listens to the radio or watches television nowadays knows that "healthcare” in
this country – however it is defined – is undergoing a dynamic and messy
evolution influenced by a myriad of competing interests and constituencies. One
of the positive things rising out of (or perhaps enduring despite) all of the
political wrangling that makes it to NPR’s "All Things Considered” or ABC’s
"World News” is that the calls for integrated care are stronger now than they
have ever been. Whether physicians are working with therapists to help a
patient for his/her own sake or if it’s to offset forthcoming medical costs
associated with a(nother) hospitalization if they do not, really doesn’t
matter. What matters is that providers across a variety of disciplines are
increasingly working together because, somehow, everybody wins: patients are healthier,
providers are more effective, administrators are less overwhelmed, and payers’
funds are more secure.
training sites across different mental health fields prepare future healers to
enter these complex work environments, we are seeing many of yesterday’s
interdisciplinary tensions regarding who is "better” (e.g., Psychology vs. MFT
vs. Social Work) change to contemporary mutual respect and valuing of our
colleagues’ contributions to a whole that is more than the sum of its parts. This
shift is likely, at least in part, a reflection of how we are no longer working
within the comfort of private practices that are isolated (or at least insulated)
from the biopsychosocial/spiritual realities of the worlds that our patients
and families reside in. We are working on a common ground that is not claimed
by any single mental health discipline. We are on Medicine’s turf now, wherein
most of us – whether we identify personally as a "family therapist,”
"psychologist,” "social worker,” or "counselor” – are seen by everyone else as
a "mental health clinician,” "behavioral medicine practitioner”, or "shrink.”
Defining and Proving the Profession
trenches of day-to-day practice, many would argue that our medical colleagues,
patients and families, and other treatment team members do not care what
discipline us mental health providers were originally trained in. And I would,
in many cases, agree with them as long as key facets and processes of what I
espouse to be essential to good collaborative care are advanced (e.g.,
biopsychosocial/spiritual sensitivity to the systemic nature of
patients’/families’ presentations, active efforts to promote agency and
communion). However, from the 1000-foot view of health care policy and 3rd
party payer systems, the disciplinary home-base of mental health providers is
in fact VERY important. Psychology, for example (with its uncompromising
efforts to advance – and deep pockets to support – research, political advocacy,
and lobbying for preferential coverage), has long been able to keep other
mental health fields from sitting at the healthcare table and/or drawing
equally from available funds for service.
As a medical family therapist, it
would be easy to demonize Psychology’s efforts to establish itself so well at
the head of this table (to the detriment of me, my own specialty, or
professional home). However, doing so without challenging MedFT’s contribution
to this imbalance would be irresponsible. For example, Tyndall’s (2010) recent review
of almost two decades of literature found only 65 articles about Medical Family
Therapy, almost all of which are focused on the history, development, and/or
application of clinical skills and processes – i.e., NOT on the evaluation of
MedFT’s effectiveness or efficacy. In my opinion, we must compare this paucity
of published work to the hundreds (if not thousands) of articles that highlight
interventions housed within Psychology – or even Social Work – and ask, "Where
are the MedFT researchers?”, "What are they doing?” and/or "Who do you think
HMOs and other health systems are more likely to pay for, given the available
To be sure, it
important for all mental health disciplines involved in the evolution of
collaborative and integrated healthcare to work hard to produce solid empirical
evidence to survive. For MedFT per se, I believe that the first thing we must do
toward this goal is to establish and settle-upon what it is we do and how this
overlaps with and is distinct from other types of care. Extant literature
regarding our efforts to date is very messy in this regard (e.g., defining
MedFT inconsistently from one article to the next), and this makes it difficult
for researchers to take ensuing steps to assess which components or processes of
MedFT contribute to desired outcomes, and/or to evaluate and compare MedFT
approaches to standard care alone and other collaborative models.
Drawing from the foundational work of
McDaniel, Hepworth, and Doherty (1992), along with writings by Lindville,
Hertlein, and Prouty-Lyness (2007) and Tyndall (2010), key components of what
MedFT looks like on-the-ground are now coming together. They include: a) a theoretical
foundation in MFT and systems theory; 2) biopsychosocial / spiritual
sensitivity in care; 3) targeted efforts to empower patients’/families’ active
participation and influence in care (i.e., "agency”); 4) purposeful supporting
of and attention to emotional connections between patients and family members
and other important persons within their immediate social systems (i.e.,
"communion”), and 5) interdisciplinary collaboration within the contexts of a
larger care team and supporting organizational structure.
the Right Questions
Okay, there’s our baseline definition.
Now we have to get to work. We must advance research that documents MedFT’s applications/variations
from this baseline characterization, and its processes within different teams
oriented to different patient and family presentations. Across Peek’s (2008) three
worlds of health care, we must evaluate MedFT across clinical, operational, and
financial arenas. We can do this through qualitative methods that tap
patients’, families’, providers’, and/or administrators’ experiences across
different care types and clinical procedures. We can do this through
quantitative methods that compare and track disease-related outcomes, cost offset
data, and/or inter-member functioning and satisfaction in care teams. We can do
this through mixed-methods approaches that simultaneously capture the richness
of participants’ experiences alongside objective measures of beneficent change.
Wherever we choose to start, and whatever we choose to do, we will be advancing
MedFT – because at the present time our specialty is so novel that there are
more "gaps” in what we know than there are empirically supported areas of what
I am not advocating that we set out to
"prove” MedFT’s universal superiority over any other discipline, nor have I
ever found inter-departmental squabbling over whose field or approach is "best”
to be very helpful as it relates to clinical work. I believe that graduate
students within any discipline do better when they are exposed to each other’s
fields and learn how their own and other’s respective efforts contribute to a
larger mosaic of high quality and effective care. Just as there are some tasks
in which a hammer is more appropriate than a screwdriver (and visa versa),
there will be some scenarios in which MedFT is a better fit than a
straightforward psychological assessment or intervention (and visa versa). But
in order for MedFT to have a stable place at the healthcare table, it (we) must
catch-up and establish our right and our worth be there.
And so, let’s get started. Now.
D., Hertlein, K. & Prouty-Lyness, A. (2007). Medical family therapy:
Reflecting on the necessity of collaborative healthcare research. Families, Systems and Health, 25, 85-97.
S., Hepworth, J., & Doherty, W. (1992). Medical
family therapy: A biopsychosocial approach to families with health problems.
New York: Basic Books.
C. (2008). Planning care in the clinical, operational, and financial worlds. In
& D. Stafford (Eds.), Collaborative
medicine case studies (pp. 25–38). New York: Springer.
L. (2010). Medical family therapy:
Conceptual clarification and consensus for an emerging profession.
Unpublished doctoral dissertation. East Carolina University.
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.
He holds an adjunct faculty position in the UMN's Department of Family
Social Science and mentors doctoral
students who are completing the UMN’s Preparing Future Faculty series in
college-level teaching. 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.