Relationship based practice works – the evidence
Anyone might be in favour of ‘relationship based practice’ in the same way we are all against sin (hopefully). But when asked to produce evidence that it ‘works’ we become hesitant. Where exactly are the definitive, gold standard research studies? Well, evidence that it does work has arrived from a somewhat surprising quarter, in the writings of this year’s BBC Reith lecturer Atul Gawande http://www.bbc.co.uk/programmes/b00729d9 His most recent book Being Mortal: Illness, death and what matters in the end’ should be a must read for all social workers, and perhaps anyone with an interest in the meaning of life. Along the way, he produces extraordinary evidence not just that relationship based practice works, but also how.
Gawande is a surgeon, but in his book he interrogates the limitations and failures of medicine in relation to helping people at the end of their life, and charts the problems arising from the medicalization of care of the dying. His method combines a thorough knowledge and understanding of the research, trust in his own practice wisdom, and much story-telling, some of it very painful and close to his personal as well as his professional experience.
In essence he believes that the medical approach to death and dying has been a ‘heroic’ one, in which prolonging life at all costs has dominated thinking and decision making. Instead, he proposes a more ‘stoical’ stance in which people nearing the end of life are helped to make choices and decisions about how they would prefer to live out their final weeks and days. Often this entails refusing viable but debilitating medical interventions that might prolong life but at the expense of quality of life. These are painful choices, for both patients and clinicians. For each they entail accepting that death is coming, and the ability to engage in communication about decisions with a sense of realism. Gawande calls these encounters ‘hard conversations’.
The hard conversation approach not only puts suffering and dying people back in charge of their lives – as their lives are ending – it also has other unexpected and beneficial effects. Controlled trials in the USA have showed that people who saw a palliative care specialist, stopped chemotherapy earlier, entered a Hospice programme sooner, experienced less suffering at the end of life, and also lived 25% longer than those who opted for conventional medical treatments. As Gawande says, ‘The lesson seems almost Zen: you live longer only when you stop trying to live longer’. But it is the skill of initiating and sustaining hard conversations that underpins the outcome.
Difficult conversations – the heart of relationship based practice
Last week I spent a day with the whole staff group of a family assessment centre who wanted to think about their future in a rapidly changing policy and practice context. They were an impressive multi-disciplinary group, although the majority of them were social workers. Much of their work is with parents and carers who face the possibility of losing their children if they cannot change sufficiently to mitigate the risks they pose to their children. The staff think of the assessment process as a relationship based intervention that aims to promote change and development rather than just collate information. They are clearly very skilled at intensive relationship based work, and discussed how they can sustain trusting relationships with families through a blend of compassion, directness and therapeutic ability. But strikingly they referred to the core feature of their practice as involving ‘difficult conversations’. Their experience suggests that families welcome these respectful but clear engagements, because they know they are in real difficulty, and also know the consequences of failing to engage and change. The analogy with people who know they are dying, but still have the capacity to ‘face reality’, make choices and be authors of their lives despite the shadow of death, struck me forcibly.
I have borrowed the language of ‘heroic and stoical’ responses to adversity from Tim Dartington’s book Managing Vulnerability: the underlying dynamics of systems of care (Karnac 2010). Like Being Mortal Tim’s writing is also born out of a complex blend of professional and personal experience. During the day I spent with the family centre I was also reminded strongly of my own experience of researching how child protection work is practised, and organisationally and politically framed in other European countries. In many continental countries a much more dialogue based and negotiated approach to working with families predominates, with the courts and the judiciary as full partners in this process. Formalised institutional ‘spaces’ of various kinds act as holding frameworks for the difficult conversations that child welfare work entails. The family centre seemed to operate rather like one of these formalised spaces. This kind of approach is close to the model used by the Family Drug and Alcohol Court (FDAC), a system that is now being rolled out across the country with government backing and funding.
So, Atul Gawande’s experience, and the research he draws on, seem to decisively show that relationship based practice works. But when you read his book you also understand that creating the professional, social and political conditions for this kind of practice involve something of a cultural transformation. It is not just a question of developing a ‘method’, trialling it, producing the evidence, and replicating it. There are many social and cultural obstacles to the task of enabling ourselves to think of ‘hard conversations’ as ordinary, and necessary. The sober reality is that we often prefer easy conversations, even if the financial, psychological, and quality of life costs they generate turn out to be higher.