I work in a large team of clinicians. We have clinicians from occupational therapy, physiotherapy, nursing, social work, clinical psychology and specialist medics with anaesthetic, musculoskeletal and occupational backgrounds. Teamwork is absolutely vital to our work.
When we start to work with an individual, we work in much smaller teams of two or three: someone with a psychosocial flavour, another with a functional flavour, and (often) someone with an applied focus.
While scouting around in my office I found an old book chapter from a book called “Pain Management. A Handbook of Psychological Treatment Approaches” edited by A. D. Holzman and D. C. Turk. It’s an old book, published by Pergamon Press in 1986, but don’t let that fool you – a couple of the chapters in this book are real gems, one of them being “The interdisciplinary pain center: An approach to the management of chronic pain”.
A couple of things caught my eye when I flicked through this chapter:
“The continued application of acute pain treatment menthods to the chronic pain patient not only fails to relieve the patient’s suffering, but often aggravates, complicates, and intensifies the patient’s disability and severely reduces the changes for successful pain rehabilitation.”
“Out of the general medical model framework comes the basic peripheralist’s view of pain, which places the etiology of chronic pain within the nervous system and the nociceptive stimulation process. The peripheralist believes that if the underlying pain generator or the “organic” mechanism producing the chronic pain can be eliminated, the pain patient’s suffering will be relieved.”
“By contrast, the centralist’s view of chronic pain takes into consideration a myriad of factors ranging from the patient’s verbalisation of discomfort, socioeconomic variables, family problems, vocational and avocational aspects, emotional and intellectual factors as well as the cultural context within which these variables occur.”
And about teamwork?
“Our teams are interdisciplinary as opposed to multidisciplinary because they operate as democratic sharing units with integration of therapeutic modalities and without deference to some arbitrary hierarchy. Often a ‘multidisciplinary’ model can be little more than an accumulation of individuals, each performing his or her own area of therapy in a serial consultation or poorly integrated fashion.”
I couldn’t agree more!
As Newman and Sere put it “There is significant crossover of practice between disciplines…although this mau seem somewhat strange to the inexperienced observer, the fact is, as a therapeutic team works together daily over the years, there is a tremendous amount of learning and cross-fertilisation of ideas and knowledge, which makes each member quite expert in the basic application of the others’ disciplines.”
Onto the practicalities when applying this kind of approach.
This morning I start working with a woman who has a two-year history of CRPS of her nondominant hand. She has had previous treatment and made good progress with movement quality of her hand – but she’s struggling to integrate this beautiful movement into function. She’s still not working, and she’s very frustrated and fed up with the whole process.
Who does what with this lovely lady?
Our small team consists of a clinical psychologist, physiotherapist and myself as vocational occupational therapist. We’ve worked together for about three years now, and know each other well. I’m the longest serving team member, but that doesn’t mean I’m ‘in charge’ – we all are!
We’ll meet before we see our patient, and discuss her case formulation (as far as it has been developed), and establish our broad contributions to her pain management programme. While we come from different disciplines, we’ve often crossed over in terms of what we contribute – it’s not uncommon for me to discuss panic management, carrying out a functional analysis of the ABC’s of that problem. It’s also not uncommon for our psychologist to discuss managing the daily activity profile and scheduling pleasurable activities and exercise. Our physiotherapist (and I) regularly explore automatic thoughts as they arise during developing an exercise programme, and we’ve all contributed to the overall management plan.
I love working in this small team! It means that as issues arise during sessions, we can bring them back to the team to problem-solve. If one of us identifies something during a session, we pass it on to the next clinician to ensure a consistent approach within the team. If one of us has a major area of work with our patient that comes up, something like an acute mood problem, then others in the team can pick up on important aspects of the programme that could otherwise be delayed.
We recognise that no single discipline can hope to address the multiple areas that are influencing this person’s presentation to us at this time. The contributions evolve over the course of the person’s treatment, and as a team, our contributions to the team evolve over the time we work within that team. While we come from various disciplines, we hold in common our understanding of the cognitive behavioural approach to managing pain, and form an overarching case formulation to which we all contribute. And as we work together, each of us develops certain ‘specialties’ or special areas of interest or skill that the other team members respect and can draw upon.
What makes this little team special? I think it’s communication – and respect. It’s really only through these two aspects of teamwork that the common model and nonhierarchical nature of our team can function effectively. Through communicating well, and respecting each other’s clinical ability (and tendency to go to the literature to find out answers!) that the high level of trust we’ve developed can happen.