Working within a Multi-Disciplinary Team: Psychologist's Perspective PDF

latrobe.edu.au Working within a multi-disciplinary team_ a psychologists perspective Slide 1 | Version 2  latrobe.edu.au Acknowled...

latrobe.edu.au Working within a multi-disciplinary team_ a psychologists perspective Slide 1 | Version 2  latrobe.edu.au Acknowledgement of Country Slide 2 | Version 2  latrobe.edu.au Learning objectives  Understand the role of a psychologist – The scientist-practitioner model – Scope of practice – Overview of Theoretical Approaches to treatment  Understand what is meant by multi-disciplinary and interdisciplinary collaborative care and its benefits  Recognize the knowledge, skills, attitudes, and values that interact and influence collaborative practice, including person centred care and why role clarification and good communication are important  Explore the role and contributions of a psychologist in interdisciplinary teams  Common models used to formulate client care in interdisciplinary teams Bio-psycho-social model; Trauma informed care; Slide 3 | Version 2 4 latrobe.edu.au Psychologists perspective A psychologist assesses psychological problems, and provides psychological interventions to treat those problems They do this by applying scientific knowledge and evidence using clinical judgement They work within a scientist practitioner model They apply specific, evidence based treatments Slide 4 | Version 2 5 latrobe.edu.au Scientist Practitioner Model Emphasizes the complementary connection between research and professional practice. - Psychologists training includes learning skill in research. - Some psychologists go on to be scientists and study human behaviour and develop new psychological treatments. - Psychologists who work clinically use their training in research to help them critical evaluate and apply scientific evidence to practice - For ethical practice they must keep up to date with research evidence relevant to clinical practice - Take a “scientist – practitioner approach “ to their evey day practice. - Use a hypothesis testing approach to understand a person’s presenting problems Use feedback to monitor and evaluate the effectiveness their therapeutic interventions. Including validated measurement tools to increase objectivity Engage in deliberate reflection and supervision regarding their practice Note: research usually simplifies systems to build an evidence base; clinical experience and opinion must be used to interpret for complex systems and translate this research to fit a particular person at a particular time and situation. The scientist practioner approach embeds some checks and balances and is very important for ensuring best ethical, quality care Slide 5 | Version 2  latrobe.edu.au General Psychologists and Clinical Psychologists All Psychologists must have undertaken 6 years of training and be registered with the Australian Health Practioners Registration Agency (AHPRA) and must uphold the ethical standards of the profession. A Clinical Psychologist is a specialist who works with clinical presentations, where mental health issues are affecting a person’s functioning and wellbeing. They undertake an additional 2 years of training and receive an “endorsement” in their area of practice (Clinical Psychology) from the Psychology Board of Australia. Generally work with more complex presentations, may lead clinical teams, specialists in diagnosis and may have a particular area of clinical expertise Other specialisations include Neuropsychology, Counselling, Health, Education and Developmental, Organisational, Community, Forensic, Sports and Exercise Slide 6 | Version 2 7 latrobe.edu.au A day in the life of a clinical psychologist ▪ Direct work with clients Meeting with clients and sometimes their families Assessing psychological problems via interviews (current symptoms, personal and family history); psychometric tests and observations Formulating a picture to understand the presenting problem (scoring of tests, diagnosis and formulation) Delivering psychological interventions via individual or group therapy ▪ Communicating to coordinate care (report writing, letters, phone calls and case conferences or consultation with other treating professionals) ▪ Administration and management (triaging and managing waiting lists, scheduling appointments, case notes) ▪ Research and professional development. - Review of literature and clinical guidelines relevant to current cases or for own knowledge building, regular supervision, and sometimes conducting clinical research (efficacy trial; service based reviews) Slide 7 | Version 2 8 latrobe.edu.au Scope of practice  Clinical psychologists work with people across the life span, with a range of issues including psychological disorders, intellectual and physical disabilities, psychological difficulties secondary to physical illnesses, stress associated with major life transitions, such as infertility, child bearing adoption, fostering relationship issues, and bereavement  Clinical psychologists work in many settings including primary care (private practice); community mental health teams, hospitals, disability services, aged care, family services, specialist services (Addiction, chronic pain)  Clinical psychologists work as independent practitioners or part of multidisciplinary teams: - good practice always involves interdisciplinary consultation and collaboration Slide 8 | Version 2 9 latrobe.edu.au Understanding psychological problems - Theoretical Approaches to practice Psychologists draw on various theoretical models and scientific evidence bases to understand psychological problems Influential approaches to practice include  Biological or “Medical” model  Psychoanalytic model  Cognitive Behavioural model  Family systems model  Humanist models such as positive psychology Slide 9 | Version 2  latrobe.edu.au Take home messages Range of models have in common they all identify multiple bio/psycho/social/cultural factors as important for influencing mental health They all seek to articulate, delineate and integrate these factors with various emphasis to provide useful models for fitting pieces of the puzzle together – and highlight helpful focus’ for treatment They each provide a different emphasis and lens to focus through. Each model makes various assumptions or has different emphasis and each has brought both achievements and limitations to the practice of psychology – it is a young and evolving field! Influential models define constructs clearly and have a scientific evidence supporting efficacy of treatments Research has shown it matters less which model a psychologist uses, than that they do take a theory informed and evidence based approach to their practice! As knowledge built over time theories tend to draw from one another – importance of a wholistic picture that includes biology, cognition, developmental, social and relational, cultural and spiritual factors, to understand the aetiology of a mental health issue and target treatment. Slide 10 | Version 2 11 latrobe.edu.au Cognitive Behavioural model  Incorporates a range of psychotherapeutic theories and practices, rooted in learning theory, such as behaviour therapy, behaviour modification, cognitive therapy and cognitive-behaviour therapy.  Assumes psychological problems are distressing habits learned through same process as normal behaviour (operant and classical conditioning, imitation and insight)  Draws attention to importance of cognition as mediator (in particular self-talk) of emotional state (situation – interpretation – feelings – behaviour)  Therapy involves helping clients replace distressing habits of thinking and behaving with more adaptive ones  Collaborative interviewing and observation helps identify antecedents, triggers and reinforcing consequences related to problematic behaviour, beliefs and feelings,  Interventions include changing consequences of behaviour, challenging non-adaptive beliefs and thinking patterns, skills training, Slide 11 | Version 2 12 latrobe.edu.au Cognitive Behavioural model Achievements Limitations Draws attention to importance of individual’s (learnt) Risk of trivializing psychological problems, construing as meaning/interpretation of an event for influencing emotional “bad thinking habits” response – This is an accessible target for treatment Development of brief, (1-30 sessions) effective approaches to Danger of disregarding possible role of organic factors in therapy applicable to a wide range of presentations aetiology (despite extensive evidence for role of genetics and neurobiological factors) Empirically tested treatment strategies Risk of not taking clients wider social context into account Advocated and successfully integrated within mainstream medical and mental health industry Widespread dissemination, highly accessible to range of mental heath professionals and translation to self-help and facilitated self-help increasing client agency Slide 12 | Version 2  latrobe.edu.au Image: Bio Psycho Social Model of Metal Heath. (From The Open University) Slide 13 | Version 2  latrobe.edu.au Collaborative Interdisciplinary Mental Health Care Slide 14 | Version 2 15 latrobe.edu.au Interdisciplinary mental health care – the role of a psychologist – Why is interdisciplinary care important? – How does the psychology discipline work with other disciplines involved in mental health care? – Principles of good interdisciplinary care – Approaches to practice for communicating psychology input across disciplines 4P’s bio-psycho-socia model Trauma informed care Slide 15 | Version 2 16 latrobe.edu.au What are Interdiscipliary teams? Just like there are many elements contributing to mental health, there are many disciplines that can contribute to mental health care. Medicine, Psychiatry, Social Work, Nursing, Lived Experience, Psychology, Occupational Therapy Like theories that aide our understanding, different disciplines emphasise different factors as important focus for treatment and care. Important to recognise this “disciplines” approach to health and mental health has a historic and cultural context. Different cultures study and explore and treat mental health differently, many with less ‘siloed’ approaches. Over time, knowledge base and approach of each discipline tending to recognise importance of a wholistic picture Specialist understanding still very important contribution provides depth. Interdisciplinary teams can work together to draw on depth of specialist competency and breadth of different disciplines’ approaches to provide better care. Slide 16 | Version 2  latrobe.edu.au Multi-disciplinary vs interdisciplinary care?  An interdisciplinary approach to client care involves team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities.  The client, their family and carers are also involved in shared decision making at every step of the process: assessment, diagnosis, intervention, goal-setting, treatment planning and implementation.  In contrast, a multidisciplinary approach involves team members working independently to create discipline-specific care plans that are implemented simultaneously, but without explicit regard to their interaction.  Different contexts may facilitate different collaborative care models Slide 17 | Version 2  latrobe.edu.au Slide 18 | Version 2  latrobe.edu.au Why is interdisciplinary care important  Co-morbidity is the norm in mental health, rather than the exception. Even more so when we consider a person in context and all aspects of bio- psycho-social health  Evidence based: interdisciplinary care produces better health outcomes – Integrated care and good communication improves treatment efficiency and effectiveness – Shared responsibility for decision making avoids risk averse approach – Better health and mental health outcomes (shorter treatment times; greater mental health gains; shift from siloed, acute care to longer term, preventative care ) – Client satisfaction and quality of life from improved clarity and efficiency of coordinated treatment – Engagement and retention in treatment – Practitioner feelings of support, shared responsibility and professional satisfaction (which all impact client outcomes) – Practitioners can focus on area of expertise Slide 19 | Version 2  latrobe.edu.au Slide 20 | Version 2  latrobe.edu.au Roles for a psychologist in interdisciplinary teams How does the psychology discipline work with other disciplines involved in mental health care? Think about the role of a psychologist – What skills do they bring? – What focus to they have? – Values and priorities of psychology profession? – Limitations of profession and practice models – How does this integrate well with other disciplines, how could it be difficult? Think about roles, responsibilities and practices of other professionals – Social Worker, Occupational Therapist; Speech Pathologist; Vocational Worker; Peer Worker; Aboriginal Liaison Officer; General Practitioner; Psychiatrist; Mental Health Nurse – Think about the similarities and differences Slide 21 | Version 2  latrobe.edu.au Roles for a psychologist in interdisciplinary teams  Provide primary intervention when there is a mental health issue  Care coordination  Consult with medical practitioners and other health care professionals to implement client programs to promote health, prevent illness and to facilitate self- management  Help individuals to make lifestyle changes (for health and mental health)  Help treat substance use disorders  Client’s emotional and behavioural issues related to adjustment to chronic conditions or injury  Clients with life-threatening conditions to manage pain, cope with medical interventions and the side effects  Clients to adhere to treatment regimes  Support collaborative case formulation and reflective practice Slide 22 | Version 2  latrobe.edu.au Key elements of Interdisciplinary Collaborative Care Collaborative Care Slide 23 | Version 2  latrobe.edu.au Key elements of Interdisciplinary Collaborative Care Person-centred Care Interprofessional Communication (and conflict resolution) Role Understanding Collaboration and Leadership Underpinning those are shared values and priorities including: shared-decision making client-focus respect trust Slide 24 | Version 2 25 latrobe.edu.au Slide 25 | Version 2  latrobe.edu.au Person Centred Care Seek out, integrate and value, as a partner, the input and the engagement of the patient/client/ family/community in designing and implementing care  support participation; Ask, Advocate  share information: All need access to the relevant information in order to make meaningful contribution; confidentiality must be respected  ensure appropriate education available: For clients; for clinicians – each should contribute from own perspective, not feel or try to talk outside own capacity  listen respectfully: Clients are seen as experts in their own lived experiences and are critical in shaping realistic plans of care. Results in more relevant, reliable and doable and effective treatment. Nothing about me, without me. Slide 26 | Version 2  latrobe.edu.au Mental Health Act 2014 Core principles and objectives of the Act  assessment and treatment are provided in the least intrusive and restrictive way  people are supported to make and participate in decisions about their assessment, treatment and recovery  individuals’ rights, dignity and autonomy are protected and promoted at all times  priority is given to holistic care and support options that are responsive to individual needs  the wellbeing and safety of children and young people are protected and prioritised  carers are recognised and supported in decisions about treatment and care. Slide 27 | Version 2  latrobe.edu.au Person Centred Care  Benefits: – more agency, by in from client = better treatment outcomes! – better engagement and retention in care – facilitates clinician understanding therefore more relevant and effective care provision Slide 28 | Version 2  latrobe.edu.au Role clarification Think of a basketball team: how does the game go when one player runs the court? How would it go if everyone tried to be the goal scorer? How would the team work if no one was clear on their role or that of others?  Lack of clarity about roles can lead to power struggles, confusion, irritation, inefficiency, redundancy, working outside the scope of practice  Benefit of interdisciplinary team is diversity of health and social roles and responsibilities and competencies working collaboratively together. Slide 29 | Version 2  latrobe.edu.au Working within the bounds of competence: APS Code of Ethics Ethical Standard B: Competence B1.2 Psychologists only provide psychological services within the boundaries of their professional competence. This includes, but is not restricted to: – (a) working within the limits of their education, training, supervised experience and appropriate professional experience; – (b) basing their service on the established knowledge of the discipline and profession of psychology; – (c) adhering to the Code and the Guidelines; – (d) complying with the law of the jurisdiction in which they provide psychological services; and – (e) ensuring that their emotional, mental, and physical state does not impair their ability to provide a competent psychological service Slide 30 | Version 2  latrobe.edu.au Interprofessional communication What is tricky about interprofessional communication? What are characteristics of effective interprofessional communication? Slide 31 | Version 2  latrobe.edu.au Interprofessional communication Practitioners from different professions communicate with each other in a collaborative, responsive and responsible manner:  Actively listening  Using understandable language  Negotiating, consulting, interacting,  Articulating relevant information discussing or debating  Present clinical cases clearly, effectively  Transparency in all interactions with and appropriately others including patients/clients/families  Initiating sharing of information  Trust  Documentation and storage to allow  Encouraging ideas and opinions of effective follow-up and good clinical others handover  Timely communication  Respect  Respectfully seek information from  Flexibility professional colleagues  Ability to speak up with questions or concerns Slide 32 | Version 2  latrobe.edu.au Context Think about how context can influence interdisciplinary collaboration: Stable teams: e.g. CAHMS, residential care, long term private practice. Comprehensive and consistent team approach consolidated over time. Dynamic teams: e.g. shift work, emergency triage, hospital, cross organisational teams (e.g. school, home, community health) Collaboration required, but may only work together for short time before shifts change or client discharged. Different approaches for simple vs complex contexts: e.g. of sprained ankle. As complexity increases so does ambiguity and uncertainty. Coordination and specialised expertise required, interdependent factors and non-linear outcomes. Slide 33 | Version 2 34 latrobe.edu.au Approaches to practice for communicating psychology input across disciplines Good interdisciplinary care depends on good communication 5P’s case formulation bio-psycho-social model Slide 34 | Version 2 35 latrobe.edu.au 5 P’s case formulation and the Bio-Psycho-Social Model  Case formulation aims to organize clinical information to coherently understand a presenting problem and directions for effective intervention  The formulation asks what is wrong, how it got to that way, and what can be done about it  Practiced across different disciplines, but integral and routine in psychological care  Different theoretical models outlined earlier may offer alternative formulations of a presenting problem  Formulation is an alternative and complimentary to diagnostic systems, it accounts well for context and development of a problem and is well suited for interdisciplinary communication Slide 35 | Version 2 36 latrobe.edu.au 5 P’s case formulation and the Bio-Psycho-Social Model  Clinically intuitive model often used in interdisciplinary contexts is the 4 or 5P’s  Accounts for a – Presenting problem’s – Predisposing (origin or risk) factors, – Precipitating factors, – Perpetuating (maintaining) factors, and – Protective factors  Ofters targets for intervention  Often used in combination with bio-psycho-social model in interdisciplinary care Slide 36 | Version 2 37 latrobe.edu.au Bio-Psycho-Social Model  George Engel’s Biopsychosocial model attempted to broaden physicians understanding of illness, away from medical model to understand patience in context  In some ways an integration, quite complimentary, to leading theoretical approaches to understanding psychological disorders we talked through earlier Slide 37 | Version 2 38 latrobe.edu.au Slide 38 | Version 2 39 latrobe.edu.au Slide 39 | Version 2  latrobe.edu.au Slide 40 | Version 2 41 latrobe.edu.au Slide 41 | Version 2 42 latrobe.edu.au Reflective practice  Another important element from the tradition of psychology that can foster good collaborative care and supportive interdisciplinary teams is regular reflective practice.  In psychology focus can be both on client care plan, but also developing and supporting craft and practice of the practitioner, via reflection of impact of work on them and visa versa  Example of truly interdisciplinary reflective practice: Schwartz Rounds Slide 42 | Version 2  latrobe.edu.au E.G. Schwartz Rounds  Schwartz rounds are a forum for clinical and non-clinical staff to come together to discuss the social and emotional aspects of working in healthcare.  Purpose is to understand the challenges and rewards intrinsic to providing care. Not focus on solving problem or clinical aspects of care  A group reflective process  Stories shared remind staff of their shared motivation to help clients  Normalises emotions (often kept under surface)  Help staff feel more supported. Non-hirachcical. Time and space to reflect on roles.  - staff feel less stressed and isolated, increasing insight and appreciation for each other’s roles  - Reduces hierarchy and focuses attention on relational aspects of care.  - Compassion can make big difference to patient’s care. To provide compassionate care, staff must feel supported in their work. Slide 43 | Version 2  latrobe.edu.au Collaborative Interdisciplinary Mental Health Care Better outcomes together Slide 44 | Version 2 45 latrobe.edu.au Biological model  Also sometimes called “Medical” or “Disease” model  Assumes psychological difficulties have discrete neurobiological origins (CNS abnormality) and that corresponding specific treatments may be identified Achievements Limitations Led to development of mental health legislation (idea of impaired Mental Health Legislation has been abused to limit judgement due to mental illness) and creation of asylums where freedom people could receive humane treatment. Development of systematised classification systems (DSM, Psychological problems distributed in the population ICD) providing avenue for less ambiguous communication dimensional rather than categorically between professionals Use of scientific methods and quantitative techniques to Psychological problems not caused exclusively by organic study psychological problems factors. Draws attention away from important psychosocial and political changes that may be required to alleviate psychological distress Development of techniques and technologies for Non-medical professions (including clinical psychology) monitoring CNS activity (MRI, fMRI etc) marginalised in the development of mental health services Physical treatments (surgery, psychopharmacology, ECG, Many pharmacotherapies have harmful or unknown side- MRI) effects  Stress-vulnerability model a modern variant accounting for interaction of biology and environmental factors Slide 45 | Version 2 46 latrobe.edu.au Psychoanalytic model  Assumes psychological problems are symptoms of underlying unconscious conflict or psychopathology  Utilises transference and counter-transference in the therapeutic relationship as a means of gaining insight into unconscious patterns and defences and working through unresolved feelings Achievements Limitations Notion of the unconscious, as an active set of Imprecise constructs and diagnostically vague and psychological processes untestable propositions Demonstrating continuity between normality and Traditionally only seen as suitable for treating young, adult, psychoigical problems verbal, intelligent patients Establishment of talking therapy as valid treatment Too time consuming and expensive to be viable treatment (some recent briefer derivatives using psychoanalytic ideas) Insights into conflicts, defences and transference Freud speculations regarding infantile sexuality in error, phenomena that are part of psychopathology overlooked likely sexual abuse of his patients. Slide 46 | Version 2 47 latrobe.edu.au Family systems model Assumes psychological problems are maintained by patterns on interaction and belief systems within the family and wider social systems of the client Many different schools of family therapy in terms of central focus or emphasis (historic predisposing, problem maintaining belief systems, or behaviour pattens) Multi person sessions working with family using a range of interventions to recognise unhelpful patterns (gaining multiple perspectives), and disrupt problem-maintaining behaviour patterns, build helpful patterns, change personal narratives that keep them ‘stuck’ in unhelpful patterns and support wellbeing Achievements Limitations Highlights social context in aetiology and treatment of psychological difficulties Danger of vagueness Cost effective and evidence based Risk of losing sight of needs and rights of the individual Systems theory offers wholistic integrative framework for Danger of not taking into account considering not just social, but biological and psychological factors – especially useful in managing complex cases neurobiological factors Slide 47 | Version 2 48 latrobe.edu.au Other models Many other frameworks that influence the way clinical psychologists conduct their work including - client-centred humanistic tradition: use of therapeutic relationship between client and therapist as a resource in promoting personal growth (e.g. Carl Rogers) - personal construct psychology: Assumes people’s problems rooted in the way they interpret the world, explore and transform client’s belief systems - positive psychology: strengths focus, understanding and facilitating well-being, development of meaningful, positive relationships.. Slide 48 | Version 2 49 latrobe.edu.au Cognitive Behavioural model  Incorporates a range of psychotherapeutic theories and practices, rooted in learning theory, such as behaviour therapy, behaviour modification, cognitive therapy and cognitive-behaviour therapy.  Assumes psychological problems are distressing habits learned through same process as normal behaviour (operant and classical conditioning, imitation and insight)  Draws attention to importance of cognition as mediator (in particular self-talk) of emotional state  Therapy involves helping clients replace distressing habits of thinking and behaving with more adaptive ones  Collaborative interviewing and observation helps identify antecedents, triggers and reinforcing consequences related to problematic behaviour, beliefs and feelings,  Interventions include changing consequences of behaviour, challenging non-adaptive beliefs and thinking patterns, skills training, Slide 49 | Version 2 50 latrobe.edu.au Cognitive Behavioural model Achievements Limitations Development of brief, (1-30 sessions) effective approaches to Risk of trivializing psychological problems, construing as therapy applicable to a wide range of presentations “bad thinking habits” Empirically tested treatment strategies Danger of disregarding possible role of organic factors in aetiology (despite extensive evidence for role of genetics and neurobiological factors) Advocated and successfully integrated within mainstream Risk of not taking clients wider social context into account medical and mental health industry Widespread dissemination, highly accessible to range of mental heath professionals and translation to self-help and facilitated self-help increasing client agency Slide 50 | Version 2