"The Synergistic Treatment Team"

by Sharon Klingman, M.S., L.C.P.C., C.A.D.C.

In treatment, we teach patients about synergism, emphasizing how the combined effects of certain substances can potentiate others and create a more powerful overall reaction. Synergism in this context is usually something to be avoided; however, creating synergism within a treatment program team is a goal worth achieving. Program managers often recognize the value and skill each individual team member brings to his or her job, but some managers may not always take time to work on establishing a core of understanding and respect that will promote staff synergism. Consistently working to build a synergistic foundation will maximize individual skills and creat a stronger team. Patients ultimately reap extra benefits from this unified atmosphere.

Most professionals in addiction treatment recognize the importance of utilizing a multi-disciplinary approach to patient care. For instance, good programs assemble treatment teams representing the medical, psychological, clinical and environmental needs of the patient, using input from each member of the team to direct the patient’s recovery. Although professionals recognize the value of that team in the overall rehabilitation picture, keeping in mind each discipline’s importance and respecting the differing approach each discipline brings to the treatment setting is a process that should be continually cultivated and reinforced if the team is to be therapeutic.

Program managers have the opportunity to oversee the development of the program team and to experience first hand the issues that arise as treatment “partners” on the team attempt to understand each other and work together. Often the clinical formulation of each patient is the piece of the team approach that best lends itself to understanding. When problems do appear, it’s often around the specific policies and protocols each discipline brings to the management of the case, and the many ways, those protocols bump into each other every day.

Two disciplines that may find themselves at odds are the counseling and medical professions. The educational and professional backgrounds of each of these team members seem to direct their views of treatment-team roles. Counselors may tend to be biased towards the importance of the clinical-treatment work while becoming indifferent, at times, to the role their medical team partners play.

The approach to daily operations on the unit must draw from these two very different viewpoints, yet preserve a unified end goal of quality patient care. The nursing coordinator, for example, must network with the other RNs, the unit physician, the patient-records department and with the hospital nursing-practice organization. There is incredible attention to detail demanded by this discipline, and many factors must be considered when making each patient decision.

Nursing is an exact science. Nurses assigned to an addictions unit must impose protocol in some extremely volatile situations. Decisions such as medication withdrawal regimens must be handled carefully, as there are many potential pitfalls. A patient must be monitored, medicated to ease discomfort, yet not overmedicated. Today’s patient often presents with multiple addictions, resulting in difficult and painful withdrawals. In these cases, every decision is crucial, and an uncomfortable patient is at risk to leave treatment prematurely, something treatment teams work to avoid.

Behind the scenes, the unit nurses work to ensure compliance with the regulatory bodies to keep the QA program in compliance and successful. When all is said and done, at discharge, the nurse’s record of care must be clear and each decision justified by scientific and medically based reasoning. Instead of impatience, counselors would do well to develop an appreciation of the nurse’s efficiency, attention to detail and the crucial role the medical staff play in day-to-day patient care.

One area that helps develop appreciation is clinical supervision with counselors. Questions about the need to comply with every policy and procedure often arise during supervision as counselors struggle to meet all the demands of administrative case management while working to achieve intrinsic satisfaction from their daily work with the patients. Counselors, it seems, are forever pondering the time spent on charts just to get the i’s dotted and the t’s crossed. The question basically comes down to the same issue, “What does this have to do with treatment?” Frustrated counselors wonder at times what the nursing staff is doing to help them, and may feel that the average treatment day leaves little time for them to interact with the “other side” when everyone is busy providing his or her own piece of the treatment program.

Counselors can miss the perspective that program managers gain from the close quarters they share, so supervisors should work to find ways to share that perspective with them. How to help them gain that understanding may be a difficult mission. For example, focusing only on the importance of the policy and procedure in the workings of the system is not likely to accomplish this goal. Instead, counselors must be able to value the precise world of the nurse, while managing the daily ambiguity and ever-changing dynamics of the patient population. There are places, however, where the bridge can be created.

Management teams can utilize patient staffing as chances to introduce each other’s discipline, not just in the approach to a specific patient, but in asking general questions about differing approaches to treatment. Such a discussion may enlighten everyone as to why a certain medication was used, what might be expected from patients in terms of physical and mental responses to treatment based on certain pre-existing conditions. Likewise, counselors can be tapped to share their expertise in working with dually diagnosed patients and dialoging on how a patient’s long term emotional or traumatic issues may affect their ability to gain from the treatment experience.

Taking advantage of opportunities to use unit staff meetings to recognize each other for excellent patient care is another potential area for growth. Clinical managers can look for opportunities to recognize the nurses, and the nursing coordinator can do the same for the counselors. Managers can model communications techniques with the goal of increasing comfort with each other’s realm. Clinicians see how to ask questions about medical decisions to increase their knowledge base, and nurses can take opportunities to suggest clinical interventions to stretch their own skills. The whole team will benefit from a decrease in tension as this gap is bridged.

Efforts like this result in fewer errors as the team works together to create the kind of chart that demonstrates excellent patient care. In the long term, deeper level changes develop as the team partners work to accommodate each other’s needs. Clinical input becomes a valuable part of many nursing decisions, and, while protocol is followed completely whenever possible, rigidity lessens and each considers the other’s view more often on a regular basis. Experience has also shown that patient crises have a way of bringing the disciplines together and creating a bond between them. No nurse is appreciated as much as when a medical complication arises. Counselors look to the nurses for direction and breathe a sigh of relief when the nurse competently approaches and addresses the situation. There is the likelihood that the entire team will walk away from those emergencies with true appreciation for the training and competence of the medical team partners. Also, a patient in emotional crisis tends to bring out the best skills of the counseling team. Good counselors rise to the occasion and view the crisis as an important opportunity for intervention, which may well turn the corner for the patient in treatment. The nurses appreciate the availability of the counselors during such moments and seek their expertise in directing the patient and dealing with the aftermath. Managers can take advantage of such crisis situations to provide learning experiences for the whole team in recognizing the competence and skill of team members. These situations give staff experiences they remember and can use later when they must tolerate policies and protocols with grace.

Not to be minimized for a moment is the ever-present opportunity to bring humor into the mundane operations of the unit. Any time the team can look at its own shortcomings, addressing them good naturedly while acknowledging the base of respect and trust under the laughter, bonds are created. Those moments are usually repeated as similar situations arise, and the memories may subsequently resolve a standoff and bring about growth as well. A good team feels comfortable together. Like a family, there are many layers of dynamics, but under it all, there is a foundation that stands firm and will hold up to outside criticism as well as unexpected crisis in patient care or just standard program operations.

In the contemporary treatment world with the involvement of managed care, we must all be prepared to back clinical decisions with medical as well as clinical expertise. No one discipline can succeed without the contributions of the other. In order for a treatment program to succeed, the team must work together and consistently look for ways to appreciate and acknowledge the unique contributions each discipline brings to the treatment setting. Letting indifference take over this effort can be disastrous because discontent is difficult to overcome. The need for intervention will fluctuate over time, but when managers see team members regress, they can be prepared to intervene. Ultimately, though, the unfailing effort managers can make and consistently model will have the strongest effect. Challenges like this serve to keep each member of the team aware of his or her own role and of the impact each person can have on the others to create a synergistic effect from which everyone will benefit.

Sharon Klingman has her master's degree in counseling psychology and is also a certified addiction counselor.