Clinical practice in healthcare settings is different than the conventional stand-alone mental health clinics and/or private practices that most Couple/Marriage and Family Therapy (C/MFT) programs prepare their students for. And while some trainees in C/MFT are situated in programs that offer a Medical Family Therapy (MedFT) specialization, there are far more who are not. As demand for MedFTs continues to rise across both internship- and postgraduate workplace- sites, it is important to consider what trainees can do to: 1) prepare for such opportunities, and 2) effectively adjust and thrive once they are there. In this two-part account, we describe concrete strategies for students to effectively achieve these goals.
Preparing for Clinical Work within Medical Contexts
Before actually beginning your work as a MedFT trainee, it is important to make a conscious decision about what you are getting into, work through your own personal biases, and develop specific knowledge and skillsets.
Learn What You are Getting Into
Mental health providers who work in healthcare settings encounter stressors and clinical presentations that are often comparatively more complex, intense, and/or acute than "traditional” or conventional therapy settings. It is important that you understand this, and to ultimately make a personal and professional decision about whether this type of work is a good fit.
|In conventional C/MFT settings, patients and families present with a variety of struggles, including depression, anxiety, parent/child conflict, marital discord, and seeking personal growth (broadly defined). They come to us, as their primary provider, each week for hour-long visits, wherein we advance clinical interventions through our preferred theory(ies) and approach(es). We consult with colleagues/supervisors between sessions and try out new angles, ideas, and strategies along the way and in accord to how our patients/families are progressing. We perceive the conduct of 5-6 (sometimes 7-8) therapy sessions in one day as "a lot” – and we are tired when we go home.
|Make a personal and professional decision about whether this type of work is a good fit
In medical settings, patients and families can present with these same straightforward struggles, but those that do are often experienced by MedFTs as our less-complex – or even "easy” – cases. Most of our work in health care is situated earlier-on in these clinical sequences, such as when a depressed patient first reaches out for help or is imminently suicidal, when sexual abuse is first discovered, or immediately after (or even during) a traumatic loss. Many of the presentations we see – unlike the ones portrayed in our textbooks – are cases for which there will not be a "cure” or resolution (e.g., patients and families who are coping with serious accidents, chronic illnesses, or death). We function as part of treatment teams (not as sole providers, and usually from positions of less hierarchal power vis-à-vis our medical colleagues), and we hardly ever see people for hour-long visits. Seeing 5-6 (or 7-8) patients/families in one day means that we took at least half of the day off.
If you are interested in MedFT, it is important that you expose yourself to, and learn about, the culture and everyday processes of medical care sites. Many scholars and field leaders in MedFT have contributed to literature regarding these early preparatory steps 1-4. Common themes in advice here relate to reading first-hand accounts of MedFT on-the-ground 4-6, seminal texts about MedFT tenets and applications 7-10, and/or refereed journals that publish cutting-edge research and accounts of interdisciplinary collaboration (e.g., Annals of Behavioral Medicine; Annals of Family Medicine; Families, Systems, & Health). You can do this through informational interviewing with MedFTs already working in the field and/or shadowing MedFTs or other similarly-situated behavioral health providers (e.g., Medical Social Workers, Health Psychologists). Attending grand-rounds presentations at local healthcare facilities and collaborative care conferences/workshops/trainings (e.g., CFHA, STFM) can also be valuable.
As you do this, we encourage you to take a deep and honest look inward. Ask "Is this the kind of environment I can thrive in, or will it burn me out?”, "Do I want the predictability and structure of private practice, or would I get bored with that?” MedFT is a great fit for some C/MFTs. For others, conventional therapy sites are a great fit. It is important to figure out for yourself where you will be most fulfilled.
Work through your Personal Biases
You, as a MedFT trainee, have made a conscious decision to work in a healthcare context. You must, then, behave in a manner that is conducive to this. There are many biases about Medicine that you might hold, and these biases can hinder your working relationships and ability to collaborate. Common biases we hear include: physicians are too busy to collaborate; they just don’t "get” what we are talking about; they will not listen to therapy jargon; and/or that they need to be convinced to collaborate with mental health providers. Biases can go the other way, too (i.e., those that we hold against ourselves); these can include things like: we need to "sell” our potential contributions before they will be valued; we need to maintain a hard external persona (i.e., never show weakness); we cannot talk too much about "warm and fuzzy” emotions and feelings; and/or that we must not speak until spoken to.
Like any stereotype, we can always find supporting evidence for our biases. Some physicians are, indeed, very busy and cannot recognize the value in collaborating with a behavioral health provider. Some therapists do, indeed, work hard to never show vulnerability to medical colleagues. However, we also know that most stereotypes are unfair (and usually negative) globalizations of a group’s character – and in integrated care environments, holding them will almost invariably sabotage effective teamwork.
|Think through and articulate your personal preconceptions about medicine
||It is important for you to think through and articulate your personal preconceptions about functioning in a medical context before you get there. You can do this through a combination of individual- and group- exercises and discussions about these preconceptions with colleagues and supervisors familiar with MedFT. Taking the time to do this (because we all have personal biases) enables students to process and allay what could be personal/professional blind-spots later down the road. It also can serve to better equip you with knowledge regarding Medicine’s structure (yes, it is very hierarchal) and how to function effectively within it (which we will address further in the second half of this two-part blog entry).
Develop Specialized Knowledge and Skillsets
Moving beyond the baseline-competencies that any C/MFT is expected to have (i.e., the ones that are advanced by AAMFT regarding admission to treatment, clinical assessment and diagnosis, treatment planning and case management, etc.), MedFTs must develop skillsets specifically targeted to our efforts within medical contexts. Field-leaders are working hard to articulate and advance shared-understandings regarding these unique competencies 11-13, targeting domains like medical culture/systems, effective interdisciplinary collaboration, theories like the biopsychosocial-spiritual model and three-word view (clinical, operational, financial), self-care, and others. Competencies within these domains include clinical skills (e.g., promoting patient/family agency and communion, facilitating communication between medical providers and patients/families), alongside skills in training/supervision, policy, and research.
It is important, too, that you understand the financial world(s) of Medicine, and how mental health services fit into these complex and dynamic structures. MedFTs are reimbursed in similar and different ways (and at similar and different rates) than their sibling disciplines – and this varies in accord to where you live, the site in which you practice, and the current-day status of the politically-charged debates between local-, State-, and Federal- stakeholders fighting for recognition and market share. Field-leaders are working hard to articulate and advance shared-understandings of these foci, as well 14-16.
You can begin to develop knowledge and inform these skillsets through aforementioned seminal texts and journals, together with core coursework that – in our view – anyone planning a career in MedFT should (must) take. These include courses in medical terminology, psychopharmacology, physiology/anatomy, and "special topics” like health policy, healthcare administration, principles of health maintenance organization management, and spirituality and healing.
Laying the foundation through the knowledge acquisition and preparatory strategies we have outlined above will prepare you as a C/MFT student to be competitive for clinical opportunities and training in MedFT. As you gain entry into integrated care sites – whether they are facilities that are already established in and conversant with integrated care, or just getting started – the guidelines we will offer in the second half of this two-part account serve to represent strategies and learning we have found to be most helpful. Stay tuned…
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