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A former 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 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. He 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. I see this sort of dynamic frequently in play in one form or another across not only the psychological helping professions but also across healthcare more broadly. Time and again this conclusion emerges: Alone, we miss things, and together, we do more good and less harm. Better care is provided together.
Expanding the Treatment Horizon
Collaborative care involves the sharing of perspective, not necessarily an agreement of perspective. While collaboration in treatment between a nurse and a psychiatric prescriber may look different than between a psychotherapist and a psychiatric prescriber, the spirit of collaboration is the same.
We naturally and inevitably bring with us our own toolbox of experience, perspective, knowledge, and skills. Yet to the extent we resign ourselves to treatment in a vacuum, we neglect the treatment, as collaboration is essential to effective health care, not elective. We each naturally and necessarily engage in our work with people from different angles.
When the psychotherapist communicates perspective and priorities through the lens of the psychotherapy, the psychiatric prescriber's perspective widens. When the psychiatric prescriber communicates perspective and priorities through the lens of psychiatric medication management, the psychotherapist’s perspective widens.
Think of perspective as standing in a place and looking out over a horizon. As we move about from this position to that, 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, which expands. 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.
As we do so, our treatment horizon is being continually formed. The philosopher Hans-George Gadamer (1975) contended, “We have continually to test our prejudices, and in so doing, adjust our understanding" (p. 273). This humility is fundamental to good treatment. To "do no harm" often requires a whole-person perspective, and to reach it, we usually need multidisciplinary partners.
Improving Case Consults
The purpose of psychiatric case consults, for instance—a more formalized venue for such collaboration—is to aid in diagnostic assessment and treatment planning, consult on issues of safety and risk, discuss developmental concerns (if applicable), provide reports related to behavior and treatment compliance, address concerning family and social dynamics, consider relevant community referral needs and options, and share critical case updates. Clinicians typically have only about 15 minutes (or less) to staff cases with psychiatric providers. Here’s some guidance:
Tell the story (succinct, contextual). The introduction to a clinical case staffing should provide clinical 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.
Identify concerns (direct, incisive). 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 __________?”
Tie services together (reiterative, actionable). End discussion about a clinical case by hitting the high points of any clinical feedback provided, clarifying loose ends, itemizing any specific recommendations made, and assigning actionable follow-up. Ensure clinical case staffing and follow-up, as appropriate, is reflected in the official case record.
A Word of Caution
Psychological knowledge and jargon often stand between well-intentioned clinicians and effective mental health treatment. Curiosity always runs the risk of gossip. Clinical case consult groups are filled with far too much clutter, too often driven by insatiable curiosity rather than conscientious health care. Jargon and gossip increase tone deafness in clinicians.
The racy details of people’s lives ever risk 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. Yet we all have blind spots. We all get stuck in ruts of routine and habit.
Conscientious mental health professionals aim to treat the whole person, not just the part they are apt to see at first assessment. A collaborative approach enhances communication of evaluative and ongoing therapeutic feedback, increases clinicians’ adherence to the treatment plan, and helps reduce risk and frequency of crises. For those with severe and persistent mental illness, such an approach can be critical in reducing the number of avoidable emergency room visits and inpatient stays.
We see more effective treatment outcomes when we share not only our perspective but also responsibility as we partner to provide optimal care. It is important for mental health providers to be well connected to and collaboratively engaged with multidisciplinary care teams to ensure that the most effective and integrated treatment that can occur does occur.
References
Gadamer, H. (1975). Truth and method. London: Sheed and Ward.
