Why collaborate?

Collaboration is a process where two or more people work together towards a common goal with the purpose of improvement in health outcomes for the patient. Over forty randomised control trials give support to the view that the inclusion of the family and other carers in the patient's treatment results in improved outcomes for the patient, their carers and clinicians when using a collaborative approach.^{(1, 2, 3)}  The main outcomes include:

•  a reduction in relapse rates (up to 20%) resulting in a reduced number of hospitalisations
•  better adherence to medication
•  reduced psychiatric symptoms. ⁽³⁾ 

Additional outcomes include:

• improved social functioning of the consumer
• increased employment rates
• increased involvement in the community
• reduction in the burden experienced by family carers
• improved relationships between family members, including improved relationship with the consumer
• cost effectiveness.

Studies have also shown family collaboration to be effective in different cultural settings – China, Spain, Scandinavia – and this should be considered valuable when working within Culturally and Linguistically Diverse communities in Australia and New Zealand.⁽³⁾

The Collaborative Therapy work by Castle et al looks at holistic treatment of people with mental illness. It has been widely acknowledged as a leading example of comprehensive consumer-oriented care, and has been adopted by mental health services both within Victoria and nationally in Australia.

Patients’ comments on collaboration

'It can work well and should be considered much more than it currently is. It is about doing business differently moving away from the medical model of care and embracing the team approach where consumer, carer and psychiatrist work together for the best outcome for the person with the chronic condition.'

'See them as a whole person not just a condition. Set goals that have meaning in their life.'

'This is vital to getting the best outcome for consumers. Also carers' independent needs have to be kept in mind. Frequently plans are proposed that only work if there is a carer/family member able to help execute and monitor the plan.'

'Empowerment was most rewarding.'

'When conducted by a skilled psychiatrist the process can be magic! There is little doubt that where the consumer is treated with respect and as a person, not as an object to be controlled with medication, and where their family is involved as part of the support team, progress towards recovery is far less stressful for both consumer and family.'

'It is my firm belief that where psychiatrists can work collaboratively with carers and consumers, self-management can be achieved at a much greater level.'

'Relationship between all parties needs to be based on a reciprocal basis of trust, respect and support. There also needs to be an open style of communication and understanding so all concerned feel they are being heard.'

The treatment alliance

The psychiatrist, patient and carer relationship is explained in the Treatment Alliance Model below. A critical part of a collaborative approach is the interaction process ⁽⁴⁾ and while patients are self-managers, their contact with the psychiatrist and others is critical in making decisions and solving problems. It shows the changing role and responsibilities of all parties, as the stage of the condition changes.

Stage 1: The psychiatrist takes the lead

At initial contact, it would be expected that the psychiatrist would take the lead as carers and the patient look for answers. The emphasis is on establishing a compassionate, trusting, empathic, humane approach to carers and the patient who are most likely confused, frightened and bewildered by the sudden changes.⁽⁵⁾ The psychiatrist could also take the lead in a situation such as a relapse, when the patient in particular is not in a position to make decisions.

Stage 2: Equal contributions from carers, patient and psychiatrist

This rehabilitation stage requires all three parties to interact equally to achieve the best possible results. This includes using the knowledge of patients and carers gained through their experiences, and advice from the psychiatrist on methods to develop problem-solving and communication skills. By working in collaboration, resources and ideas are shared to achieve positive health outcomes.⁽⁵⁾

Stage 3: Psychiatrist to be available when needed

The final stage represents the patient and carer having come to terms with the condition. The patient, in conjunction with the carer is willing to self-manage the condition and to make contact with the psychiatrist in times of need. Reaching stage 3 does not necessarily mean remaining here. A relapse situation may require a return to a previous stage.⁽⁵⁾

Collaboration and the carer

The literature and the feedback from the Consumer and Carer Survey and Focus Groups all suggest that the carer is under-used and under-valued in the care process. Most felt that they were not listened to and became extremely frustrated as a consequence. Yet the carer has developed applicable knowledge and skills through a ‘lived experience’, skills and understanding that many mental health professionals will not have.⁽⁶⁾

A new addition to the Australian Mental Health Act in 2007 is the directive that mental health services must recognise the contribution that carers can offer and provide information to carers for people with a mental illness. The outcomes of engaging carers of patients are well demonstrated in international literature. By including carers from the initial contact through to the discharge phase, psychiatrists can make a huge difference to the carer’s journey and the patient’s outcome.⁽⁷⁾     

References

1. Berk M, Berk L, Castle D. A collaborative approach to the treatment alliance in bipolar disorder. Bipolar Disorders 2004;6(6):504-18.
2. Bauer MS, McBride L, Shea N, Gavin C, Holden F, Kendall S. Impact of an east-access VA clinic-based program for patients with bipolar disorder. Psychiatric Services 1997;48(4):491-6.
3. Froggatt D, Fadden G, Johnson D, Leggatt M, Shankar R. Families as Partners in Mental Health Care: A guidebook for implementing family work. World Fellowship for Schizophrenia and Allied Disorders, 2007. Available from Victorian Mental Health Carers Network www.carersnetwork.org.au
4. Sajatovic M, Davies M, Bauer MS, McBride L, Hays RW, Safavi R, Jenkins J. Attitudes regarding the collaborative practice model and treatment adherence among individuals with bipolar disorder. Comprehensive psychiatry 2005;46(4):272-7.
5. Leggatt M. Working Together. Southern Mental Health Association Inc, Victoria, 2006.
6. Leggatt M. Training Family Peer Support Workers in an Early Intervention. Orygen Youth Health, 2009.
7. Bickerton A, Hossack K, Nair J. Connecting with Carers is Everybody’s Business: A training resource for family friendly mental health services. Woking With Families Program, Sutherland Division of Mental Health, 2007.
8. Leggatt M. New thinking and acting for turbulent and challenging times. Working with Families in Mental Health – The evidence base. Victoria, Australia.

Continue to Module 1.7: Why Use a Collaborative Approach?