Posted By Leatrice Sherer,
Tuesday, August 19, 2014
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Being family-centered, the (also Hmong) physician had scheduled the appointment for both the man and his wife to see me, and both had come. Yet, when I entered the exam room, the man was alone. I immediately addressed bringing his wife in. He said she could come in later but first he wanted to speak with me alone. I “met him where he was” and began by speaking with him alone, actually for most of the session. He struck me as intelligent and insightful.
|The physician’s request was compelling: “I have made an appointment for you with a 33 year old Hmong man and his wife. He has already had 2 heart attacks, from which he had to be resuscitated. His wife witnessed everything. He is being prescribed medications that could greatly prolong his life, but he is very depressed and noncompliant. He takes his meds some of the time, if his wife reminds him. He misses appointments. If he does not change soon, he will die soon, and I have told him that over and over again. I have told him to think about his 3 young kids, even if he doesn’t care about himself. You have to do something!”|
At the time I received this request, I had worked full-time at this FQHC for 8 years. Despite having integrated records, and receiving occasional requests for crisis intervention, Behavioral Health Services was unfortunately still functioning pretty much as a co-located mental health service. Finally, after years of lobbying, I had been given the reluctant go-ahead from the Executive Director to embed within the clinic for one half-day per week for one-month, and “then we will see about continuing it”. The physician’s request came in the third week of the “let’s see” period. Frankly, it felt like a do-or-die situation for both the patient and me.
|"If he does not change soon, he will die soon "|
He had immigrated to the USA at 15 (just before his own father died of a stroke), so he did not get a decent formal education. He had only his physical body to rely on; he became an award-winning body builder, laborer and unlicensed auto mechanic. Following his heart attacks and surgeries, he lost his short-term memory and could no longer work as a mechanic. He had misunderstood post-surgery instructions to abstain from physical work as meaning “forever”, so he stopped all exercise. He had misunderstood instructions regarding his pacemaker and thought he had to stay away from electricity. That eliminated cooking, mowing, and fixing things. He now felt he could contribute nothing to his family. His wife periodically pointed that out and threatened to leave him.
At the time, this FQHC had a Hmong mental health case manager on staff, being paid by a grant. She and I discussed which cultural factors and family dynamics should inform our interventions. The case manager reminded me that because mistresses are common in the Hmong-American culture, she would have to start by allying with the wife to “gain permission” to take over some of the wife’s duties. I educated the case manager about the over-responsible/under-responsible dynamic and to be aware that the patient might try to get her “to do for him” instead of learning to “do for himself”. She did a good job; she helped him gain the knowledge and tools to gain access to the resources he needed to rehabilitate. The case manager frequently visited with the wife to maintain trust and to keep her anxiety level better managed. We both used some motivational interviewing to increase the patient’s commitment to self-care.
|Okay, I passed his test, but would I pass muster with his wife? |
Without his income, his wife was trying to start her own business. She needed the use of the one car and the one telephone they could afford. His days were spent sitting in her store front, watching the pre-school aged kids, relying on her to make his phone calls, remind him of things, and take him to appointments. He acknowledged his depression and hopelessness but said he wanted to live for his children’s sake. He also said that he had to depend on his wife for many things “no man should have to”, and between her alternately smothering him with advice and berating him about his irresponsibility, he felt like giving up altogether.
I asked his wife to join us, mostly to apologize for making her wait and to assure her that I would involve her soon. She immediately burst into hysterics, alternately crying and angrily “tattling on him”. He responded by acting alternately “stupid”, passive or rebellious. I immediately realized that this man had structured our initial interview correctly. First, in the absence of his wife, he showed me the man he could be, if treated respectfully. Second, with his wife present, he showed the relationship dysfunction that defeated both of them. Third, he was testing whether I would respond in a different way than his other providers. Okay, I passed his test, but would I pass muster with his wife? Structurally, I had to help her back away from either caretaking him or withdrawing from or carping at him. But I had to plan interventions that would earn her trust, help her understand that her over-reactive behavior was triggered by trauma, and help her manage the intensity of her anxiety and anger.
My job was two-fold:
• With the patient, addressing the many losses underlying his depression, affirming his effort and progress, and giving him “tips” about negotiating marital conflicts and strengthening his family relationships. (He and his wife could not manage to get into the clinic together for couples’ work).
• With the physician, making her aware that her style of interacting with the patient had become similar to that of the wife, with the same counter-productive results. She too had a high level of anxiety. As a first-generation Hmong professional, she was tremendously motivated to be a great doctor, and she was very committed to her community. The man’s frail health and noncompliance frightened her, and she made herself responsible to keep him alive. Once she understood, and I promised to keep her informed, her anxiety lessened and she was able to develop a more appropriate interactive style with the patient.
When I left the clinic 5 years later, this man was still alive and living with his wife and children. He was still not the most compliant patient in the world, but he was medically stable due to his greatly improved self-care. Looking back, I believe that no matter the type or number of behavioral interventions I could have used in this situation, none would have succeeded without the family-systems-informed context within which we worked, both within the patient’s family and within that health care delivery system. The principals would have continued to behave the same, and I would have become just another health care provider to avoid. I was fortunate to have had: 1) a case manager – who could work out in the community and whom I could supervise; 2) access to the primary care provider – who had learned to trust me; 3) the autonomy to develop a treatment plan that combined “behavioral” and “mental” health interventions; and 4) the availability of all the component services and an integrated communication tool, all centered in one place.
Unfortunately, when I left this clinic, the Hmong mental health case manager had been gone for 2 years; her grant had ended. A new CEO was more open to methods of integrated care, but “productivity” remained the bottom line. All health care providers were being hounded to see more patients for shorter periods, in part to pay for case management services. Locally, behavioral health providers in the FQHC consortium who had already gone to the half-hour appointment model were asking, “When do people find the time to chart? Talk? Think? Do teams?”
|No interventions would have succeeded without the family-systems-informed context within which we worked |
Nationally, some behavioral providers are suggesting that only “primary, behavioral care” should occur in the primary clinic and that “secondary, mental health care” should be referred out. Some behavioral providers – mindful of time pressures, privacy issues, and woefully inadequate EMR templates – are suggesting that we document only the minimum information necessary to get reimbursed by insurance. It is ironic that, while the philosophy of health care is moving more towards being more family-and-community centered, collaborative and integrated, financial and other factors are enticing providers to structure our health care environment in ways that can defeat the system-informed care that we know is best for patients and for us.
If we don’t make time to talk, and we don’t use chart notes as a way to inform and integrate all providers involved with the patient and family’s care, and we put up additional barriers by adding on outside providers, are we not in danger of colluding in the creation of a disengaged, poorly communicating, dysfunctional “family system” of health care delivery? Wherever our creativity and practicality lead us in designing new systems of health care, we need to remember that structure determines function. We need to design systems that facilitate both family-centered care and the collaborative, communicative work environment that allows the entire family of health care providers to do their best work.
Leatrice Mankin Sherer, PhD, LP, LMFT received her doctorate in Clinical-Child Psychology from the University of Massachusetts-Amherst and later pursued family therapy training. She “lucked” into her first job, as a faculty member in a family medicine residency program. Although she was initially frightened that this unusual position would prevent her from getting a “real” psychology job in the future, it did not matter. She “lucked out” again; she had found her passion. Her career has been spent providing family-centered, integrated care, primarily within medical settings. She has served on the faculties of three family medicine residency programs, in SC, ME and MN. In the latter position, she established a medical family therapy internship program. She and the medical program director developed curricula to teach residents systemic thinking, to teach team-building skills using in situ learning opportunities (e.g., practice management committee), and to mobilize healthy aspects of the medical education system to help residents in difficulty. These curricula were presented through various STFM workshops and through consultations at several family medicine and other residency programs. She has also provided training to diverse medical and behavioral providers in medical and academic settings. Most recently, Dr. Sherer was the Director of Behavioral Services at an FQHC, where she provided patient care, physician consultation, and supervision of behavioral staff and medical family therapy interns.
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