Posted By Barry J. Jacobs,
Wednesday, March 15, 2017
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This piece originally appeared on the Huffington Post. Posted here with permission.
“You are treating her like she’s a piece of meat,” Tony was shouting angrily at me. I hadn’t the power to change the care his 62-year-old wife was receiving in my hospital’s intensive care unit—for the past two years, I had been their psychologist, not nephrologist—but, for the moment, I became the embodiment of all Medical Authority. “She just lies there, unconscious and horribly swollen. You don’t do anything for her except stick her with more needles.” The look on his face then shifted slightly from accusatory to imploring. But I couldn’t save her.
His wife, Elena, had been bedbound in their tiny apartment in suburban Philadelphia for at least five years because of chronic, severe back and knee pain. She’d become confined there as the result of a series of personal and medical missteps—or, put another way, lack of steps. Once she’d entered middle age and her girth thickened, her joints had started aching because of the increased weight they supported and she consequently walked less. As she’d walked less and took to her “sick” bed more often, she burned fewer calories but never adjusted her diet and consequently gained more and more weight. Taking handfuls of pain pills every day didn’t relieve her joints and propel her off the mattress; instead, they only sedated her into a supine stupor in front of the TV. And the long-term narcotic use gradually took its toll: Her kidneys and other organ systems were now shutting down.
Tony was her devoted enabler. He’d waited on her slavishly, bringing her favorite foods, sitting bedside with her every day for hours to watch TV and listen to her steady complaints. He owed her, he felt, because she had stuck with him through his wild drinking years until he finally sobered up. He’d paid her back by sticking with her through her retreat from the world and now he was still sticking with her in the hospital, like he thought he was supposed to do. He would plead with the doctors to make her whole. He would utter lengthy beseeching prayers during sleepless nights in the armchair in Elena’s ICU room. But he could see that none of it was working. He was frightened for her life. He was afraid he was letting her down.
My job, it seemed to me, was not to try to persuade her medical specialists to make hail-Mary efforts for Tony’s sake. Neither dialysis nor multiple meds were working. My job was to convince him that Elena’s condition had taken a discernible turn. Family psychiatrist John Rolland of the Chicago Center for Family Health has written compellingly about the phases of illness—acute, chronic, terminal—and how hard it is for patients and families to switch their expectations and actions from one phase to another. We all believe at first that our ailments have a cure until some professional tells us that our condition is chronic and that we will have to learn to live with managing the symptoms. We are all lulled into believing that life with that chronic condition will go on and on until the end hits us shockingly like a sucker punch. This is the hard stop on hope.
“Tony, I’m worried that Elena won’t make it,” I said quietly. He stiffened and said, “No,” but the word sounded more resigned than forceful as if he knew that protesting wouldn’t change anything. We’d worked together for two years and he trusted me. By stating the inevitable first, I was giving him permission to begin thinking about the possibility of her death without feeling guilty. “You’ve been a very good husband to her for a long time,” I went on. And then to suggest a way he could continue to be good to her, I said, “I think it’s time to talk with her doctors about considering hospice.”
“Yeah, well, we’ll see,” he said gruffly. Over the next few days he continued to push her physicians to try new interventions as if defying what I’d said. But our short exchange had a started a process. He didn’t want to accept that she was in the terminal phase but he now knew it. When the doctors themselves approached him with the suggestion of taking her off of life supports, he acquiesced. She died a day later.
In our initial meetings in the months afterwards, he was still angry at her doctors and at what he saw as an uncaring world. But time passed and anger abated and he began to allow himself to feel relieved of the burden of caring for her without also feeling guilt for getting rid of her. “You were a good husband,” I kept telling him. With time, he came to see that that didn’t mean preserving her life, but accompanying her through its vicissitudes, termination included.
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Posted By Kaitlin Leckie, Kristine Miller,
Wednesday, February 15, 2017
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During the 2015 CFHA
conference plenary, Vincent Felitti likened poor health behaviors (e.g.,
smoking cigarettes; IV drug use; overeating) to the smoke in a house fire. If
you see the smoke as the problem, and use fans to blow the smoke away, you will
not only fail to put out the fire, you will fan the flames. Treating poor
health behaviors as the primary problem, without attending to the real underlying issue(s), will have a
similar effect, according to Felitti.
Felitti’s analogy reminds
me (KL) of the Process Model of Addiction and Recovery (Harris &
Tabor-Wilkes, 2011), whereby the desire to cope with negative feelings caused
by underlying pain (be it spiritual, emotional, relational, physical, etc.)
drives the decision to adopt an unhealthy or compulsive behavior (e.g.,
hoarding, smoking, IV drug use, alcohol, overeating). While this behavior may
provide an instantaneous but short-lived rush of relief, the resulting feelings
of shame and guilt are longer lasting. This perpetuates the experience of pain,
thereby re-starting the cycle.
The pain that people are
trying to overcome often began in childhood, as a result of what Felitti,
Robert Anda, and their research team (1998) call Adverse Childhood Experiences,
or ACEs. The main categories of these experiences include household
dysfunction, neglect, physical abuse, psychiatric disorder of a parent,
parental substance abuse or incarceration, childhood maltreatment, and sexual
abuse. These experiences can be objectively scored on a questionnaire. Scores
range from zero to ten. Ten indicates that the respondent experienced an event
in each of the ten categories at least once.
An ACE score of four or more (at
least one event in four different ACE categories) correlates strongly with
increased prevalence of chronic disease in adulthood, as well as a high
prevalence of multiple unhealthy lifestyle behaviors, such as smoking, IV drug
use, and promiscuous sex (Felitti et al., 1998). In a sampling of findings from
the longitudinal ACE study, Felitti and Anda (2010) summarize other strong and
significant relationships of ACE scores to biomedical disease, psychiatric
disorders, unhealthy behaviors, and healthcare costs.
During the plenary, Felitti
highlighted that people who are seeking to relieve their pain are mostly
interested in feeling relief as quickly as possible. They typically are not
thinking about the long-term consequences of their choice. Hence the ineffectiveness
of telling a smoker about the likelihood of future lung disease. Instead of
inducing behavior change, the response is akin to: "Smoking provides me relief
right now, which is what I need.” Until the underlying pain is
addressed/treated, the likelihood of people being willing to change an
unhealthy behavior they have adopted to help them cope is pretty slim.
from understanding this truth, successful intervention should rely on a
multi-faceted approach; comprehensive and integrated health care is an ideal
way to address and treat pain from the past. Yet, we can do better than that. Particularly
in primary care/family medicine, we train clinicians to be proactive, not
merely reactive. As such, prevention of ACEs is vital for individual, family,
and population health.
At our primary care
clinic, Southern Colorado Family Medicine (SCFM), the proactive approach we
developed to prevent ACEs for our patients is called SCAN: Score, Connect, and
Nurture. First, we educated our entire
clinic staff about ACEs and then trained our clinicians how to talk to patients
about ACEs. We now assess ACEs in expectant
parents and parents of 0-18 year old patients, focusing our efforts on breaking
the cycle of ACEs often observed across generations. We perform universal
assessments on this targeted population because ACEs affect everyone,
regardless of sociodemographics. We educate parents about what having
experienced ACEs means for their health and what can be done to try to decrease
the risk of their children going through some of the same experiences.
intervention centers on meeting participants where they are. For example, with
parents who have experienced ACEs, the clinician normalizes and explains that
some people feel they have overcome some of their difficult experiences from
childhood but may feel "tripped up” by others. To help meet their specific
needs, all families are offered resources by a family resource specialist, a
social worker embedded in our clinic by a local community resource organization.
Examples of resources offered include parenting education and support with home
visits by a community-based parenting specialist, financial assistance,
children’s books, and mental health treatment referrals.
Of the many success
stories we have had throughout the year, one example that stands out is one of
our first SCAN families. This couple was
expecting their first baby while facing multiple psychosocial concerns. In
addition to having minimal social support, they were being evicted from an
apartment that was later condemned. Of the ten main categories on the Adverse
Childhood Experiences questionnaire, the expectant mom endorsed 9 of them, and
the soon-to-be father had experienced all ten ACE categories, a score of 10 out
Yet, their ACEs scores
and their struggles represent the beginning
of their SCAN story, not the end. Both parents also scored highly on a measure
of resiliency--also part of the SCAN intervention--indicating they were
resourceful and skilled at successfully overcoming challenges. They were scared
and voiced a strong desire to parent their child differently than they
themselves had been parented. They were motivated to get help in order to be the
parents they wanted to be to their child. We provided them with a supportive
and understanding healthcare environment, and our Family Resource Specialist
linked them with several resources to boost their confidence and enhance their
Ultimately, we assisted them in locating safer housing, helped him get
a new job, connected them with mental health services, and enrolled them in a
parenting education and home visiting program for continued support after the
baby was born. The impact of the SCAN intervention, including their perception
of our healthcare environment as safe and accepting, was made evident when,
after a later traumatic event occurred, they returned to our clinic to seek
additional care and support.
The adoption of unhealthy
behaviors is not the only explanation behind the strong connection between ACEs
and later development of chronic disease, as pediatrician Nadine Burke Harris
explains in her TEDMED talk on the profound ways in which the
ACE study changed her clinical practice. Even so, reframing our way of looking
at unhealthy behaviors--not as problems themselves but as adaptive solutions to problems--broadens our
perspective and increases the likelihood with which we are able to intervene
and help patients to adopt healthier behaviors.
References and suggested
Burke-Harris, N. (2014). How childhood trauma
affects health across a lifetime. TEDMED 2014.
Felitti, V. J., & Anda, R.
F. (2010). The relationship of Adverse Childhood Experiences to adult medical
disesae, psychiatric disorders, and sexual behavior: Implications for
healthcare. In The Hidden Epidemic: The Impact of Early Life Trauma on
Health and Disease. Ed. Lanius, R. & Vermetten, E. Cambridge University
Felitti, V. J., et al. (1998). Relationship
of childhood abuse and household dysfunction to many of the leading causes of
death in adults: The Adverse Childhood Experiences Study. American Journal
of Preventive Medicine, 14, 245-258.
Harris, KS, Smock SA, Tabor Wilkes, M. (2011).
Relapse Resilience: A Process Model of Addiction and Recovery. Journal of Family Psychotherapy 22 (3),
|Kaitlin Leckie, PhD, LMFT, is the Director of
Behavioral Medicine at the University of Texas Medical Branch’s Department of
Family Medicine in Galveston, Texas. |
|Kristine Miller, D.O., is a faculty physician in
Pueblo, Colorado, at Southern Colorado Family Medicine Residency, where she
serves as the Clinic Director and Director of Osteopathic Education. |
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Posted By Matthew P. Martin,
Tuesday, January 10, 2017
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According to the U.S. Census, 87% of Americans live with a
family member. That’s 8.7 out of 10 human beings in the U.S. living with a
loved one. That’s huge! Let that sink into your brain for a moment. That means
that most of us are sharing a house, a condo, an apartment, or other dwelling
with someone we consider to be "family”, however you define it. In the words of
Joe Biden, "That’s a big … deal”. My goal is to convince you that the family
should be at the heart of our health care system but that evil forces are
conspiring to kick it to the curb in favor of "population health” and
"community” (I’m dramatically using both of my hands to make these air quotes).
Family relationships impact your health. Did you know that family
dynamics can even lower glycated hemoglobin levels and increase knowledge of chronic
disease like diabetes? It can even predict
the body mass index of youth! Imagine a doctor prescribing family time like
a drug. "And one more thing, Mr. Martin. I’m prescribing you 20 mg of quality
communication with your wife. There may be some side effects like loss of
football knowledge and increased libido but you should be okay.”
Despite this evidence, family-centered care is much more the
exception than the norm. Even though many medical clinics emblazon the words
"family care” on their door sign, you would be hard pressed to find physicians
who encourage bringing family members to an appointment or who even ask how
family life is affecting your health. Usually "family care” means that the
physician can treat anyone in your family; just don’t expect the doctor to ask
a patient what his wife thinks about his smoking.
It wasn’t always this way. In the famous painting "The
Doctor” by Sir Luke Fildes (1891), a general practitioner sits all night with
parents whose daughter is sick from an infection. Sure it’s a romanticized
ideal, but house calls in the past probably included a conversation with the
rest of the family. An astute doctor making a house call would collect more
health information in 30 seconds than in three medical appointments. Fun fact:
in 1949, this painting was used by the American Medical Association in a
campaign against a proposal for nationalized medical care put forth by
President Harry S. Truman. How times have changed!
House calls aside, we have lost our way in this post-family 21st
century of self-driving cars and 3-D printers. The family has been cast aside
in favor of the greater neighborhood and community. Public health officials and
policy wonks dream of a health care machine that looks beyond the tight-knit
relationships of family units to broader systems of "population health”. This
globalist view maligns the bi-directional influence of family dynamics and
health and supplants it with a broad focus on systems that are too big for any
medical exam room.
It’s time to bring health back to the family! Imagine a
health care system in which nurses inquire about blood pressure as well as
marital pressure. Imagine a system in which physicians ask how the newly
diagnosed diabetes is affecting family meals or how the adult children can help
the patient manage stress better. That is the kind of system that will make
family great again and lower health care utilization and costs. That is the
system that leads to winning, so much winning that you may get tired of it and
say to your physician, "Doctor, please, we’re tired of all this winning”. And
she’s going to say, "I’m sorry but we have to keep winning”.
Now, a word of caution: the other side will attempt to
convince you that the family is passé and that the future is the "population”,
the "community”. They will cleverly concede that the family was instrumental in
helping our pre-industrial progenitors but that now is the time for the
physician to look beyond the family and into a patient’s "community”. They
believe that it takes a village to care for your sickly grandfather and not the
adult children. They believe your neighborhood is going to give you a hug and
encourage you to cut back on your drinking. They believe in population health,
not family health. Little do they know, the family is the basic unit of any
population. Strong families lead to a strong population. It’s a beautiful
thing, am I right? Of course I’m right.
Here are two ways to make the family great again in our
healthcare system. First, family caregivers need more support and attention. Most
patients want to stay at home and be cared for by a loved one, but this
presents financial and medical challenges for caregivers. Insurance companies
should make it easier for caregivers to be trained and compensated for their
time. Not only does this save money for society, it improves the patient’s
quality of life.
Second, researchers need to determine the best practices of
family-centered care and educators need to teach these practices to healthcare
professionals. Right now, we have a strong group of cheerleaders championing family-centered
care but no clinical competencies and evidence-based teaching strategies. We
need family champions, but we also need a big, beautiful wall of evidence that
family-centered care works.
We need to drain the swamp of public health and policy
centers everywhere and get "Big Data” out of the healthcare system. If not now,
then when? If not us, then who? Please join with me in bringing health back to
the family, back to the basic unit of society. Thank you and God bless.
Martin, PhD, LMFT, serves as the Director of Behavioral Medicine at Southern
Regional AHEC in Fayetteville, NC. He is the CFHA Blog Editor. |
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Posted By Lisa Zak-Hunter,
Wednesday, December 14, 2016
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NOTE: in an
earlier blog, I
addressed how personal definitions of family impact care (explicit biases).
Therefore, this blog focuses only on implicit biases.
A physician was in disbelief. He anchored
himself in the belief that people were not inherently better or worse than
others based on factors such as gender, race, disability, sexual orientation,
religion etc. Yet here he sat, faced with his online score on the Implicit
(IAT) hosted by Harvard University. It read: strong preference for light skin over
dark skin. He struggled to comprehend what this meant. Deep down, was he
racist? He so firmly believed otherwise, that he didn’t understand how to
comprehend the results and what it meant for how he practiced.
Stereotypes surround us. They are the
learned associations between a characteristic and a social group. They may be
true at a group level but inaccurate individually. For example, most people in
Kansas City are Royals fans but some may be Cardinals fans. Although some
stereotypes are benign, there are a number of stereotypes that are more
contentious and have implications related to power, equity, safety, and legal
concerns. Explicit bias refers to the stereotypes one readily acknowledges that
they hold. "I believe women are more nurturing than men”.
implicit bias refers to the stereotypes or associations that occur
unconsciously or outside of conscious control. They develop early based on
reinforced social stereotypes. For example, implicit beliefs about race are
established in childhood whereas explicit beliefs change with age1. By definition we are ignorant
to our implicit biases and not immune to their power. Simply knowing a
stereotype can distort information processes, despite self-reported beliefs.
For example, college students’ implicit race bias did not impact self-reported
egalitarianism, but did predict friendliness towards Black students.2 Students who thought they
felt Blacks and Whites should be treated equally, were not, in fact, as
friendly to Black students.
What are the implications for healthcare
delivery? The literature on bias and physician decision making reveals that
even when physicians endorse no explicit negativity to various groups, they
still hold a number of implicit biases such as: Blacks were associated with
being uncooperative, especially regarding procedures, Whites were linked with
greater compliance, and obese persons were correlated with negative words such
as lazy, stupid, or worthless.3-5 If physicians have these biases but don’t
realize it, what impact does that have? It’s hard to completely tell, but
we do see that patients view physicians more negatively, and physicians make
different assessments and treatment choices.
For instance, even if physicians
think they hold little race bias but have high implicit race bias, Black
patients rate them as less team-oriented, friendly, and warm.6 If patients have negative
perceptions about their physician or their ability to establish a relationship
with their physician, how likely are they to adhere to treatment regimens or
return for follow-up appointments? Other examples indicate that elderly
patients are offered less treatment than younger patients for depression and
suicidality, or women are less likely than men to receive knee arthroplasty when
indicated. These findings have led some to propose that implicit biases are a
contributing factor to health disparities.7
An area of research that has yet to be
explored is family composition or constellation bias. This is a term I coined
to refer to the type of bias about who makes up a family or who is ‘in’ a
family. Nuclear family bias has been examined in stepfamily research, but this
term fails to address parental sexual orientation. Traditionally, the preferred
family is a heterosexual married couple with children.
Based on the research of
other forms of bias in healthcare, it would not be surprising if provider
implicit bias about who should be in a family would impact how they work with
that family. I argue this could have important implications for relationship
building, treatment adherence, assessment, and treatment choice- similar to
what the literature indicates with other implicit biases. Even providers who
ascribe to the notion ‘the patient defines their family’, may have some strong
implicit biases that negatively impact their care.
are some ways to address this?
Accept your implicit biases. Respect they impact your work. Understand
they come from reinforced stereotypes. The more you see a stereotype- in the
clinic, on the news, with friends, at the movies etc, it reinforces the
Address the source of implicit biases: stereotypes.
Be mindful when you encounter a stereotype and call it
out as such. There is power in making the implicit explicit, moving the
unconscious to conscious.
Commit to learning.
Read the research. For example, what ARE the outcomes for
children raised by gay or lesbian parents?
Get connected with local community centers, churches,
organizations that support different forms of family. Have a liaison speak to
Stay humble and curious. Don’t assume. Always ask about personal
you don’t already, try letting the patient define who is ‘family’. Ask
how family members should be included in care. This may get tricky with legal
concerns, documentation, or space concerns (how many people can we
realistically cram into an exam or labor and delivery room?).
Be careful about venting. Venting has the tendency to reinforce
stereotypes and feed implicit biases.
Do your own work or provide a space for others to do theirs.
Make your own genogram complete with all the relationship
connections- many a genogram look like a defensive coordinator’s playbook.
Examine how your experiences shape your understanding about family.
Think about the types of families you encountered growing up. What
were your impressions of them/how were they discussed? How did that inform your
thoughts about ‘family’? Where did you learn what makes a ‘preferred family’
vs. a ‘non-preferred family’?
you work in a training facility, consider a lecture or didactic on this
1. Baron AS, Banaji MR.
The development of implicit attitudes. Evidence of race evaluations from ages 6
and 10 and adulthood. Psychol Sci. 2006;17(1):53–8.
2. Dovidio JF, Kawakami
K, Gaertner SL. Implicit and explicit prejudice and interracial
interaction. J Pers
Soc Psychol. 2002; 82(1):62–8.
3. Green AR, Carney DR,
Pallin DJ, Ngo LH, Raymond KL, Iezzoni LI, et al. Implicit bias among
physicians and its prediction of thrombolysis decisions for black and white
patients. J Gen Intern Med. 2007;22(9):1231–8.
4. Sabin JA, Rivara FP, Greenwald AG. Physician
implicit attitudes and stereotypes about race and quality of medical care. Med
Schwartz MB, Chambliss HO, Brownell KD, Blair SN, Billington C. Weight bias
among health professionals specializing in obesity. Obes Res.
Penner LA, Dovidio JF, West TV, Gaertner SL, Albrecht TL, Dailey RK, et al.
Aversive racism and medical interactions with Black patients: a field study. J
Exp Soc Psychol. 2010;46(2):436–40.
Chapman, EN, Kaatz, A, Carnes, M. Physicians and implicit bias: How doctors may
unwittingly perpetuate healt care disparities. J. Gen Intern Med. 2013 28(11)
Zak-Hunter, PhD, LMFT is Assistant Professor and Coordinator of Behavioral
Science at St. John’s Family Medicine Residency at the University of Minnesota
Department of Family Medicine and Community Health. Her interests include
family healthcare, practitioner wellness, resident education, and the impact of
trauma and adverse events on health outcomes and point of care interventions to
address these. Within CFHA, she co-edits the Families and Health Blog and
serves as Social Media Director.
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Posted By Alexandra E. Schmidt, D. Scott Sibley, & Caroline Dorman ,
Tuesday, November 29, 2016
| Comments (0)
As we prepared to present this topic at CFHA 2016, our team quickly
realized that the therapists in the group used the term "family legacy” while
our physician colleagues used the term "family culture” to describe how
families impact health. We began to wonder, are they the same concept? Related?
Totally different? How could we apply both concepts in our clinical work to
connect better with patients, improve quality of life and daily functioning,
and work towards better health outcomes?
As Ernest Burgess wrote over eighty years ago, "Whatever its
biological inheritance from its parents and other ancestors, the child receives
also from them a heritage of attitudes,
sentiments, and ideals which may be termed the family tradition, or the
family culture.” Family culture encompasses values about what’s important, what
behaviors are acceptable, and what our relationships should be like. We believe
family culture extends beyond parents and children to extended family interactions
and families of choice, those not related by blood.
Patients’ decisions about how to care for themselves and how to
engage with the healthcare system are infused with multigenerational cultural traditions.
Family health culture provides the foundation for beliefs about the role of the
patient and the role of the physician, value and meaning assigned to
caregiving, causes of illness, and confidence to engage in health maintenance
and improvement behaviors. Culture also shapes routine habits and behaviors
related to eating, exercising, managing stress, and taking medications.
or detrimental, we don’t get to choose our family health culture since it’s a
composite of many family members’ beliefs and actions. We can’t change the
foods placed on our childhood dinner table, the ratio of our parents’ active
versus sedentary time, or how our families and communities have navigated
difficult decisions about how and where to care for sick loved ones. As we
acknowledge the role of family health culture, where do we honor the impact of
individuals’ personal choice on health behaviors and beliefs?
Family legacies, on the other hand, emphasize how individuals take
the past and craft it into current actions and use it to influence the future. As
Boszormenyi-Nagy and Krasner wrote, "It is the task of the present generation
to sort out that which is beneficial and
translate it into terms of benefits for future generations.”
In essence, we
funnel down the parts of our familial culture (beliefs, values, attitudes) that
we wish to pass down to future generations to create a family legacy – in this
case, our story about illness and wellness. Rather than passively receiving the
habits and beliefs handed down to us, we have the ability to craft our legacy into
a story we want others to remember. In addition, we can choose to emphasize health-related
habits and beliefs that offer us the most options for a fulfilling life.
As healthcare professionals, what is our role in helping patients develop
a healthier legacy? We recommend starting with one simple question: "If you
were to change one aspect of how your family approached (or approaches) health,
what would it be? How can I partner with you to work towards that goal?” Some
patients might need to be prompted with areas for consideration, such as
balancing work and self-care time, diet and nutrition, exercise, or
communicating with healthcare providers.
The question could also be rephrased
as: "What is one thing you learned from your family about how to take care of
your health that has worked well for you? How has this been beneficial for
you?” We also think it wise to begin asking these questions early with children,
rather than wait until they are adults to reflect on healthy habits: "What is
something you think your family does a good job of to be healthy and set up
good habits? How can you keep up that habit?”
If we want healthier patients who use our
valuable healthcare resources responsibly, we don’t have the luxury of ignoring
familial cultural beliefs that influence their decision making and goals of
care. We must take the time to inquire about patients’ beliefs and habits and
how those are influenced by their family culture, even when we feel pressured
with packed schedules and growing lists of clinical quality measures.
lead the conversation with patients in discussing how to harness the best parts
of that family culture to craft a strengths-based legacy that bolsters personal
purpose and growth, even in the context of disease, pain, and hardship.
Although not the only way, we believe this approach provides a powerful
starting point for helping patients and families enjoy as many days with fair
winds as possible and have the stamina to endure stormy seas.
Burgess, E. W. (1931). Family tradition and personality. In K.
Young (Ed.), Social Attitudes (pp. 188-207). New York, NY: Henry
Boszormenyi-Nagy, I., & Krasner, B. R. (1986). Between give
and take: A clinical guide to contextual therapy. New York, NY:
|Alex Schmidt, PhD, LMFT-A is an avid advocate of family-centered
healthcare. She received her PhD in Marriage and Family Therapy from Texas Tech
University and completed a Medical Family Therapy fellowship at St. Mary’s
Family Medicine Residency in Grand Junction, CO. She now works as an Integrated
Behavioral Health Advisor for Rocky Mountain Health Plans, where she partners
with primary care practices in strategic scheming and dreaming to sustain
integrated behavioral health practices and puts her graduate school research
skills to good use to track down relevant, practical resources for providers. |
|D. Scott Sibley, PhD, LMFT, CFLE enjoys teaching and researches commitment
in couple relationships. He received his PhD in Marriage and Family Therapy
from Kansas State University. He completed an internship at the University of
Nebraska Medical Center in the Department of Family Medicine. He is currently an
assistant professor in Human Development and Family Sciences at Northern
Illinois University. |
|Caroline Dorman, MD attended medical school at Oregon Health
Sciences University after receiving an undergraduate degree in Psychology. She
completed her residency at St. Mary’s Family Medicine Residency in Grand
Junction, CO. Post-residency, she modeled herself after Dr. Quinn Medicine
Woman and practiced in the isolated town of Craig, CO, where she did a little
bit everything including CBT and making house calls on horseback. She returned
to St. Mary’s to teach and mentor family medicine residents, where she has been
inspiring young physicians for ten years. Next year, she’ll enter a new phase
of her career providing hospice care. |
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Posted By Jeremy Yorgason,
Thursday, November 17, 2016
| Comments (0)
This post is a reprint of a piece from the Families and Health Blog. Click here for the original post.
Health problems are generally seen as a stressor to those in committed, couple relationships. That is, when a partner becomes ill, it often puts a strain on the relationship through the ill partner (a) not being able to perform the same level of household chores, (b) losing time at work/earning money, (c) having to pay for doctor bills and prescriptions, (d) having less positive or increased negative mood, and (e) having fewer positive and more negative couple interactions. These stressors associated with poor health within couple relationships have been established in the research literature.
At the same time, there are a number of studies that have indicated paradoxical outcomes within couple relationships in the context of illness. For example, research has shown that some couples suggest that their relationship has become closer in ways because of one partner having diabetes, hearing loss, a disability, or arthritis symptoms. So which is the right answer? Does illness strain couple relationships, does it bring partners closer together, or can couples expect both strain and closeness? The answer may depend on how we view illness.
Our perceptions of illness provide the lens through which we see health challenges. From a health STRESSOR perspective, illness can present difficult challenges for individuals and couples. From a RESILIENCE perspective, some people are strengthened in their relationships when faced with illness challenges. In fact, some couples’ relationships may be stronger than they would have been had they not faced a health challenge together and bonded through that adversity.
Given that not all people respond to illness or health stressors the same way, and that some couples apparently develop stronger relationships through health adversities, what factors might more readily lead to "paradoxical” or beneficial results? Research suggests the following factors likely benefit couples:
- Having a strong marriage relationship prior to illness onset
- Communicating openly about health challenges
- Having empathy for an ailing spouse
- Having resources that can be tapped such as social support and appropriate medical care
Other studies suggest that being over-controlling and overprotective as a caregiving partner has detrimental effects.
|Relationship resilience is possible among all couples||There is so much more that we can learn about the bi-directional relationship between health and couple relationships. Future research ideas include examining partner flexibility in future life planning, relationship history of overcoming past challenges together, and whether healthy partners choose at some point during an illness to be committed to their relationship, to their partner, and to working through whatever may come regardless of the outcome. In short, the mechanisms of health challenges linked with stronger couple relationships are largely unknown.|
From a clinical perspective, relationship resilience is possible among all couples wherein one partner or both are faced with health challenges. At the same time, the reality is that health problems are nearly always a stressor on couples. Perhaps the acknowledgement of stress with the willingness to pursue resilience in response to health challenges will provide hope and courage to struggling couples. Perhaps even relationships that are "on the rocks” or experiencing a pile-up of stressors can emerge stronger when faced with health challenges. Clinicians might specifically encourage couples to:
- Communicate regularly about the health problems, and the difficult decisions and topics they may face
- See themselves as collaborators in facing illness, rather than as being alone in the process
- Consider the illness as not being part of the ill person’s identity or the identity of the couple relationship
- Discuss what is helpful support, and what, if any, types of support might feel overinvolved or controlling to the ill partner
- Try to balance autonomy in the patient, while allowing appropriate dependence or interdependence between partners
Hopefully with the encouragement of healthcare professionals more couples facing serious illness will experience the health paradox within marriage.
|Dr. Jeremy Yorgason is an Associate Professor and Director of the Family Studies Center within the School of Family Life at Brigham Young University. He is also a licensed marriage and family therapist in the State of Utah. His research is focused on marriage health in later life, with an emphasis on how couples manage chronic health conditions. His research often involves daily diary surveys as well as information from both spouses in the relationship. He has studied couple relationships in context of various health concerns including osteoarthritis, acquired hearing impairment, diabetes, arthritis, disability, and declines in self-rated health. |
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Posted By Valerie Ross,
Tuesday, November 8, 2016
| Comments (0)
"If you are interested in applying for the BFEF fellowship, the
application can be found at the link here. You may also contact the
fellowship director Kathryn Fraser at firstname.lastname@example.org.”
The job of residency behavioral
scientist is complex. I was lucky to have had a mentor when I started. This was an unusual circumstance. Most
behavioral scientists work alone and training is limited. For example, one of
my colleagues was simply handed a box of old teaching files as his/her orientation
to the job.
About 7 years ago I was offered a
chance to be a small group mentor for a new program: the STFM Behavioral Science/Family
Systems Fellowship Educator Fellowship (BFEF). I felt honored and excited, and wondered what
would evolve. It turns out that agreeing
to be part of this effort has been one of the most rewarding experiences of my
professional life. The BFEF is a year-long
mentorship program for new behavioral scientists.
Since it began, more than 100
behavioral scientists have gone through the BFEF program. Fellows are coached in groups of four by two seasoned
faculty mentors: a family physician and
a behavioral scientist. Groups meet in
person at two conferences, and monthly through conference calls. Co-mentors strive to support each other, while
creating a space for professional metamorphosis for the fellows.
I have now coached two groups of
fellows. Each year when I meet the new fellows they talk about struggling to create
a professional identity and understanding the intricacies of the job. Throughout
the year together we celebrate successes, provide basic curricular resources, problem
solve around professional challenges, and help fellows develop a scholarly
By the end, having been initiated into a group of creative and
committed educators, fellows are more confident in their professional
identities. The mentees’ trust,
vulnerability and appreciation have helped me to become a better teacher and
more confident in my abilities as well.
My co-mentors have also taught me to be more skillful as a leader and
Over the years the roles of mentee and mentor
give way to that of colleagues and friends. I treasure my connection with this
growing community of dedicated people who share the vision of a more integrated
and humane medical system, aspire to lead, and are always willing to listen and
share resources. We continue to evolve and grow together in ways we never imagined.
Valerie Ross MS, LMFT,
has been Director of behavioral science for the University of Washington
Family Medicine Residency since 2003.
Her academic interests include:
relationship centered care, narrative medicine, direct observation for training
residents in patient centered skills and self-assessment, complexity in primary care, and mind-body
medicine. Her professional writing has focused on narrative ideas, direct
observation, and complexity care plans. Lately, she has been enjoying exploring
the application of theater improvisation in medical training (medical
improv). She loves spending time with
family and her wonderful 6yo golden retriever, playing cello, practicing yoga
and meditation, and hiking in the beautiful Northwest.
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Posted By Jess Goodman, Erin Sesemann,
Wednesday, October 5, 2016
| Comments (0)
This post is a nod to the upcoming, opening plenary address at the 2016 CFHA Conference in Charlotte, NC.
health of children and adults who identify as lesbian, gay, bisexual, or
transgender (LGBT) has the potential to be greatly
impacted by their family, health care system relationships, and the broader
context of where they live. The research tells us this can be done in both
tremendously helpful and hurtful ways. Let’s take a deeper look…
Growing up, it was common to
have my mom accompany me and help me fill out forms detailing my personal
information when I went to see my primary care provider. The forms provided my healthcare
team basic background information like my demographics (i.e., gender, age, or
ethnicity) and personal/family medical histories (i.e., history of smoking,
heart attacks, or cancer). But, what if this basic information isn’t actually
so basic? What if my mom didn’t really know everything about me? What if it’s
because I couldn’t tell her everything about me?
Through all these background
forms we completed in my childhood, I didn’t tell my mom that I’m transgender.
I didn’t tell my mom I didn’t feel like a girl. I didn’t tell my mom that I
wanted the world to know and see me as a boy. No one knew the emotional turmoil
I kept inside me. No one knew about the anxiety and depression I felt every
time I was called a girl. The sigh I breathed and how I hung my head every time
I had to check the female box on my background forms.
doesn’t reflect all family dynamics and reactions to children who identify as
LGBT. There are many warm, accepting families that would adjust and support
Jenna sharing her identification as transgender. They might listen and validate
her struggles of being called, categorized, and labeled as female when she
actually felt and considered herself male.
A supportive family might even walk
with Jenna as she explores changing her name, preferring to be acknowledged by
the pronoun "he” rather than "she”, wearing different clothes, or beginning
hormone replacement therapy. They might, again, return with Jenna to the
primary care healthcare team to help start the conversation about what options
are available to address not only the physical symptoms, but also address the
anxiety, depression, and lifestyle changes.
what if our patients do feel similar to Jenna? What if our patients’ families
are dismissive or rejecting? What if they don’t understand and/or wouldn’t
accept their LGBT family members? Maybe there are some themes from Jenna’s
story that do apply to our patients.
If so, are there ways we can communicate
acceptance and safety in our offices to the LGBT community when they may be too
afraid to start that conversation? Are there resources/handouts available to
patients who might be secretly struggling? Are we, as the healthcare team, able
to offer patients safe spaces to begin talking about the issues that so far
they can only communicate about through their physical ailments?
primary care health care center, I spoke with a healthcare team that included 2
primary care providers (PCPs), a nurse, and case worker. Through this
conversation I realized there are many small acts that healthcare teams are
already doing that communicate care and support. This can be done in a more
indirect approach, such as asking teens about dating both boyfriends and
girlfriends at child-well checks, or it can be more direct, such as asking
specifically about a patient’s sexual orientation in relation to their physical
or mental health symptoms.
Within the family context there are also some ways
that a healthcare team can intervene to help restructure the family’s
communication about the patient identifying as LGBT. The specific intervention
or treatment approach will differ based on the personality and preference of
the PCP, nurse, or case worker but there are some general tips to keep in mind
when attending to patients who identify as LGBT:
Barriers to Consider and Possible Interventions
LGBT youth can lack power within the family system to
have control over their lives or access to their prescribed treatments.
ask LGBT youth about family reactions to their identity to assess for level of
family rejection, if any, and related health risks
- Ask questions such as: "Who are you out to”?
- If out to family, "How has your family reacted
to you coming out to them, or sharing this part of your identity with them”?
- If not out to family, "What do you think is
getting in the way of coming out to, or sharing this part of your identity with
psychoeducation to families of LGBT youth about the health risks associated
with lack of support for the youth based on sexual orientation and gender
identity, and ways to be supportive and engaged4.5,6,7,8
a safe, non-reactive space for LGBT patients to share through active listening
and empathic statements
- Become familiar with medical and behavioral health
providers in your are that have experience working with LGBT populations
- Provide information about LGBT community and
support groups in your area that can offer peer support and mentorship
on age, safety, and level of independence of patient, it may be appropriate to
help connect LGBT patients to public transportation, local community resources
that provide transportation, or mail-delivered prescriptions, if appropriate
and legal (Consult with PCP, pharmacist, and other health care providers as
- Refer patient and/or families to trained family therapy
providers, strength-based support groups or peer counseling, and on-line
credible resources for families of LGBT youth; follow-up with youth and
youth and adults may remain in silence
or denial about LGBT identity due to assumptions or fear of experiencing dismissive or rejecting reactions from the healthcare team, which may prolong
physical and mental health symptoms
posters or flyers in your clinics that include LGBTQ youth, same-sex couples,
all staff on LGBT health and competencies1
single stall, gender- neutral bathrooms1
gender identity and sexual orientation in non-discrimination policies1
patients to identify their sexual orientation and gender identity, as well as
preferred name and pronouns on appropriate forms1
office policy in compliance with local laws regarding confidentiality for
health history as a conversation, not a check list1
sensitive topics, such as sex and substance use, as routine questions for all
patients, using non-judgmental tone and body language1
youth, use the mnemonic H.E.A.D.S.2 for taking social and behavioral
questions about gender and sexuality, and don't make assumptions
- Use questions and statements
am going to ask you some questions about yourself and I want you to tell me how
you feel, not how you think others see you or how others think you should feel.
These are questions I ask all my patients.1
you attracted to boys/men, girls/women, or both? 1
do you feel about your attractions?1
words do you use to describe your sexual identity?1
gender do you consider yourself to be regardless of what body parts you may
- How do you feel about your gender? 1
patients may lack a social support
system due to family and/or community cultural values or religious beliefs that do not accept, tolerate, or embrace
LGBT patients quit taking medications for symptoms
(such as depression or anxiety) because they do not believe the medications
will help treat the root of their problems (i.e., stress of identifying as a sexual or gender orientation minority,
family rejection, community isolation, etc.)
for support needs in a respectful way by inquiring about the presence and types
of social supports of patients
opportunities for disclosure of relationships and supports, including respectfully
inquiring about patients’ relationships with others accompanying them at
appointments, keeping in mind it may or may not be family members or local
patients with LGBT community resources and trained behavioral health
specialists in LGBT care, as needed
patients with supportive online/social media LGBT resources
validation and normalization statements to increase LGBT patients’ communion
with others from the broader LGBT community and local healthcare center
Motivational Interviewing3 techniques to assess and promote
different ways patients’ may exercise their agency within their context.
Examples may include:
open-ended questions to help patients verbalize how they are making meaning
about the possible discrepancies between their personal identification and
cultural or family or religious values
- Provide affirmations to patients’ strengths
throughout the encounter, such as his/her courage to self-disclose in
respectfully curious about the reason they have stopped taking their medication
validation for patients’ experiences without expressing agreement
for possible additional personal or cultural biases related to medications that
may inhibit their willingness to adhere to treatment (i.e., medication =
patients on the health risks associated with stopping medication, stress, and
lack of social support
- Discuss alternatives to medication, including
journaling, meditation, increasing activity levels, individual and family
counseling, and offer LGBT community resources and supports
about a patient you’ve seen in the past that you may or may not have asked
about their sexuality or gender identity. How did knowing or not knowing this
information impact the care you provided? Were you curious about their sources
of support? Did you make assumptions about the sources of support they had, or
did you ask about it? How did it help to know the answer, or why do you wish
you would have known?
didn’t ask about these things, what do you think got in the way? What do you
think it will take for you to be able to ask these questions?
of our beliefs, we need to be prepared to have conversations that foster
openness and understanding with all patients. The healthcare team is uniquely
positioned to assess for social support needs and work with patients and their
families or families of choice to access the care and services they need for
whole health. Take a moment to think about your office and the ways you can
better create a safe space for your LGBT patients and their families, help
patients utilize social support for better health and healing, reduce the
health disparities and discrimination, and promote every aspect of our LGBT
Additional resources for
providers support LGBT adults and their social support networks:
- Fredriksen-Goldsen, K. I., Hoy-Ellis, C. P., Goldsen, J., Emlet, C. A.,
& Hooyman, N. R. (2014). Creating a vision for the future: Key competencies
and strategies for culturally competent practice with lesbian, gay, bisexual,
and transgender (LGBT) older adults in the health and human services. Journal
of Gerontological Social Work,57(2-4), 80-107.
- Lim, F. A., Brown Jr, D. V., & Kim, S. M. J. (2014). CE: Addressing
health care disparities in the lesbian, gay, bisexual, and transgender
population: A review of best practices.AJN The American Journal of
resources for providers supporting LGBT youth and their families:
- Ryan, C. (2009). Supportive families, healthy children:
Helping families with lesbian, gay, bisexual & transgender children.
San Francisco, CA: Family Acceptance Project, Marian Wright Edelman Institute,
San Francisco State University.
- Ryan, C., & Monasterio, E.
(2011). Providers’ guide for using the
FAPrisk screener for family rejection & related health risks in LGBT youth.
San Francisco, CA: Marian Wright Edelman Institute, San Francisco State
- Substance Abuse and Mental
Health Services Administration (SAMHSA). (2014). A practitioner’s resource guide: Helping families to support their LGBT
children. HHS Publication No. PEP14-LGBTKIDS. Rockville, MD: Substance
Abuse and Mental Health Services Administration, 2014.
1The National LGBT Health Education Center. Caring for LGBTQ
youth in clinical settings. Retrieved August 8, 2016 from http://www.lgbthealtheducation.org/training/learning-modules/
2Goldenring, J. M., & Rosen, D. S. (2004). Getting into
adolescent heads: an essential update.CONTEMPORARY
3Miller, W. R., & Rollnick, S. (2012). Motivational interviewing: Helping people
York: Guilford Press.
4The National LGBT Health Education Center.
Resources and suggested readings. Retrieved
September 19, 2016 from http://www.lgbthealtheducation.org/lgbt-education/lgbt-health-resources/
5Bouris, A., Guilamo-Ramos, V.,
Pickard, A., Shiu, C., Loosier, P.S., Dittus, P., Gloppen, K., & Waldmiller, J.M. (2010). A systematic review
of parental influences on the health and well-being
of lesbian, gay, and bisexual youth: Time for a new public health research and practice agenda. Journal of Primary Prevention, 31, 273-309. doi:10.1007/s10935-010- 0229-1
6Ryan, C., &
Chen-Hayes, S. (2013). 13 Educating and Empowering Families.Creating Safe
and Supportive Learning Environments: A
Guide for Working With Lesbian, Gay, Bisexual, Transgender,
and Questioning Youth and Families, 209.
7Ryan, C., Huebner,
D., Diaz, R.M., & Sanchez, J. (2009). Family rejection as a predictor of negative health outcomes in white and
Latino lesbian, gay, and bisexual young adults. Pediatrics, 123,
346-352. doi: 10.1542/peds.2007-3524
8Ryan, C., Russell, S.
T., Huebner, D., Diaz, R., & Sanchez, J. (2010). Family acceptance in adolescence and the health of LGBT
young adults.Journal of Child and Adolescent Psychiatric Nursing,23(4), 205-213.
|Jessica Goodman received her M.S. in Family Therapy from the
University of Massachusetts in Boston. She is currently a Ph.D. Student in the
Medical Family Therapy program at East Carolina University. Her present
research goal is to develop an evidence-based integrated care protocol for the
ED to reduce health disparities among minority and underserved populations
experiencing diverse concerns in an emergency setting. |
|Erin Sesemann is a current Ph.D. Student in Medical Family Therapy at East Carolina University. She has experience working in community mental health agencies, private practice, and integrated behavioral health care in primary care. She graduated with her M.S. in Marriage and Family Therapy from Oklahoma State University in Stillwater, OK.|
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Posted By Tina Schermer Sellers,
Wednesday, September 28, 2016
| Comments (0)
Tina will host a Masters Lecture at the upcoming 2016 Annual Conference in Charlotte.
It’s 9 am and you are already
behind. Bob, 56, is on your schedule. It’s a follow up for his
diabetes and blood-pressure. You have seen Bob, his wife Anne, and their
three kids for over ten years. As you walk in, Bob seems anxious. You talk
about the local football team, how the kids and Anne are doing, and then about
his issues. You ask about how he is doing generally. Bob says he is
really slammed at work and has been traveling a lot.
He then says, "Hey doc,
we’ve been friends a long time, right?” "Yea, I’ve been seeing you for a long
time”, you answer. "Well”, Bob continues, "I need you to keep a secret. I need
you to run a little test for me. You see, I have this weird burning
sensation when I pee, and I haven’t exactly been faithful. But you can’t tell
Anne!” "Holy crap”, you think, "I saw Anne on my schedule for her annual
In the hamster wheel that is primary
care, clinicians master the art of moving and thinking fast - morning until
night – except for those precious moments when they give patients their
expansive attention. But the expansiveness stops there. If the provider is
impacted by an ethical dilemma, where is the time to process this? If there
were time, is consultation encouraged in the clinic culture? If it is, who is
available to consult?
Dilemmas such as these come in many forms, from patients
presenting lifestyles that conflict with the provider’s beliefs and values, to
being placed in a triangle. A patient might consent to something that puts
their emotional or physical health in danger or a loved one might make a choice
for a dying patient that you disagree with, or another family member disagrees
with. There are many situations that potentially fall outside the realm of what
is clearly defined by a clinician’s guild.
For example, do you know how to deal
with the kink couple who has a fetish that involves injury? Would you be able
to distinguish this from abuse? What kinds of questions would you ask to be
sure consent was being given versus coercion? How do you feel about treating a
transgender adolescent? What if their parent is against their transition?
How do you feel about treating a gender fluid teen? What if you had a patient
with a rare benign brain tumor that went metastatic and now looked like it would
be fatal, but she was refusing to tell her teen daughters and forbidding her
husband to tell them also?
Do you know how to deal with the kink couple who has a fetish that involves injury?
Since it is impossible to prepare for
all ethical dilemmas that might confront the clinician in primary care, the
provider must broaden their awareness of what triggers their reactivity in the
face of ethical dilemmas, and closes their curiosity and openness – a kind of
provider self-inventory. This is done through two primary avenues. First is to
explore key beliefs and values that inform their spirituality or sense of
truth, and examine the positive and negative sides of these beliefs with regard
to how they influence their work as a clinician.
Second is to stay focused on
their concern for the health and well-being of their patient and of the family system.
To do this, they ask open-ended questions about how well-being is or is not
being maintained, and the potential dilemmas being imposed. Beyond these two
avenues, it is important for the clinician to create strategies to support
themselves. These kinds of situations take an emotional toll.
Strategies both at the clinic, and outside of the clinic, must be in place to
restore and renew the provider if they are to thrive as a healer.
Come explore as we unpack the wild and
mysterious underbelly of primary care, where the clinician’s heart meets the
patient’s autonomy … and they don’t see eye to eye.
|Tina Schermer Sellers, Ph.D., LMFT, the director of the Medical Family Therapy Post-graduate Certificate Program in the Department of Marriage and Family Therapy at Seattle Pacific University. She has been a member of the Collaborative Family Healthcare Association (CFHA)since 1993, is a past board member and is currently on the CFHA Advisory Board. She is also a Certified Sex Therapist and Supervisor for AASECT. |
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Posted By Ryan Jackman,
Tuesday, September 20, 2016
| Comments (1)
I first met Nick (name changed) in May of 2016 in a rural
Emergency Department in Western Colorado as I placed a central line into his
neck after he had been intubated. Nick, like far too many others, had overdosed
on opioids. It was three days until Nick was extubated because of aspiration
pneumonia sustained during the episode, and it was three days until I got the
entire story – a story that unfortunately is not unique.
Nick had been working
on sobriety from prescription opioids and heroin on his own, and had managed to
endure withdrawal and cravings for three weeks before a relapse. When he
relapsed he returned to taking the same dose of heroin he had previously used. Without
the tolerance he had previously developed, his brain was overwhelmed by the
heroin and his respiratory drive was compromised to the point that when his
aunt found him the next morning and called 911 he was blue, unresponsive, and
Drug overdose is the leading cause of accidental death in
the US (having surpassed motor vehicle crashes and firearm related death in
20081,2), with 47,055 lethal drug overdoses in 2014. Opioid
addiction is driving this epidemic, with 18,893 overdose deaths related to
prescription pain relievers, and 10,574 overdose deaths related to heroin in
2014.3 Even more alarming are the number of non-fatal overdoses,
estimated to be 25-30 times greater. These
astonishing numbers have led the CDC and Obama Administration to name the
current opioid crisis an epidemic and one of the top four epidemics currently
facing the U.S. including obesity, heart disease, and cancer.4,5
addition, these numbers have attracted record media attention with numerous
research studies, news stories, and television documentaries all seeking to
quantify and characterize the problem; something that Scott Pelley’s recent 60 Minutes
monologue summarized well: "After 40 years and a trillion dollars, the nation
has little to show for its war on drugs. Prisons are beyond crowded and there’s
a new outbreak in the heroin epidemic. If it’s time for a change, it would be
One way that this change has come is in the form of naloxone,
or Narcan®. It is a medication that is well known in the field of medicine, but
until relatively recently was not endorsed to be prescribed to the general
public; a fact that research is now showing was a fatal mistake. 7,8,9,10,11
Opioids do their most damage during an overdose by decreasing
a person’s respiratory rate, which can ultimately produce coma, heart failure,
and death from lack of available oxygen. Thus, reversing opioid effects in a
timely manner is crucial when an overdose occurs. So crucial, that waiting for EMS to arrive and
administer naloxone may be too long. For this reason, a national effort is
being made to increase outpatient naloxone prescribing and training.12
At the Center for Dependency, Addiction, and Rehabilitation
(CeDAR) in Denver, Colorado, where I work, specific attention is being given to
train patients with opioid use disorder and their loved ones on the use of naloxone.13
This training consists of: Didactics on recognizing overdose vs
overmedication, the value of naloxone in an overdose, assessing breathing and
how to deliver rescue breaths if needed, administering intranasal naloxone, and
involvement of emergency services.
Beginning in 2014 CeDAR began training these
individuals in the inpatient rehab setting, and has received significant
positive feedback from patients, family members, and friends as well as a
report of an overdose reversal. Given the success of this program it was
quickly expanded to the outpatient setting where it was implemented in an
opioid support clinic that has been embedded into a local patient-centered
medical home family medicine clinic, complete with integrated mental health
Reversing opioid effects in a timely manner is crucial
This setting, with all of its services and team-based integrated care
has not only allowed for this program’s streamline implementation but has also
allowed for the program to be improved upon. Some of the ways in which this
program was improved upon and patient care was expanded through an integrated
care model include:
The flexibility of performing training in both
individual and group settings.
Recognizing that naloxone training naturally
provides multiple intervention/discussion points that are benefited by integrated
behavioral health co-visits where the team is able to point out that:
Naloxone offers patients and loved ones, who
often feel powerless, a tool and sense of empowerment in addressing a disease
that impacts every component of their lives. Additionally, it empowers the
patient to treat an overdose in another person if needed.
Addiction is a chronic disease with a
relapsing-remitting pattern, and prescribing naloxone is evidence of the
patient’s commitment to treatment rather than providing a patient permission to
A naloxone prescription further invests the patient
and his/her support team in his/her care
o Multiple team members available to contribute and
lead training which allowed for efficiency, including working with pharmacies
to have naloxone prescription available to distribute at the training.
o Continuity and breadth of care which help to
increase patient and his/her support team’s buy in.
o Advocacy by members of the team for patients and
within the medical community, helping to address misperceptions by other health
care providers regarding naloxone and addiction.
The bottom line is that opioids are killing people and
destroying social constructs, such as family, that are crucial for health.
Naloxone is a tool that has been under-utilized, but that integrated health
care is in the perfect position to effectively utilize and increase the number
of lives that are saved. Naloxone isn’t the "silver bullet” to the opioid
crisis, but like epinephrine in anaphylaxis; naloxone is the life-saving
"second chance” that patients like Nick need.
Imagine a scenario where Nick’s
aunt had naloxone on hand for immediate treatment and knew the symptoms of
overdose to look for. He may not have required the same level and duration of
care, and even if he had, the sense of purpose his aunt would have experienced
in the moment would be much preferred to the sense of utter helplessness she
experienced instead. When I met with Nick before he left the hospital for a
rehab intake appointment, a prescription for naloxone in his hand, he said
"Thank you. That was eye-opening. I’m glad I got to wake up.”
For additional clinical guidance the following online
resources are available:
SAMHSA Opioid Overdose Toolkit: https://store.samhsa.gov/shin/content/SMA13-4742/Overdose_Toolkit_2014_Jan.pdf
1. U.S. Department of Justice Drug
Enforcement Administration. (2015). National
Drug Threat Assessment Summary (DEA-DCT-DIR-008-16). https://www.dea.gov/docs/2015%20NDTA%20Report.pdf
Aleshire, N.,Zibbell, J., Gladden, RM. (2016). Increases in Drug and Opioid Overdose Deaths
— United States 2000–2014. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6450a3.htm
3. Center for Disease Control and
Prevention, National Center for Health Statistics, National Vital Statistics
System, Mortality File. (2015). Number
and Age-Adjusted Rates of Drug-poisoning Deaths Involving Opioid Analgesics and
Heroin: United States, 2000–2014. Atlanta, GA: Center for Disease Control
and Prevention. http://www.cdc.gov/nchs/data/health_policy/AADR_drug_poisoning_involving_OA_Heroin_US_2000-
Center for Disease Control and Prevention. (2016). Injury Prevention and Control: Opioid Overdose. http://www.cdc.gov/drugoverdose/epidemic/
5. The White
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|Ryan Jackman, MD is a
board certified family physician that is currently completing a one-year
addiction medicine fellowship at the University of Colorado, Denver. He
recently completed his family medicine residency in Grand Junction, CO. In
addition to addiction medicine, his clinical interests include full spectrum
medicine, obstetrics, rural medicine, and clinical-based research which
currently includes a joint project for STFM-NIDA focused on expanding addiction
medicine curriculum in family medicine residencies. He is married with two
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