1) At the core of a family-centered mental health system is the relationship between the family and the therapist/doctor: There is actually a literature on this, the famous "what do patients want" studies. Ten years ago, an early website (they build the internet with stone knives and bearskins, you know) asked that question, and got a plethora of responses that all meant relationship. Last year, a more formal study in South Africa showed that we want
"values in a doctor that range from fairness, lack of discrimination, autonomy, dignity, warmth and taking time to do a job properly. .... The definition of a good doctor as provided by the participants was not based on strict technical/clinical criteria, but rather on the patients' and the community's recent experiences of care under that particular doctor. The typical good doctor is a popular, friendly person who does not discriminate along racial lines, listens seriously to anything presented to him or her and examines the patient properly. He/she takes the patient's illness seriously, refers when necessary and gives sick leave that can be used to see a traditional healer. "No surprise there. Whether a primary care doc, a specialist or a mental health therapist, we want a doctor who is smart, listens well and understands where we are coming from. It is the relationship that we crave.
2) that relationship, critical though it is, is hard to capture in an outcome measure, Is the only way to measure relationship is to ask about it? We certainly do that a lot, but, in general, most of our patients like us a lot. Deborah Roter talk us how to tape record the interaction and analyze it for quality. Either way, surveys or tape recordings, this is not data that is easy to capture. Sometimes we survey some patients, but these are not the outcome measures most commonly used in assessing the quality of a system.
3) that evidence-based practice may not be the best way to get to a relationship-centered system. The evidence that we use is based on studies and surveys and other things that are not geared to assess the "goodness" of the relationships that we are forming. The evidence is based on impact on depression scales, and hospital/ER utilization and missed days of work- longer term outcomes that often follow on good relationship. Unless we take care to measure the intermediate outcomes of patient satisfaction, there is no reason to think that we are going to get our system of care to the place that patients want it to be.
Therein lies the dilemma of Rosie D (and all other efforts to build a mental health system). We want the system to be comprehensive- that means we need a system build on evidence, funding those things that work. To know that it works, we must study it outside of the context of the relationship that makes it possible. It is altogether too easy to forget that we need to allow the evidence-based piece to be placed in the context of an ongoing relationship; otherwise the people will find themselves teated as robots. Not good; the relationship is the glue that holds the whole thing together. The Parent Partners, the collaborative approach, the family inclusion in the wraparound model- all of these things are meant to meet the expressed need of the patient for relationship. The evidence to support this part of the new system, however, is thin indeed.
It would be such a simple gift, to make mental health care incorporate the aspects of personal relationship that we all think is critical to its success. But, as the fabulous four classical musicians showed us on inauguration day, it is often challenging to do the simple correctly.
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