Collaboration isn’t a dirty word

I would seem weird if we had a hospital visit and the doctors and the nurses didn’t communicate with each other and tried to treat you for different things. While each has specific and different duties, one will guide the other which will guide the first. That is, the doctor’s diagnosis will guide the care the nurses give you, and the nurses observations will guide the doctor’s diagnosis.

Our podiatrist and dentist almost never need to talk to each other because they are working on very different parts or our health. However our Ears Nose Throat (ENT) specialist may need to talk to our dentist, or our GP may have to if we have certain blood conditions as they do have an overlap in our health. Frequently, though, we just tell our dentist the basic gist of why we might have an ENT or what blood condition we have that may affect dentistry and never the two specialists will speak.

It seems odd to me that when it comes to mental health, people are very reluctant to talk to their specialists openly or allow them to talk to each other. Confidentiality means that if you are my client, then I can’t talk to other professionals about you without your express permission. If a doctor has referred you to see me, built into my treatment contract is permission to send them progress reports. However that doesn’t cover other professionals that may be in your treatment team.

When I worked in hospitals it was clear that there was a treatment team. The confidentiality contract was with the hospital, so if it was relevant to your health, I would go to the OT (occupational therapist) and ask for them to support you with X, or let your doctor know they should check out Y, or ask the nurses to remind you to do Z and report back to me how that went. We worked as a therapeutic team to help you get out of hospital fastest. Once a week we professionals would all meet up and discuss your case and compare notes on progress. One of us (usually me) would come and talk to you about progress and your goals. Sometimes there would be an incidental meet up with professionals to discuss a thing, or with you and a few professionals. Every couple of weeks there would be a team meeting with you to discuss what is needed and what goals need to be hit to get you home and how we would get you there. (I appreciate that not all people get this holistic experience from hospitals, but that is how my team worked).

For some reason, once you are out of hospital, that all changes. We professionals don’t tend to talk to each other. There is no longer a “case manager” ensuring that your treatment is a cohesive holistic whole. And the fault isn’t just with the professionals not talking to each other – often you, the client, will hoard information and not tell relevant professionals relevant information. This can lead to two or more professionals trying to fix the same problem in non-compatible ways, or aspects about your health being missed because no one knew it wasn’t being taken care of.

I guess we kind of expect that you, the client, will be the case manager and get us all to do our bits. But how on earth can we reasonably expect you to be an expert in case management? Don’t get me wrong – some people become that expert and do a pretty good job at it, but that is often through lots of trial and error.

Frequently in therapy, I’ll ask my clients (who have just disclosed a thing to me) “Have you informed X about this?” where X is the relevant expert in that aspect. Frequently the answer I receive back is “no”, generally in a tone of “of course not”. I will ask the client to do so, then ask if they will do so and if not, what is holding them back and do they need support (it can be scary to be the one to initiate certain conversations).

What I want is that holistic care you get with a hospital allied health team, where we all know what the goals are, have a rough plan of how we are all going to get you there and a list of which bit each professional is going to work on. We then have accountability for doing our jobs and you get the benefit of that. Naturally you are involved with the creation of that plan and the goals and have a say about who and how those things are done.

I appreciate that it is hard to get all of the professionals together in one place when you live in the community and those professionals are your GP at one medical centre, a counsellor somewhere else, maybe a support worker from that agency etc and maybe a few more besides. Sometimes it has to be a phone in, or communications via paperwork. But mostly it comes down to you – start opening up to each of your team and tell them what is going on, what the other professionals are doing and what you want and need. Also give them permission to talk to each other.

There are three major levels of community need when it comes to mental health. 

  • Entry level – two to three professionals – eg: GP and therapist (and maybe psychiatrist)
  • Middle level – four or five professionals – eg: GP, therapist, psychiatrist, support worker
  • Pre-acute level – six or more professionals – eg: GP, therapist, psychiatrist, support worker, domestic agency, community nurse, Guardian, Administrator … etc

(After pre-acute, you are in hospital, which is no longer community)

At the Entry level, all you generally need is for your professionals to send reports to each other. Ask for “Release of Information” forms (or similar) to be signed by you for them to talk to each other. Ask them to send reports and updates to all participants.

At the Middle level, beyond “Release of Information” forms, it is important for one of the professionals to start taking on more of a coordinator role. Likely that will be the therapist, but may be another.

At the Pre-acute level you have reasonable grounds to have a dedicated Case Manager, who will coordinate the goals, care and outcomes of your team. Several of your team should be able to meet up monthly or 3 monthly (depending on your needs) with a few call ins via phone/video to have an allied health team meeting. The odds are that you are being considered for or are already on NDIS, so try to factor this role into your NDIS budget.

I’ve said that this is fairly rare, that most of my clients do not have this. I suspect that this is because of a few factors. Either my clients are a bit embarrassed that they need help and don’t want to fully admit to how complex their situation is, or they don’t trust one or more of their professionals. Sometimes there just isn’t budget (time or money) to make this happen.

Embarrassment is connected to public perception. It is time to see past the attempt of the ignorant public to try to blame you for what you are going through. We don’t stigmatise eye sight, diabetes or heart conditions. Why do we stigmatise mental health? Don’t fall for their ignorance and please, talk to your therapist about why you find it hard to open up to your other professionals. If it isn’t embarrassment, it could be denial about how complex your situation is, and again, your therapist is a good person to talk to about getting over that. You are too important to let a thought error get in the way of good care.

Trust can be a major problem. If there is a professional that you don’t trust, or feel good opening up to, that can be an indication that you need to swap that person out for someone you do trust. Almost all of your team can be swapped (unless you are under community treatment orders, where you can request for a change – and sometimes you just have to work with the least bad person assigned to you). Remember that they are your employees. They have to do what you say (within their code of professional ethics), and if you don’t like or trust them, you can fire them and get another. If you are not sure about this section, talk to your therapist. If your therapist is one of the people on that list, talk to your GP about getting a new therapist. If your GP is also on that list, go to a new GP and if you like the new GP, ask for your records to be transferred.

Many hands in the team will help lift your load

It is your health, and the best way to look after it is for the relevant professionals to have a more complete picture about what is going on for you and for a coordinated plan to be made and implemented to sort out the problem that you are experiencing. It is time to take the power back and push for this to be done. Get those documents signed so they can talk to each other, push for that coordination, and push to be central and involved in the plan.