These three foundational positions can be summarized as (a) the communicative theory of action underlines negotiations, consensus, and the reaching of agreements through communicative actions; (b) dialogicality as the fundamental feature of human life underlines diversity, difference, and the polyphonic; and (c) the philosophy of personhood establishes autonomy, dignity, and singularity as the core values and positions that undergird what is to be a person and live a fullest possible life. Within these three sets of concepts, there is a clear tension. A tension between agreement, and as such, the value of sameness on one side and difference and diversity on the other side expressed through a concept of singularity that consolidates a radical “otherness” as the core of individuality and personhood. This echoes the work of Hannah Arendt. She states: "Plurality is the condition of human action because we are all the same, that is, human, in such a way that nobody is ever the same as anyone else who ever lived, lives or will live" [41, p. 8]. Dutch educational theorist Gert Biesta [42, 43] uses this to make a distinction between uniqueness-as-difference and uniqueness-as-irreplaceability. In the first, we all can be described through different concepts, theories, and descriptive systems, but also limited within these conceptual manners of describing and understanding the Other. Uniqueness-as-irreplaceability connects to Arendt`s plurality and the type of “otherness” that we meet in both Bakhtin and Levinas` work: That which is never met before and as such outside our descriptive and knowledge repertoire. This part brings in a fundamental uncertainty in any communicative and dialogical encounter. Relying on the sameness between what I know of similarities between persons and what I meet in the other, cannot save me from the fact that the uniqueness-as-irreplaceability always opens up for the not-met-before, the not-known and the radically new as that which will mark my encounter with the other, and therefore I can never know (anything) for certain.
The field of tensions described by bringing together these three foundations can be found in the empirical findings brought out in Part One of this series of papers from our projects. This field of tension can be seen as an ethical field because it is never given how to respond to the other in the singular meeting. This must be found out, negotiated and brought forth in the actual collaborative process.
The Collaborative, Dialogue-based Clinical Practice (CDCP) Model
This proposed CDCP Model for community mental health care, draws from the framework of collaborative practice proposed by Ness et al. [20]. This framework is configured by four components: (a) the frame orientation for collaborative practice, (b) the structures of collaborative practice as the domains of collaboration, (c) the key principles of collaboration, and (d) the processes of collaboration. Although we take this framework as the basis in its structures, we have reworked and revised the framework by replacing some of the terms with more appropriate ones and elaborating on the component on the processes of collaboration specifically to make the model focus on the practice involving clinical relationships between persons and professionals as depicted in Figure 1. The shaded area of the figure refers to the focus of the CDCP Model development.
The first component of this framework is the overall frame orientation for a collaborative practice that consists of person-centered care, recovery-orientation, and a pluralistic orientation. Person-centered care and recovery-orientation are the practice philosophies and perspectives that are key to user-involvement in care processes as these are oriented to achieving mutual understanding, shared decision-making, co-management of care, support of self-management and empowerment, and supportive care. Partnership with persons, dialogue for shared decision-making, and tailoring the care to the person are the key ingredients of these frame orientations [24, 44, 45]. The perspective of person-centered care focuses on the care ‘of the person’, ‘by the person’, ‘for the person’, and ‘with the person’ [46], and the key dimensions underlying person-centered care include (a) holistic, multidimensional perspective for a person, (b) the perspective of client-as-individual, (c) sharing power and responsibility in decision making, and (d) therapeutic alliance [47]. The recovery-orientation, in addition, focuses on the person and his/her everyday life rather than on pathologies or symptoms with the personal unique process as its central core, including person-centeredness, empowerment, purpose, and hope as the key components [8, 48, 49, 50]. Recovery-orientation in MHSA care focuses on individuals to attain and maintain active, meaningful personal social lives in the context of mental health problems. In developing the model of care process for MHSA practice proposed in this paper, the perspective of pluralistic orientation [51, 52] has been added to the frame orientation of person-centered practice and recovery-orientation. This has been added because the model focuses on clinical practice, which needs to embrace not only the differences in individualities of persons and professionals but also in terms of options, choices, variations in the modes, methods, and approaches of care and therapy. Pluralistic orientation means that one seeks to have access to as many options on how to collaborate in both selecting specific modes of treatment and care, as well as in applying chosen modes of care and treatment with persons [50]. This orientation points to the possibility and availability of choices in a repertoire of therapeutic approaches and modes of care, in the routes in shared decision-making, and the configurations of MHSA service provision. A pluralistic orientation points out that clinical practice processes must also embrace tailored forms of collaboration through the acceptance and integration of the notion that people are different and contexts of people’s lives and their effects on our choices are varied.
The second component of the framework identifies the domains of collaborative practice specified at three levels: (a) collaboration between persons (and/or families) with professionals and (b) collaboration among service providers (i.e., professionals), and (c) collaboration among service sectors. This specification of the domains emphasizes the critical features in collaborative practice in healthcare that has to encompass both at the individual clinical practice level and the healthcare service provision level involving various service providers and organizational sectors. Our focus of the proposed CDCP Model is oriented in the structure of the collaboration between the person/family and the professional.
The third component of the framework identifies the most essential principles that promote collaboration among people. The key values for collaboration emphasized in the literature are (a) shared value in collaboration, (b) equalization of power in relationships, (c) mutual trust and respect, (d) sharing of visions and goals, (e) developing and maintaining interpersonal alliance, (f) self and mutual understanding, and (g) open communication. Three essential principles encompassing all of these values are included in this framework identified as self-understanding, mutual understanding, and shared decision-making. The principles of self-understanding and mutual understanding form the first-line posture that can commit people for collaboration. Self-understanding encompasses knowing one’s strengths and weaknesses, one’s history, one’s attitudes toward people including self and others, and one’s wishes, hopes and despairs. Such self-understanding is the base from which the directions, courses, and trajectories of clinical processes begin. Self-understanding is critical for all participants in collaborative work as it is the base upon which mutual understanding can develop. On the other hand, mutual understanding is the key principle for collaboration because collaboration begins with the appreciation of and understanding of the other’s needs, goals, and postures in social relationships. Since the discourse in clinical practice is a form of social relationship, mutual understanding of participants (that is, the person and the professional) in interactions of clinical practice is the precondition for collaboration. In clinical practice, interactions involving back-and-forth movements, specified as turn-taking [25, 53], brings about collaboration emerging through self-understanding and mutual understanding. The third principle in this framework is shared decision-making. All forms of collaborative endeavors are rooted in shared decision-making which is based on the respect and appreciation of each other’s views, postures, and needs concerning what to do, how it is to be done, and where this should lead the participants. In developing the CDCP Model for collaborative practice focusing on the person/professional relationships, we have revised this set of principles specified in the original framework, replacing them with the principles of mutual understanding, negotiation, and working together. In our explication of the processes of collaboration in our empirical works reported in Part One of this series, we delineated these three principles as the guiding posts for the application of collaborative processes in practice. Mutual understanding encompasses self-understanding as the pre-condition, while negotiation embeds the principle of shared decision-making but goes further by integrating the concept of consensus building. The principle of negotiation encompasses the openness to other’s perspectives and positions, and the willingness to come to agreements regarding whatever disputes exist in situations. In addition, we found the concept of working together as the major driving force for collaboration in practice. Working together means being partners in accomplishing the work of recovery and getting or remaining well in the context of MHSA care. Working together is based on mutual understanding regarding what needs to be accomplished and how participants will contribute to accomplishing the work together. It is based on an ancient proverb that states: “Even a piece of paper is lighter when lifted by two people together.” Collaborative processes explicated in our work are the ways to bring about the commitments to these three guiding principles in clinical practice.
The fourth component of the framework is the specification of the essential processes of collaboration identified as open dialogue and participatory engagement in the original framework. We have reformulated this component to encompass three essential process-types including (a) interactive-dialogic processes replacing the concept of open dialogue, (b) negotiated-participatory engagement processes clarifying the concept of participatory engagement, and (c) negotiated-supportive processes as an additional type of processes through our empirical work presented in Part One of this series. The proposed CDCP Model for community MHSA care focuses on this fourth component through the elaboration of the types of collaborative processes pointing to specific collaborative strategies in each type applicable in practice. These three types of collaborative processes (i.e., interactive-dialogic processes, negotiated-participatory engagement processes, and negotiated-supportive processes) are essential for achieving mutual understanding, negotiation, and working together in person/professional relationships and in bringing about best person outcomes possible in terms of clinical management, recovery, and socially meaningful and active life in the perspective of citizenship. Replacing “open dialogue” with the term, interactive-dialogic process-type is a way to go beyond the limited meaning of open dialogue that has its beginning in the therapeutic application for psychosis and discursive acts [54]. By reformulating this type of collaborative processes designated as “interactive-dialogic processes” we expand the process of interaction between the person and the professional to include various discursive as well as non-verbal interactive strategies beyond those identified in the open dialogue framework. The interactive-dialogic process-type focuses on interactions which are comprised quite heavily of conversations between participants as “unconstrained back-and-forth exchanges of meanings, voices, and interpretations, and of creating shared meaning through which common understandings regarding situations, problems, goals, and approaches are developed and shared” [20, p. 12]. The process-type of negotiated-participatory engagement refers to active sharing and negotiated involvement of participants in the work of shared decision making, goal setting, planning, and implementing therapeutic plans and approaches. The processes of negotiated-participatory engagement in clinical practice between persons and professionals also encompass the active involvement of both participants in carrying out activities and interventions by sharing information and resources. The processes of participatory engagement are always negotiated regarding participants’ (i.e., the person and the professional) needs, wants, and goals as well as in terms of their respective strengths, resources, preferences, and responsibilities. The major focus of the processes of negotiated participatory engagement is “working together.” The third additional process-type specified as “negotiated-supportive processes” refers to the ways of supporting persons to attain and maintain active and meaningful social lives, which are the critical aspects of the recovery-oriented MHSA care. From the perspective of collaboration, support has to be based on negotiation and alliance with persons’ perspectives of their needs and goals. The support process focuses on persons’ needs associated with their lives in the contexts of everyday life, in communities and society at large as well as in relation to their being the recipients of healthcare services. Supportive processes as a form of collaboration are rooted in the professionals’ understanding and appreciation of the person’s needs, goals, and wants in everyday lives as well as the person’s difficulties in dealing with the healthcare system, the community, and the society at large. The supportive processes are necessary and critical in the clinical practice of MHSA care addressing persons’ needs and problems that are not directly associated with their mental health problems but are experienced because they are “users” of services and are living in specific personal and social contexts with MHSA problems. In this sense, the supportive processes are not strictly “therapeutic” but are oriented to enhancing users’ quality of life and recovery as persons and social agents. Supportive processes in the context of collaborative practice require the involvement of persons and professionals in a concerted effort to bring about socially active and meaningful lives for the persons. Table 1 lists specific collaborative strategies in the three types of processes that are integrated into the proposed CDCP Model for community MHSA care reported in Part One of this series. The proposed CDCP Model is specifically at the level of person/professional collaboration and is depicted in Figure 2 anchored in the framework by Ness et al. [20] incorporating the revisions and additions discussed above.
Table 1 Collaborative strategies in three types of processes
Process Types for Collaboration
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Specific Collaborative Strategies
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Interactive-dialogic process
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- · Maintaining human relationship
- · Walking alongside
- · Information sharing
- · Seizing the present moment
- · Taking the perspective of the other
- · Aligning & Scaffolding
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Negotiated-participatory engagement process
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- · Feedback-informing process
- · Putting differences to work
- · Negotiated partnering
- · Accommodating user participation
- · Addressing the tension between help and control
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Negotiated supportive process
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- · Helping in context
- · Coordinating
- · Pulling together
- · Advocating
- · Availing
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The CDCP Model for community MHSA care depicted in Figure 2 incorporating the collaborative strategies listed in Table 1 for three types of collaborative processes is applicable in clinical practice involving encounters with users and/or users’ family members (or significant others) involved in the care of users of MHSA services. Clinical encounters between users (and family members) in community MHSA care can be characterized in many ways according to the types of users’ needs for services such as prevention, MHSA episodes, continuing care/service, or crises, and may occur at various healthcare settings as well as at users’ homes. While specific dynamics of various clinical encounters may vary in their contents and progression, the basic assumption is that collaboration between users and professionals in clinical encounters is one of the key processes that are critical in bringing about the best outcomes in users. The proposal for the application of the CDCP Model in MHSA care requires professionals to become knowledgeable about the framework and competent in the application of the collaborative strategies of these three process-types in their clinical encounters with users and/or family members.
In the following section, we present a clinical case illustrating the application of the CDCP Model for community MHSA Care. This illustration is a description of the case, in which one of the authors was a member of the therapeutic team, reflecting upon the CDCP model.
Clinical Application of the CDCP Model for Community MHSA Care – An illustration
The case illustrated is reconstructed from the clinical notes of an adolescent user at a municipal unit for mental health for children and adolescents. A pseudonym is used and no personal information is included in this scenario in order to protect the identity of the user. Joe has dropped out of school and he has been referred to the family therapy team, a team that is part of Mental Health for Children and Adolescents in a Norwegian city. Joe is 14 years old. The practices of this team can be seen as exemplifying the CDCP-model. This team is person-centered in the sense that in any meeting and treatment session each person`s perspectives and concerns must be voiced and heard. This requires each person to be seen and understood in their context of living and predicaments of life. Central in the person-centered perspective of this team is to acknowledge that personhood of the single individual arises only as person-in-context. Any attempt to see the person as a member of a group based on a descriptive, diagnostic, theoretical or other categorization, means a reduction of the unique personhood of each individual. In the case of Joe, non-diagnostic and non-theoretical descriptions were, therefore, the continuous ways of focusing on him as a person, at the same time assuring his rights for diagnosis and assessments. This was done by inviting Joe and especially his family to tell their personal stories around Joe falling out of school and any other parts of their life stories that they felt were important. Together with this orientation, the recovery orientation sought to strengthen this through a focus both on the rights of Joe and his family, and on securing service-user participation on all levels of the contact between Joe, the family, the team, and other collaborative partners. The recovery orientation was applied for capacity building to promote human rights and to combat stigma and discrimination. Furthermore, the recovery orientation was the base for the application of various strategies to strengthen Joe, his family, and his social network for their participation in choice and decision-making. The recovery orientation also laid out the foundation for supporting the development of civil society movement to conduct advocacy and influence policymaking at various institutional levels critical for Joe’s recovery [55]. Securing participation on all levels of contact between Joe, the family, the team, and other collaborative partners were emphasized. Throughout the contact with Joe and his family, the pluralistic orientation was exemplified by the therapists’ use of different tools, techniques, manners of thinking and being together, which were evaluated together with Joe and his family as helpful. We used Routine Outcome Monitoring [56] as the central collaborative activity with Joe and his family to obtain their feedback on the processes and outcomes and also to secure their rights and participation in the care processes. Falling out of school is a type of event that mobilized great fear and concern both in parents, therapists, school personnel, social services, and other concerned citizens. This points to the second component of the CDCP-model; user/professional collaborative practice. In the first part, the collaboration between Joe and the family and the therapists of the team, developed in a struggling manner because Joe was very reluctant to talk with any of the therapists in the team. Due to prior experiences with mental health services he simply stated that: “I have had enough of such people. They only make things worse.” Based on this message, it was decided that the therapists talked with Joe`s parents and did not intrude on him. The parents had two main concerns outside the situation of not attending school. The first was collaborative problems with personnel from the school where they both felt accused of mishandling their son. They had a contrary experience in which they believed the mishandling was happening in the school. They stated that something had to be done with both their and Joe`s relationship to the school. The other concern was that they were worried that something had happened to Joe outside of the school, bullying or some other incident that had scared Joe. They described their son as a bit timid and socially awkward and felt that he needed help with both such a possible incident and his sociality in the world. The parents and the team’s therapists jointly decided for the team to contact the school to arrange for a meeting. The parents wanted therapists to have this meeting without them for the therapists to make up their own opinions. This exemplifies the second part of this component of the model. A meeting was held between the principal, teachers, school social- and health care personnel. The beginning of the collaborative process was established and the care process for Joe was established in the mode of collaboration. The third component of the CDCP Model points out the most essential principles that promote collaboration among people: mutual understanding, negotiation, and working together. For the therapists, it became important to make more visible for all involved participants the diverse understandings and positions in the situation of Joe, his family, and the school. A simple principle of practice was guiding the therapists: all perspectives are relevant and speak to import parts of the predicament of all involved persons. This invites conversation around how each understands one’s own and the situation of all the other participants. Further that any decision that touches upon any of the participants must be a shared decision involving those touched by the decision. To reach such a goal, negotiations become the central part of conversations with the aim to be able to work together toward common goals.
The realization of these three principles happens through the actual and practical work within the fourth component of the CDCP Model: the collaborative process types and their specific collaborative strategies. In the situation of Joe, his family and the school, the following can be marked as especially important: Any meeting is built on the ability of the therapists to create an opportunity for turn-taking. What became clear was that it would be important for everybody if somebody could involve Joe in such turn-taking conversations as an interactive-dialogic process. It happened that Joe was at the beginning of realizing his interest in learning to play the guitar. This opened up the opportunity for the music teacher to come to Joe’s home and help him with his learning objective concerning the guitar. In this situation Joe told about bullying incidents and that he felt anxious about going outside the house. The teacher asked if he could invite in one of the therapists of the team to talk about this. This therapist also played the guitar and through collaboration around playing the guitar, this opened up possibilities for Joe, the teacher, and the therapist to talk also about the effects of the bullying and what to do about it. As a consequence of this discovery, conversations on bullying spread to all meetings involved in the work with Joe and from there into the whole school milieu. The specific collaborative strategies important in this situation were walking alongside, seizing the present moment, and aligning and scaffolding. Especially the use of the feedback tool involving feedback informing process with Joe as an informed, service-user involved process contributed to the collaborative work exemplifying the negotiated-participatory engagement process of the CDCP Model. The interactive-dialogical process established in various meetings sought to maintain all the relationships as a human relationship of respect and equal power. Respect and equality were sought and maintained by the therapist keeping everybody informed of what was being done and explicitly stating their understanding of all the other participants’ perspectives. When discrepancies between these perspectives and understandings were discovered, these were rectified and corrected through discussions. Again, the use of formalized feedback exemplified the presence of the negotiated-participator engagement process with a clear weight of putting all the different perspectives to work and that accommodating user participation meant that everybody should have a say in decisions that touched upon their situation. Lastly, the strategies in the negotiated supportive process were applied in this situation as well. The strategy of “helping in context” was applied in having the first meeting of the therapist with the school personnel without the presence of the parents following the request of the parents and also in organizing the help needed by Joe for guitar lessons. Coordinating was evident in the team’s concerted work involving the parents, the therapists, and the school personnel to provide multi-faceted approaches to help Joe, while “pulling together” was apparent in the efforts to help Joe’s problems with bullying involving all members. The therapists along with the music teacher advocated for Joe specifically to the school to deal with not only the problems of bullying of Joe but bullying in school in general. “Availing” was apparent in the willingness for the music teacher to give lessons to Joe, and the therapeutic team’s approach in working with Joe and his family.
In order to provide help concerning the family’s economic problems, the therapists took part in helping to get economic support from social services. The school needed to attend to the bullying situation which was discovered not only to have affected Joe but other adolescents too. The therapists took part in meetings on anti-bullying work and supported through the specialist’s declaration that for a period some boys, who perpetrated the bullying, needed extra teaching resources from the psychological-pedagogical services as support of the teachers in their anti-bullying work.
The contact with Joe, his family, and his school continued for almost 2 years. After about 8 months into the collaboration, Joe started to attend school again. In the following period, he got some therapeutic help with his anxiety and social awkwardness. The bullying was now a collective concern of the whole school and all the students and teachers were involved in the anti-bullying work so Joe was no longer a special case, but one of many who had felt the effects of bullying, something of which he expressed appreciation. The worries of the parents were lowered and their situation around the economy was resolved as well. Six months before ending contact there was only one meeting to decide if there were reasons to continue the contact. Both parents and school wanted to have the possibility of contacting the team if there was any change back to the original situation. During the ensuing 6 months there was no contact and through telephone calls to all involved participants, it was decided that the contact between Joe, the family, the school and the team would be terminated, closing the case.