Collaboration involving service users in health care processes has become a desired approach to attain better outcomes in health care. Many countries have sought reforms aimed at maximizing the potential of service users to regain as much control as possible over care decisions and through the trajectory of care (European Commission, 2005; Norwegian Ministry of Health and Care Services, 2008-2009; World Health Organization, 2013).
D’Amour and Oandasan (2005) in their model of Interprofessional Education for Collaborative Patient-Centred Practice (IECPEP), which has been implemented in Canada, proposed that service users are active partners positioned at the center of the healthcare processes in the interprofessional collaborative practice framework. The World Health Organization (WHO) also has accepted the idea that collaborative practice in health care occurs when multiple health workers provide comprehensive services by working together synergistically along with patients, their families, care-givers and communities to deliver the highest quality of care across settings (World Health Organization, 2013).
The inclusion of service users in collaborative practice is supported by a growing body of research on service users’ preferences for mental health care and service provision (e.g., Craven & Bland, 2006; Crocker, Trede, & Higgs, 2012; Kates, McPherson-Doe & George, 2011; Mickan, Hoffman, & Nasmith, 2010), recovery (Borg & Davidson, 2008; Davidson, et al., 2009; Glover, 2012; Perkins, Repper, Rinaldi, & Brown, 2012; Slade, 2009), person-centeredness (Stanton, 2002; McCormack & McCance, 2010) and shared decision-making (e.g., Deegan, 2010; Drake, Deegan, & Rapp, 2010; Drake & Deegan, 2009). Service provision with input of lived experiences and personal perspectives into care (e.g., Davidson, et al., 2009; Perkins & Slade, 2012) and incorporating positive relationships between service users and professionals (Anderson & Gehart, 2007; Jones et al., 2009; D’Amour, Ferrada-Videla, Rodrijuez, & Beaulieu, 2005; Suter et al., 2009; Weinstein, Whittington, & Leiba, 2003) seem to be more effective in producing better outcomes for service users than those not involving service users in the provision of care. The competence and capability of people in listening, taking each other seriously and believing in the perspectives of others concerning both the relationship and the partnership they are involved with have been found to promote collaborative relationships (London, St. George, & Wulff, 2009; Strong, Sutherland, & Ness, 2011). Making collaboration successful requires feedback from all parties engaged in the development of effective collaborative practices (Sundet, 2011).
In the research literature the models and frameworks that keep the person at the center of decision-making (and de facto in a collaborative relationship with health professionals) focus on essential principles for collaboration. These include working with (sometimes competing) beliefs and values, power and power balancing, engagement strategies, consistency of care delivery, relationship competencies, role blurring and negotiated decision-making (Strong, 2010; McCormack & McCance 2010). However, such models tend to be structurally organized about various factors that influence collaboration and do not illustrate and identify key processes of collaboration that need to be integrated into practice (see for example, Bedwell et al., 2012). The literature on collaborative practice is also rich in delineating the characteristics and essential features of collaboration, personal and institutional factors influencing professionals’ collaborative behaviours, and the effects of collaboration on outcome. However, an in-depth elucidation of what participants (i.e., professionals and service users/families) should «do» to make the practice to be collaborative is lacking. In addition, we did not find work that elaborates on actual processes of collaboration involving service users.
In this paper, we illustrate the key processes of collaboration applied in practice in two case studies and integrate these processes into a collaborative practice model for mental health care in the community. Drawing on the findings of the two case studies applying participatory research, we followed an iterative process that has been previously developed by McCormack and McCance (2006) to develop the model. Therefore, our presentation of research findings is focused and selective toward developing this model. The model specifies the key processes that are critical in attaining collaboration among participants including service users and families in mental health care.
Two case studies applying action research provide the findings elaborating the processes of collaboration applied in practice, which are incorporated in developing a model of collaborative practice. Action research method applied in these two case studies was participatory and used multiple data collection methods including field observations, in-depth interviews and focus group discussions. Participatory action research is viewed to be one of the most appropriate methods to gain an understanding regarding processes of collaboration from the participants’ perspectives (Borg, Karlsson, Kim, & McCormack, 2012).
Study 1: Crisis resolution and home treatment project.
A case study of a Crisis Resolution and Home Treatment (CRHT) team was carried out in the Health South Region of Norway from 2007 to 2011 during a period of its establishment and operation (Karlsson, Borg, & Kim, 2008). The overall aim of the research project was to develop knowledge for new forms of community-based practices for people experiencing mental health crisis (Borg et al., 2012; Karlsson et al., 2008; Karlsson, et al., 2012). The research project, of which the case study of a CRHT is a sub-study, applied various research methods including a participatory action research, a phenomenological descriptive method, and a quantitative method. This case study used a participatory inquiry methodology applying multistage focus group interviews to elicit and include voices of health care professionals, service users and family members (Heron, 1996; Karlsson et al., 2008). The major themes addressed in the focus group interviews were the participants’ meanings of mental health crises, practice approaches, and issues in the practice of CRHT within the mental health services. Three sets of multistage focus group interviews were held during the period of 2008 to 2010 involving (a) health care professionals, (b) service users, and (c) family members as separate groups.
The multistage focus group interviews with the health care professionals were carried out monthly for 24 months from January 2008 to January 2010, involving all members of the CRHT team that included 12 professionals – one psychologist, two social workers, and nine mental health nurses. The duration of these focus group interviews was between 1 and 1.5 hours. Three multistage focus group interviews were held with the service users during a period of 6 months in 2009. Four women and two men who were service users of the CRHT were participants in this set of focus group interviews with all six participating in the first group interview, and only five (four women and one men) participating in the second and third group interviews. The participants were recruited from the total list of service users of the CRHT team. The age of this group ranged from 24 to 64 years. The duration of these focus group interviews was 1.2 to 2 hours. The focus groups were led by the researchers. Three additional multistage focus group interviews were held during a period of 6 months in 2010 with 7 family members who were parents of children who had experienced mental health issues over a long period of time, some of them more than 10 years. Five women and two men were participants who were recruited through the nominations by the mental health professionals in the community. The duration of these focus group interviews was 1.5 hours. The focus groups were led by the researchers. All meetings were audio-taped and transcribed verbatim. Summarized notes of the transcripts for each meeting were shared with the respective participants (the persons with lived experiences) at the beginning of the subsequent meeting for feedback and to provide a context for open dialogue. Thereafter the data were analyzed using a thematic analysis based in a hermeneutic-phenomenological approach to derive key themes across the different sets of data (Braun & Clarke, 2006).
Study 2: A national program to develop person-centred practice in residential aged care.
The second case study is a participatory action research project of the Older Persons Services National Practice Development Program that began in 2007 working with care home staff in the Republic of Ireland to develop a person-centred approach to care. The program implemented a framework for person-centred practice for older people across multiple care home settings in Ireland, (n=18) through a collaborative facilitation model and carried out an evaluation of the processes and outcomes. The program methodology was that of emancipatory practice development (Manley & McCormack, 2003) underpinned by a specific, person-centred practice framework (McCormack & McCance, 2006). At each participating site, following an initial awareness campaign involving all staff, residents and families at each participating site, internal facilitators were selected and a practice development programme group representing staff from different areas and different grades was established. The emancipatory practice development for person-centred practice ensued with a formal programme and skills development day every 6 weeks involving all participants at each site (n = 360) including the internal facilitators and the external facilitators from the Nursing and Midwifery Planning and Development Units (NMPDU) and the national/university coordinators. In addition, a range of interim meetings, project working groups and discussion groups were held with the participants throughout the length of the project. All participants including the facilitators were engaged in workplace learning activities to develop person-centred practice at the sites. The effectiveness of the development processes were evaluated through records of all development activities (meetings, working groups, discussion groups, workplace learning activities and action plans for change). These data were analysed using thematic analysis to derive key themes across the different data sets. Nursing outcomes were evaluated using the Person-centred Nursing Index (PCNI) and the Person-centred Practice Index (PCCI) (Slater, O’Halloran, Connolly, & McCormack, 2010) in order to examine the effects of person-centred practice learning and implementation. These tools measure the processes and outcomes of person-centred practice from the perspectives of registered nurses, unregistered care staff and patients at three different time points from 2007 to 2009.
The Regional Medical Research Ethics Committee, Health Region II (South) of Norway and the Norwegian Social Science Data Services on behalf of The National Inspectorate approved Study 1. Ethical approval for Study 2 was received from six individual regional ethics committees. The university facilitators developed a ‘core protocol’ and supporting letters, information sheets and guidance notes. They then worked with each NMPDU facilitator to contextualize the core materials to each regional ethics committee as they all had different requirements. The protocol took account of development activities, individual site evaluation activities and the overall programme evaluation framework.
The focus of our presentation of the results is limited to the processes of collaboration as they emerged in these two studies. As the two research projects had multiple aims in their designs, the overall results include various aspects related to the development of a CRHT and the institution of the person-centred service programs, some of which are not directly related to collaborative processes. The findings presented in this section are those directly related to how the research participants progressed in becoming collaborative.
Findings from Study 1.
Crisis resolution and home treatment project. This participatory action research was carried out with the focus group interviews as the major method applying open dialogue as the approach for the practice development at a newly established CRHT team. Open dialogue (OD) both as the philosophy and the process was the basis for practice development in the CRHT team as well as for the research process. Open dialogue was introduced at the initial meetings and reinforced through discussions at the following sessions as the approach for group discussions and as a way to develop practice approaches. The perspective of and process in open dialogue (Seikkula et al., 2003; 2006) underline the use of dialogic reflection among all participants in a group. The major tenets of open dialogue originally developed as an approach for psychiatric care by Seikkula and colleagues (2003, 2006), which include (a) listening, (b) openness to others’ experiences, views, meanings, and interpretations, and (c) dialogic togetherness, were applied in the focus group discussions. In a sense this application of open dialogue encompasses both the clinical (i.e., psychiatric) orientation and a non-clinical group-work orientation. The integration of open dialogue in the focus group interviews meant for all participants (i.e., the co-researchers including service users, service providers/family members and the researchers) to be engaged in the process of open dialogue for clinical problem solving, in developing practice approaches, and in dealing with differences, conflicts, and misunderstandings.
The major themes emerging from the process of open dialogue in this research were (a) valuing uncertainty, and (b) tolerance for uncertainty (Borg et al., 2010; Borg et al., 2012). The focus group discussions engaged all participants in in-depth dwelling for explorations of complicated situations from a variety of perspectives, avoiding closures with conclusive or fixed ideas. This involved learning to value uncertainty and a genuine commitment to helping all participants to remain open-minded. Possessing and drawing upon previous clinical experiences were helpful in this as well as being open and willing to work with exemplars that the co-researchers presented and discussed. Valuing uncertainty also meant an acceptance of varying or opposing interpretations as viable ones. In addition to valuing uncertainty, the participants articulated the continuing need to remain open-minded especially in dealing with controversial clinical practice issues. Acknowledging that there is no one «right» answer or approach was critical and represented the theme of tolerance for uncertainty. Tolerance for uncertainty implied being able to be flexible in thinking and expecting the unusual and extraordinary in situations, and was evident in appreciating and listening to what people involved actually had to say. It encouraged dwelling on issues, opening up for a variety of perspectives on what was going on and trying to find words for the experiences and activities.
Open dialogue, in which valuing uncertainty and tolerating uncertainty were upheld, was the process through which collaboration among the participants was achieved to handle situations of differing opinions and approaches and to arrive at mutually acceptable solutions. Open dialogue made it possible for the participants to reveal themselves without constraints so that both self-understanding through reflections and mutual understanding through realization of others’ perspectives were possible (Borg et al., 2012). This was important, as self-understanding is vital for negotiating mutual understanding (Strong et al., 2011). Open dialogue enhanced shared decision-making that was based on understanding others’ perspectives and discussions of implications from multiple view-points (Borg et al., 2010).
Findings from Study 2.
A national program to develop person-centred practice in residential aged care. The collaborative facilitation model adopted for this research involved both a structured framework to facilitate and support the implementation of a practice model in the care settings and a process framework to work collaboratively in the regional and local settings. The structured framework for this project included research coordinators, regional and local facilitators, and all care-home staff as the co-researchers involved in every aspect of the research project including data collection and data analysis. The process framework was based on the philosophy of collaboration and facilitation, by which the progress of the local care home groups in learning and adopting the person-centred culture was sought as a group and was supported by facilitative processes built into the tiered structure. Collaborative practices were evident during all stages of the work and included participation in all decisions about practices to be developed, negotiation with managers and leaders for resources and support, facilitation of discussions with patients/residents/families and use of tools and processes to ensure that all participants had an equal say in all decisions and activities.
It was participatory group work that facilitated shared decision-making and shared learning in the groups. Participatory engagement of the members was the major process for successful implementation of the person-centred practice model. Participatory engagement in various aspects of service delivery implicates participants for identification and responsibility, especially in terms of outcomes (Carr, 2012). Participatory engagement refers to a direct, personal involvement of professional providers and service users/families in all aspects of service delivery, including assessment, planning, implementation, and evaluation.
The results of the two case studies suggest that healthcare teams need to apply open dialogue as a mode of communication and to participate actively in every aspect of the team’s work in order for the teams to practice in a collaborative mode. Open dialogue that embraces valuing and tolerating uncertainty makes it possible for team members to dwell on and deal with controversial issues addressing differences in understandings, opinions, and approaches. It is the process critical for attaining collaboration among members. On the other hand, collaborative practice involves team members’ active participation in the activities of the team’s work, making the ownership of the practice to be held equally by all members. Although these results were obtained from two different case studies, the two processes identified in these studies can be brought together as the two complementary sides of collaborative practice.
The processes of open dialogue and participatory engagement are integrated into a comprehensive model for collaborative practice as the processes have to be considered within the complex system of mental health care provision. We followed an iterative process that has been previously developed by McCormack and McCance (2006) to develop the model. The process involved a series of systematic steps to the model development including; (a) the mapping of data from the two case studies to existing models of collaboration and partnership; (b) the identification of potential key components of the model; (c) designing a draft model; (d) checking out the draft model with the whole research team; (e) redrafting of the model; and (f) testing of the model for face validity and acceptability with colleagues undertaking partnership research.
Collaborative practice in mental health care is conceptualized as an approach to enhance the effectiveness of care to service users in community settings. It is a service model that involves collaboration among the professional service providers, service users and families in (a) assessing mental health problems and personal resources (Beresford & Carr, 2012), (b) developing plans of care and selecting approaches to treatments and interventions (Evans & Jones, 2012), (c) implementing and working through care and treatments (Gabbay & Le May, 2011), and (d) evaluating outcomes of services (Purtell, Rickard & Wyatt, 2012). The model is composed of four components: (a) the framework for service orientation, (b) two interconnected collaborative structures, (c) the principles of collaboration and (d) the processes of collaborative practice as shown in Figure 1.
Component One: The framework – The philosophical and theoretical foundation for collaborative service orientation.
The first component in the model is ‘the framework for service orientation’, which provides the philosophical and theoretical underpinnings for the practice of community mental health care. The framework is comprised of two perspectives: (a) person-centred practice and (b) recovery-orientation. These two components together inform an integrated commitment to user-oriented practice. Collaborative practice is philosophically oriented to the critical philosophy of mutuality in social life, human autonomy as the critical humanistic value, and self-determination as an approach to human life. Thus the theoretical perspective for collaborative practice for mental health care grounded in two key orientations of person-centred practice and recovery-orientation puts service users at the center of service delivery.
The concept of person-centered practice sees users and their family members as equal partners in planning, developing and assessing mental health care to make sure it is most appropriate for their needs. Person-centeredness is an ideology that is based on the concept of the singularity of persons and the values of autonomy and self-determination. In mental health care and psychiatry, person-centred practice has its roots in the client-centered therapy of Carl Rogers (1951) from the tradition of humanistic psychology. Person-centred practice as in Rogers’ client-centered therapy puts the individual at the center for discovering and transforming oneself and one’s life. Person-centred practice involves putting users and their families at the heart of all decisions (McCormack & McCance, 2010; McCance, McCormack, & Dewing, 2011). Person-centred practice requires the formation of therapeutic relationships between professionals, service users and their family members, which are built on mutual trust, understanding and sharing collective knowledge (McCormack, 2003; McCormack & McCance, 2006; McCance, et al., 2011; Nolan et al., 2004; Binnie & Titchen, 1999; Dewing, 2004). Person-centred practice has been shown to advance concordance between mental health care providers and service users on treatment plans, improve health outcomes, and increase user satisfaction (Ekman et al., 2011).
Although recovery orientation in general refers to shifting the aim of mental health care from maintenance to recovery and from illness-orientation to everyday life orientation, there are many different conceptualizations and approaches in recovery orientation (Bonney and Stickley, 2008; Stickley and Wright, 2011a; 2011b). The recovery-orientation in mental health care adopted as the theoretical base for collaboration in this model views recovery as an individual process (e.g., Deegan, 1988; Hydén, 1995) and a social process (Borg & Davidson, 2008; Topor, et al., 2011). First, recovery is viewed as a process that takes place within and by the individual. This means that the aim of the recovery process is defined at the individual level and the central actor in the recovery process is the individual him- or herself (Davidson, 2001; 2003; Strauss, 1996; Topor, 2001). A deep understanding of persons’ own thoughts, experiences and points of view in their recovery process is emphasized (Topor et al., 2011). Second, the individual’s recovery process is viewed as a social process (Borg & Davidson, 2008; Tew, 2008; Topor et al., 2011). This means that there are many contextual aspects that are implicated within an individual’s recovery process, such as impending relationships, life conditions, services and systems of care, making the nature of recovery in terms of social integration (Topor et al., 2011). Recovery models focusing on recovery as an individual process emphasize the importance of developing self and self-identify (Bonneys & Stickley, 2008), while recovery models focusing on recovery as a social process accentuate processes aimed at social inclusion as in the work of Repper and Perkins (2009). In our proposed model of collaborative practice, however, the concepts of person-centred practice and recovery orientation are combined to formulate a theoretical perspective for the model.
Collaborative practice is then a way to take into account person-centred practice and recovery orientation to improve community mental health care. The concepts of person-centred practice and recovery orientation emphasize the need to have the service user at the center of service-process in mental health care both to tailor the care by pivoting decision-making in concert with person-centred needs and also to frame the movement toward recovery in the context of the service user’s needs through the service user’s active participation in the service process. Collaborative practice in which assessment, care planning, and treatments are processed through sharing, dialogue, and negotiation can integrate person-centredness and recovery-orientation, resulting in better outcomes for service users (Borg, et al., 2012; McCormack & McCance, 2006; Sundet, 2011; Strong et al., 2011).
Component Two: The structural component of collaborative practice for mental health care.
The second component of the model illustrates the dual-structured collaborative practice of mental healthcare, one focusing on collaboration within service processes and the other focusing on coordination/collaboration within the healthcare system involving healthcare providers and service sectors (i.e., system-oriented collaboration) to meet service users’ multifaceted needs. The model thus encompasses two collaborative structures – collaboration in service processes and collaboration within the mental healthcare system. Collaborative practice within service processes refers to direct service relationships between professional service providers and service users. It may be as simple as the one between a mental health professional and a service user or as complex as in team approaches involving multiple mental health professionals from various service sectors along with a service user and his/her network members. Collaboration in the mental healthcare system specified in the model addresses particularly the needs for collaborative practices in the context of community mental health care, in which diverse forms and modalities of services and care are available for people with mental health problems. In community mental health care, there are multiple service types such as individual practice, care teams, clinics and day-care centers provided by various mental health professionals, organized in a complex web of interrelations and independency. Collaborative practices within the health care system are structurally oriented to the design of healthcare organization for a given community.
This interrelated form of collaborative practice is critical for community mental health care, both for clinical outcomes and clinical integration. The major goal for collaborative practices within service processes is for best clinical outcomes. On the other hand, the system-oriented collaboration addresses clinical integration. Clinical integration refers to «the extent to which patient care services are coordinated across people, functions, activities, and sites over time so as to maximize the value of services delivered to patients» (Shortell et al., 2000, p. 129). Clinical integration seeks to offer appropriate services to service users, to make connections among service organizations and providers, to facilitate communication among different sectors of service provision, and to streamline and limit duplication in services. Ultimately the goal of clinical integration is an improvement in clinical outcomes through coordinated services. Thus, these two forms of collaboration in community mental health care are interconnected to produce best outcomes in service users. Involvement of service users in these two types of collaboration in community mental health care is thought critical in this model. Inclusions of service users and their families in discussions, deliberations, and decision-making in both clinical integration through system-oriented coordination and service-processes for clinical outcomes are critical in this collaborative model.
Component Three: The principles of collaboration.
The third component in the model specifies a set of three principles constituting the foundational guidelines for collaboration. The principles are the starting points for a collaborative process clarifying the premises upon which various interactive processes must occur. The principles stem from the values inherent in the theoretical perspective for collaboration. We propose in this mode three principles as the most critical for collaboration to be successful from the process perspective: (a) self-understanding, (b) mutual understanding, and (c) shared decision-making.
The principle of self-understanding upholds for people to have a firm grasp of their own perspectives, knowledge, motivations, and biases. Self-understanding is critical, especially in establishing relationships because people usually think and act through the reflection on one’s desires and goals (Taylor, 1985). While the principle of self-understanding is subject oriented, the principle of mutual understanding is relationship oriented. Mutual understanding based on Habermas’ (1984) critical philosophy is considered to be the primary basis for avoiding or correcting distortions, domination/oppression, and coercion in the conduct of social life. In order to achieve mutual understanding, people must be engaged in communicative actions to tease out differing validity claims of truth, rightness, and truthfulness (Habermas, 1984). The principle of shared decision-making is a necessary condition for any collaborative work, because people involved in collaborative practice should be able to make decisions together and share responsibilities. It not only involves mutual goal-setting but also making decisions regarding assessments and treatment together. Mutual goal setting means working together toward goals that are understood and accepted by the participants involved in the practice through cooperative decision-making involving negotiations that are based on openness and respect.
These three principles need to be incorporated in the different contexts they are applied, because the context in itself has meaning for how collaborative practice develops (Ness & Strong, 2013; McNamee & Gergen, 1992; Strong, 2010). Collaborative practice requires for all participants to understand each other’s roles and diversity if tasks and roles are essential for a successful collaboration (Tomasello, 2009). Self-understanding is a pre-requisite to mutual understanding, and these two principles together allow people to gain and appreciate differing perspectives, values and motivations. This is what London et al. (2009, p. 1) call “equal footing”, which means that collaborative efforts by all partners are based on the sense that all of the collaborating participants are worthy and important in the efforts. On the other hand, the principle of shared decision-making is at the heart of the collaborative process resulting in the nature of collaborative work. Shared decision-making as a principle is infused in dialogical processes such as mutual turn-taking (Bateson, 1975) or mutually negotiated dialogue (Strong et al., 2011).
Component Four: The processes of collaboration.
The critical aspect of collaborative practice is how collaboration actually occurs in mental health services. Collaborative practice is shaped as participants meet together in order to address and respond to the needs of service users. It thus requires ways of doing the work of collaboration that are identified in these two studies as the processes. In addition, collaborative practice is depicted by various characteristics in the literature including: cooperative endeavor; team approach; partnership and willing participation; interdependency; sharing in planning, decision making, intervention and responsibility; mutual respect and trust; symmetric empowerment and power sharing; understanding and respecting others’ perspectives, values and philosophies; and colocation (Banfield & Lackie, 2009; Bronstein, 2003; Craven & Bland, 2006; Henneman, Lee, & Cohen, 1995; Reese & Sontag, 2001; Way, et al., 2001). In order for collaborative practices to represent such characteristics, some processes are essential. Two key processes for collaboration elaborated in the two case studies are the essential modes through which collaboration occurs among participants and the ways to produce these characteristics of collaboration.
The two key processes upholding the principles of collaboration as elaborated through our studies are (a) open dialogue and (b) participatory engagement. Both of these processes are interactional and focus on how people need to work together to achieve best outcomes. The process of open dialogue based on the work of Seikkula and colleagues (2003, 2006) originally developed as an approach to treat psychosis, involves unconstrained back-and-forth exchanges of meanings, voices and interpretations, and creating shared language through which common understandings regarding situations, problems, goals, and approaches are developed and shared. Two themes that emerged in Study 1 – valuing uncertainty and tolerance for uncertainty – are embedded in the process that aims for common understandings among participants. Valuing uncertainty and tolerance for uncertainty generate the freedom in participants to address different options and choices in meanings, interpretations and courses of action. In the process therefore participants are symmetrically empowered and are not fearful or uncomfortable with the generative nature of the group’s work.
The process of participatory engagement is sharing in all aspects of a group’s work by its participants willingly, without feeling constraints or prejudices and bringing in ‘expertise’ of each participant. The process is also underpinned by the principles of self-understanding, mutual understanding and shared decision-making, as the process calls for active sharing involvement of participants in a group’s deliberations and actions with a deep understanding of one’s own and each other’s contributions. Active sharing involvement means being directly and personally engaged in sharing every aspect of a group’s work whether it is dialogue or action and whether it is for understanding, goal-setting, planning, or intervention. Participatory engagement as a process in community mental healthcare in its first part then is through discursive practices involving all participants (professional providers, service users, and network members) for gaining mutual understanding and intersubjectivity, and for decision-making regarding the nature of problems, goals, and approaches to problems. The second part of participatory engagement is for action-sharing in which all participants are involved in the implementation of service plans, as well as for shared monitoring of their progress. Participatory engagement therefore implies a shared view of the situation, a shared material and world and a joint response. Participatory engagement is relational in that it is shaped by the dynamics of a group’s work and of participants’ relationships that are shaped both by the principles and the process of interaction. This means that the process of participatory engagement is not only fundamentally guided by the principles for collaboration but also is influenced by the nature of interaction. Therefore, the process of open dialogue is intrinsically embedded in the process of participatory engagement.
The proposed model for collaborative practice in community mental health care addresses how successful collaboration can occur in the practice of community mental health care, placing service users at the center of practice. The model is normative in the sense that it preconfigures the framework for practice that puts service users at the center of practice and specifies collaboration that is shaped by three principles and two key processes. This paper addresses the current mandate for mental health care that emphasizes coordination and collaboration. Since the proposed model is a normative one, it is critical to gain further understandings regarding its applicability in mental health practice.
The current mandate for mental health care emphasizes coordination and collaboration.
Anderson, H., & Gehart, D. (Eds.) (2007). Collaborative therapy: Relationships that make a difference. New York, NY: Routledge.
Banfield, V., & Lackie, K. (2009). Performance-based competencies for culturally responsive interprofessional collaborative practice. Journal of Interprofessional Care, 23(6), 611–620. doi: 10.3109/13561820902921654.
Bateson, M. C. (1975). Mother-infant exchanges: The epigenesis of conversational interaction. In D. Aaronson & R. Rieber (Eds.), Developmental psycholinguistics and communication disorders. Annals of the New York Academy of Sciences (pp. 101–113). Volume 263. New York, NY: Academy of Sciences, Bayley.
Bedwell, W. L., Wildman, J. L., DiazGrandados, D., Salazer, M., Kramer, W. S., & Salas, E. (2012). Collaboration at work: An integrative multilevel conceptualization. Human Resource Management Review, 22, 128–145. doi: 10.1016/j.hrmr.2011.11.007.
Beresford, P., & Carr, S, (Eds.) (2012). Social care, service users and user involvement. London, UK: Jessica Kingsley Publishers.
Binnie, A., & Titchen, A. (1999). Freedom to practise: The development of patient-centred nursing. Oxford: Elsevier.
Bonney, S., & Stickley, T. (2008). Recovery and mental health: a review of the British Literature. Journal of Psychiatric and Mental Health Nursing, 15, 140–153. doi: 10.1111/j.1365-2850.2007.01185.x/a>.
Borg, M., & Davidson, L. (2008). The nature of recovery as lived in everyday experience. Journal of Mental Health, 17(2), 129-140. doi: 10.1080/09638230701498382.
Borg, M., Karlsson, B., & Stenhammer, A. (2013). Recoveryorienterte praksiser: en systematisk kunnskapssammenstilling [Recovery oriented practice: A systematic review]. Rapport 4/2013. Oslo, Norway: Nasjonalt kompetansesenter for psykisk helsearbeid (NAPHA).
Borg, M., Karlsson, B., Kim, H. S., & McCormack, B. (2012). Opening up for many voices in knowledge construction [37 paragraphs]. Forum Qualitative Sozialforschung/Forum: Qualitative Social Research, 13(1), Art. 1.
Borg, M., Karlsson., B., & Kim, H. S. (2010). Double helix of research and practice – developing a practice model for crisis resolution and home treatment through participatory action research. International Journal of Qualitative Studies on Health and Well-being, 5(1), 4647–4655. doi: 10.3402/qhw.v5i1.4647.
Braun, V. & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77–101. doi: 10.1191/1478088706qp063oa.
Bronstein, L. (2003). A model for interdisciplinary collaboration. Social Work, 48(3), 297–306.
Carr, S. (2012). Participation, resistance and change: Examining influences on the impact of service user participation. In P. Beresford, & S. Carr, (Eds.), Social care, service users and user involvement (pp. 52-68). London, UK: Jessica Kingsley Publishers.
Craven, M. A., & Bland, R. (2006). Better practices in collaborative mental health care: An analysis of the evidence base. Canadian Journal of Psychiatry, 51(Supplement 1), 1s–72s.
Crocker, A., Trede, F., & Higgs, J. (2012). Collaboration: What is it like? – Phenomenological interpretation of the experience of collaborating within rehabilitation teams. Journal of Interprofessional Care, 26(1), 13–20. doi: 10.3109/13561820.2011.623802.
D’Amour, D., Ferrada-Videla, M., Rodrijuez, L. S., & Beaulieu, M. (2005). The conceptual basis for interprofessional collaboration: Core concepts and theoretical frameworks. Journal of Interprofessional Care, Supplement 1, 116–131. doi: 10.1080/13561820500082529.
D’Amour, D., & Oandasan, I. (2005). Interprofessionality as the field of interprofessional practice and interprofessional education: An emerging concept. Journal of Interprofessional Care, Supplement 1, 8-20. doi: 10.1080/13561820500081604.
Davidson, L. (2001). Us and them. Psychiatric Services. 52(12), 1579–1580. doi: 10.1176/appi.ps.52.12.1579.
Davidson, L. (2003). Living outside mental illness: Qualitative studies of recovery in schizophrenia. New York: New York University Press.
Davidson, L., Tondora, J., Lawless, M. S., O’Connell, M. J., & Rowe, M. (2009). A practical guide to recovery-oriented practice: Tools for transforming mental health care. New York: Oxford University Press.
Deegan, P. E. (1988). Recovery: The lived experience of rehabilitation. Psychosocial Rehabilitation Journal, 9(4), 11-19.
Deegan, P. E. (2010). A web application to support recovery and shared decision making in psychiatric. Psychiatric Rehabilitation Journal, 34(1), 23–28. doi: 10.2975/34.1.2010.23.28.
Dewing, J. (2004). Concerns relating to the application of frameworks to promote person-centredness in nursing with older people. Journal of Clinical Nursing, 13(3a), 39-44. doi: 10.1111/j.1365-2702.2004.00925.x.
Drake, R. E. & Deegan, P.E. (2009). Shared decision making: Whose decision? (In Reply) Psychiatric Services, 60, 1555-1556.
Drake, R.E., Deegan, P.E., & Rapp, C. (2010). The promise of shared decision making in mental health. Psychiatric Rehabilitation Journal, 34(1), 7–13. doi: 10.2975/34.1.2010.7.13.
Ekman, I., Swedberg, K., Taft, C., Lindseth, A., Norberg, A., Brink, E., Carlsson, J., Dahlin-Ivanoff, S., Johansson, I. L., Kjellgren, K., Lidén, E., Öhlén., J., Olsson, L. E., Rosén, H., Rydmark, M., & Sunnerhagen, K. S. (2011). Person-centred care – ready for prime time. European Journal of Cardiovascular Nursing, 10(4), 248–251. doi: 10.1016/j.ejcnurse.2011.06.008.
European Commission (2005). Green paper: Improving the mental health of the population: towards a strategy on mental health for the European Union. COM (2005)484. Brussels: EU Health and Consumer Protection Directorate-General.
Evans, C., & Jones, R. (2012). Changing patterns of service user involvement, 1990-2010. In M. Barnes, & P. Cotterell (Eds.), Critical perspectives on user involvement (pp. 89–99). Bristol, U.K: The Policy Press.
Gabbay, J., & LeMay, A. (2011). Practice-based evidence for healthcare: Clinical mindlines. New York, NY: Routledge.
Glover, H. (2012). Recovery, life long learning, social inclusion and empowerment: Is a new paradigm emerging? In P. Ryan, S. Ramon, & T. Greacen (Eds.), Empowerment, lifelong learning and recovery in mental health: Towards a new paradigm (pp. 15–35). London, UK: Palgrave Publishers.
Habermas, J. (1984). The theory of communicative action (Vols. I & II). Boston: Beacon Press.
Henneman, E., Lee, J., & Cohen, J. (1995). Collaboration: A concept analysis. Journal of Advanced Nursing, 21, 103–109.
Heron, J. (1996). Co-operative inquiry. London, UK: Sage.
Hydén, L. C. (1995). The rhetoric of recovery and change. Culture, Medicine and Psychiatry, 19, 73–90. doi: 10.1007/BF01388249.
Jones, I. R., Ahmed, N., Catty, J., McLaren, S., Rose, D., Wykes, T., & Burns, T. (2009). Illness careers and continuity of care in mental health services: a qualitative study of service users and carers. Social Science & Medicine, 69(4), 632–639. doi: 10.1016/j.socscimed.2009.06.015.
Karlsson, B., Borg, M., & Kim, S.H. (2008). From good intentions to real life: introducing crisis resolution teams in Norway. Nursing Inquiry. 15(3), 206–215. doi: 10.1111/j.1440-1800.2008.00416.x.
Karlsson, B., Borg, M., & Emaus, H. S. (2012). Ambulante akutteam ved distriktspsykiatriske sentre – en oppfølgingsstudie [Crisis resolution home treatment teams in community mental health centers in Norway. A follow-up study]. Nordisk sygeplejeforskning, 4, 284–296.
Kates, N., McPherson-Doe, C., & George, L. (2011). Integrating mental health services within primary care settings: the Hamilton Family Health Team. Journal of Ambulant Care Management, 34(2), 174–182. doi: 10.1097/JAC.0b013e31820f6435.
London, S., St. George, S., & Wulff, D. (2009). Guides for collaborating. International Journal of Collaborative Practices 1(1), 1-8.
Manley. K., & McCormack, B. (2003). Practice Development: purpose, methodology, facilitation and evaluation. Nursing in Critical Care, 8(1), 22–29. doi: 10.1046/j.1478-5153.2003.00003.x.
McCance, T., McCormack, B., & Dewing, J. (2011). An exploration of person-centredness in practice. OJIN: The Online Journal of Issues in Nursing, 16(2), Manuscript 1. doi: 10.3912/OJIN.Vol16No02Man01.
McCormack, B. (2003). Researching nursing practice: does person-centredness matter? Nursing Philosophy, 4, 179–188. doi: 10.1046/j.1466-769X.2003.00142.x.
McCormack, B., & McCance, T. (2006). Development of a framework for person-centred nursing. Journal of Advanced Nursing, 56(5), 472–479. doi: 10.1111/j.1365-2648.2006.04042.x.
McCormack, B., & McCance, T. (2010). Person-centred nursing: Theory and practice. London, UK: Wiley-Blackwell.
McNamee, S., & Gergen, K. J. (Eds.) (1992). Therapy as social construction. London, UK: Sage.
Mickan, S., Hoffman, S. J., & Nasmith, L. (2010). Collaborative practice in a global health context: Common themes from developed and developing countries. Journal of Interprofessional Care, 24(5), 492–502. doi: 10.3109/13561821003676325.
Ness, O., & Strong, T. (2013). Learning new ideas and practices together: A cooperative inquiry. Journal of Family Psychotherapy, 24(3), 246–260. doi: 10.1080/08975353.2013.817268.
Nolan, M. R., Davies, S., Brown, J., Keady, J., & Nolan, J. (2004). Beyond person-centred care: a new vision for gerontological nursing. International Journal of Older People Nursing, 13(3a), 45–53. doi: 10.1111/j.1365-2702.2004.00926.x.
Norwegian Ministry of Health and Care Services (2008-2009). The coordination reform: Proper treatment – at the right place and right time. Report No. 47. to the Storting. Oslo: Norwegian Ministry of Health and Care Services.
Perkins, R., & Slade, M. (2012). Recovery in England: Transforming statutory services? [Research Support, Non-U.S. Gov’t]. International Review of Psychiatry, 24(1), 29–39. doi: 10.3109/09540261.2011.645025.
Perkins, R., Repper, J., Rinaldi, M. & Brown, H. (2012). Implementing recovery through organisational change briefing paper 1. Centre for Mental Health.
Purtell, R., Rickard, W., & Wyatt, K. (2012). Should we? Could we? Measuring involvement. In M. Barnes, & P. Cotterell (Eds.), Critical perspectives on user involvement (pp. 209-216). Bristol, U.K: The Policy Press.
Reese, D., & Sontag, M. (2001). Successful interprofessional collaboration on the hospice team. Health and Social Work, 26(3), 167–175. doi: 10.1093/hsw/26.3.167.
Repper J. & Perkins R. (2009). Recovery and social inclusion. In P. Callaghan, J. Playle, & L. Cooper (Eds.), Mental health nursing skills. Oxford: University Press.
Rogers, C. (1951). Client-centered therapy. Boston: Houghton Mifflin.
Seikkula, J., Aaltonen, J., Alakare, B., Haarankangas, K., Keränen, J., & Lethinen, K (2006). Five-year experience of first episode nonaffective psychosis in open dialogue approach: Treatment principles, follow-up outcomes and two case studies. Psychotherapy Research, 16(2), 214–228. doi: 10.1080/10503300500268490.
Seikkula, J., Aaltonen, J., Rasinkangas, A., Alakare, B., Holma, J., & Lethinen, V. (2003). Open dialogue approach: Treatment principles and preliminary results of a two-year follow-up on first episode schizophrenia. Ethical and Human Sciences and Services, 5(3), 163–182.
Shortell, S. M., Gillies, R. R., Anderson, D. A., Erickson, K. M., & Mitchell, J. B. (2000). Remaking health care in America: The evolution of organized delivery systems (2nd Ed.). San Francisco, CA: Jossey-Bass.
Slade, M. (2009). Personal recovery and mental illness. A guide for mental health professionals. New York, NY: Cambridge University Press.
Slater, P., O’Halloran, P., Connolly, D., & McCormack, B. (2010). Testing of the factor structure of the Nursing Work Index-Revised. Worldviews on Evidence-Based Nursing, 7(3), 123–134. doi: 10.1111/j.1741-6787.2009.00158.x.
Stanton, M. W. (2002). Expanding patient-centered care to empower patients and assist providers. Research in Action, Issue 5. AHRQ Publication No. 02-0024. Rockville, MD: Agency for Healthcare Research and Quality.
Stickley, T, & Wright, N. (2011a). The British research evidence for recovery, papers published between 2006 and 2009 (inclusive). Part one: a review of the peer-reviewed literature using a systematic approach. Journal of Psychiatric and Mental Health Nursing, 18, 247–256. doi: 10.1111/j.1365-2850.2010.01662.x.
Stickley, T., & Wright, N. (2011b). The British research evidence for recovery, papers published between 2006 and 2009 (inclusive). Part two: a review of the grey literature including book chapters and policy documents. Journal of Psychiatric and Mental Health Nursing, 18, 297–307. doi: 10.1111/j.1365-2850.2010.01663.x.
Strauss, J. S. (1996). Subjectivity. Journal of Nervous and Mental Disease, 184(4), 205–212.
Strong, T. (2010). Collaboration, generativity, rigor, and imagination: Four words to focus and animate our practice-oriented inquiries. Human Systems: Journal of Therapy, Consultation & Training, 21, 380-396.
Strong, T., Sutherland, O., & Ness, O. (2011). Considerations for a discourse of collaboration in counseling. Asia Pacific Journal of Counseling and Psychotherapy, 2(1), 25–40. doi: 10.1080/21507686.2010.546865.
Sundet, R. (2011). Collaboration: Family and therapist perspectives of helpful therapy. Journal of Marital & Family Therapy, 37(2), 236–249. doi: 10.1111/j.1752-0606.2009.00157.x.
Suter, E., Arndt. J., Arthur, N., Parboosingh, J., Taylor, E., & Deutschlander, S. (2009). Role understanding and effective communication as core competencies for collaborative practice. Journal of Interprofessional Care, 23(1), 41–51. doi: 10.1080/13561820802338579.
Tomasello, M. (2009). Why we cooperate. London, UK: MIT Press.
Taylor, C. (1985). Philosophy and the human sciences (Philosophical papers, vol. 2). Cambridge, UK: Cambridge University Press.
Tew, J. (2008). Social perspectives on mental distress. In T. Stickley & T. Basset (Eds.), Learning about mental health practice. West Sussex: John Wiley & Sons, Ltd. doi: 10.1002/9780470699300.ch13.
Topor, A. (2001). Managing the contradictions. Recovery from severe mental disorders. SSSW no 18. Stockholm, Sweden: Stockholm University, Department of Social Work.
Topor, A., Borg, M., Di Girolamo, S., & Davidson, L. (2011). Not just an individual journey: social aspects of recovery. International journal of social psychiatry, 57(1), 90–99. doi: 10.1177/0020764009345062.
Way, D. O., Jones, L., & Baskerville, N. B. (2001). Improving the effectiveness of primary health care through nurse/family physician structured collaborative practice. Ottawa, Canada: University of Ottawa.
Weinstein, J., Whittington, C., & Leiba, T. (Eds.) (2003). Collaboration in social work practice. London, UK: Jessica Kingsley Publishers.
World Health Organization (2013). Comprehensive Mental Health Action Plan 2013-2020. Resolution WHA66/8. Geneva, Switzerland: World Health Organization.