9: Anticipating Challenges and Troubleshooting

Differences in Organizational Culture

Teams are influenced by power, culture, and structure of existing entities. MDT members are representing different agencies and as such each brings their own culture.

Differences among member organizations can include:

• Philosophical (causal) approaches and organizational missions
• Language
• Systems of rewards and punishments
• Operating procedures and organizational capacities to serve victims (bureaucracies, regulations, tradition, financial shortages)
• State laws (APS is guided by social services or state’s reporting law and law enforcement guided is by criminal law)
• Policies related to confidentiality
• Tension between agencies that can affect cross-reporting
• Methods of meeting with and relating to families
• Approaches to case planning, types of interventions, tracking of progress, and case closure
• Different frameworks:
  • Social work model
    Client focused in the context of their social lives and adheres to the philosophy of self-determination.
  • Medical model
    Beneficence approach, which means doing the best for the individual without necessarily consulting the victim.
  • Criminal justice model
    Focus on the perpetrator via prosecution, emphasizing justice for the victim
     

Differences in Organizational Structure

In addition to different cultures, agencies’ structural realities impact the MDT. For example:

• Frequent or continual reorganization
• Frequent staff turnover
• Lack of qualified staff
• Financial uncertainty
• Incompatibility of information technology systems
• Shortage of professionals (e.g., neuropsychologists)
   

Differences among Team Members

Team members also bring with them differences that might impact the MDT. For example:

• Distrust (e.g., fear of being blamed)
• Differences in attitudes (e.g., towards victims, perpetrators, other agency representatives)
• Perceptions that the cost of being on the team outweighs the benefits (e.g., members’ feeling time is not well spent; perceptions that MDTs are time consuming)
• Animosity among members
• Differences in degree of commitment
• Differences in degree of knowledge
• Lack of engagement
• Concerns about continued funding of the MDT may take a toll on morale
• Lack of understanding about how an MDT can assist members

Challenges Unique to the MDT

There are also challenging aspects uniquely associated with being on an MDT. For example:

Unequal status among MDT members

Lack of participation by certain disciplines

Maintaining an adequate number of cases (APS staff members are too busy to prepare case summaries)

Failure of certain groups to present cases

Unrealistic or unclear goals for the MDT

The team lacks the power or authority to resolve problems being presented

Failure of team members to follow through on agreed-upon actions

Role Confusion

Some MDT members may have dual identities, using the term “we” to refer to both members of their profession as well as members of the MDT. In addition, for some MDT members, interacting with other MDT members raises difficult ethical issues. Information sharing is a critical aspect of an MDT, yet this raises concerns about confidentiality, informed consent, and privacy. Psychologists have an ethical obligation to their clients, but also an obligation to share information among MDT members. For example, mental health professionals on MDTs can experience role confusion in that they participate in information gathering while also interpreting evidence. The MDT will need to determine appropriate boundaries around MDT members to prevent role confusion.

Anticipate Change

Be prepared for organizational development and change over time.

Consider the decisions being made at this point as preliminary. The relationship between the MDT and the agencies represented on the MDT may change over time. MDTs are practically living entities that will require room for growth and development. The needs of your MDT will change, as will the needs of the community. Be prepared for change.

Overcoming Barriers

Potential solutions to a number of the barriers identified above are described below. This list is by no means exhaustive, and in many cases, solutions for one challenge may positively affect other challenges as well.

MDT Members Fail to Bring Cases

You may be concerned that although you “built it – they did not come.” This is not an uncommon experience. You will need to establish trust among your MDT members before they feel comfortable enough to bring cases for MDT members to review. Getting to know one another more deeply, resisting the tendancy to place blame, and having clear and agreed upon guidelines for all aspects of working together, are all great ways to build a foundation of trust. Be patient and persistent as your team grows. Offer assistance in preparing presentations. During presentation, the MDT Coordinator should facilitate the discussion to tamper down power differentials and avoid “blaming” anyone. You may also want to consider holding after-meeting debriefing sessions with presenters to think through what went well and what might be improved in real-time. This prevents negative impressions from festering and works to better prepare team members for their next presentation.

Lack of Trust

Building trusting relationships is challenging under any circumstance, but particularly when a diverse group of professionals are gathered for the purposes of integration and cohesion. Some team building can occur informally, such as conversations before the case review meeting. More concerted efforts include engaging in team building exercises, attending trainings as a group, to the extent possible engaging in social activities outside of work, and providing a safe zone for MDT members to express their opinions without fear of ridicule or reprisal.

Avoid the Pitfalls of the Blame Game

While reviewing a case, there will be times when the MDT identifies a system failure in which an agency or its representative could have responded in a more proactive manner. Mistakes will happen. While there may be the temptation to blame the agency representative for the failure, refrain. The better approach is to discuss ways to prevent the failure in the future. A focus on what is best for the victim - rather than how an agency failed - will keep the discussion from derailing. Use this opportunity to focus on how the system can respond better in the future. The MDT must be a safe place for honest expression.

Team Meeting Attendance is Low

Studies find that attendance is an ongoing problem for many MDTs. Absenteeism is partly an issue of not having sufficient time to attend meetings, but it is also an issue of commitment. Team members may not attend if they feel they are not benefiting sufficiently. Determine the underlying reason for lack of attendance. For example, one study found that when the primary focus of an MDT shifted from prosecuting cases to providing services, participation by law enforcement officials declined. Consider videoconferencing (e.g., Skyping) or other new technological advances if the appropriate security measures can be assured. Additionally, it may be useful to see if team representatives from local agencies can volunteer to participate in the elder abuse MDT based on their interests rather than being assigned. Sometimes, team members may resent being assigned to a community meeting and resist attending. While this cannot always be avoided, there are often personnel within each agency that would enjoy participating in the MDT if the opportunity was presented. Having team members that value the work of the MDT is crucial to the effectiveness of the team.

Absence of Clerical Support

The MTD Coordinator has many tasks for which s/he is responsible. If possible, consider providing some clerical support. Perhaps an intern at from a nearby university could enter data, send out email reminders about upcoming case review meetings, and provide other appropriate clerical support. Volunteers are another option, although considerations about confidentiality and conflict of interest will need to be addressed.

Unequal Status of MDT Members

Teams can be crippled by inequality among the MDT members, stifling the voices of some while other voices remain dominant. When MDT members with lower status feel less confident, they are less likely to voice their opinion, which may result in less advocacy for a client. If social workers are quiet in a room of physicians, the client’s medical needs may be met but not their social needs. However, under most circumstances, medical problems are not more important than social problems so no one discipline should dominate care planning. One way for the MDT to address equity is by acknowledging the inequality among MDT members. Income is one indicator of a status differential. For example, a psychologist earns 2.5 times as much as a social worker. Professional status is also important. Physicians can sometimes be intimating for other MDT members. District Attorneys are sometimes a dominant personality, but also have greater status that most MDT members. In addition, some disciplines hold unfavorable perceptions of other disciplines. For example, “Protective service investigators are not investigators in the way that criminal investigators are investigators.” Such attitudes, whether expressed or implicit, undermine the MDT’s cohesion and ultimately, their ability to work together. The express purpose of the MDT is to elicit all opinions in order to arrive at the best resolution for a client. Ensure that all members are expressing their opinions and that MDT members feel their opinions are valued. Periodically remind each team member that his or her unique knowledge and contribution to the team is invaluable. Perhaps alert your potential MDT members that explicit attempts will be made to equalize the MDT members. Adopting guidelines for how team members will interact and participate in meetings can be a useful tool to head-off potential conflict.

Different Reward Structures

MDT members are likely aware that reward structures differ among agencies, but may fail to consider how that impacts the MDT. Medicine and social services operate under a model of specialization, which reduces the amount of turnover among these disciplines. However, law enforcement values a well-rounded experience and frequently rotates their personnel, resulting in turnover every two years (in many agencies). Likewise, some agencies focus on individual rather than team achievements, which may disadvantage some team members. Another example involves District Attorneys, who focus on cases with the potential for criminal liability, while APS has a wider focus to include noncriminal cases such as self-neglect.

Turnover

It may be frustrating to be always “training” new MDT members, but that is endemic to MDTs. Embrace turnover as an opportunity to broaden the understanding of MDTs for a range of professionals within an agency as well as increasing the number of contacts the MDT has at each agency. Even when an MDT is rotated off the MDT, that person will have the experience of having served on an MDT, which may influence the way they function in their new position.

Sustainability is Difficult

Sustainability is one of the most vexing challenges associated with MDTs. The MDT may need to be creative and request funding from several sources, both private and public. It should be noted that generally funding becomes easier once the MDT has been operating for some time and has had an opportunity to “prove” (demonstrate) its value. Many MDTs begin with grant funding and then transition over to more stable sources of funding once their value is appreciated. For example, California’s Santa Clara County now sustains their FAST MDTs with state and county funds.

MDT Coordinator’s Salary

Salaries for the MDT representatives are typically supported by the member’s agency. However, the MDT Coordinator may require dedicated funds that can be obtained through contracts and grants, such as state VOCA grants. A related expense may be liability insurance, depending on the tasks performed by the MDT Coordinator.

Hierarchical Structure

The hallmark of an MDT is mutual collaboration and group decision-making. This is not always easy for agencies more familiar with a hierarchical structure. Team training is designed to alleviate this challenge.

State and Local Statutes Stilt Information Sharing

Although the vast majority of states have some provision or mechanism for sharing information (for more information see Toolkit item: Statutory Review of Multidisciplinary Teams and Information Sharing, there may be some need for legislative action that makes information sharing explicitly available and/or promotes the use of MDTs. Legislative change can be a long process, but it is worth pursuing. However, recognize that there are pros and cons associated with legislation.

Team Goals are Lost

With so many different agendas and mandates represented on the MDT, selecting and maintaining team goals can be challenging. Referring to the mission and vision statement at the beginning of each team meeting can help maintain a focused team.

Stakeholder Resistance

When an MDT is in the initial stages of development, there will always be an agency administrator or two who declines the offer to participate in the MDT, or worse, prohibits an employee from joining the MDT. Your charismatic team leader will be an important force in persuading these individuals of the benefits of an MDT. Be persistent.

Case Content is Disturbing

MDT members unfamiliar with elder abuse may find these cases disturbing if not unbelievable. As mentioned, engage the entire team in elder abuse training. The advantages of an MDT are both educational, in affirming these cases really occur, and in providing emotional support when dealing with these disturbing cases becomes overwhelming. Members need to be mindful of secondary trauma by identifying it and getting help for those who need it.

Losing Focus

By keeping a victim-centered focus these challenges can be overcome. Hosting an annual working retreat can provide a forum for the team to discuss problems and work together to find solutions. Focus, goals, mission, procedure and any other aspects of the MDT can be revisited and improved. Additionally, retreats can assist greatly with team building and help provide a forum for cross-training for new members and for those agencies that have high turnover.