The Agential Stance

This is part of a series of posts reporting outcomes from a project on Agency in Youth Mental Health, led by Rose McCabe at City University. In the previous post, the project team provided some evidence of epistemic injustice in clinical encounters. Today, Clara Bergen and Lisa Bortolotti discuss a new approach to protecting the sense of agency of young people meeting a crisis team for mental health problems.

Clara Bergen

Lisa Bortolotti

In our project, we wanted to ask: How can practitioners avoid undermining a young person’s sense of agency in a mental healthcare encounter? We adopted an absolutely unique analytic approach to find out the answer.

“We” are a group of six experts in philosophy, psychology, psychiatry, clinical communication, clinical practice, and public involvement in research (Interdisciplinary Academic Researchers), and five young people aged 17-25 with experience of accessing mental health services for diagnoses including post-traumatic stress disorder, major depressive disorder, generalized anxiety disorder, autism spectrum, and emotional dysregulation (Youth Lived Experience Researchers).

Both groups collaboratively analysed clips from video-recorded mental health encounters for young people seeking crisis support for self-harm or suicidal thoughts (see Bergen & McCabe 2021). During meetings in which the Youth Lived Experience Researchers watched and analysed video data, we identified what aspects of agency were most relevant to these mental health encounters. Five aspects of agency were thought to be important to young people but often undermined in the video-recorded mental health encounters. 

The young person:

1. is a subject of experience and their perspective matters;
2. can take action to change their situation by seeking help;
3. may have multiple and conflicting needs and interests;
4. with adequate support, can contribute to positive change;
5. with adequate support, can participate in decision-making.

Next, we observed which communication practices that supported and undermined these five aspects of agency in the video-recorded mental health encounters we observed. When practitioners use practices that protect the young person's sense of agency in the encounters, we say that they adopt the agential stance towards the young person, that is, they treat the young person as an agent. 

Here, we consider the two aspects of agency that the young people identified as fundamental, validation and legitimisation. 

1. An agent is a subject of experience and their perspective matters.

Validation is a critical tool for showing that the young person’s experiences and perspectives matter. A practitioner can show understanding and acceptance of the young person’s experience, without having to express agreement or approval. Some mental health assessments lack validation, as the main focus is on risk assessment and problem solving. 

You need to say, “You’re really distressed. You’re in a lot of pain.” I think that kind of acknowledgement alone can be really, really powerful.

 

2. An agent can take action to change their situation by seeking help.

Legitimisation of help-seeking expresses that the young person made the right choice in seeking help. Communication techniques include for the practitioner to clearly state that the young person had genuine grounds for concern and deserves support. However, during assessments for suicidal thoughts, we observed that practitioners often implied that the young person didn’t need help, which could make them feel like they had no genuine concerns and did not deserve support.

With that sort of interaction, of “Oh you’re not planning to do anything now so it’s fine.” … You know, the department said it’s not an issue so it’s fine sort of having these thoughts… You wouldn’t think “Well maybe it’s really serious, maybe I do need to tell someone to help me.”

 

If you want to know more, the McPin Foundation created a podcast on our study, summarising all the findings.