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Core Clinical Competencies for Family Therapists Working in Healthcare Settings

Posted By Matthew P. Martin, Monday, April 16, 2018
Updated: Tuesday, April 17, 2018

This piece is a reprint of a publication from the American Association of Marriage and Family Therapy. Click here for the original post. Check back soon for a post on Core Scholarship Competencies.

Family therapists are well equipped to work in healthcare settings across clinical, training/supervision, management/policy, and scholarship efforts. This blog post is the first in a series (of four) that highlights core competencies across these respective foci. It begins by describing how field leaders worked with AAMFT to identify said competencies, and then highlights those specific to clinical efforts. These efforts are anchored within systems-, biopsychosocial/spiritual-, collaboration-, leadership-, ethics-, and diversity- domains.

Core Clinical Competencies for Family Therapists Working in Healthcare Settings
In 2013, a team of field leaders in Medical Family Therapy came together to develop competencies for family therapists working in healthcare settings. They initiated these efforts in response to the increasing numbers of therapists being sought-out for and placed within such settings, alongside a recognition that clear guidelines regarding knowledge, skills, and abilities for effective engagement in such placements were not yet available. Over the next four years, this team worked across small- and large- group formats to identify key domain areas, associated skillsets, and target indicators relevant to this work. For a thorough description of the steps encompassed in this effort, see American Association for Marriage and Family Therapy [AAMFT] (2018).

Core competencies for family therapists working in healthcare settings are situated in four principal areas: (a) clinical skills; (b) training and supervision; (c) healthcare management and policy; and (d) scholarship. Each of these domains are further anchored in six domains (systems, biopsychosocial/spiritual, collaboration, leadership, ethics, and diversity).

The following is a summary of core competencies related to clinical skills; ensuing blogs on this website will highlight competencies in training and supervision, healthcare management and policy, and scholarship.

Clinical Competencies

As clinicians who are excited about our own work in healthcare contexts, we have been energized by the opportunity to present at AAMFT conferences and publish on our experiences in a variety of healthcare settings. Over the years, a number of family therapists would ask what they need to know in order to work in a healthcare context. First and foremost, we believe that clinical competencies for family therapists in healthcare settings must be grounded in the AAMFT’s Code of Ethics (2015) and MFT Core Competencies (2004). A team of family therapists then united to offer additional competencies uniquely constructed for family therapists in healthcare settings. Leaders in the field agreed that there was a need for additional specialized training and skills in order to maximize employment in and collaboration with healthcare settings and systems. Below is a sample of the clinical competencies via the six domains:

Clinical competencies related to general systems. Family therapists working in healthcare settings must advance clinical efforts in a manner that recognizes and honors multi-level and multi-directional influences between family members (e.g., patients, spouses, parents, children), between healthcare providers (e.g., behavioral, biomedical, pastoral), and between families and healthcare providers (as active participants in team-based care). They are thereby able to engage patients and families in support regarding, processing of, coping with, and effectively managing health crises/conditions/challenges, while at the same time facilitating valuable communication and collaboration between multiple providers involved in their care.

Family therapists in healthcare contexts balance conversations across the continuum from illness to well-being, deficits to resilience, strengths to weaknesses, hope to despair, and acceptance to agency toward change. They maintain competence in explaining literature and implementing practice through best- and systemic- interventions across multiple fields (e.g., Family Therapy, Medicine, Nursing), and through a variety of theories and models as they interface with systemic health concerns (e.g., motivational interviewing with patients who wish to stop smoking, structural family therapy + psychoeducation for adolescents living with diabetes).

Clinical competencies related to biopsychosocial-spiritual (BPSS) systems. Family therapists in healthcare settings consistently work to advance clinical care with clear knowledge regarding the biological components of – and biomedical interventions for – diseases that are customary to the care sites within which they are positioned and how those components interface with psychosocial and spiritual health and beliefs. For example, those working in endocrinology are familiar with metabolic processes, disease management strategies, and medications core to diabetes care as they interface with health behaviors and spiritual practices; those working in oncology are similarly conversant with physiological processes, testing sequences, and care-strategies common in cancer care – particularly as they intersect with relational decision making and mental health comorbidities. They are up-to-date in psychopharmacology (e.g., medication classes, common uses, common side effects), especially regarding drugs most frequently prescribed in their sites. They communicate in manners that demonstrate healthcare literacy across multiple disciplines (e.g., medical- and psychological/psychiatric- terminology, disease- and/or diagnosis- specific nomenclatures), and regularly articulate the manners in which multiple BPSS dimensions interact with each other in the present, across the lifespan, and with consideration of cultural / spiritual beliefs and practices.

Clinical competencies related to collaboration. Connecting the multiple and complex-overlapping dots of systems- and BPSS- sensitive care, family therapists in healthcare settings work hard to employ evidence-based models that promote interdisciplinary collaboration and relational care. They do this in a manner driven by respectful working alliances with patients, families, and other involved professionals working together en route to shared treatment goals. Family therapists in healthcare contexts must know how to navigate collaborative relationships through careful, purposeful, and flexible attention to collaborative efforts that span across workflow time (before, during, and after care encounters) and mediums (verbal, written, electronic, etc.).

Clinical competencies related to leadership. Family therapists in healthcare settings work hard to create and/or promote evidence-based models of integrated behavioral health care in collaboration with patients, families, healthcare team members, supervisees, administrators, community partners, researchers, and policy-makers. They do this through providing education about, modeling, and/or advancing clinical practices that maximize care outcomes, cost efficiency, and/or training and mentoring development. Given the systemic and BPSS training of family therapists in health care contexts, it is not uncommon to be asked to serve in leadership roles such as behavioral health director. Many also secure advanced credentialing and/or certification in leadership and supervision, which further-establishes their integrity as advocates for (and others’ receptivity of) the content and practices that they espouse.

Clinical competencies related to ethics. Family therapists in healthcare settings must demonstrate adherence to ethical practice in all that they do. This is a complex undertaking, however, because it requires practicing with informed knowledge regarding one’s own and other providers’ overlapping and distinct disciplinary guidelines that regulate foci like scope of practice, confidentiality, and billing – alongside appropriate and purposeful problem-solving vis-à-vis commonplace ethical dilemmas. Combined with these baseline knowledge areas and skillsets, these therapists must function in a manner that is consistently receptive to (and seeking of) input and support from colleagues, supervisors, site administrators, and legal counsel.

Clinical competencies related to diversity. Family therapists in healthcare settings must show awareness of, curiosity about, and respect for different biopsychosocial/spiritual beliefs, practices, and traditions across the intersection of social locations (e.g., ability, age, sexual orientation, gender identity). Furthermore, family therapists must be informed of historical marginalization and be aware of how to honor preferred treatment options for diverse populations. These understandings enable unique and/or sacredly-held viewpoints and customs to be effectively carried out, accommodated, and/or integrated into care provision (inside- and outside- of the clinic/hospital). These therapists also regard “diversity” as encompassing attention to social locations, and they work to incorporate sensitivity to these foci across the purposeful design, implementation, and evaluation of treatment plans. They do this with explicit recognition of their own personal biases and beliefs, and openly seek support/training/supervision to process and/or improve their efforts as indicated.

Conclusion

Core clinical competencies for family therapists working in healthcare settings cut across systems-, biopsychosocial/spiritual-, collaboration-, leadership-, ethics-, and diversity- domains. Crossing primary (e.g., family medicine, pediatrics), secondary (e.g., OBGYN, emergency medicine), tertiary (e.g., hospice care, alcohol and drug treatment), and other care environments (e.g., employee assistance programs, military care systems), these skillsets are essential for the effective integration of family therapists into medically-oriented treatment and interdisciplinary care teams.

Note: As outlined in this blog’s introductory text, ensuing installments will highlight other core competencies for family therapists in healthcare settings. These will include attention toward training and supervision, healthcare management and policy, and scholarship.

Click here to download your free copy: http://www.aamft.org/healthcare   

References

American Association for Marriage and Family Therapy (2018). Competencies for family therapists working in healthcare care settings. Retrieved from www.aamft.org/healthcare

American Association for Marriage and Family Therapy (2015). Code of ethics. Retrieved from http://www.aamft.org/iMIS15/AAMFT/Content/Legal_Ethics/Code_of_Ethics.aspx

American Association for Marriage and Family Therapy (2004). Marriage and family therapy core competencies.

Authors: Tai Mendenhall, Ph.D., LMFT; Angela Lamson, Ph.D., LMFT; Jennifer Hodgson, Ph.D., LMFT; Lisa Tyndall, Ph.D., LMFT; Jackie Williams-Reade, Ph.D., LMFT; Stephanie Trudeau, Ph.D.

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A Squeeze of the Hand: What Does a Son Owe His Mother?

Posted By Barry J. Jacobs, Monday, March 26, 2018

This piece is a reprint from October 2017. Click here for original publication. 

For 58 years, from my birth until her death, my mother and I clashed over money and material values, cents and sensibilities. We were as mismatched as a Hermes scarf atop a Yankees sweatshirt. In my early life, she wrestled me into blue blazers against my will at upscale New York clothiers. In her late life, I berated her for sneaking to Talbot’s with her home health aide to buy wool slacks she didn’t need and couldn’t afford. Our differences made our respective caregiving—her tussling with me as a rebellious child; me struggling with her as a resistant elder—fraught with resentment.


She was a slim, pretty redhead who called herself a princess but came from humble origins. Her parents were poor, uneducated Jewish immigrants from a Polish country village. They and their children spoke Yiddish in their Bronx tenement apartment. Her amiable but careworn father washed storefront windows for a living. Her stern, little mother, trapped as an unhappy wife and homemaker, lashed out at her three children. My mother, the youngest, felt neglected because her disabled brother and popular sister garnered most of the attention. But my mother had unquestioned smarts and drive, excelling at school. She entered City College of New York in 1946 at the age of 16—one of only a handful of women in a class of thousands of war-hardened, returning GI Joes—and became a teacher and an accountant. She benefitted from American meritocracy, escaping the Bronx for Queens and then the suburbs, and later, South Florida, vaulting into the upper middle class and beyond.

These are the things I admired about my mother: her charisma, thirst for new knowledge and experiences, and fierce protectiveness. Wherever she lived, she engaged everyone around her with her warm gaze and intense interest. She then became their leader, energetically running play groups and carpools, PTAs and condo boards. She read incessantly. She called and confronted the parents of the older kids who bullied me on the playground.

But her early years had left her with a gnawing sense of economic and emotional deprivation. This was compounded by real hardships. Her first husband, a boy from down the block, left her for another woman after my mother had supported him through medical school. Her second husband (my father) died from brain cancer when she was only 43. Her third husband was a Korean War vet with PTSD. Despite how far she’d come, her standing in life always felt precarious to her. As time went on, she dressed better and better (designer silk blouses and dress pants), was more coiffed (brightly dyed bouffant hair and polished nails), and bedecked herself with more gold jewelry (necklaces, rings, and earrings)—all means, perhaps, to make herself feel more secure. But she never received all the comfort and distinction she felt she was due.

If life felt like a disappointment to her, then I only added to it. An early Super 8 film shows me as a toddler, chortling with laughter, as I ran away from her in a supermarket and she chased me in anger. I had my own smarts and excelled in school, but never quite conformed to the shining and obedient child she thought she deserved. I was an undiagnosed ADD kid—sloppy and dreamy. Where she thrived in social circles, I was the shy boy who withdrew, much to her irritation. I didn’t aspire to become a physician or a lawyer. I didn’t place family togetherness above all else. I wasn’t thankful enough for all she did for me. We argued a lot during my adolescent years, and then settled into a distant relationship when I went away to college and made my life afterward far away from her.

Nothing about this is unusual for many mother–son relationships. We spent decades seeing each other infrequently and not knowing one another as adults. But then old age hit.

When my mother called me each week from her gated Florida golf community, I noted a growing anxiety in her tone as she complained about my stepfather’s forgetfulness and confusion—early symptoms of Alzheimer’s dementia. I offered my help as an expert on family caregiving, but my mother scoffed at the notion she needed assistance. Then she surprised me by calling me while I was at work one day to ask, “Can you send me $30,000 right away?” I was aghast. They’d enjoyed the high life, travelling the world, leasing new cars every two years. Now the story came out. They’d taken two mortgages on the condo, had run up their credit card balances, and were more than $200,000 in debt. In the struggle to meet her bills, she was depleting her meager savings. I didn’t send her the money but flew down to set her up with a bankruptcy attorney. Their house of cards had collapsed, and she felt humiliated and wronged by misfortune.

Those were the trying circumstances under which my mother, at 80, and me, at 52, began to grapple with one another as adults, and we were often at odds. In her mind, I was supposed to support her exalted view of herself by helping to pay for it, while I was appalled by her disregard for how her overspending affected others, including my family. I couldn’t bring myself to empathize with the small, needy girl behind her outsized desires.

As I helped pack up her condo to move her and my stepfather into an apartment a mile from my Pennsylvania home, I was shocked to find a full rack of expensive blouses and slacks that still bore price tags. But rather than recognize her shopaholism as a symptom of the emptiness she felt, especially caring for a husband with dementia, I lit into her profligacy. Her fall in status and new dependence on me were hard enough, but my condemnation—kicking her when she was down—made her livid. She took her own shots in response. When she arrived in the tidy apartment my wife and I had purchased for them, she pronounced it just like the homely Bronx tenement from which she’d spent most of her life trying to distance herself.

Over the following years, I played the dutiful caregiving son, taking them to doctor’s offices and supermarkets, museums and restaurants. My stepfather eventually went into a nursing home, where he died, and my mother lived in the apartment alone. But there was no joy in being together while living in the same community as her for the first time in more than 30 years. Instead, there was constant underlying tension about money.

My mother would rise late each day and then, with stylish clothes and perfect hair, go into our town’s commercial center to buy lunch for herself and her aide. Later, after I’d found out about that, I’d become aggravated with her for frittering away her scant money. She’d look at me in sour silence. When I’d press her, she’d blurt out, “I gotta live!” as if that were explanation enough. When I’d respond in anger, telling her she was still living in her fantasy world of ease, she’d dismiss me with “I’m too old to change.”

A cousin to whom I described these impasses advised me to resign myself to just letting her spend the way she wanted. I couldn’t bring myself to do it, though. I worried about her bills because she wouldn’t. There was also too much at stake for me emotionally. She may have felt entitled to a grand lifestyle, but I felt entitled to a less solipsistic mother—one who relished, not hated, my help.

We battled in person and behind each other’s backs. I went to her dry cleaners and hairdresser to tell them she was broke and couldn’t afford their services, and I begged the home health agency to stop its aides from lunching with my mother. I found out later that she was hocking her remaining gold jewelry to continue to have pocket cash for clandestine shopping and nice meals. To her, I was a controlling tormentor. To me, she was a selfish ingrate.

If my mother had died at that point, five years into our caregiving journey together, then I’d have been forever bitter toward her. But her continued physical and cognitive decline, which now took a decided turn, created tragedy and opportunity for us. In what seemed a matter of months, she could no longer safely organize her pill box or remember our arguments from one day to the next. She began to fall in her apartment—where her aides would find her splayed on the carpet when they arrived—and in the street, breaking her tailbone and bruising her head. Living was becoming hazardous for her. In 2015, she was hospitalized three times for injuries and changes in mental status. We couldn’t afford to have someone stay with her round-the-clock, and neither she nor I wanted her to move into my house. I felt constantly anxious and guilty.

Then my mother did me a favor that still stuns me: she opted to move into a nursing home. It was a Jewish facility where she could speak Yiddish and eat kosher food like her mother had served. She made it clear that this was her gift to me so I wouldn’t feel so burdened by caring for her any more. A month later, however, she hated the food, the boredom, and the constant din of dementia patients, and wanted to move back into the apartment. Fearful she’d just resume falling, I said no. She fumed. But from that point forward, something changed in our relationship.

Freed from having to police her spending and safeguard her health, I was able to relax and just be her adult son in a way I’d never experienced. Even when she complained about the nursing home in an accusatory tone, I could hear her suffering without feeling responsible and defensive about it and could respond gently. Though her love of jewelry had always struck me as vain, I now found it touching that she wore bracelets and necklaces made of beads she’d strung at an arts-and-crafts session. After three months in the nursing home, she noticed I’d changed and said, “I don’t understand why you’re being so nice to me now.” I answered, “Because you aren’t in a position to defy and hurt me any longer.” She stared at me and slowly nodded.

Every weekend, I drove the hour-and-a-half round trip to the nursing home to lunch with her. There was little substantial conversation—my mother and I never learned to talk deeply with one another—but we sat in her bedroom or the unit sunroom eating sandwiches and then looking at photo albums of her past trips to Thailand, France, and Argentina, or at pictures of my grown kids on my phone. I’d push her in her wheelchair to sit by the flower garden near the back patio or roll along the paths of the lovely grounds. She couldn’t walk, talk, or think the way she wanted, and she was very unhappy. I felt for her. We were both witnessing the spectacle of her dying a little at a time, and it seemed to wipe away our previous conflicts. She took solace from my empathy. One day, while in the elevator on the way back to her room, she suddenly grabbed and squeezed my hand in a small, tender gesture. I took it to mean thank you for being here, but also we’ve been through a lot and have reached a better place, as well as wordless acknowledgement that she was moving toward the end.

A year and a half after the move to the nursing home, I received a call while I was giving a lecture on family caregiving on the other side of the state: my mother was in and out of a coma. As I drove for six hours to be with her, I reflected on our flawed relationship. When I arrived, she was lying in her bed with gaping mouth and eyelids shut. I called to her and she opened her fog-bound eyes briefly before shutting them again. I positioned myself in front of her and called her loudly again. When she opened her eyes and looked at me, seeming to recognize me this time, I told her I forgave her for things she’d done to hurt me and asked for her forgiveness for hurtful things I’d done. I expressed regret that we hadn’t found a way to be closer. She held my gaze a moment longer and then shut her eyes again. A few hours later, she took two last short breaths and died.

I’m troubled by many of my memories of my mother, the mismatch in our styles and convictions, and our inability to understand one another better. But I’m also grateful for the time we had to try, especially through her dementia and dying. Love, I learned, isn’t about agreement. It’s about connecting on that most elemental level: being there, accepting, a nod, a squeeze of the hand.

 

 

Barry Jacobs, PsyD, is the director of behavioral sciences for the Crozer-Keystone Family Medicine Residency Program, the author of The Emotional Survival Guide for Caregivers, and coauthor with Julia Mayer of AARP Meditations for Caregivers. He’s on the Caregiver Advisory Panel and writes a monthly column for AARP.org. Contact: barryjjacobs@gmail.com  

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Where There’s Smoke, There’s Fire

Posted By Kaitlin Leckie, Kristine Miller, Monday, March 12, 2018

This post is a reprint. Click here for the original publication. 

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.


Aside 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.


The SCAN 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 of 10.




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 skills.


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 resources:

www.acestudy.org

http://www.cdc.gov/violenceprevention/acestudy/

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 Press.

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), 265-274.



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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Family Therapy for An Entire Nation

Posted By Matthew P. Martin, Monday, February 26, 2018

You don't need a family therapist to realize how divided many Americans are today. Whether the conversation is about gun control, health care, globalism, the US military, or even if LeBron James should leave Cleveland, the levels of civility and communication seem to have hit new lows. Tragedies like the senseless violence in Florida magnify these divides leading to more of the same: Americans talking at and past each other.

David Brooks of the New York Times recently commented on this situation in his article "Respect First, Then Gun Control". He argues that issues like gun control become flash points in which we feel and react from strong emotions, often doing more harm than good. But for any progress to be made, he states, there has to be trust and respect first before crucial decisions are made. Hey family therapists out there, does this sound familiar?

Brooks cites the recent work of a group of citizen professionals, David Lapp, David Blankenhorn and  prominent family therapist, Bill Doherty, who are using their organization, Better Angels, to bring heavily polarized groups into the same room together for a good dose of reframing and clarifying communication. These long, humbling conversations between people on different ends of the spectrum have lead to some incredible outcomes and may signal one strategy for moving past the "tribal" thinking that seems to dominant the current airwaves. 

I reached out to Bill Doherty and asked him some question regarding Better Angels. He responded quickly:

1. What seems to drive polarization within any group or organization?
Loosing sight of the relationships when people differ on viewpoints or emotional stances.  In relationships beyond dyads, this is usually associated with forming coalitions--an insider tribe and an outside tribe. Over time, the relationships become more distant, people don't know each other well, and they objectify and stereotype each other.  Tribal loyalty replaces commitment to the common good--the overall relationship.  At a national level, the big divide is between conservatives and liberals, many of whom view the other tribe as not just wrong-headed but dangerous.  

2. How does "Better Angels" attempt to address deep divides between groups?  Through red/blue workshops where we bring together 7 people from each side for three hours or a day, in a structured process of coming to understand each other beyond stereotypes and look for common ground.  Through skills workshops (for any number of reds and blues) where people learn skills for having cross-partisan conversations.  And through Better Angels Alliances (groups of reds and blues) which spring from the red/blue workshops, with the goal of spreading the depolarization work and seeking common ground policy issues to work on (examples thus far: gerrymandering and money in politics).  We developed the workshops, took them on the road in two bus tours where we refined them, and now we are training professional around the country to moderate local workshops.


3. What divisions do you think exist in health care that CFHA members might experience? From my frame of mind, CFHA members could view health as involving the civic health of the nation, and thus get involved in Better Angels work. I certainly see it that way, and it's an idea behind being a "citizen professional." I'm also doing a Police and Black Men Project, and that again is about the health of the commonwealth.

If you are interested in supporting Better Angels, you are welcome to donate, pay a $10 subscription per year, or volunteer to help. 



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Mindfulness for Parents of Children with Autism Spectrum Disorder

Posted By Katy Oberle, Tuesday, February 13, 2018

Parents of children with autism spectrum disorder (ASD) often experience high stress in the form of psychological problems, marital strain, and/or family interaction difficulties. [1-4] This is especially the case when the child with ASD exhibits challenging behaviors. [5, 6] Mindfulness-based interventions have been found to be beneficial for these parents in many ways, such as decreasing their levels of depression, stress, and emotional reactivity to “aversive stimuli” such as challenging child behaviors. [7] Additionally, many parents of children with ASD who engage in a mindfulness-based practice see a decrease in their child’s aggression and challenging behaviors and an improvement in the child’s overall functioning. [8, 9] Preliminary evidence suggests that the above benefits may be long-lasting, even months after the mindfulness training has occurred. [10, 11]

The Mechanisms of Mindfulness

Mindfulness has come to be defined as the non-judgmental awareness of the present moment. [12] When we practice mindfulness, we increase our psychological flexibility—the ability to consider each situation with fresh eyes and to select a response that is consistent with our values. [13, 14] For a parent of a child with ASD, this is the difference between yelling to get a disruptive behavior to stop, and pausing to consider the possible function(s) of the behavior so that he/she can respond intelligently and effectively to the child.  The “non-judgmental” aspect of mindfulness means that parents are developing more compassion for themselves instead of feeling like it’s the end of the world when they do yell. Instead, they can mindfully reflect, repair if needed, and try again. [15]

Mindfulness-Based Interventions for Parents of Kids with ASD

Before discussing interventions, it’s important to understand that mindfulness, in the words of Mindfulness-Based Stress Reduction (MBSR) creator Jon Kabat-Zinn, “isn’t one more cognitive-behavioral technique to be deployed in a behavior change paradigm, but a way of being and a way of seeing that has profound implications for understanding the nature of our own minds and bodies, and for living life as if it really mattered.”

That being said, one way to develop a mindfulness-based skillset is to participate in a structured mindfulness-informed group or curriculum (i.e. Mindfulness-Based Stress Reduction (MBSR), Mindfulness-Based Cognitive Therapy (MBCT), Acceptance and Commitment Therapy (ACT), etc). Tasks common to most mindfulness-based approaches include: making contact with the present moment; exploring breathing techniques; increasing awareness of bodily sensations, mental states and emotions; practicing non-judgmental acceptance and self-compassion; and committing to behavior change. [7] These above tasks—with the exception of in ACT—are accomplished through the practice of mindfulness meditation, which can be done seated (on a cushion or in a chair), lying down, or walking. However, it’s important to know that any activity can be done with mindfulness, including parenting! [8, 12]

One Minute Counts

Mindfulness meditation is most effective when practiced on a daily basis. That doesn’t necessarily mean that parents need to be folded up in the lotus position for 1-2 hours a day—though they would likely gain benefits from doing so—but it does mean that parents need to be encouraged to schedule intentional time each day for meditation. Parents can be coached to take “breathing breaks” during the day in which their focus would be on taking 5-10 deep breaths with eyes closed or gaze softened. Often parents need help creatively thinking about how they could squeeze in this type of intervention in their busy lives. [16]

I have found that the image of putting on your own oxygen mask first before assisting your child with theirs resonates with many parents in order to clarify the distinction between self-serving/selfish and self-care/self-sustaining behaviors. I remind parents that they are the foundation of their family, and that it’s not only okay but actually necessary to care for their body, mind, and spirit so that they can be their best selves as parents, and in many cases, as partners to their spouses. For parents who are tech-savvy, there are many good apps on the market (some of which are free) that offer mindfulness-based content and guided meditations. One of my favorites is the app “10% Happier”. Check out the quick guided meditation “1 Minute to Sanity” by Dan Harris.

Practice, practice, practice!

The takeaway is that the biggest benefits from mindfulness come with practice—intentional, consistent, and structured practice—and that this practice doesn’t have to be complicated. I am in the process of adapting a mindfulness-based curriculum for parents of children with ASD for use at my workplace, and I would encourage anyone who is interested in similar endeavors to consult the below references for guidance. As professionals who work with these parents, we are witness to their struggles, and we are best-positioned to assist them in developing a mindfulness practice that can not only sustain them but can allow them to thrive in their experiences as parents, partners, and human beings.

 

Katy Oberle, MS, IMFT is a family therapist at the Child Development Center (CDC) of Nationwide Children's Hospital. She conducts diagnostic assessments for children and teens with developmental and behavioral health concerns, and she provides systemically-focused therapy services to CDC clients and their families. Her clinical interests include couple relationship enhancement for parents of children with special needs, and systemically-geared mindfulness-based interventions delivered in the context of various healthcare settings. 

 1.         Bitsika, V.S., CF, Stress, anxiety and depression among parents of children with autism spectrum disorder. Australian Journal of Guidance and Counselling, 2004. 14(2): p. 151-161.

  2.         Gau, S., Chou, M-C, Chiang, H-L, Lee, J-C, Wong, C-C, Chou, W-J, & Wu, Y-Y, Parental adjustment, marital relationship, and family function in families of children with autism. Research in Autism Spectrum Disorders, 2012. 6: p. 263-270.

 3.         Hartley, S., Barker, ET, Seltzer, MM, Floyd, F, Greenberg, J, Orsmond G & Bolt, D, The relative risk and timing of divorce in families of children with an autism spectrum disorder. Journal of Family Psychology, 2010. 24(4): p. 449-457.

 4.         Pozo, P., Sarria, E & Brioso, A, Family quality of life and psychological well-being in parents of children with autism spectrum disorders: A double ABCX model. Journal of Intellectual Disability Research, 2014. 58(5): p. 442-458.

 5.         Estes, A., Munson, J, Dawson, G, Koehler, E, Zhou, XH & Abbott, R, Parenting stress and psychological functioning among mothers of preschool children with autism and developmental delay. Autism, 2009. 13: p. 375-387.

 6.         Beer, M., Ward, L & Moar, K, The relationship between mindful parenting and distress in parents of children with an autism spectrum disorder. Mindfulness, 2013. 4: p. 102-112.

7.         Cachia, R., Anderson, A & Moore, DW, Mindfulness, stress and well-being in parents of children with autism spectrum disorder: A systematic review. Journal of Child and Family Studies, 2016. 25: p. 1-14.

8.         Singh, N., Lancioni, GE, Winton, ASW, & Fisher, BC, Mindful parenting decreases aggression, noncompliance, and self-injury in children with autism. Journal of Emotional and Behavioral Disorders, 2006. 14(3): p. 169-177.

9.         Singh, N., lancioni, GE, Winton, ASW, Karazsia, BT, Myers, RE, Latham, LL & Singh, J, Mindfulness-based positive behavior support (MBPBS) for mothers of adolescents with autism spectrum disorder: Effects on adolescents' behavior and parental stress. Mindfulness, 2014. 5: p. 646-657.

10.       Blackledge, J.H., SC, Using acceptance and commitment training in the support of parents of children diagnosed with autism. Child and Family Behavior Therapy, 2006. 28: p. 1-18.

11.       Bazzano, A., Wolfe, C, Zylowska, L, Wang, S, Schuster, E, Barrett, C & Lehrer, D, Mindfulness-based stress reduction (MBSR) for parents and caregivers of individuals with developmental disabilities: A community-based approach. Journal of Child and Family Studies, 2015. 24(2): p. 298-308.

12.       Kabat-Zinn, M.K.-Z., J, Everday blessings: The inner work of mindful parenting2014, New York, NY: Hachette Books.

13.       Kashdan, T.R., J, Psychological flexibility as a fundamental aspect of health. Clinical Psychology Review, 2010. 30: p. 865-878.

14.       Dumas, J., Mindfulness-based parent training: strategies to lessen the grip of automaticity in families with disruptive children. Journal of Clinical Child and Adolescent Psychology, 2005. 34(4): p. 779-791.

15.       Wong, C., Mak, WWS & Yu-Hsin Liao, K, Self-compassion: A potential buffer against affiliate stigma experienced by parents of children with autism spectrum disorders. Mindfulness, 2016. 7(6): p. 1385-1395.

16.       Harris, D., 10% Happier: How I tamed the voice in my head, reduced stress without losing my edge, and found self-help that actually works--a true story2014, New York, NY: HarperCollins.

 

 

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Postpartum Depression Screening in Pediatric Primary Care

Posted By Matthew P. Martin, Wednesday, January 31, 2018

"I should be happy but I feel nothing right now" Nadiya thought to herself. She had a brand new beautiful boy that looked like her husband but Nadiya felt none of the joy or excitement that she heard other mothers describe. She worried that her feelings would negatively affect her son and lead to future problems. Nadiya kept her feelings to herself and even acted upbeat during the pediatric medical visits. After several weeks, she began to wonder if she would ever feel normal again.

 

Nadiya's story is familiar to medical providers who work in primary care, especially pediatricians. Studies show that nearly 1 in 5 women experience postpartum depression (PPD) and that many go undiagnosed. PPD negatively affects a mother's ability to engage with her family and child at an emotional and cognitive level, placing the child at greater risk for impaired development. Despite these consequences, early detection and management can make a significant difference for mothers who suffer from PPD. 

 

The American College of Obstetricians and Gynecologists (ACOG) recommends that clinicians screen patients at least once during the perinatal period for depression and anxiety symptoms and then provide close follow-up and treatment for qualifying mothers. However, it's one thing to make recommendations and another thing to actually implement these guidelines. A recent literature review found that although most pediatricians felt a responsibility for identifying PPD, pediatricians were the least likely of the three provider groups included to use a screening tool to assess for PPD, at 7%, compared with 31% for family physicians and 36% for obstetrician-gynecologists.1 Pediatricians were also the least confident in their skills to recognize PPD yet were the most likely to rely on their own clinical judgment rather than a screening tool to detect PPD.

 

So, how can pediatricians, who work at the forefront of child primary care, increase screening rates for PPD? A new study on clinical decision support provides a helpful algorithm (see graph below) to guide pediatricians.2 Using a validated depression screening tool (e.g., PHQ-2, PHQ-9, EDS), pediatricians can use specific cut-off scores to determine if a mother qualifies for no referral, a referral to mental health, or immediate emergency services. This quick and simple decision tree easily guides pediatricians through the evidence-based process of decision-making. 

 

 

In addition, the authors conclude that a warm handoff with a behavioral health provider is ideal and shows that the pediatrician cares about what happens to the mother and child after the medical visit. The next step in this line of research is to disseminate this algorithm and help practices quickly implement these evidence-based guidelines. There are many mothers like Nadiya out there that deserve to talk with a health professional about postpartum depression.

 

References

1. Evans, M. G., Phillippi, S., & Gee, R. E. (2015). Examining the screening practices of physicians for postpartum depression: implications for improving health outcomes. Women's Health Issues, 25(6), 703-710.

2. Waldrop, J., Ledford, A., Perry, L. C., & Beeber, L. S. (2018). Developing a Postpartum Depression Screening and Referral Procedure in Pediatric Primary Care. Journal of Pediatric Health Care.

  Matt Martin, PhD, LMFT is Clinical Assistant Professor at the Arizona State University Doctor of Behavioral Health Program. He serves as the CFHA Blog Editor.  

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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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What We Do

CFHA is a member-based, 501(c)(3) non-profit organization dedicated to making integrated behavioral and physical health the standard of care nationally. CFHA achieves this by organizing the integrated care community, providing expert technical assistance and producing educational content.