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ONLINE JOURNAL OF THE INTERNATIONAL CHILD AND YOUTH CARE NETWORK (CYC-Net) – ISSN 1605-7406

ISSUE 60 JANUARY 2004 •  CONTENTS •  HOME PAGE

practice

Abbott and Costello meet the Multi-Disciplinary Team

Michael Demers and Christopher Gudgeon

ABSTRACT: Many child and youth care workers are expected to work beside professionals from other disciplines. The nature of such relationships offers a mirror that reflects the status and role of child and youth care. The microcosm of this order is the multidisciplinary team. This article looks into the mirror and reveals what we expect to see—ourselves.

"Who’s on first!"
"I don’t know?"
"No, I don’t know’s on second."
"Who’s on first"
"Now you’ve got it."
"Now I’ve got what?!"

Child care workers are the Lou Costellos of human service multidisciplinary team. They lack a clear intellectual base for their work which means they must rely on the often incomprehensible language and theories of other disciplines. This has its advantages, though. As they bumble through the human service maze they have a certain innocence. They ask questions even when the answers seem obvious. Why is this six-year-old on Ritalin? What is this girl doing in a residential treatment centre? How can you call a moody thirteen-year-old pre-psychotic?

In their most famous skit (above), Lou tries to comprehend the structure of Bud’s mythical baseball team. The joke is that the logic of everyday life has been turned on its ear; words no longer hold their original meaning. Lou cannot take the giant step. He cannot see that these words have taken on new logic.

Let’s update the skit. Now, a child care worker stands, trying to comprehend the structure of human service’s mythical multidisciplinary team. What does team mean? Why is it good for kids? Who really benefits from teamwork? The answers to these questions sound garbled, convoluted. The joke is that there is in fact no logic behind the concept of teamwork in human services. Very, very little research exists on the comparative effectiveness of teamwork, which only makes sense because the terms "teamwork" and "team" lack operational definition. Like the players on Abbott’s baseball team, the multidisciplinary team concept is built around an imaginary logic, a set of six unfounded assumptions. Let’s call these the Pillars of Team Wisdom. Have a good laugh now because these "pillars" provide the support for the multidisciplinary team system, a system which dominates the working life of thousands of people in the human services and the approach to caring for the millions of children and teenagers.

Hey, A-bbott!

The Six Pillars of Team Wisdom

Pillar Number 1. "Teamwork" and "team" are clear and concrete concepts.
For almost forty years, writers have extolled the virtues of "teamwork" while in the same breath confessing that the term lacks clear meaning. Whitehouse (1951), a strong supporter of teamwork in rehabilitative medicine, nevertheless complained that the term had "become a blanket for all the old ones implying joint action and cooperative effort" (p. 45). Holzberg (1960), writing for the Journal of Orthopsychiatry, the discipline from which psychiatric-social work-psychological teams emerged, wondered if there was any concept in mental health "subject to more ambiguity and disagreement" (p. 88). To this day, there remains "little agreement on the definition of "professional teamwork"" (Ducanis & Golin, 1982, p. ix). Even current definitions sound ambiguous:

Team: A group of individuals assigned to work with a specific group of children...

Teamwork: A process in which team members convene on a regular basis to design and implement individual treatment plans for their assigned group of children and families (Krueger et al. 1987, p. 132).

...the interdisciplinary team will be defined as a functioning unit, composed of individuals with varied and specialized training, who coordinate their activities to provide services to a client... (Ducanis & Golin, p. 3).

"Team" here is described rather than defined; "teamwork" becomes the work done by those etherial team members. Some might argue that the terms are simply too complex to define in a concise statement. This is undoubtedly true, and perhaps we should acknowledge the futility of using such broad terms in a narrow, technical sense. The term has some advantages. It functions as a rhetorical device, a "linguistic tool...used to concert separate pieces of action by reference to a conceptual formula" (Dingwall, 1982, p. 82). Like any slogan "team" and "teamwork" help motivate action by appealing to an emotional level. Meanwhile, the scope, quality and content of the action remains undefined.

Pillar Number 2. Human beings are complex organisms; "teamwork" is a holistic approach, the most logical way to treat the whole person.
As old as the concept of "teams" is the belief that "teamwork" provides a more holistic approach to the client. Whitehouse says that human beings are "an interacting, integrated whole" and that "teamwork, an interacting partnership of professionals," is the logical way of addressing the problems of the whole client (pp. 45-46). This holistic perspective was the driving force behind the orthopsychiatric movement: "The clinic team emerged out of the recognition that man was ... too complex to be fully understood through the eyes of a single discipline" (Holzberg, 1960, p. 89). The "holistic perspective" continues as a goal of "teamwork" (Krueger, 1987, p. 133). It is a noble idea, this holistic approach, and it is hard to argue against the premise that human beings are complex, interacting organisms. Yet, it does not follow that the best way to meet these complex needs is with a team made up of numerous members.

There is no reason to believe that six people have a more holistic perspective than one. It is the perspective that matters not the number of people. Although treatment teams offer a greater number of perspectives there is nothing to guarantee that any of these perspectives are holistic. Team members are able to focus on different dimensions—nutrition, education, family dynamics, recreation—but in every case the focus is on treatment. The perspective is limited to seeing the child as a client or patient, someone who has something wrong with him, and not the child as an integrated whole. If we wish holistic teams, why not invite philosophers, poets, garbagemen, Flamenco dancers or, at the very least, parents and children to join? But this would not necessarily come any closer. Durkin (1983) complains that the "team approach" is little more than an update of the old medical model so that "psychologists, social workers and child care workers can now all focus on pathology" (p. 2). Only a group whose intent was a holistic perspective could overcome the limitations of a group whose intent is, in fact, a pathology-orientated treatment perspective.

Pillar Number 3. The "team" is an effective treatment decision-making body.
This is perhaps most tenuous of all the Pillars of Team Wisdom. To accept this assumption one must accept a number of equally shaky assumptions. First, you must accept that the concept "team" exists; we will not return to that. Next you must accept that the "team" should make decisions, that the ultimate goal should be treatment, and that decisions made by an effective decision making body will be effective decisions. If you have accepted all this on faith hang on; now you must accept the overall assumption that groups of people naturally make decisions more effectively than individuals. But then, what does "effective" mean? More accurate? Faster? Most easily operationalized? Is what is effective for the team effective for the child? This one needs a little more work before we even consider arguing against it.

Pillar Number 4. "Teamwork" relies on a democratic administrative style; decisions made in this way are most favorable.
Democracy has long been the aim of "teamwork" with the suggestion being that democracy is a morally superior administrative style. Ackerly (1947) connects "democracy" to "the principal of self-realization" (p. 195). Whitehouse equates a democratic team setting to a "freedom" without which "the highest level of operation will never be reached" (p. 46). Support is still strong for democratic administrative systems for teams. Ho (1977) speaks of the need for workers to develop "a collaborative interdependent working relationship with others on the team" (p. 287). Schmitt and Carroll (1978) say that it is a team leader’s goal to "maintain an informal, democratic atmosphere" (p. 203). Krueger et al. (1987) say that "effective team functioning... depends on compromise, consensus building and role flexibility (p. 133).

Two different ideas are at work here. One is the idea of democracy as social equality; all team members are created equal. The other is that the decision-making process should be democratic with a final choice being the one which most team members agree to.

A need for equality among team members seems to make sense; with so many different disciplines represented on the team the opportunity for conflict is ripe. There is always the danger that a "single profession should assume constant hegemony over the team" (Valletutti & Christopolos, 1977, p. 11). The idea that different professions conflict lacks research support and appears somewhat exaggerated. Guy (1986) even suggests "that there is not necessarily greater conflict across professions that within" (p. 111). In any case, someone must bear ultimate fiscal and legal responsibility for the child, usually a doctor, clinical administrator or their designate. Given their de facto authority they can hardly be called equals. And any child care worker who realizes that the rest of the team earns two to ten times more cannot be blamed for wondering if some are not created more equal than others.

A greater misperception is that the decisions, given they were reached through some democratic process, are somehow better. There is not reason to believe that the process involved improves the quality of decisions (see Swap, et al., 1984). Democratic systems have elected both Abe Lincoln and Adolf Hitler. Moreover, Bay and Bay (1973) maintain that systems which emphasize compromise lead to decisions, in the health care field, which are irrational and immoral:

...the conventional wisdom of liberal make-believe generally seems to consider pluralist compromise, not social justice, as the highest good...the rules of our pluralist games of politics place a premium on the art of compromise, not on the achievement of justice for those who cannot bargain effectively (pp. 58,60).

The problem occurs when the process of decision making is emphasized, rather than the quality of rational thought behind the decision. In child care this means decisions should be made because they will clearly improve the health, safety, and potential of a child. Decisions should be made not because the team treatment system demands some decision be made; not because there is a decision most people can agree on; decision should be made because they are in the child’s best interest.

Pillar Number 5. When the "team" does not work it is because someone is not playing along.
When writers discuss the value of cooperation and unity within the "team" their tone often approaches that of a boy scout pledge. Deviation from the "team" is considered subversive. Individual character flaws threaten to "undermine the team’s effectiveness and even its survival" (Schmitt & Carroll, p. 201). Those not familiar with team practice are accused of emphasizing "its negative and limiting aspects" (Bartlett, 1961, p. 73). Ho (1977) reflects this tone:

...collaboration also requires the evolution of mutual respect for differences in the kinds and patterns of services rendered individually, and working together in good faith toward a common goal of service to youngsters (pp. 286-287).

Emotional pleas, particularly in professional literature, can be an indication of a weak or irrational argument. We suggest that given the tenuous research and theoretic base which supports the team concept emotional arguments are the only ones left to keep team members committed. It is an invitation to scapegoat and persecute non-conformists. It encourages team members to blame individuals for the failure of the team concept. But the culprit is likely the concept itself. If your car did not work, would you blame the driver? Maybe it is time to look under the hood.

Pillar Number 6. "Teamwork" allows workers a say in how the organization is run; in this way "teamwork" enhances child care’s professional development.

So you’ve bought it all so far have you, Mr. Costello? You’ve given up trying to understand what a team is and who’s on first? Good, because now we’ll sell you the big one. Not only is teamwork essential for the whole client, not only does it enhance the decision-making and treatment processes, but it is also good for you. Don’t worry if it doesn’t taste so good; it’s the asparagus of the human service diet.

This final assumption relies on the blurring of the "team" ideal that "each member...would contribute as an equal partner" (Whitehouse, p. 47). The way the team should operate is confused with the way the team does in fact operate. Child care workers are seen as "partners" (Klien, 1975, p. 81), "equals" (Krueger, 1987, p. 453), and becoming "fully contributing participants in the multidisciplinary process" (Fewster & Garfat, 1987, p. 15). The implication is that because child care workers are being allowed a voice in the decision-making process they are achieving status equivalent to other professionals.
Not everyone is convinced that teams are beneficial to child care. Durkin (1987) believes that the shift from the medical model to "teamwork" is "like changing deck chairs on the Titanic" (p. 358). Historically, the child care worker’s position on the team has been clear with no pretention of equality. They were the "behavior change agents" who use their "relationship with the children and a variety of behavior-modifying techniques to implement desired behavior changes" (Gold & Mihic, 1971, pp. 1-2). Professionalization was seen as the entrenchment of child care’s role within the treatment process not as a march for equality.

We have already stated our doubts about the nature of equality on the multidisciplinary team. Today, even the strongest supporters of teams acknowledge that professional inequities exist. Krueger et al. say that in most systems "those who have the most contact with the youth generally have the least status and influence on teams" (p. 133).

All this aside—and supporting child care workers want their professional position enhanced, whatever that might mean—there is no evidence to suggest that membership on a team ensures mutual respect. Other team members will not necessarily respect the child care worker, nor will they necessarily listen to what the child care worker has to say. Common sense suggests that team members would likely respect the opinion of someone who seemed to understand the child’s world, or someone who offered clear and effective direction which somehow improved or maintained the child’s well-being. Child care’s image is based on the quality of those in the business. (The fact that child care workers are permitted to speak at meetings affects neither the quality of child care workers or their standard of living). Frankly, we would be happiest if the rest of the multidisciplinary team just left child care workers alone so they could get on with the job they do best—caring for children.

Who’s On First?

Where are we now, Mr. Costello? We have a meaningless term to guide the lives of millions. We have a better understanding of the assumptions that power this meaningless term. Have we an alternative? We do not say that there are better ways to use teams, or that they could be organized more effectively. We say the concept is meaningless. It serves a purpose in that it helps to mobilize action and to let people feel good about the work they do. Well, maybe we should just let well enough alone.
But, the innocent reader may ask, why have teams at all? Why not just put someone good in charge and let him/her tell everyone what to do? Or why not let child care workers be the boss? They could consult with "team" members as the need arises as a parent might. These ideas just might work better, and perhaps we could do a little research....

Assuming, of course, child care workers really want their programs to run better. So far, they seem to be contented stumblebums, secure in the knowledge that their role is fixed; the chubby innocent, ever waiting for the answers they cannot understand.

References

Ackerly, 5. (1947). The clinic team. American Journal of Orthopsychiatry, 17, 191-195.

Bartlett, H. (1961). Social Work Practice in the Health Field. Washington: National Association of Social Workers.

Bay, J., & Bay, C. (1973). Professionalism and the erosion of rationality in the health care field. American Journal of Orthopsychiatry, 43, 55-64.

Dingwall, R. (1982). Problems of teamwork in primary care. In A. Clare & R. Corney (Eds.), Social Work And Primary Health Care (pp. 8 1-103). London: Academic Press.

Ducanis, A., & Golin, A. (1982). The interdisciplinary Health Care Team: A Handbook. London: Aspen Systems Corporation.

Durkin, R. (1983). The crisis for children’s services: The dangers and opportunities for child care workers. Journal of Child Care, 1, 1-14.

Durkin, R. (1987). Restructuring for competence: A case for the democratization and communitization of children’s programs. In R. Small & F. Alwon (Eds.), Challenging the Limits of Care (pp. 353-368). Needham, Massachusetts: Albert E. Trischman Center.

Fewster, G., & Garfat, T. (1987). Residential child care. In C. Denholm, R. Ferguson & A. Pence (Eds.), Professional Child and Youth Care (pp. 9-36). Vancouver: University of British Columbia.

Gold, S., & Mihic, V. (1971). Changing models in therapy and child care. Child Care Quarterly, 1, pp. 13-20.

Guy, M. (1986). Interdisciplinary conflict and organizational complexity. Hospital and Health Sciences Administration, 31, pp. 110-121.

Ho, M. (1977). An Analysis of the dynamics of interdisciplinary collaboration. Child Care Quarterly, 6, 279-287.

Holzberg, J. (1960). The historical traditions of the state hospital as a force of resistance to the team. American Journal of Orthopsychiatry, 30, pp. 87-94.

Klien, A. (1975). The Professional Child Care Worker. New York: Associated Press.

Krueger, M. (1983). Careless to Caring For Troubled Youth. Milwaukee: Tall Publishing.

Krueger, M. (1987). Making the team approach work in residential group care. Child Welfare, 66, 447-457.

Krueger, M., Fox, R., Friedman, J., & Sampson, J. (1987). The generic team approach. Child and Youth Care Quarterly, 16, 13 1-144.

Swap, W., Bedau, H., Chechile, R., Dunn, J. Jr., Gibson, J., Hill, P., Krimsky, S., Rubin, J., & Seasholes, B. (Eds.). (1984). Group Decision Making. London: Sage Publications.

Schmitt, B., & Carroll, C. (1978). Human aspects of teamwork. In B. Schmitt (Ed.), The Child Protection Team Handbook (pp. 199-206). London: Garland STPM Press.

Valletutti, P., & Christoplos, F. (1977). Interdisciplinary Approaches to Human Services. Baltimore: University Park Press.

Whitehouse, F. (1951-52). Teamwork, an approach to a higher professional level. Exceptional Children, 18, 75-82.  

This feature: Demers, M. and Gudgeon, C. (1989) Abbott and Costello meet the Multidisciplinary team. Journal of Child and Youth Care, Volume 4 Number 2, Pages 11 to 19