With several different professionals routinely involved in rehabilitation, challenges can emerge in shared goals and understandings which keep the client at the centre of the process.
Having seen differing perspectives at play and finding it harder to coordinate a package of care, PsychWorks Associates has devised a model to help achieve an interdisciplinary way of working which keeps the client at the heart at all times and that maximises rehabilitation outcomes.
Following the publication of the model last month, Dr Shabnam Berry-Khan, clinical psychologist, Advanced BABICM case manager and founding director of PWA, tells NR Times more
In rehabilitation, we talk about client-centric approaches, client-focused service – and while that’s always the intention, it can sometimes be difficult to achieve, particularly when several different agencies are involved.
We’ll have the legal requirements, the client’s needs, the family perspectives, the carers as the ever-presents on the ground, therapy and other medical input too, with the case manager trying to piece it all together.
There isn’t always a mechanism to share the knowledge and fully coordinate an approach where everyone is collaborating. Often, it can feel like there are a series of different camps around the case manager, with the case manager at the centre as the keeper and holder of all the knowledge that has been collated. That is a lot of pressure for the case manager, to go between all of these different camps to piece together, coordinate and review everything within the package.
Given the many dynamics at play, and the logistics of coordinating this, it becomes easy to see how a client can become lost in the process, which is absolutely not what any of the parties involved in their rehabilitation wants.
As a case manager with psychological training to inform my clinical stance, I found it easier to think about my clients when I borrowed from my psychology toolkit. In particular, my case conceptualisation skills – or formulation to those with psychological background – seemed so appropriate and helpful for assessment, planning, interventions and reviewing the packages of care and therapy.
Formulation – or case conceptualisation – is described as a story or narrative that is pulled together collaboratively between client/family and professionals. In this way, client life experience and intuitions about their life are put together with the clinical skills and observations brought by the team for a ‘best guess for now’ shared understanding of the client and their needs. Formulations are revisited throughout the input and it becomes a process by which distress, needs and successes can be made sense of for those with a role to improve outcomes.
There isn’t a known model to help us think and process a case managed personal injury client’s needs with the wider family and teams involved and so I began to develop one, which we hope will underpin a shared rehabilitation process to keep the client at the centre, and to crucially promote the value of interdisciplinary working in securing the best possible outcome. It originated from working with ethnic minority clients and wanting to make clear the challenges that are experienced and soon developed into a model that could fit any client in a case management context.
The client – the central component
The Personal Injury Formulation and Intervention Model (PIFIM) I devised is just at its preliminary stages, but it’s so far been quite effective in the case management and treating psychology work we are doing.
The model places the client at the heart of everything the team does, guiding the care and therapy towards personally held life goals and aims. Family can often be involved in this goal-setting experience especially when the client is a child, has a significant brain injury and/or lacks capacity. Eliciting client goals as part of the Immediate Needs Assessment or prior to a first care or therapy meeting is key.
The model recommends learning about the client, their life, their story, their personality, their sleep, their cognitive impairments and fatigue levels, to gain the understanding that is needed to work with them therapeutically. This exercise gives us an idea about how our client or their family were like premorbidly and upon which we can gain huge insights about the initial parameters our client and their family bring to the rehabilitation table.
From there, we can widen out to look at factors like the client’s environment, their accommodation, the importance of fit of carers and therapists to the client and family. Carer and therapist retention in particular is improved if you have already come to know the client and family perspectives.
Once we have a basic sketch of our client’s overarching goals, their background story as they see it, their challenges that need to be considered, the kind of likely best fit personality the team around them need to exhibit and their surroundings, we can develop some accurate care plans and risk assessments.
Also key to understanding how our clients might think and feel are linked to socio-cultural factors that have shaped and continue to shape their experiences in life – what I sometimes call ‘hidden factors’ – such as trauma, attachment style, culture, feeling like they belong, all of which affect the language we use, the boundaries we keep and how attuned we can be to our clients. Maintaining engagement and a supportive therapeutic alliance is dependent on understanding these key factors.
The model goes on to use signs of distress in client and/or setting to determine how well we are meeting their needs. If distress is identified, the model proposes a cycle to further assess, treat and measure the distress to review interventions, until distress is minimised.
To learn more about how PsychWorks Associates are using the PIFIM model with some of our cases, visit here.
The value of interdisciplinary working
Where multiple professionals are involved in any situation, attention to the system is vital to support relationships and manage dynamics to promote engagement and joint working. In the case of a client’s rehabilitation, which is typically pitched as a whole person approach, it can be very damaging, and can create a gap in understanding if the differing parts of the package are not communicating and the work is not collaborative with the client, family or colleagues.
Without the overarching, guiding goals from the client/family, there is a risk of each professional group working in a silo pattern, where goals are independent of one another, uncoordinated and potentially confusing for the client/family. After all, it’s much harder to understand the greater purpose of the hard work they are undertaking when the goals are potentially unrelated. It can also be much harder for a case manager to determine the value and progress of the package as a whole.
To be efficient in our working and to allow for a more shared perspective, we need to see more interdisciplinary working. More collaboration, more sharing, more joint work, more co-created programmes and a shared underpinning or formulation to frame the work the whole team is doing while holding the client at the centre. There is then an opportunity for the team and the work to become bigger than the sum of its parts, which is vital in achieving the best outcomes for our client.
To enable this to happen, and for everyone to feel heard and involved in the process, it is important to have a mechanism in place to help recognise this, which is where formulation works very well. PIFIM is one of the first formulation models available to case managers working in personal injury that considers the client’s needs at the core of the decision-making, which then emanates out to the wider professional teams, pulling them together using the power of co-created, evolving narratives.
And this formulation is something that should be revisited and re-evaluated until we are confident that we are meeting the client’s needs, and that there is minimised distress. We can share the knowledge we have individually and piece it together in a jigsaw that we are all working to complete. By working in this way, we would hope that, in theory, this would lead to less distress for the client.
By working in an interdisciplinary way, with consideration given to client need, group dynamics, team formation, we can all work more effectively together for the good of our client, to ensure we are delivering on our commitment to act in their best interests and support their rehabilitation in every way we can.
At PsychWorks Associates, we are trialling the model and we look forward to sharing more updates in due course.
In the meantime, if you would like to read more about the model, please see Chapter 7 in Boayke and Mwale’s book on systemic approach to brain injury published in December 2022. If you feel you clients could benefit from a streamlined, coordinated care and therapy package, we would be happy to see how we might be able to support your client and their family.
