The roles and relationships of psychiatrists and other service providers in mental health services

Introduction

The way that psychiatrists and other mental health professionals work together has an impact on standards of clinical care and professional satisfaction. Although in the past many psychiatrists have worked in relative isolation, today it is rare for mental health care to be provided by a single professional, even where one person is designated as the primary direct-care provider. Public-sector mental health services in Australia and New Zealand are predominantly provided by specialised multi-disciplinary teams working in inpatient and other community settings (Herrman, 1998; Boyce and Tobin, 1998). As teams often work across settings to promote the required continuity of care, there is growing acknowledgment of the need for an expanded notion of ‘teamwork’ operating between professionals, relatives and carers, self-help groups, non-government agencies, and statutory authorities providing housing and social security (Lief and Brotman, 1968; Benierakis, 1995). Although the range of available professionals and services may be narrower in the private sector, most people receiving services from psychiatrists will receive services from others as well, regardless of the setting.

The advantages of teamwork include continuity of care (Rimmer et al., 1988), the capacity to take a comprehensive view of the patient’s networks and problems (Watts and Bennett, 1983), the availability of a range of skills (Division of Clinical Psychology, 1998), and mutual support and education (Onyett and Ford, 1996). A well functioning team with a shared sense of responsibility may be more than the sum of its parts: the team can produce more and better work than its individual members working as solo practitioners (Benierakis, 1995). However, working in clinical teams which are not functioning well can also be a source of professional dissatisfaction for psychiatrists and other clinicians (The Sainsbury Centre for Mental Health, 1997), and can contribute to unsatisfactory care for patients and families.

Method

The Professional Liaison Committee of the Board of Professional and Community Relations of the Royal Australian and New Zealand College of Psychiatrists (RANZCP), identified the betterment of working relationships between psychiatrists and other mental health professionals as a matter of pressing concern. The Committee obtained a strategic planning grant from the College to examine the problems facing psychiatrists in professional relationships, and to make recommendations to the College in the areas of training, maintenance of professional standards, and leadership and management. 

The Committee is based in Melbourne and has representation from a range of mental health professions. It convened a workshop “Defining Best Practice in Inter-Disciplinary Teamwork” at the Mental Health Services (THEMHS) Conference in Sydney in 1997 and presented the central themes emerging from that workshop at the THEMHS conference the following year in Hobart (Macdonald et al., 1998). The work was also presented at the Congress of the RANZCP in Melbourne in May 1998. Subsequently, the Committee held a series of meetings facilitated by JW. Research and writing support was provided by TT. The Committee reached a number of conclusions which are summarised here. 

The Committee has produced a report that will form the basis of a College position statement after the College consults with consumer and carer, government and other professional organisations.

Effective teamwork and collaboration

A team is a small group of people who come together for a common purpose. Effective teamwork and collaboration is supported by key elements including:

• agreed goals, usually seen as patient benefit
• an agreed approach, including a common understanding about the philosophy of care and a collaborative style between the patient, family and clinicians
• effective communication styles, with agreements to aim for clear and open styles of communication through opportunities for all members to contribute to decisions, and adequate face-to-face meetings. In particular this includes an attitude of openness in expressing disagreement and acknowledging the presence of conflict, together with agreed avenues for conflict exploration and resolution
• established ground rules which guide interpersonal behaviour within the team. An attitude of respect for the professionalism of every member when disagreement and conflict arise, will both enhance the possibility of conflict resolution and reduce destructive interactions
• clear team roles
• competent leadership, which has more than one component, is distinguished from professional responsibility, and can be a contentious issue in clinical teamwork.

The first four key elements (i.e., agreed goals, an agreed approach, effective communication styles, and established ground rules) can usually be achieved with a general commitment to and understanding of the benefits of teamwork. The last two elements (i.e., clear team roles and competent leadership) are more difficult to achieve, and can be obstacles effective teamwork and collaboration (Berg, 1986).

Obstacles to effective teamwork and collaboration

Obstacles to effective teamwork and collaboration include the following:

• ambiguity or conflict over roles
• conflict and confusion over leadership
• differing understandings of responsibility and accountability
• interprofessional misconceptions
• differing rewards between professions.

Ambiguity or conflict over roles in teams can lead to personal strain and poor function (Watts and Bennett, 1983; Shectman and Harty, 1982; Vaccaro and Clark, 1987; Onyett et al., 1997; Ovretveit, 1994). Conflict and confusion over leadership can disable a team. The distinction between clinical responsibility and clinical authority was identified as a major issue for  discussion in policy, services and teams (Norman and Peck, 1999; Onyett, 1995).

Leadership of teams is usefully distinguished from clinical responsibility. Equating these can lead psychiatrists to have considerable reservations about working in teams, and to cloud the discussion about team leadership. Responsibility refers to being called to account for one’s actions, while leadership refers to a team function. The former is individual and the latter is interpersonal. Legal responsibility or negligence can apply only to an individual (or legally incorporated company). Team members are responsible for such matters as duty of care and standards of care. The concept of an individual having ‘ultimate’ or ‘overall’ responsibility for the actions of all members of a team is not applicable for this reason (Division of Clinical Psychology, 1998), but often is a source of concern for psychiatrists.

The concept of clinical authority, on the other hand, is useful (Beigel and Santiago, 1995). The clinical authority vested in the psychiatrist by virtue of training and experience can be supported rather than threatened by good teamwork. Agreeing on goals, approach and rules of communication, and clarifying roles will allow the tasks of leadership to be defined. Psychiatrists may or may not have the desire, aptitude or skills to assume leadership of the team’s strategic and operational functions and one or more people may undertake this task. Some teams have found that a partnership between a psychiatrist and team coordinator provides a workable combination of skills and functions to cover clinical decision-making, quality reviews, supervision, planning and administration (Burgoyne and Lorbiecki, 1993).

Psychiatrists along with clinicians from other disciplines need training in the principles of teamwork, an important aspect of community psychiatry (The Sainsbury Centre for Mental Health, 1997; Pinkerton et al., 1987; Moss, 1994). With the move from the hospital as the main focus of care to the less structured ‘ward in the home’ and clinic, the needs of patients and families have changed. The training of all the disciplines including psychiatry will desirably equip them in the principles of teamwork and understanding each other’s roles, in negotiating shared care, and in the skills of leadership. In some settings the need for this cross-discipline training has been translated into encouraging the emergence of so-called ‘generic’ mental health workers. This development can be confusing, lead to loss of focus and discipline-specific skills in a service (Farhall, 1998), and potentially make a psychiatrist’s interactions with co-professionals less rewarding.

If mental health care is to advance with mental health service reform, psychiatrists will continue to have an important place in public psychiatry, where work is more clearly based in multidisciplinary teams, as well as in private practice. The need for psychiatrists in mental health care, with or without teams, is equivalent to that of other medical specialties in terms of the effect on service standards. The psychiatrist is an essential contributor to care, working alongside professionals from other disciplines such as clinical psychology, social work, nursing and occupational therapy. Confusion and conflict over team roles, leadership and responsibility are contributing to difficulties in recruiting and retaining psychiatrists in state funded services, and restricting partnership roles for psychiatrists in private practice.

Recommendations

The Committee was able to compose a number of recommendations to assist the College in identifying and dealing with each of the obstacles to effective teamwork and collaboration. These can be presented according to actions possible at three levels: LEVEL 1 - Education and training providers, LEVEL 2 - Professional organisations, and LEVEL 3 - Workplace organisations and government. One set of these recommendations has been discussed with the RANZCP Training Committee, and educational aims for trainees and supervisors Several recommendations involve collaborative activities with other professional organisations.

At the level of education and training, the recommendations relate to teaching and examination about team dynamics, structure and function, in the context of contemporary understandings about organizations. Training programs, perhaps inter-disciplinary, could aim to produce a conscious shift in attitude toward working in teams, and the syllabus include training in teamwork and the associated personal skills. Such training could include both didactic and experiential aspects. Teaching could also include consideration of the legal concepts of responsibility, accountability, and leadership.

Turning to recommendations at the level of the professional organization, relationships with other professions could be enhanced by joint projects, and joint statements on matters of mutual concern. Recommendations also relate to shaping the expectations of workplace organizations, governments, and healthcare standards bodies about the attitudes and actions of professionals, especially as far as team roles is concerned. Programs for the maintenance of professional standards could give credit for developmental and educational activities relating to teamwork. Professional leaders could acknowledge and promote the fact that there are many valuable and satisfying roles for psychiatrists in teams which include but are not restricted to administrative oversight.

Finally, at the level of the workplace, the recommendations recognise the desirability of clear and agreed job descriptions, which include expectations of collaborative working. Team protocols which establish the service objectives and the roles and functions of the various members, and position specifications making a clear separation between leadership or coordinating functions, and professional and clinical responsibilities, would achieve a great deal. More opportunities could be created for shared leadership functions. 

Success in resolving these problems will assist unity of purpose among the College Fellows, and the advocacy role of the College in ensuring appropriate levels of clinical expertise, supervision and standards in mental health care. Discussion of these issues with other professional groups, governments, policy makers, and representatives of consumers and carers, will help shape the ideas and may continue to have an influence on policy and practice.

References

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Benierakis CE (1995) The function of the multidisciplinary team in child psychiatry: Clinical and educational aspects. Special Issue: Child and adolescent psychiatry. Canadian Journal of Psychiatry 40:348–353.

Berg M (1986) Toward a diagnostic alliance between psychiatrist and psychologist. American Psychologist 41:52–59.

Boyce P, Tobin M (1998) Defining the role of the consultant psychiatrist in a public mental health service. Australian and New Zealand Journal of Psychiatry 32:603–611.

Burgoyne J, Lorbiecki A (1993) Clinicians into management: the experience in context. Health Services Management Research 67:11–31.

Division of Clinical Psychology (1998) Draft of "Responsibility and accountability in clinical psychology: issues for professional practice and multidisciplinary teamwork". London, UK: British Psychological Society.

Farhall J (1998) Interdisciplinary teamwork: clinical Psychology and the Common Good. In: 33rd Congress of the Royal Australian and New Zealand College of Psychiatrists. Melbourne.

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Onyett S, Standen R, Peck E (1997) The challenge of managing community mental health teams. Health and Social Care in the Community 5:40–47. 

Ovretveit J (1994) Coordinating community care. Multidisciplinary teams and care management. Philadelphia USA: Open University Press.

Pinkerton RS, Moorman JC, Rockwell WK (1987) Multidisciplinary training in the college mental health service. Hospital and Community Psychiatry 38:656–661.

Rimmer JR, Buckingham WJ, Farhall JF (1988) Achieving continuity of care in comprehensive psychiatric service systems - Victoria's approach. Sydney, Australia: International Congress of Psychology

Shectman F, Harty MK (1982) Mental health disciplines in conflict: The patient pays the price. Bulletin of the Menninger Clinic 46:458–464.

The Sainsbury Centre for Mental Health (1997) Pulling Together: the future roles and training of mental health staff. London, UK: The Sainsbury Centre for Mental Health.

Vaccaro JV, Clark GH (1987) A profile of community mental health centre psychiatrists: results of a national survey. Community Mental Health Journal 2:282–289.

Watts F, Bennett D (1983) Management of the staff team. In: Watts FN, Bennett DH (eds) Theory and Practice of Psychiatric Rehabilitation. New York, USA: Wiley.

Disclaimer: This information is intended to provide general guidance to practitioners, and should not be relied on as a substitute for proper assessment with respect to the merits of each case and the needs of the patient. The RANZCP endeavours to ensure that information is accurate and current at the time of preparation, but takes no responsibility for matters arising from changed circumstances, information or material that may have become subsequently available.