Case Analysis – Collaborating with Outside Providers Prior to beginning work on this assignment, read the PSY650 Week Three Treatment Plan and Case 9: Bulimia Nervosa in Gorenstein and Comer (2014)
Eating Disorders, 21:185–205, 2013 Copyright © Taylor & Francis Group, LLC ISSN: 1064-0266 print/1532-530X online DOI: 10.1080/10640266.2013.779173 Promoting Optimal Collaboration Between Mental Health Providers and Nutritionists in the Treatment of Eating Disorders LEIGHANN D. DEJESSE California School of Professional Psychology, Alliant International University, San Francisco, California, USA DIANE C. ZELMAN California School of Professional Psychology, Alliant International University, San Francisco, California, USA The mental health provider–nutritionist collaboration is a primary partnership in the treatment of eating disorders, and its integrity is important for good patient care. Utilizing critical incident qualita- tive methodology, 22 professionals who specialize in the treatment of eating disorders (12 mental health providers, 10 registered dieticians) were interviewed about instances of problems in col- laborations between these two professions, and the impact and resolution of such con icts. Findings were used to compile a list of best practices. Results are interpreted with reference to research on professional health care teams in medical settings. Implications for interprofessional education and training are discussed.
Multidisciplinary and collaborative care for eating disorders has become stan- dard clinical practice over the past 30 years (Becker, 2003; Henry & Ozier, 2006; Irwin, 1993; Joy, Wilson & Varechok, 2003; Kaplan, 2002; Lock, le Grange, Agras & Dare, 2001; Ruddy, Borresen, & Gunn, 2008;, 1993; Stewart & Williamson, 2004; Weiner, 1999). The American Psychiatric Association’s (APA) published guidelines advise that care for eating disorders should include nutritional rehabilitation, counseling and medical monitoring (Yager We thank Joanna Bressler, Shannon Casey, Lauren Kettmann, Bernie Perlstein and Michael H. Bond for their valuable contributions to an earlier version of this article.
Address correspondence to Diane C. Zelman, California School of Professional Psychology, Alliant International University, One Beach Street, San Francisco, CA 94133, USA.
E-mail: [email protected] 185 186L. D. DeJesse and D. C. Zelman et al., 2006). As far back as the nineteen-sixties, practitioners have empha- sized the need for good professional relationships and open communication among providers who treat eating disorders, to seek common goals, air emotional reactions and solve interpersonal problems among professionals (Rollins & Blackwell, 1968).
The mental health provider (MHP) and nutritionist (NT) address two primary aspects of the eating disorder: underlying psychological issues and the patient’s relationship with food, and their successful collaboration is of enormous importance (Reiff & Reiff, 1992; Saloff-Coste, Hamburg, & Herzog, 1993). Their collaboration is challenged, however, by different training, treat- ment philosophies and goals, having different practice sites, and the many pressures of working with patients and families facing a serious emotional and medical condition. The purpose this research was to identify the char- acteristic concerns that arise in collaborative relationships between MHPs and NTs in the treatment of people with eating disorders and to provide recommendations on how to anticipate and resolve these differences.
Speci c team roles of MHPs and NTs depend on the level of medical acuity and the treatment philosophy of the clinical setting. In some inpatient settings, the MHP may be only peripherally involved until the resolution of acute medical risk (Cahill, 1994). In others, the MHP coordinates the treatment team, shares information regarding patient progress, and discusses patient stressors that may affect treatment (Joy et al., 2003). In outpatient private practice settings, the MHP must more intentionally seek collaborative relationships and may even be the rst professional to determine that medi- cal and nutritional care are needed. Some important factors that hamper the MHP’s collaborative efforts include a lack of familiarity with the medical risks inherent in eating disorders, lack of time to pursue professional relationships and a lack of suf cient local professional resources.
A 2006 American Dietetic Association position paper on the role of nutritional intervention in the treatment of eating disorders describes the nutritionist as a fundamental member of the treatment team with unique skills to address food-related behaviors and assist in medical monitoring (Henry & Ozier, 2006). Although these guidelines advocate a primary role for the NT, in current practice, the NT role varies in onset, content, and fre- quency of patient contact. A clinical handbook written in 1992 by Dan and Kathleen Reiff,Eating Disorders: Nutritional Recovery in the Therapy Process, outlined ve models of NT collaboration (Reiff & Reiff, 1992). These models range from continuous contact with the patient and MHP throughout treat- ment, to direct intervention to help the patient change eating behavior (the behavioral model), to nutrition education only, to provision of only a food plan or occasional, ad hoc sessions as requested by the MHP.
Noting that professional roles in eating disorder treatments often overlap, Saloff-Coste and colleagues emphasized that it is valuable for NTs to be aware of the typical psychodynamics of people with eating Optimal Psychotherapist-Nutritionist Collaboration187 disorders, particularly when non-food issues directly in uence eating behav- iors (Saloff-Coste et al, 1993). Familiarity with approaches of motivational interviewing (cf. Brug et al., 2007) and cognitive behavioral therapy gives the NT a framework by which to identify and challenge patients’ nega- tive cognitions about their body and their ability to overcome the eating problem. Noting that the NT is not traditionally trained to explore trans- ference and countertransference reactions in professional care, Saloff-Coste and colleagues (1993) remarked that NTs may be susceptible to feeling over- whelmed, self-critical, excessively preoccupied, or over-identi ed with the patient.
In sum, the high level of potential medical risk to patients, differences in treatment strategies and therapeutic goals, potential overlap of services, and the emotional intensity that accompanies intervention for eating disorders can set the stage for professional con ict that might undermine treatment.
There is a need to identify sources of con ict, and to consider their pre- vention and their resolution. The goal of this study was to build on existing knowledge about collaboration between NTs and MHPs through the use of interviews with professionals who specialize in eating disorders. These interviews focused on disagreements between MHPs and NTs and requested recommendations for how to resolve these and similar disagreements. The ultimate goal of the inquiry was to inspire therapeutic and training models that facilitate optimal collaboration. METHOD AND DESIGN Twenty-two care providers consisting of 12 mental health practitioners (MHPs) and 10 registered dieticians (abbreviated as NTs, to re ect the broader eld of nutritional counseling) participated in semi-structured inter- views utilizing critical incident methodology (Flanagan, 1954) regarding a case in which they had collaborated with a professional counterpart (MHP or NT) in the treatment of an individual with an eating disorder, during which a difference in treatment strategy or a problem in the working rela- tionship emerged. In critical incident methodology, the interview focuses on unique and memorable events depicting the phenomenon of interest as a springboard for further exploration of ideas and feelings (Butter eld, Borgen, Amundson, & Maglio, 2005).
Participants Participants were 22 members of the online community of the International Association of Eating Disorder Professionals who responded to an online recruitment notice. Inclusion criteria required that participants be either 188L. D. DeJesse and D. C. Zelman licensed MHPs or registered dieticians with a minimum of two years of expe- rience treating individuals with eating disorders, who collaborated on a regu- lar basis with their professional counterparts (MHP or NT) in such treatment.
All participants were female. Of the 12 MHPs, six had a Ph.D., one had a Psy.D., three were licensed M.F.T.s, one was an L.C.S.W., and one was a licensed professional counselor (L.P.C.). Their mean years in professional practice were 14.31 (SD=6.57), with a range of 5 to 25 years of practice.
Current practice sites were outpatient private practice (n=11), residential treatment (n=1), day treatment (n=1), hospital-based outpatient care (n=2), and an outpatient community counseling center (n=1).
The 10 NTs’ mean years in professional practice were 11.9 (SD=6.67), with a range of 2 to 20 years. The NTs currently practiced in outpatient private practice (n=8), college counseling centers (n=2), partial day treat- ment programs (n=2), a residential unit (n=1) and intensive outpatient treatment programs (n=2). Several MHPs and NTs worked concurrently in both private practice and institutional settings, and most of those in cur- rent outpatient private practice had previously worked or trained in inpatient eating disorder treatment settings. Of the MHPs, two primarily used a team model of collaboration, four collaborated consistently (de ned as commu- nication about shared cases at least biweekly), and six collaborated on an occasional basis. Of the NTs, three currently worked in a team treat- ment setting, four used consistent collaboration and three used occasional collaboration.
Experimental procedures were approved by the Institutional Review Board of Alliant International University.
Interview Content Critical incident technique is a qualitative research strategy that has been utilized in mental health and medical research and in prior studies of interdis- ciplinary team collaboration in both healthcare and non-healthcare settings (e.g., Atwal, 2002; Butter eld et al., 2005; Cormier, 1988; Delsignore et al., 2010; Furr & Carroll, 2003; Kvarnstrom, 2008; Silen-Lipponen, Tossavainen, Turunen, & Smith, 2004).
Data acquisition in critical incident methodology focuses on an identi- ed critical incident that re ects the phenomenon under consideration, has an apparent purpose and signi cance recognizable by the participant and researcher, and for which the consequences are known (Flanagan, 1954).
Data can be gathered by observation or interview. When data are gathered by interview, participants are asked for a detailed description of the event, including their thoughts, feelings and re ections during and after the event (Schluter, Seaton, & Chaboyer, 2008). Data collection is considered complete when the addition of more incidents or participants no longer yields new content, an outcome that is analogous to the concept of saturation in other Optimal Psychotherapist-Nutritionist Collaboration189 forms of qualitative research (Flanagan, 1954). One bene t of critical inci- dent methodology is that although it focuses the participant on a particular incident, the telling of the narrative typically triggers further emotions and thoughts.
At the time of scheduling the interview, participants were asked, “Prior to our interview, please be prepared to discuss a case example in which you collaborated with an MHP [or NT, depending on discipline of the participant], to treat a patient with an eating disorder. Please be prepared to discuss any differences in treatment strategy or goals, or other differences that arose.” Interviews were conducted by phone and lasted between 45 to 75 min- utes, with the exception of one interview which lasted only 20 minutes yet yielded interpretable data. During the interview, after some initial questions to identify the current practice setting and the level of current profes- sional collaboration, participants were provided with the same initial prompt described above. Unless such information was offered spontaneously, the researcher asked questions to clarify the nature of the incident, the par- ticipants’ perception of the impact on the patient, the treatment, and the collaboration, efforts to resolve the situation, the ultimate outcome or resolu- tion, and re ections on how to manage similar incidents in the future. After exploration of an initial critical incident, the participant was asked to provide a second incident, and the same follow-up questions were asked.
Although the critical incident technique was used to generate speci c case examples, in almost all the interviews, participants described general past or current concerns. To maintain rapport and ow of the interview, if the researcher considered that the material re ected signi cant and typ- ical professional concerns, she continued exploring the topic rather than redirecting the participant to a speci c case.
Data Analysis Interviews were audio recorded, transcribed and then read by the authors, an advanced graduate doctoral student of psychology and a psychology professor with research and clinical experience in eating disorders and health psychology. The raters rst identi ed the list of critical incidents and preserved illustrative comments.
In data analysis in critical incident methodology, it is important to iden- tify the “core” or underlying cause of each incident in order to enable appropriate categorization into themes that are practical and meaningful (Byrne, 2001; Schluter et al., 2008). For example, a number of professionals described con icts in which it appeared that the “core” cause was that one professional judged that her counterpart overstepped professional bound- aries. These were compiled under the theme “encroachment,” which was de ned as “con ict when one professional provides advice or treatment ordinarily provided by the other professional.” In the process of re-reading 190L. D. DeJesse and D. C. Zelman critical incident data, new categories emerged and some of the original categories were re ned. This process was continued until all incidents were categorized and all categories were de ned to the satisfaction of both raters working together. RESULTS The raters identi ed 49 critical incidents in the transcripts which were grouped into ve themes (see Table 1). They also identi ed 65 attempted solutions to con ict and 20 outcomes of con icts, which, due to overlap of content, were condensed into a single category, Attempted Resolutions, and grouped into four themes. Lastly, based on providers’ nal re ections, the raters identi ed seven “best practices” that promote positive working relationships over time.
Critical Incident Themes Encroachment.Participants described eight incidents in which they or their counterpart provided services they believed to be more appropriately provided by the other professional. Although conceding that overlap of ser- vices is inevitable, MHPs were upset when NTs provided psychotherapeutic advice, and NTs were concerned when MHPs provided nutritional advice that contradicted their own clinical approach. One NT reported, The patient would come to our sessions and say, “my therapist said I should eat more carbs.” I would be taken off guard because it was not consistent with what we were working on in session...the patient would ask, “what do I do?” I’m telling her to listen to her body, eat when she wants to eat, include all foods and not focus on one food group. Another NT addressed the negative impact of receiving discrepant informa- tion, noting, “the way the anorexic brain works is that if it hears two different pieces of information, it will think, ‘Both are wrong, I will do neither.’” Putting the patient in the middle.Five participants described incidents during which one professional expressed a concern about their counter- part’s work by informing the patient or the patient’s family, rather than by informing their counterpart. This included advising patients and families to discontinue services with the other professional, questioning the professional judgment of one’s counterpart, coaching patients to engage in particular dialogues with one’s counterpart, delivering treatment recommendations to one’s counterpart by sending messages through the patient or the family, and drawing negative conclusions about one’s counterpart based only on the Optimal Psychotherapist-Nutritionist Collaboration191 TA B L E 1Critical Incident Themes: Challenging Interactions Between NTs and MHPs Description (# of incidents) Representative comments Encroachment (8): Con ict when one professional provides advice or treatment that is ordinarily provided by the other professional.NT: One therapist on my team said to our patient, “you need to eat more protein.” So I called her up and said, “I’m telling her to eat other things, but you’re pushing protein, so the patient is hearing two different pieces of information.’” MHP: I referred a patient to a dietician and, and the client started to see the dietician for psychotherapy.
Putting the patient in the middle (5): The patient or family are used as intermediary, concerns are not shared directly between professionals.NT: The therapist said, “tell your nutritionist to do this and that, tell her to make you a 2000 calorie meal plan.” And the patient told me this and said, “I rehearsed this with my therapist.”AndsoIaskedher,“youare rehearsing with your therapist what you say to me?” MHP: The dietician told me she is really concerned with the patient, that she has major depression and needs to be in a higher level of care. She had already talked to the mother about it and the mother called me and was all upset....I told the dietician, I understand, but we need to talk about this among ourselves rst.
Lack of expertise in eating disorders (18): Practitioner does not trust the competence of the other professional to treat eating disorders; one professional doesn’t understand second practitioner’s expertise.NT: Research shows that psychodynamic therapy alone is not helpful in treatment of eating disorders. One woman had been in psychodynamic therapy for years, she is 50 years old, 80 lbs., and in therapy two times per week. Low weight is not a topic in her therapy, so she keeps going to that therapist, but her eating disorder is not addressed.
MHP: Those nutritionists have no training in eating disorders. A lot of times, my clients come back to session with me with more resistance and they are more triggered than if I hadn’t bothered or encouraged them to go to the dietician in the rst place.
Clashing treatment strategy (15):
Disagreement regarding interventions, goal weights and level of care.NT: I worked with a client with anorexia and she left the treatment facility I was at AMA [against medical advice] because she wouldn’t eat. Her therapist should not have continued to work with her after she left at a body weight of 85 lbs. with no nutritional backup. She’s having dizziness, chest issues.
As far as the paperwork goes, hey that’s ne; they’re seeing a therapist, right? (Continued) 192L. D. DeJesse and D. C. Zelman TA B L E 1Continued Description (# of incidents) Representative comments MHP: The patient was 98 lbs. and didn’t have endurance to walk a block and the nutritionist said she was in a safe range. But she can’t even walk a block! But she was 120 lbs. in college and she had an anorexic bent and didn’t get her period back until she was back up at 115. Ultimately the patient ended up saying she wasn’t getting enough structure and support to dare and try and bring her weight to a better place. She knew herself that she wasn’t at the right weight.
Lack of communication (6):
Important topics are not discussed between the professionals or one of the professionals does not openly communicate during treatment.MHP: It’s usually the same situation with each non-responsive dietician. They don’t get back to me and it becomes my responsibility to chase them and I stop trying eventually.
MHP: With no responses from the nutritionist, I got mad and I complained. I went to her boss. I said, “I won’t refer anymore to this program unless this changes.” patient’s report. One MHP described, “I had a case a few years ago where the family took my patient to see a NT who was anti-Maudsley. She told the family, ‘You can’t do this approach because your kid will hate you.’” One NT noted that even when engaged in a professional dispute, the profession- als must remember to protect the “sick person in the middle.” Practitioners described these events as particularly detrimental to long-term professional relationships, creating hurt and angry feelings as well as capitalizing on some patients’ tendency to in ame divisive relationships among the treatment team (i.e., splitting).
Lack of expertise in eating disorders.The most common concern, described in 18 incidents, involved doubting the competence of one’s coun- terpart to treat patients with eating disorders. NTs recounted instances during which they felt that MHPs failed to address signs of medical danger or pro- vided psychotherapy that did not directly address disordered eating behavior.
One NT noted, I still get therapists who will call me and say, “I’ve been seeing this patient for therapy for two years and I’d like her to see you.” And I say, “You have been seeing a patient with an eating disorder for two years and you don’t have a team together?” And the patient walks into my of ce and she is medically fragile and so out of it. It’s unbelievable; they see patients for so long without contacting a medical doctor.
An additional concern of NTs, mentioned in three incidents, was when therapists saw nutritional intervention as unnecessary, or wished to limit the Optimal Psychotherapist-Nutritionist Collaboration193 scope of NT intervention to creation of food plans and monitoring of food intake. One NT noted that she had been trained in motivational interviewing to help change her patients’ eating behaviors, but that her expertise was dismissed by the MPH as lay psychotherapy. She noted, “It’s like she’s saying, ‘we don’t need you to provide a service to the patient. We just need you for keeping track of calories.’” Two incidents involved NTs’ concerns with MHPs who did not wish to work with patients’ families. One noted, The therapist did not want to do anything other than individual therapy sessions. I think that she did not know how, or she did not want to manage multiple people. She was new to ED [eating disorders] treatment.
Perhaps I should have said, let’s go to lunch. Let’s sit down, talk about how we work, talk with her about the Maudsley model.
MHPs noted that many traditionally trained NTs lacked knowledge about eating disorders or experience with those patients suffering from eating dis- orders. They described incidents in which NTs were insuf ciently attentive to their patients’ emotional concerns related to food intake. Noted one practitioner, This dietician knew nutrition, but not the psychological aspect of eating disorders and the fears of an eating disordered patient. So the way she said things to the patient was not right or appropriate. I referred this client who had been restricting for many years, and she gave her a 2000 calorie- a-day goal, and she was expecting her to follow this?
In three incidents, MHPs described particular NTs who they believed had insuf ciently resolved their own problems with body image and food restriction. MHPs felt that this led these NTs to prescribe excessively low calorie diets, to fail to feed to proper weight, or to prematurely discharge a patient. One MHP re ected, There are really good NTs out there, who are keeping up on eating disorder treatments, and then there may be people who are new to the eld and anxious. It makes a lot of people anxious to work with someone with an eating disorder. And then there are NTs who have their own eating disorder and have fairly rigid beliefs about nutrition.
Clashing strategies.Common areas of disagreement in treatment strat- egy (15 incidents) involved criteria for readiness for discharge in hospitalized patients, determination of need for hospitalization among outpatients, and what to do if the patient refuses to work with the counterpart (e.g., should a MHP refuse services if a seriously ill patient wishes to attend psychotherapy 194L. D. DeJesse and D. C. Zelman but refuses to work with an NT?). Sometimes discrepant treatment goals re ected typical goals of the professional’s discipline; NTs often adhered to a weight target or medical goal and were critical of situations in which MHPs focused primarily on emotional, cognitive or interpersonal signs of resolu- tion of the eating disorder. One NT explained: “If the psychologist is saying they’re doing xyz in therapy, but the client hasn’t gained a pound in two months...that’s not progress.” One MHP felt that the NT needed a more ambitious refeeding program, The weight tables may have a recommended BMI, but some people’s bodies are just supposed to be bigger, it’s in their genetics, their basic body structure. But it’s as if the nutritionist said to this patient, let’s keep you thinner, and continue to prolong your eating disorder, basi- cally because I am rigid and anxious about you gaining weight. This nutritionist had this patient in the inpatient unit for 3 months, and she never gave her more than 800 calories a day. Now I don’t know of any paradigm that says that is OK.
Five incidents re ected disagreements regarding whether to use a Maudsley family-oriented treatment model or to otherwise work with family members. Noted one NT, The therapist said she was doing individual sessions with the patient and not focusing on the parents. That was unheard of for me. I said, “the parents should be included, there is a concern of low body weight, we may have a hospitalization situation in the future, and the girl is 15.” The therapist was adamant.
Lack of communication.In six instances, participants expressed con- cerns about insuf cient professional communication during treatment. One NT complained that she received inadequate relevant patient information from the MPH, noting, The therapist didn’t tell me there was an abuse history...you know, if I was going to back her up, I needed to know this. I think the therapist didn’t want to give up a lot of information. She wasn’t open, and she felt threatened by the team approach. Other incidents re ected unanswered e-mail or phone communications and irregular treatment updates.
Attempted Resolution Communication and confrontation.The providers said that they usu- ally rst attempted direct communication and confrontation to coordinate Optimal Psychotherapist-Nutritionist Collaboration195 treatment plans and resolve personal issues. Noted one NT, “If the therapist is telling the patient one thing and I’m saying another thing, my goal is to get us saying the same thing.” When patients or family disapproved of their counterpart’s practices, the providers said that they rst attempted to verify the patient’s or family’s comments with their counterpart.
One MHP who served as an inpatient setting team leader noted that inpatient teams require rapid resolution of differences, noting that, I always recommend being open and communicating with the members.
If it’s a difference of opinion on a weight goal, it really needs to be discussed. As the psychologist, I need to bring these issues to the fore, talk about them at team meetings or send out an email. I try to see that things are dealt with pretty quickly. Practitioners noted that they try to anticipate concerns at the outset of treatment. One MHP explained, I try to facilitate the collaboration in advance. I communicate with the dietician about any potential issues that will interfere in their relationship, and this gives the dietician a heads up, and my expectation is that the dieticians I work with will treat me in the same way.
Several providers remarked that having long-term professional relation- ships made it possible to address differences of opinion in amicable and creative ways. Describing a case of a client with anorexia shared with an NT with whom she had collaborated for years, one MHP noted, We had a difference of opinion, but it was okay because we understand one another. I said, “Well, I think we should let her exercise, let’s throw her a bone, cause she may unhinge if we don’t. She is going to lose motivation for treatment if we don’t let her exercise a bit.” And in another situation the NT said to me, “hey, can you knock off the trauma work while we’re trying to help her gain weight?” An NT noted that her professional circle of psychotherapist colleagues was so familiar with her treatment strategy, that “if a patient goes to them and says, ‘the dietician said it was OK to exercise,’ the therapist will say, ‘No, no, no...I know that she would never say that to you.’” Interventions via the patient and family.Providers noted that if they anticipated that direct communication with their counterpart would be unsuccessful, they instead intervened with the patient or family (15 instances). When treatment strategy differed between the MHP and NT, the provider might explain the difference of opinion and recommend that the patient or family choose between the two pieces of advice, 196L. D. DeJesse and D. C. Zelman I have a patient who was two years post-laparoscopic band surgery. She said the NT was telling her that she can’t eat vegetables, and it didn’t make any sense to me. So I encouraged her to research the issues herself and bring that information to the NT. I did not get involved in this case.
I felt that it was up to the patient to work out this problem with the NT.
One NT explained that she would attempt to steer families away from psychotherapists who she felt were not experienced and towards therapists whose expertise she trusted. She explained, Most of the time when parents come and see me, they ask who I work with and they’ll go to them. They’ll change therapists. Parents have no problem changing therapists like that. Basically you learn what to tell parents. You gracefully learn to tell them, “Here are the best practice guidelines for anorexia.” Another way in which providers intervened with patients is through attempts to prepare the patient for an anticipated stressful or negative experi- ence with another professional. One MPH lived in an unpopulated area with limited access to NTs trained in treatment of eating disorders. She explained, I nd that it’s really helpful if I say to the client rst, “I don’t know if this person knows about eating disorders.” I might say, “This is what you can expect from the NT. They’ll have you write food preferences, do a 24-hour recall of what you last ate, and food logs.”...and I’ll say, “don’t get scared by the NT’s meal plan.” So I basically prepare them so they don’t get scared.
Discontinuing collaboration.Nine participants indicated that inability to resolve a professional dispute led them to discontinue work with the patient, or in serious disagreements, to end a professional relationship. Noted one NT, “I was open with what I thought and it was not in line with what the therapist thought, so eventually the patient stopped seeing me.” Another indi- cated that since a serious dispute regarding a case, “I haven’t taken a referral from that therapist since then. We have two different treatment approaches and that is ne, I do not have to work with everyone.” In ve cases, participants described the loss of personal relationships as well.
One NT noted, I promptly stopped referring patients to her, and we didn’t share any patients for a very long time. And we were once friends. I was a nutrition director at a residential unit and she came to work there and I showed her the ropes...but I don’t need friends like that. Optimal Psychotherapist-Nutritionist Collaboration197 Organizational-level approach.Lastly, six strategies to resolve con ict were aimed at organizational-level changes through education of other pro- fessionals, seeking institutional policy change, and working with department supervisors. One MHP explained, Our university health care system now has legal protocols in that they can cancel nutritional counseling if the person doesn’t have a therapist.
I helped put that in place, because I had a few people who weren’t seeing a therapist and I’m like, are you kidding me? Another NT provided direct education to her professional counterpart, I spoke with this therapist openly and honestly and gave her some edu- cation about the use of MI [motivational interviewing]. I talked with her about how I counseled someone through a situation, such as adding a new food to their diet and I let her know that we talk about food and nutrition. I gave the therapist examples of other patients I’ve worked with and how I used MI and showed her that it may look like psychotherapy but it’s about food.
One MHP noted that she offered to provide in-service training for an insurance company that employed NTs who were new to the treatment of eating disorders. Best Practices Seven broad themes captured how providers created and maintained positive collaboration with their counterparts (see Table 2).
Cultivating a provider network.Our most experienced providers said that they have developed a network of trusted providers who share the same treatment philosophy and collaboration style. One outpatient NT elaborated, I have my dream team of therapists I work with, my eight “go-to” thera- pists, and it’s because I participated in their training, I worked with them during their postdoctoral training, and they specialize in eating disorder treatment for real.
Accepting differences.Some professionals were able to accept their dif- ferences, acknowledge that con ict is natural and can be fruitful, and tried to assure that disagreements were not taken personally. One NT noted, “We are a team. We joke that our strength is that we often disagree, which is valuable.” One MHP noted, similarly, 198L. D. DeJesse and D. C. Zelman TA B L E 2Best Practices in Mental Health Professional–Nutritionist Collaborations Theme Description Cultivate a provider network Develop long-term relationships with other providers who share the same treatment philosophy and communication style, and who agree upon mutual team collaboration and roles.
Accept differences Acknowledge that con ict occurs, that con ict can be valuable and do not take disagreements personally.
Build good fences Providers respect the expertise and practices of their team members. Roles are well-de ned at the outset of collaboration. Providers accept occasional overlap of roles.
Communicate Open dialogue to understand each provider’s treatment philosophy and practice. Share important information to the other provider about their interactions with the patient. Communicate about areas of disagreement.
Value counterparts Seek out information about other disciplines’ roles.
Show high regard for collaborative approach in interactions with each other, with patient and family, and with treatment system (hospital, third party payers).
Seek team consensus Seek consensus with the other professionals regarding major treatment decisions prior to discussion with patient or family, avoid use of patient or family as “middle-man.” Educate Educate others (individual providers, organizations and third-party payers) about one’s role in eating disorder treatment. It gives me the opportunity for self-re ection. I always appreciate it when the dietician that I work with, challenges my thinking. Perhaps I’m missing something, or I am caught up in my own countertransfer- ence, and they can ask what is going on....So those times, when you disagree about something, are what I like about collaborative relation- ships. Because I don’t have to think of everything myself, it makes me dig deeper, asking myself, what is going on here, what is my motivation.
I feel relieved.
Building good fences.Experienced professionals emphasized the value of de ning mutual practice boundaries at the outset of collaboration. This clari es one’s professional domain and conveys respect for the expertise and contributions of other team members. Also, providers trusted each other to be exible in roles when necessary, and did not feel threatened by occasional overlap of services. One NT stated:
So I said to the patient, “I think this is more of a topic for your therapy?” The instinct is to feel guilty that I stepped over the line into therapy, but my take is that you don’t know that you stepped over the line until you step over the line. I thought it was going to be about this topic, and Optimal Psychotherapist-Nutritionist Collaboration199 then it turns out to be about that. And you can’t feel like a bad dietician because you don’t know, until you have sifted through the information, really what the topic is about and whether it’s just about food or about something deeper. And the therapist is going to thank you because you got to the bottom of something and can pass this information along.
Another NT who worked with a consistent network of MHPs said that she felt con dent that her colleagues understood her treatment approach enough to make interventions when necessary. She explained, Boundaries, yes, they’re important, but I will not be upset if you tell patients who are starving to eat breakfast and give them an example!
Yes! Please do that. I would love a therapist to say, “Your dietician said to have breakfast and you’re not doing it.” That’s backing me up, if they say to them, “how about having an English muf n, you’re not following your menu plan.” Ongoing communication.Participants described the need for consis- tent open dialogue to understand each other’s treatment strategy. They also supported regular sharing of important information with the other provider about their interactions with the patient, and, nally, direct communication about areas of disagreement. One MHP described, ...setting aside time to really talk about those issues, hearing each other out, and making the decision that is in the best interest of the patient after hearing both sides. For the most part, this mindset will work well in nding a good solution satisfactory to both providers.
Valuing counterparts.Participants valued colleagues who show high regard for the collaboration in interactions with each other, with patients and families, and with other entities in the treatment system (e.g. hospital, third party payers). They reach out by learning about each other’s professional roles, interacting socially and attending professional conferences together.
One MHP explained that she respected her team members because of the perspective that each discipline provides, You need to be open to new data, always open to the possibility that you don’t know, and that you may be wrong. If it’s a healthy team...dis- agreements are where you learn, not where you get shamed. In healthy teams there lies a whole lot of opportunity to learn new information.
Seeking team consensus.Participants acknowledged that professionals should generally seek consensus regarding major treatment decisions prior to discussion with either the patient or the family. They tried to avoid using 200L. D. DeJesse and D. C. Zelman the patient and/or the family as “middle-man.” One NT stated, “I do not like to discuss disagreements that I have with the therapist with the patient and it is vital to present one group opinion of the treatment team to the patient, and really to the parents in this situation, about course of treatment.” Participants noted that presenting as a uni ed team to the patient and family conveys stability, minimizes confusion and anxiety, and promotes treatment progress Education.Providers sought to impart and gain information on each other’s professional practices. Described earlier in this manuscript, this included personal interactions as well as offering in-service training within their institutions and partner organizations. DISCUSSION This is the rst study of its kind to speak with NTs and MHPs about their struggles working together. This study enriches the recommendations on collaboration provided in prior literature by utilizing real-life clinical situa- tions to illustrate breakdowns in collaborative relationships. It shows how practice can deviate from models recommended by experts, and how expe- rienced practitioners create a more supportive and interpersonally rewarding environment for service delivery.
Con icts emerge in the collaborative treatment of eating disorders among well-intentioned professionals who otherwise wish to be accommo- dating and team-focused. Their con icts re ect their dedication to quality patient care, and even a sense of helplessness in the presence of severe patient pathology and its potential for serious medical consequences (Henry & Ozier, 2006; Katzman, 2005; Williams, Goodie & Motsinger, 2008). They also re ect power struggle, striving for the respect of their colleagues, and crises of boundaries and trust. Our professionals noted that it is particu- larly important to model strong professional collaboration skills when serving families who are under severe stress and may themselves have dysfunctional family communication styles. They also noted that even one strained clini- cal interaction with their professional counterpart could lead them to end a professional relationship. This termination can undermine the effectiveness of inpatient teams, and challenge effective community care where there are only a few local professionals with expertise in treatment of eating disorders.
Our ndings were consistent with studies of con ict among multi- disciplinary teams in primary care and intensive care medical settings.
Primary sources of con ict included power struggles within teams, uncer- tainty regarding role boundaries and scope of practice, concerns about accountability, and disagreement on treatment strategy (Bailey, Jones, & Way, 2006; Brown et al., 2011; Meth, Lawless, & Hawryluck, 2009; Studdert et al., 2003). Optimal Psychotherapist-Nutritionist Collaboration201 Our providers identi ed a number of attempted solutions, citing both satisfactory and unsatisfactory outcomes. Future research is warranted to establish the impact of various con ict resolution strategies on patient outcomes. In the current study, direct communication and confrontation sometimes resolved disagreements (especially in established professional relationships) and at other times led to a parting of the ways. Managing a disagreement with a professional counterpart by intervening with the patient and family was described as both a solution and a source of resentment (“putting the patient in the middle”). Informing patients and families about providers’ disagreements provides transparency to consumers but leaves them to resolve discrepant information on their own.
The professionals in this study underscored the general conclusion that they were typically satis ed with their collaborative relationships and that over the years they had established best practice procedures that tended to create and sustain these relationships. They minimized con icts by cultivating provider networks and clarifying the collaboration plans at the outset. Topics to discuss in an initial case consultation might include: (a) medium and frequency of communication; (b) content of communication; (c) providers’ treatment philosophy and approach with a particular patient; (d) how each provider de nes and evaluates progress; (e) policies regarding disclosure of patient’s grievances about the counterpart; (f) level of colleagues’ training in intervention for eating disorders; and (g) emergency protocols.
Both MHPs and NTs remarked that they wish that they had received more training in professional communication, negotiation and collabora- tion. Mental health education often focuses on development of oneself as an independent provider rather than as a member of a larger system.
Recent increasing use of interdisciplinary assessment, intervention and goal setting in health care teams suggests the need for training experiences to prepare professionals for collaborative care roles, in contrast to multidisci- plinary care in which professionals work primarily in parallel (Mirjam, 2010; Zeiss & Steffen, 1996). Interprofessionalism is a new concept for profes- sional education that describes conjoint training of students who will enter different disciplines (Baldwin, 2007; Thistlethwaite, 2012). In a classroom setting, mental health and nutrition students might simulate a case col- laboration, or MHPs and NTs can present instances of their teamwork to other professionals. By training together, professionals can learn each other’s professional languages, treatment philosophy and interventions. Future stud- ies of training in eating disorders interventions may wish to examine the impact of interprofessional education on patient outcomes, profes- sional collaboration, and professionals’ subjective experience, such as career satisfaction.
It is important to consider limitations in the interpretation of these ndings. In order to capture expert opinion, we interviewed experienced 202L. D. DeJesse and D. C. Zelman professionals in the eating disorders eld, all of whom who value and give considerable thought to collaborative work. The study did not interview male professionals, professionals who collaborate rarely or unsuccessfully, who have no experience with eating disorders treatment or who only occa- sionally encounter patients with eating disorders. Thus, the sample was not inclusive of all MHPs and NTs who treat individuals with eating dis- orders. Furthermore, many of the critical incidents were associated with negative outcomes such as termination of professional relationships or nega- tive impact on patients. Researchers using critical incident methodology have observed that incidents associated with negative emotion are more readily recalled from memory (Kensinger, 2007), perhaps due to a sense of lack of resolution or feelings of anger, regret or failure. Fortunately, although the critical incident data did not often re ect successfully resolved con icts, the recording of participant’s other experiences yielded abundant information on successful collaborations.
One way to express the primary ndings of this research is to present the concerns of the NT and MHP as a series of hypothetical requests. Both the NT and the MHP wish to be liked and respected by each other. They seek consensus and prefer direct communication to airing grievances via patients and families. The NT asks that the MHP learn about the contributions that a properly trained NT can provide in the treatment of eating disorders. She/he wants the MHP to understand that when intervening to promote change in eating behaviors, the distinction between nutritional counseling and psy- chotherapy may occasionally become blurred. The NT wants the MHP to utilize suf cient medical and nutritional backup to maintain patient safety.
She/he wants the MHP to share enough about the patient’s psychotherapy to help her know how to best motivate their patient (cf. Knowles, 2009).
Finally, the NT asks that the MHP check in with her prior to telling the patient what to eat.
The MHP wants the NT to acknowledge that working with patients with eating disorders requires additional training. She/he wants the NT to understand the client’s extreme anxiety related to food and weight gain that can manifest as resistance to the NT’s food plans or emotional dynamics with treating professionals. The MHP wants the NT to explore his/her own emotions or judgments related to weight and body size, and to put these subjective issues aside when working with people with serious eating prob- lems. The MHP wishes the NT to be wary of incursions into psychotherapy, and asks to be informed when the patient discusses serious psychological concerns such as suicidal feelings.
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