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The Children's Hospital of Philadelphia

Posted By Matthew P. Martin, Wednesday, January 2, 2013
Updated: Tuesday, January 1, 2013

This post is the first
in an ongoing series
highlighting hospitals
across the United
States that offer
family-centered care.

Numerous hospitals, community medical centers, and policy groups are recognizing the importance of collaborating with patients and families to improve safety, quality, and treatment outcomes.  For some organizations, family- and patient-centered care has long been a part of the organization’s culture and approach to health care.  The Children’s Hospital of Philadelphia (CHOP) has consistently been ranked by U.S. News & World Report, Child Magazine, and other organizations as the best hospital for children in the United States. Those awards are the result of the hospital’s top notch clinical programs and clinicians as well as their commitment to involving patients and families as integral partners in the care process as much as possible. 

According to the Director of Family Relations at CHOP, Rachel Biblow-Leone, MSW, LCSW, family centered care (FCC) is not just a "box to check off, it’s how we do what we do”.  Since 1994, CHOP leaders have worked hard to create a culture that makes family-centered care a priority.  Indeed, when hiring new professional staff, hospital leaders seek professionals who consider it a privilege to collaborate and communicate with patients and their families.  Family Consultants (family members of past patients who are paid staff members) even participate in the hiring process and orientation of new hospital professionals.  The first touch point during orientation is with a Family Consultant who shares a personal story with new hires that illustrates the standard of care at CHOP.  

Family Consultants, who play an invaluable role at CHOP, also help families navigate the complex healthcare system by offering a personal perspective and by communicating patient and family needs to nurses and physicians. They also serve on a large number of hospital committees and planning projects.  Other FCC initiatives, among many, include: the Family Advisory Council, a multidisciplinary group consisting of hospital professionals and family members with a wide range of backgrounds and diseases who offer input on hospital projects, programs, and policy development; family resource centers, which provide families a place for information, rest, support, and other resources; the Youth Advisory Council, a group that provides the child and teen patient perspective for hospital projects; and Family Partners who are credentialed volunteers who work alongside Family Consultants. 

Quality improvement, especially patient safety, is an ongoing goal for CHOP and patients and families play an important role in improving hospital services.  In fact, preliminary data has shown that family members were instrumental in reporting over 90 "catches” of patient safety events in real-time situations to staff who listened and responded (e.g., questioning medication that looks different before it is given to a patient to prevent a potential medication error). "This is a clear sign that when working with families, as partners, we are better able to deliver safer and higher quality care because there is mutual trust and encouragement for everyone to speak up for safety” says Rachel. Tip sheets are given to families that detail common safety concerns and strategies for communicating these concerns to hospital staff.  

During bedside rounds, family members are consistently included to help physicians and nurses identify potential problems.  Including families during bedside rounds also helps hospital staff to measure the amount and accuracy of information that family members have about patients’ condition and treatment. Although some have argued this model increases the length of time for rounds, the reality is that bedside rounds allow physicians to answer the questions and concerns of family members, which can save time in the long run and improve the hospital discharge process.

 "Family-centered care can seem like common sense, but we know common sense is not always commonly practiced.” says Rachel. CHOP maintains their commitment to keeping patients and families at the center of everything they do.  They also continue to set an inspiring example to other organizations looking to offer family-centered care. As Rachel concludes so well, "this is the right work to be doing. We have the same goals. We want to be more effective, more accountable, and provide greater health outcomes.  We want to see a better approach to well-being and achieve the optimal state of health”.  

Matt Martin is a licensed marriage and family therapist and is currently working as a post-doctoral fellow with the Chicago Center for Family Health and the Illinois Masonic Family Practice Residency Program. He received a master’s degree in Marriage and Family Therapy from Brigham Young University and just recently a doctoral degree in Medical Family Therapy from East Carolina University. His interests include integrated primary care, behavioral health, and family medicine residency education.

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The New Generation of Behavioral Health Providers

Posted By Melissa Lewis, Tuesday, December 18, 2012

New Faculty Forum

Melissa Lewis's blog is the last post in a month-long series from recent graduates in their first semester of a faculty or junior faculty position.

Please read the previous posts.

1. Dear student of behavioral health,

Congratulations on your pursuit to build a healthier world for all of us one client, couple, family or community at a time! You are being trained in the classroom, in the clinic, in local agencies, and for some of you in medical settings. As I reflect on my training as a marriage and family therapist (MFT) compared to the training that is currently needed, I envision a new direction for behavioral healthcare based on our understanding of what health and healing now are. When I was trained as an MFT utilizing systems theory consisted of addressing behavioral health from an ecological and not a linear, reductionistic way. In practice this meant utilizing MFT theories and addressing problems within the relationship(s) and it ended there (see diagram to the right).

Engel's Systems Levels

 Today, things look very different. Addressing psychosocial symptoms alone and within the confines of the behavioral health clinic solely have been shown to not only be inadequate for client outcomes, but also is an extremely limited use of systems theory (Craven & Bland, 2006). Now we know that pain and fatigue associated with chronic illnesses, for example, have a strong effect on mood, relationships, and parenting (Lin, Lai & Ward, 2003; White, White & Fox, 2009).

With the clear understanding of the dynamic nature of biological, psychological, social and spiritual (BPSS) effects on health outcomes, our systems of care must reflect these patterns. For instance, cold handoffs (i.e., referrals without introduction) not only result in a lack of needed patient services but represent an old way of understanding health; experts in separate realms of health (Craven & Bland, 2006). While the BPSS components of our health system interact, so must our health systems. Students must learn the models and techniques of collaboration so that they can conduct a warm hand-off, understand the medical system, interact confidently with medical providers, and assess and treat using their expertise as well as that of their medical provider and the patients simultaneously.

Further, integrated careis quickly becoming strengths-based care, patient-focused care (equitable and culturally competent), collaborative care, cost-effective care, and evidenced based care which are the pillars of the Institute of Medicine aims. The behavioral health skills needed to work in this system look much different than the skills that were needed in the previous system of healthcare 20 years ago and will continue to change in the coming years. The way health research is being conducted is a sign of what is to come.

For instance, Cutrona and colleagues (2003) have discovered that neighborhood level effects (i.e., safety, financial status, racism) are related to individual health, as well as relational outcomes. The work of Karen Matthews and colleagues (2003) has shed light on the process of cardiovascular health and its link to early childhood psychosocial traumas. Both in utero and early childhood biopsychosocial traumas are linked to worsened mother-child relationships, reduced cognitive and verbal development, and even increased risks for obesity, diabetes, and heart disease later in life (Hart & Risley,1995; Shonkoff & Phillips, 2000; Kaati, Bygren, Pembrey, & Sjöström , 2007; Gluckman, Hanson, Cooper, & Thornburg 2008; Boynton-Jarrett, Ryan, Berkman, & Wright, 2008).

 The implications of this kind of epigenetic work will be astounding for our field and will demand that in the next 20 years, behavioral healthcare providers are aware of and can treat the devastating effects of adverse childhood events, historical traumas, and current micro and macro traumas (BPSS). We will not only be asked to treat those affected by these events but also create programs to prevent these events from happening. This, I believe, will require all behavioral healthcare providers to lower themselves from an expert hierarchical position (i.e., dictating treatment protocol) and learn to work with broader systems (i.e, communities) in a more equitable and empowering way to improve individual as well as larger health systems (see Doherty & Mendenhall, 2006). Given the popularity and success of community based participatory research in empowering communities to use their local knowledge and resources to improve health and standards of living, behavioral healthcare providers will soon be required to learn these research and clinical techniques as the new standard of care for health promotion, prevention, and treatment.

 This is an exciting time in healthcare with amazing possibilities for positive changes in the healthcare system. Good luck in your journey in becoming a collaborative and integrated behavioral healthcare provider!


 An MFT professor 1


2. Dear MFT professor,

 As an MFT student, I feel that I need MedFT training because the medical care system affords us with a unique opportunity to serve our clients. Specifically, we can collaborate with professionals within the medical system and bring a fresh systemic perspective which will hopefully produce better client outcomes. Nonetheless, I am excited and a bit nervous about learning integrated care! While I feel competent in the theoretical and clinical components of my MFT program, I am still nervous about working as a MedFT in this local hospital system in my upcoming internship.

 As system thinkers, I know that each system is unique in so far as it has a power structure, roles, and almost unconscious rules that govern the systems. In MFT we know about the impact of trangenerational thinking. In the Medft world, I do not know the historical structures and systems of a hospital system. Who is a resident? Who is an attending? What does a short white lab coat mean opposed to a longer one? What is a charge nurse and what is an RN, BSN, or LPN? Is a DO really a doctor and what does social work do? I will be thrust into a system not knowing how it works; I wish I knew ahead of time so I can be as effective of an MFT as possible.

 We know that the system of a medical care facility is different than a clinic. We may only see a client once, twice or maybe three times due to HMOs and PPOs. How does the therapist "do” therapy in such a short about of time? If I can only see them twice, do I still do a genogram? Can I do structural therapy in one session?

 Lastly, do I need to learn anatomy and physiology, especially neurology? I worry when my clients discuss stage three cancer I will not know if it is worse that stage one. What if my client is on medications for their illness, does that affect their psychological health?

 I know this is asking a lot, and I hate to be a bother. I entered this field with a strong desire to serve my clients through a relational lens in a medical setting and can’t wait to get started!


Thank you for your time,

An MFT (aspiring MedFT) Graduate Student2


3. Dear future students, clinicians and professors of behavior health,

I am a doctoral student at University of Akron who has worked and interned in several integrated and non-integrated care sites and would like to tell you a little bit about my experiences. Specifically, my internship experiences at St. Thomas Hospital and Akron Children’s Hospital in Akron, Ohio has grown my understanding of healthcare immensely. In these training positions, behavioral health providers are required to collaborate with other healthcare providers to support the patient’s specific needs. This opportunity to work alongside professionals who are stronger in the medical/biological aspects of treatment allows for a more holistic treatment approach for me. It has been very beneficial to learn to collaborate with those outside of my scope of training because it has significantly broadened my understanding of healthcare. This would not have been possible in a traditional MFT internship.

Part of my experience as an intern has opened my eyes to healthcare costs, reimbursement, and healthcare policy. I have learned that it is important to provide care that is empirically supported for cost effectiveness and I am fortunate to have been trained in an area that is becoming increasingly more supported. It is important to understand cost effectiveness and offset of integrated care treatment, as well as the importance of tracking and measuring biopsychosocial health markers to specialize and improve patient care.

Training that provides a foundation for this increased knowledge and collaboration will provide a more enhanced training experience that will equip individuals in the Marriage and Family Therapy field to work within the medical and hospital setting. My training has allowed me to encourage the integrated team to not look past the family system and, instead, provide support and structure for the families. This has been very fulfilling as an MFT in a medical setting as I learn my place in the medical system.

I have noticed an observable difference in the engagement of the family in behavioral health services in behavioral health versus hospital settings. I have found that within the medical setting there is a decrease in stigma around behavioral health talk giving me more of an opportunity to address psychosocial stressors and coping mechanisms. While at first I was unsure about how family therapists can fit into the medical model, instead I learned that this is exactly where we need to be!


An MFT Student 3


¹ Melissa Lewis is a Visiting Professor at University of Akron in the MFT program. She is a licensed Marriage and Family Therapist and an approved AAMFT Supervisor. She received her Master's degree at Arizona State University (MFT) in 2007 and her PhD from East Carolina University (MedFT) in 2012. Her research area broadly encompasses the relationship between stress response and BPSS outcomes. Specifically, she studies the stress transmission model with military couples and is also evaluating integrated care interventions aimed to reduce BPSS health symptoms in both Native American and military populations. Melissa can be contacted at

² Michael Polnik is married and a proud father of three. He holds his MA in biomedical ethics from Case Western Reserve University and is pursuing his PhD in MFT from The University of Akron. Michael can be contacted at

³ Ryan Cook is a husband and a father to one son and has a daughter on the way. He is a licensed MFT and PCC in the state of Ohio. Ryan is in his final year in the Doctoral Counselor Education and Supervision program specializing in Marriage and Family Therapy at the University of Akron. He has experience working in a small agency where he provided family therapy to foster care and adopted families. He is currently a clinical therapist at St. Thomas Hospital and Akron Children’s Hospital’s Partial Hospitalization and Intensive Outpatient Programs. Ryan can be contacted at 
Melissa Lewis



Boynton-Jarrett, R., Ryan, L. M., Berkman, L. F., & Wright, R. J. (2008). Cumulative

violence exposure and self-rated health: Longitudinal study of adolescents in the United States. Pediatrics, 122(5), 961-970. doi:10.1542/peds.2007-3063.

Craven, M.A., Bland, R. (2006). Better practices in collaborative mental health care: an

analysis of the evidence base. Canadian Journal of Psychiatry, 51 (6 Suppl 1): 7S-72S.

Doherty, W. J., & Mendenhall, T. J. (2006). Citizen health care: A model for engaging

patients, families, and communities as coproducers of health. Families, Systems, & Health, 24(3), 251-263. doi:10.1037/1091-7527.24.3.251

Gluckman, P. D., Hanson, M. A., Cooper, C., & Thornburg, K. L. (2008). Effect of in utero

and early-life conditions on adult health and disease. The New England Journal Of Medicine, 359(1), 61-73. doi:10.1056/NEJMra0708473.

Kaati G; Bygren LO; Pembrey M; Sjöström, M. (2007). Transgenerational response to

nutrition, early life circumstances and longevity. European Journal Of Human Genetics: EJHG, 15(7), 784-790.

Lin C., Lai Y.L., & Ward, S. (2003). Effect of cancer pain on performance status, mood

states, and level of hope among Taiwanese cancer patients. Journal Of Pain And Symptom Management, 25(1), 29-37.

White, C., White, M. B., & Fox, M. A. (2009). Maternal fatigue and its relationship to the

caregiving environment. Families, Systems, & Health,27(4), 325-345. doi:10.1037/a0018284.

Cutrona, C. E., Russell, D. W., Abraham, W., Gardner, K. A., Melby, J. M., Bryant, C., &

Conger, R. D. (2003). Neighborhood context and financial strain as predictors of marital interaction and marital quality in African American couples. Personal Relationships, 10(3), 389-409. doi:10.1111/1475-6811.00056.

Matthews, K.A., Salomon, K., Brady, S.S., & Allen, M.T. (2003b). Cardiovascular reactivity

to stress predicts future blood pressure in adolescence.Psychosomatic Medicine, 65, 410-415.

Risley, T. R., & Hart, B. (2006). Promoting Early Language Development. In N. F. Watt, C.

Ayoub, R. H. Bradley, J. E. Puma, W. A. LeBoeuf (Eds.) , The crisis in youth mental health: Critical issues and effective programs, Vol. 4: Early intervention programs and policies (pp. 83-88). Westport, CT US: Praeger Publishers/Greenwood Publishing Group.

Shonkoff, J. P., Phillips, D. A., National Academy of Sciences - National Research Council,

W. S., & Institute of Medicine (NAS), W. C. (NAS), Washington, DC. (2000). From Neurons to Neighborhoods: The Science of Early Childhood Development.

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Integrated Care, Residency, and PCMH: A Basic How To Start

Posted By Lisa Zak-Hunter, Wednesday, December 12, 2012
Updated: Tuesday, December 11, 2012
New Faculty Forum

Lisa ZakHunter's blog is the second post in a month-long series from recent graduates in their first semester of a faculty or junior faculty position.

Please check back
each week.


Since the end of June, I have been serving as behavioral science faculty within the second largest family medicine residency in the country. It is three times the size of the residency where I completed my doctoral internship-yikes! The program has been taking steps toward becoming a Patient Centered Medical Home (PCMH). What an opportune time to introduce integrated healthcare! But, how??

My original intent was to try to answer that question in this post. After some investigating, I have few answers, but more and more avenues of investigation. Simultaneously, I’ve had personal and professional experiences with colleagues that have reminded me of the struggles mental health professionals face entering the fast-paced, hierarchical world of medicine. Therefore, what I offer are starting points for new professionals to become better integrated within medical training programs as they drive toward the PCMH.

stages of change

Even though you might already be burgeoning with ideas and energy better suited for a preparation or action stage, the program may be precontemplative or contemplative.

 When You Start

  • Create your own job description: Include roles and responsibilities that are specific to your personal strengths, talents, and interests. Note what types of psychotherapy you provide, your clinical and research interests and specializations, populations you like to work with, specific ways you plan to attend to resident education, languages you speak, other skills etc. Get used to repeatedly being asked what you do, what types of concerns or diagnoses you’ll see, and different ways you can help the residents (personally and professionally). Spending time to write this down will help you answer these directly and succinctly. You can also turn this into a brief ‘advertisement’ to put at the nurses stations, resident lounge, and precepting room, complete with your business cards or contact information.
  • Get visible within the residency AND the clinic: Join committees; attend any and all faculty AND staff meetings (even if you feel out of place at both!); get to know the nursing, front desk, and management staff; hold brief one-on-one meetings with residents and faculty; volunteer to help on projects such as resident observations or meeting with residents who are struggling; be involved with interviewees; present at noon conference; host a ‘get to know the behaviorist’ luncheon; precept (even if you don’t really know how!). Sit near the preceptor so you can listen to the cases for opportunities to offer the classic "how do you think this patient’s depression is affecting his diabetes management?” or "have you screened that patient for past abuse?”. Then you can offer suggestions to the treatment plan or to meet with the patient/s during the visit. Practice being brief, to the point, and straightforward.
  • Don’t move too fast and be persistent! Take time to understand the culture of the program, how faculty and residents interact with each other and the clinical staff, and how patients are perceived. Ask, what is the residency known for? What are its strengths and what draws students to it? Within that, what has been the role of behavioral medicine? What was their vision in hiring you? How do you work within and enhance the culture while simultaneously respecting it? This will help you determine how and who to approach with your ideas. Remember than medical systems move slowly and are much more complicated than you are aware. Think in terms of 1, 3, and 5 year plans, and, metaphorically speaking, prepare to swim through molasses for a while.

Introducing Integrated Healthcare within PCMH

  • Familiarize yourself with Patient Centered Medical Home Standards: In 2011, NCQA outlined new standards for PCMH. There are also principles for medical education in the PCMH. These will help you understand both the clinical and educational aspects of PCMH that a residency will be trying to accommodate.
  • Meet the program where it’s at: Think Prochaska’s stages of change. Even though you might already be burgeoning with ideas and energy better suited for a preparation or action stage, the program may be precontemplative or contemplative. Recall the traditional role of behavioral medicine at your facility. Talk with your office manager, program director, chief residents, and faculty one on one. Learn what they have already done for PCMH and whether they want NCQA’s accreditation. The fact that PCMH encourages integrated and streamlined behavioral healthcare works in your favor!
  • Identify and include all angles and stake holders: This would include clinic operations (management, scheduling, referrals etc), faculty leaders and liaisons, patient education groups or protocols for certain diagnoses, residents, nurse practitioners or physician assistants, those in charge of your EHR system, potential collaborators in other departments (e.g., psychiatry, pharmacy) or other institutions (e.g., social work, family therapy, psychology graduate programs). Speak with them frequently and offer small bits of information on integrated care each time. Consider additional training that all staff (including yourself and other behavioral health specialists) may need to understand integrated care and how to carry it out. You may think your ideas are the best thing since sliced bread, but they (and possibly your reputation) will fall flat if you only consider your own perspective, role, and talents.
  • Get familiar with billing! It can be challenging to charge for integrated care since in some states is illegal to charge for same day service. As you think of different models of care, they must be sustainable. Management and clinic operations will be interested in fine print, so be prepared to try to give it to them! Additionally, the Current Procedural Terminology (CPT) codes (i.e., the billing codes) for psychotherapy and psychiatry are changing in 2013. Investigate Medicaid’s Health Behavior Assessment and Intervention (HBAI) codes to determine if they can be used at your site. Understand what mental health services CMS (Centers for Medicare and Medicaid Services) reimburses such as depression and substance abuse screening. Once you’re familiar with these, I suggest setting up an appointment with someone in your organization’s main business office and compliance. The last thing you want to do is begin creating or implementing a model that is non-compliant!
  • Remember this is a training program! Whatever model of integrated care gets established must dually enhance patient care AND resident education. If your role is more educational than clinical, make certain the model does not have you involved in clinical work that detracts from your teaching.
  • Determine your role. Do you want to lead or develop the entire model? Do you want to form a committee to help? Which of your stakeholders should be part of the committee?


Personal Sanity

  • Stay connected: Talk with your mentors, seek connections with similar providers in your community or department in your medical school, and other new professionals. In my personal experience, I’ve found I was a little sheltered in my safe little collaborative care bubble. I was aware my supervisor faced challenges with faculty and upper administration. However, I didn’t know all the details and I was never solely responsible for addressing them.
  • Be patient. Be persistent.

Overall, know that some of the struggles and suggestions for addressing them that are outlined in the seminal collaborative care and medical family therapy texts are very applicable. My ideas are reflective of where I am in the process of settling into a new community and introducing integrated care. I welcome further comments, suggestions and the opportunity to normalize experiences for others new to medicine or new to life after graduate school!

Some helpful websites:


Lisa Zak-Hunter

Lisa Zak-Hunter, PhD, LMFT is behavioral science faculty with the Via Christi Family Medicine Residency and Clinical Instructor with the University of Kansas School of Medicine-Wichita ,in KS. She earned her PhD in Child and Family Development, specializing in Marriage and Family Therapy, from the University of Georgia. Her main clinical, teaching, and research interests lie in the realms of collaborative health care and increasing biopsychosocial understanding of mental and medical health conditions. She has a particular interest in adult eating disorders.

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Behavioral Healthcare in Immokalee, FL: The discovery of a beautiful culture and their strength in the midst of hardship

Posted By Molly Coates, Wednesday, December 5, 2012
Updated: Tuesday, December 4, 2012
New Faculty Forum

Molly Coates's blog is the first post in a month-long series from recent graduates in their first semester of a faculty or junior faculty position.

Please check back
each week.


I left the mountains of Colorado to move my family to Southwest Florida, a place I knew little about other than my fellow Coloradans’ dire warnings of the potential and looming disasters-- hurricanes, snakes in the toilet, flying roaches as large as palm fronds, alligators waiting for a misstep, and the exotic Nile monitors that run loose in the city with carnivorous desires. However, all that being said, I was ready for an adventure and the spirit of Florida State University College of Medicine was calling. 

FSU College of Medicine has a particular mission statement, one that speaks to me deeply. The college’s mission emphasizes providing primary care to Florida’s elderly, rural and other medically underserved populations and places value on the doctor-patient relationship, generalist medical care and working as part of the health care delivery team, including behavioral health. I was first attracted to and excited about the job position as providing entry into what I believe is the future of healthcare delivery, an integrated and holistic model of care.

"...exotic Nile monitors
run loose in the city with
carnivorous desires."

However, when I arrived onsite at the Immokalee Health Education Site, I became immersed in a challenge greater (and more exciting) than just starting a new job. I was mostly aware of the cultural differences I would encounter, in a theoretical and academic sense. Speaking with my colleagues on the first day of work, I received some wise advice that gave me valuable perspective and a glimpse into the reality of the population--If you ask one of your pediatric patient’s where he/she would chose to go on his/her "ideal vacation,” you just might get the "Walmart” in the next town over as a response. In context, the closest Walmart is 30 miles away and not a typical experience for our patients—imagine what you might buy! This anecdote begins to accurately depict a population whose struggles are very unique.

The medically underserved in this area consist of migrant farm workers following the Eastern route. This population has been referred to as the Nation’s Invisible Population with an estimated 1-3 million taking the annual trek. Resources are scarce to non-existent, life stressors beyond compare, and fear of deportation thriving. The cultural differences are immense and more so when considering this is a population displaced from their home country for various reasons. In Immokalee, families are hesitant to leave the township other than to travel to other migrant farm villages.

The predominant languages are Creole and Spanish, and they must learn to speak two or more languages while navigating systems (e.g., school, healthcare) delivered in their second, sometimes third, language. They have limited access to healthcare and other resources, while their healthcare needs are immense. Their children face changing schools several times a year as the family follows the harvests. Many are victims of chronic and complex trauma. Their life is hard-- listening to the multitude of complex stressors they experience and barriers to accessing resources, it is easy to feel overwhelmed.

How do I best serve my patients in Immokalee? I feel honored to bear witness to all of my patients' narratives, and I am continually reminded of the remarkable resiliencies of this group. They not only survive their hardships, but display an amazing resilience that they do not always recognize. Empathically relating to their narratives, reflecting on their strengths and suffering, and respecting the shared human experience allows me to help foster a self-image of resiliency and pride in my patients. I hope that with this knowledge, perhaps another change is being effected—one of self-efficacy, confidence, and hope as they navigate their life realities.

Molly Coates

Molly Coates, PsyD is a Postdoctoral Psychology Resident at the Florida State University College of Medicine, serving at the Immokalee Health Education Site, Isabel Collier Read Medical Campus. She works in pediatrics and women’s health. Her research interests include chronic pain management, obesity prevention, psychological assessment, and ADHD, Autism and Behavioral Disorders in children.


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Mentorship in Collaborative Care

Posted By Lindsey Lawson, Tuesday, November 27, 2012

If you haven’t already, be sure to take a peek at Deborah Taylor’s blog on mentorship. From someone on the receiving end, mentorship IS the cat’s meow!

When I began my clinical work at the medical center here in Loma Linda, I was surprised to discover that I would be doing co-therapy with other MedFT students and my supervisor, and in front of medical students and residents. Yikes! Previous experiences for me consisted of individual therapy sessions, and the occasional videotaped clips shown to my supervisor (which at times I’m sure inadvertently left me describing what I was hoping would happen in session rather than what actually did - I know I’m not the only one here). The idea of this new mentorship model was, to say the least, scary for me: I had visions of someone discovering that I wasn’t very confident in what I was doing and that at times I lacked direction and focus in session.

Those first few months were stressful; I remember feeling intense pressure to "perform” in front of my peers and colleagues. I was frustrated and felt that perhaps my sessions during those times didn’t reflect my actual abilities as my nerves took over and made me tentative and self-conscious. But with time and a purposeful group shift towards a more collaborative model, things began to change.

Lindsey Lawson
"Mentorship gives us space to have honest conversations about what is working and areas of growth..."

To my surprise, I discovered that working closely as co-therapists with fellow students and my supervisor was the best thing to happen to me professionally in a long time. I found myself being pushed in a safe, productive way towards being a better clinician. Conceptual ideas about how to do good therapy came to concrete life before my eyes as I watched others work and thought, ‘that’s how it’s done!’ I was able to see things modeled in session and then practice them myself within the safety net of more experienced therapists who would help me if needed.

I remember one session in particular, in which I was working closely with another doctoral student several years ahead of me. We were in a difficult spot: our patient was extremely anxious, and was making demands of staff that were impossible to meet. We’d been asked to help mediate the situation, and because I’d spent the most time with her, I was asked to lead our session.

My student mentor pulled me aside before we went into the room, and together we talked about how the session might go and what might be particularly helpful in trying to navigate this sensitive issue. As a result of our conversation, I felt confident going into the room, and the gentle coaching of my classmate paved the way for a successful interaction with our patient and several additional weeks of continued work together. Sure, I might have been able to do this on my own, but there was something about knowing that my mentor believed in me and would be there to help me should I need it that made this experience meaningful.

There are several things that have been particularly helpful for me in being the process of being mentored:

Feeling safe in my relationships with mentors. Mentorship requires a great deal of vulnerability on the part of the individual with less experience, and initially, it can feel as though you’ll never be quite "yourself” in therapy. It has helped me immensely to work with people who’ve been perceptive enough to hone in on my strengths and believe in me wholly - sometimes even before I believed in myself.

Practicing active, live co-therapy. Co-therapy does not mean that my mentor will "rescue” me whenever I am stuck. When one does step in to help guide me in a more therapeutic direction, I feel more equipped to try these skills myself in our next session. Rather than becoming a crutch, these have been empowering experiences for me.

Addressing the power differential. By its very nature, mentorship helps to level the power differential as MedFTs-in-training are allowed to see challenges and mistakes made by someone with more experience. This gives us space to have honest conversations about what is working and areas of growth, and allows me to see my mentors in more of a collaborative, rather than evaluative, role.

Mentorship may be an especially good fit for therapists in medical settings as it aligns with the traditional model of healthcare providers working in teams and may provide additional support for new therapists stepping into a setting with a unique set of rules and norms. As Deborah suggests in her previous blog, having experienced successful mentorship makes me want to "pay it forward” through developing these same times of relationships with new medical family therapists coming into the field. Who wants to join me?



Lindsey Lawson is a third-year PhD MFT student at Loma Linda University and has worked at the Loma Linda Medical Center for the past two years. Her professional interests include all things medical family therapy, as well as gender and power dynamics in couple relationships.


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Happy Birthday Families and Health Blog!

Posted By Randall Reitz, Tuesday, November 20, 2012

Welcome to the 1st anniversary of the Families and Health Blog. Let’s take a minute to look back and look forward. This blog started in November 2011 through the efforts of CFHA’s Medical Family Therapy Work Group. For most of the first year I partnered with Dan Marlowe to recruit and post excellent pieces to promote the role of families in healthcare. Many have been from leaders of our field, others from the rising generation to whom the collaborative torch has been passed. The topics have varied from clinical, to policy, to scientific, to Clinician-as-Self.

Here are a few highlights:

Clinical: Last week provided a saucy review of sex therapy in primary care by Kenny Phelps and Tina Schermer Sellers. Previously, Joe Scherger delineated the value of family therapy in the patient-centered medical home. Matt Martin recalled an 80’s fastfood ad in describing his surprise that family medicine is often bereft of families. Harold Starkman described team-based and family-focused care for high-risk teens with diabetes. Theodora Ooms and Jana Staton described clinical pathways that fully integrate spousal caregivers. And,Lisa Zak-Hunter reviewed systemic care for adult eating disorders.
Baby eating cake

Policy: Jessie J asserted that it’s not about the money, money, money, but Barry Jacobs begged to differ. Dan Marlowe described a big tent vision for family therapy in medical settings.Deepu George revealed his scheme for positive deviance. And, JoEllen Patterson reviewed JAMA’s October 2012 advocacy for families in healthcare.


Scientific: John Rolland provided a reaction to research documenting the relational sequelae of a wife’s breast cancer. And, in separate posts, Melissa Lewis and Tai Mendenhall conceptualized a research paradigm that moves beyond reductionism.


Clinician-as-Self: Jeri Hepworth evoked Rosie the Riveter in calling for stronger leadership.Jackie Williams Reade delineated the connections between reality, hope, and denial. And, Stephanie Trudeau Hern shared how treating her patients’ breast cancer educated her on life.

Our most widely read post was from Carol Levine and Barry Jacobs on geriatric spousal murder/suicides. It was picked up by the New York Times’ New Old Age Blog and resulted in over 3000 hits to the Families and Health blog.


Moving Forward

At the meeting of the MedFT Work Group at the CFHA Austin conference, the group voted to change the name of the blog to better match the broad perspectives that the blog attracts. Our advocacy for family-oriented care extends beyond any one discipline and we felt that the blog’s name should reinforce that. We also hope to better align ourselves with CFHA’s journal, Families, Systems, and Health. So, we settled on the new name "Families and Health”.

In addition, starting in 2013 Matt Martin will assume co-editorial duties from Dan Marlowe .

We will always warmly welcome insightful posts on the role of relationships in healthcare. Please inquire or submit your ideas to me or Matt. And, if there is one thing I would change about the blog, it would be to increase the conversation in the comments section. You will need to log-in to the website to add your thoughts, so please track down your username and password. If you don’t have one, you can create one for free. If you have trouble logging in, please check with Bill Steger.

A special thanks to Dan Marlowe and everyone else who has posted with us.

Thanks for a great first year. We look forward to many more to come!


Randall Reitz
Randall Reitz is CFHA's Director of Social Media and the Director of Behavioral Sciences at the St Mary's Family Medicine Residency in Grand Junction, CO. He is the founding editor of CFHA Blog and Families and Health blog.


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Let's Talk About Sex

Posted By Kenny Phelps and Tina Schermer Sellers, Tuesday, November 13, 2012
Talking about sex...It is difficult to avoid the multiple sexualized images in American culture. From Janet Jackson’s Superbowl peepshow to the popularity of the Sex and the City episodes to television programs of young girls being dressed up like 21 year old beauty queens, the messages of sex are inescapable in recent years.

While the quantity of sexual images and information has increased in our society, the quality of this information is severely lacking. Myths and misnomers about contraception and human anatomy are two examples of how we have a lot of information, but also a lot of misinformation. Additionally, the medicalization of sex has led to conceptualizations of the sexual response cycle separate from the inherent relational and systemic dynamics involved.
US Surgeon General David Satcher
"Sexuality is an integral part of human life. It carries the awesome potential to create new life. It can foster intimacy and bonding as well as shared pleasure in our relationships. Sexual health is inextricably bound to both physical and mental health" .
  --U.S. Surgeon General

Certainly, we must conceptualize sexual health as a biopsychosocial phenomenon. For the past several decades, there has been increasing recognition in medicine of the importance of sexual health and sexual health education in supporting both physical and emotional health(Foley, Wittmann, & Balon, 2010). In 2001, the surgeon general made this statement about the importance of sexuality as a contributor of overall quality of life: "Sexuality is an integral part of human life. It carries the awesome potential to create new life. It can foster intimacy and bonding as well as shared pleasure in our relationships. Sexual health is inextricably bound to both physical and mental health” (Satcher, 2001). Thus, is seems only natural that sexual health should be a part of the dialogue between patients and providers, but is it?

While professionals might recognize the importance of sexual health in the life of their patients, this is not equating to an increase in sexual education or patient assessment, treatment or referral. Sexuality is routinely overlooked in primary medicine (Owens & Tepper, 2007). Studies reveal that only 10%-30% of primary care physicians obtain sex histories (Lewis & H, 1987)(Gemson, Colombotos, & Elinson, 1991). Challenges to the progression of sexual health care range from a significant lack of sexual education for most ‘would be’ medical providers, a lack of adequate sexual education in medical school and residency, a shared ignorance and unease about sexual health between patient and provider, a lack of time (Morreale & Arfken, 2010; Foley, Wittmann, & Balon, 2010) and a complex set of biopsychosocial issues playing into a person’s sexual health and sexual satisfaction (Geraci, 2010). What role does integrated and collaborative care play in overcoming these challenges? How can medical and mental health providers working in tandem create small ripples of change that may lead to larger changes in our current rates of STIs, teenage pregnancy rates, and reports of relational discord?

We propose that integrated care and intensive collaboration between providers should be the rule rather than the exception when addressing sexual health. Providers can work together to: screen for sexual concerns (Are you currently sexually active? Are your partners men or women? Are you satisfied with your sexual life? How can I be helpful to address any sexual or relational problems you are having?); provide education on most common problems (desire, premature ejaculation, performance anxiety, erectile dysfunction, etc.); and frame intimacy/sexuality as part of a larger relational and cultural picture (How did what your parents or culture tell you about sex influence your current preferences?).

Due to the biopsychosocial nature of sex, it requires multiple providers who are wearing "different hats.” For instance, a patient with erectile dysfunction needs a thorough evaluation of current medical concerns and medications, psychiatric comorbidities, automatic thought prior and during sexual activity, and current relational satisfaction. Patients who are parents of young children also need our guidance providing age appropriate sex education to their children. Research shows that youth need 100 one minute conversations about sexuality versus one 100 minute conversation (Martino, MN, Corona, DE, & MA, 2008). The vast majority of our patients grew up in homes that were silent and often reactive to sexual curiosity. This leads to parents of young children who are unaware of how sexual curiosity is expressed by children and ill-equipped to provide ongoing sex education. This anxiety often leads to repeating the cycle, becoming mostly silent and reactive to the sexual interest of their children.

In our opinion, integrated care delivered by systemically minded professionals is an ideal place to facilitate this dialogue. In other words, let’s talk about sex with our patients…they want us to!


Kenny Phelps
Kenneth Phelps, Ph.D., LMFT is an Assistant Clinical Professor in the Department of Neuropsychiatry and Behavioral Science at the University of South Carolina School of Medicine. He is a member ofthe Collaborative Family Healthcare Association (CFHA)and Co-Chair of the Membership Committee. He is also a member ofthe American Association of Sexuality Educators, Counselors, and Therapists (AASECT) and working toward Certification as a Sex Therapist. Contact info:
Tina Schermer Sellers
Tina Schermer Sellers, Ph.Dc., LMFT, the director of the Medical Family Therapy Post-graduate Certificate Program in the Department of Marriage and Family Therapy at Seattle Pacific University. She has been a member ofthe Collaborative Family Healthcare Association (CFHA)since 1993, is a past board member and is currently on the CFHA Advisory Board. She is also a Certified Sex Therapist with the American Association of Sexuality Educators, Counselors, and Therapists (AASECT). Contact info:;


Foley, S., Wittmann, D., & Balon, R. (2010). A Multipdisciplinary Approach to Sexual Dysfunction in Medical School Education. Academic Psychiatry, 386-389.

Gemson, D., Colombotos, J., & Elinson, J. (1991). Acquired immunodefiniency syndrom prevention: knowledge, attitudes, and practices of primary care physicians. Archives of Internal Medicine, 1102-1108.

Geraci, R. (2010). Sex in the Fifties. Washington, DC: AARP.

Haeberle, E. (1983). Education and Treatment in Human Sexuality: The Training of Health Professionals Report of a WHO Meeting. In Workbook Part 1 for Associate in Sex Education and Clinical Sexology Certificate. Exodus Trust.

Lewis, C., & H, F. (1987). The sexual history taking and counseling practices of primary care physicians. Western Journal of Medicine, 165-167.

Martino, S., MN, E., Corona, R., DE, K., & MA, S. (2008). Beyond the "big talk": the roles of breadth and repetition in parent-adolescent communication about sexual topics. Pediatrics.

Morreale, M., & Arfken, R. (2010). Survey of Sexual Education Among Residents From Different Specialities. Academic Psychiatry, 346-348.

Owens, A., & Tepper, M. (2007). Sexual Health - State of Art Treatment and Research. Westport: Praeger.

Reid, R., Coleman, K., Johnson, E., Fishman, P., Hsu, C., Soman, M., et al. (2010). The Group Health Medical Home at Year Two: Cost Savings, Higher Patient Satisfaction, And Less Burnout for Providers. Health Affairs, 835-843.

Satcher, D. (2001). The Surgeon General's Call to Action to Promote Sexual Health and Responsible Sexual Behavior.

Tsimtsiou, X., Hatzimouratidis, K., & Nakopoulou, E. (2006). Predictors ofPphysician' Involvement in Addressing Sexual Health Issues. Journal of Sexual Medicine, 583-588.

Wimberly, Y., Hogben, M., Moore-Ruffin, J., Moore, S., & Fry-Johnson, Y. (2006). Sexual History-Taking Among Primary Care Physicians. Journal of the National Medical Association, 1924-1929.

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JAMA Advocates for Families in Healthcare

Posted By Jo Ellen Patterson, Tuesday, November 6, 2012

Several years ago the Board of CFHA did some soul-searching about the name of our association. Some members wondered whether "family” should remain in the title since most medical care is, in fact, individual care.

I thought about the discussion that the Board had when I read a recent editorial in the Journal of the American Medical Association. A health policy expert from Johns Hopkins reiterated the importance of including families in both service delivery and policy decisions (Wolff, 2012). I was not surprised when she drew on research and policy that focused on older adults and the aging of the American population. As the baby boom generation enters old age and lives longer than any previous generation, Americans face a crisis. Who will care for aging Americans, and how will that care be paid for? Wolff quotes a Congressional Budget Office report that says, "The value of donated care probably exceeds that of any other category of long term care financing but is difficult to quantify in dollar terms” (p 1529).

Wolff goes on to note the many barriers to supporting families. She references legal barriers that exclude family members from both knowledge and decision-making capacity about their loved ones. Her description of legal and medical-culture barriers made me think of a family crisis I recently observed.
JoEllen Patterson
"Families with small children, disabled members, and chronically
ill loved ones all struggle with inclusion, confused roles, and boundary ambiguity when they
face health crises."

A hospitalized male patient had both leukemia and bipolar disorder. During his hospital stay he became violent but was restrained. His family had little understanding of his recent diagnosis of bipolar disorder and felt panic as they watched their loved one decline. Citing legal reasons and hospital policy, the floor nurses said they could not provide the family any information about his erratic behavior. Eventually his sixty year old wife and eighty-two year old mother awoke at 4:00 a.m. so they could be at the hospital by 5:00 a.m. in case the oncologist rounded that early. When that effort failed, they "camped out” in the physician’s office waiting room for five hours only to be told that the oncologist did not have consent (from a manic patient) to release medical information to them. While this difficult situation unfolded, the wife’s unspoken fear was that her violent husband would be sent home, and she would be fully responsible for his care. She simultaneously felt terrified of his violent behavior and fearful of watching his painful death. She felt overwhelmed.

Caregiver burnout, fear, guilt, and confusion are common emotions of patients’ families. In spite of families’ confused roles in health care, Wolff suggests that families now serve "as the backbone of medical and long-term care delivery” (p 1530). She also suggests that families’ contributions must be measured and documented before they can be valued. She offers specific suggestions on ways to include families:

  1. Health information should be made available to family members according to patients’ expressed wishes.
  2. Important aspects of family functioning that influence caregiving should routinely be documented in the medical record.
  3. Screening of family caregivers should be part of routine care.
  4. Family members’ presence and identity at a patient’s health care encounter should be documented, and different perspectives on the problem should also be included in the patient’s documentation.

Families with small children, disabled members, and chronically ill loved ones all struggle with inclusion, confused roles, and boundary ambiguity when they face health crises. When a patient leaves the physician’s office or the hospital, his care often becomes the primary responsibility of family members. While older patients are not the only family members that need their clinicians and family member to work together, a possible benefit of the health care crisis created by aging baby boomers could be that the American health care system finally takes the contributions of families seriously.


Congressional Budget Office. Financing long-term care for the elderly. Washington, DC: Congressional Budget Office; 2004.

Wolff, J. Family matters in health care delivery. Journal of the American Medical Association. 2012; 308(15):1529-1530.


Jo Ellen Patterson, Ph.D. is a professor at the University of San Diego. She is also a Clinical Associate Professor in the Departments of Family Medicine and Psychiatry at the University of California School of Medicine in San Diego.

Please add your thoughts regarding Jo Ellen's post. This requires logging-in to a free CFHA account.

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Where the Candidates Stand on Healthcare's Key Issues

Posted By Dan Marlowe, Tuesday, October 23, 2012

I figured with the elections right around the corner we could tip our hats to those conversations in our own MedFT-esque kind of way. Instead of a charged debate with all the trappings of finger-pointing, name-calling and record challenging tomfoolery, here is a list compiled by The Hastings Center. They are "a nonpartisan research institution dedicated to bioethics,” detailing a synopsis of where each candidate/platform stands on issues we post about here (e.g., caregiving and healthcare costs) along with other topics we might (and should) be interested in. Take a look and weigh-in below in the comments section.

A big thanks to Jackie Williams-Reade for posting this to the MedFT Facebook page, which you should all take a look at and join for more MedFT related articles and commentary.

"Healthy citizens are the greatest asset any country can have.”

Winston Churchill


Dan Marlowe
Dan Marlowe is the co-editor of the Growing MedFT Blog, and the Director of Applied Psychosocial Medicine for the Duke/Southern Regional AHEC Family Medicine Residency Program in Fayetteville, NC. He obtained his MS in Marriage and Family Therapy and PhD in Medical Family Therapy from East Carolina University in Greenville, NC.

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Do Medical Family Therapists Bring Value to Health Care?

Posted By Joseph Scherger, Wednesday, October 10, 2012

I suspect any family therapist reading this question would quickly say, "Yes, of course we add value to health care”. From a health care policy perspective value is not a simple intuitive concept. Value is quality divided by cost, and today every health care system is focused on becoming value driven.

That the U.S. spends way too much money on health care is well known. Our health outcomes place us low in the world even though we spend twice as much or more on health care as other industrialized countries. Our spending is not sustainable, especially in Medicare with the influx of the Baby Boomer generation. We have to figure out how to spend less money.

A new IOM report indicates that we spend 700 billion dollars in health care every year that is of no benefit to patient care. These include unnecessary tests and procedures, overly expensive drugs when generics would do fine, and excessive treatment, especially at the end of life. Rather than just squeeze this money out of the system, the potential is here for transforming the system to provide value – actually improve the quality of care while we reduce costs."The most important work
of family therapists today
is to make the case for
being vital members of
PCMH practice teams."

Information technology makes much of value driven care possible. For the first time we can look at populations of patients in detail and make proactive strategic decisions to improve their health efficiently. Diabetic patients who are well controlled are much less expensive than ones who are out of control and develop complications. Through internet applications, we can communicate and care for patients at minimal costs compared with face-to-face visits.

So what role do family therapists play in this? We know that psychosocial problems are frequent in health care and usually are masked by physical complaints. Addressing the psychosocial problems early creates great efficiency rather than waiting until every physical evaluation has been done, only to show the patient is "simply” anxious or depressed. Yet this obvious situation remains hidden from the strategic planning to too many health systems.

Regional health systems committed to becoming value-driven are joining the Accountable Care Organization (ACO) movement. Developed by the Centers for Medicare and Medicaid Services (CMS), an ACO is committed to the Triple Aim:

1. Improving the individual experience of care

2. Improving the health of populations

3. Reducing the per capita costs of care for populations

Health systems know the future of health care financing will be directly tied to achieving these aims with their care, and information systems are able to measure it. At the patient care level, teams will operate in ACOs using the principles of the Patient Centered Medical Home (PCMH). PCMH practices have advanced information and communication technologies and are able to provide continuous access to strategic, proactive care rather than the tradition of simply reacting to patient appointments. Patients become activated to play an active role in the own care, ordering desired tests and treatments, according to accepted guidelines.

The most important work of family therapists today is to make the case for being vital members of PCMH practice teams. Working alongside physicians, nurse practitioners, pharmacists and others, family therapists will ensure that patients receive true biopsychosocial care from the beginning. Independent private practice is rapidly becoming a thing of the past. Organized and integrated health systems are the future. Family therapists are not automatically included in this discussion in most settings, so becoming knowledgeable about ACOs and PCMHs is critical today. Assertive inclusion of family therapists in demonstration projects around the country is needed to ensure the proper composition of team practice in the future.

Reference for more detail on ACOs, PCMHs and the Triple Aim:

Edwards TM, Patterson J, Vakili S, Scherger JE. Healthcare Policy in the United States: A Primer for Medical Family Therapists. Comtemp Fam Ther (2012) 34:217-227.


Joseph E. Scherger, M.D., M.P.H., is Vice President for Primary Care & Academic Affairs at Eisenhower Medicine Center in Rancho Mirage, California. Dr. Scherger is Clinical Professor of Family Medicine at the University of California, San Diego School of Medicine (UCSD), and at the Keck School of Medicine at the University of Southern California (USC). Dr. Scherger’s main focus is on the redesign of office practice using the tools of information technology and quality improvement.

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