Posted By Jodi Polaha,
Thursday, January 10, 2013
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|Jamie and Jeff's |
blog is the second post
in a month-long series
on integrated care in
Read the entire
Tedder, M.S.East Tennessee
always viewed the stepped care approach (e.g., see Bower & Gilbody, 2005)
to mental and behavioral health service delivery as being like a relay race
where the participants are various health and mental health providers. The professionals at each stage provide
treatment within their area of expertise and within the constraints of their
practice before "passing the baton” to the next provider. This was the image I had in mind when I
walked into my first external placement; a rural pediatric clinic with a
co-located mental health specialty service. I was to practice population-based care -- the
first runner on the mental health relay team.
few patient contacts I realized I was more like the Lone Ranger than a relay
racer. I felt many of my patients could
benefit from more lengthy and frequent treatment than I was able to provide in
population-based model, but the co-located service and the community mental
health center in town is typically "booked out” about 8 weeks. The nearest "next best” referral source is
over 30 miles away. By the end of that
first day I was overwhelmed, to say the least.
are no easy solutions for the challenges, such as this one, that are raised in
a rural setting. This year, we are
experimenting with a creative solution that builds in technology. Thus, one day each week I travel about 60
miles to the rural clinic described above, in Rogersville, Tennessee, to
provide behavioral health consultation services. Three other days a week I (along with my
colleague, Jeff) staff a telehealth clinic based out of Johnson City, where we
are based, at East Tennessee State University.
Several rural primary care clinics across the state have access to our
services through the telehealth clinic, including my site in Rogersville. This allows me greater flexibility to
schedule follow-up visits for patients who need more frequent treatment, longer
sessions, or who simply can’t make it into the clinic on the day I’m
there. I also access supervision and
consultation through telehealth as needed.
New and innovative treatment modalities such as the one described above
give rural behavioral health consultants more options in underserved areas, and
decrease the feeling of professional isolation often experienced by
practitioners in rural areas.
my graduate training, I have had the opportunity to work on-site as a
Behavioral Health Consultant (BHC) in two rural Appalachian primary care
practices and via telehealth at several others.
These experiences have shown me that, while every primary care clinic faces
unique challenges (e.g. the types of patients seen, the physical space
available, the workflow, etc.), the lacking availability of community resources
is a constant challenge among rural practices.
As a BHC in non-rural settings, I have enjoyed my role as a component in
a stepped care approach, where more intensive outpatient services are available
to patients who do not benefit from brief, problem-focused treatment in the
primary care setting. In rural
communities, however, I quickly learned that lacking specialty services made
such referrals impossible. Thus, in rural practice I feel a pull to treat
a much broader spectrum of problem types and severities than would ideally be
the case in population based mental/behavioral health care. It is a challenge to navigate
this dilemma, allocate clinical time, and prioritize clinical services to make
the greatest impact.
attempts to make this dilemma more manageable have led us to experiment with a
variety of possible solutions, some novel and innovative and others
common-sense. One way that we have risen
to this challenge has been by developing a telehealth infrastructure in the
clinics in which we provide service.
This has allowed us to allocate more of our time to clinic coverage (due
to reduced travel time to and from these rural clinics) and has reduced the "lone-wolf”
feeling when we are providing on-site services (because of the potential to
access additional consultation, supervision, and support via video).
We have also experimented with setting aside
dedicated time each day for brief appointments with patients requiring longer
term management (e.g., specialty services) while making it clear to providers
that appointments can be interrupted for consultation and warm handoffs as
needed. Although we have had some
success with interventions such as these, rural practice as a BHC is a daunting
calling and one that begs persistence, flexibility, and creative thinking at
Ellison and Jamie Tedder are advanced students in the doctoral program
in Clinical Psychology at East Tennessee State University, which has a
rural, integrated care.
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Posted By Jodi Polaha,
Thursday, January 3, 2013
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|Natasha and Alysia's |
blog is the first post
in a month-long series
on integrated care in
Read the entire
The following highlights
insights from two pre-doctoral interns working in rural, integrated primary
care clinics. Their doctoral programs
differ in foci of training, but do overlap in their focus on providing care to
rural, underserved populations. They are
both currently on internship thru a novel "grow your own” model at Stone
Mountain Health Services (SMHS).
Natasha Gouge, MA
|Cummings, O’Donohue, and
Cummings (2009) put it best: "integrated behavioral/primary care is like a
pomegranate: overwhelmingly people say they like it, but few buy it” (pg.
6). I read this statement a few years
ago while reviewing literature for a term paper, and these words have been
engrained in my mind ever since. The
statement, although originally associated to the economic hurdles associated
within integrated care, is not limited to health care costs or
Within my own graduate
training program, which is tailored to train clinicians to work within
integrated care settings and/or among rural populations, several individuals
"don’t buy it”. Despite the program’s
mission offering an appealing training specialty at the onset, as students get
exposure to integrated care and working within rural areas their commitment to
the model and region often seems to wane.
So I might add a similar statement like, "integrated care and working
within rural areas are like vegetables:
overwhelmingly people recognize they are needed, but few enjoy eating
them every day”.
The ideals of integrated
care and of offering services to underserved areas are generally supported in
theory. However, supporting those ideals
and working in the service of those ideals are two very different tasks. And the result? Turnover.
Students, interns, post docs, residents—the list goes on, embark on
clinical experiences in line with these ideals, only to seek other career
opportunities after their initial obligation is over. So after the 9-week rotation, or semester
practicum, or yearly internship comes to a close, some individuals decide they
no longer have a taste for their vegetables.
(Or worse, in the case of rural underserved regions, this realization
occurs after an individual has received their loan reimbursement installments!)
About Stone Mountain
Alysia Hoover-Thompson, MS
My path to liking vegetables
was a long one, as I suspect is the case with many other clinicians in
integrated care. I had an undergraduate
double-major in physics and anthropology (seriously…what was I going to do with
that combination?) and worked in IT staffing and boarding school admissions
prior to applying to Master’s programs in Counselor Education. I loved my Master’s program, but felt that
pursuing a doctoral program that offered more intensive clinical training, as
well as the opportunity to conduct research, really appealed to me.
My doctoral training
program, which has a focus on rural mental health and additional emphases on
cultural diversity, social justice, and evidence-based practice in psychology,
is designed to train generalists in rural mental health. During my final year as a practicum student,
I had the opportunity to work at a Free Clinic doing integrated care. Beyond coursework and readings, I had limited
exposure to the world of integrated care, prior to this opportunity. I vividly remember my first day at this new
site - I could work in a fast-paced environment, seeing patients alongside
medical providers, doing more than just traditional mental health and someone
would eventually pay me for this? Sign
me up for a vegetarian diet!
While integrated primary
healthcare is right for me, it is certainly not the right fit for
everyone. Along the way, I have often
been asked- "How can you see someone in 15 minutes?” "Don’t you miss really
getting to know your clients?” "How do
you work without an office?” Yes,
these are very good questions but are easy to answer for someone who fits in
this model of care. Do I miss having a
cushy couch to nap on over my hour-long lunch break? Yes.
Do I wish that I could go home every day and not have blisters on my
feet from running around the office in impractical heels? Yes.
Would I trade this vegetarian diet for something less PETA friendly? Definitely not.
The farm that produces our
vegetables is SMHS, a Federally Qualified Health Center that consists of 11
primary care clinics in rural, Southwest Virginia. The mission of SMHS is to promote and
provide quality primary health care that is accessible, affordable, and
community-based for the people of Southwest Virginia. Following from this
mission, the organization’s vision is to be the recognized leader in the
provision of accessible health care in our communities, through integrity,
excellence and diversity of services. Services offered by clinics include:
family health care, black lung, assistance in obtaining medication, x-ray and
laboratory, dental and behavioral health counseling. In 2011, SMHS, in conjunction with East
Tennessee State University and Radford University, created the pre-doctoral
internship to address the needs of this patient population.
We both desire to remain
working in rural primary care after the completion of our internship. Are we the norm among doctoral trainees? Probably not.
Most interns uproot themselves and their families for a 1 year training
experience and then move on. To provide
consistent, doctoral-level providers, SMHS created a "grow our own” model. Two
interns began in August of 2011 and they are now both psychologists within the
organization. We began in August of 2012
and hope to also be offered positions to stay on board. To date, we have seen over 300 patient
contacts (in addition to all of our hours of supervision and didactic
Organizations that wish to
train or employ psychologists who enjoy a daily dose of those rural integrated
care veggies, have quite the challenge!
SMHS recognizes that psychologists who desire working in integrated care
can move to a rural region and lose interest in maintaining their position due
to a lack of resources professionally (e.g., referral options for their
patients) and personally (e.g., academic or extracurricular opportunities for
their children); likewise, psychologists who desire serving the underserved, do
not necessarily want to work within primary care settings. With internship opportunities, employment,
and funding ever in flux, how can a better match between an organization and
applicants be found? Well, SMHS has
taken a novel approach: seek out the
vegetable-friendly professionals already residing in the region and grow them
into vegetable connoisseurs.
Alysia Hoover-Thompson is a doctoral candidate at Radford University in the Counseling Psychology PsyD program. She received her MS in Community Counseling from Radford University in 2009. Her research interests include: women’s issues, body image and rural practice.
Natasha Gouge is a doctoral candidate at East Tennessee State University in the Clinical Psychology PhD program. She received her MA in Clinical Psychology from ETSU in 2011. Her professional interests include dissemination and implementation science; program development, innovation, and evaluation; primary care, rural practice, and pediatrics.
Cummings, N.A., O’Donohue,
T.O., & Cummings, J.L. (2009). The
financial dimension of integrated behavioral/primary care. Journal of Clinical
Psychology in Medical Settings, 1-9. DOI 10.1007/s10880-008-9139-2
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Posted By Lauren DeCaporale,
Thursday, December 27, 2012
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When I was interviewing for graduate school, I was asked if I thought my dual major as an undergraduate in sociology and psychology would be "detrimental” to my career as a geropsychologist. Evidently, it was the interviewer’s belief that systems had little to do with the individual adult. I have often reflected on that moment and recognized the critical role it played in my professional development. It is difficult for me to imagine working with an older adult and not knowing his or her background, not exploring the interplay between one’s social structure and sense of self, and not integrating families and other professionals into a patient’s care. However, there are many that do not know the benefits of this work or how it can be done, particularly as it pertains to older adults.
As I participated in this year’s CFHA conference, I was surprised by how few people I met expressed interest in geriatrics. In fact, I was alarmed. It was disheartening to hear Doctors Blazer and Martinez report on the "silver tsunami” and the Institute of Medicine’s report on the limited number of workforce prepared to care for this rapidly growing population.
I wondered: how could this be? Is it a lack of funding? A lack of educators? A lack of awareness? And the answer seems to be: All of the above. So how do those of us who are passionate about our work with this population demonstrate that it is a worthwhile endeavor desperately needed in our current culture?
The numbers alone should demand our attention:
- 72.1 million: the number of older adults projected by 2030 in the US alone (Administration on Aging, 2011).
- 7 - 8%: the number with severe cognitive impairment (Freedman, Aykan, & Martin, 2001).
- 5 - 10%: the number of older adults seen in primary care suffering from major depression and dysthymia (Lyness et al., 1999).
- 20%: the number of older adults with chronic disabilities in the US (Manton & Gu, 2001).
- 29%: the number of the US population providing care for a chronically ill or older adult family member (National Alliance for Caregiving, 2009).
Though these numbers are powerful, they do not capture the full story of our aging population. There are many families who invite us into their lives to share their experiences of successful and sometimes less than successful aging. Recently, I was meeting with an aging patient and her friend. They both expressed gratitude to me for not shouting and talking down to them as if they were children, noting that this was so often their experience with others. I was reminded during this encounter of the stigma attached to aging. Why is it that we assume we must shout or that an aging individual must be suffering from cognitive impairment? These assumptions are unhelpful.
I am fortunate enough to have learned many lessons on aging from all four of my beloved grandparents and my parents who provided them with much of their care. I was taught to live and breathe the idea of respect for my elders, but it was more than that: it was a message of providing the aging people around me with dignity and a listening ear. It was from them that I learned how to grieve and on some days, how not to. I learned how to be flexible, as they gracefully made transitions and altered their expectations when necessitated by medical and physical need. I learned perseverance as my grandmother insisted she was not old, not ready to die, and kept taking the stairs rather than using an elevator at the age of 90. When I wasn’t learning from them, 30 older adults and their professional caregivers at adult daycare facility were teaching me every summer during my adolescence about the power of gentle touch and laughter as sources of healing.
I recognize that others are not as fortunate as I, who had the wonderful opportunity to know all four of these people until my early adulthood. But I challenge all providers who have not had such opportunity to listen to your older patients, to hear their stories, and to learn from them. Geriatric educational programs might not be accessible to all of us, but these patients are abounding, and ready and willing to teach us. Let us take a moment to be educated through their experiences, their voices, their families, and their lived-wisdom.
Lauren DeCaporale, PhD is a second-year postdoctoral fellow in Primary Care Family Psychology with a specialization in geriatrics/internal medicine at the University of Rochester Medical Center, Institute for the Family, Rochester, NY.
Administration on Aging (2011). Profile of older Americans. Aging statistics. Retrieved from http://www.aoa.gov/aoaroot/aging_statistics/index.aspx
FreedmanVA, AykanH, MartinLG.Aggregate changes in severe cognitive impairment among older Americans: 1993 and 1998.J Gerontol B Psychol Sci Soc Sci.2001;56:S100-S111.
Lyness JM, Caine ED, King DA, Cox C, Yoediono Z. Psychiatric disorders in older primary care patients. J Gen Intern Med. 1999;14:249–254.
MantonKG, GuX.Changes in the prevalence of chronic disability in the United States black and nonblack population above age 65 from 1982 to 1999.Proc Natl Acad Sci U S A.2001;98:6354-6359.
National Alliance for Caregiving (2009). Caregiving statistics. Who are Family Caregivers?. Retrieved from http://www.thefamilycaregiver.org/who_are_family_caregivers/care_giving_statstics.cfm
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Posted By Zephon Lister,
Thursday, December 20, 2012
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What experience in your professional or personal life was
most influential in your development as a family-oriented behavioral healthcare
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.
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
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
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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Posted By Barry J. Jacobs,
Thursday, December 13, 2012
Updated: Wednesday, December 12, 2012
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In the evolution of
healthcare, demographics will shape our destiny. On the horizon is the so-called "silver
tsunami”—the increasing prevalence of aging Baby Boomers using more and more
healthcare resources. But there’s a
dearth of American healthcare professionals interested in geriatrics. And there are relatively few collaborative,
team-based programs focused on the needs of aging adults.
|Psychologist Sara Honn
Qualls, Ph.D. has spent her career integrating the evidence-based
gerontology with both elegant and pragmatic formulations of family
thinking. The Kraemer Family Professor
of Aging Studies and the director of the Gerontology Center at the
of Colorado, Colorado Springs, she is one of the country’s leading
writers and educators about families in late-life. Her latest book,
Caregiver Family Therapy (co-written by Ashley A. Williams) was
recently published by APA Books. It should
become a foundational text of not only medical family therapy academic
but of all family-oriented healthcare training.|
I had the privilege of
working closely with Dr. Qualls for a year-and-a-half as members of the APA
Presidential Task Force that produced the Caregiver Briefcase, a web-based
resource on family caregiver research, practice and policy. It was good to hear
her quick, incisive voice again as she talked with me about her new book.
BJ: What has led you to focus your career on aging families?
SHQ: My family-of-origin had exposed me to a lot of aging
families. Then, while I was an
undergraduate during the late-70s and early-80s, I did a workshop in
gerontology for which we went out in the field.
I was hooked. I just got it. I became interested in the psychology of aging
families but there wasn’t much information out there. At the time, however, there was a rich family
therapy literature that was mostly based on families with young children. It was fascinating for me to try to translate
those early family therapy models into ideas about families of older adults in
which there was a lot more ambiguity about what family roles could or should
be. When I started working as a
psychologist in the aging field, it was clear to me that family is the key
social and service context for older adults.
Families ought to be key members of the integrated healthcare team but
are often considered outside the pale and are left outside team deliberations.
BJ: Why write the book Caregiver
SHQ: In the field of gerontology, family caregiving
interventions have had a focus on the individual framed mostly in a stress and
coping paradigm. But what struck me
while talking to caregivers in our clinic is that most of them didn’t seem to
think of themselves as individual caregivers dealing with stress so much as they
saw themselves as part of families in late-life transition.
We wrote the book because there was a need to
integrate various caregiving interventions into a systemic framework that isn’t
addressed in the stress and coping paradigm.
How do we help family members walk through an illness trajectory while
identifying the transition points that challenge the whole family’s
organizational structure. How do we help
family members make the transitions they need to make while supporting the
development of all family members? All
these types of changes require a systems frame to understand and intervene.
BJ: You focus in your book on "naming the problem.” What do you mean by that?
SHQ: Families come into treatment because something isn’t
going right for them. Their name for the
problem is often not what the healthcare system calls it. That’s a disconnect. For example, caregivers may call me to see
their mother for depression when it’s clear to me that their mother also has
cognitive changes, possibly dementia. As
a professional, I have to gather all the assessment data and integrate it and
make sense of it. And then I have to
offer that understanding to the family in a way that will be useful to them so
that it matches their value system and cultural context and positions them to
respond to the practical health and well-being needs of their elder.
BJ: You also focus on what you call "role structuring.” How do you help family caregivers shift into
SHQ: We have to increase their awareness of the transitions
that are required to deal with aging and illness, especially dementia. We then have
to figure out the barriers that are keeping them from smoothly making those transitions. In our clinic, we use role plays or imagery
exercises to help family members understand what would be a more effective
strategy and to make real the risks they run if they insist on playing the same
roles they’ve always played.
BJ: You engage family caregivers in problem-solving. What evidence do you have that that kind of
cognitive process is effective?
SHQ: Insight is necessary
but rarely sufficient, especially when it comes to changing fundamental aspects
of our roles across generations. By
engaging family members in problem-solving, we are more likely to elicit the
real barriers to action or transition—e.g., guilt or fear of conflict with a
sibling. The power of change is in
helping family members see the problem in a new frame and exploring new resources.
BJ: How can family-oriented healthcare professionals improve
their effectiveness with family caregivers?
SHQ: By asking family caregivers to collect clinical data
about the patient for us—say, through using reporting scales-- healthcare
professionals may become aware of problems that we didn’t even know about. This will lead us to ask ourselves different
questions about how to help our aging patients and their devoted family
Barry J. Jacobs,
Psy.D. is the Director of Behavioral Sciences for the Crozer-Keystone Family
Medicine Residency Program in Springfield, PA and is the author of The
Emotional Survival Guide for Caregivers.
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Posted By Bill Gunn and Julie Schirmer,
Thursday, December 6, 2012
Updated: Monday, December 3, 2012
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What the heck is a "learning community?” The definition we
are using is: a group of like- minded individuals working
together to learn what’s working, what’s
not working, and how to change our systems
to be more collaborative.
This collaboration is necessary with patients, families, health care
teams and systems.
Management consulting guru, Peter Vaill,
describes the constantly changing world we are in as being in "constant white
water”. There are no pools to
recover and rest before the next set of rapids.
We just need to learn how to paddle the boat better through the white
water of change. Rather than just
working harder, Vaill proposes strategies of working smarter, specifically
working "reflectively smarter” and "collectively smarter”. The learning community model uses both
strategies. The integrated care "river” is moving forward all over the
country. In the aftermath of the
election and the move towards population-based "accountable care
organizations", we all need to work "collectively smarter.”
"There are no pools to recover and
rest before the next set of rapids.
We just need to learn how to
paddle the boat better through the
white water of change."
There are other organizations using this strategy. For example, The Institute for Healthcare
Improvement (IHI) sponsors ” learning collaboratives”, bringing in hospitals, clinics and other
organizations to provide technical assistance for their change efforts. The National Council of Behavioral Healthcare
sponsors learning communities among behavioral health organizations, which
provide integrated primary care health services for the severe and persistently
We need to look for partners in our local systems and in our
geographic regions to share sustainable models, influence new policies, and
collect mutually agreed upon data to discern the impact of different models of
care. CFHA has been a leader in conducting national meetings held in regions
where there is strong interest and activity in integrated care. Each of the meetings has held a local
"summit” that has brought together leaders from the region to learn together
and ideally create integrated care workplans.
We know that many folks from other parts of the country think that in
New England "good fences make good neighbors”,
but our experience with integrated care has shown this not to be
true. We have created a steering
committee and workgroups around training, advocacy and quality improvement with
representatives from Maine, New Hampshire, Vermont, Massachusetts, Rhode
Island, and Connecticut. We have had
monthly steering committee phone calls, two face-to-face meetings, and plans
for more to work on projects of common interest in the region. These projects are in the areas of training,
advocacy, and quality improvement.
There is another organization, the Family Medicine Education
Consortium (FMEC), whose mission is to move important primary care health
projects along and to promote family medicine.
The goals of FMEC and CFHA overlap around integrated behavioral health
care. The two organizations sponsored
two preconferences in the fall of 2011 and 2012 on Supporting Sustainable
Integrated Care. The 2011 meeting kicked off the New England Learning
Community. The 2012 meeting in
Cleveland, Ohio set the stage for a state-wide Ohio Learning Community and
planted the seeds to bring together the 4-5 Pennsylvania integrated care
state-wide organizations in the fall of 2013.
The Ohio proceedings included
lessons learned from providers, administrators, funders, and foundations.
Jennifer Hodgson started the meeting with an overview of the impact of the
Accountable Care Act on behavioral health integration and the cutting edge advocacy work taking
place in North Carolina. The panelists
and discussions were very dynamic. The meeting ended with learning community
strategies for the states represented at the meeting. The Ohio group has
created a listserve and is approaching a couple of groups in northern Ohio to
"house" a state-wide learning community, connecting it to the good
work of Janice Bogner and colleagues at the Health Foundation of Cincinnati
Susan Labudo-Schrop at the University of Ohio College of Medicine Family
Medicine Department (NEOMED).
One of the surprise outcomes of this Ohio meeting was
identifying the North East Learning Community Theme Song. We had not yet read Randall Reitz's blog
regarding a theme song for the CFHA. So, although we "ain't got much
money", we do have fun AND a theme song!
If you are at all curious, click here to view the original Youtube
version. We really like the chorus. It's
catchy, great to dance to. Yet we need to rewrite the rest of the lyrics As with behavioral health integration, we
aren't satisfied with the traditional organization of the song. An integrated
care transformation is needed to benefit patient satisfaction, clinical
outcomes and cost! Maybe selling the
rights to the new lyrics will bring in money to support our efforts. Stay
In southwest Virginia, another regional effort is taking place,
sponsored by Radford University and the primary care clinics in that area. Cathy Hudgins and Bill McFeature have
organized an annual conference and provided technical assistance to clinics and
behavioral health organizations in that area.
Through the North East, our hopes are to connect these
efforts: informing our care, strengthening our ability to learn from each
other, uniting to influence policies to improve care, and "taking it to the streets". We have
an assumption that there are many more efforts local and regional efforts to
promote integrated care and we hope this blog will encourage others to let us
all know what you are doing.
Bill Gunn PhD is a
faculty member of the NH/Dartmouth Family Medicine Residency in Concord, NH and
holds a clinical appointment at Dartmouth Medical School. He is a
board member of the Collaborative Family Healthcare Association. Bill is a co-author of Models of
Collaboration (2006) and The Collaborative Psychotherapist (2009).
He coordinates with Julie Schirmer, LCSW an integrated care "learning
community” in New England which meets regularly. He is membership co-chair of CFHA, and
co-chair with Nancy Ruddy, PhD of the Division 38 primary care subcommittee.
Julie Schirmer, LCSW is Director of Behavioral Health at the
Family Medicine Department of Maine Medical Center and Assistant
Director of the Family Medicine Clerkship at Tufts/Maine Medical Center
School of Medicine. She is Co-chair of the North East Regional
Integrated Care Learning Community, Past President of the Family
Medicine Education Consortium, and upcoming Director of the Behavioral
Science/Family Systems Educator Fellowship of the Society of Teachers of
Family Medicine. She is author and co-editor of Behavioral Health in Primary Care: A Global Perspective(Radcliffe, 2010).
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Posted By Larry Mauksch,
Thursday, November 29, 2012
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The Don Bloch Award,
CFHA's highest honor, was presented to Larry Mauksch by a group of
his colleagues, Barry Jacobs, Valerie Ross and Randall Reitz
on October 5, 2012 at the CFHA annual Awards
Luncheon. In his acceptance speech, Larry Mauksch shared thoughts on his
experience in the collaborative care movement over the last twenty
I want to thank the
CFHA board for this great honor. Recognition from one’s peers is about
as a high an honor as one can receive perhaps only eclipsed by
recognition from one’s family. Today I am a fortunate man as both my
professional and personal family members are present.
I feel a deep sense of gratitude receiving this award. I called Don Bloch
to express my thanks for his contributions and his influence on me and
on the field. My thoughts also go to many others who have in one or more
ways helped me learn and grow. I started making a list. Behind me on
the screen is a Wordle. When text is inserted, it arranges the words in
different ways allowing you to choose designs and colors. One other
feature of a Wordle is that it alters the size of the word to reflect
the number of times it appears. I listed everybody once, except for Don,
in his honor. Many people in this Wordle are in this room. Family
members are listed with first and last names, colleagues are listed by
last name, sometimes with a first initial. To all of you I wish to
express my deepest appreciation for your gifts. I needed your
encouragement, your voices, and your care.
In reflecting on your gifts it occurred to me that they
affect different aspects of my growth and at the risk of being too
personal, I want to share some of this with you. In 1982, when I was
fresh out of graduate school, two family physicians took me into their
practice and trusted me with their patients. This was truly a gift. The
referrals came fast and I sought supervision, at one point from 4
different people at the same time, each with different areas of
expertise. One supervisor was a former graduate school faculty member.
We met weekly at a local health food cafe. He allowed me to buy him a
whole-wheat cinnamon role and a latte but at first would not accept
payment. I would tell him about my patients, like the woman who
complained about her husband and tried to convince me that he would not
participate in counseling. My supervisor suggested I call the husband in
front of the woman and say, " Mr. Thompson, I am the counselor who is
working with your wife. I can tell she loves you and I know that you two
are struggling with some things. I miss your voice and I have no
question that your perspective on this relationship is really important.
Would you be willing to join us next week?” Then we would talk about
theory and strategy. What stayed with me was his voice. He taught me
from the inside out, starting with application and demonstration of
skill. This gave me confidence, clarity, and direction. I used his words
with my patients. As the years went by, I helped patients by sharing my
voice. Saying what seemed helpful, then conceptualizing what came out
of my mouth, became a way to tap into my own wisdom. I have shared
phrases with trainees just like my teacher did with me. In fact, when I
now lapse into first person dialog, acting as a therapist or a physician
or a medical assistant, I look around and people are writing down my
phrases. It helps people get started talking about hard topics like
trust and abandonment and inadequacy
and risk behavior and love. We need to share our voices to help our
clinical team members take the risk of trying new skills. Taking these
new steps helps lesser trained clinicians go to interpersonal places
that feel uncomfortable. This is part of what one colleague in this room
described in a mountain climbing metaphor as "the belay of
If a large part of my career was spent working on
finding a voice as a clinician and teacher an equal or greater part of
time has been devoted to finding a scholarly voice. Writing is
terrifying. It is personal. Comparing myself with those who are well
published is intimidating. The prospect of rejection and criticism can
be disabling. New knowledge is old before it’s published. Conducting
research means accepting incompleteness, uncertainty, imperfection, and
compromise. In this audience, and elsewhere, including many anonymous
reviewers, are people who gave me the gift of honest, and usually kind,
feedback. One life long friend suggested I might benefit from reading
William Zinsser’s classic, "On Writing Well”. He was right. I learned to
cut out the lard. There are also some in this room and elsewhere who
gave me the gift of scholastic opportunity and responsibility. They
asked me to co-author papers, write reviews, chapters, and even to a
co-author a book. Others taught me research methods. I recall one
physician executive who spent hours helping me understand reimbursement
models beyond fee-for-service. Hurrah.
I can honestly say that embracing scholarship has taught
me to cherish my mistakes as ways to continually learn. Sharing the
failures, limitations, challenges and responsibilities of scholarship
with collaborators has made my learning easier, more efficient, and much
Collaboration is the last gift I want mention. In this
room and elsewhere are many people who have offered me the opportunity
to build a new curriculum, transform a clinic system, and lead an
organization. These are incredible gifts. They forced me to think at
many levels. How do you lead an organization that has a great mission
but financially is barely surviving? One of you offered the "pilot light
approach” that emphasized holding on to relationships, mission, and
conserving resources for the right time. How do you help a clinic system
where the biopsychosocial mission and commitment of its providers is
inspiring but also leaving them exhausted and frustrated? This clinic,
with full board support, brought me in for an entire year. Their
clinicians allowed me to watch them interact with patients. The
executive leadership agreed to regularly cancel half days of clinic and
hire locum tenens support so everyone could participate in my system
wide educational sessions. These experiences stretched my intellectual
and interpersonal abilities. Eliciting the ideas of others took on new
meaning because I at once had to make people feel heard and move forward
in ways that might be new or risky. With their trust, I was able to
challenge students and fellow board members, medical assistants and
physicians, and administrators and faculty, to learn new skills or even
entertain new cultural values.
Today, we in CFHA are part of an amazing cultural
transformation in health care. People are experimenting with new team
designs, financial models, and interpersonal skills. Behavioral health
integration is common place in safety net settings and other clinical
arenas with a knowledge base that fills the curricula in multiple
training programs. We look to broader and deeper impact on systems,
families and policies. The collective wisdom in our organization
represents incredible potential to learn and make a difference in how
health care is provided in our country. I share my experience with you
because I hope that all of you can exchange similar gifts with fellow
clinicians, teachers, students, scholars and leaders: teach them, share
your voices, celebrate their ideas, and help them take on new
responsibilities. Once again, thanks for your feedback, your time and
encouragement, your trust, your voices, your friendship and so much
1. Lorenz, A. (1999). Reflections: The belay of collaboration. Families, Systems, & Health, 17(1), 133-135.
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Posted By Barry J. Jacobs, Valerie Ross, and Randall Reitz,
Thursday, November 29, 2012
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At the 2012 conference in Austin, the CFHA Board of Directors presented the Don Bloch Award to Larry Mauksch. This award is the association's highest
recognition for contributions to the field of integrated and collaborative care
that are pioneering, or in some way help bridge the mind-body gap and pursue a
more humane, egalitarian and interdisciplinary healthcare system. Three of Larry Mauksch's colleagues presented the nomination at the conference awards luncheon:
Barry J. Jacobs
Let me make the case for Larry Mauksch, M.Ed for the
Don Bloch Award for this year. Without his service to CFHA as a board
member and later president in the '90s and early 2000s, our organization
wouldn't exist today. He gave us passion and selfless leadership during
his tenure--a time when the survival of CFHA was in question. He served
as the crucial bridge between the vision of our founders and the more
pragmatic, membership-oriented organization we are currently. Even after
he stepped down as president, he has remained engaged with CFHA as a conference
attendee and participant and key advisor to the board and board staff
Larry’s contributions to the field of collaborative
family healthcare go well beyond his service to CFHA. Through his
long-time association with the Department of Family Medicine at the University of Washington, he is one of the best known
and most highly regarded behavioral science faculty members in the
country. His 2-year tenure as a visiting clinician at the Marillac Clinic
helped make that community health center one of the early models for
community-centered collaborative family healthcare. In the past decade he
has co-written important articles in the major primary care journals on
patient-centered communication and, more recently, integrated healthcare
teams. He currently provides trainings around the country on those
subjects and serves as a national champion for behavioral healthcare within the
In addition to these many accomplishments, Larry is
one of the warmest, funniest, most generous people I've encountered in the
collaborative family healthcare field. I've benefitted from his
encouragement and mentoring. He has been the Yoda to many budding
is the warm, generous heart of the collaborative care movement. When I asked his colleagues across the nation
to describe him. They called him
visionary, caring, diligent, energetic, determined, and thoughtful.
him as an ideal mentor. Through a lucky
accident, Larry took me under his wing back in 2000. I was fortunate to complete my PhD internship
at Marillac Clinic shortly after Larry’s year-long sabbatical during which he
established Marillac’s collaborative care program. My internship was funded through a 5-year RWJ
grant Larry had co-authored. During my
years there, Larry returned to Grand
Junction yearly to offer training and conduct
research. My first published research
was with him as a first author, and my early professional presentations
included him as co-presenter. On
multiple occasions I’ve slept in his home, eaten at his table, and soaked in
his rooftop hot tub. I’ve called him for
advice before each major decision of my career.
He personally nominated me when I was invited to join CFHA’s board.
I share my
experience with Larry because I have personal knowledge that he has provided
similar tutelage to many, many young collaborators. This room is full of people for whom Larry
has had a deep and enduring impact.
about a story to share that would typify Larry, the most poignant memories are
actually of hearing Larry brag on his wife and children. If allowed, he will share stories of their
academic success, deep humanity, and outdoor adventures for hours. Larry lives
the family in collaborative family healthcare. His family is with us today and
I’d like to thank Sally, Claire, and Eli for sharing your remarkable husband
and father with us for these many years.
I have been asked to reflect on my experience
of Larry as a teacher and educator. It’s
been my privilege to be both Larry’s student, colleague, and friend for the
past 15 years.
Larry is one of the most generous and
creative people I know. His work is infused
with a deep understanding of collaboration and coaching.
1985 Larry took over the behavioral science program in the UW Family
Medicine residency. The position
became a base for his almost 30 year- exploration in training healthcare
1996 he started an Internship for Master’s level therapists in
Collaborative Care. To date 19 therapists have graduated from the program,
myself among them, many of whom are working in medical settings and
involved in healthcare change.
scholarly work as an educator has focused on defining, describing and
teaching skills at the interface of time management and quality patient
- He has
been influential in developing methods for innovative clinical training,
marrying skill articulation with, direct observation and feedback, video
review, and self-reflection.
A few of Larry’s contributions include:
materials in patient centered communication such as "The Patient Centered
Observation Form” and accompanying on-line videos
Paired Observation Video Editing Course: a course that utilizes peer observation and has been adapted in
medical schools around the country.
Larry served on the Competency Task Force for the Council of Academic
Family Medicine. He is developing
new training materials in response to this experience.
focus in clinical training is evolving from an individual to a team
focus. He is working with health
systems around the country to promote well functioning teams in the
Larry’s impact on me has been profound, both
professionally and personally. Barry
asked me tell you all some anecdotes that help to capture who he is. I thought
to myself: "Well, we have been on this big adventure together – an adventure we
all in CFHA are on -- trying to figure out how to change the healthcare system.
For me, a formative part of this adventure has taken place in conversations in
Larry’s office. Not a setting for dramatic story telling. So I tried to think
of archetypes to more dramatically capture what it has been like to take part
of this adventure with Larry.
Harry Potter, Larry is a leader
among peers, a change agent from within guided by the values of social
justice, compassion and the importance of relationship
in age he is closer to Dumbledore.
He shares the qualities of a wise supportive mentor who is there
when you need him and moves out of the way when it’s time to let his
student grow. He is caring,
challenging, and his door is always open.
is little bit of Yoda in him too.
He is a guide with a big picture view
- Then again he does have an edge – like
say – Hans Solo. He is a great co-pilot, he does not let the rules, or
that fact that he is in an imperfect ship get in the way of his creativity
or taking risks.
then there is his style; which is
really a little more like Columbo (without the cigar) : a bit rumpled in
appearance, messy office, he always greets you with a big warm smile on
his face, a twinkle in his eye signaling delight, and he is always
thinking outside the box.
Recently Larry and I were talking about
something that happened in the department that seemed like a step backwards, reversing some of the important work we had
both done in the residency. That step
backwards was bothering me. Larry leaned back in his chair and said: "I have
really come to think of my work as just a grain of sand in a much bigger
evolution.” Then we set to work planning how to move forward again. This is one
of the most important lessons I learned form Larry. I will just call it: Think Zen.
Don’t take your self too seriously, recognize
that your work may be but a flicker of light or grain of sand in the evolution
of healthcare, AND invest 110% or more of yourself in that work.
Don’t get hung up in judging whether a situation is good or bad. Look for openings to move towards creation of
a more humane and quality system…whether it is teaching, or attending a faculty
meeting, or trying to change a culture …listen…
think systemically… do your research …get to know your collaborators …
and take risks. You never know what will
come of it.
I have tremendous gratitude for my
relationship with Larry and all he has taught me and I am so pleased that CFHA
is honoring him in this way.
The text of Larry Mauksch's acceptance speech is available here.
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Posted By Pamela Williams,
Thursday, November 22, 2012
| Comments (2)
As readers of this blog are well
aware, depression and anxiety "are a major cause of disease burden and
disability with depression projected to become one of the three leading causes
of burden of disease by 2030.” It is estimated that 90% of people who suffer
from depression and anxiety are treated solely by their primary care physician,
and the majority of these interventions are exclusively pharmacological. Many people also report being unsatisfied
with the level of care they receive. While these facts point toward
collaborative care being a logical and effective treatment model for depression
and anxiety, there was not enough research that provided conclusive evidence to
support recommending collaborative care for those with depression and anxiety
problems until this year.
A recent review
summarized in the Cochrane Library and authored by Janine Archer, Ph.D. of the
school of Nursing, Midwifery and Social work at The University of Manchester in
the U.K. provides promising results for collaborative care as an evidence based
treatment for anxiety and depression. Reviews from the Cochrane Library are widely
considered the gold standard of evidence-based medicine.
As described on the Cochrane website:
care is associated with significant improvement in depression and anxiety
outcomes compared with usual care, and
represents a useful addition to clinical
for adult patients with depression and anxiety.”
"Each systematic review addresses a
clearly formulated question; for example: Can antibiotics help in
alleviating the symptoms of a sore throat? All the existing
primary research on a topic that meets certain criteria is searched for and
collated, and then assessed using stringent guidelines, to establish whether or
not there is conclusive evidence about a specific treatment."
The collaborative care review looked at seventy-nine
randomized control trials (which included 24,308 patients) that compared the
collaborative care treatment model with either standardized care or alternative
treatments. The review required four key criteria to be considered part of the
collaborative care model: 1) a
multi-professional approach to patient care, 2) a structured management plan,
3) scheduled patient follow-ups, and 4) enhanced inter-professional communication.
The results suggest that "collaborative
care is associated with significant improvement in depression and anxiety
outcomes compared with usual care, and represents a useful addition to clinical
pathways for adult patients with depression and anxiety.” Patients who were
treated with a collaborative care model also reported being more satisfied with
their level of treatment than their counterparts receiving standard or
alternative care. Research increasingly
supports a systemic approach to healthcare and a collaborative care model that
also provides patients with a high level of satisfaction.
|Pamela Williams is a graduate student at the University of
San Diego obtaining her masters degree in marital and family therapy. She is passionate about collaborative care and
working with families with young children and hopes to combine these two
passions in her future work. |
Archer J., Bower
P., Gilbody S., Lovell K., Richards D., Gask L., Dickens C., Coventry P. (2012)
Collaborative care for depression and anxiety problems. Cochrane Database of Systematic Reviews, 10. DOI:10.1002/14651858.CD006525.pub2.
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Posted By Golnoush Yektafar,
Wednesday, November 21, 2012
Updated: Monday, December 10, 2012
| Comments (0)
As a new doctoral student in Marriage and Family Therapy with a concentration on Medical Family Therapy, I have been expanding my understanding of the social context of illness. I have read about the ways in which Western society has placed an important concern on the medicalization of an illness, emphasizes the biological aspects of the physical malady rather than considering the psychosocial-spiritual impacts of illness on the individual and family, and emphasizes the medical provider as the "expert.”
As I continue to learn from the literature about how social context of health impacts health and collaborative care overall, I am also better understanding my personal experiences and how they relate to these ideas.
From the time that I had the ability to comprehend what being "sick” entailed, I came up with a few observations. I often associated "sickness” with medications of sorts, visits to doctors, and feelings of fatigue and irritability. These were the things that I experienced growing up because my father was diabetic and had chronic cardiovascular disease. Ironically, looking at my father’s appearance, he was the epitome of health. A tall and slender man who enjoyed playing tennis and going for daily runs. To my father’s misfortune, the cause of his poor health was based on genetics. My paternal grandparents had both died from sudden heart attacks, and at the time of their death, their social context was a key contributing factor to their inability to gain access to the appropriate medical attention they needed. Living in Iran, a foreign country where the socioeconomic gap between the rich and poor is a problem that still exists today, it was apparent that the wealthy had more privilege in issues related to healthcare access and advanced technologies. Inevitably, these and other social factors prevented my grandparents and father from gaining knowledge on preventative measures when dealing with chronic illness.
Fast forward to three years ago when my father was admitted to the hospital by his primary care physician who after running numerous tests concluded that congestive heart failure (CHF) was the diagnosis. Since my father had a history of chronic cardiovascular illness and diabetes, the doctor informed my family and me that it would be best for him to remain in the hospital overnight. That evening, the cardiologist came in and poked and prodded my father. After asking a few questions, he concluded that the diagnosis of CHF was correct. As he was writing down notes he informed my family that he would be adding a new medication to my father’s existing medication regimen.
I remember the nurse coming into the room late one night and simply handing my father a cup of water and a small plastic container with about ten different pills. This routine continued for another three days, however the morning of the fourth day was different. As I entered my father’s hospital room I was greeted by a primary physician, a cardiologist, and a nephrologist. They all looked concerned and began their interaction with my family by saying that my father may not be released as early as my family had hoped for. With a panicked look on his face and a trembling in his voice, the primary care physician said that according to recent lab results, my father’s kidneys appeared to not be functioning. A new diagnosis was blurted out; they said it was end-stage renal failure and an immediate procedure had to be done in order to insert a fistula so my father could begin hemodialysis. I remember having a million questions running through my mind, but I could not verbalize a single one. As I muttered out a quiet "Why?” the cardiologist said that the only answer he has is that one of the medications that my father was given to treat the CHF had an adverse effect on the kidneys. Since he was diabetic, he already had under functioning kidneys, but the medication had worsened the existing functioning capabilities of his organs. As the three physicians left the room all I kept thinking and questioning in my mind was how a doctor could not know what medication was contraindicated with another.
As I fast forward to one year after that incident, I have experienced my father not only go through the physical disadvantages that result from chronic illness, but psychological difficulties in dealing with the social context of his illness. The way society perceives him as "ill,” the way our family views him, his role in our family system shifting from breadwinner to someone who is unable to work, and a plethora of other setbacks that had contextual factors that were socially based.
Looking back on this experience as a doctoral student who is interested in medical family therapy, I can clearly see the need for collaborative care between physicians and all those involved with the patients. I have learned firsthand how important it is those nurses, physical therapists, family therapists, and anyone else who interacts with a patient work together in order to provide the patient with the best overall care. My hope is that one day, the social context of illness can be transformed in such a way that all medical professionals work collaboratively with other medical caregivers, patients, and family members in order to best treat the whole patient- mind, body, and soul.