A colleague of mine, a psychiatric nurse, was working alongside a psychiatrist who would often be insistent about his intention to change a patient’s medication regimen before they even had an opportunity to see the patient together. She recalled that on one such occasion, she boldly interrupted the psychiatrist as he reported his clinical perspective and intentions. “No, doctor,” she urged. “Just because he’s had an increase in psychotic symptoms does not mean we need to increase his risperidone. He’s been on meth all week. We need to prioritize getting him off of the drugs he’s been using before we start changing his meds!”
The psychiatrist hadn’t seen the bigger picture, had been operating with a kind of clinical tunnel vision out of habit, and her boldness to voice her perspective broadened his, ultimately increasing the quality of the care for the patient. The doctor, for his part, was responsive and did not change the patient’s medication regimen as he had intended.
What Does It Look Like to Promote a Collaborative Care Environment?
Collaborative care involves the sharing of perspective, not necessarily an agreement of perspective. While collaboration in treatment between a nurse and a psychiatrist may in some ways look different than that between a psychotherapist and a psychiatrist, the spirit of the collaboration is necessarily the same—that in our work with people, we naturally and inevitably bring with us our own toolbox of experience, perspective, knowledge, and skills. And to the extent we resign ourselves to treatment in a vacuum, we neglect the person’s treatment, as collaboration is essential, not elective. We each naturally and necessarily engage in our work with people from different angles.
When the therapist shares the angle of the therapist, the psychiatrist’s perspective widens. When the psychiatrist shares the angle of the psychiatrist, the therapist’s perspective widens.
Think of perspective as standing in a place and looking out over a horizon. As we move about, so changes our available horizon and, thus, our perspective, and yet we are able to take the previously seen horizons with us, aren’t we? In our mind’s eye, in our understanding, we integrate them into our inner map. To acquire a horizon means that one learns to look beyond what is close at hand—not in order to look away from it, but to see it better within a larger whole and in truer proportion.
Therapists, therapeutic case managers, psychologists, psychiatrists, and other mental health clinicians best serve people when they share perspective and responsibility in meeting people’s needs and ensuring therapeutic progress toward established treatment goals.
The horizon of the present is being continually formed, in that, as the philosopher Hans-George Gadamer contended, “we have continually to test our prejudices, and in so doing, adjust our understanding.” This sort of humility is fundamental to good psychotherapeutic and medical treatment.
The purpose of clinical staffing is to aid in service planning, consult on issues of safety and risk, discuss developmental concerns, collaborate on behavior and mental health assessment, address concerning family and social dynamics, consider referral options, and share critical case updates.
Each case presented will typically either qualify as a “consultation” or an “update.” Clinicians usually have only about 15 minutes to staff cases. Here’s how I encourage clinicians to approach clinical staffing and, essentially, all forms of collaborative care:
- Tell the story (brief): Just as the case record documentation should provide a narrative of services rendered, the introduction of a person in a clinical staffing should similarly provide context. Facilitate talk about engagement in services, home and social dynamics, relevant historical considerations, psychological profile, academic, vocational, and/or behavioral functioning, and recent events that may be relevant to any concern.
- Identify concerns (robust): Share clear and present concerns. Use clarifying statements, such as, “I am concerned because __________.” Express particular observations, such as, “I have noticed __________.” Ask specific questions, such as, “Why do you think __________?” Strike a tension between curiosity and clarity. If you fail to bring clarity and direction to a consult, time will waste away.
- Tie services together (summary): It is your responsibility to end discussion about a person by providing specific feedback. Try to summarize any recommendations and clarify the who and what of any follow-up to result from the staffing.
A Caution to All Clinical Professionals
Psychological knowledge and jargon are dangerous, often standing between well-intentioned clinicians and effective mental health treatment. Curiosity always runs the risk of gossip. Clinical case consult groups scattered across our fair land meet frequently and are filled with far too much clutter, too often driven by curiosity rather than care. Jargon and gossip increase tone deafness in clinicians.
We all have our blind spots, and we all get stuck in ruts of routine and habit. And details learned about people’s lives ever tempt therapists, psychiatrists, and the like toward distraction. There is a distinct difference between a personality and a person, a diagnosis and a destiny. It is our responsibility to stir hope and catalyze strengths rather than to stew history and analyze at length.
Effective mental health treatment should always aim to treat the person—the whole person. A collaborative mental health treatment approach should enhance communication of relevant evaluative and ongoing therapeutic feedback, increase clinicians’ adherence to a person’s treatment plan, and reduce risk, frequency of crises, and unnecessary emergency room visits and inpatient stays.
It is important for all mental health providers to be well connected to and collaboratively engaged with multidisciplinary networks to ensure the most effective and integrated treatment that can occur does occur. Therapists, therapeutic case managers, psychologists, psychiatrists, and other mental health clinicians best serve people when they share perspective and responsibility in meeting people’s needs and ensuring therapeutic progress toward established treatment goals.
© Copyright 2016 GoodTherapy.org. All rights reserved.
The preceding article was solely written by the author named above. Any views and opinions expressed are not necessarily shared by GoodTherapy.org. Questions or concerns about the preceding article can be directed to the author or posted as a comment below.