Print Page | Contact Us | Your Cart | Sign In
CFHA Blog
Blog Home All Blogs

A Call to Engage Youth in Collaborative and Integrated Care: Part 2

Posted By Tai J. Mendenhall, Ph.D., LMFT, CFT, Thursday, June 30, 2011
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.

References:

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.

Tags:  Behavioral Health  family therapy  medical 

Share |
PermalinkComments (1)
 

A Call to Engage Youth in Collaborative and Integrated Care: Part 1

Posted By Tai J. Mendenhall, Ph.D., LMFT, CFT, Thursday, June 23, 2011
The call for interdisciplinary collaboration in health care is a longstanding one, and our collective efforts to do this are evolving across medical- and mental health- training programs and care facilities today more than they ever have. Recent advancements in the Patient Centered Medical Home (PCMH) movement are arguably pushing team-based approaches in continuous and coordinated care toward the middle of the bell-curve, wherein someday soon our integrated models will represent the rule (not the exception) to how health care is done.

My experiences as a clinician and researcher in this exciting time in health care have exposed to me to a variety of definitions of what "integrated”, "collaborative”, or "medical home” sequences looks like, and efforts by the CFHA and others to standardize and clarify these characterizations are presently underway. However, while common themes throughout these descriptions encompass the collaboration between professionals who represent different disciplines (e.g., a family physician with a marriage and family therapist) and/or the collaboration between professionals and patients (i.e., encouraging and facilitating patients to take active roles in their own health), most hallway conversations, formal presentations, research studies, professional literature, and clinical work that I have taken part in (or am aware of) around the PCMH frame patients as adults.

I believe that it is important to extend our call to engage "patients” in collaborative and integrated care to purposively include children and adolescents. I support this call on two primary grounds:

• First, many of the most prevalent and difficult presentations in health care today (defined as those that are the most common, most expensive, and/or most connected to co-morbidities and death) begin early in life. Diabetes, for example, is highly correlated with cardiovascular diseases (which represent the #1 cause of death in the United States), kidney disease, reduced or lost vision, amputations, and depression – and is directly connected to the rising epidemics of childhood obesity and sedentary lifestyles of America’s youth. Smoking is similarly correlated with cardiovascular diseases (as well as asthma, diabetic retinopathy, optic neuritis, influenza and pneumonia) – and most smokers (up to 90% of them) begin as teenagers or young adults. Put simply, then, it is easier to prepare than it is to repair. By engaging patients in health-related activities early in life, it is more likely that they will avoid experiencing commonplace troubles later on down the road.

• Second, the advancements of the PCMH and parallel efforts in community-based participatory research (CPBR) bring with them a sharing of responsibility between providers and patients. While providers maintain responsibility for learning and appropriately using knowledge in the prescribing of medications or performing medical procedures, for example, patients maintain responsibility for managing their diets, physical activity and other health-related behaviors. This is important to note because it transcends conventional provider/consumer models in which passive patients are rendered care (i.e., "fixed”) by all-knowing/all-powerful providers. And just as adult patients must assume responsibility for their own health within the PCMH, so to should children and adolescents. As we encourage and facilitate our youth to do this, a new generation of active (not passive) patients is born.


As I have advanced the call for active engagement of youth in health care across a variety of formal and informal meetings with colleagues, almost everyone has agreed that the idea carries a great deal of face-validity. They add that, too, that oftentimes kids (read: teenagers) will listen to each other more than they will to an adult, and that facilitating care sequences and/or supportive interventions that allows for this may offer a great deal.

But it’s when my colleagues ask about evidence of such efforts being effective that I really light up. Beyond the (admittedly limited) articles that any of us could find through a literature review regarding youth-engagement in health, I have been involved in several such projects since beginning my current position at the University of Minnesota. In my next blog entry, I will highlight some of these projects – and the extraordinary work our youth can do as we facilitate their active participation in care.

*This is the first of a two part blog on engaging youth in collaborative and integrative care.




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.

Tags:  Behavioral Health  community health  family medicine  Integrated Health  medical  Youth 

Share |
PermalinkComments (0)
 

Medical Family Therapy Intern Part II: How do I Help?

Posted By Lisa Zak-Huner, Wednesday, June 15, 2011
November 2010:

It’s 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.

After 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.

In 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 the office.

Another 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.

I 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.

The 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.

The 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 competence.


Today:
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.

Tags:  family therapy  medical 

Share |
PermalinkComments (0)
 

Contact Us

P. O. Box 23980,
Rochester, New York
14692-3980 USA
info@CFHA.net

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.