, during midterms and final term papers, I needed to be working and focused almost all of the time. In the choice between skipping a few meals here and there and failing, I did the one that wouldn’t mean paying extra tuition to repeat whole classes.

One model for responding could have pointed out that this is known as anorexia, and it is not good for your health, Kate. I tried this! For a while I was chronically panicky during finals: freaking out when I ate food and tried to focus, feeling overwhelmingly guilty (I was failing at recovery!) when I didn’t. I had even more meltdowns, I was able to focus even less.

The other option pointed out that I did have some interest in continuing to eat food, but that this was harder to do during final exams. Sometimes the most adaptive option I had at hand, given my anorexia-brain was to eat very little food when I needed to focus for a long period of time. An empowerment model might point out that this is sometimes the only adaptive choice I have at hand…and then looks for  ways to decrease the instances where this is the only adaptive choice. Can I figure out what things make food the least stressful? Can I work on my midterms beginning much earlier, therefore allowing me to focus less each given day?

And this worked! It’s worked so well that it’s still my strategy: as soon as mid-semester rolls around I switch to having lots of enticing, low stress food around and I’m willing to settle for a lower grade if it means I have to force myself to focus a little less frequently each day.

….but actually, I don’t often enjoy when I’m on the receiving end of empowerment-based interventions. And this is probably because I’m not a good fit for them! By the time I end up on the client side of the couch, I’ve gotten to the point where I don’t think I’m currently making the best choices for myself on my own steam (that is, I’m decision fatigued).  Therefore, I’ve called in the therapist to help. And the conversations can feel like this:

Therapist: “I’m allowing you to determine what’s best for you, and give you control in a way that will empower you to make decisions in the future. Some options you have include, Options A, B, and C. ”

Me: “I’m here because you are trained to be the expert! I’m not able to currently trust decisions I make! None of the list of options seem obviously bad, but you have more knowledge about what happens in each scenario! Now I feel like I’m trying to read between the lines, when you could just tell me what tends to work for people with my particular issue.”

In fact, when I’m particularly anxious and decision fatigued, this resolves in irritation: “I do NOT care what my list of options are, I want an ANSWER about the BEST option right now.”

But I live in a world where I get to (mostly) make all of my own choices and (mostly) have everyone assume I am deserving of autonomy. It’s cool and interesting and ‘powerful’ when I am open about mental illness, rather than unavoidable or ‘gross’ or ‘disturbing’. I get to make my own choices…so much so that it’s sometimes exhausting! Empowerment approaches feel like they add to the mental work of choosing when I’m at my least capable. But if I never got treated as though I were capable of making my own choices? Or I stated my choices, and then people nodded a bit and said those were silly decisions that indicated I was clearly incapable? The empowerment style would probably feel incredible.

It reminds me a little of picking a restaurant with your friends. If you have three friends who never ever ask you where you’d like to go out to eat, or take into account the fact that you hate Thai food, the first time they say “Hey, Joe, where should we eat tonight?” it’ll be great! But if the four of you always trade off on picking restaurants, and one night, everyone says “Nah, I don’t care, I’ll eat whatever” and nobody picks a place to eat?  You’re going to be annoyed. (And hungry.)

Related, on both food and empowerment grounds: poverty and the marshmellow test

*there’s a mediating effect of coping skills, but the short version is that having an internal sense of control seems to be related to a large number of positive health and mental health outcomes.

One thought on “Empowerment Exhaustion

  1. Have you by any chance read Edward C. Banfields The Unheavenly City Revisited? Deals with similar issues from a sociology angle. Written in the 1960’s but references many interesting studies that are not well known even today. Basically saying stuff like how poverty and other problems are correlated to impulsive, short-term oriented behavior, which is correlated with disempowerment, believing your own actions have no effect on your future because you are a pawn of forces beyond your control. Tries to find the ur-cause of it, cannot, but has some interesting hypotheses, the best one is a study claimining that it is all decided in the first few weeks of a baby. If mothers or other caretakers are attentive, and the baby learns this causality that I whine and get fed so my actions contribute to my well-being, will be okay, if not, disempowerment. Anyway one of the most important aspects of the book is saying once people have grown up, you have no chance of fixing it.

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