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TRAINING FOR COLLABORATION: COLLABORATIVE PRACTICE SKILLS FOR MENTAL HEALTH

PROFESSIONALS

Richard J. Bischoff, Paul R. Springer, Allison M. J. Reisbig University of Nebraska-Lincoln

Sheena Lyons Devereux

Adriatik Likcani Kansas State University

The purpose of the study was to identify skills that mental health practitioners need for successful collaborative practice in medical settings. Known experts in the field of collabo- rative health care completed a survey designed to elicit their suggestions about what is needed for successful collaborative care practice. Through qualitative analysis, a set of 56 skills was developed. These skills are organized into three general categories of compe- tency: (a) skills for working in a medical setting; (b) skills for working with patients; and (c) skills for collaborating with healthcare providers.

In their landmark text, Medical Family Therapy, McDaniel, Hepworth, and Doherty (1992) introduced an approach to health care delivery based on the Engel’s (1977) biopsychosocial (BPS) model. The foundation of medical family therapy (MedFT) is an acknowledgment that ‘‘all human problems are BPS systems problems: there are no psychosocial problems without biological features and no biomedical problems without psychosocial features’’ (McDaniel et al., 1992, p. 26). The authors reasoned that treatments will be more effective and outcomes more positive when biological and psychosocial dimensions of functioning are considered and addressed simultaneously. This is facilitated by maximizing the collaboration between physi- cians and mental health therapists.

While the scholarship of the practice of collaborative health care predates the publication of this text, it has increased dramatically since 1992. Other texts promoting the practice of MedFT have been written (e.g., Blount, 1998; Patterson, Peek, Heinrich, Bischoff, & Scherger, 2002; Prouty-Lyness, 2003; Seaburn, Lorenz, Gunn, Gawinski, & Mauksch, 1996), giving stu- dents of the approach a library of literature on the practice. While started in 1983, the journal Families, Systems, and Health has since become a premiere journal in this specialty area of mental health care. Research has established the link between biological, social, and psychologi- cal systems (see Campbell & Patterson, 1995) and the positive impact of psychotherapy, espe- cially relational approaches to treatment, on health outcomes (Cambell, 1996; Crane & Christenson, 2008; Law, Crane, & Berge, 2003). The Collaborative Family Healthcare Associa- tion, an association devoted to collaborative care practices that are characteristic of MedFT, has matured into a multidisciplinary association giving those interested in collaborative care practices a place to come together to share ideas and advance the practice, research, and theory of medical family therapy (Bloch & Doherty, 2001). It would be difficult to imagine that one could graduate from a clinical training program in marriage and family therapy, psychology, or

Richard J. Bischoff, PhD, is a Professor and Director in the Marriage and Family Therapy Program at

University of Nebraska-Lincoln; Paul R. Springer, PhD and Allison M. J. Reisbig, PhD, are Assistant Professors in

the Marriage and Family Therapy Program at University of Nebraska-Lincoln; Sheena Lyons, MS, Devereux,

Arizona; Adriatik Likcani, MS, is a Doctoral candidate in the Marriage and Family Therapy Program at Kansas

State University.

Address correspondence to Richard J. Bischoff, Marriage and Family Therapy Program, University of

Nebraska-Lincoln, PO Box 830800, Lincoln, Nebraska 68583-0800; E-mail: [email protected]

Journal of Marital and Family Therapy doi: 10.1111/j.1752-0606.2012.00299.x June 2012, Vol. 38, No. s1, 199–210

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social work without an understanding of the BPS model, collaborative care practice, and Med- FT. However, even with the existence of several degree granting and postdegree training pro- grams in MedFT and many more programs that have emphases in medical family therapy and collaborative health care, little is known about the competencies needed to practice MedFT.

It is clear from reading any of the several texts on the subject that MedFT is different from the traditional mental health care practice. Those practicing MedFT need to have the same skills that are needed for traditional practice environments as well as many other skills unique to the collaborative health care environment. However, as yet, these skills have not been orga- nized nor explicitly identified. The development of a succinct set of skills, similar to that of the American Association for Marriage and Family Therapy (AAMFT) core competencies (Nelson et al., 2007), would be a step in the direction of developing training and practice guidelines for this rapidly developing approach to health care. This is particularly important in this age of outcomes-based educational standards (Maki, 2004; Miller, Todahl, & Platt, 2010; Nelson et al., 2007).

The purpose of this study was to develop a set of skills that would aid educators and train- ers interested in preparing mental health therapists for practice in collaborative health care set- tings. This was achieved through a qualitative design that began with inductive qualitative inquiry with leaders of collaborative care practice in an effort to understand the competencies that mental health therapists need to work effectively in collaborative health care settings.

METHODOLOGY

Participants After receiving Institutional Review Board approval, a purposive sampling strategy was

used to invite experts in MedFT to participate in this study. To be identified as an expert, indi- viduals had to meet one of the following criteria: (a) the person was an author on a minimum of two peer-refereed journal articles directly related to collaborative care practice or training or (b) the person was identified as an expert by someone meeting the two publication criterion. The first criterion allowed for the inclusion of those identified as experts because they were advancing the field through publication. The second criterion allowed for the inclusion of prac- titioners who have influence on the development of the practice of MedFT through clinical practice. Thirty-three experts were invited to participate, and 25 contributed data for the study (a response rate of 76%). Sixty percent of the participants were men and 80% were over 35 years old. Sixty-eight percent reported that they had more than 5 years of experience work- ing collaboratively in a medical setting practicing the principles identified in the research, and 24% reported more than 15 years of experience. Sixty percent reported their primary place of employment as a medical setting (11 respondents worked in a medical residency program, three in a medical school, and one in a primary care medical setting). The remainder reported that their primary employment setting was a university-based mental health training program. Fif- teen respondents identified their primary professional affiliation as MFT. Other respondents were primary care physicians (5), psychiatrists (2), psychologists (2), and one nurse.

Survey A survey consisting of 13 questions was developed for the purposes of this study. Six open-

ended questions were designed to elicit skills needed for successful collaborative practice. These questions elicited data about knowledge (biomedical and mental health) and clinical skills needed for successful practice in medical settings. Participants were also asked to relate an inci- dent that exemplifies successful medical, mental health collaboration. Six closed-ended questions elicited demographic information. The final question requested that the respondent identify oth- ers who they would consider to be experts on collaborative care practice and who might be able to provide useful information. In an effort to facilitate participation, participants either could choose to complete the survey on-line through a secure, password-protected website or through a paper version that was mailed to them. Potential respondents were contacted both by email (if an email address was available) and by a letter sent via US mail requesting participation in the survey.

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Data Analysis Data were initially analyzed using a process similar to the constant comparison qualitative

data analysis method (Miles & Huberman, 1994) by the primary researcher and a research assistant. Using this method, content analyses were performed, and a preliminary codebook of themes or skills was inductively identified. Specifically, each participant’s response was read in its entirety to understand the skills being emphasized by each respondent. Each reader kept a list of skills that emerged from the data. They then met to review and compare their separate lists and come up with a consensus list. No skills identified by readers were eliminated from the list. Both the primary researcher and the research assistant then separately returned to the data to carefully examine the responses to each question. All responses to question number one were read, identifying support for the skills identified on the list and adding new skills to the list by comparing incidents in the data with all others. Question number two was then analyzed simi- larly, and so on. Subsequent responses were compared with those preceding them in the analy- sis, with the result being the addition of new skills or the addition of evidence for skills already noted, as appropriate.

The validity, or substantive significance, of the data was established through analyst trian- gulation (Patton, 2002). Using a deductive method, three secondary coders reviewed and vali- dated the presence and salience of each theme identified by the primary coder and his research assistant. Skills that lacked clear support in the data were discussed and compared with all other skills that had been identified. This process helped establish the validity of the primary researcher’s and the graduate assistant’s preliminary coding of the data. The primary researcher and secondary coders then collapsed and sorted each theme or skill into categories and subcate- gories. The result of this process ensured that all categories and subcategories were examined and agreed upon by all coders. In addition, this process ensured that the interpretation of the data was comprehensive and accurate.

RESULTS

Qualitative analysis of the survey responses resulted in a set of 56 skills that uniquely char- acterize MedFT. It is evident from the data that while the practice of MedFT includes compe- tence in the practice of psychotherapy, it also includes skills unique to working in medical settings and to collaborating with medical providers and other professionals. Consequently, the identified skills have been clustered into three categories that represent logical groupings of these skills: (a) skills for working in a medical setting; (b) unique skills for working with patients in medical settings; and (c) skills for collaborating with healthcare providers. Skills within each category are further broken down into subcategories. The skills are presented by category in Tables 1–3. Each category is described below.

Skills for Working in a Medical Setting Participants were careful to explain that working in medical settings is different from work-

ing in traditional mental health practice settings. In describing this difference, one respondent explained that the medical setting is ‘‘a fast paced environment that has an organizational structure entrenched in traditional biomedical influence.’’ Others created lists such as: ‘‘differ- ences in language, pace, communication styles, confidentiality expectations, team roles, and documentation.’’ Differences such as these require those practicing MedFT to demonstrate competence in working within this unique practice environment. These skills can be organized according to those relating to (a) the unique practice culture of the medical setting, (b) medical knowledge, (c) accommodating to the medical setting, and (d) nurturing one’s professional identity.

The unique practice culture of the medical setting. When stepping into a medical setting, one is stepping into a unique culture; one that is different from traditional mental health care practice. Those practicing MedFT recognize this work to understand the culture, and to prac- tice in culturally sensitive ways. One respondent counseled that ‘‘It is important for the mental health professional to recognize that he or she is entering a different culture.’’ Another respon- dent explained that ‘‘a medical setting is part of the culture of medicine. It has a language, a

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history, a set of shared myths and archetypes like any culture.’’ The data suggest that it is par- ticularly important for mental health therapists to attend to the following characteristics of this unique culture.

Language. Respondents explained that the language of medical settings has been devel- oped to facilitate the work of medicine and that this language is unique and different from that found in traditional mental health care settings. One respondent explained,

Bridging the language barrier is [important]. Many MHPs [Mental Health Providers] enter into a medical setting speaking therapy and not understanding medicalease. [Developing a common language] means abandoning the terms that we learned in graduate school for more user friendly words that medical professionals understand.

Another respondent explained that ‘‘The language is instrumental and action oriented. [It] mirrors the kind of expectations that the [medical provider] may have of mental health provid- ers (what can you do rather than what do you think).’’ Another respondent succinctly wrote that there is a ‘‘preference for concreteness over abstractions.’’ The importance of the language used applies equally to verbal and written (e.g., charting) communication. Several respondents explained that mental health therapists ‘‘should understand the abbreviations for medication

Table 1 Skills for Working in a Medical Setting

The unique practice culture of medical settings Medical family therapists . . .

Recognize that medical settings have a unique practice culture Recognize and respect the professional hierarchy in medical settings Respect the differences between medical and mental health providers in scope of practice, practice patterns and strategies, approach to patient care, etc.

Know the difference between primary, secondary, and tertiary care Respect and value the contributions of the biomedical approach to care Are curious and willing to learn about unfamiliar, new, and nontraditional approaches to healing and promoting wellness

Know the services that are available and how to utilize them Are visible within the medical environment as an active participant of the care team

Medical knowledge Medical family therapists . . .

Speak the language of the medical setting (e.g., medical terms, abbreviations, jargon) Access and use medical and pharmacological information from reliable sources Know the diagnostic tests and treatments that are commonly used for patient medical care

Accommodations to the medical setting Medical family therapists . . .

Match the pace of the medical setting Are comfortable with frequent interruptions by medical staff during treatment sessions Are flexible in working with patients and families in examination rooms and other nontraditional settings

Accommodate to how confidentiality is handled in medical settings Document patient progress consistent with medical setting protocols Have the ability to be an excellent short-term interventionist

Nurturing professional identity Medical family therapists . . .

Are willing to be shaped in professional identity and role Stay connected with mental health colleagues

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(e.g., QID, QD, PO)’’ and should be able to document psychotherapy consistent with medical charting protocols and in a way that will make this information useful to medical providers.

Time management. It is important to attend to the pacing of the medical setting and in how medical providers manage time with patients. One respondent explained that ‘‘MDs [Medical Doctors] carry a case load of several thousand and see a minimum of [four] patients per hour.’’ Another explained that ‘‘The medical clinician is usually working with [two] patients at one time.’’ This use of time can be disconcerting for the naı̈ve mental health therapist. But, echoing the sentiment of others, one respondent wrote, ‘‘MDs must be action oriented. This time crunch should never be interpreted as evidence that the MD does not care about his ⁄ her patients.’’

The team approach to patient care. Contrary to the independence and autonomy that are hallmarks of traditional mental health practice, treatment in medical settings is typically charac- terized by a team approach where health care providers from various specialties and disciplines work together in caring for a patient. There are two noteworthy consequences of this approach for mental health therapists. First, the mental health care is often not the primary focus of the treatment. As one part of the overall care plan, the mental health treatment must support and complement the other parts of the care plan, some of which have greater immediacy and demand more attention than the mental health concerns. Second, the therapist may not occupy a primary role in direct patient care and may at times not even see the patient. There is a

Table 2 Skills for Working with Patients

The practice lens Medical family therapists . . .

Conceptualize pathology from the biopsychosocial perspective Medical knowledge

Medical family therapists . . . Have a basic understanding of biochemical processes and pharmacology Have a basic understanding of anatomy and physiology Know about the biological processes of diseases Know the medical conditions that commonly have psychosocial comorbidity Know mental health conditions that commonly manifest through physical symptoms Know common psychiatric medications, names and abbreviations, doses, and side effects

Patient care Medical family therapists . . .

Are skillful in working with a wide variety of treatment modalities (e.g., couple, family, individual, group)

Assess and diagnose mental disorders using the current DSM and ICD Provide patient psychoeducation in both individual and group formats Engage patients who do not see the connection between their medical conditions and other areas of functioning

Respond to a wide range of patient responses to illness and medical treatment Organize and conduct family meetings Know when and how to effectively intervene in the physician-patient relationship to improve treatment outcomes

Facilitate patient groups including psychoeducational groups Are able to manage chronic illness and stress Effectively apply evidence-based brief psychotherapies Effectively apply evidence-based psychotherapies to the treatment of specific problems Teach mind–body techniques Understand that the medical provider may be more invested in the patient’s mental health treatment than the patient

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hierarchy within the medical setting that must be respected to honor the team approach to care. One respondent simply stated: ‘‘You are part of a team, but your work is not at the center [of patient care].’’ Another provider pointed out: ‘‘You are likely to feel one-down, and you should not take this personally, but see it in part as part of the culture of medicine.’’ Third, there is an expectation that necessary information will be readily shared among professionals. Each per- son’s job in patient care is dependent on information obtained by other members of the care team. One respondent explained:

It is . . . normal for treatment in medical settings to be done in teams . . . Information flows freely on the team because life and death matters are often involved. This may pose a problem for mental health professionals who have a more traditional view of how confidentiality should be dealt with. The mental health provider must think of him ⁄ herself as part of a treatment team; that communication within the team is as important as anything else the mental health provider may do, that his ⁄ her role may be consultative as often as it will be treatment oriented, that he ⁄ she may need to be flexible with regard to availability.

Table 3 Skills for Collaborating with Medical Providers

Relationship building Medical family therapists . . .

Understand the importance of relationship building to effective collaboration Build relationships with medical providers and office staff Are available, accessible, and visible to healthcare providers and flexible in style of working

Actively collaborate with health care providers as a member of the care team Place self in the traffic pattern without getting in the way

Collaborative communication skills Medical family therapists . . .

Work within multidisciplinary teams, keeping lines of communication open to coordinate treatment

Communicate with medical providers in an efficient and clear manner Fluently use appropriate medical terminology Talk about mental health problems in a way that is easily understood by health care providers and that is respectful of all perspectives

Keep medical providers informed of progress and changes in care As invited, feel comfortable to provide feedback on the work of medical provider colleagues in the treatment of their patients

Interpersonal expertise Medical family therapists . . .

Understand that many medical providers become frustrated when dealing with chronic mental health problems

Perceive medical provider distress and respond appropriately to alleviate the distress Monitor and appropriately respond to emotional reactivity in oneself and in medical providers

Think relationally, not just in conceptualizing patients’ experiences, but also in conceptualizing the relationships among providers

Assess one’s own participation in and contributions to the relationship with medical providers

Evaluate the effectiveness of the collaborative relationship among care team members and among treatment providers and patients

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Many respondents explained that they use their skills as a family therapist in their interac- tions in the multidisciplinary team in culturally sensitive ways. Similar to others, one respondent wrote that to be successful in the practice of MedFT ‘‘we need to use our therapeutic skills in order to join with this new system just like we would with a new family in therapy . . .’’ Another respondent emphasized: ‘‘MH providers need to JOIN, JOIN, JOIN with the culture and the providers.’’

Medical knowledge. Medical knowledge is the foundation of the language of medical set- tings. While mental health therapists do not need to be medical experts, it was consistently underscored that they need to have enough knowledge that they can have sufficient conversa- tional fluency to participate as team members in patient care. This includes knowing basic information about diseases, disease processes, course, and treatments, including pharmacologi- cal treatments. They should have a basic understanding of pharmakinetics and psychopharma- cology and know how and where to access medical and pharmacological information on an on-going basis. They should be able to discuss the impact of commonly used medications on patient functioning and should recognize that medical providers may want to consult with them about pharmacological treatments. A few respondents indicated that it is important to know the ‘‘difference between primary and tertiary care and understand the domains of vari- ous specialties (e.g., neurology, endocrinology, oncology, obstetrics and gynecology, rheuma- tology).’’ Familiarity with most commonly used medical terms, abbreviations, and jargon in medical settings was also cited as important. One provider wrote:

I don’t think the person has to be an expert or even very authoritative in all of these areas, especially in the beginning of the collaborative relationship. But an acknowledg- ment of their importance and a willingness to continue learning are crucial.

Accommodating to the medical setting. Mental health therapists trained to work in tradi- tional mental health care settings need to accommodate their style of practice to fit the practice environment of the medical setting. One respondent wrote: ‘‘The medical system is bigger than us. MHP-s are the ones that need to do the cross-over learning and bridge the two cultures.’’

Several respondents were careful to point out that not all medical settings are alike, even though the culture of medicine is common to each. Medical settings differ according to spe- cialty, treatment emphasis, population served, and other factors. The therapist’s ability to adapt their own way of working to match that of the setting is a key to success. Most respondents identified attributes that facilitate adaptability including ‘‘humility, patience, curiosity, non- judgmental attitude toward physician behavior, empathy, and willingness to take risks,’’ ‘‘lots of flexibility,’’ ‘‘self-motivation, persistence,’’ ‘‘openness,’’ and ‘‘a sense of humor.’’ These attri- butes allow therapists to adapt their approach and apply their expertise to the unique medical practice setting within which they are working.

Mental health therapists cannot succeed if they treat it as a traditional mental health care practice setting, nor can they succeed if they attempt to practice traditional psychother- apy. Two representative examples from the data describe the types of accommodations that need to be made. First, the fast-paced nature of the practice of medicine places constraints on traditional mental health treatments. Respondents emphasized the importance of applying brief focused therapies that match the problem-focused, outcomes-oriented approach of med- icine. Second, the respondents pointed out the need to adapt the traditional role of the therapist as a treatment provider. A respondent explained that in these settings, therapists need to

Be able to expand [their] sense of mental health treatment beyond the 50-minute ses- sion, for example, to see the opportunities such as being available for informal consul- tations, joining an MD in a medical visit with a challenging patient, considering issues related to the general mental health of the staff and work relationships, attending to the relationship between the health care providers and patients, etc.

Nurturing one’s professional identity. Mental health therapists working in medical settings can expect to experience a challenge to their professional identity, which could result in a redefini-

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tion of how they see themselves as professionals and in how they see themselves in relation to their peers who are not working in medical settings. One of the respondents related the following:

One should expect a redefinition of one’s professional identity. When I started in this setting . . . I thought of myself as a family therapist. But over the years that has proven to be an inadequate designation. I see individuals as much as anything else. Often the main focus of the treatment I provide is to help the MD ⁄ patient relation- ship. I consult and educate as much as provide therapy. My most important interven- tions often have little to do with what goes on in the therapy hour (which is often not an hour!). I think that mental health professionals who want to work in collaborative settings must realize that the setting will shape them, and this can be very exciting and enriching, but it can also be disorienting.

Respondents explained they found it important to stay connected and involved with other mental health colleagues and with their professional organization. Another respondent cau- tioned: ‘‘Establish a support network with other mental health folks, either on site or in other settings. Share experiences. Consult regarding systems issues, and support each other. Take care of yourself. Have fun.’’ Staying connected to and grounded in the mental health discipline helped these respondents stay oriented and helped them preserve a coherent sense of professional identity. It also allowed them to test out their evolving ideas, to stay abreast of advances in men- tal health treatments, and to ensure that they were engaging in ethical mental health practice.

Skills for Working With Patients All the competencies needed for traditional mental health care practice are needed for work

in medical settings. Respondents explained that mental health therapists practicing MedFT need ‘‘sound therapy skills, including individual, couple, and family’’ and ‘‘excellent interview- ing skills.’’ But, working with patients in a medical setting also requires the use of unique skills in patient care.

Conceptualizing patient problems. Participants uniformly identified the BPS model as the most useful conceptual model when providing direct patient care. They explained that those practicing MedFT need to recognize that most patients get mental health treatment only after seeking help for medical conditions or relief from biological symptoms. Often the mental health problem is co-occurring with a biological health problem, and both must be considered in order for mental health treatment to be successful. The patient perspective, like that of the medical provider, is first biological and then (if at all) psychosocial.

Knowing about the patient’s medical condition. Respondents acknowledged that patients expect mental health therapists working in medical settings to be part of the health care team. Therapists demonstrate that they are part of the team through their comfort with biomedical language and knowledge and curiosity about biomedical conditions. It is expected that they will use language that, while it may not be the same as that used by the medical provider, is at least consistent with that used by the medical provider. The therapist should be familiar with the patient’s medical condition and the diagnostic tests and treatments associated with that condi- tion. While they do not need to know everything about it, they should ‘‘know enough of the medical condition and treatments in order to explain it to patients.’’ What the therapist does not know, they should be willing to learn. One respondent wrote:

I think that there is a difference between what information a mental health profes- sional should know and what they should be willing and able to learn. . . . So, in a sense, I believe that would serve the mental health professionals (and the PCP [Primary Care Providers] and patient) the best to ‘‘know’’ how to access this information.

Patient care. Respondents wrote that mental health therapists working in medical settings are expected to assess and diagnose patients using the approved nosology found in the current versions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) and Interna- tional Statistical Classification of Diseases and Related Health Problems (ICD). They are expected to know the evidence-based protocols and have competency in applying accepted

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treatments to specific mental health diagnoses. One respondent described this expectation in the following way:

Medical providers are interested in problem-based knowledge. They are not interested in one’s conceptual framework, they are interested in what problems you can address. The biggest problem is depression. Other problems are anxiety, substance abuse, pain management, smoking cessation, weight loss, ADHD. I think that these problems pre- dominate because they are very challenging for MDs to treat. All these problems require an understanding of DSM IV categories. It is fine to treat these problems in a family systems modality, but it is vital that the mental health professional feel comfort- able with traditional diagnostic categories. MDs expect mental health professionals to be able to assess, diagnose, treat, and make recommendations to the physician regard- ing how to manage these patients in office visits. They expect the kinds of things they would expect from any specialist.

Mental health therapists can also expect that they will be asked to work with the most difficult patients. One respondent explained that therapists need to be prepared to work with ‘‘somatically-oriented, drug-seeking, dependent, hopelessly depressed, and chronically mentally ill patients.’’ These are patients who are often unwilling to accept that there are psychosocial problems co-occurring with (or in some cases, superseding) the biomedical ones. They should be able to creatively work with these and other patients who may not be interested in even acknowledging a mental health problem, let alone willing to accept a referral to a mental health therapist.

It was common for respondents to explain that while this work with difficult patients is designed to improve patient functioning, that much of the mental health therapist’s work with these patients is to provide relief and support for the medical provider. One respondent explained: ‘‘You are a resource to clinicians for their own development of comfort with patients.’’

Skills for Collaborating With Medical Providers It is clear from the data that multidisciplinary collaboration is a hallmark and essential

characteristic of MedFT. Collaboration is facilitated as mental health therapists (a) build rela- tionships with medical providers, (b) ensure frequent and accurate communication about patients, and (c) objectively attend to relationship processes.

Building relationships with medical providers. Mental health therapists working in medical settings must recognize that the relationship among providers is the foundation for collabora- tive health care and that they must attend to these relationships if they are to be successful. One of the respondents wrote: ‘‘The most important key to success is the relationship between providers.’’ Another added that relationships among providers ‘‘are the basis for referral and collaboration.’’

Respondents emphasized that medical providers are problem-focused and action-oriented. Mental health therapists build relationships by being available to medical providers, by showing a willingness to accommodate to the pace of the work environment, and by actively participat- ing with medical providers in their patient care activities, such as rounds, care team meetings, and patient interviews. They should be flexible in their style of working (e.g., accepting inter- ruptions during treatment sessions, curbside consultations), and they should be able to place themselves in the traffic pattern without getting in the way.

Collaborative communication. Frequency, length, and content of communication character- ize collaborative relationships in medical settings. Respondents indicated that medical providers expect regular communication about patients and treatment progress and that this communica- tion should be of sufficient frequency that medical providers can feel they are included in the treatment, that they have not lost their patient. ‘‘Once the collaborative medical professional refers a patient he or she will also want to be updated regularly and be included as part of the treatment process.’’ This level of communication respects the hierarchy within the medical setting and acknowledges that the medical provider is ‘‘in charge’’ of patient care.

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Because the use of language in medical settings is instrumental and action-oriented, the mental health therapist should match this communication style. Messages should be efficient and clear. One respondent explained that ‘‘most collaboration occurs through interactions that last <5 min. These are the bumps in the hall.’’ Because of this, being ‘‘accessible’’ and ‘‘visible’’ were repeatedly mentioned as essential to effective communication and collaboration.

Several respondents stressed that medical providers expect to hear ‘‘what works and what one can do rather than what one thinks.’’ The caution to traditionally trained mental health therapists is to limit theoretical explanations and to stick to what is directly relevant to the care plan. One respondent counseled: ‘‘Don’t bore people with details that don’t impact patient management.’’ Similar advice was given by another who wrote: ‘‘Be able to be concise and jar- gon free about what you believe is going on in a case.’’ Another wrote: ‘‘willingness to talk the medical language as much as possible and minimize psychobabble.’’ Another respondent even went as far as to caution well-intentioned therapists to be careful not to ‘‘proselytize’’ or become too ‘‘psychosocially fixated.’’ Yet another wrote that a successful mental health thera- pist is ‘‘one who does not feel he ⁄ she needs to preach systems to those who work in the setting; very off- putting.’’

Communicating in this way requires mental health therapists to be ‘‘comfort[able] with their own skills [without a] continuous need to prove oneself [and an] ability to function without a lot of . . . validation.’’ As participants in the communication dynamic within a medical setting, thera- pists are confident, assertive, patient, flexible, and accommodating. The respondents explained that this stance leads medical providers to ‘‘confidently value the role you play.’’

Be relationship experts. It is clear from the data that one of the roles played by mental health therapists, as relationship experts, is to attend to the relationships among providers and between providers and patients, and to intervene in a way that improves collaboration and health outcomes.

Respondents explained that medical providers expect the mental health therapist to objec- tively observe these relationships and to intervene appropriately.

DISCUSSION

This study results in a greater understanding of the practice of MedFT, and the unique skills needed to engage in this practice. It is clear from the data that the practice of MedFT is different from traditional mental health care practice. There appear to be two primary differ- ences. First, in addition to requiring competency in the practice of psychotherapy, MedFT requires additional competencies unique to working within the culture of medicine. Second, some competencies, while perhaps not unique to MedFT, are noteworthy because they are uniquely prominent in the practice of MedFT. So, for example, while all MFTs should have competency in multidisciplinary collaboration, it is uniquely prominent in the practice of Med- FT where therapists must negotiate daily professional relationships in a multidisciplinary envi- ronment that is inherently hierarchical.

These two types of unique competencies are most likely an outgrowth of the application of the BPS model that requires therapists to consider multiple systems of functioning simulta- neously. In the practice of MedFT, the curative work of the therapist includes both interactions with the patient and family as well as interactions with medical providers and others involved in the patient’s care. A true acknowledgment of the biological system begs multidisciplinary col- laboration just as a true acknowledgment of the social system begs family involvement in treat- ment. Consequently, the application of the BPS model expands the practice and the treatment to include interactions with other systems and people. This requires competencies in addition to those expected of skilled marriage and family therapists.

Multidisciplinary collaboration appears to be a hallmark of MedFT. The modern medical system is inherently collaborative, while the modern mental health care system is not. Medical systems generally adopt a leadership model of collaboration that has a clear hierarchy with physicians, and in some cases, mid-level medical providers in the leadership role. It is clear from the data obtained from those experienced in the practice of MedFT that if MFTs are to succeed in a medical system, they must understand and respect the leadership model of

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collaboration. They may need to change their way of practicing to accommodate to the system rather than try to change the system to fit their way of doing things. This may even include the way that psychotherapy is practiced. Participants frequently extolled the importance of flexibil- ity in practice, curiosity about new ways of doing things, and willingness to learn.

The results of this study are the next step in articulating the competencies mental health therapists need to have to practice what has come to be known as MedFT. It would be a mis- take to assume that the set of competencies generated through this study is exhaustive. Perhaps if we would have returned to the participants to request additional competencies, others would have emerged. We know through the literature that other skills have been identified that were not mentioned in the data that we obtained. For example, some authors have expanded the BPS model to include the spiritual dimensions of patient functioning (e.g., Prest & Robinson, 2006), yet none of our participants acknowledged the spiritual dimension nor skills specific to working within this dimension. Also, while participants indicated that it was important to be curious about nontraditional approaches to care, only one participant made even passing refer- ence to mind–body techniques. Yet, the literature suggests that these techniques are particularly efficacious (Astin, Shapiro, Eisenberg, & Forys, 2003) and within the scope of practice of mar- riage and family therapists (McCollum & Gehart, 2010). We are aware of some therapists working in medical settings who regularly teach mind–body techniques to their patients and to medical students (Saunders et al., 2007). Other skills not mentioned include the importance of knowing how patients move through the medical system and being able to intervene on the patient’s behalf, skills specifically related to making referrals so that the biological dimensions of mental health problems are addressed, and understanding how payment and billing occur within the medical setting in which one is working (Patterson et al., 2002).

Emphasized in our data was the importance of cultural competence in relation to the culture of the medical system. Given that this was such a prominent theme, we found it curious that we were not able to find references to the importance of demonstrating competency with the culture of the patient’s system. Similarly, while participants were careful to identify the importance of recognizing and negotiating power imbalances in the medical setting, they did not identify the importance of being sensitive to how these same power dynamics impact patients and families and the role of the therapist in helping them navigate these power imbalances. That these two seemingly important skills were not mentioned may be a function of how the questions were worded; we specifically asked for unique knowledge and skills to the practice of MedFT. It may be that participants see these competencies as important to the practice of marriage and family therapy and psychotherapy in general and not unique to the practice of MedFT.

It is possible that had we asked specifically about these, and other techniques gleaned from the literature and experience, that we would have been able to develop a more comprehensive list. But, then we might have sacrificed coming to understand those competencies that are spe- cifically unique to the practice of MedFT. Additional research is needed to further refine and expand this list of skills. Specifically, it is possible that the application of a Delphi methodology (Stone Fish & Busby, 1996) could be helpful in clarifying those skills that are particularly important to the practice of MedFT. This method has been used successfully by others to develop lists of skills, most notably the list that has become the AAMFT core competencies (Nelson et al., 2007).

Implications for Training and Practice Identifying competencies is a first step toward developing learning and assessment activities

that will expedite student learning (Maki, 2004). A logical next step is to develop learning and assessment activities, similar to what has been carried out with regard to the AAMFT core competencies (Hodgson, Lamson, & Feldhousen, 2007; Miller, Linville, Todahl, & Metcalfe, 2009; Openshaw et al., 2006; Perosa & Perosa, 2010). The results of this research will facilitate the development of these learning and assessment activities. Developing these activities in light of learning outcomes will lead to training that is more focused and efficient and that will better prepare students for the realities of collaborative care practice. The results will also help experi- enced therapists interested in expanding or changing their practice to include work in medical settings and medical, mental health collaborations. These therapists can use this research to

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understand the skills unique to the practice of MedFT. Attending to these unique skills will help them appropriately incorporate these skills into their practice, thereby increasing the likeli- hood that the transition in their practice will be successful. Those already working in medical settings will find that these results provide them with literature that will help to document and articulate the competencies needed for MedFT. This may be particularly important in attempt- ing to described MedFT to those who may not be familiar with it. It may also help by provid- ing a useful organization of these skills and practices unique to MedFT. These and other implications are important to the advancement of the practice of MedFT.

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