December 2008 Volume 1 Issue 3
The Center for Collaborative Psychology and Psychiatry
Steven A. Frankel, MD, Center Director
December 2008 Newsletter
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News!
We're moving along. Steve's new book "Evidence from Within:
A Paradigm for Clinical Practice" (April 2008) is now out in
paperback (see below for details).
Our method of working, authored by Phil Erdberg and Steve
Frankel, is well along in its evolution. We included a clinical
description of our work with one of these patients, Owen, in
our first newsletter. You can read that issue at
http://www.stevenfrankelmd.com/newsletters/april2008.html .
Appropriately, this method emphasizes accountability and
transparency in clinical practice and is called the
Collaborative Treatment Method. In addition to its
collaborative emphasis, it involves the use of diagnostic
instruments, self-assessment and psychologist administered,
to assure diagnostic accuracy and follow treatment
progress. To learn more about it, take a look at our fact sheet
at http://www.collaborativepsychology.com/CCP-Fact-Sheet.pdf .
Also, we now have an opening in our bi-weekly consultation
group with Steve Frankel and Phil Erdberg. Participation
will entitle you to receive continuing education credit as a
psychologist, social worker, or MFT. Let us know if you might
have some interest in joining. To find out more, visit
http://www.collaborativepsychology.com/workshops.html.
You can email Steve at stevenfrankelmd@earthlink.net or Phil
at Phil.erdberg@gmail.com, or call us at 415 456-6611. We'd love to hear from you.
The subject of this quarter's newsletter, accountability, is
so broad and critical for mental health practitioners that we
will devote two newsletters to it. The first installment
follows.
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~ Accountability in Clinical Practice, Part I ~
In our last newsletter, we discussed the pluses and minuses of
clinical judgment, the compass we all use to guide us from
moment to moment in our office treatments. The major question
asked was: How reliable is clinical judgment and how to KNOW
that you are doing the right thing?
Here's an example that is likely to seem familiar to most of us:
"Don't go to a shrink. Once they get you hooked they never let
go," said her mother to 38-year-old Amanda. And she wasn't
kidding. Once Asperger's-like Amanda started to go to treatment
her parents were unrelenting in insisting that she finish as
soon as possible. When Amanda stayed on and began to make some
connections to other human beings, the mother was careful never
to approve of anything Amanda did, always seeing failure and
regression where we judged there was progress.
Steve was the therapist and Phil the assessor. As usual, we
structured our work according to our Collaborative Treatment
Method (See
http://www.collaborativepsychology.com/CCP-Fact-Sheet.pdf).
Amanda had a life-long history of social and
professional failure. Soon after treatment began, the refrain
of objections started. "What's your evidence?" "What convinces
you that Amanda is progressing?" "But, my girlfriend Barbara
said..."
Substitute any patient. Isn't there usually a time when
support, emotional and financial, for the treatment typically
begins to dry up? The beginning is upbeat. (In "Hidden Faults"
[2000] Steve calls this early high, "incipient conjunction.")
Then you begin to hit some hard spots: issues the patient
doesn't want to think about, financial priorities redirecting
money to a coming vacation, just boredom. Of course, not all
treatments are like this but since it happens so often...
So, how can we, as therapists, argue in defense of the patient
and the treatment? What data DO we have? This is not a trivial
question, especially if someone other than the patient is
holding the purse strings. Note that this issue is somewhat
beside the point when we are dependent on a third party for
payment. In those cases, the issue of run-on treatments has
already been dealt with and sharp restrictions on the frequency
and duration of treatment have already been imposed. But
outside of managed care, we are talking mostly about out-of-
pocket payment situations. Justification for treatment in these
cases is mostly a private matter between patient or parents and
therapist.
Our treatment protocol is described in Steve's most recent
book, "Evidence From Within: A Paradigm for Clinical Practice."
In the beginning of a case, he does a clinical evaluation and,
as soon as feasible, gets psychological or neuropsychological
testing. He does this with adults as well as children.
Alternatively, self-assessment tests may be all that a patient
is willing to afford or tolerate. When Phil has been included
as an assessor, the feedback from these assessments is used
therapeutically according to the principles of collaborative
psychology and psychiatry (Engelman and Frankel 2002, Finn
2007). Steve then creates a report, outlining tentative
impressions and a collaboratively arrived at treatment strategy
and plan. Matched with Steve's report is Phil's counterpart,
reflecting the testing data. By this point the patient and
Steve have an idea of the kind of clinical process the patient
is willing to undertake. Ideally, after testing, there is a
trial period of several months when the proposed clinical
strategies are evaluated for efficacy. Verbal or written
reports, including modified treatment plans, are created
successively in response to changes and progress in treatment.
These may be schematic and often are delivered at four-month
intervals. These reports serve the secondary purpose of
providing an excellent means of enhancing therapist-patient
communication.
In our opinion, the extra cost and time required for such an
assessment and treatment approach are more than justified by
its built-in checks and balances as well as the added
likelihood of clinical accuracy. The combination of clinician
self-discipline and psychological or neuropsychological testing
pretty much assures that as a clinician you will not miss much
or overtreat the patient. The probability of the clinician
lapsing into formulaic practice, such as automatically seeing a
psychotherapy patient once weekly for many months or even
years, is much reduced. The choice of a therapeutic approach,
cognitive-behavioral or psychodynamic, for example, is based on
test results and a well-considered diagnosis. Consultation with
other experts is used liberally, and collaboration with spouses
or family members is frequently called for.
The benefits of such a process? Simple. More focused and
efficient treatments. The ability to identify patients who
cannot really benefit from psychotherapy alone. And, most
particularly, results, results, results, as opposed to simply
assertions that what you do works.
Returning to Amanda, she is still in treatment and is
sharpening her social interest and skills. In the past,
learning to communicate with and enjoy other people seemed
entirely beside the point to her. It is, of course, slow and
steady work. Her personal and psychological progress has been
followed clinically by Steve, and formalized collaboratively
through check sheets we constructed around her goals for the
treatment, as well as through selected psychological tests
administered by Phil. At the beginning of treatment, Phil did a
full battery of psychological tests. This information is
repeatedly supplemented through self-assessment protocols,
including some of the more informative batteries such as the
PAI and MMPI II.
Amanda's parents are even becoming less contentious as her
progress becomes harder to overlook. Having data, including
literature which places Asperger's in the category of a
disorder of temperament (developmental, "brain based"), has
clinched our case with them. Amanda had been in treatment twice
before, but without discernable benefit. This time there are
results, plenty of them.
We hope we have made a good case for therapist responsibility
for articulating and measuring results as a treatment
progresses. The advantages? A distinctly more accurate and
efficient process. The cost of these extra measures are almost
always less over time than the expense of ongoing, unfocused
treatment. And in the end, regardless of our professional
discipline, whether psychology, social work, marriage and
family therapy, or psychiatry, we adhere to our mission to heal
and keep track of the patient's progress.
Philip Erdberg, Ph. D. and Steven Frankel, M.D.
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~ To Find Out More ~
Would you like to know more about the work of the Center? If
so, you may be interested in reading my book "Evidence from
Within: A New Paradigm for Clinical Practice," published by
Rowman and Littlefield in March 2008. Information about the
book can be found on the Center website
http://www.collaborativepsychology.com.
We welcome your feedback and suggestions. You can email Steve
at stevenfrankelmd@earthlink.net.
Or write to us at:
Center for Collaborative Psychology and Psychiatry
contact@collaborativepsychology.com
1044 Sir Francis Drake Blvd.
Kentfield, CA 94904
415-456-6611
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Thanks for reading,
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