We often focus on the benefits of collaborative, interdisciplinary, joined-up working for our clients and their families to achieve goals in a sustainable and timely way. While this will always remain our focus, there are other benefits to this communication-based approach that works well for the service providers that is hardly talked about.
Here, Dr Shabnam Berry-Khan, MD, clinical psychologist and Advanced BABICM case manager at PsychWorks Associates, discusses the pressures on rehabilitation providers in the current climate, especially those offering mental health support, and how faster and more efficient ways of assigning funding are also at the heart of improving outcomes for clients in the longer-term
For those of us working in rehabilitation, our aims will no doubt be the same – to be able to deliver person-centred rehabilitation and improve our clients’ lives at the times they need it most.
In terms of personal injury rehabilitation, this is no different. And indeed any difference lies more in the setting and how the complicated, multisystemic medico-legal machine works. So, while it is of course the ambition of the personal injury process to provide the best support, it is not always possible to achieve because of the administrative elements surrounding injured clients.
Why collaborative, interdisciplinary, joined-up work works
You can read my idea about the benefits of interdisciplinary team working in a recent article here. The key tool of any approach that requires teams of people to work together on a single client’s needs is communication. It is through regular, timely and concise communication that busy clinicians can get to the core of their involvement around a client’s goal and can contribute meaningfully to the aims and objectives of the rehabilitation plan.
When communication is limited, delayed and/or unclear, any joint working is affected and goals are consequently slowed down. It reminds me of the saying “you’re only as fast as the slowest runner”. While I’m not likening rehabilitation goal-setting to a race, the imagery of a process being impaired by someone not able to provide what’s needed feels like it could fit here.
The upshot of good communication in a multi-systemic rehabilitation package is always going to feature coordinated goals, happier clients and families and a therapy team that is likely to be retained longer-term.
Good communication also means expedited decisions
We know the positive difference good rehabilitation can make to clients and their families, and we’ll no doubt be aware of the very damaging consequences of gaps in therapy provisions – whether delays in accessing therapy or therapy being withdrawn due to fundings issues.
Not that professionals purposely form gaps in a given package, it has become more apparent to me that gaps in provisions are more likely when the administrative aspects of a package are not addressed in the same way as perhaps the clinical work itself.
To give some context here, in personal injury work, often a therapist undertakes a piece of work that is reported on with recommendations that need considering. Assuming the report is of a good standard and clinically sound, the report would need to be reviewed by the case manager, sent to the legal teams involved for consideration before approving any funds. The case manager would then need to seek consent from the client/family to ensure they want to receive the treatment. Only then will the therapist get a response. This process can take at least a week if undertaken quickly and when there are no major queries or concerns. However, in the main, it is my experience as a case manager that this process will take approximately 2-4 weeks where the delays are related to poor quality reports, professionals in the wider system not prioritising the processing of the report and queries around funding/budgets. At least this is what I tend to see. In the meantime, our clients are waiting patiently to receive the input they have consented to, and may need quite desperately.
Risks caused by delays
The emotional energy that is needed for a client and family to share their story is typically high and this can be a factor in how ongoing therapy needs to be dealt with. Clients are usually referred to us when they are overwhelmed and/or they are in crisis. Expressing their experiences, retelling their distressing stories and then feeling vulnerable as their story is shared not knowing tmwhat the outcome will be is often unhelpful to the client. We therefore want to manage the system to reduce delays and limit additional psychological damage.
Adding to that, what we have also found at PsychWorks Associate is that delays particularly for psychologists is problematic for clinicians as well as clients. It is a challenge to find good quality psychologists (or any therapist, really) who are willing to undertake home visits. So, when a service like PsychWorks Associates finds a clinician with the right skills and flexibility to provide catastrophic injury work, we jump for joy! We then want to keep them involved by providing them with appropriate referrals. When funding is delayed, it can put off a busy competent clinician (and goodness knows, in the current mental health crisis, psychologists are in demand!) who simply wishes to help alleviate client distress and to do so in a timely way to maintain rapport.
The other risk is that if a significant gap has been incurred between accepting the referral and receiving Ts&Cs or between assessment and approval of recommendations for treatment work, the clinician may not have the capacity anymore to take on the work. There would need to be more than a month’s delay for this response, but nonetheless, being aware that clinicians are in demand and will go to clients/systems ready to take on the work.
Therapeutic alliance must be preserved wherever it can, and understanding that the simple reading of a proposed clinician’s CV can be enough for a client in distress to feel supported and hopeful. Changing clinicians at any stage is a rupture that may result in a client rejecting further similar input. This is particularly true if there is a change of clinician between assessment and therapy. We all know that maintaining a strong therapeutic alliance is synonymous to being person-centered care so we would do well as a system to bear this in mind.
Sudden endings
You know that feeling of being engrossed in a film, book or game, and suddenly being asked to stop the activity. It’s why we give children ‘5 minute warnings’. All clients will have been told how long the input is available for. For those clients who have been promised a block of therapy that is suddenly withdrawn (it has happened – usually due to funding reasons), the damage this act can cause can be irreparable. To invest time and energy in a process which is then ended abruptly can be very disruptive, disorientating and hugely uncontaining for a client and their family.
Consequently, some clients and families would be reluctant to recommence a therapy process that seeks the sharing of personal and often painful or traumatic information because they experience terminated therapy due to circumstances beyond their control. This can be particularly problematic for clients who are already in distress.
A collaborative and shared way forward?
I know we are all so busy so this is not meant to be a professional-bashing piece, designed to make readers feel bad. It’s more about reflecting reality and proposing some solutions because there are some great clinicians out there willing to work with our clients because client distress is real and, as professionals, we truly want to help not harm our clients. Yet, dispute these best intentions, delays happen and clients do not always get the best deal.
So, this is what we at PsychWorks Associates advise the professional networks around the client to implement to minimise delays and therefore risks to clients:
- We manage clinicians’ expectations when they start working with us or when a new case is being referred to them: if they know there will be a delay due to the complexity of the system, clinicians can manage their other commitments accordingly.
- When referrers are seeking costs for an assessment, we provide sample costs for therapy so fundholders can potentially earmark some additional funds for treatment work.
- Clinicians must write good reports that tell the client’s story and provide solid evidence for a set of recommendations. This makes it easier for the fundholder to see the link between clinical need and the funding requested.
- We have started stating in reports the urgency of the input and what would be most helpful for the therapeutic alliance in terms of commencing the work. It’s part of the expectation management, but also means we can build on the momentum developed so far… which is often hard for a client to do.
- Cost-effective recommendations are key: if working with a complex client, break costings into blocks of input and make clear in the report that more input might be needed in X months’ time following a review.
- If funding becomes problematic for fundholders, draw on your trauma-informed awareness and knowledge to allow any therapy input to end well. This will allow a return to similar therapy to feel less unsafe.
Being mindful of our individual parts of the network holding the client safely, we need to play our role carefully and thoughtfully. Considering the impact our role may have on incurring delays. There is a role to evolve, be innovative and interdisciplinary in the way we work together. On every aspect of our work – clinical or administrative – so we can provide our client with the best possible options to guide them out of distress compassionately.
For treating psychology or case management that is underpinned by collaborative approaches to maximise rehabilitation, we invite you to contact PsychWorks Associates via www.psychworks.org.uk or admin@psychworks.org.uk – we would be happy to support your client with you!
