I work in a solo private practice. Many of the children on my caseload are nonverbal (or not able to effectively meet their communication needs verbally) and have significant behavioral challenges. In addition to their school teams, they have community-based behavior specialists, as well as other community-based professionals. Because of administrative systems and restrictions in place above me within which I must operate (i.e. legislative, insurance, etc.), I am usually relegated into an intrA-disciplinary role; me sitting at the proverbial table by myself. I do what I can to maintain connections to the larger team. But it is tough. And requires effort from others. Whenever possible, I include parents in my therapy sessions. This helps them learn their child's AAC (communication) system, and provides me with opportunities to coach them on how to model and incorporate the AAC system into their lives outside of therapy. I email. I create documents and packets to share. I have an open door policy - a standing invitation to any team member who wants, and is able, to come join my therapy sessions with our shared client. Most often it is the behavior specialist that can come (because funding and systems are in place for their profession to do so). But it typically isn't as often as would be ideal. They are busy, too, after all. Very occasionally, parents are able to pay (or have access to special grant funds) for me to attend a meeting or provide a training. That is definitely not the norm. And, more often than not, there are times when it is just me and the parent - which puts the parent in the unenviable (and stressful) position of being the go-between, trying to share information from one therapist to another and to coordinate all of us professionals. Their child’s “team”.
I distinctly remember learning about different types of "teams" in graduate school: intra-disciplinary, multi-disciplinary, inter-disciplinary, trans-disciplinary.
Intradisciplinary is me at my own little table all by myself, working alone.
Multidisciplinary is me sitting at the big table with all the other disciplines (professionals). We are working together but with little interaction across disciplines. We are telling each other what we are working on and how it is going, but it pretty much stops there.
Interdisciplinary is me sitting at the table with all the other team members. We are sitting close to each other and starting to integrate our interventions. Our "role boundaries" are starting to breakdown so that we can coordinate our efforts toward our common goal.
Transdisciplinary is all of us at the table intertwined into one holistic approach that is more than the sum of our respective parts. There is a lot of crossover between disciplines and role release without anyone overstepping what is ethical and appropriate. We remain respectful of each other’s expertise, but learn from each other and apply that knowledge.
The ideal, we were told, was to be part of a transdiciplinary team.
I feel extremely lucky to have since worked in positions that allowed for strong teaming, both within and across disciplines. The ultimate was when I worked for a residential facility for individuals with developmental disabilities. I was part of the crisis stabilization teams who cared for incoming clients in a state of medical, behavioral, and/or psychiatric crisis. Because of the high level of need of these clients, our teams typically met as a full team at least every two weeks (with communication between various team members happening daily). That team included the doctor, nurse, psychologist/behavior analyst, occupational therapist, speech-language pathologist, case manager, house/staff manager, and potentially others (depending upon the needs of the client). When members of the team were able to release a little control (and ego) and really listen to and work with each other - man, was it amazing to see what we could accomplish for our clients.
It was here that I learned how much more effective I could be when I was aware of everything that was going on with my clients. I knew that challenging behavior was based in communication breakdowns - but I didn't really KNOW. This is when I learned how pivotal my role is in helping to address an individual's challenging behaviors. Many of our clients came to us (as adolescents or adults) with NO REAL FUNCTIONAL COMMUNICATION. On top of everything else, they had no way to express their thoughts, feelings, wants, or needs. My number one priority was getting an augmentative-alternative communication (AAC) system in place to establish (and teach) a means of functional communication. This is also when I learned the importance of training and working through caregivers. To be effective, communication interventions and supports need to be infused throughout the client's day - all day, every day, with all communication partners. My communication recommendations were integrated into their behavior plans. When I was aware of their daily behavioral challenges, I was able to brainstorm (on my own, as well as with team members, especially the behavior specialists) what communication breakdowns may be contributing to the behavior and how I could assist in intervening. Maybe a social story would help. Or maybe visual supports were needed to help improve the client's receptive understanding (and to support memory issues). Maybe (s)he needed a means of communicating a specific message in a more socially acceptable way.
My point is, I was invited to the big table and able to collaborate with fellow team members. The result was that I was able to be much more effective in addressing the communication (and cognitive and social) needs of my clients. The direct impact this had on my clients was tremendous.
Last year I participated in an online AAC conference focused on "interprofessional strategies". Presenter after presenter told us about how research and evidence based practices demonstrate the need for "interprofessional collaboration". The resounding response from participants was: how do we put this into practice, because "the powers that be" will not reimburse for meetings and other means of collaboration. The reality is we know best (and more efficient and effective and, in the long run, cost-effective) practice is for collaboration and teaming, however that information has not reached the decision makers. As professionals, we need to keep advocating and educating for what we know is best practice, but ultimately it will be up to parents advocating for their children and demanding a (truly collaborative) team approach for things to really change. Parents are the consumer, of both the specialty services and the funding sources (insurance, waivers, etc.). Most agencies do want a good reputation and customer satisfaction, which means it is parents (and clients) who have the "ear" of the powers that be.
I want my invitation to the big table. Other team members have valuable information and ideas that I am missing out on. I have valuable contributions to make beyond the direct therapy I am providing to the children in my care. Instead, I am rendered less effective in my isolation. In the meantime, we need to keep thinking outside of the box and working hard to maintain a TEAM approach.
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