Posted By Shelley L. Meyers,
Saturday, June 22, 2013
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Some time ago, I wrote this "open letter" to a master's level Marriage and Family Therapy ethics class. I was the teaching assistant at that time and thought that the family crisis I had just experienced would be relevant and applicable to many of the issues discussed in class. I am not sure why, but I never sent the letter. I actually forgot about writing it until recently when I was searching my computer for documents related to my current doctoral course in Medical Family Therapy. My hope is that my story will facilitate discussion about some of these issues and possibly provide some additional insight into the experience of a family dealing with a loved one's terminal illness. I recognize that the events may not be typical or standard procedure and do not wish to imply that they are; this is one person's perspective.
An open letter to the Fall 2011 MFT Ethics Class:
I wanted to share a personal experience with you all that
highlights some of the recent issues you have been studying in class regarding
ethics in general, as well as medical family therapy and end-of-life issues.
Please note that I asked for permission from those mentioned below prior to
sharing this with you and also changed some names.
A little background info… my husband is from Canada, and the
majority of his family live in the province of British Columbia. In early to
mid-October my mother-in-law Heather had some medical tests done as she was
losing a great deal of weight and had little appetite for foods other than
liquids. On October 19th, we were informed that she had cancer but
the exact type was undetermined. It was in her lung, liver and lymph nodes but
the source would need to be determined via biopsy in order to figure out the
course of treatment (you learn a lot about cancer during these times). When we
first learned that she was ill, we planned a visit at Christmas since both my
husband and I would be out of school for break and he would have some time off
from work. When we got information about the extent of her illness, we
purchased tickets to fly out on November 5th. The oncologist told us
that "you might want to come sooner”, which is obviously NOT a very good sign,
and we rushed to fly out on Friday, October 28th.
By this time, Heather has been admitted to the hospital and a
biopsy was done on Thursday the 27th (yes, that’s right…8 days after the diagnosis). We were
told that we were "lucky” that it had been moved up a day earlier to Thursday as
it was originally going to take place on Friday. So, we wait for results that,
honestly, probably wouldn’t matter. At this point, Heather was very ill and any
potential treatment would most likely cause more harm than good. During all of
this, Heather’s family doctor had told her that she had three weeks to live. We
didn’t realize this conversation between the doctor and Heather had taken place
My husband Shayne and I saw Heather in the hospital on
Saturday the 29th. She looked ill and fatigued, but not as sickly as
I had been expecting considering the diagnosis. Shayne’s sister Connie and her
husband were there as well. Connie had been bearing much of the burden of this
situation as she lived in the same town as their mom and was spending time at
doctor’s appointments and at the hospital. She and her husband Andy also have
one adult and two younger children at home and had to manage their normal
family responsibilities. Shayne, Connie and I spent as much time as possible
with Heather at the hospital. Andy, Heather’s sister, and the kids were there
quite often as well. Heather was in a room with another patient who also had
visitors often (and usually loud) which made things awkward at times.
We also had a meeting during that weekend (in the TV lounge,
but at least no one else was in there) with Heather’s family doctor. Obviously we had some questions. One thing I
asked the doctor was why she (the generalist) was the one explaining the
diagnosis and possible outcomes rather than the oncologist (the specialist).
She became very defensive, appeared to be insulted, and said that she was
trying her very best to help Heather, that she was working tirelessly, that she
was here on the weekend to meet with us….etc. etc. Her tone and her
defensiveness surprised and angered me. A few minutes later I felt the need to
excuse myself from the conversation and wander the hospital stairwells,
eventually finding the "Sacred Space” room (similar to a chapel). After some
crying and yelling, I composed myself and returned. By that time, the family doctor
had gone to check on something and I spoke with Connie. Connie told me that she
had asked the doctor a question regarding the biopsy procedure. The doctor
became teary-eyed, then began talking about how horrible it was for her to lose
Heather’s illness began to progress. She was noticeably
weaker and having difficulty with breathing. On Monday the 31st, we
met with the oncologist with Heather at her bedside as well as…in the hallway outside of Heather’s
room. She discussed Heather’s prognosis with us and mentioned the possibility
of hospice care. My husband and I had originally planned to return home to
Pittsburgh the following weekend and asked about the feasibility of coming back
for another visit with my mother-in-law, maybe near the Christmas holiday. The
oncologist looked at me and said, "we’re talking a few days to a few weeks”. Of
course the entire conversation was extremely emotional for the whole family,
but excruciatingly painful for Shayne and Connie. As for me, I felt trapped and
helpless. I have never felt as useless as I did in those moments when I had no
way to "fix” the situation or ease the pain. I also struggled with the
practical questions that came up for me…. had anyone asked Heather about her
plans? What if she did die soon? What would she want? How does all this stuff
happen? Would we have enough time? How do we pay for all of this? Who do we
call? Of course, my stomach churned at the thought of even bringing up any of
So, Monday the 31st was Halloween night. Shayne
and Connie wanted to stay with their mom overnight at the hospital. Andy wanted
to spend as much time as possible there too. The kids went trick-or-treating
that night, so I waited for them at the house until their dad got there. Later
I returned to the hospital and stayed with Shayne and Connie.
By late Monday or early Tuesday, Heather was not able to clearly
communicate. She slept almost constantly, and when she was "awake”, it was
difficult to tell if she was able to understand what was happening around her.
The nurses told us that most likely she had some awareness, so we continued to
talk to her, stroke her gently and hold her hand. They were able to move her to
a private room, which was very helpful.
There’s another twist to the story. Shayne has a 12-year old
son, Brian, who lives about three hours’ drive from this town. Brian has an
older sister, Ariel, who is 17. She is not Shayne’s biological daughter,
however he has always been a father-figure to her. I called their mother
Vanessa to explain the most recent circumstances though she was already aware
that Heather was ill. Vanessa said that
she was allowing the children to make the choice as to whether or not they
wanted to see Heather. She said that they had a very difficult time when her [Vanessa's]
father died from cancer nine years ago. She also said that Brian really didn’t
feel comfortable coming and that Ariel was "on the fence”. I tried very hard to
maintain my composure. I said that I was only relaying the information, however
I would not want anyone to have regrets later should they miss this opportunity
to see her. She said she would call me back. She called a short time later and
said that Ariel would take a bus the next morning and that Vanessa's brother
and sister-in-law would be picking her up as they lived in this town. I made the assumption that Brian was still
not going to be coming. I didn’t ask.
Later in the day on Tuesday we realized that the nurses no
longer came in at regular intervals to check Heather’s vital signs (no, she did
not have the machine that continually monitors them). We made the assumption they were "telling us
without actually telling us” that there was little time left. Shayne and Connie barely left their mother’s
side, even hesitating to go get something to eat. That evening (Tuesday) I went
back to Corinna’s house and gathered some supplies. Most of the immediate
family was jammed into that hospital room…me, Shayne, Connie, Andy, and
Heather’s sister, Aunt Rose. Connie’s oldest son Darrin stayed as well and
fortunately we were able to find friends to watch the younger boys. There was
one recliner-type chair in the room and a couple of regular chairs. I found a
yoga mat in Connie’s linen closet that I brought along with some blankets and
pillows. We tried to sleep at least a little bit. I napped on the yoga mat for
a little while but later went to the TV lounge to sneak some sleep on a sofa.
Aunt Rose went to the lounge too, and everyone else stayed in Heather's room.
Wednesday morning, 3 am, Darrin comes into the lounge. He
said, "She’s gone”. I felt my stomach churn (and actually still do as I write
this) and a sense of panic accompanied by horrible guilt. I so desperately
wanted to support my husband and in the moment he would need me the most I
wasn’t there. Damn! I was so angry with myself and thought about that part in
the Bible where Jesus tells the disciples (my paraphrase), "Geez, couldn’t you
guys stay awake for even an hour???”
I hurried to the room. The sadness was almost tangible; the
crying and wails of despair broke my heart. The guilt I already felt was
intensified by my relief that Heather’s struggle was now over. I had prayed
that if God didn’t see fit to heal her could He at least take her home quickly.
My prayer had been answered. I know now and I even knew then that I did not
"want” her to die, but I still felt awful.
After some time a few of us looked at each other having
absolutely no idea what to do next. I went to the nurse’s station to ask and
was given the necessary information. Eventually we gathered our things and left
Heather’s room, an experience that felt somewhat odd and…. I don’t know…
callous? Disrespectful? We waited for the doctor to arrive and make the
"official” pronouncement. She arrived, spoke with us briefly and then finally,
we all went back to the house. At about 7 am I called Vanessa and gave her the
news. Ariel did not take the bus to her
aunt and uncle’s house at that point. Vanessa asked me to keep her informed
about any memorial plans.
Obviously we now had a lot to do, including planning for a
memorial and other preparations. This is a difficult process in any situation,
but it becomes even more stressful when little has been discussed or prepared
in advance. It’s also a very expensive undertaking. Heather had a very limited
income and a sparse life insurance policy. Of course, none of us have much
extra income either so there was the added stress of figuring out how we were
going to pay for all of this. We finally made the necessary decisions at the
funeral home then worked quickly to prepare a memorial service.
Let me fast-forward a bit. We pulled together a beautiful
service for Heather which was held on Saturday morning, November 5th…coincidentally,
the day we had originally planned to arrive in Canada. After the service, which
in large part was scheduled based on our plans to fly back home that Saturday
night, we had lunch with several family members and friends including Vanessa,
Ariel and Brian. We then had to make a 6-drive back to Seattle, return the
rental car and catch our red-eye flight back to Pittsburgh which included a
lovely layover in New York at JFK.
So, why in the world am I writing all of this (and,
honestly, there is MUCH more but this experience is emotionally exhausting)?
Well, it may sound strange but I thought of your class several times during all
of this. So many issues seemed to arise that were either potential ethical
dilemmas or blatantly obvious ethical mishaps. In addition to the ethical
issues involved, there were numerous times that I shook my head and thought
about how things could have been done differently from a therapeutic standpoint.
How could a MFT have approached the situation in a more helpful way? How could
MFTs help to educate medical personnel so that they might better serve their
patients and their families?
These are some of the questions and thoughts I had and wanted
to share with you. Even if you never "answer" me back, I thought it
would be a rare opportunity for you to enter the world of one particular
client/family and consider the ways in which you might encounter these issues
in your own work. I hope that as you contemplate some of these things you find
How do you feel about giving clients information
about "how much time they have left"? Is it helpful, ethical, honest?
Is it potentially harmful?
How can you respectfully bring up issues such as
terminal illness or funeral arrangements/plans with clients and families?
What is the role of hospital staff when it comes
to providing information to clients and families? If it is "bad
news", should they leave that to a therapist? Where should they talk? With/without
How can hospitals provide more respectful and
compassionate care for families without incurring a great deal of expense?
Think about the dilemmas faced by blended
families. What is the role of the non-parent spouse (me) in this kind of situation?
How involved should this person be regarding communication with their current
How much decision-making power should a parent
give to a child? What are your thoughts about Vanessa's perspective regarding the
children visiting their grandmother?
How would you address the intense feelings of
guilt experienced by someone who lost a loved one, including the "I
should/could have done more" statements?
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.
Posted By Jennifer Hodgson ,
Thursday, December 1, 2011
Updated: Thursday, December 1, 2011
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burgeoning success of integrated care brings with it a complicated
by-product. The diverse range of behavioral and mental health
professionals are stepping up to the plate. Many of these
professionals, trained under the "old guard” as competitors in the
market, are now tasked to re-align in the context of a new paradigm. The
following represents insights from a year-long conversation (tongue in cheek) between two friends and colleagues, one a clinical psychologist
and the other a medical family therapist who are in search of a model of
intra-disciplinary collaboration. Dr. Jodi Polaha, Most Awesome Clinical Psychologist (and humble too):
Last fall, I sat through an uncomfortable board meeting. I was charged to
work with a Clinical Social Worker, Licensed Practicing Counselor, a
Counseling Psychologist, and a Licensed Nurse Practitioner to develop an
integrated care training program as part of a rural workforce
development project. Whose students could provide treatments in
behavioral medicine? Whose students could help develop programming?
Whose students understood research well enough to do program
evaluation? "Ours!” I said, smiling.
So did the other professionals in the room.
I shouted in my mind. I tried to keep my facial expressions in check,
but it was hard. Everyone knows social workers help people get food
stamps and find support groups, right? Everyone knows our counseling
friends deal mostly with life-adjustment issues, right? And everyone
knows that clinical psychologists are superheroes, trained in the
scientist-practitioner model, who REALLY CAN do everything…RIGHT?
was challenged by this conversation, and recognized my long-held,
inaccurate stereotypes of other mental health disciplines, including my
own. Still, some questions made me itch: Can mental health
professionals from various training backgrounds work harmoniously in
integrated care? If so, could their roles be interchangeable? Should
I took my questions to Dr. Jennifer Hodgson. Who would know better
than the president of CFHA? Granted, she is a marriage and family
therapist (or medical family therapist as she calls herself these days),
so she lacks the finely-honed analytical skills of a clinical
psychologist. She can pick out a cute suit, though, so I felt it was
worth a try.Dr. Jennifer Hodgson, Supreme Marriage and Family Therapist:
I would like to say, when Jodi Polaha approached me with questions
about intra-disciplinary collaboration, I had to hide my confusion. Why
would a clinical psychologist be concerned about this? Don’t they mainly
do testing and inpatient work with serious and persistent mental
illness? Isn’t their training mainly in one specific area of health or
mental health? What are they doing in primary care? I would not want a
foot specialist operating on my eye, after all! How does she figure she
is a team player with the likes of medical family therapy, who, we all
know, leads the field in advancing integrated care! I know what is
going to happen, she just wants psychologists to take over the
leadership of this integrated care movement. Arguably, they do have
Medicare in their back pockets, but so do social workers. Does that mean
though that they are better integrated care clinicians?
are so many inaccuracies in how different mental health disciplines are
trained that perpetuate the ideas that others are less well trained
simply because of their degree. Why can’t a social worker, pastoral
counselor, professional counselor, or family therapist (had to get my
field in there somehow) run an integrated care service with a blend of
professions present? Of course we can work harmoniously Jodi, but we
first have to be willing to be vulnerable and willing to learn from one
another in the field.
have gotten to a place where I just want all mental health disciplines
to stop figuring out who is best based on degree and to start taking
classes together, training in the field together, and promoting policy
for parity together. We would be even better together…if only we knew
how to share the space. It is the old adage of those who have power want
to hang on to it and those who want it are working hard to get it. I
tell my students that there is plenty of room in the sandbox so no need
to throw sand to create space.
healthcare professionals just want someone who can do the job and
cannot understand why some mental health providers cannot work together
easily. I go back to how people were trained, Jodi, and I believe
strongly that we can be retrained to learn models of integration that
embrace multiple disciplines in the same location. We can share the
work, divide the responsibilities, and promote one another’s strengths.
We can embrace hiring someone not because of the degree, but because he
or she meets the patient population’s needs and has the core
competencies (to be determined) to provide integrated care services.
starts at the training level and I believe CFHA is the place where we
can drop our labels and learn the core competencies needed for the work.
I know my calling is to train the next generation to behave
differently, but it starts with me and sometimes I struggle with it too.
I want to understand why we cannot just drop the entitlements...but as a
systems thinker I know that change happens slowly, thoughtfully, and
organically (with a smidge of encouragement from associations like
CFHA). Dr. Jodi Polaha
funny, in spite of my reaction to that board meeting last year, this
year in Philadelphia, I had so many positive interactions with
professionals from so many varied disciplines. In that forward-thinking
environment, Jennifer, it was truly effortless to meet the spirit of
your ambition for all of us. I learned from social workers, public
policy people, and physicians. I exchanged cards with a school
psychologist from Florida, with similar research interests to my own.
The energy in this mixed group was incredibly engaging and specific
credentials, training history, and even experience seemed to fade away.
In another week, I am off to a clinical psychology conference and,
reflecting back, I feel I was more among "my people” at CFHA than I will
occurs to me that the mental health professionals involved in
integrated care have so deftly cast off the old guard notions about the
50-minute session, the cozy psychotherapy room, and even the term
"mental health.” I’d like to see your vision become a reality,
Jennifer. Perhaps, the stereotypes and competitive dispositions will be
the next to go.
PhD, is a licensed Marriage and Family Therapist, Associate Professor
in the Departments of Child Development and Family Relations and Family
Medicine at East Carolina University, and outgoing President of CFHA. She has
over 18 years clinical experience and has served on numerous boards and
committees related to healthcare and mental health care issues. She is
co-author to the first doctoral program in medical family therapy in the
|Jodi Polaha, Ph.D. is an Associate Professor in the Department of Psychology at East Tennessee State University where her primary professional interest is research, training, and workforce development in rural integrated practice. In addition to her work, she spends lots of time with her husband and two young boys swimming, biking, and hiking in the surrounding mountains.|
view expressed in the blogs and comments should be understood as the
personal opinions of the author and do not necessarily reflect the
opinions and views of the Collaborative Family Healthcare Association
(CFHA). No information on this blog will be understood as official. CFHA
offers this blog site for individuals to express their personal and
professional opinions regarding their own independent activities and
Posted By Tai J. Mendenhall, Ph.D., LMFT, CFT,
Thursday, June 30, 2011
| Comments (1)
Last week In my previous blog entry, I advanced a call to purposively engage youth in our efforts in collaborative and integrated care. As I have spoken-up regarding this topic across a variety of forums with colleagues, most have initially responded with a strong sense of enthusiasm, followed by a want for evidence that such efforts can be effective.
I have been involved in several community-based participatory research (CBPR) projects in health since beginning my current position at the University of Minnesota, and have seen time-and-again how professionals and patients learn new ways of working together that are different from conventional top-down/service-delivery models of care-provision (i.e., wherein professionals learn to function as citizens of the research process (vs. rigid leaders of it), and patients learn to not instinctively look to professionals for leadership or answers (and to instead work to tap resources within themselves and their communities that have heretofore not been tapped)). Generally this process evolves over several months as a new project begins and/or for new members to orient and function within CBPR-principles. However, I have noted that young persons appear to learn and adopt these principles very quickly (usually faster than adults), and they do extraordinary work.
The SANTA project (Students Against Nicotine & Tobacco Addiction), for example, is a health initiative that engages local medical and mental health providers in partnership with students, teachers, and administrators in a Job Corps training site/community to reduce on-campus smoking. The project has endeavored to better understand the causes of students’ smoking behaviors; change the campus environment in ways facilitative to stress-management and boredom-reduction; revise the manners in which smoking cessation and support services are conducted; and establish the project as a sustainable and stalwart presence on-campus. Every facet of SANTA’s efforts is owned-and-operated by its students, which is a driving force behind its sustainability and integration into campus culture. Since its establishment in 2005, campus-wide smoking (including new and established students) has decreased from almost 60% to 36%, and evaluations across several cohorts of students show that smoking rates decrease significantly with prolonged exposure to SANTA interventions (Mendenhall, Harper, Stephenson et al., 2011; Mendenhall, Whipple, Harper et al., 2008).
The ANGELS project (A Neighbor Giving Encouragement, Love & Support) is a health initiative through which adolescents and their parents who have lived experience with diabetes (called "support partners”) are connected with other families (called "members”) who are struggling with the illness. These efforts begin at the time of diagnosis, which occurs almost universally in the context of an emergency hospitalization. It is during this time that the initiative’s teens maintain that they want the ANGELS to connect with members, because the motivation to adopt healthy lifestyles is the highest at a time of crisis. Support partners and members meet in a variety of combinations (e.g., adolescents with adolescents, parents with parents, families with families), and they continue to meet off hospital grounds (or via telephone, e-mail, internet discussion boards) after initial hospitalization. Sometimes members simply need a pep talk; other times ongoing support is offered for several months (Mendenhall & Doherty, 2007; Mendenhall & Doherty, 2005).
Other arenas that I and my colleagues have worked in to engage youth in health care include physical activity, obesity, teen pregnancy, and interpersonal violence. Across all of these initiatives, our youth have risen to the challenge of taking an active part in their own health (Berge, Mendenhall & Doherty, 2009; Doherty, Mendenhall & Berge, 2010; Mendenhall, Berge, Harper et al., 2010; Mendenhall, Doherty, Baird et al., 2008; Doherty, Mendenhall, & Berge, 2010).
So why is it that teenagers appear to have less difficulty in learning how to work with providers in the PCMH and/or in CBPR? Is it because they have not yet been socialized into the conventionally passive patient-roles that are so consistent with conventional Western health care and/or "standard” education? Is it because they have not yet been socialized to presume that "real change” (however defined) takes a long time?
Honestly, I am not sure that it matters. What is important is that we not leave our youth on the sidelines as we advance our efforts in collaborative and integrative care. As we work to engage them, we will bestow in our youth the honor and confidence that they can take responsibility for their health and well-being. Their voice(s) and involvement represent an essential piece to a larger puzzle, and they are up for the task.
Berge, J., Mendenhall, T., Doherty, W. (2009). Targeting health disparities though community-based participatory research. Family Relations, 58, 475-488.
Doherty, W., Mendenhall, T., Berge, J. (2010). The Families & Democracy and Citizen Health Care Project. Journal of Marital and Family Therapy, 36, 389-402.
Mendenhall, T., Berge, J., Harper, P., GreenCrow, B., LittleWalker, N., WhiteEagle, S., BrownOwl, S. (2010). The Family Education Diabetes Series (FEDS): Community-based participatory research with a Midwestern American Indian community. Nursing Inquiry, 17, 359-372.
Mendenhall, T., Doherty, W. (2007). The ANGELS (A Neighbor Giving Encouragement, Love and Support): A collaborative project for teens with diabetes. In D. Linville and K. Hertlein (Eds.), The Therapist’s Notebook for Family Healthcare (pp. 91-101). New York: Hayworth Press.
Mendenhall, T., Doherty, W. J. (2005). Action research methods in family therapy. In F.
Piercy, D. Sprenkle (Eds.), Research Methods in Family Therapy (2nd Edition) (pp. 100-118). New York: Guilford Press.
Mendenhall, T., Doherty, W., Baird, M., Berge, J. (2008). Citizen Health Care: Engaging patients, families and communities as co-producers of health. Minnesota Physician, 21(#12), pp. 1, 12-13.
Mendenhall, T., Harper, P., Stephenson, H., Haas, S. (2011). The SANTA Project (Students Against Nicotine and Tobacco Addiction): Using community-based participatory research to improve health in a high-risk young adult population. Action Research, 9, 199-213.
Mendenhall, T., Whipple, H., Harper, P., Haas, S. (2008). Students Against Nicotine and Tobacco Addiction (S.A.N.T.A.): Developing novel interventions in smoking cessation through community-based participatory research. Families, Systems & Health, 26, 225-231.
||Tai Mendenhall is an Assistant Professor at the University of Minnesota (UMN) in the Department of Family Medicine and Community Health, the Associate Director of the UMN’s Citizen Professional Center, and the co-Director of mental health teams within the UMN’s Academic Health Center / Office of Emergency Response’s Medical Reserve Corps (MRC). He is the Coordinator of Behavioral Medicine education at the UMN / St. John's Family Medicine Residency Program, and holds an adjunct faculty position in the UMN's Department of Family Social Science. Dr. Mendenhall’s principal investigative interests center on the use and application of community-based participatory research (CBPR) methods targeting chronic illnesses in minority- and under-served patient and family populations.|
Posted By Lisa Zak-Huner,
Wednesday, June 15, 2011
| Comments (0)
a typically non-typical day at the family medicine primary care clinic.
ALL my morning patients show up. That must be a record! More often than
not, my patients no-show. That’s just one of the changes I’m getting
used to working here. As I’m working to fulfill my university’s
graduation requirements for clinical hours, I sometimes feel stressed
when patients do not show. Other times, I am quite relieved to have some
time to write case notes, consult with other providers, process, and
maybe catch a bite to eat. It feels like a roller coaster.
this morning, my head is as full as my caseload. At maximum, I have
about 5 minutes between sessions to digest what just occurred with one
patient and prepare for the next. This particular day, I’ve switched
therapy rooms twice- conducting therapy in two of the faculty
physicians’ offices. The clinic serves a very high needs population- low
income, immigrant, severe psychosocial stressors, complex health
concerns (diabetes, chronic pain, GI problems, renal failure, obesity
etc), non-English speaking, severe mental health issues (PTSD, severe
depression, severe anxiety problems) etc. So, I sometimes pray for the
days in grad school where a couple’s ‘only’ problem was infidelity.
the past four hours, I have worked with someone who has severe
depression, anxiety, and alcoholism. The depression is so severe that we
mostly sit in silence. The patient struggles to make eye contact and
stutters out a few short sentences while staring out the window. The
safest topics to discuss include children, the weather, sports, and
plans for the weekend. I feel like it’s a combination of an interview
and an awkward conversation with a stranger. I wonder how this has been
helpful for the past 5 weeks. My head tells me this must be or the
patient would probably not keep coming. Regardless, I feel uneasy. Even
with all my knowledge of projection, transference, and counter
transference, I can’t help but feel depressed and anxious as we leave
patient is struggling with chronic pain from an old injury. She retells
the same story about medical mismanagement of her pain. I can almost
recite the ten year history with her. Most of session is spent
validating feelings of mistrust, deceit, hurt, and skepticism. I think
back to Arthur Kleinman’s book Illness Narratives.
Conceptualizing her story from this perspective helps guide our
sessions, my suggestions to her physician, and my sense of competence.
The anxiety and depression from session one has waned. Instead, I want
to feel comfortable with the repetition and make sense of it. I come
back to the same question. Am I helping? How? It certainly doesn’t feel
like I’m pulling much from the different models of family therapy I
learned that are supposed to guide my interventions. No time to process
that- the next patient is here.
spend the next two hours in another crash course on Hmong culture. One
patient’s depression and suicidality have decreased, but perhaps only me
and her primary physician notice. The depression remains severe. I go
with my gut on this one. Teach me about your culture, I ask. If I don’t
understand what guides your interpretation of past and present
experiences, therapy won’t be the most effective. The patient’s normally
flat affect disappears a little and I see a small amount of brightness.
Even though we’re working through an interpreter, (which normally seems
to slow down the process) the session flies by. I’m soaking up
everything I’m learning, and the patient is very interactive. I’ve gone
from feeling uncertain and somewhat uncomfortable about the first two
sessions to feeling like I’m on track.
next patient is new and not really sure what I do and how I can help.
It ironically parallels my own general feelings this fall. We talk
(again through an interpreter) about what the primary physician
recommended for treatment and how she’s described my role. The patient
is not very clear, and my explanation does not seem to clarify anything.
However, since the physician has said I can help, she is more than
willing to keep returning for future sessions. Right now, I’m not sure
where to head with her case either.
rest of the day flies by. I try to make sense of what happened during
the morning. Over lunch I balance supervision, food, case notes, and
more spontaneous consultations with other clinic staff. During the
afternoon, I switch gears. I’ve gone from provider to teacher. I walk
into the precepting room to see which resident I have not shadowed and
evaluated. I ask one if I can tag along for the afternoon to help him
get his patient-centered evaluations out of the way. We don’t know each
other well since our time at the clinic hasn’t overlapped much. I don’t
know what to expect or how he might view a mental health intern serving
as a mental health preceptor for the afternoon. I’m acutely aware of the
power dynamics- I am younger, female, an intern, and a mental health
professional. I’m also still learning what I can offer in the world of
medicine and how to do it. Everything I’ve learned in theory is being
tested. In all, we see about ten patients ranging from well-child checks
to chronic pain, tension headaches, and diabetes management. By the end
of the day I am exhausted. I’ve gone up and down, riding a roller
coaster of stress, emotions, and feelings of incompetence versus
This blog feels long, overwhelming, pressured, and too detailed.
Perhaps it’s the perfect way to communicate my experience. I can’t edit
these days. They occur in full force- fast, detailed, and sometimes
overwhelming. I’ve learned how to ride the roller coaster a bit better.
I’m far from being comfortable, but I know how to hold on and not get
sick. And every now and again when it takes an unexpected turn, I get
excited. I don’t panic. I hold on tighter, lean into the curve, and look
around. Just as the roller coaster drops, I relax a little. Through
this, I see how I can help and am reminded of why I enjoy this work.
|Lisa Zak-Hunter, MS is a doctoral candidate specializing in family
therapy at the University of Georgia. She is currently completing a
behavioral medicine internship with the Department of Family Medicine
and Community Health at the University of Minnesota.
Her main clinical, teaching, and research interests lie in the realms
of collaborative health care and increasing biopsychosocial
understanding of mental and medical health conditions. She has a
particular interest in adult eating disorders.