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Stepping It Up: Innovation to the Stepped Care Model to fit Rural Settings

Posted By Jodi Polaha, Thursday, January 10, 2013
Rural blog series logo
Jamie and Jeff's
blog is the second post
in a month-long series
on integrated care in
rural settings.

Read the entire
series here.


Jamie Tedder, M.S.

East Tennessee
State University

I’ve 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.

Within a 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.

There 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.

Jeff Ellison, M.S.

East Tennessee
State University

Through 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.

Our 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 each "step.”

Jeff Ellison and Jamie Tedder are advanced students in the doctoral program in Clinical Psychology at East Tennessee State University, which has a focus on rural, integrated care. 


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Growing Vegetable Connoisseurs

Posted By Jodi Polaha, Thursday, January 3, 2013
Rural blog series logo
Natasha and Alysia's
blog is the first post
in a month-long series
on integrated care in
rural settings.

Read the entire
series here.

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

Natasha Gouge, MA
East Tennessee
State University
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 sustainability.

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!)

Alysia Hoover-Thompson

Alysia Hoover-Thompson, MS

Radford University

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.

About Stone Mountain Health Services

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 training).

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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Geriatric training: Allowing our patients to be our educators

Posted By Lauren DeCaporale, Thursday, December 27, 2012

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.

Silver Tsunami

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

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

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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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Gray Families: An Interview with Sara Honn Qualls

Posted By Barry J. Jacobs, Thursday, December 13, 2012
Updated: Wednesday, December 12, 2012

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 insights of gerontology with both elegant and pragmatic formulations of family systems thinking. The Kraemer Family Professor of Aging Studies and the director of the Gerontology Center at the University of Colorado, Colorado Springs, she is one of the country’s leading clinicians, 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 programs but of all family-oriented healthcare training.

Sarah Honn Qualls   Caregiver Family Therapy

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 Family Therapy?

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 new roles?

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 members.

Barry J. Jacobs

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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Integrated Care Learning Community – New England Style

Posted By Bill Gunn and Julie Schirmer, Thursday, December 6, 2012
Updated: Monday, December 3, 2012

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.”

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."

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 mentally ill.

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 tuned!

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

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
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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Larry Mauksch Receives CFHA's 2012 Don Bloch Award

Posted By Larry Mauksch, Thursday, November 29, 2012

Larry Mauksch 

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 years.



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 collaboration1."

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 more meaningful.

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 opportunity.

1. Lorenz, A. (1999). Reflections: The belay of collaboration. Families, Systems, & Health, 17(1), 133-135.


Larry Mauksch and Ben Miller 

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Larry Mauksch Nominated for CFHA's Don Bloch Award by Three Colleagues

Posted By Barry J. Jacobs, Valerie Ross, and Randall Reitz, Thursday, November 29, 2012
Larry Mauksch et al

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 Jacobs

   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 members.

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 in Colorado 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 PCMH.

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 collaborative Jedi.

Randall Reitz

    Randall Reitz

Larry Mauksch 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.

I describe 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.

In thinking 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.

Valerie Ross

   Valerie Ross

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.

  • In 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 professionals.

  • In 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.

  • His scholarly work as an educator has focused on defining, describing and teaching skills at the interface of time management and quality patient centered care.

  • 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:

  • Training materials in patient centered communication such as "The Patient Centered Observation Form” and accompanying on-line videos

  • The Paired Observation Video Editing Course: a course that utilizes peer observation and has been adapted in medical schools around the country.

  • Recently 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.

  • His 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 medical home.

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.

  • Like 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

  • However, 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.

  • There 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.

  • And 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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Collaborative Care is an Evidence Based Treatment Model for Depression and Anxiety

Posted By Pamela Williams, Thursday, November 22, 2012

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:

Cochrane Library Logo

"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.”

"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
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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The Need for Collaborative Care

Posted By Golnoush Yektafar, Wednesday, November 21, 2012
Updated: Monday, December 10, 2012

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.

Tags:  collaboration  family medicine  family therapy  Integrated Health 

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Contact Us

P. O. Box 23980,
Rochester, New York
14692-3980 USA

What We Do

CFHA is a member-based, 501(c)(3) non-profit organization dedicated to making integrated behavioral and physical health the standard of care nationally. CFHA achieves this by organizing the integrated care community, providing expert technical assistance and producing educational content.