Client Literacy and Collaborative Care in Liberation-Based Psychotherapy: An Evidence-Based Framework

Abstract

The therapeutic process usually entails a patient having some kind of mental health alignment. They attend an appointment with a health professional, and are prescribed a treatment protocol that the patient is supposed to follow until symptoms abate. This is known clinically as achieving stasis. This paper looks at how collaborative care models that support the prioritization of a client's understanding of their treatment, and/or the theoretical framework, and/or options that might exist in support of their care create better outcomes overall. These are the tentpoles for what we call ‘client literacy’ as best practice, which disrupts the hierarchical power dynamics that are often inherent in traditional clinical settings.

Clinical Case: How traditional care models can fail clients

A 42-year-old woman who is married and living in Brooklyn was suffering from a mental health condition. She was referred to us by a general practitioner from a large community health center. The woman, whom we will call Hattie, was referred to our practice by the GP who had initially sent Hattie to see a psychiatrist in the Bronx. Hattie came to the appointment with her husband, both of whom were Creole-speaking. The GP was doing her best to organize care for her, sending her to a psychiatrist for medication and using language accessibility for therapy with a social worker in the clinic. However, after a year, Hattie was referred to our remote practice after not adhering to her medication, and the GP recognized that the language barrier was too difficult for them to manage. The referring doctor spoke of her "medication non-compliance," which the doctor believed was the core of this client’s issue. When attempting to coordinate care with her white male psychiatrist in the Bronx, he, too, detailed Hattiet's "refusal to engage in treatment." Her chart was full of “evidence” in a narrative that made her seem resistant to the ‘protocol’ and ‘unwilling to accept his diagnosis and treatment plan for her. The referring psychiatrist's final note read: "Patient continues to reject pharmacological intervention despite repeated psychoeducation regarding the necessity of mood stabilization. Recommend transfer to practice with cultural competency in working with Creole-speaking populations."

To be clear, our practice does not involve medication management, and we were initially reluctant to take the case. We are a primarily remote private practice that does not provide wraparound services at this time.  The Creole-speaking therapist was eager to speak to Hattie, having not had many Creole-speaking clients; she understood the cultural reluctance that the other providers were seeing as ‘resistance’. And although we do not do medication management, we did note that the narrative from the other providers was missing some key details. We discovered that the client's husband had never been invited to a single appointment. No one had asked about the family's cultural understanding of mental illness; no mention of family history of mental illness either. There wasn’t any mention of their previous experiences with hospitals or their concerns about medication side effects. All communication had occurred in English, with the client alone with providers despite the client’s lack of knowledge of the language or the health care system, or knowledge of her rights as a patient to have her husband in these appointments. The treatment protocol was strictly individual, medication-focused, and dependent on a definition of "compliance" that assumed the client's sole responsibility for treatment adherence without any acknowledgement of the social determinants or, at a minimum, the ‘person in context’ that could possibly impact outcome. 

When the client took the consultation with our therapist in Creole, because we are remote, we had to do the intake paperwork with the therapist in order to make sure the client understood the paperwork. This would be unorthodox in most settings, however, we made sure the spouse was also present with the client’s permission. Rather than focusing on the lack of medication adherence. The therapist chose to begin with a normal intake gathering family or origin history, and simply asking "What has this been like for both of you? What do you understand about what has been happening during these previous appointments? What are you most afraid of?"

For a few subsequent sessions, it was just the wife present. The wife presented intact, with low affect, with some thought-blocking and rumination. The rumination centered on the previous medical experiences of being perceived as “mental” or "Li gen pwoblèm nan tèt li”.  There was no complete denial of her situation; the client was attending appointments, much to her husband’s support and insistence. And it was also clear that the client was struggling to grasp what was occurring, which often happens with clients who are suffering from acute mental illness. The client was attending the appointments but was afraid and did not fully grasp what was required or, more importantly, why it was required. I would like to pause here and say that I would give the benefit of the doubt to my colleagues in the field who were previously working with this client. I would not be so bold as to say that they didn’t try to explain the necessity of the medication or the possible side effects. So much in our field is trial and error, but taking the time or having the courage as practitioners to explain this to people in crisis becomes difficult. Practitioners want to instill confidence in our clients, as the ‘experts’; practitioners do not want to give so much information that clients get overwhelmed and cannot understand; then add it language and cultural barriers the time it might take to spend with any one client to get them literate to what is happening for them:we can see in an overflowing community clinic environment, with tight insurance protocols and regulations. The concept of client literacy could get lost. 

The client spoke about feeling "controlled" by medications, about providers who "talked at her but never listened," about a diagnostic label she’d been given but did not agree with. She presented intact for a few sessions, however, subsequently, she began to decompensate, showing different symptoms of mania and paranoia. The therapist's swift thinking called for supervision, where, with a supervisor on the line, she was able to convince the client to also speak with her husband for further understanding of the client’s history of behavior. The husband spoke of his frustration about being barely understood by people who knew nothing about their life.

 At this particular moment, they were in a crisis, where we were further able to educate the husband and the client together about the need for a visit to the hospital, where she was subsequently admitted. Over this period, the treatment shifted from individual sessions with the wife to family-based care. The husband participated in every session while the wife was discharged. Continued psychoeducation about bipolar disorder was offered in Creole and family therapy because it is more useful than individual therapy. Medication was discussed not as a mandate but as one tool among many, with transparent conversations about side effects, alternatives, and the couple's values and priorities. When the client expressed ambivalence about a medication, rather than documenting "non-compliance," the therapist explored what specifically concerned her, and the family collaborated to problem-solve, including the choice of which hospital to go to and when for her necessary further evaluation.

The couple felt "part of the treatment" rather than being subjected to it. They understand the diagnosis through how the patient described how she felt, instead of the clinical terms she did not understand. Together, the couple was able to identify early warning signs of mood destabilization, particularly the husband, who was trying to manage his own understanding and anxieties, not knowing “which wife he was going to wake up to.” It’s not perfect, but there is better literacy about what is happening. Hattie sais, ‘Anvan, nou te jis swiv sa yo te di, menm lè sa te fè nou pè. Mwen toujou pè, men kounye a nou konprann poukisa; Translation: Before, we just followed what they said, even when it made us scared. I’m still scared, but now we understand why.”

Hattie’s experience shows us how clinical outcomes can improve dramatically when treatment moves from expert-driven models to collaborative approaches that center client and family understanding, honor cultural context, and prioritize shared decision-making over compliance.

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