Accountability in Clinical Practice, Part I

In our last newsletter, we discussed the pluses and minuses of clinical judgment, the compass we all use to guide us from moment to moment in our office treatments. The major question asked was: How reliable is clinical judgment and how to KNOW that you are doing the right thing?

Here’s an example that is likely to seem familiar to most of us:

“Don’t go to a shrink. Once they get you hooked they never let go,” said her mother to 38-year-old Amanda. And she wasn’t kidding. Once Asperger’s-like Amanda started to go to treatment her parents were unrelenting in insisting that she finish as soon as possible. When Amanda stayed on and began to make some connections to other human beings, the mother was careful never to approve of anything Amanda did, always seeing failure and regression where we judged there was progress.

Steve Frankel was the therapist and Phil Erdberg the assessor. As usual, we structured our work according to our Collaborative Treatment Method. Amanda had a life-long history of social and
professional failure. Soon after treatment began, the refrain of objections started. “What’s your evidence?” “What convinces you that Amanda is progressing?” “But, my girlfriend Barbara said…”

Substitute any patient. Isn’t there usually a time when support, emotional and financial, for the treatment typically begins to dry up? The beginning is upbeat. (In Hidden Faults [2000], Steve calls this early high, “incipient conjunction.”) Then you begin to hit some hard spots: issues the patient doesn’t want to think about, financial priorities redirecting money to a coming vacation, just boredom. Of course, not all treatments are like this but since it happens so often…

So, how can we, as therapists, argue in defense of the patient and the treatment? What data DO we have? This is not a trivial question, especially if someone other than the patient is holding the purse strings. Note that this issue is somewhat beside the point when we are dependent on a third party for payment. In those cases, the issue of run-on treatments has already been dealt with and sharp restrictions on the frequency and duration of treatment have already been imposed. But outside of managed care, we are talking mostly about out-of-pocket payment situations. Justification for treatment in these cases is mostly a private matter between patient or parents and therapist.

Our treatment protocol is described in Steve’s most recent book, Evidence From Within: A Paradigm for Clinical Practice. In the beginning of a case, he does a clinical evaluation and, as soon as feasible, gets psychological or neuropsychological testing. He does this with adults as well as children. Alternatively, self-assessment tests may be all that a patient is willing to afford or tolerate. When Phil has been included as an assessor, the feedback from these assessments is used therapeutically according to the principles of collaborative psychology and psychiatry (Engelman and Frankel 2002, Finn 2007). Steve then creates a report, outlining tentative impressions and a collaboratively arrived at treatment strategy and plan. Matched with Steve’s report is Phil’s counterpart, reflecting the testing data. By this point the patient and Steve have an idea of the kind of clinical process the patient is willing to undertake. Ideally, after testing, there is a trial period of several months when the proposed clinical strategies are evaluated for efficacy. Verbal or written reports, including modified treatment plans, are created successively in response to changes and progress in treatment. These may be schematic and often are delivered at four-month intervals. These reports serve the secondary purpose of providing an excellent means of enhancing therapist-patient communication.

In our opinion, the extra cost and time required for such an assessment and treatment approach are more than justified by its built-in checks and balances as well as the added likelihood of clinical accuracy. The combination of clinician self-discipline and psychological or neuropsychological testing pretty much assures that as a clinician you will not miss much or overtreat the patient. The probability of the clinician lapsing into formulaic practice, such as automatically seeing a psychotherapy patient once weekly for many months or even years, is much reduced. The choice of a therapeutic approach, cognitive-behavioral or psychodynamic, for example, is based on test results and a well-considered diagnosis. Consultation with other experts is used liberally, and collaboration with spouses or family members is frequently called for.

The benefits of such a process? Simple. More focused and efficient treatments. The ability to identify patients who cannot really benefit from psychotherapy alone. And, most particularly, results, results, results, as opposed to simply assertions that what you do works.

Returning to Amanda, she is still in treatment and is sharpening her social interest and skills. In the past, learning to communicate with and enjoy other people seemed entirely beside the point to her. It is, of course, slow and steady work. Her personal and psychological progress has been followed clinically by Steve, and formalized collaboratively through check sheets we constructed around her goals for the treatment, as well as through selected psychological tests administered by Phil. At the beginning of treatment, Phil did a full battery of psychological tests. This information is repeatedly supplemented through self-assessment protocols, including some of the more informative batteries such as the PAI and MMPI II.

Amanda’s parents are even becoming less contentious as her progress becomes harder to overlook. Having data, including literature which places Asperger’s in the category of a disorder of temperament (developmental, “brain based”), has clinched our case with them. Amanda had been in treatment twice before, but without discernable benefit. This time there are results, plenty of them.

We hope we have made a good case for therapist responsibility for articulating and measuring results as a treatment progresses. The advantages? A distinctly more accurate and efficient process. The cost of these extra measures are almost always less over time than the expense of ongoing, unfocused treatment. And in the end, regardless of our professional discipline, whether psychology, social work, marriage and family therapy, or psychiatry, we adhere to our mission to heal and keep track of the patient’s progress.