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Family Oriented Behavioral Health: An Interview with John Rolland

Posted By Zephon Lister, Thursday, December 20, 2012
Zephon Lister:  What experience in your professional or personal life was most influential in your development as a family-oriented behavioral healthcare practitioner?

John Rolland: Near the end of medical school I debated between family medicine and psychiatry and ultimately decided to go into community psychiatry and public health. There have been both personal and professional experiences that I believe have influenced my development as a family focused practitioner. Personally, I was influenced by two experiences during my psychiatric residency. First, my mom had a stroke, which became one of my first close encounters with how families and the healthcare system interacted. Later in my residency my first wife developed and later died of cancer. I remember there being no advice or support provided to the family. I saw how marginalized the family was, and that there was little effort to reach out to those outside of the "patient”, who were also suffering.

As I reached out to the providers and my professors for insight and understanding, I began to realize that there was no road map given to help individuals, couples, and families, navigate these situations. No one had anything to offer to me in the situation. Almost everything was pathologizing. There was no guidance on whether what I and we as a couple were experiencing was normal or dysfunctional. I remembered how I felt during that experience and knew I wanted to help families not go through what I went through. I also wanted to help providers do a better job of understanding the importance of family and how illness impacts the entire family system.

John Rolland
"I saw how marginalized the family was, and that there was little effort to reach out to those outside of the 'patient', who were also suffering."
 Professionally, some of the experiences that had a significant impact on my career path were my exposure to early system thinkers such as John Weakland and Don Bloch. One of the first papers that excited my interest in family and illness was John Weakland’s, "Family Somatics”- A Neglected Edge” (1977). In addition to my personal family experiences with illness and readings, I was strongly influenced by my primary mentors, Betty Carter in family life cycle and Dan Levinson in individual life cycle development. They informed and inspired my conceptual thinking about how illness, family system, and individual family member’s development interact across time. Don Bloch was another very influential person that led to my focus on health and the family. He had the vision of the field and its potential. I remember how he was able to bring "kindred spirits” together from different disciplines to collaborate around family systems and healthcare. These collaborations led to foundational and lasting contributions to the field of family systems in healthcare especially through the establishment of the journal Family Systems Medicine, now Family, Systems, and Health and the Collaborative Family Healthcare Association (CFHA).

 

ZL:  What do you consider your most important contribution to the family systems in healthcare field or literature?

JR: I think my most important contribution to the field of family systems in healthcare is the Family Systems Illness model I initially developed during the late 80’s and early 90’s, which ultimately culminated into my book Families, Illness, & Disability: An Integrative Treatment Model published in 1994. It has been gratifying to see how well it has been received among mental health professionals and some healthcare disciplines, such as Family Medicine and Nursing. However, it was also my hope to expose these ideas more to other medical disciplines, especially those who are less familiar with systems thinking in relation to family and illness (i.e. physicians, family educators, healthcare administrators and policy-makers).

 

ZL:  What do family-oriented behavioral health clinicians most need to move into the mainstream of healthcare?

JR: I would say a greater effort on visibility and marketing. Medical family therapy is not just a discipline but an orientation and way of practice that is not limited to family therapists or providing just family therapy. Personally, in medical settings, I prefer to identify myself as a "family-oriented behavioral health consultant.” Certainly as a psychiatrist, this is more acceptable to patients and their families, who have no prior exposure to mental health professionals. Outside of my practice or a mental health clinic setting, I have always found the term "consultant” an easier entry point to a relationship with patients/families.

Regarding visibility, I believe the family-oriented behavioral healthcare field has done a pretty good job integrating into primary and secondary care settings. The next step, I believe, is expanding the family systems training in current curricula across mental health disciplines to incorporate the skills needed for better integration into tertiary, quarternary, and home/community healthcare environments. My own work has always centered more in this area. To me, there is a huge opportunity for family-oriented behavioral health clinicians to provide services in chronic illness-based and specialty medicine. Some of the areas I think family-oriented clinicians should give increased attention to include: oncology, cardio-vascular disease, diabetes, rehabilitation medicine, pediatrics, obstetrics and gynecology, and palliative care/hospice.

Since it is by definition family-based, the burgeoning field of genomics is particularly well-suited to our skills. Many of these settings have a collaborative team ethos and structure that is just not family-oriented enough and lacks a team member with advanced family-oriented behavioral health skills. Greater access to medical in-patient services would be terrific. It is typically a crisis-point in healthcare, where patients and their families are vulnerable, biomedical providers often need behavioral healthcare support, and all are usually brought into closer physical proximity.

While it is important to continue to develop the field of family-oriented behavioral health practitioners across professional disciplines, in terms of the MFT discipline specifically, I think there is a unique opportunity to train its practitioners to be more integrationist. At this point of the field’s development, instead of focusing energy on describing how different MFT’s are as a discipline and potentially isolating themselves, I would suggest, take the skills that MFTs have cultivated and collaborate more with other healthcare disciplines and environments to demonstrate how MFTs fit into a broad range of multi-disciplinary healthcare teams and healthcare settings.

I think that fields that are ripe for integration with MedFTs would include disease specialties, hospice/palliative care, and genomics. MedFTs should make a more concerted effort to attend and present at professional conferences outside of their discipline (e.g. Psychosocial Oncology, Behavioral Medicine and become more involved in non-guild organizations, such as the American Family Therapy Academy (AFTA) and the National Council on Family Relations (NCFR). They should also write towards journals in other healthcare areas, emphasizing the application and benefits of a family systems perspective and the role of MedFTs within various healthcare contexts and illnesses.

ZL: You have been successful in collaborating with various organizations to promote and implement funded family-centered care approaches, what advice or suggestions would you have for young family-oriented behavioral health clinicians who wish to pursue similar collaborative relationships?

JR: The first step is helping other healthcare professionals understand what family-oriented behavioral health clinicians do and then helping them understand how you can help in their particular healthcare environment. It is important to be able to concisely describe how your presence will benefit the organization in the short and long term in order to get buy in. Often, to gain initial access to a clinical service or organization, it is useful to provide services at a lower cost and intervene with complex cases to demonstrate your effectiveness. I think that a couple underutilized resources are forging relationships with family (e.g. National Family Caregivers Association, Well-Spouse Foundation) and illness-oriented consumer-based organizations (e.g. MS Society, American Diabetes Association). More attention should also be given to the executive team, such as medical directors, administrative leadership of healthcare systems of care, and benefits directors. These are the individuals that have or know how to access financial resources to support integrated care services. Forging an effective relationship with a clinical service’s/center’s medical and nursing directors greatly benefits overall development and implementation of family sensitive service delivery models.

In recent years, I have become increasingly interested in funding for family-centered prevention models of integrated behavioral healthcare. This means both providing family-oriented behavioral healthcare to individuals/families at high risk for a condition, such as diabetes, and families entering the world of chronic illness, such as cancer, cardiovascular disease, or dementia. I have had most success implementing brief family psychoeducation consultations that can be incorporated as a family-oriented behavioral consultation in routine intake protocols, or multi-family groups psychoeducational "modules” (e.g. 4 evening sessions or a weekend ½ - 1 day skills-building format). The latter is very cost-effective, identifies higher-risk families, and networks families facing the same disease. I have found prevention-based models of integrated behavioral healthcare to be more challenging in terms of getting the buy-in needed to access the financial and administrative resources to establish an effective program. Ultimately, I think these types of prevention-oriented initiatives would need support at the government and policy levels if any real impact is going to be made long term.

ZL: What areas do you believe family-oriented clinicians are not taking full advantage of in the areas of research and practice and how could the field improve upon these areas over the next 10 years?

JR: Reflecting on the points made in questions 3 and 4, I think making a deliberate effort to expand into tertiary, quarternary, and home/community healthcare environments as well as being more intentional in integrating into other organizations. I also believe we should place a greater emphasis or both clinical and cost benefit research. While it is difficult to demonstrate how integrated family-oriented care can increase revenue short term, research should seek to identify how the use of our services reduce cost more long term. In general, we need more empirical support for systems-of-care and disease specific family-based interventions.

 

John Rolland, MD LMFT is internationally recognized for his Family Systems-Illness model, clinical work, and research with families facing serious physical disorders and loss. His book,Families, Illness, and Disability: An Integrative Treatment Model (Basic Books), was nominated for book-of-the-year by the American Medical Writer’s Association. He is currently co-author of a new book, Individuals, Families, and the New Era of Genetics: A Biopsychosocial Perspective (Norton). He has given over 250 national and international presentations on topics related to his work.

Zephon Lister, PhD LMFT earned his doctorate in Marriage & Family Therapy from Loma Linda University with an emphasis in Medical Family Therapy and completed his post-doctoral training at the Chicago Center for Family Health an affiliate of the University of Chicago. His clinical and research interests have focused on the recursive influences of family relationships and chronic health conditions and the integration of behavioral health into health care settings. Dr. Lister is the director of the UCSD family medicine integrative collaborative care program where he facilitates behavioral science training for family medicine residents, supervises MFT clinical training, and facilitates learning groups with medical students.

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