Collaborative Care: The Team as a Social-Relational Healing Tool

How can a refocus on relationships, connections, and dialogue improve the overall patient experience?

“I cannot bear the thought of one more practitioner telling me they think they have the answer for me,” said “Molly” during a particularly difficult session when we were talking about her chronic low mood, pain, and difficulty sleeping. What she meant was that after hearing so many people say, in so many different ways, that they believed they could help her, she was learning and becoming overwhelmed by all of the things within her that did not work. Her nervous system, her diet, her sleep habits, her neurotransmitters, her thoughts, her ability to emotionally regulate … all of it was “broken.”

It was so difficult to watch Molly continue to suffer. The part of me shaped by solution-focused and efficient care wanted to jump up and say, “but have you tried X, Y, and Z?” Instead, I called on curiosity and attunement. I slowed down, and we talked about her frustration and her hopelessness. About how, although her team—myself included—all meant well, we were making it worse. About how, with every “solution” that did not work came another wave of believing she was unfixable. I saw hope begin to regrow as we sat through the pain of the hopelessness. We started talking about what should happen next (because honestly, even the best-laid plans still often need some level of goal setting), but this time, the conversation was different. I was looking to her to tell me what she needed from her entire team. I was asking her what she needed relationally.

I may not have had the answer that would solve all her ailments, but I did have the knowledge and ability to share with her team what I believed she needed from us: a willingness to reach a common goal and a common belief in her ability to heal. I was lucky enough to be working alongside practitioners who were willing to slow down and step away from having the answer. Rather than seeking information that validated our professional opinions, we sought to listen to the ways the client was experiencing her therapeutic experience with each of us (and I mean that in the sense of her entire being, not simply her mental health).

I would love to say that within months all this client’s symptoms miraculously improved, but in all honesty, we are still all actively working to help get her to where she wants to be. What did change, though, was the client’s belief she had in herself and her hope that things would improve. When a person believes in their ability to heal and feels they have an honest stake in their treatment, they are more likely to engage in their own care, thus improving treatment outcomes.1 With Molly, it was the shift to focusing on her experiences within relationships with her team that allowed this to happen.

Taking a Step Back

Sue Johnson, EdD, a researcher and clinician who has taken Bowlby’s attachment theory and molded it into Emotionally Focused Therapy, one of the most well-researched relational modalities of today,2 elaborates on Bowlby’s belief that “the human psyche, like human bones, is strongly inclined towards self-healing.”3 She shares that although this is true, it is validation and an environment that feels safe that allows this healing to actually take place.3 Similarly, Deb Dana’s application of polyvagal theory to clinical settings has shown that providing emotional connection and safety for our clients means improved physiological and psychological health outcomes.2

Unfortunately, as the third, fourth, and now fifth waves of therapy have studied and encouraged this importance of relationship and safety to promote healing, the systems that push for efficient and solution-focused care have put pressures on us to do the very opposite. These systems put pressure on us as providers to have answers as quickly as possible, and do not leave time for honest inquiry or dialogue. This means little to no opportunity to explore beyond measurable outcomes and desired goals, or to talk with the client’s other team members about how they experience this client, their areas of struggle, or their hopes for the client’s healing. It means that even with the best of intention, the relational experience often stops at the door.

Typically, when a client leaves our office, we have little to no control over what they do with their time and our recommendations after or between sessions. Although our clinical opinion is likely well-thought-out and offered with the intention of encouraging growth and change, the exchange of information can only go so far. The current system of care encourages clients to come to us because of our knowledge, skillset, and the answers we have for them—answers that we hope will lessen their pain and enhance their ability to live the life they want to live. Unfortunately, it is the idea that we, as the mental health providers, have all the answers that can hinder the development of relationships necessary for meaningful healing, thus impacting effectiveness of support.4,5

A New Approach: Relationally Focused Care

In Molly’s case, it was both my responsibility to share my knowledge and the responsibility of my team members to value my knowledge as we navigated this case. This exchange, in practice, models and encourages a similar exchange in our clients. It provides them with the opportunity to learn to believe in themselves and in their team. Emphasis on the relationships between providers, between providers and clients, within clients themselves, and between the entire team and the community is referred to as relationship-centered care (RCC), which conceptualizes health care by the quality of these relationships.4 The 4 principles of RCC go beyond the technicalities of providing care and can be seen in the Figure.

Even in settings in which there may be opportunity for RCC, emphasis on measurable outcomes can hinder collective conversation. Data obtained as part of an action research study aiming to understand the way professionals navigate discord and decision-making in a team-based format highlights these hindrances.6 The study showed that socioemotional concerns are introduced to team discussion far less frequently than task-oriented concerns, thus limiting cross-discussion between disciplines and even among mental health team members.6 Here we see, once more, the necessity of valuing and making space for conversation and exploration over efficiency.

Commitment to relationally focused care opens the door for us to move beyond the confines of efficiency and into “a state of connection [where] health, growth, and restoration are possible.”1 When it comes to supporting our clients, I believe it is our job, as practitioners and team members, to create an environment and experience that encourages our clients to make the choices that will improve their overall health and healing, mirroring the very environments and experiences Johnson and Dana write about. In order to do this, we have to believe that our clients are more than a system of pulleys and chains—we have to believe that they are one integrated system, thus requiring relationally oriented and integrated care.

When clients come to us, as the experts, looking for answers, we too can be fooled by the expectation that we should be able to give it to them. I believe, as the professional in the room, it is up to us to model for our clients that their whole story and experience with us in the moment matters, not just the measurable outcomes. In order for this to happen, we need to begin to move away from the idea that we, as any particular type of practitioner, are the best, most knowledgeable, or only option. This means valuing our role while also valuing the roles and knowledge of others. John Shotter discusses the danger of generalizability, which he defines as “continual rediscovery of sameness.”7,8 He posits that as soon as we place a label on someone, it narrows what we have the ability to discover and thus help to heal that person.7,8 In a field in which we are encouraged to silo, to find a specialty, we are ripe to fall into this risk of generalizability.9 If instead we permit ourselves, and encourage one another, to remain open to the answers, we open ourselves up to endless options for potential healing for our clients.

As a therapist who focuses much of her work on complex trauma, I am no stranger to the pull to have an answer for a client in pain. I also fall victim to the pressure to fix. Sometimes it takes the honesty of a client’s experience to remind us of the bigger picture, and that is exactly what happened with Molly.

The Search for Answers and the Collaborative Process

Whether we are talking about changing the way we collaborate individually with our clients, with our colleagues, or with the team supporting our clients, perhaps the place we ought to begin is with ourselves. Understanding what drives us to seek answers instead of exploration, be it societal, cultural, or internal forces, is a necessary step toward RCC. Becoming aware of our own relational tendencies can help navigate intentionally toward connection. Becoming self-informed through tools like The Attachment Project’s Attachment Quiz can be a great place to start.10 Beyond understanding ourselves, we can start to get curious about our colleagues’ experiences, all in an effort to prioritize relationship.

The evidence is clear that relationship, dialogue, and connection affect patient experience,4,5,9 and the more positive the experience, the more likely treatment is to have the desired effects of healing, growth, and change.9 RCC contributes to the development of a safe environment, encourages open dialogue, and creates a shared experience of goal development and attainment.4,5,9 The idea that we as practitioners should be able to cure or heal our clients by ourselves is an outdated and limiting model of treatment. If we do the work to understand our own selves relationally, and the beliefs that may contribute to our own need for success, we provide an opportunity to shift the focus to where it belongs: on the relationship. We need one another, and our clients need us to model connection and belief in one another so that they can believe in the possibility of their healing.9

Ms Genet is a licensed independent clinical social worker in the state of New Hampshire and a therapist and owner of Soul’s Nest Counseling & Wellness LLC.

References

1. Dana D. Polyvagal Exercises for Safety and Connection: 50 Client-Centered Practices. Norton Professional Books; 2020.

2. Johnson SM. Attachment theory and emotionally focused therapy for individuals and couples: perfect partners. In: Attachment Theory and Research in Clinical Work With Adults. The Guilford Press; 2009:410-433.

3. Bowlby J. A Secure Base. Basic Books; 1988.

4. Beach MC, Inui T; Relationship-Centered Care Research Network. Relationship-centered care. A constructive reframingJ Gen Intern Med. 2006;21 Suppl 1(Suppl 1):S3-S8.

5. Miller RC. The somatically preoccupied patient in primary care: use of attachment theory to strengthen physician-patient relationshipsOsteopath Med Prim Care. 2008;2:6. Published 2008 Apr 29.

6. Atwal A, Caldwell K. Do all health and social care professionals interact equally: a study of interactions in multidisciplinary teams in the United KingdomScand J Caring Sci. 2005;19(3):268-273.

7. Shotter J. Goethe and the refiguring of intellectual inquiry: from “aboutness”-thinking to “withness”-thinking in everyday life. Janus Head. 2005;8(1):132-158.

8. Shotter J. More than cool reason: “withness-thinking” or “systemic-thinking” and “thinking about systems.”Int J Collab Enterp. 2012;3(1):1-13.

9. Anderson H. Collaborative-dialogue based research as everyday practice: questioning our myths. In: Systemic Inquiry: Innovation in Reflexive Practice Research. Everything is Connected Press. 2014;60-73.

10. Attachment style test. The Attachment Project. Accessed December 1, 2021.