Collaborative Practice: The Good, The Bad, The Dangerous

“Sorry I’m late, I couldn’t find parking!” My 1 p.m.  patient said from the doorway clasping her hands nervously.

Emily S walked quickly into my therapy office. My initial impression was that she was anxious and then my second thought was that she had put some effort into looking well put together. However, her dress, her styled hair and artfully applied make up did not cover the pained expression on her face or the aura of distress that surrounded her. I smiled, welcoming her in.

Somewhere in the middle of the session her protective shield crumbled under my gentle encouragement and she collapsed into a miserable ball of tears. Emily had complex co occurring issues; an eating disorder hidden for 15 years and triggered by relationship problems, anxiety, depression and dependence on pain medications.

She was struggling; she was lost and very frightened.

This encounter would be a change-making experience in my practice as I had just learned that my collaborator (a coach with “expertise” in mindfulness, addiction recovery treatment and nutritional ) had breached our informal verbal agreement in several ways.

He did not have formal training in the nutritional domain. He was in partnership with four other therapists and was collecting surplus/cash fees apart from the “package” that our office charged our patients.

This individual was my first “collaborator” and he was my sister’s friend.  The expectation had been that our work would provide patients who had co occurring, difficult problems with resources and treatment that was based upon the recovery model with addiction as a core focus .

This area was not in my domain of expertise and the inclusion of a specialist within my office would meet clients’ needs for immediate and targeted help that was carefully integrated with the method of psychotherapy that I practiced.

Emily, and many other patients, needed psychotherapy for her depression and anxiety as well as coaching with nutritional input for the hidden, neglected eating disorder and help for her drug dependence.

If I referred her to outside specialists it would incur waiting for appointments and communication issues that might be too much for her to undertake in her emotionally and physically drained condition.

In this case, given the problems with my partner, I did have to refer her to outside specialists and it was a laborious process that could have been much more helpful to her.

What I learned was vitally important for the continuance of a functional and sustainable collaborative practice.

Formal Collaboration Should Be Viewed as a Business

It is important to use a business model when you engage another individual in your practice if the goals are the following;

To achieve a professional and sustainable model of practice that is based upon mutual trust and agreement upon basic ethical principles of practice

To provide clients with a full range of therapeutic strategies in a timely fashion without interruptions because of differences in practice models or breaches in agreements.

The agreement between partners should be in writing and specify the following items with more added as needed.

• The location of the sessions
• Fee schedule
• Number of clients to be taken on
• Length of time for each session
• Guidelines for emergency situations
• Need for documentation
• Schedule of review meetings between consultant and primary practitioner
• Plans for back up in the event of illness or other unexpected occurrences.

There are Positives of a Collaborative Practice. They include:

• Clients are provided with multiple resources for achieving changes and recovery
• The process may be more time efficient that benefits a client suffering from multiple sources of pain
•  Collaboration gives each partner an opportunity to discuss avenues of treatment and their own views of the patient–more objective
• Simplification:  A package option in terms of fees may reduce complexity of paying for the services

The Cons of a Collaborative Practice include:

• Sharing a client may be difficult for the solo practitioner in initial phases. There may be differences in perception of the client and their needs, in plans for intervention and in other domains. Collaboration will entail an ability to be flexible but always keeping the patients’ well being in focus.
• The issues of finances; what insurance covers and what it does not will come into play and may necessitate a blended protocol with insurance covering part of the therapy
• The client may not be familiar with the dual process and can be somewhat resistant. This reluctance will necessitate education about the benefits of this model.
• The timing of each partners’ therapies can be difficult. For example, one may tend to advance in treatment at a faster pace.  They must communicate on a frequent basis so as not to precipitously  introduce or terminate a strategy
• The roles and training levels of each provider differ and have to be clearly delineated and then explained to the client. There may be issues in regard to decision making and final responsibility that will need a full discussion prior to agreement.

The Dangerous Issues in a Collaborative Practice are:

There are perils that may compromise the helping process and do harm to the patient and the psychotherapist.

• The collaborator has poor boundaries and extends his work into other realms where he or she has no expertise
• The collaborator has not been transparent about skills, certifications, fees collected
• The collaborator makes a separate commitment to the client for such things as continuing services after termination or being available during non-working hours
• The collaborator has a need for control over the process and undermines the therapist and his or her treatment and expertise.

Recognizing the positive and negative aspects of collaborative practice is a core element of homework that precedes finding that individual who fits well and becomes a strong asset.

There are several essential elements in the development of a collaborative practice between therapists and consultant. First and foremost is the need to understand the roles, skills and knowledge of each individual.

Other important factors include meeting initially to define shared authority, accountability and coordination of care and to develop mutual trust and respect. Collaboration should be viewed as an opportunity to enhance professional relationships, optimize practice and provide the structure for a  positive working relationship capable of enhancing patient care.

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