The Role of the Primary Clinician in the Multidisciplinary Team

G.Tobias G. Haslam-Hopwood, PsyD
Topeka, Kansas

This paper explores the role of the Primary Clinician as an integral member of the modern inpatient psychiatric treatment team, as it is practiced on the Professionals in Crisis Program at the Menninger Clinic. The modern inpatient team consists of individuals from multiple disciplines and acts as an embodiment of the neo-biopsychosocial model with each team member providing not only a unique perspective on viewing the patient, but also offering unique opportunities to aid in creating an environment that is conducive to change. The role of the Primary Clinician as the conduit of communication between various treaters and as the individual who provides oversight of the patient’s treatment is described. The unique therapeutic elements that this role brings to treatment, with particular respect to the four cornerstones of psychotherapeutic success (alliance, activity, focus and expectancy) are defined.

The author would like to acknowledge Tracy Wechselblatt, PhD for her helpful comments and editorial assistance on drafts of this paper.

Dr. Haslam-Hopwood is a staff psychologist on the Professionals in Crisis Program at The Menninger Clinic. Correspondence may be sent to Dr. Haslam-Hopwood at The Menninger Clinic, PO Box 829, Topeka, KS 66601-0829.

Introduction.
The aim of this paper is to describe the role of the Primary Clinician in the modern inpatient team as it is practiced on the Professional in Crisis program at the Menninger Clinic. The purpose is to highlight the specific therapeutic elements that this role adds to the overall treatment of patients, thereby giving a framework for clinicians to think about how they can enhance the positive impact that this role can have on helping the patient to create change. As a means of introducing and defining the role of Primary Clinician it is important to understand the evolution of the modern inpatient team as it is practiced at the Menninger Clinic.

As in most psychiatric, and even non-psychiatric medical treatment teams, the traditional team consisted primarily of a physician whose sole responsibility it was to make decisions regarding the course of treatment. The physician assessed the patient, largely independently, created a prescription and wrote orders that were passed down to the rest of the team, along with the patient, to follow accordingly. If refinements were to be made to this initial assessment they were made again by the physician who would when needed ask for collateral data from a variety of additional professionals waiting in the wings to provide assistance if asked to do so. As Menninger (1997) states the term treatment team only “usually meant that there were other mental health professionals with some contact with the patient, but that each was relatively isolated from the others, operated quasi-independently and communicated only with the doctor” (p.1).

The gradual shift to a more integrated and inclusive team approach to treatment occurred at Menninger as result of the recognition by the clinic leaders that there was specific and vital value of having an input of multiple perspectives based on “different professional approaches, different areas of special attention and different kinds of information” Menninger, 1997, p.3). Pruyser (1982) marked this shift in his introduction to the special edition of the Bulletin that described and defined the “Guide to the Order Sheet” by Dr. Will Menninger in stating “prescriptions though still written by physicians were best formulated collectively by the whole treatment team, with periodic adjustments based on accumulating observations about the patient’s behavior by all the participants in the treatment” (p.7)

The Treatment Team.
The integrated team of professionals working in concert to provide the best available treatment to those with psychiatric difficulties is what epitomized the Menninger way as the hospital rose to prominence in the American psychiatric community. However, the well publicized, and occasionally lamented, shifts in the fiscal return for psychiatric services as a result of the growth of managed care in this country over the last 25 years has necessitated adjustments and accommodations to this treatment team. Although this team approach represented an ideal in treatment, it was no longer financially viable, or even possibly financially responsible, to throw the kitchen sink along with the entire armamentarium of the biopsychosocial approach at the patient with the knowledge, and occasional hope, that something would stick. In addition, the time that the team had to assess, intervene and discharge the patient was being reduced annually by those that held the purse strings of treatment, as is exemplified by Menninger (1997) who showed that between 1992 and 1996 the average length of stay per discharge was reduced from 76 to 25 days.

The drive, as well as the push, was for a swifter, more responsive team that could use the collated resources of its members more efficiently and effectively to assess the need for services, and implement these accordingly. This need resulted in the development of the modern multidisciplinary treatment team that, according to Munich (2000) is, in reference to the traditional team, “like comparing a battleship with a destroyer: the contemporary team is leaner, usually consisting of only four members - a psychiatrist, a primary clinician/therapist (usually a psychologist, social worker, nurse practitioner or psychiatric resident) a nurse and the patient” (p.488).

The philosophy behind the modern inpatient team is a renaissance of the biopsychosocial model of treatment first proposed by Engel (1977). Munich (2002) describes the neo-biopsychosocial model in terms of a systemic approach to the patient and having four interactive domains: the physiological, the psychological, the familial and the socio-cultural. He describes the modern team as incorporating each of these elements, and, in meeting on a regular basis in rounds with the patient, creating an environment in which the patient can attend to the relative mix of his internal or external world necessary to create the requisite change.

The division of labor in the team is such that each of the domains of the biopsychosocial model is represented in that it “integrated its members with defined roles of responsibility and expertise and operated on a broadly functional rather than a narrowly medical or hierarchical basis” (p.488). The team leader’s role is to ensure good communication and collaboration between team members as well as to provide a conduit between the team and administration.

The Roles of the Team Members.
The psychiatrist’s role in the team, in conjunction with the nurse, is to be responsible for the biological aspects of the treatment. The psychiatrist prescribes and follows medication as well as attends to the patient’s medical concerns. The nurse, in addition to collaboration around biological issues, is the main source of information about socio-cultural aspects of the patient’s treatment as it manifests in the milieu. The nurse has the greatest presence on the unit and is therefore in the best position to observe the patient in respect to “daily psychopathology, sociability, social skill level and deviant and adaptive behaviors, and the positive and negative consequences of treatment interventions” (Munich, 2002, p.11). The Primary Clinician is, according to Munich (2002), the

“main engine of treatment…(in that)…he/she will be the main factor in actualizing the treatment plan, advocating for patient interests when necessary, providing daily monitoring of the treatment and treatment resources, institute and maintain fist line contact with the family and referral source, be available for flexible therapeutic interventions, actively in liaison with the individual and family therapist when those modalities are prescribed and oversee discharge planning” (p.10).

The addition of the patient to the team creates an environment that approximates the nuclear family. The patient is provided an environment with sufficient structure to allow for the degree of holding, attunement and safety necessary for exploration and change of the presenting concern to take place.

The Role of the Primary Clinician.
The role of the Primary Clinician (PC) at Menninger has been defined, with revisions, through the work of individuals involved with the Primary Clinician Performance Improvement Team lead by Nadine Dexter (Menninger Foundation 2000). This study resulted in the expectation that the PC was responsible for:

1. Being engaged in the initial admission process and establishing an understanding the patient and his/her needs
2. Accepting primary responsibility for the Master Treatment Plan (MTP)
3. Overseeing the implementation of the MTP and documenting the process of treatment
4. Assuring the inclusion of the family and/or support system throughout the course of the treatment and discharge
5. Coordinating and managing treatment issues with individuals external to the core treatment team
6. Assuring that an appropriate discharge plan is created and appropriate referrals and appointments made

Thus the PC is the single person that works to provide oversight of the patient’s treatment with particular reference to the construction and compliance with the MTP. The PC role ensures that there is a smooth continuance of care from pre-admission to post-discharge. At admission, the PC gathers collateral information about the patient and his/her prior treatment successes and failures by talking with both referring clinicians and with family members. The PC integrates this information with the patient’s self report to create a comprehensive Psychosocial Assessment that together with material gathered about the patient’s presenting complaint is subsumed into the MTP. In accordance with the MTP, and following team discussion, the PC aids in making referrals for specialized treatments tailored to the patient and his/her presenting complaint. The professionals responsible for providing the specialized treatments, such as psychotherapy (ranging from psychodynamically oriented psychotherapy to behavior therapy) or psychological testing are usually from outside of the core team thereby allowing for additional input into the patient and his/her concerns. The PC provides the communication between these individuals and the team ensuring that the treatment is consistently heading towards the goals set on the MTP and reducing the likelihood of either fracturing the communication between the various individuals responsible for the patient’s treatment or creating polarization among team members. In the time leading up to discharge, the PC helps the patient and the referring clinicians locate any additional resources, as necessary, and communicates with these parties about the course of treatment together with any recommendations from the team. In the time following discharge the PC remains available to the patient and his/her outpatient clinicians to ensure that service delivery is as continuous and seamless as possible.

Thus the role of the PC allows for the speedy and efficient integration of information about the patient and his/her concerns and a comfortable transition of this information to the team. The PC can work to keep the treatment on track, in accordance with the MTP, and can aid the patient in integrating the various aspects of his/her treatment. Following the conclusion of the inpatient treatment the PC can help the patient bridge the gap between his/her inpatient and outpatient treaters.

The process by which the PC achieves the aims and goals that this role demands is as varied as those who function in the role. As previously stated, individuals with different professional backgrounds (psychologists, social workers, nurse practitioners and psychiatry residents) perform this role at Menninger, and accordingly each brings with them the lens that their particular profession lends them. In addition the Menninger clinic employs professionals with a variety of theoretical backgrounds further adding differing perspectives between PCs. This begs the question as to what, if anything unifies the additional therapeutic value that this role provides to the patient. The following section of this paper attempts to answer this question.

The Four Cornerstones.
Early research into the effectiveness of psychotherapy consistently failed to find differences between different therapeutic modalities, even showing that in some cases non-trained college professors had similar outcomes to trained psychotherapists (Beutler, Machado and Neufeldt, 1994). Such findings called into question the very utility of psychotherapy. Such concerns were especially roused when research showed that therapy often was not able to demonstrate an effectiveness beyond that produced by placebo treatments (Lambert and Bergin, 1994).

The idea of comparing psychological treatments against a placebo originated out of medicine wherein new pharmacological agents are compared with substances that are considered inert. Often those taking the placebo receive some benefit as a result of the psychological effects of simply receiving treatment. As a result any additional benefit found in the patients taking the new agent over the benefit received by those taking the placebo can be attributed to the therapeutic effect of the new agent. (Lambert and Bergin 1994).

Initially this appeared to be a good model for psychotherapy researchers to use. However, the utility of any comparisons between treatment and placebo were confounded by the psychological effects of simply receiving a placebo, which might be, for example, the kindly nature of the college professor recruited to talk to subjects. In studying the reasons why those receiving the placebo had similar levels of change to those receiving the treatment researchers utilized the term ‘nonspecific factors’ to refer to those factors that are present in all therapeutic approaches, such as human contact. This term fell under some level of criticism as it assumed that such factors could not then be specific factors associated with a particular school of therapy and therefore the term ‘common factors’ came into use.

For some time the placebo effect, or the change produced by these ‘common factors’ remained simply as a bane to researchers, seemingly existing only to confound the results of research. However, as clinicians began to pay attention to this research the utility of these common factors began to be recognized. Even as recently as only last year articles in journals such as the British Journal of Psychiatry (Andrews 2001) posed the question “perhaps we should actively strive to potentiate the placebo effect when treating people with depression” (p.195).

It is the thinking that we should attend to, and even enhance, the placebo effect in psychotherapy to better help our patients that lead Peebles-Kleiger (in press) to enumerate the qualities underpinning effective psychotherapy. She termed the basic, yet vital roles of activity, focus, alliance and expectation as the “four cornerstones” of psychotherapeutic success.

The Cornerstones and their existence in Primary Clinician work.
It is Peebles-Kleiger’s contention that the outcome of psychotherapeutic interventions can be improved if the cornerstones are attended to and even, if possible, enhanced. Therefore it is indeed possible that the positive impact of the PC, as part of the core treatment team, can be improved by attending to these specific factors. The rest of this paper will describe the findings associated with the four cornerstones and how they play a role in the work of the PC.

Alliance.
The formal study of the alliance and its impact on the success of therapy began with Rogers (1957) who described a strong positive alliance as providing the necessary and sufficient conditions for change. In providing a good overview of the concept of the alliance and its place in outcome research Orlinsky, Grawe and Parks (1994) listed 132 findings relating the quality of the therapeutic bond and outcome and found only one negative finding. Horvath and Luborsky (1993) following extensive review rather casually concluded that the “positive relation between good alliance and successful therapy outcome is reasonably well documented” (p.569).

Further research into this construct revealed that there are two important stages of the therapeutic alliance, the first being in the initial stages of therapy during which time "satisfactory levels of collaboration and trust must be established' (Horvath and Luborsky p. 567), and that this is based on the patient's experience of the therapist as "supportive and helpful" (p.563). The second stage arises through the course of the work together and is centered around a sense of "we-ness - a shared responsibility for working on the problems" (p.563). Although a good alliance is particularly important in the initial stages of therapy the quality of the alliance continues to be correlated with positive outcome throughout the course of psychotherapy (Horvath and Symonds, 1991).

In exploring what constitutes a good alliance Allen, Newsom, Gabbard and Coyne (1984) examined the level of the patient’s trust in the therapist, his/her sense of being accepted and a feeling of optimism as a result of the interaction with the therapist. Williams and Chambless (1990) highlighted the patients’ experience of the therapists’ warmth, respect, interest and encouragement.

The PC in taking such an active role in the patient’s admission process is ideally suited to work to initially engender and then enhance the alliance between the patient and the treatment team. As a sort of ambassador to the treatment, the PC can set the stage for the collaborative work between the patient and the members of the team. In conjunction, in taking a thorough history and attending specifically to the patient’s understanding of his/her needs an initial foray into trust has begun. The process of the data collection as is necessary to build the Psychosocial Assessment and the MTP allows the patient to experience the team as both comprehensive and interested. The PC through his/her ongoing communications with the variety of individuals who work with the patient, both on the core team as well as others, can use this knowledge to present the patient with ongoing refinements of the initial assessment exemplifying to the patient the team’s ongoing interest and investment. This stance continues to be taken right through the discharge process allowing the patient to experience the team as not only initially supportive and helpful, but also sharing the responsibility for the work in hand.

Activity.
The idea that patients need to be engaged in the activity of psychotherapy is central to most theoretical schools. Each modality of therapy has a concept associated with the patient being engaged in some form of activity that is central to the change process, examples being mastery, exposure, challenging irrational beliefs and working through. Studies comparing the level of activity of patients and the impact on treatment were performed by Gomes-Schwartz (1978) who found that the level of patient activity and involvement in treatment provided for the best predictor of outcome. This finding is supported by Orlinsky, Grawe and Parks (1994) who demonstrated that patients who are more active in therapy (by their definition more verbal) had the best outcomes.

The PC is in a unique position in the core treatment team to both assess and encourage the patient to engage him/herself more in the treatment process. By having the opportunity to talk regularly with the core team, as well as others involved in the treatment, the PC can hear reports about the various aspects of the patient’s treatment and can help the patient recognize weaker areas and, correspondingly, can make suggestions about how to better round out the treatment. For example the PC can hear feedback in rounds from the nurse that a patient is not engaging with peers on the unit and is instead isolating in his/her room. The PC, during regular scheduled meetings with the patient, can not only encourage the patient to explore the meaning of this behavior in both individual and group therapies, but can also make practical suggestions to support the patient in increasing social contact.

As well as helping monitor the patient’s activity in the treatment milieu, the PC acting as an observer who is, by definition, both outside and inside of the treatment, can help the patient become more active in addressing problems, anxieties, and questions that the patient has about a particular treatment intervention. For example, a patient may meet with the PC and express anger towards his/her therapist in that the therapist had seemingly not heard or understood the import of a communication. Within this unique role, the PC can help the patient explore the potential advantages and disadvantages of addressing his/her dissatisfaction with the therapist. Since the PC is not the therapist, he or she frequently finds him or herself in the role of confidant and can stimulate therapeutic progression by encouraging intimacy and authenticity. In addition to specific instances in which such experiences may occur, the PC also serves to help contain transference reactions so that the patient can manage his/her anxiety to a degree that allows the patient to push forward in treatment despite uncertainty about outcome, fear of emotionality or shame about desires for nurturance.

Focus.
The introduction and proliferation of briefer forms of therapy provided the frame in which the importance of having a specific focus for treatment was recognized. Orlinsky, Grawe and Parks (1994), in their review of outcome research findings, cite 35 studies that demonstrate the importance of having clarity and consensus of goals for positive outcome. They state that these findings demonstrate that having a specific focus leads to better outcome both from the patient’s perspective and from objective measures. Even dynamically oriented treatments have supported the need for a focus of treatment as is demonstrated by the findings of the Penn Psychotherapy Research Project that cited the necessity of highlighting the Core Conflictual Relationship Theme to achieving success in treatment (Luborsky, Crits-Cristoph and Barber, 1991). The research has also supported the idea that it is primarily the therapist’s responsibility in determining and consistently returning to the focal area in successful therapy (Koss and Shiang, 1994).

An initial role for the PC to perform is to integrate data from the patient with information gleaned from the collateral data sources of former therapists and family and, in doing so, create the Psychosocial Assessment. In completing this task and formulating the MTP the PC is given the perspective that can allow him/her to help the patient create a specific focus for treatment. The PC can help the patient refine his/her view on what has led to this particular admission and can help the patient recognize what needs to change in order for the patient to be able to make better use of coping strategies. The PC enters these focal areas as the principle areas of concern in the MTP, creating the document through which the PC communicates to the rest of the professionals engaged with the patient what needs to be attended to throughout the course of treatment.

As previously stated the PC continues to meet with the patient to assess the effectiveness of treatment and to help provide additional referrals to round out the treatment, as necessary. The PC has the role of updating the MTP, on a regular basis, and in doing so is consistently returned to the principle areas of concern highlighted at the outset of treatment. As a result the PC is in the position of being reminded of the focal areas and needing to assess whether these goals are being met. In doing so the PC can help remind the patient, as well as the team, of what needs to be achieved to meet the goals of treatment.

Expectations.
The positive relationship between patient expectancies and outcome have been well established starting with Frank (1959) who showed that the beliefs that one has about the effectiveness of the treatment is correlated with the degree of results of the treatment. Barker, Funk and Houston (1988) supported this finding by providing a review of studies examining the role of placebo effects in outcome research. Their review showed that the greater the positive expectation of an intervention the higher the level of improvements in the subjects. The most famous, and perhaps most often cited example of the effect of expectation on outcome is the example of the Rosenthal effect (Rosenthal and Jacobson 1968) in which teachers were told that randomly picked children were on the verge of a spurt in intellectual growth and correspondingly those particular children recorded the greatest gains in cognitive measures over the period of the study.

More specifically research studying the effect of expectancy throughout the course of treatment found that expectancy is more important in the beginning stages of treatment than it is later on in the process (Tollington 1973). This finding is supported by Orlinsky, Grawe and Parks (1994) who cite three studies that show that patients who were prepared by their therapist on what to expect from therapy fared better than those who were not prepared.

These findings have a particular importance for the PC. As described, the PC has a particularly active role in the admission and early stages of treatment. Following the findings of these studies it is vital that the PC works to assess the patient’s expectations about treatment and intervene if necessary. Soon after admission the PC should ask the patient about their expectancies concerning treatment such as how they understand change taking place, how long these changes will take, what will the patient experience and how will they know that change has taken place. The PC has the opportunity to enhance these with the patient by talking to them about the process and about what can be achieved in treatment. The PC should also use one of the early meetings to orient the patient so that they know what to expect from treatment.

By enhancing expectancy and educating the patient to the structure of the treatment, at the outset, the PC is using the findings associated with the placebo effect to the potential benefit of the patient and his/her treatment. This should not be done to the point that the confines of reality are stretches but it remains a sine qua non that the patient who arrives for treatment convinced that treatment will not help is unlikely to be surprised. As Dr. Karl continues to remind us one of our responsibilities is to help find hope when there appears to be very little.

Conclusion.
The role of PC is indeed a vital one in the team, even if the PC simply provides communication between various aspects of the patient’s treatment. However, with particular attention to these, and other therapeutic opportunities, the PC has the potential to have a very significant impact on the patient and the potential outcome of the treatment. In this respect the PC role moves far beyond what can appear to some as a simply a case management role.

In the current managed care environment that requires fiscal judiciousness the use of the PC model has important implications for the inpatient team. In working from the outset to help create a strong positive alliance, treatment is enhanced both early on, as trust and collaboration are engendered, and later, as the stage is set for successful outcome.

It is also well established that successful positive outcome is related to positive patient expectation. In the particular role of the PC in the admission and early stages of treatment the PC can educate the patient about treatment and help enhance patient expectations about the effects of treatment.

The PC is also in the best position, as the facilitator of communication between various treaters to help assess and encourage patient activity. The PC integrates data from the patient with information garnished from collateral resources and in such a role can help create a tight streamlined focus to treatment and continually keep the treatment team and patient on task. The specific therapeutic elements that this role adds to the overall treatment of patients have been highlighted in this paper. It is hoped that an active PC with solid clinical understanding, can utilize these findings and factors in a manner that allows for clinicians to respond to the best of the challenges of managed care and help the patient create change more speedily and effectively.

In attending to the factors described in the paper the PC makes the most of his/her contribution to the integrated biospychosocial perspective engendered by the modern inpatient team. The primary focus of the role is to enhance and encourage the psychosocial aspect, but by encouraging clear communication between the patient and his/her psychiatrist the PC has the opportunity to have an impact on the bio aspect as well. In this respect the PC serves as the reminder to the patient that he/she is a human being with an active mind and is influenced by all the domains of the integrated biospychosocial perspective. The PC finds him/herself in a position in which he/she can help the patient create a map to find their way out of whatever mire they find themselves, and in doing so find the life that is evading them.

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