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MedFT as Flower: Family Caregiving as Forest

Posted By Barry J. Jacobs, Tuesday, July 24, 2012

From that magical moment in the Minnesota hot tub in 1991 when Susan McDaniel, Bill Doherty and Jeri Hepworth coined the term "medical family therapy,” the field has had a slow but steady growth, sending tendrils into curricula for family therapists and other healthcare professionals and blossoming into a dozen or so certificate and degree programs around the country. For this progress, we all should be proud. But MedFT, to me, is like a delicate, hothouse orchid, assiduously watered and trimmed, surrounded by a burgeoning forest of more lush and verdant organic growth. The towering trees nearly blocking out the sun nowadays are the results of a fertile, consumer-initiated movement that took root around the same time as MedFT. That movement—now this country’s chief focus on families and illness--is called "family caregiving.”

Orchids and oaks, you say. Apples and oranges. Family caregiving, you contend, is what devoted family members do for an ill loved one; medical family therapists use systemic expertise to foster that endeavor. But while the term "family caregiving” is used to describe the sacrifices and struggles of over 60 million Americans in their provision of care to ailing relatives and friends each year, it also denotes a multi-disciplinary research, advocacy, and clinical effort with a complex infrastructure of federal, state and local support programs, disease- , relationship- and culture-specific research, and public and private funders and policy mavens.
Apples and oranges
Orchids and oaks, you say. 

Apples and oranges.

 

All that MedFT is striving to achieve—to better understand how families are buffeted by illness and disability and can continue to develop resiliently—the field of family caregiving has also striven for and has far outgrown us. 

Take research, for example. Empirical studies within MedFT are relatively few, are based on small subject groups, and have limited generalizability. In contrast, the research conducted over the past 25 years by psychologists, nurses, social workers, family physicians and others, particularly about dementia caregiving families, has been extensive, broad and deep. The original question those researchers undertook to answer—how family caregivers are affected by caring for someone with Alzheimer’s disease—has long been answered with evidence of increased morbidity (insomnia, depression, musculoskeletal problems; see Schulz & Martire, 2004) and mortality (see Schulz & Beach, 1999). These diverse researchers have also largely answered the next question—what kind of supports better help family caregivers cope (see here)—and are now working on how to translate those findings into effective public programs on the state and local levels.

Then there’s advocacy. MedFT academicians and practitioners have attempted and accomplished little in the policy arena. The powerhouse family caregiver consumer groups (e.g., National Family Caregivers Association, National Alliance for Caregiving, Family Caregiver Alliance) and other larger organizations with a strong interest in family caregiving (e.g., AARP, Alzheimer’s Association) have lobbied for and helped push through landmark federal legislation, including the Family and Medical Leave Act (1993), the National Family Caregiver Support Program (2000), and the Lifespan Respite Act (2006). Family caregiver advocates have made sure politicians know that there’s a growing constituency of Baby Boomers who want more monies earmarked for supporting their aging parents. Even in tight budgetary times, those funds have gradually increased.

The family caregiving movement’s clinical efforts might not be recognized by medical family therapists as "clinical” at all. Largely consisting of psychoeducation, screening for depression and anxiety, and providing respite care, the caregiver support programs are not particularly systemic in orientation, tending to focus on the needs of the primary caregiver. (Here’s where we have something to teach them about better harmonizing the interactions among various family members to produce better outcomes for the patient and family.) But given the widespread availability of caregiver support services, covering every county in this country, the family caregiving movement is meeting more of the basic psychological needs of the vast majority of families dealing with illness than MedFT could ever hope to achieve.

So what should all this mean for medical family therapists? A few thoughts:

  • MedFT should make every effort to become part of the family caregiving movement: That movement has been intensively collaborative, drawing on the strengths of a broad range of healthcare, legal and financial disciplines, as well as family members and patients. Yet because medical family therapists have been toiling in a few relatively isolated outposts, most family caregivers and leaders in the family caregiving field have never even heard of MedFT. I believe that the systemic expertise that we have to offer would greatly enhance the current efforts of family caregiving to roll out effective community-based programs.
  • We need to call our research family caregiving studies, not MedFT studies. Our researchers need to publish in the major journals for family caregiving, such as The Gerontologist and Aging and Mental Health. That’s how our work with be more widely recognized, disseminated and implemented.
  • We should be pitching ourselves clinically to the public and to colleagues from other disciplines on primary and specialty healthcare teams as "family caregiving experts,” not medical family therapists. This will better communicate who we are and what we do than the current identity we have. This is, in fact, truth in advertising—we are family caregiving experts!
  • Our MedFT associations—e.g., the CFHA MedFT work group and the MedFT Facebook group—should be advocating for improved services for family caregivers. We should join with dozens of other healthcare professional associations in the large and powerful coalition known as the National Alliance for Caregiving (www.caregiving.org). NAC is the single strongest voice advocating in Congress and in the academies today for the needs of families struggling with illness and disability.

In short, we need to branch out of the insular hothouse world and roam the forest. We need to cross-fertilize with other disciplines more. We need to pollinate their ideas with our own and improve their systemic understanding and efficacy. We have to trust that who we are and what we do will matter--and not just get lost in the scenery.

References

Schulz, R & Martire, L (2004). Family caregiving of persons with dementia: prevalence, health effects and support strategies, Am J Geri Psychiatry, May-June, 12(3), 240-9

Schulz, R & Beach (1999). Caregiving is a risk factor for mortality: the Caregiver Health Effects Study, JAMA, Dec. 15;282(23):2215-9

 

Barry J. Jacobs, Psy.D., Director of Behavioral Sciences for the Crozer-Keystone Family Medicine Residency Program in Springfield, PA, has long been involved in the family caregiving movement. He is the national spokesperson on family caregiving for the American Heart Association and an honorary board member of the Well Spouse Association. Most recently, he was appointed to the Caregiver Advisory Board of AARP. He has long written the advice column for "Take Care,” the newsletter of the National Family Caregivers Association, and is also the author of The Emotional Survival Guide for Caregivers (Guilford, 2006).



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Comments on this post...

Janelle Jensen says...
Posted Tuesday, July 24, 2012
This a bold and creative challenge you propose.....I accept! The numbers around caregiving families, both currently and the projected growth, are astounding and will demand attention, no doubt. I agree that we have an opportunity to respond and are well equipped to branch out, with purpose and confidence, into the forest closing in on us. I have recently been volunteering with my local chapter of the Alzheimer's Association, working with caregivers and individuals with memory loss and it has been nothing short of a collaborative and systemic medical, family, and therapy experience. Thank you Barry for your passion and energy around family caregiving and I look forward to continued conversation and response.
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Matthew P. Martin says...
Posted Tuesday, July 24, 2012
Terrific post Barry. Thanks for sharing your ideas and your passion about a very important community of researchers and clinicians. As someone who is almost completely ignorant of the family caregiving (FC) community I appreciate learning more about the examples that members of this group have shown. A couple of thoughts:

1. The caregiving community and movement is a great example of the power of interdisciplinary collaboration. The community spreads across many different disciplines and benefits as a result. MedFTs could stand to take a page from that playbook. Although many MedFTs are embedded within multidisciplinary sites, it often feels like we are isolated due to a lack of self-promotion and clear conceptualization. It sounds like the FC community does not struggle in this way.

2. On a related note, if you are saying that MedFTs as a whole should pitch themselves as family caregiving experts I disagree. I do believe that MedFTs should be passionately and actively engaged in the FC community and individual MedFTs can certainly assert themselves as FC experts. But to describe all MedFTs as FC experts might be too broad of a generalization especially considering that some MedFTs, like myself, have little experience in family caregiver treatment. MedFTs should have expertise in working with families struggling with chronic illness and disability and caregiving.

Hopefully though there are MedFTs who are encouraged and intrigued by this post, like myself, to move themselves towards becoming more involved in FC.
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Randall Reitz says...
Posted Tuesday, July 24, 2012
See my response here:
https://cfha.site-ym.com/?ReitzResponse
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Jennifer Hodgson says...
Posted Tuesday, July 24, 2012
I absolutely love the diagram that Randall put together and could not agree more with the ideal for MedFT. I also concur with Matt that MedFTs are not focused exclusively on family caregiving. The idea of MedFT paying homage to the biopsychosocial model with continuous consideration of the systemic context is paramount. The idea that all MedFTs need to be proficient in family therapy is not a requirement. However, all MedFTs should be skilled at engaging families about the challenges, benefits, and impact of illness on the individual and system. MedFTs by design are well trained to rally systems and help initiate integrated care models that are accountable to a family-centered model of care. People should be trained to provide MedFT and depending on how much training may engage in family therapy services.
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Janelle Jensen says...
Posted Tuesday, July 24, 2012
Does not illness or disease demand caregiving? If we are systemic and collaborative, how are we not including the caregiving team, which directly impacts the patient’s biopsychosocial experience? Again, I think we have a great opportunity to respond to the reality of what lies ahead- millions of family care providers who are experiencing increased medical and psychological needs directly related to caregiving, that often go undiagnosed or unattended to, increasing the risk of becoming a care receiver, and creating a dysfunctional and costly cycle of medical and psychological services required and provided. By default of numbers, we are encountering family caregivers everyday in our profession. Perhaps MedFT, who by name, claims that we have a unique understanding of medicine, families, and therapy can be of more assistance to the community and have greater access to families in dire need of support by broadening our own view and interpretation of our work.
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Barry J. Jacobs says...
Posted Wednesday, July 25, 2012
Thank you Janelle, Matt, Randall and Jennifer for your interesting comments. (I especially liked your comments, Janelle.) Randall, your visual depiction of what you believe reminded me of the pre-Copernicus, geocentric depictions of the universe. In the idealistic, distorted universe you depict, MedFT is at the center, the linch-pin. As much as I love MedFT's basis in the biopsychosocial model, as a field it is not close to the center. (Perhaps it's slowly drifting in the asteroid belt.) We can be a bigger, more central player only by leaving our cold, solitary orbit and joining others in the greater expanse of thought on families and illness. And I don't mean positioning MedFTs to be the behavioral health collaborators par excellence in primary care and other medical settings. I mean that we have to touch the greater planets--family caregiving among them--with the fire of biopsychosocial-systemic knowledge..

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Dan Marlowe says...
Posted Wednesday, July 25, 2012
Barry and Janelle,

I would have to say I am with Matt and Jennifer on this one. While I agree that MedFT should coordinate many of its efforts with the family care-giving field, I want to emphasize my choice of language- ‘many.’ Again, I think some of us are getting caught up on the name, as lovely as it might be, and with it run the risk of pigeon-holing the field into oblivion. Like family therapy in general, it has never been about working exclusively with families/couples, which again falls back to the assumptions people make about the name. The terms family, couple, and marriage ultimately become the backdrop through which patterns of communication and relating inter- and intra-personally are seen as facilitating the context that sustains or resolves whatever the problem might be (I’m thinking classic family therapy here; e.g, MRI), and are not descriptive of whom we work with or what the field is exclusively focused on- the terms become a metaphor for a ‘relational’ focus not a focus on interpersonal relationships.

If we are saying that MedFT is ONLY about family caregiving, I believe we are cutting ourselves off at the knees regarding the breadth of application for systemic/relational thinking in medicine, the healthcare system and to health in general (this is what I believe MedFT to be). Think about the recent blog post with Cleveland Shields, one of his main focuses is on patient/provider communication- with and without families. Or even Bill Doherty and Tai Mendenhall’s Citizen Healthcare project that is not exclusively focused on families but activating entire communities- neither of these would be considered family caregiving research per say. What about improving communication and relationships within the healthcare team itself? These patterns of relationship and communication are the foundation of any integrated/collaborative care model and may/may not include a patient or family.

I think ultimately, it comes down to a difference, like in family therapy, of how people within the field conceptualize and understand the term ‘family.’ One can see ‘family’ as THE unit of care, which is where I think both of you are going with it, or as the most readily accessible conceptualization/description of a relational way of thinking. It is the difference between a Minuchin-esk and Batesonian view of family (of which I have the latter). Bringing it back to some of the recent conversations about MedFT, we as a field (if we are calling it that) are taking the stance that MedFT is not specific to marriage and family therapy with the hope of broadening the appeal of the field as a whole. Why then would we simply trade one constraining alliance for another?
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Elizabeth Doherty Thomas says...
Posted Wednesday, July 25, 2012
I just have to post because this is all so fascinating! I talked with my father on the phone (the Bill Doherty in your post) and he laughed out loud about the hot tub reference in this blog post.

I'm in "serious research mode" right now and having a blast absorbing not just raw information, but the culture of CFHA, of MedFT, of family caregiving, and all the organizations out there. Your blog post was exactly what I wanted to read based on my early impressions of things (well, early after growing up with all this because of my father....)

I'm thrilled to be a new member of CFHA, and to attend the October conference. My passion is to bring my couples and family therapy, marketing and internet native passions to the field, reaching the masses in a collaborative, intelligent way... (after I get my MFT degree in May 2013.)
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Janelle Jensen says...
Posted Thursday, July 26, 2012
Dan, good points. I think it would be fantastic if all involved could come to MedFT and family caregiving with the Batesonian stance, and feel, for the most part that I do. It seems the trouble is that we know the difference, but possibly the general public is not as familiar with this framework and could possibly become confused. Perhaps within "family caregiving" we can better communicate our understanding of the broader context of caregiving - family members, facilities, docs, etc. But again, as you point out we are just exchanging on constraint for the other. It seems to me that perhaps we have strides to take in how we are communicating and possibly part of the point is that the term family caregiving is a natural entry point for the public to understand our work, and if nothing else, I think it is definitely something MedFT should prioritize in our research and practice. Regardless, I am just excited that we are having conversations about caregiving!
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Lauren N. Decaporale-Ryan says...
Posted Sunday, July 29, 2012
After reading Barry’s post and the comments that follow, I’m so grateful for the various opinions on this important issue. Though I don’t believe that all in the MedFT field should be pitching themselves as “family caregiving experts,” I would love to see MedFT becoming a more active part of the family caregiving movement. As so many have noted above, the caregiving community is a terrific example of what can be achieved through interdisciplinary care. However, there is a significant lack of mental health professionals and other service providers who are entering the world of geriatrics. With the recent report from the Institute of Medicine regarding the need for service in the field of mental health for aging, this is a wonderful opportunity for MedFTs to bridge the gap between integrated care and family caregiving services, creating the vision that Randall captured in his diagram. In addition to bridging this gap that exists in geriatric family caregiving, I would challenge that the family caregiving movement be more broadly defined: caregiving encompasses many generations and many different demographic groups – all of whom would benefit from the involvement of MedFTs and a collaborative approach to their care. As Barry so appropriately noted, MedFTs must “cross-fertilize” with other disciplines more, and the broad world of family caregiving would allow for this nicely.
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