No care without collaboration?

Citation

(2012), "No care without collaboration?", Advances in Dual Diagnosis, Vol. 5 No. 4. https://doi.org/10.1108/add.2012.54105daa.001

No care without collaboration?

Article Type: Editorial From: Advances in Dual Diagnosis, Volume 5, Issue 4

Certain phrases and words litter the clinical guidelines for working with complex mental health and substance misuse problems (Department of Health (DH), 2002). I would like to focus on one particular concept for the editorial: “collaboration”. I would like to reflect on what genuine collaboration should look like, why it is so important and what needs to happen in order to promote a climate within service provision where true collaboration is possible.

According to the National Institute for Health and Clinical Effectiveness (NICE) (2011) guidance for psychosis and co-existing substance misuse problems:

People with psychosis and coexisting substance misuse should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals (NICE, 2012 ).

So, what do we mean by collaboration? Definition suggests collaboration involves two or more people working co-operatively. Co-operation requires working together towards the same end, purpose, or effect. This suggests a certain level of agreement about what the purpose or goals should be and also that the people involved would have an equal say in decision making.

Collaboration has its main roots in Rogerian “person-centred” therapy. Carl Rogers believed that people have the solutions to their own problems and that a therapist’s role is to allow the person to explore their problems and identify their own unique solutions for their recovery. This may involve people trying out a range of options, evaluating them, making mistakes and changing their plans.

This level of autonomy conferred to the person in treatment has always been a difficult one to marry with today’s culture of risk management in both mental health and drug and alcohol settings. Philosophically, autonomy (self-determination) and duty of care can be poles apart. For example, if someone has decided to take their own life, then a mental health professional has a duty of care to do everything possible to prevent the person acting on this (including detaining them against their will using the Mental Health Act). I think for this reason, mental health professionals and to a lesser extent, substance misuse workers struggle with collaboration. There is a fear that by letting people determine their own path through their recovery, they will make catastrophic errors including suicide and self-harm, and relapse of their mental health and/or substance misuse issues.

However, my argument would be that to impose a treatment regime, demand compliance and offer limited options is more likely to result in treatment drop-out and an increase in risk. Working respectfully with people “where they are at” and offering people what they want rather than what has been decided a priori is vital.

Two therapeutic approaches adopted across dual diagnosis services both have roots in the humanistic person-centred approaches: cognitive behavioural therapy and motivational interviewing. One of the generic competences in CBT is the ability to engage and develop a positive working alliance. The CBT competence framework (Increasing Access to Psychological Therapies (IAPT), 2007) highlights in some detail both the skills and attributes required for effective collaborative working including warmth and friendliness of the therapist, an ability to be flexible and adapt approach to suit the individual and/or their changing needs, as well as being able to (and wanting to) grasp the person’s own unique world view and perspective and work alongside this.

Motivational interviewing (Miller and Rollnick, 2002) has evolved from an analysis of what good therapists (with better treatment outcomes and retention) were doing compared with those with less good outcomes in the alcohol field. It is a client-centred approach that focuses on raising awareness of the person’s own unique perspective on a particular health behaviour change. The therapist works collaboratively with the person to engage them in a meaningful therapeutic alliance, fosters autonomy and choices, as well as actively reflecting back examples of positive “change talk” such as desire, need, ability, reasons so that the client is only being influenced by their own words. The therapist is careful not to impose their own views or opinions. Advice can be given as long as it is invited by the client.

This can be challenging to put into practice when someone presents with complex needs and risk of self-harm or harming others. It also does not sit comfortably with the role of being a “professional” which by definition confers a certain power position in the treatment alliance as well as identity as an “expert”.

So how do we find the right balance? I would suggest that an honest dialogue with the person seeking or requiring treatment is the first place to start. Transparency and honesty about the limitations and constraints within your role and the parameters of the service can really help engender the boundaries of the collaboration. For example, agreeing on what decisions the person is free to make for themselves (whether to try a new anti-psychotic or stay with the same one), and also clarifying where the services will be obliged (by law) step in (e.g. child protection issues, drug dealing, etc.). Even within secure settings there is scope to offer as much autonomy as is feasible and safe. Working in collaboration or not is often a philosophical choice for a mental health or substance use worker. In order to create a collaborative environment in the wider multi-disciplinary team, it is important that workers are able to access appropriate training and professional development opportunities as well as clinical supervision with a person skilled in promoting collaborative working practices.

This leads into an introduction to the papers published in this issue. Clive Long and colleagues have examined the factors associated with non-engagement with treatment for women with dual diagnosis (personality disorders and substance misuse) in secure mental health settings. By interviewing the women themselves, they identified that one of the main barriers were thoughts and beliefs about what the treatment entailed and that it would not be of any benefit to them. This led to a discussion about the need to do some initial pre-treatment engagement work to explore peoples’ ideas and perceptions about treatment options, and also utilise some motivational enhancement work to help the women feel more positive and engaged with the treatment regimes.

Gail Gilchrist and colleagues examined the needs of drug using mothers with perinatal depression to identify what they felt they needed from services at this critical point in their lives, just after having a baby. They also interviewed staff in the associated services and triangulated the findings. Whilst this was a small study, the findings echoed the ideas of collaboration and engaging people in treatment that they want. The suggestions were that the period of perinatal support should be extended for this vulnerable group of women, as well as increasing availability and access to mental health services. Barriers to treatment included judgemental attitudes of staff (towards drug using mothers) and fear of child protection repercussions.

Jacqui Cameron and colleagues undertook a small-scale pilot study of clinical case management with staff working with young people with substance misuse issues in Australia. Case management is a brokerage system of care where a case manager identifies areas of priority and then signposts or refers to appropriate services. This service model has shown some benefit in getting peoples’ wider social needs met (e.g. housing and education) but less impact on substance misuse and other clinical outcomes. Clinical case management model attempts to bridge the gap between clinical interventions and the brokerage function of case management. They found that the workers who received the training in CCM found it useful and relevant to their work, and that it also improved engagement and retention in treatment. A further, larger study is required to evaluate its full benefit on longer term outcomes but it does show promise as an approach.

Whilst these papers are all quite different, one thing they all have in common is the idea that working alongside, developing collaboration and engagement is really beneficial. In order to develop services that will be attractive to people with complex needs we need to really focus on engagement and collaboration, as well as understanding what people want and need for their recovery.

The final paper in this issue is a descriptive paper describing the evolution of two local networks and a regional network for dual diagnosis workers and service users in the North of England. Networks are vital for practitioners to meet, share ideas (and frustrations) and also to discuss and debate issues of how to collaborate and engage people in services. The Leeds Dual Diagnosis Experts group is particularly powerful as it is service user-led and is influencing the development of local services, pathways and future commissioning.

I hope you find these articles of interest to your own area of practice or interest and I invite everyone to consider their own understanding and practice in terms of collaboration with service users, carers, other colleagues and people from other teams and disciplines. We are always stronger together.