Promoting interdisciplinary care of the seriously ill is an important goal for mental health services. This goal encompasses both the enhancement of the structure and function of units that deliver care, and the training of new professionals who are adept at working together in these settings. The President’s New Freedom Commission of Mental Health states, “Every mental health education and training program in the Nation should voluntarily assess the extent to which it … prepares students and trainees to work in interdisciplinary environments.” (1) A 2006 report from the U.S. Department of Health and Human Services on Caring for Persons with Disabilities states, “In the field of mental health, there has been some recognition that serious mental illness and substance abuse are so complicated that they reach beyond the purview of any one discipline … though some current practices in parallel training of professionals in these fields impede taking a collaborative approach to service delivery” (2). In the United Kingdom, where the commitment to “interprofessional education” is well established, the values and impact of learning how to work together are distinguished from simply shared learning, i.e., learning in the same environment (3, 4).
In the United States, Hoge et al. (5, 6, 7) have emphasized the importance of enhancing both aspects of professional and workforce development to meet the needs of those we serve, by teaching graduate-level trainees the specific skills and knowledge involved in the treatment of the seriously ill and how to collaborate with colleagues in delivering that care. Liberman et al. (8) have outlined the specific and varied competencies of the members of multidisciplinary teams, highlighting that “Because it is practically impossible for one caregiver to master the entire range of relevant competencies [in psychiatric rehabilitation] the optimal vehicle for integrating and adapting diverse intervention is the multidisciplinary team.”
Although policy-makers and researchers consistently endorse the importance of interdisciplinary education, questions remain about the effectiveness of training efforts to develop the requisite values and skills. In a recent survey Yedida et al. (9) found discrepancies between those tasks of working with the seriously mentally ill that were deemed important by clinical leaders and what was actually being taught in residencies. A 2000 Cochrane Review of the interprofessional education literature concluded that the published studies lacked the necessary scientific rigor to provide evidence of the impact of interprofessional education on professional practice or patient outcomes. There is clearly a need and an increasing momentum to develop and study the impact of these ventures (10, 11).
Development of an Interdisciplinary Seminar
The Connecticut Mental Health Center is an urban, academic, community mental heath center jointly run by the State of Connecticut and Yale University. The majority of those served are indigent and experiencing severe and persistent mental illness and/or addictive disorders. Trainees from psychiatry, psychology, nursing, and social work are integrated into each of the clinical programs. In an effort to improve both interdisciplinary collaboration and trainees’ overall level of satisfaction in their work with seriously mentally ill patients, the Center’s Graduate Education Committee developed a seminar for all of the trainees assigned to the Center’s Ambulatory Services. Although each of the disciplines provides its own didactic seminars and supervision on standard topics such as psychotherapeutic and biological approaches, there is a body of knowledge about recovery-oriented care of seriously mentally ill patients that cuts across disciplinary boundaries. The primary course objective was to increase the trainees’ knowledge about interdisciplinary recovery oriented care, and we hypothesized that possession of this knowledge would enhance trainees’ experience in working with our patients. Secondarily, we believed that learning together with students from other disciplines would facilitate interdisciplinary collaboration, which would in turn increase trainees’ levels of satisfaction in their work.
A seminar called “Treatment of chronic or recurrent mental illnesses: recovery, rehabilitation and interdisciplinary collaboration” was launched in the 2004–2005 year, and, based on feedback from trainees, the seminar evolved into a 33-session series for the 2005–2006 year. The first session, “The Multidisciplinary Approach to Treatment,” in which faculty from social work, nursing, psychology and psychiatry spoke about the similarities and differences in their roles within the team, was devoted to a faculty panel discussion. The other topic areas, which emphasized collaborative approaches and recovery-oriented care, included the following modules: The Recovery Model; Course of Illness and Stages of Treatment; Entitlements, Money Management, and Conservators; The Person with the Illness; Pathways to Community Integration; Cooccurring Substance Abuse; Physical Health Issues and Treatment; and Legal Issues. Within each topic area, sessions were led by experts from the university community. For example, during the Legal Issues module, presentations were made on legal competency issues, jail diversion, and outpatient commitment. During the Pathways to Community Integration section, trainees learned about housing and homelessness, vocational services, and social rehabilitation. Under Course of Illness and Stages of Treatment there were three sessions each on schizophrenia, affective disorders, personality disorders, and cooccurring mental illness and substance abuse. Additionally, trainees worked together in small interdisciplinary groups throughout the year to make joint presentations, which required several planning meetings outside of seminar sessions.
Pre- and postseminar surveys were administered in order to test the hypothesis that a seminar designed to address these content areas would have a positive impact on trainees’ attitudes about working with the seriously mentally ill and within an interdisciplinary team. A combination of 5-point Likert scales and open-ended questions were used to gather the data. This educational research project was determined by the University’s institutional review board to be exempt from committee review.
The preseminar survey posed questions about trainees’ discipline, the amount and types of experience they had working with seriously mentally ill patients, and what they expected to find both challenging and gratifying about their work during the year with this patient population and within an interdisciplinary team. The postseminar survey included questions about the same content, but asked the trainees to comment on their actual rather than expected experience.
Paired samples t tests were conducted to test for significant differences between the pre- and postmeasures. A section on qualitative evaluation of the course itself was also included.
The seminar participants included 24 students from psychiatry, nursing, social work, and psychology with a wide range of experience. Ten students held Bachelor’s degrees, seven had Masters’ degrees and seven held medical doctoral, doctoral, or both degrees. The level of previous clinical experience was also varied, with 45% of participants reporting from zero to 6 months of experience, and 45% having worked in clinical settings for more than 24 months. The majority of respondents had previously worked with individuals with serious mental illness (75%), and nearly 80% had prior experience on an interdisciplinary team.
Complete survey data were obtained from 14 (58%) participants (Table 1
). Due to administrative complications (related to academic schedules of different disciplines) not every student was able to participate through the final session. The descriptive statistics for this group closely mirrored those of the entire group of seminar participants; the vast majority had prior clinical experience (79%), had worked with individuals with serious mental illness prior to the seminar (71%), and had been a member of an interdisciplinary team (79%).
Participants reported the extent to which they found various components of their experience challenging (1=not challenging, 5=very challenging) and gratifying (1=not gratifying, 5=very gratifying). When they were asked to rate how gratifying the work would be compared to how gratifying it actually was, the participants reported the work to be less gratifying than anticipated (Table 2
). Collaboration with other disciplines was also noted to be less gratifying than expected. When asked how challenging it would be or was to maintain optimism and hope, which are considered essential components of recovery-oriented care, the participants reported that it was less challenging than anticipated.
The open-ended questions on the surveys invited participants to list some of the advantages and challenges of working on interprofessional teams. Expected and actual advantages of care-oriented collaboration included “different perspectives,” “enriched formulations,” “more efficient,” and “higher quality of care.” Qualitative responses about the advantages of the actual experience of shared learning included “meeting other professionals,” “peer support,” and “learning different skills and techniques.” Some of the challenges of working together represented the mirror image of the reported potential and real advantages, including “differences of opinion” and “different skills and models.”
There is a growing body of literature promoting interdisciplinary training in collaborative, recovery-oriented care for seriously mentally ill patients. The results of this pilot survey highlight some of the challenges of doing so, and reflect that efforts to provide a structured seminar were not sufficient to enhance the self-reported experiences of the participants.
It is possible that the difficult realities of the work itself within this particular setting overshadowed the gratification that the participants might experience. It is also possible that the structure or content of the seminar could be improved in order to achieve its stated goals and objectives. Another limiting factor may have been the small sample size. Finally our survey instrument had not been validated, and could have contained more detailed questions.
The course was redesigned for the 2006–2007 year, and based on these data we have refined our approach. In order to emphasize the different roles and perspectives of the disciplines, we have increased the diversity of faculty presenters, and have encouraged discipline leaders to attend and participate actively in the sessions. Presenters have been asked to describe their own career paths and how they have come to work with this population. Examples include a social worker who coordinates a clinical research program on smoking cessation for seriously mentally ill patients, and advanced practice nurses who described their professional training and backgrounds and how that experience helps them to address highly personal health care issues with their mentally ill patients. These explicit discussions about pride in their respective roles and commitment to this population have added an element of “role modeling” that has thus far been received enthusiastically by new trainees.
Despite the limitations of the study, the results do suggest that further development of strategies to inspire professionals—those in training and those already in the field—to engage in and promote interdisciplinary care of seriously mentally ill patients is needed. The challenges of teaching these concepts are clear. The rewards of continuing to try to develop and refine strategies to reach as many trainees as possible to instill hope and a sense of gratification when working with the seriously mentally ill, along with a sense of pride in one’s own discipline and the value of collaboration, are enduring.