Theoretical Implications

As noted in Chapter 2, Cyril, Smith and Renzaho’s (2015) systematic review of empowerment measures in health promotion, described the psychometric qualities of quantitative scales used in measuring empowerment in health promotion settings and gaps in the measurement of various domains of empowerment using these. The current research findings concurred with the diversity found in the concept of empowerment, as psychological, social, economic, organisational, political and community contexts were all encountered and referred to by the fifteen participants involved. Cyril et al.’s scales failed to adequately measure the community and organisational domains however, which are arguably equally important for the achievement of health programme outcomes. These scales would therefore likely need adaptation to make them adequate in coverage and suitable for use with PWLD, in all domains of empowerment being measured. As this relates to the present research, it would have been interesting to use a specific empowerment scale to measure changes before and after the therapy sessions, in the participants with learning disabilities, as well as

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further consideration of concrete examples of empowerment which could be better communicated to and understood by PWLD.

In terms of how this current research can inform such scales, the findings indicate firstly, that psychological empowerment was the priority here and was the main form of empowerment being investigated; this only represents one dimension of empowerment however, so future research could perhaps beneficially focus more upon the social and political elements involved, which were also mentioned to a lesser degree. The 20 scales examining

empowerment measures that were reviewed by Cyril, Smith and Renzaho (2015) looked at domains ranging from personal competence, group orientation, self-determination and positive identity (Brookings & Bolton, 2000), emotional empowerment, inner peace, capacity, functional empowerment, healing and connection (Haswell et al., 2010), to self-esteem self-efficacy, power-powerlessness, community activism, optimism and control over the future and righteous anger (Rogers et al., 2010) and intention, participation, motivation, critical awareness (Kasmel et al., 2011).

Section 4.2 outlines the participant conceptualisations of empowerment that were highlighted as important in this study and include some of the above domains, such as those relating to self-esteem, self-determination, choice and control, functional empowerment in terms of making practical life changes (from moving into own flat, to learning to travel independently and communicate their wishes more effectively). The definition of empowerment used in section 1.2.1, as well as Table 4.2 (Participant Conceptualisations of Empowerment) could be helpful in informing such domains for subsequent or future measures of empowerment.

Secondly, the findings (although focusing upon personal or psychological empowerment, as opposed to community and patient empowerment, for example), highlight that when

measuring empowerment, as suggested by Cyril et al. (2015), mixed methods may be helpful to enable adequate measurement of empowerment across a variety of domains.

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Obtaining information that is meaningful and accessible to the PWLD involved in such research is clearly essential. Use of adapted resources and materials, as well as a variety of formats appears important (symbols and pictures were included in both the therapeutic sessions carried out by therapists and the research materials included in this present study – e.g. the adapted version of the Information Sheet in Appendix H). Further use could be made of ‘talking mats’ and other visual and multi-sensory information-presentation formats (similar to the Easy-Read versions of leaflets suggested by Ward & Townsley (2005), in section 2.7.2). Several of the client participants in the present study found such information and resources important throughout their therapy sessions, including Sid in Triad #1, who could not read so benefitted from the use of pictorial aids (e.g. the ‘compassionate owl’ that his therapist Eve helped develop) and Edward in Triad #3, who mentioned the adapted smiley face chart he had created alongside his therapist Tim.

Particular implications in terms of social justice research and social equity have been mentioned from the perspective of PWLD and also in Section 5.4.7 below, regarding this study and the area of empowerment for PWLD via therapy. Section 2.2 also referred to some of the reasons for the greater prevalence of psychological problems and well as other life challenges and resulting feelings of disempowerment in PWLD, which result from power imbalances, stigma and social inequalities. This can cause reduced well-being, feelings of alienation (Swain, 2012) frustration and rejection, which the present research identified in some of the PWLD interviewed, such as the client Edward who spoke about work-place bullying and being paid less than people without learning disabilities. This was also raised in Section 2.2 by previous researchers and policy-makers, having been shown to be greater in the population of PWLD, resulting in greater need for psychological support (NICE, 2018).

Theoretical implications relating to definitions of empowerment and the therapeutic

relationship include alignment with Zimmerman’s (1995) reference to enabling people to act on their own in order to reach their self-defined goals: the findings in the present study were

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in agreement with this theoretical stance, such as client Abbey’s personally set relationship and communication goals and progress for example, or client Sid’s feelings of empowerment and goal-attainment as a result of therapist Eve’s presence and the therapeutic relationship involved. The Latin root ‘passe’ mentioned by Zimmerman (equating to power and freedom) was very relevant for most of the participants interviewed based on their accounts. Similarly, Zimmerman’s (1995) personal, psychological empowerment arguably dominated this present research, as most referred to their direct personal experience of the PWLDs: for example, client Jacky becoming more assertive, more able to travel independently and engaging in less self-harming behaviours.

Cattaneo and Chapman’s (2010) model of empowerment which focused on actual, physical evidence that empowerment has created an impact upon the person, their relationships and social surroundings, was also directly relevant to the findings in the current study, as it was not just the subjective feelings of being empowered, but increased social influence that was seen and reported by various participants. An example of this can be seen in Triad 3, where client Edward’s support staff and others involved all experienced the positive impact

resulting from his therapeutic sessions, as well as Edward himself. This links to the use of empowerment measurement tools mentioned earlier. Cattaneo and Chapman also

mentioned the importance of empowerment being a dynamic process, meaningfully goal-orientated: their six steps could perhaps be usefully included in future similar interview questions, or the importance of each step of their model measured in turn.

Oladipo (2008) argued that any economic or social empowerment of the masses may not be possible without psychological empowerment (PE) and linked this to Maslow’s (1943)

Hierarchy of Needs model. This study included the example of client Edward, whose

personal processes affected his interaction more widely and created a greater social impact with others, but the PE came before the additional benefits.

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Figure 1 below is visual representation of empowerment processes which can occur via the therapeutic process derived from the accounts and findings in this present study.

Figure 1: Diagram showing an elaboration of how we theoretically understand empowerment via the therapeutic process, from the perspective of PWLD & other related stakeholders