What is collaborative care in mental health?
Collaborative Care is a healthcare philosophy and movement that has many names, models, and definitions that often includes the provision of mental health, behavioral health and substance use services in primary care. Common derivatives of the name collaborative care include: “Integrated Care”, “Primary Care Behavioral Health“, “Integrated Primary Care”, and “Shared Care”.
Recently, there have been efforts to provide a methodology for defining a lexicon for collaborative care.
The key features of Collaborative Care models are:
- Integration of mental health professionals in primary care medical settings
- Close collaboration between mental health and medical/nursing providers
- Focus on treating the whole person and whole family.
- There are various national associations committed to collaborative care such as the Collaborative Family Healthcare Association.
Whenever you talk about collaborative care in mental health, at some point, the term win-win is bound to come up.
The term win-win was first coined in the 1920s by human relations and management pioneer Mary Parker Follett. The concept has caught fire in the business world because clients and consumers tend to be far more open to cooperating —say, signing a contract or buying a product— when they believe that their needs are being respected and accommodated. The term has more recently entered the mainstream, generally referring to attempts to accommodate the needs of all individuals involved in some sort of interaction or negotiation.
In a mental healthcare setting, the notion of win-win covers a good bit of ground.
Perhaps most obviously, it applies to power dynamics, recognizing a fairly universal need for individuals to experience a sense of autonomy and control in their lives, and knowing that people tend to be far more cooperative (and far less defiant or passive) when these needs are met. It applies to social interactions and the desire for dignity, belonging, and respect, acknowledging the fact that people in such environments are encouraged to treat others in kind.
And win-win also allows mental healthcare patients to be successful and appropriately challenged in an environment that respects the ways they absorb, process, and express information, knowing that these people tend to demonstrate higher levels of engagement, performance, progress, and achievement than when their cognitive and personal needs are ignored.
Given these benefits, you’d think win-win mental health practice would be an easy sell. But considering the win-lose nature of the systems most of us have experienced (as patients, family members and doctors), a bit of skepticism is understandable.
Win-win presumes a certain degree of autonomy and respect for the wishes and preferences of everyone involved. Yet doctors are commonly assigned to a clinic , given an office, and handed a schedule and patient roster, often without their input ever being solicited. Similarly, patient and family interests and preferences rarely drive the treatment plan, except perhaps in specialized programs.
And how can win-win objectives thrive in a system traditionally characterized by top-down management, scarcity thinking, social cliques and hierarchies, bell curves, standardization, and competitive grading?
Obstacles to Win-Win Thinking
Win-win thinking faces a number of obstacles in mental health practice. To some doctors , the notion of patients “winning” may be unsettling, especially if we perceive that this can only happen when other members of the family lose control.
Win-lose conditioning incorrectly suggests that the only alternative to an authoritarian approach to management is a permissive approach —letting patients do what they want. But while powering offers limits and permissiveness promises freedom, only a win-win authority relationship offers to fulfill both needs for patients, putting another family member in charge without having to control or disempower anyone —much less compete for authority.
The win-win concept is likewise subject to misinterpretation with regard to clinical issues. Win-win is impossible if patients can’t succeed, but this certainly doesn’t mean dumbing down the program, babying patients, or rewarding poor performance.
On the contrary, win-win doctors work hard to challenge all patients appropriately. They’re willing to go back and fill in the blanks, securing a strong cognitive foundation, rather than simply barrel through a treatment plan regardless of what their patients need.
Win-win doctors know that their role is not to document failure, but to prevent it.
Win-win requires a shift away from the zero-sum, competitive paradigm so prevalent in medicine today. As long as we evaluate patients —by comparing them to one another, we compromise the potential for collaboration as well as the synergy that comes from individual strengths and cooperation.
Standardization undermines the engagement and achievement that occur when we help patients not only build skills but also develop their interests, talents, and passions. It’s likewise hard to establish win-win approaches in an environment where superficial remedies focus exclusively on one aspect of complex problems, or where policies, beliefs, and adult behavior are inconsistent with win-win intentions.
Of all the hurdles to establishing win-win attitudes, behaviors, and interactions, perhaps the most destructive is negativity. Whether reflected in our focus on errors, mistakes, and omissions —think of the feedback we give and receive— or the powerful impulse to react to misbehavior with blame, punishment, or other negative consequences, this inclination can consistently compromise the emotional environment. Win-win thinking requires that we break the habit of catching patients being wrong —that we instead see their mistakes or failings as opportunities to build responsibility and teach the positive behaviors we desire. It also requires that we overcome a natural resistance to change and the tendency to accept destructive traditions just because they’ve been around for a while.
Still, despite these obstacles, there’s no reason to throw in the towel. Every day, doctors manage to quietly shut their doors and create a little bubble of sanity within even the most negative mental healthcare clinical climates. By simple considerations and small acts of grace, these doctors work in the service of win-win ideals. They manage to establish an atmosphere of safety and acceptance, encouragement and guidance —all the while maintaining and modeling impressive standards for performance and comportment, considering their patients’ needs as well as their own.
Here’s the good news: There are plenty of win-win strategies you can implement, simply and unobtrusively, right within the walls of your own clinic. You don’t need nationwide adoption, a commercial program, or extra funding. And you don’t have to overturn 300 years of history and tradition all at once. The most effective shifts from win-lose to win-win thinking happen slowly and quietly, through little changes in attitudes, priorities, language patterns, and reactions to mistakes and misbehavior.
You’ll develop the “starter” for this recipe through the power dynamics you establish. Motivation and discipline look different in a win-win environment than in a more traditional authoritarian environment where control is vested in the power and conditional approval of the adult. A win-win approach emphasizes giving patients opportunities to develop self-management and self-control, freeing up time otherwise consumed by reminders, punishing, or reporting patients. It leverages cooperation and commitment by offering some control and autonomy within a structure that protects the teacher’s ability to teach and the patients’ ability to learn. Here are a few specific, practical strategies to get you started.
In an environment in which patients are so often simply told what to do, giving them a few options about routines or assignments can inspire a tremendous amount of cooperation and engagement. Many doctors already provide choice to some extent, depending on the discretion and latitude they are accorded in the system. Yet even in the most scripted and restrictive environments, it’s possible to invite input and account for patient preferences. If you have to assign the problems at the end of chapter four, do the patients really need to do all of them?
Likewise, offering choices about sequence (which activity to do first, or when the patients can do the work); location (where in the clinic, patients can work on an activity); social preferences (with a partner, group, or working alone); can defuse the complaints or opposition often occur when these options are not available. You might even allow your patients to make decisions about treatment plans, choosing their own issues to focus on, selecting activities from a given list, or designing their own projects. (One social worker who had very little wiggle room with her program still managed to engage her patients just by letting them vote on which unit to do first.)
Focus on positive consequences.
Despite its simplicity, this strategy is incredibly powerful. Transform a threat into a promise and watch the effect your statement can have. Instead of saying, “If you don’t come to today’s session, you can’t take have another one,” try, “Sure you can have an additional session with Jane, as soon as you complete the session we have today”.
Negative consequences, even if they are logical and reasonable, have a punitive energy. Focus on the positive consequences and you not only reduce the potential for conflict and opposition, but you also shift the responsibility back to the patient . Offer the possibility of earning access to a desirable outcome as soon as the negative, resistant, or passive behavior changes, and you have a powerful incentive.
Is this a bribe? Of course! There is no such thing as unmotivated behavior. All choices are motivated by the most desirable outcome, whether it’s an interest in the activity, a general love of learning, a good grade, or merely the desire to get a task out of the way so that you can go on to something better. And make no mistake, threatening patients with failure, lost recess, detention, or a call home are also bribes, as is conditional caring —none of which contribute to a win-win culture.
Improve clarity in your communications.
We’re far more likely to generate cooperation from others when they have a clear sense of what we want. How often do doctors encounter unexpected reactions to simple requests to “clean up this center,” “behave yourselves,” or “do your work neatly”? (I once observed a group of school-age patients reduced to tears when the mental healthcare worker said, “You can go home as soon as you pick up the floor.”)
Assumptions, unclear instructions, and nonspecific limits are prone to misinterpretation. The markers in my middle school clinic didn’t stop drying out until I actually took the time to show the patients how to make the caps click when they were finished writing with them. Think through what you want ahead of time, and communicate details as clearly and specifically as possible. (If you really want to increase the odds of patients getting it right —and not ask you to repeat your instructions ad nauseum— offer the information both verbally and in writing.)
Respond to conflict nonreactively.
Our commitments to creating a win-win practice will be most sorely tested when a patient objects or refuses to do what we’ve asked. One of the greatest lessons I ever received came from a teaching intern. After several days of unsuccessfully trying to get her patients to complete 10 problems in the time she allotted, the next day she came in and assigned 15. When one boy flat-out refused because “15 is too many,” she actually agreed with him, admitted to having gotten carried away with the assignment, and invited the entire class to just pick the 10 they felt like doing. When the same boy came in a few days later grumbling that he was sick of doing the problems on the board, she invited him to pick 10 of the problems on a specific page in the book or to make up 10 of his own.
Although I could see that this was clearly working, I was concerned that her approach was teaching him that it was OK to be disrespectful. So imagine my surprise when she laughed and said, “I’m not teaching him that it’s OK to be disrespectful. I’m teaching him that it’sunnecessary.”
It was at this point that I finally got my head around what win-win was all about. Respect really is in the eye of the beholder, and being able to not take confrontations personally will save you a lot of grief.
Instead of criticizing, scolding, punishing, or simply labeling, respond to negative behavior with useful information, perhaps asking for what you want. “That’s inappropriate” gives patients absolutely no instruction about how to behave in more appropriate ways. On the other hand, “We don’t use that word here” asks patients to change their behavior without attacking them or making them wrong. Yelling at patients for interrupting you or shaming them for being needy is likewise far less effective than telling them when you’ll be available (and letting them know that it’s important for you to hear what they have to say at that time).
Build relationships with parents/members of the family
Parents and family members, especially those with extremely problematic patients— are so accustomed to hearing from the clinic only when there is a problem that the defensiveness doctors encounter should come as no surprise.
One of the most effective ways to reverse this pattern is to let parents hear from you about positive behavior or progress on a regular basis. The time and effort you invest in sending a good note home every week (ideally for every patient in the clinic, or every patient in your toughest group), can pay tremendous returns. A simple checklist with about five desirable behaviors —simple things you know all your patients are capable of achieving— won’t take more than a few minutes to complete. Be generous with the checkmarks or stars you give, even if you have to dig a little. And if you really want this to amplify the impact, add a couple of positive, appreciative words at the bottom of the paper.
When you do need to contact parents about an incident or concern, it’s best to just inform them about what’s going on and how you’re handling it. The more you can avoid asking the parents to correct their patients’ behavior, the more support you’re likely to receive.
A contingency is only as good as your follow-through. We undermine our authority any time we give warnings or accept excuses, so avoid any inclination to do either. Build in some flexibility ahead of time —for example, give patients a “get out of jail free” card to use when they’ve had a bad night. Some doctors require 90 percent of the assignments to get in on time; others set a 48-hour deadline.
Create a safety net before you have to ask for excuses.
If you have to withdraw a privilege, do so quietly. “We’ll try again tomorrow (or later)” makes your point without blaming, and gives patients another chance to earn the privilege. When patients cooperate, avoid using praise and conditional approval. Instead, describe the behavior and tell them how their positive choices pay off for them: “Hey, you got your report in on time. Now you can go to practice.” “You remembered your library book. Now you can take another one home.”
A Positive treatment dynamic
Although these strategies are simple and straightforward, they can create a solid win-win authority dynamic by minimizing power struggles and negative behavior resulting from patients’ desire for autonomy. A win-win clinic gives you much to look forward to —not just more instructional time when you’re not spinning your gears competing for control, but also the knowledge that patients in a win-win environment will be the first ones to cut you some slack when you have to say no, or need more quiet than usual.
And in the end, our mental health practice—indeed our civilization— will only be as good, as caring, and as positive as the efforts and intentions of the individuals in them.
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