Melissa Lewis's blog is the last post in a month-long series from recent graduates in their first semester of a faculty or junior faculty position.
Please read the previous posts.
1. Dear student of behavioral health,
Congratulations on your pursuit to build a healthier world for all of us one client, couple, family or community at a time! You are being trained in the classroom, in the clinic, in local agencies, and for some of you in medical settings. As I reflect on my training as a marriage and family therapist (MFT) compared to the training that is currently needed, I envision a new direction for behavioral healthcare based on our understanding of what health and healing now are. When I was trained as an MFT utilizing systems theory consisted of addressing behavioral health from an ecological and not a linear, reductionistic way. In practice this meant utilizing MFT theories and addressing problems within the relationship(s) and it ended there (see diagram to the right).
Today, things look very different. Addressing psychosocial symptoms alone and within the confines of the behavioral health clinic solely have been shown to not only be inadequate for client outcomes, but also is an extremely limited use of systems theory (Craven & Bland, 2006). Now we know that pain and fatigue associated with chronic illnesses, for example, have a strong effect on mood, relationships, and parenting (Lin, Lai & Ward, 2003; White, White & Fox, 2009).
With the clear understanding of the dynamic nature of biological, psychological, social and spiritual (BPSS) effects on health outcomes, our systems of care must reflect these patterns. For instance, cold handoffs (i.e., referrals without introduction) not only result in a lack of needed patient services but represent an old way of understanding health; experts in separate realms of health (Craven & Bland, 2006). While the BPSS components of our health system interact, so must our health systems. Students must learn the models and techniques of collaboration so that they can conduct a warm hand-off, understand the medical system, interact confidently with medical providers, and assess and treat using their expertise as well as that of their medical provider and the patients simultaneously.
Further, integrated careis quickly becoming strengths-based care, patient-focused care (equitable and culturally competent), collaborative care, cost-effective care, and evidenced based care which are the pillars of the Institute of Medicine aims. The behavioral health skills needed to work in this system look much different than the skills that were needed in the previous system of healthcare 20 years ago and will continue to change in the coming years. The way health research is being conducted is a sign of what is to come.
For instance, Cutrona and colleagues (2003) have discovered that neighborhood level effects (i.e., safety, financial status, racism) are related to individual health, as well as relational outcomes. The work of Karen Matthews and colleagues (2003) has shed light on the process of cardiovascular health and its link to early childhood psychosocial traumas. Both in utero and early childhood biopsychosocial traumas are linked to worsened mother-child relationships, reduced cognitive and verbal development, and even increased risks for obesity, diabetes, and heart disease later in life (Hart & Risley,1995; Shonkoff & Phillips, 2000; Kaati, Bygren, Pembrey, & Sjöström , 2007; Gluckman, Hanson, Cooper, & Thornburg 2008; Boynton-Jarrett, Ryan, Berkman, & Wright, 2008).
The implications of this kind of epigenetic work will be astounding for our field and will demand that in the next 20 years, behavioral healthcare providers are aware of and can treat the devastating effects of adverse childhood events, historical traumas, and current micro and macro traumas (BPSS). We will not only be asked to treat those affected by these events but also create programs to prevent these events from happening. This, I believe, will require all behavioral healthcare providers to lower themselves from an expert hierarchical position (i.e., dictating treatment protocol) and learn to work with broader systems (i.e, communities) in a more equitable and empowering way to improve individual as well as larger health systems (see Doherty & Mendenhall, 2006). Given the popularity and success of community based participatory research in empowering communities to use their local knowledge and resources to improve health and standards of living, behavioral healthcare providers will soon be required to learn these research and clinical techniques as the new standard of care for health promotion, prevention, and treatment.
This is an exciting time in healthcare with amazing possibilities for positive changes in the healthcare system. Good luck in your journey in becoming a collaborative and integrated behavioral healthcare provider!
An MFT professor 1
2. Dear MFT professor,
As an MFT student, I feel that I need MedFT training because the medical care system affords us with a unique opportunity to serve our clients. Specifically, we can collaborate with professionals within the medical system and bring a fresh systemic perspective which will hopefully produce better client outcomes. Nonetheless, I am excited and a bit nervous about learning integrated care! While I feel competent in the theoretical and clinical components of my MFT program, I am still nervous about working as a MedFT in this local hospital system in my upcoming internship.
As system thinkers, I know that each system is unique in so far as it has a power structure, roles, and almost unconscious rules that govern the systems. In MFT we know about the impact of trangenerational thinking. In the Medft world, I do not know the historical structures and systems of a hospital system. Who is a resident? Who is an attending? What does a short white lab coat mean opposed to a longer one? What is a charge nurse and what is an RN, BSN, or LPN? Is a DO really a doctor and what does social work do? I will be thrust into a system not knowing how it works; I wish I knew ahead of time so I can be as effective of an MFT as possible.
We know that the system of a medical care facility is different than a clinic. We may only see a client once, twice or maybe three times due to HMOs and PPOs. How does the therapist "do” therapy in such a short about of time? If I can only see them twice, do I still do a genogram? Can I do structural therapy in one session?
Lastly, do I need to learn anatomy and physiology, especially neurology? I worry when my clients discuss stage three cancer I will not know if it is worse that stage one. What if my client is on medications for their illness, does that affect their psychological health?
I know this is asking a lot, and I hate to be a bother. I entered this field with a strong desire to serve my clients through a relational lens in a medical setting and can’t wait to get started!
Thank you for your time,
An MFT (aspiring MedFT) Graduate Student2
3. Dear future students, clinicians and professors of behavior health,
I am a doctoral student at University of Akron who has worked and interned in several integrated and non-integrated care sites and would like to tell you a little bit about my experiences. Specifically, my internship experiences at St. Thomas Hospital and Akron Children’s Hospital in Akron, Ohio has grown my understanding of healthcare immensely. In these training positions, behavioral health providers are required to collaborate with other healthcare providers to support the patient’s specific needs. This opportunity to work alongside professionals who are stronger in the medical/biological aspects of treatment allows for a more holistic treatment approach for me. It has been very beneficial to learn to collaborate with those outside of my scope of training because it has significantly broadened my understanding of healthcare. This would not have been possible in a traditional MFT internship.
Part of my experience as an intern has opened my eyes to healthcare costs, reimbursement, and healthcare policy. I have learned that it is important to provide care that is empirically supported for cost effectiveness and I am fortunate to have been trained in an area that is becoming increasingly more supported. It is important to understand cost effectiveness and offset of integrated care treatment, as well as the importance of tracking and measuring biopsychosocial health markers to specialize and improve patient care.
Training that provides a foundation for this increased knowledge and collaboration will provide a more enhanced training experience that will equip individuals in the Marriage and Family Therapy field to work within the medical and hospital setting. My training has allowed me to encourage the integrated team to not look past the family system and, instead, provide support and structure for the families. This has been very fulfilling as an MFT in a medical setting as I learn my place in the medical system.
I have noticed an observable difference in the engagement of the family in behavioral health services in behavioral health versus hospital settings. I have found that within the medical setting there is a decrease in stigma around behavioral health talk giving me more of an opportunity to address psychosocial stressors and coping mechanisms. While at first I was unsure about how family therapists can fit into the medical model, instead I learned that this is exactly where we need to be!
An MFT Student 3
|¹ Melissa Lewis is a Visiting Professor at University of Akron in the MFT
program. She is a licensed Marriage and Family Therapist and an
approved AAMFT Supervisor. She received her Master's degree at Arizona
State University (MFT) in 2007 and her PhD from East Carolina University
(MedFT) in 2012. Her research area broadly encompasses the relationship
between stress response and BPSS outcomes. Specifically, she studies
the stress transmission model with military couples and is also
evaluating integrated care interventions aimed to reduce BPSS health
symptoms in both Native American and military populations. Melissa can
be contacted at email@example.com|
² Michael Polnik is married and a proud father of three. He holds his MA
in biomedical ethics from Case Western Reserve University and is
pursuing his PhD in MFT from The University of Akron. Michael can be
contacted at firstname.lastname@example.org.
Cook is a husband and a father to one son and has a daughter on the
way. He is a licensed MFT and PCC in the state of Ohio. Ryan is in his
final year in the Doctoral Counselor Education and Supervision program
specializing in Marriage and Family Therapy at the University of Akron.
He has experience working in a small agency where he provided family
therapy to foster care and adopted families. He is currently a clinical
therapist at St. Thomas Hospital and Akron Children’s Hospital’s Partial
Hospitalization and Intensive Outpatient Programs. Ryan can be
contacted at email@example.com.
Boynton-Jarrett, R., Ryan, L. M., Berkman, L. F., & Wright, R. J. (2008). Cumulative
violence exposure and self-rated health: Longitudinal study of adolescents in the United States. Pediatrics, 122(5), 961-970. doi:10.1542/peds.2007-3063.
Craven, M.A., Bland, R. (2006). Better practices in collaborative mental health care: an
analysis of the evidence base. Canadian Journal of Psychiatry, 51 (6 Suppl 1): 7S-72S.
Doherty, W. J., & Mendenhall, T. J. (2006). Citizen health care: A model for engaging
patients, families, and communities as coproducers of health. Families, Systems, & Health, 24(3), 251-263. doi:10.1037/1091-75184.108.40.206
Gluckman, P. D., Hanson, M. A., Cooper, C., & Thornburg, K. L. (2008). Effect of in utero
and early-life conditions on adult health and disease. The New England Journal Of Medicine, 359(1), 61-73. doi:10.1056/NEJMra0708473.
Kaati G; Bygren LO; Pembrey M; Sjöström, M. (2007). Transgenerational response to
nutrition, early life circumstances and longevity. European Journal Of Human Genetics: EJHG, 15(7), 784-790.
Lin C., Lai Y.L., & Ward, S. (2003). Effect of cancer pain on performance status, mood
states, and level of hope among Taiwanese cancer patients. Journal Of Pain And Symptom Management, 25(1), 29-37.
White, C., White, M. B., & Fox, M. A. (2009). Maternal fatigue and its relationship to the
caregiving environment. Families, Systems, & Health,27(4), 325-345. doi:10.1037/a0018284.
Cutrona, C. E., Russell, D. W., Abraham, W., Gardner, K. A., Melby, J. M., Bryant, C., &
Conger, R. D. (2003). Neighborhood context and financial strain as predictors of marital interaction and marital quality in African American couples. Personal Relationships, 10(3), 389-409. doi:10.1111/1475-6811.00056.
Matthews, K.A., Salomon, K., Brady, S.S., & Allen, M.T. (2003b). Cardiovascular reactivity
to stress predicts future blood pressure in adolescence.Psychosomatic Medicine, 65, 410-415.
Risley, T. R., & Hart, B. (2006). Promoting Early Language Development. In N. F. Watt, C.
Ayoub, R. H. Bradley, J. E. Puma, W. A. LeBoeuf (Eds.) , The crisis in youth mental health: Critical issues and effective programs, Vol. 4: Early intervention programs and policies (pp. 83-88). Westport, CT US: Praeger Publishers/Greenwood Publishing Group.
Shonkoff, J. P., Phillips, D. A., National Academy of Sciences - National Research Council,
W. S., & Institute of Medicine (NAS), W. C. (NAS), Washington, DC. (2000). From Neurons to Neighborhoods: The Science of Early Childhood Development.