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Happy 6th Birthday, Families & Health!

Posted By Matthew P. Martin, Thursday, January 11, 2018

The beginning of this year marks the 6th birthday for the Families & Health blog. Here are some highlights from the past year of posts.

 

In January, we published a tongue-in-cheek piece about "Making Family Great Again".

"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."

 

In February, we published a piece on adverse childhood events called "Where There's Smoke There's Fire".

"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."

 

 

 

In May we published an insightful person piece about caregiving called "My Vexing/Gratifying 7 Years of Caregiving". 

"As a clinical psychologist specializing in helping families struggling with illness, I thought I had some idea of what I was getting into. But, looking back, I did only partially. Real-life caregiving for my mom was much more personal and perturbing, complex and challenging, gratifying and vexing than my clinical work or academic reading could have prepared me for. Like all family caregivers, I suffered growing pains but learned a great deal."

 

In July we published a first-time series on spirituality. Here is an excerpt from Part 1.

"Not too many moons ago I stumbled over how to assess spirituality in the clinical setting. Even with the presence of prompting question on the diagnostic assessment, I still threw out: “you’re religious right?” nodding my head in hopes we wouldn’t have to “go there”. It wasn’t until I was steeped in a family medicine residency program serving a high-risk population (e.g., multiple health disparities, trauma histories) that I made an intentional move to ask more purposeful questions regarding the role of religion and spirituality in my patient’s illness and suffering narratives."

 

 

 

In September, we published a piece on "Socially Assistive Robots". 

"There is enough evidence and momentum now to suggest that robots will likely begin to help with integrated behavioral health services in the next five to ten years. Will robots also help in family-centered care? Can they use a complex model like emotionally focused therapy to help a couple facing infertility issues? That future is way down the line in my mind."

 

Finally, in October, we published a piece on "Latino/a populations".

"The family was concerned that the doctors and nurses would see them just as they saw themselves: broken. Together we met with the team and discussed the themes and concerns that had come up and how we could clarify the treatment plan so that the family felt comfortable in returning. The team reflected that their aim was to build up patients with follow up and recommendations so that patients can return to a stable life. The team was excited to adapt their approach with cultural considerations by checking in with the family each step of the way to not only heal the body, but to treat the self too."

 

 

We have some great stuff planned for this coming year. Be sure to subscribe to email notifications, follow CFHA on Twitter, or check back on the website. 

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What Japan Can Teach America About Family Caregiving

Posted By Barry J. Jacobs, Thursday, January 4, 2018

This piece is a reprint from the Huffington Post. Used with permission here.

One after another, three young social work students stood up and tearfully shared their experiences of growing up caring for grandparents with dementia in their family homes. Later, a middle-aged physician talked with pride about frequently visiting his still-healthy, 94-year-old mother to support her choice to live in her own apartment. These were prime examples of “filial piety”—the millennia-old, ingrained tradition of devotion to elders—that I had anticipated.

But there was much I didn’t expect. A social work faculty member ruefully described the growing phenomenon of adult children who had moved to the big city for jobs and no longer wanted responsibility for their aging parents, alone and isolated in their home villages. Such careerists had divorced themselves morally and emotionally from their parents, leaving it up to local government to tend to them.

These were the sharply contrasting attitudes about eldercare that my wife, Julia L. Mayer, Psy.D., and I heard during a recent visit to Japan. We had been invited to give lectures on aging and resilience at the Kanagawa and Tokyo campuses of Tokai University as part of a year-long celebration to mark the founding of the university’s Faculty of Health Management, an ambitious, interprofessional program of professors, researchers and clinicians from a broad array of medical and social sciences. The divergent sentiments we heard at our lectures offered lessons—and perhaps a glimpse into the future—for America’ aging families and caregivers.

This was my first trip back to Japan since I spent a college semester there in 1979 to study its Confucian culture. I found much that was still familiar to me, including the country’s sometimes jolting blend of old traditions—such as its love of tatami mats and hot springs baths—with the ultra-modern—such as uncannily efficient subways, ever-present vending machines and green tea Kit Kat bars. But the Japan I knew from nearly 40 years ago has gone through an extreme demographic shift because of increasing life expectancies (now 4 years longer than in the U.S.) and decades of low birth rates. (There are supposedly more pets than children in Japan today and more diapers sold for adults than babies.) It is now far and away the most rapidly aging nation in the world with about the same population as when I was last there (120 million) but triple the proportion of people over 65—over a quarter of the population. That number is expected to rise to an astounding 40% by 2060. U.S. senior citizens, in contrast, now comprise 15% of our population and will top out at only 20% in 2030.

Japan has been whipsawed by its demography and is consequently experiencing contradictions and ambivalence about eldercare. In the 1990s, many Japanese women were overwhelmed with caregiving and work duties; reports of caregiver abuse of older relatives began to rise. The government responded in 2000 with a mandatory long-term care insurance program for all Japanese over age 40, as well as the introduction of such community-based services as case management, adult day care centers, and home companions. Today, the tradition of “sansedai kazoku” (three-generation households) still exists among 60% of the populace. But, according to a 2014 Pew Research Center survey, 87% of Japanese think aging is a “major problem” for the country (the world’s highest percentage) and only a third of them believe that families should bear the “greatest responsibility for the elderly.” (Thirty-six percent think it’s the government’s job.) There have been more and more highly publicized cases in which family caregivers murder the parents they’re caring for and then commit suicide. Filial piety, it seems, is on the wane.


What can Americans learn from Japan’s struggles? Here are two thoughts:

When the number of aging citizens reaches certain thresholds, societies must respond with increased services: If there was any country whose long tradition of family values would have sustained its commitment to eldercare, in my mind, it was Japan. But the sheer volume and needs of the old began to crush even stalwart Japanese. Its government responded accordingly and appropriately. When America’s aging “problem” increases in the next 15 years, will our local, state and federal governments respond with the same compassion and thoughtfulness? I hope so but am concerned. As with Japanese society, there will be dire consequences for U.S. individuals and families if we don’t devise and pay for the right supports.

When governmental supports are put in place, family commitments change: Because of Japan’s long-term care system, including increasing numbers of residential facilities, more Japanese feel entitled to have the government support their aging parents. That is a radical departure from Confucian tradition. Could the same happen in the U.S. if our long-term system was greatly expanded? Would Americans have less compunction about walking away from a perceived caregiving “burden” if they knew that the safety net for their parents was actually safe and strong? I don’t know the answer but expect that, as our caregiving systems necessarily change in the next two decades, our family values will, too.

  Barry J. Jacobs, Psy.D. is a clinical psychologist, family therapist and the Director of Behavioral Sciences for the Crozer-Keystone Family Medicine Residency Program in Springfield, PA. He is the co-author (with his wife, Julia L. Mayer, Psy.D.) of AARP Meditations for Caregivers—Practical, Emotional and Spiritual Support for You and Your Family (Da Capo).

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Sometimes a hug is all you need to feel better

Posted By Vanessa Stoloff, Monday, December 4, 2017

I felt a bit tainted as I headed out to my first memorial service for one of my patient’s since starting my job as a college health physician. I had seen many people pass away over my training years -- some old, some young, but this felt different, somehow. Because she was the saddest girl I had seen in a while.

 

As I entered the relatively large room filled with many young faces from our student body, I was pleasantly surprised. Because she was the saddest girl I had seen in a while, she had always seemed all alone. But apparently, she did have friends after all, whether she had realized that or not.

 

None of her family was present as I scanned about the room. More peers than I had expected. A few professors. Her college house dean.  From the college house where her lifeless body was found, hanging in her dorm room.

 

I was originally asked to see her at the health center by my colleagues at the counseling center as there were “weight concerns”. And while she was definitely tall and lanky in appearance, the cut marks on her forearm that she hid from me, the perpetual pout, and the poor eye contact seemed far more pronounced than her slenderness. I was later to learn that my colleagues at the counseling center had known about her rope. They had surely heard all of the “suicidal ideations” she spoke of. I had too. While I saw her for her “medical” needs, once even throwing sutures into her frayed arms, I had heard of how she would be “better off dead”. I had seen the disturbing pictures she drew for me. I heard about the threats (and yes, even thwarted one of her attempts by staging an intervention). I reached out to my colleagues. They seemed confident that she was getting enough care. I was to keep to the medical aspect and leave the mental health aspects to them. She remained the saddest girl I had seen in a while.

 

The day she asked for a hug, it seemed a no-brainer. She was in my office – unhappy -- the saddest girl I had seen in a while. She clearly hadn’t had an upbringing with a lot of affection.

And I like to think of myself as part-doctor, part-mother in my role as a primary caregiver to the students at my university, and our health center a kind of “home-away-from-home”.

 

That was the first and last hug I gave her.

 

Regrettably, there was not a lot of collaboration in her care, despite many attempts. I was reminded that, as her physician, I was to tend to her medical needs. And worse yet, I was “scolded” for having given her a hug… having crossed that line…per my mental health associates.

 

Why I felt shamed into refraining from providing a therapeutic touch to her again by my colleagues, in spite of her asking me for hugs on subsequent visits, I will never know. But the morning I was paged by the Emergency Department… and my half-asleep ears heard the resident inform me that there was a patient in critical condition who attempted suicide…and her name matched that of the saddest girl I had seen in a while…I felt the regret the strongest.

 

Would my hug have prevented the saddest girl in the world from making such a bad decision? Unlikely. But I might have slept better knowing that I had given her that hug. I believe the biggest privilege one earns in medical school is to learn how to touch a patient. Besides the thorough hands-on physical exam, there is something to be said for a touch on an arm, a hand on the shoulder, and yes, even a hug. Maybe we should all learn to recognize the therapeutic value of touch?

 

At least I was able to touch her shoulder as she lay in her ICU bed, attached to too many tubes to count, with purple marks across neck. Her asphyxiation kept her in a deep slumber that she would never awake from. She may have even had a wry smile on her face as she lay there. Maybe she wasn’t so sad anymore. That, too, I will never know.

 

Back in the memorial service filled with her mysterious friends, my legs unexpectedly took me to the podium where I was able to tell her… and her peers… and the college deans… and my mental health counter parts to go ahead and give hugs… as sometimes a hug is all you need to feel better.

 

Vanessa Stoloff, MD is a physician at University of Pennsylvania Student Health Service since 2003. She “specializes” in all primary care concerns, but has extra interests in travel health, eating concerns, and dermatology. 

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No Nos Entienden: Cultural Themes for Latina/o Populations in an Integrated Health Clinic

Posted By Karla V. Caballero, Wednesday, November 15, 2017

“I think that when parents realize that using words like shame and guilt and promoting those ideas. I think they realize in doing that it affects the child even more…so at some point you start noticing a shift from blaming talk or problem saturated talk to more positive uplifting supportive talk. I think that change in view has a lot to do with reclaiming of self”1 


Not too long ago, I completed a year of training as a doctoral student therapist at an integrated specialty clinic in San Antonio, Texas. This clinic provides physical and medical evaluations for children and teens that have experienced some form of sexual abuse. The integrated team includes therapists, social workers, medical doctors and nurse practitioners. As standard practice, the team offers opportunities for acute or crisis therapy services the same day of the initial visit as well as scheduled appointments. 

 

The population I worked with was primarily Latina/o and consisted of bilingual and monolingual Spanish speakers. While there, I assisted the clinic in moving towards more culturally appropriate warm hand offs, as well as considerations for working with this population in the context of trauma. This reflection will highlight my work with a Latina/o family whose 11 year old son, dubbed Niño, had experienced sexual maltreatment by a male family member. 


The mother and son were reluctant to trust the assistance of the medical profession; they were afraid to be judged and looked down on. Needless to say, they were referred to me for assistance in treatment participation. Cultural humility and competence are buzz words in the field of psychology, but what is not often discussed are the points of pride and shame that cultures seem to adhere to, especially in regards to trauma. In terms of shame, families at the clinic often expressed feelings of being sucio or dirty, they sought their child’s reclamation of innocence and an urge to maintain family honor.  

 

At 11 years old, Niño understood what had happened to him was awful and he knew he was safe now that everyone knew. That was not his concern. He was troubled that his family felt ashamed of him and of the event due to their religion. Religion coincides with purity, his mother explained, and it is an important aspect of their culture. Additionally, he felt dirty and would bathe obsessively since the incident, almost 3 months. This was another reason he was encouraged to see me. 


His mother shared that she felt as though she lost her son, he was no longer innocent; he had been defiled and was fearful that her happy child was gone. She doubted that such a clinical setting would understand these aspects and was hesitant to return for follow up appointments and treatment. “No nos entienden,” they don’t understand us. We decided that since Niño would return a few more times for medical follow-ups, we needed to address these themes as a team; the doctors, nurses, social workers and therapists.

 

The family was concerned that the doctors and nurses would see them just as they saw themselves: broken. Together we met with the team and discussed the themes and concerns that had come up and how we could clarify the treatment plan so that the family felt comfortable in returning. The team reflected that their aim was to build up patients with follow up and recommendations so that patients can return to a stable life. The team was excited to adapt their approach with cultural considerations by checking in with the family each step of the way to not only heal the body, but to treat the self too. 


The family was then asked what they needed from the team. Nino’s mom simply stated, “queremos ser puros otra vez y escuchados,” to be pure again, to be listened to. This novel idea, of listening to the story first, of considering those feelings of being dirty, shame, guilt and a loss of innocence may be more important than the physical. Finally, to acknowledge that honor is crucial to Latina/o families. Since then, the site has adapted their initial intake and assessment interviews to include discussions of the emotional changes these families may have incurred as a result of the abuse. This is owed all to the bravery of a little boy and his mother, to be heard first above all else.

References

Baldwin, M., & Caballero, K. (August 2017). Reflections of a therapist: Informing psychotherapy with Latino families of sexually abused children. Accepted for poster presentation at the Minority Fellowship Program at the 125th Annual Convention of the American Psychological Association (APA), The Society of Counseling Psychology Division 17 in Washington, DC

 

Karla Caballero, M.S., LMFT is a counseling psychology doctoral student from Our Lady of the Lake University in San Antonio, Texas. She also earned her Masters of Science in Counseling Psychology from the same institution.  

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Reflections on the Passing of Salvador Minuchin: 1921-2017

Posted By Randall Reitz, Wednesday, November 1, 2017

I was saddened to hear that one of my early professional heroes died yesterday.  Salvador Minuchin passed at the age of 96 after a long and prolific career as a founder of marriage and family therapy.

While I didn’t know Minuchin like some of the first generation of CFHA leaders, he did have a deep impact on my career and my decision to embrace medical family therapy as my preferred lens.  His conceptualizations of family structure were elegant and imminently applicable in family work.  I come from a structurally complex family that was impacted by childhood diabetes, so I eagerly consumed all of his seminal works on “psychosomatic families” and “brittle diabetics”. 


 It is definitely fair to say that some of his ideas have started to show their age, and his language reflected an earlier and less other-aware era.  And, in the hustle and bustle of integrated behavioral health, we’re often not afforded time for structural interventions with families. 

 

And yet, in this regard, our integrated models are also starting to show their age.  We are now acutely aware of the impact of social determinants of health and adverse childhood experiences.  Families-of-origin are the near universal first exposure to both of these health stressors.  We recognize relationships as the root cause of the symptoms that we attempt to manage in on-the-fly encounters. We live with the dreadful awareness that our referrals to other systems often fall through the cracks.  With the young and the aging, our societies benefit from the dedication of time, love, and resources that come from families and other loved ones.  Yet, behavioral health consultants in highly restricted settings often feel hobbled in their ability to fully engage the strengths of these systemic supports.

 

I only had the chance to meet Minuchin once. He presented at the Erickson Foundation’s Evolution of Psychotherapy conference in 2000.  I drove from Colorado to California to see him during my doctoral internship in Grand Junction.  He wore a baseball cap on-stage because his aging eyes couldn’t tolerate the spotlight. I found him to be humble and self-reflective.  He advocated for the continued relevance of his theories while also tipping his hat to the post-modern critiques that were de rigueur at the time.  He was gracious in tolerating a picture with me and a line of others after his remarks.

 

At last month’s CFHA conference I had a similar fanboy experience while sharing dinner with Susan McDaniel, Larry Mauksch, and Barry Jacobs.  Presciently, they shared their own experiences with and affection for Minuchin. I count myself as blessed to be part of our movement while it is still new enough and intimate enough to rub shoulders with our visionary founders.  It is our challenge to bring forward the legacy of their best ideas, while modernizing them to align with the ever-changing contexts in which we implement them.

Randall Reitz, PhD, LMFT, is director of behavioral sciences at St. Mary's Family Medicine Residency Program in Grand Junction, CO. 

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Improving Health Care Outcomes: It’s About Relationships!

Posted By Rick Ybarra, Tuesday, October 31, 2017

An important April 24th article published by the Commonwealth Fund is a timely and must-read article. It highlights the challenges of engaging, treating, and support persons with multiple, complex, chronic health conditions (defined as three or more health conditions, often including mental health). It supports the notion the Hogg Foundation believes in: integrated health care, team-based care, care coordination, and relationships: treating people with respect, dignity and worth.

Key takeaways:

·      Persons with multiple, complex, chronic health conditions (approximately 12 million persons) are among the 5 percent of patients who account for about 50 percent of health care spending

·      Collectively, these individuals account for more than $120 billion in health care spending annually

·      Also possess a functional limitation that interferes with basic activities of daily living

·      Persons with multiple, complex, chronic health conditions are impacted by social determinants of health, as well as socio, economic and cultural factors

·      A Commonwealth Fund survey of high-need patients found that 44 percent reported delaying care in the past year because of an access problem such as lack of transportation to the doctor’s office, limited office hours, or an inability to get an appointment quickly enough, often leading to more and more expensive care

That said, for all the money spent on multiple, complex, chronic health conditions, it is presumed that this particular patient population is not always receiving the best care or right type of care, where they need it, when they need it, and how they need it. One of the major dilemmas of health care.

Despite the challenges noted above, there are exciting and promising efforts to improve care being implemented, tested and evaluated across the nation. Collaborative, team-based initiatives with care managers such as social workers or nurses working within a medical home type setting show promise.

Many of these test programs have taken a different approach than traditional office care, emphasizing relationship - building and focusing more on meeting patients’ nonmedical needs outside the doctor’s office. Most of these programs pair patients with a dedicated care coordinator, who may or may not have extensive medical training, but who are knowledgeable and understand the complexities of the health care system well enough to help patients successfully navigate it. Importantly, these care coordinators are also strong and effective advocates on behalf of patients for housing, mental health, legal, nutritional, transportation, and other nonphysical/nonmedical needs.

The Commonwealth Fund article highlights innovative programs, patients, and care coordinators in Los Angeles, Chicago, and Minneapolis, just a small sampling of programs involved these kinds of efforts.

In these three case examples, they have several commonalities: improved health outcomes (people get better), increased engagement (people attend clinic appointments; learn about self-management of their conditions), and not requiring less ER visits and hospitalizations (you could argue less cost). Lastly, all examples point to the value and benefit of a care coordinator, who provide frequent “touch points” that do not occur in the clinic or in the health care encounter.

There is increased recognition that non-medical factors that impacts health conditions, such as coping with the day-to-day reality of living with serious, multiple, chronic illnesses, transportation challenges, a stable place to live, knowing where the next meal is coming from, affording the copay for medicines versus buying food, and the list goes on. Largely non-medical issues.

The article concludes that in the same way that medicine had to “learn” to assess and treat patients’ medical and mental health conditions, today’s real challenge is learning to assess and treat patients’ non-medical needs. Integrated health care, team-based care, and care managers, such as the examples illustrated in this Commonwealth article, may be the bridge that connects and strengthens the relationship between the patient and provider.

At the end of the day, it’s about relationship – building. Relationship between provider and patient, relationship between team members, relationship between care manager and patient, and relationships between the patient and their family/caregivers and community. Relationship – building. Not taught in medical schools and in academic graduate training programs. And most importantly, relationship – building does not come in pill form.

 


Rick Ybarra serves as program officer for the Hogg Foundation for Mental Health and leads the foundation’s Integrated Health Care Initiative. With over 25 years of clinical and administrative experience in both private and public sector behavioral health, Ybarra’s policy and program experience extends to county, state and national efforts promoting reforms, public policies and clinical practice to improve effective service delivery and health equity for racial/ethnic populations. Ybarra joined the foundation in 2007.



 

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Finding Family at the 2017 CFHA Annual Conference

Posted By Matthew P. Martin, Tuesday, October 3, 2017

The Families and Health Blog welcomes you to the 2017 annual conference of the Collaborative Family Healthcare Association! We have prepared this post of suggested concurrent education sessions for conference attendees who are interested in a special focus on families and health.

 

Is There Gold at the End of the Rainbow (Friday)

SUMMARY: Kinship caregivers of children in Protective Services custody often take on the caregiver role during a time of family crisis. The assistance of a Family Navigator, a paraprofessional with lived experience, demonstrated a reduced stress level in 74% of kinship caregivers at the Harris County Protective Services Clinic during a pilot project in 2015. These services were supported by a grant from the Hogg Foundation and were part of the clinic's Integrated Care Model.

 

Enhancing Medical Professionals' Compassion: An Interdisciplinary Collaborative Approach (Friday)

SUMMARY: This presentation will provide results from a collaborative research study in which behavioral health and medical professionals jointly trained medical residents in enhancing their compassionate response in breaking bad news to patients and family members.

 

Collaborative Family Healthcare in Specialty Settings - A Live Family Interview (Saturday)

SUMMARY: The purpose of this presentation is to highlight the intersection of illness and family issues. A therapist will conduct a live interview with a local family and a panel of physicians and therapists will discuss the case. Audience members will have time at the end for questions.

 

Family-Oriented Care Presents Obstacles, We Present Solutions (Saturday)

SUMMARY: This presentation will address common challenges associated with treating patients with their families in integrated care practices and settings. The presenters will provide a brief overview of three key barriers, will review current best practices and evidence-based guidance, and will illustrate dilemmas and the solutions in a role-play based on an actual patient/family clinical scenario.

 

Meeting Pediatric Behavioral Health Needs in Primary Care (Saturday)

SUMMARY: This session discusses the benefits and challenges of expanding integrated behavioral health to pediatric primary care and presents the data collected from a needs assessment, identifications of barriers, and provider education intervention within a large

Northwest health system.

 

Deepening our understanding of physical, emotional, and relational pain through interdisciplinary practitioner, patient, and family collaboration (Saturday)

SUMMARY: This presentation will describe how a collaborative approach between family therapists, a physician, the patient, and family facilitated an effective treatment outcome for an adolescent patient dealing with chronic pain. A deeper understanding of the bi-directional impact of the medical condition and the psychosocial stressors of adolescence and parent-child relationships will be discussed as well as a description of the treatment model and interventions that resulted in the treatment gains.

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The Future of Family-Centered Care Belongs to the Robots

Posted By Matthew P. Martin, Monday, September 11, 2017

A couple years ago I was listening to one of my favorite podcasts, Planet Money, an NPR radio show that tells terrific stories about the economy, technology, and everything in between. During this particular episode, I learned about a therapist named Ellie who is a terrific listener, asks insightful questions, and requires electricity.

 Yeah, Ellie is a robot. She was developed by the military to interact with people suffering from depression and posttraumatic stress disorder. And she’s good at her job. In a series of studies, Ellie was as good, or in some cases, even slightly better than psychologists at diagnosing PTSD and depression. And, maybe more importantly, people like talking to her.

This got me thinking (and fretting a little, to be honest): can a robot do my job? Can a robot sit with a couple facing cancer and provide a therapeutic intervention? Can a robot work with parents and a teenager struggling with pediatric obesity? The answer today is probably not, so don’t hand in your license to your state behavioral health licensing board just yet.

Then I came across this recent article in the Journal of the American Medical Association about a socially assistive robot that helps patients make behavioral changes. Here’s the first line:

 

“Speaking to a group of journalists last October at the annual meeting of the American Association for the Advancement of Science, Maja Matarić, PhD, stated the problem bluntly: “There aren’t enough people for people.””

 

I believe Dr. Matarić is correct and will go even further: there aren’t enough behavioral health providers for all the patients in the world. There never will be. But are robots the answer for this problem?

Dr. Matarić would say: absolutely. Her solution is to create robots that monitor and chat with patients, coaching and motivating their human companions to do tasks they might be disinclined to do, like exercise a stroke-affected limb. She believes in the power of social influence to change behavior and plans to release the first commercially available robot in 2019.

I want one of these robots. I think they contain the potential for providing care to thousands and thousands of patients that the health care system fails to treat. Will they replace you and your amazing talents and abilities? Will they replace family caregivers and home health aides? Those are not the right questions to ask. In fact, don’t think of these metal golems as replacements for human health workers. Your mom was right: you’re irreplaceable.

Instead, think of these automatons as enhancements and supporting cast to the vital work done each day by medical and behavioral health workers like you. Imagine working seamlessly with these little helpers to assess, treat, and follow-up with many more patients that you currently help.

Recently, I worked to integrate screening and brief intervention for substance misuse prevention (SBIRT) into a large family medicine practice. We first used paper screening tools but then discovered that the medical assistants were inaccurate in scoring the results. In response, I developed a tablet version that automatically scored the screening results. Problem solved!

Then, we worked on the brief intervention service but quickly realized that the physicians were not consistently using the training we gave them. Some did a great job talking to patients about substance use but the majority either avoided the topic or reverted back to advice-giving tactics.

I solved the screening problem with technology, but what if I could solve the brief intervention problem with artificial intelligence? Imagine patients interacting with a robot that administers all the screening protocol, provides a brief motivational interviewing conversation, and then documents and transfers the responses to your computer desktop for follow-up. Now you, as the clinician, can follow up with all patients that qualify for additional support and care management. Using this robot-enhanced system, you could spend your time helping patients get what they really need.

There is enough evidence and momentum now to suggest that robots will likely begin to help with integrated behavioral health services in the next five to ten years. Will robots also help in family-centered care? Can they use a complex model like emotionally focused therapy to help a couple facing infertility issues? That future is way down the line in my mind. But here are some ways robots can help us do family-centered care in the near future:

-        Supplement home health aide services by offering 24-hour social support

-       Assess family caregiver wellbeing during a medical visit

-       Identify patients with multiple co-morbidities who may benefit from increased family support

-       Provide psychoeducation for families facing terminal illness

-       Follow-up with patients and families who recently received a serious diagnosis

These ideas may seem weird or even heretical to some. But remember what Dr. Matarić said: there will never be enough people for people. Robots can help us fill that gap. 

  Matt Martin, PhD, LMFT is Clinical Assistant Professor at Arizona State University in the Doctor of Behavioral Health Program. He is the CFHA Blog Editor. Contact him if you're interested in writing for CFHA (matt.p.martin@gmail.com) 

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Implementing the CARE Act: What’s Working? What’s Not?

Posted By Carol Levine, Tuesday, September 5, 2017

This piece is a reprint from the United Hospital Fund website. Click here for the original publication. Reprinted here with permission.

Passing a law can be easy; implementing it can be much harder. Case in point: New York State’s Caregiver Advise, Record, and Enable (CARE) Act, which went into effect in April 2016. The law requires hospitals to carry out a series of activities to ensure that family caregivers are identified, included in discharge planning, and instructed in performing post-discharge care tasks at home. One year later, it is appropriate to ask: What’s working? What’s not?

Those questions formed the basis of an April 4 webinar drawing nearly 200 hospital staff members from around the state. Presented by UHF’s Families and Health Care Project, the webinar was sponsored by the New York State Partnership for Patients as part of its goal of reducing preventable readmissions by 20 percent.*

The webinar included a summary of CARE Act requirements, a description of UHF’s Implementing New York State’s CARE Act: A Toolkit for Hospital Staff and Next Step in Care patient/caregiver guides, and a series of polling questions to elicit hospitals’ experiences in the first year of implementation. Polling is an inexact science, and the results of an online poll taken during a webinar are far from definitive. Still, they suggest areas of consensus and those in which further exploration and guidance would be helpful. And for organizations in the more than 35 states with versions of the CARE Act, this poll identifies questions that they might ask of their own hospitals.

 

PUTTING THE ACT INTO ACTION: BASICS AND TOOLS
The CARE Act requires hospitals to:

  • Offer patients an opportunity to identify a caregiver and document that person’s contact information;
  • Obtain the patient’s written consent to share medical information with the caregiver;
  • Inform the caregiver about the expected discharge date; and
  • Provide instruction to the caregiver about post-discharge care.

UHF’s CARE Act toolkit, released in February 2017, addresses each of these requirements and adds an additional step—follow up after discharge, an important aspect of hospital-to-home transitions. Because the CARE Act does not exist in isolation, an appendix provides a “crosswalk” of New York State Department of Health regulations on discharge planning and CMS Conditions of Participation that relate to discharge planning. The Next Step in Care guides for patients and caregivers are available in a short (two-page) version and a longer one; both are available in English, Spanish, Chinese, and Russian.

 

HOSPITALS’ RESPONSES TO DATE
Hospitals are working to implement the CARE Act. That was clear from the high attendance at the webinar and responses to the polling question “Has the CARE Act required major changes in practice in your hospital?” Nearly 80 percent of those responding said yes. It seems likely that many of those changes concern identification of the caregiver and creating a field for that information in the Electronic Medical Record (EMR). When asked whether their hospital had a formal process for identifying the family caregiver, again nearly 80 percent said yes. What the remaining hospitals are doing to identify caregivers should be explored. Similarly, 72 percent of the hospitals said that they have a routine way of telling patients and caregivers about the CARE Act, but 28 percent do not. 

A follow-up poll question asked hospital staff to identify the three most important things about the CARE Act that patients and caregivers should know. “Patients will be asked to identify a caregiver” was clearly the most significant, with 88 percent of the respondents choosing this answer. The second most frequent response was “Caregiver will receive instruction about post-discharge care” (82 percent) and the third was “Patient will be asked to sign written consent to share medical information with the caregiver” (69 percent). Other options included “Caregiver can say ‘no’ to acting as caregiver” (23 percent) and “Patient can decline to name a caregiver” (19 percent).

 

PROBLEM AREAS
The relatively low percentage of respondents saying that patients and caregivers should know that the patient can decline to name a caregiver is particularly interesting in light of a further question that asked for the three most significant problems in implementing the CARE Act. Here the most common response was “Patient unwilling to name a caregiver” (51 percent). Identification of a caregiver is essential for all the other steps in the CARE Act to happen, so it is important to find out specifically which patients are declining, their reasons, and how this is being addressed.

Another high-rated problem area was “Patient unwilling to name a caregiver because of cognitive impairment” (35.9 percent). This is one situation on which the CARE Act is silent; the law does refer to patients who are unconscious but can be asked when they regain consciousness, but nothing is said about patients with erratic or permanent inability to name someone.

Other broadly noted problem areas were “Patient without stable residence or support system” (46 percent)—some of these people may be among those who decline to name a caregiver—and “Named caregiver unwilling or unable to perform required tasks” (43.5 percent); an equal percentage felt that there was not enough time to perform required instruction. Of interest is the low percentage (17.9 percent) responding that patients’ unwillingness to consent to share medical information is a significant problem. Even with the additional burden of written consent (which is notrequired by HIPAA regulations), most patients want their family and friends to know about their condition and care.

 

HOW CAREGIVERS ARE BEING TAUGHT
A final polling question asked about the ways in which instruction is provided to caregivers, a key aspect of the law: 100 percent of respondents checked “Demonstration by nurse.”  “Caregiver performing tasks to demonstrate competence” was selected by 65.9 percent; it is likely that this followed the demonstration by a nurse. The other options—video instruction (12.7 percent) and group sessions (6.3 percent)—were much less common. A few write-ins noted that printed material was also distributed.

 

FUTURE NEEDS
As experience with the CARE Act grows and as potential solutions to problem areas are identified, it will be important to continue communicating with the staff charged with the Act’s implementation. Some of the issues brought forward during the webinar stem from the law’s provisions themselves, such as lack of attention to cognitive impairment. But many relate to the realities of patients’ lives—housing instability, for example—and to caregivers’ multiple responsibilities and lack of training. Hospital staff have a difficult job in a difficult time, but the patients and caregivers they serve, as well as hospitals themselves, will be the beneficiaries of their hard work.

  Carol Levine directs the Families and Health Care Project at the United Hospital Fund in New York City. She is the editor of Living in the Land of Limbo: Fiction and Poetry about Family Caregiving (Vanderbilt University Press, 2014). 


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Angry Caregivers’ Misguided Blame

Posted By Barry J. Jacobs, Tuesday, August 15, 2017

Reprint from Huffington Post. Click here for original. Published here with permission.

“What made you decide to end your marriage?” I asked the exasperated 42-year-old woman in my office.

We were having one of those post-op individual psychotherapy sessions shortly after the couples therapy I conducted with her and her husband had failed. Our bid to save her marriage had gone poorly from the start. A year ago, her husband had had a major heart attack that killed 40% of his heart muscle and left him weak and highly anxious. Every time he felt chest pain in the months afterwards, he was convinced he was having another heart attack and repeatedly called 911 to carry him out of his workplace on a stretcher. (No further heart damage was ever detected in the emergency room.) As a consequence of these disruptions, several different employers had fired him in quick succession. During our couples sessions, he pleaded with his wife to be patient with him until he found a position that suited his now diminished physical abilities and he regained confidence in his health and safety. But she eyed him coldly and expressed no empathy—only anger.

“I’m tired of working and working and working,” she complained to me during our individual meeting. “I have to take care of the house and do hair and everything. And he just doesn’t do anything. I’m tired of him saying he can’t do things.”

“But don’t you think his heart condition has changed what he can do?” I responded.

She shot back with rising irritation, “No. It’s all mental. He’s never been able to keep a job. Not since the beginning of our marriage 17 years ago. And he’s just trying to use his heart now to manipulate me to take care of him. But I won’t let him do that any more.”

Her view of him was as unshakeable as it was unforgiving. They separated soon after. She wound up starting her own small business and eventually marrying an older, affluent man who catered to her. He crashed on friends’ couches for a few weeks before moving into a homeless shelter. He only got back on his feet when he found another woman to take him in.

So what’s wrong with this picture? He was a lousy provider, in all likelihood, who’d made her feel victimized for nearly 17 years. She had every right to decline being re-victimized as his put-upon cardiac caregiver. Some would call that karmic justice.

But what happened here, in my mind, wasn’t simply an illustration of a bad relationship history undermining the willingness to make sacrifices on another’s behalf. She attributed malice to her husband’s intentions. At the same time, she trivialized his disabling heart functioning and resultant anxiety. It was as if she believed he was a malingerer and sociopath who willfully interpreted his chest pains as heart attack symptoms just to ride the ambulance and get out of a day’s work. To me, this was a distortion of the medical reality. Worse, it was a kind of character assassination that amounted to kicking a man when he was already down.

This happens in family caregiving in more subtle ways all of the time. Think of the emotionally distant adult daughter who avoids dealing with her father with dementia because he had always been mean to her when she was growing up. She perceives his yelling now as more of his old orneriness and not the agitated protests of a diseased mind. Or consider the wife of a lung cancer patient who blames him for ruining his life and hers because of his heavy smoking. Not every one of these family members will sever their ties with the care receiver when the time for caregiving arrives. Some will keep their distance and give little. Others will give lots but do it with an edge of resentment while assuming a bossy, morally superior stance.

This kind of blaming may feel right. But I think it’s misguided. Ill-used caregivers are entitled to walk away but do themselves no honor assuaging their guilt through being vindictive toward the newly vulnerable. That turns caregiving into a grudge match which compounds the suffering of the already disabled care receiver. It precludes any possible joy in the caregiving. It impedes real understanding of and empathy for the present predicament. We need to carefully distinguish the clinical symptoms of aging and illness from the past’s negative emotional legacy or risk conflating the two. Heart attacks needn’t prompt attacks on the heart.

 

  Barry J. Jacobs, Psy.D. is a clinical psychologist, family therapist and the Director of Behavioral Sciences for the Crozer-Keystone Family Medicine Residency Program in Springfield, PA. He is the co-author (with his wife, Julia L. Mayer, Psy.D.) of AARP Meditations for Caregivers—Practical, Emotional and Spiritual Support for You and Your Family (Da Capo). 

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