Quest for client autonomy in improving long-term mental health care.

The objective of the present study was to explore how mental health-care professionals initiate, improve, and maintain client autonomy while improving other aspects of quality of care. We studied the different ways in which they approach autonomy and the dilemmas associated with them. As a methodology, we used the insights of actor-network theory, where concepts cannot be predefined, but are formed within specific situations, and therefore, should be studied by addressing the actors involved. Data were gathered by conducting ethnographic observations of national conferences of a quality-improvement collaborative and by interviewing actors involved in the improvement practices. In a bottom-up analysis, four approaches to autonomy emerged: (i) professionals removed constraints to autonomy and passed initiative to clients; (ii) professionals made an active effort to learn and support client preferences; (iii) clients were given opportunities towards independent lifestyles; and (iv) professionals tried to 'normalize' their relationship with clients to encourage roles other than those of client. The study showed that autonomy is an important issue throughout the process of quality improvement. Articulating the different approaches to autonomy and the dilemmas in these approaches contributed to reflection on the concept and highlighted the limits of the concept within a mental health-care setting.