Accountability in Clinical Practice, Part II

In our last issue, the topic was “accountability in clinical practice.” We were interested in how clinical progress could be tracked clinically and through more formal means, like psychological testing, and optimized to produce the best outcome. As always, the identity of all named patients has been fictionalized. 38-year-old Alice was our case. According to Steve she was classic for Asperger syndrome: affectless, no relationships. Her parents were skeptical about anything psychological. They thought she was just lazy. They cut some slack for depression, but that was about it. They agreed that treatment of some sort was necessary, but it had to be over as soon as possible.

After being fired from her four years long bank clerical job, Alice wandered the streets by day, relying more and more on her treasured liter-sized bottle of beer to bring herself back to a state of tranquility. In treatment, patience, the use of a symptom check list and self-assessment protocols for therapist and patient self-monitoring, combined with Phil Erdberg’s psychological testing, and a collaborative treatment approach utilizing successive, cooperatively developed treatment plans, all helped to direct treatment and keep it on track. In this manner Alice’s participation was made integral to the treatment work. As a result of her participation, she progressively recognized how critical her cooperation would be to achieving the goals she set for herself.

Now to the way professionals work — or don’t work — well together, each being accountable to the other and ultimately to the patient. When multiple health professionals are involved, our impression is that this is not always a smooth operation. Logistical and psychological components are often out of sync, pieces not optimally matched and integrated. What, for example, if the psychotherapist is not thoroughly familiar with the psychotropic medications being used, the mood stabilizer affecting the patient’s memory and even judgment and obscuring the psychological issues? That’s what happened with Edith, who was being treated with Lithium and complained endlessly in her psychotherapy about a “memory deficit.” She insisted she could not hold a job, and no doubt she could not. Her pharmacologist focused more on symptoms than those aspects of her life. When it was possible for the therapist and pharmacologist to talk and they decided together to switch Edith from Lithium to another mood stabilizer, Lamictal. At that point her memory returned to baseline.

Now let’s add an internist. Consider a patient with a subclinical thyroid problem, too little thyroid hormone. Always cold, slow moving, and most particularly slow thinking. She thinks she’s depressed and so does her family. Psychotherapy gets nowhere. Simply an oversight, or a lack of coordination, or maybe even more pertinent, no one to coordinate this complicated treatment?

As a case in point take Steve’s patient Cori. She had been treated by multiple psychotherapists and psychopharmacologists. Cori was bright and empathic, but had a history of failed relationships, depression, and withdrawal when situations soured. Following the loss of a job, Cori was forced to seek support from her aging parents.

All previous attempts at treating Cori had been disappointing. The medications prescribed by Cori’s psychiatrists and psychopharmacologists all created additional problems through their side effects. Psychotherapy was unsatisfactory, too. In part, what caused these failures was the inability of professionals to work closely together. Those who were medically oriented, in this case her psychiatrist and general practitioner, neglected to take full account of Cori’s feelings of disappointment and helplessness, while they focused on her physiology.

Cori’s situation was indeed challenging. She needed a full medication review and overhaul, a more functional support system, vocational retraining, and goal-oriented psychotherapy addressing not only her depression but also practical problems interfering with her daily life. No single issue had overriding priority and none could be resolved with conventional psychotherapy alone.

What Cori required was a new kind of approach to her treatment, one distinguished by a reliable diagnostic assessment, clear-cut goals, monitoring of progress, and above all, coordination among professionals. This is the approach we use when practicing our Collaborative Treatment Method. As therapist-coordinator of Cori’s case, Steve orchestrates and monitors the entire operation, collaborating with all the other clinicians and consultants involved, as well as the key people in the patient’s support system.

But, this brief description of Steve’s experience with Cori doesn’t capture the essence of the treatment. Cori was a complex human being and this new treatment had to be characterized by profound respect for her and her thinking. Cori needed to be a fully collaborating partner: a patient, but not JUST a patient.

When patients have a combination of symptoms, such as depression, difficulties involving family, children, relationships, or employment, and at times one or more medical conditions, the issues tend to overlap and may be hard to sort out. To find solutions to these complex problems, the therapist must closely collaborate with the patient and all the other professionals involved.

As outlined in our last newsletter, in the beginning of treatment there is a clinical evaluation. This step is followed as soon as possible by psychological or neuropsychological testing. Based on these two assessments and the data they provide the therapist-coordinator prepares a preliminary treatment plan. At this point the patient and therapist together determine the type of treatment they are agreeing to undertake. Then each clinical strategy proposed in the treatment plan is evaluated for efficacy during a trial period. Verbal or written reports successively modifying the treatment plan are created in response to changes and progress in treatment. These reports are shared with the patient and revised as a result of his or her input.  As treatment continues its progress is followed in many ways, including through check sheets that patient and therapist keep, self assessment protocols that can be administered over time, and repeat testing. With Cori we used all three.

Steve spoke with Cori’s internist on a monthly basis and adjusted her psychotropic medication himself.  In this case, since he prescribed the medication for her psychiatric needs, special measures to coordinate treatment were not necessary. Of course, in the beginning of treatment he needed to seek the input of her past therapist and psychopharmacologist. Of particular relevance in Cori’s case, however, was the liaison between Steve and Cori’s mother, father, and brother. All were welcomed as informants and integral to her support system.

Repeating a paragraph from our last newsletter: “The extra cost and time required for this comprehensive treatment approach are more than justified by its built in focus on the patient’s progressively demonstrated needs and progress. The testing and self-discipline this procedure requires of the clinician mitigates against misdiagnosis or over-treatment… Collaboration with spouses or family members is also encouraged when it is likely improve the treatment outcome.”

The bottom line, the take-away message, is clear. Due diligence, scripting and tracking of clinical work is not optional. We as clinicians have what is essentially a sacred charge:  to strategize treatment so it is optimal and is productive and to monitor its progress to make sure it is working.