Learning to be a Healthcare Team Member:
Building resilience for patients, colleagues and ourselves
Peggy A. Rothbaum
A recent article (Bray, 2006, p84) states “Working in primary care provides great opportunities and challenges for psychologists”. To adapt, psychologists “must build in an ingrained agility and flexibility to allow us to change in evolutionary and incremental ways” (Newman, 2005). This requires innovation, revisiting past ideas, applying expertise broadly, transformation, openness, and different perspectives. Further, it requires a paradigm change in “accepted examples of actual scientific practice” (Kuhn, 1970. p.10). Such fundamental changes can be challenging.
One example requiring fundamental change in practice is learning to be healthcare team members and integrating psychology into primary medical care (Bray, 2006; APA website; APA Monitor, May 2006). For this article, healthcare teams are defined as psychologists working together with each other or psychologists working with other professionals in any setting, including private practice. Psychologists, patients, and other healthcare professionals can benefit from that outcome (Bray, 2002, 2006; Haley, McDaniel, Bray et al, 1998; Kaintz, 2002; Rosenberg & Rothbaum, 2003). Kaintz (2002) emphasizes the importance of communication, availability, and relationship building with physicians for psychologists. Rosenberg and Rothbaum (2003, p. 8) conclude, “Many physicians need, but cannot find, psychologists willing to work within the existing framework of a busy practice”.
Psychologists “are often NOT trained in working in primary care or collaborating with primary care physicians” (Bray, 2006, p. 84). Rather, the emphasis is on “independence”. This can cause difficulties for psychologists. Psychologists “need to learn to better integrate their functioning within existing systems.” (Hochman, Katzive, Hillowe, et al 2006). Psychologists need “knowledge in multiprofessional teams, an understanding of medical professionals’ training and treatment emphasis, and an awareness of potential areas of difficulties and tensions” (Talen, Fraser, & Cauley, 2005, p.141).
In spite of any difficulties, psychologists are very much needed as healthcare team members. There is an increasing public focus on the “mind-body connection” (APA website; Newman, 2005). Although all patients benefit from teamwork, this is particularly true of patients with chronic or complicated health conditions. Adult patients who had pediatric healthcare conditions may need healthcare teamwork that is also sensitive to the passivity and avoidance that may result from their often traumatic healthcare experiences as children (Rothbaum and Williams, 2006).
In general, psychologists can add knowledge about behavior, development, cognition, health, and personality. Mental health professionals with other credentials do not receive training in all of these areas. Psychologists can gain respect, market share, and practice building opportunities by more successfully offering our expertise to those who seek it. By turning ourselves and our experiences into tools, we use our knowledge and build resilience that benefits patients, other professionals, and the public.
Below are some clinical examples of teamwork and resilience.
Psychologist and psychologist
1. Psychologist Adams is treating a young woman. He refers the patient and her family to Psychologist Barns for family therapy. Dr. Adams’s patient tells him that Dr. Barns is telling the family personal information about Dr. Adams.
If Dr. Barns has concerns about how Dr. Adams’s personal issues impact his work, Dr. Barns should deal with these concerns directly with Dr. Adams, as specified by the Ethical Principles of Psychologists and Code of Conduct (APA, 2003). If Dr. Barns uses personal information about Dr. Adams in the context of work with patients, not only is this unethical, but it does not promote teamwork or help patients. Dr. Barns could create a split within the family or make the patient feel torn between the 2 psychologists. If the 2 psychologists talk directly to each other, Dr. Barns’s concerns could be discussed, addressed, or corrected if they are in error. Such teamwork models healing a split for the family. Further, Dr. Adams may then feel inclined to continue making referrals to Dr. Barns.
2. Psychologist Caldwell calls Psychologist Delevan to discuss the possibility of accepting referrals. Dr. Caldwell explains that most of her referrals are from physicians. Since they expect teamwork from Dr. Caldwell, Dr. Caldwell has to expect it from the people to whom she refers. Dr. Caldwell explains exactly what she needs.
This is an invitation from Dr. Caldwell to Dr. Delevan. In addition to receiving referrals, Dr. Delevan could view this as an opportunity to make a healthcare teamwork connection with the referring physicians. If Dr. Caldwell is happy with Dr. Delevan’s work, Dr. Caldwell will tell the physicians about it since they share clinical information. This could lead to even more referrals for Dr. Delevan. If Dr. Delevan views this as an attempt by Dr. Caldwell to tell him how to run his practice, or encroach on his independence, Dr. Delevan could lose these opportunities to be a healthcare team member.
3. Psychologist Elliott has a patient with a Disorder of Sexual Development (DSD; see Rothbaum and Williams, 2006). Dr. Elliott referred the partner of the patient to Psychologist Franklin. The referral was made with the explicit requirement and explanation of teamwork since it originated with the Dr. Elliott’s patient’s OBGYN. Dr. Franklin has a preferred OBGYN.
If Dr. Franklin is unfamiliar with the advantages of teamwork, this is an opportunity to learn. In addition, it is an opportunity for Dr. Franklin to learn what Dr. Elliott needs to be comfortable making referrals. It is a marketing opportunity. If Dr. Franklin has questions about the particular OBGYN’s treatment plan, these should be discussed first with Dr. Elliott and then possibly directly with the OBGYN. Ongoing communication is very important. If, for any reason, in the middle of treatment, Dr. Franklin refuses further communication with Dr. Elliott, or somehow attempts to undermine Dr. Elliott’s relationship the OBGYN, the opportunity is lost. Patient care suffers as well. The patients might feel torn between the 2 psychologists. If Dr. Elliott and Dr. Franklin work as a team, this also models cooperation for the patient.
4. Psychologist Hill tells Psychologist Jacob that she is having a problem with one of the partners in a group of physicians and needs help strategizing to find a solution.
If Dr. Jacob uses this as an opportunity to help Dr. Hill find a solution, Dr. Hill may be grateful to Dr. Jacob and Dr. Hill might reciprocate in kind or with referrals. If Dr. Jacob approaches the physicians and offers her services as superior, Dr. Jacob may gain some referrals in the short term. However, Dr. Jacob then loses Dr. Hill as a team member, and the physicians may not appreciate this style of interacting.
Psychologist and other professional
1. A psychologist accepts a referral to evaluate a patient. The patient has a long standing relationship with a physician who supports the referral. The psychologist concludes that the patient needs certain medical tests, which the physician has already said are not medically indicated.
This is an opportunity for the psychologist to do teamwork with the physician. If the psychologist calls the physician and discusses her impressions of the patient, she can learn more about the patient’s medical condition. She can provide the physician with additional information to help with patient care. It is also an opportunity for the psychologist to answer any questions that the physician might have about the evaluation and the psychologist’s work in general. It is a marketing opportunity. If the psychologist attempts to refer the patient to another physician rather than communicating with the referring physician, this undermines the patient’s existing healthcare team. The opportunity for future referrals is lost as well.
2. A physician makes a referral to a psychologist and sometime later calls to inquire about the progress of the patient.
The physician is paying the psychologist a compliment by inquiring about the progress of the patient. The physician considers the psychologist an important member of the healthcare team. The psychologist can use this as an opportunity to explain her interest in teamwork. It is also an opportunity to learn about how the physician views teamwork. The psychologist can explain what she has to offer the patients. If the psychologist responds by analyzing the physician or telling him that his questions are a reflection of his needs for control, the opportunities are lost.
3. A lawyer hires a psychologist to do a forensic evaluation. He calls the psychologist to request a copy of the report in preparation for court.
Since the lawyer hired the psychologist, he is entitled to a copy of the report. His call is also a marketing opportunity for the psychologist. The psychologist can educate the lawyer about the details of a psychological evaluation. In addition, the psychologist can tell the lawyer about the services that she offers and find out what services the lawyer needs. If the psychologist refuses to give the report to the lawyer, an opportunity for future teamwork is lost.
4. A psychologist is treating a patient with diabetes who is quite depressed. The endocrinologist, with whom the psychologist has not been able to establish a relationship, tells the patient that she is not happy with the patient’s health status. The patient tells the psychologist.
Since diabetes has a significant behavior and emotional component, a relationship with the endocrinologist is crucial. The psychologist might prevail upon a colleague to help facilitate the relationship. Suppose aspects of the patient’s care which the psychologist had assumed were emotional turn out to be primarily behavioral? Without input from the endocrinologist, this information might not be conveyed. If the psychologist gets defensive when the endocrinologist explains what might be done differently, the opportunity for teamwork is lost. The patient’s care could suffer as a result.
Why even bother discussing choices that psychologists can make that do not build resilience and teamwork? Because they occur.
It is indisputable that many psychologists go into the field because of our own issues. As one patient said “You have to assume that someone doing this work has had a lot of feelings”. The combination of the powerfulness of our own issues and the intensity of working with people who also have issues has the potential to create strong feelings in psychologists. These feelings can interfere with patients or healthcare teamwork. However, there are productive ways to handle our own issues with patients and healthcare teams. This can also build resilience.
Working with our own transferences and countertransferences is helpful. Transference is exactly what the word means. Emotions from one situation or relationship are “transferred” onto another situation or relationship. Countertransference is the reaction to transference or the reaction of the psychologist to the patient—it is the same process in the reverse direction. The term “transferences” is used in this paper to refer to both processes.
What is the purpose of recognizing transferences? The psychoanalytic approach is that transferences should be examined and “worked through”. By so doing we can attempt to minimize their impact on our work with patients. The idea, then, is to do no harm. In addition, transferences can be invaluable tools. They can help us deepen our psychotherapeutic understanding of suffering and build resilience in ourselves, patients and healthcare teams. This can help us get past our own resistances which are an inevitable challenge to change. Our experiences can be rich reservoirs of resilience from which we can draw to aide our work (Gagnon, 1994). Our experiences can foster growth and development.
Renowned post World War II psychologists Viktor Frankl and Martin Bergman did just that. Their work focused on using their own suffering and experience to build resilience. Eileen Simpson, a psychologist, wrote about her traumatic childhood, her tumultuous first marriage, and her victory over learning disabilities (Simpson, 1991). Kay Redfield Jamison, a psychiatrist, wrote about her own struggle with manic-depression and then published Exuberance: The passion for life (Jamison, 2004). There are also examples of non-psychologists who use their own struggles and traumas to help themselves and others. Andrew Solomon (2001) wrote about his depression and that of others. Ron Goldman’s family (1997) told the story of their life before and after Ron was killed with Nicole Brown Simpson. John Walsh (1977) wrote Tears of Rage, the story of his young son’s abduction and murder. We may not all wish to talk about our own issues in such a public manner. These issues can be examined privately and then used as tools to build resilience into our work with patients and healthcare teams.
In the clinical examples above, healthcare teamwork can be helpful to patients by healing family and healthcare team splits. It also provides mutual learning and support for the healthcare team. This builds resilience. There are other examples in psychotherapy. When we work with a couple on their marriage or on parenting, we encourage them to work together. They are a team. They are a system. There are shared goals. Compromise is necessary. Neither partner can have everything that each wants all the time. A working consensus has to be reached in order to address issues. When we transfer this approach to healthcare teamwork, everyone benefits. The shared goal is patient care. It can be better achieved through healthcare teamwork. In addition to healthcare, psychologists can offer our expertise to other teams. Examples are sports and business. The goals of these teams are the same: cooperation, compromise, and consensus. The focus is on building resilience.
There are many ways to integrate resilience building into our work. The APA Practice Directorate has begun an initiative to do so. Resilience is defined as the “ability to adapt in the face of tragedy, trauma, adversity, hardship, and ongoing significant life stressors” (Newman, 2005, p.227). The Initiative is based on the finding that “a wide range of behaviors that are rather ordinary, not extraordinary, can be learned by just about everyone.” (Ibid). Some researchers concur with this conclusion. Anderson and Anderson (2003) have shown that resilience, particularly relationships, optimism, and the ability to find meaning in the face of adversity are linked to longevity. Similarly Taylor (2002) summarizes decades of research concluding that we need others for lifelong health.
If we wish to maximize our contribution to patients, colleagues, and the public, we must continue to learn to be healthcare team members. While privacy and confidentiality must be paramount in our work, the insistence on “independence” is limiting and unrealistic. People live in families, communities, schools and workplaces, not in isolation. People need to build resilience within these systems, as well as within themselves. Psychologists can help by modeling this for them. We need to “put aside unilateral needs for control” and change our focus to one of “functional interdependency” (McDaniel & Hepworth, 2004) and resilience (Newman, 2005). Psychologists have a lot to offer, and the “fluid and uncertain times” (Newman, 2005) offer us many exciting new opportunities to do so.
References
American Psychological Association website: http://www.apahelpcenter.org and http://www.apa.org. See articles on mind-body connection and Consumer Health Center.
American Psychological Association (2002). Ethical principles of psychologists and code of conduct. American Psychologist, 57, 1060-1073.
Anderson, N.B. and Anderson, P.E. (2003). Emotional longevity: What really determines how long you live. New York: Viking.
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Bray, J.H. (2006). Expanding your practice into primary care. The Independent Practitioner, 26, 84.Gagnon, J.H. (1994). Wounded Healer. Norwood, N.J.: Ablex Publishing.
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Newman, R. (2005). APA’s Resilience Initiative. Professional Psychology: Research and Practice, 36, 227-229.Newman, R (2005). Keynote speech to 2005 APA Practice State Leadership Conference. Washington, D.C.: Unpublished manuscript.
Rosenberg, A.R. and Rothbaum, P.A. (2003). Physician-psychologist teamwork: Twelve years of practice. The Independent Practitioner, 23, 6-9.
Rothbaum, P. A. and Williams, N. (2006). “Building psychological health into intersex treatment”. New Jersey Psychological Association Spring Conference, April.
Simpson, E. (1991). Reversals: A personal account of victory over dyslexia. New York: The Noonday Press.
Solomon, A. (2001). The noonday demon: An atlas of depression. New York: Scribner.
Talen, M.R., Fraser, J.S, and Cauley, K. (2005). Training primary care psychologists: A model for predoctoral programs. Professional Psychology: Research and Practice, 26, 136-143.
Taylor, S. E. (2002). The tending instinct: How nuturing is essential to who we are and how we live. New York: Henry Holt and Company.
Walsh, J. (1977). Tears of rage. New York: Pocket Books.
Peggy A. Rothbaum, Ph.D. is a psychologist, researcher, and writer. She can be contacted at 232 Saint Paul Street, Westfield, New Jersey 07090.
