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Earning our Place at the Healthcare Table: A Call for Research in Medical Family Therapy

Posted By Tai Mendenhall, Tuesday, January 10, 2012
Anybody who 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.

As our 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

Within the 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 evidence?”

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.

Asking 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 we do.

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.



References

Lindville, 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.

McDaniel, S., Hepworth, J., & Doherty, W. (1992). Medical family therapy: A biopsychosocial approach to families with health problems. New York: Basic Books.

Peek, C. (2008). Planning care in the clinical, operational, and financial worlds. In R.

Kessler & D. Stafford (Eds.), Collaborative medicine case studies (pp. 25–38). New York: Springer.

Tyndall, L. (2010). Medical family therapy: Conceptual clarification and consensus for an emerging profession. Unpublished doctoral dissertation. East Carolina University.


Tai Mendenhall

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. 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.


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