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Mirena for Crying Babies and Stickers for Older Siblings: An Image of a Biopsychosocial Physician

Posted By Scott Michaels, Tuesday, August 14, 2012
A biopsychosocial physician is one who can attend to systemic issues and mobilize patient resources. As it happens, I have had the privilege of working with such a physician. And I have taken creative liberty in recounting a peculiar patient encounter I witnessed. Some of the connections I make may also seem a bit creative.

As I was walking back to my office, I heard a large commotion in the next hallway. It turned out to be a mother and two young sons being entertained by a physician.

At first glance, a baby was crawling up his mother while crying and pining for the book the physician just stripped from his hands. I wasn't quite ready for what I saw next. In what seemed like a scene out of Monty Python, the doctor somehow harmoniously quelled the crying baby, went through an entire supply of stickers, and exhausted the reading material in the pamphlet ridden hallway.
Scott Michaels
Too often, we get so caught up in our pursuit of education, competence, and mastery of little techniques that we forget to connect with our patients.
 The physician somehow pulled off a pirouette and somersaulted behind the nurse’s station to grab what seemed like every sticker left in the clinic for the baby’s older brother. And with lightning speed he darted across the room to find seemingly nonsensical reading material for a baby. It became clear to me that this wasn’t just any old intervention; this was a master at work.

This isn't a story about when doctors lose their minds; maybe it's not a story about anything. But to me, this is a story about health literacy, a story about expanding the patient system, and a story about customer service.

You may think it is strange for a doctor to steal a book from a baby, but is it really? You may think it is strange for a doctor to replace that book with a Mirena pamphlet, but is it really? You may think what this doctor was doing may seem like nonsense, but I don't. What was really happening was a doctor planting the seeds of change.

Lesson one: what this doctor was doing was ingenious; this was a systemic intervention for health behavior change starting with health literacy. With this young brainchild knowing all there is about Mirena, and who knows, maybe next time it will be Byetta, this family will surely be healthy, knowledgeable about their health, and could teach others how to do the same.

It took me a while to understand why the older child got so many stickers. But as it so happens in primary care, patients are seen from the cradle to the grave. So this older child must've been seen by this doctor many times. And I can only imagine that the older child had already studied Mirena, Byetta, and even Abilify. Obviously, the stickers were a reward for each pamphlet the older child read.

Lesson two: expand the system! The mother of these children may not have needed Mirena, Byetta, Abilify, or really any other medication. But, this doctor expanded the system to include family members. The family is always more influential in changing and maintaining health behaviors than healthcare providers. These children can hold that young mother accountable for her health behaviors now that they’ve learned about disease processes.

The pirouette, the dash across the hallway, and what seemed like countless somersaults were not just for show. This doctor exhibited a different kind of showmanship, that is, showmanship you would see in a good salesman. These patients came for a service and who better to provide that service than a dancing, tumbling, and profusely sweating doctor?

Lesson three: your patients are customers. And as providers of a service, you have a responsibility to your customers. Sure, there are many ethical opinions, obligations, and so on. Regardless, provide service with care and enthusiasm.

Too often we forget that our patients need a little laughter; and let me tell you, this was something to laugh about.

Lesson three and a half: don't forget to laugh! This was one of the funniest things I've seen in primary care, maybe because this doctor is hysterical, but mostly because his intervention worked. This family left the clinic feeling cared for, jovial, and ready to come back.

You may realize by now, this anecdote was written in jest. However, there are some very real points here: promote health literacy, expand the patient system, provide good customer service, and use humor. Too often, we get so caught up in our pursuit of education, competence, and mastery of little techniques that we forget to connect with our patients.

I'm not encouraging all healthcare providers to abandon our quests for competency just to pirouette, somersault, and run around hallways. But I would like to encourage that we remember aspects of our practice like customer service and humor to establish meaningful patient-provider relationships.

My last pearl: this doctor was only successful because he was being himself. So when you treat your patients, remember that you don't have to be perfect. No one is; but the moment was perfect because this provider embraced who he was and the patients accepted him because he genuinely cared.

 

Scott Michaels is a Medical Family Therapy doctoral candidate at East Carolina University. He completed his Master’s degree at the University of Rochester (MFT) in 2010. He is currently the Applied Psychosocial Medicine Resident in the Southern Regional AHEC Family Medicine Residency Program in Fayetteville, NC. His academic interests include MedFT competency development and family medicine residency education.

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Exploring the "S" in BPS (BioPsychoSocial)

Posted By Melissa Lewis, Tuesday, August 7, 2012

Engel’s BPS Model has served to guide the discipline of Medical Family Therapy, reminding us to assess, acknowledge and treat each of these systems and specifically not to ignore the psychosocial when working in a medical setting. However, what exactly is encompassed in the ‘social’ realm? For social workers it may include basic living needs or connecting patients to other social service agencies. For chaplains it may be connecting the patient to a religious/spiritual community. For marriage and family therapists, it can include working to improve family relationships. Each of these disciplines is addressing important needs of patients that have been proven to aid in more effective treatment, faster recovery, and increased patient satisfaction.  

While these ‘social’ interventions are improving the health and well-being of patients, I would like to take a moment to dig a little deeper. I define the social aspects of life and health as cultural and relational ways of being. With that said, it is clear that ideas surrounding health, illness, cures, and healing will vary by individual and community. Yet we utilize ‘evidence-based’ methods that only allow for one way to see, cause and cure an illness which may be subjugating, and possibly ineffective, for the patient.
Melissa Lewis
What would you do as a MedFT if this were your patient?

Let’s continue the conversation through the comments you make!

Some interventions, such as Motivational Interviewing (MI), allow for patient goals and motivation to be accounted for. Further, Galanti (2004) suggests using the ‘4C’s (1. What do you call the problem/illness? 2. What do you think caused the problem? 3. How do you cope with the problem? 4. What concerns do you have about the problem?) can help to gain a better understanding of the patient’s view of health and illness. Next, the information gained from this assessment can be incorporated into treatment recommendations which will respect the patient’s health belief system and worldview and, therefore, are more effective.

 

I argue that a deeper and often more difficult intervention is necessary to accompany the above-mentioned techniques. I believe that using cultural humility to interact with patients will allow for some of the best health care outcomes possible. Cultural humility is the constant examination of our own biases and perspective. The regular steps of cultural competence still remain: learning/reading about a particular culture, interacting with that culture, respecting cultures other than your own. However, an additional set of criterion are necessary to become culturally humble:

1) Acknowledge that you are on equal footing as their discussant/patient-There is no better way to conceptualize health (i.e., provider vs. patient beliefs surrounding health).

2) Be aware that the discussant lives their life by a set of rules related to their family, history, and environment, which are individualized, discrete and different from your own (Ethnorelativism).

3) Be aware of how your own personal life history over time effects your thoughts, beliefs and behaviors (strengths and limitations) in relation to the discussant.

4) Acknowledge that one can never truly know the perspective of another individual or culture and that admitting your limitations opens the door to an honest conversation and does not diminish your legitimacy, credentials, or strengths and skills.

5) Does not search to become culturally competent at some distinct point, instead is continually learning about themselves and others through mutually beneficial conversations.

To demonstrate this point I offer a case example based on a real scenario:

A medical provider and her colleagues have been seeing a patient who has cancer (but has been in remission for 4 years) at 6 month intervals to ensure that the cancer (a rapid and progressive one) does not return. At the end of every visit for 4 years, the provider tells the patient and his family that he continues to be cancer-free and the family wails with joy and tears at the end of every appointment. The provider and her team have become frustrated with this response and do not understand the intense emotional reaction to what seems like a routine check-up that has resulted in the same positive outcome for many years. They hypothesize that there is some psychological trauma that the family has incurred due to this health experience that has resulted in some sort of psychological damage and are planning to refer them to psychiatric services. The patient is being seen at an Indian Health Service (IHS) facility in the Southwest United States and belongs to a Southwest tribe of Native Americans.

What do you think the provider and her team are missing from their assessment of the patient and the family? Using MI, the 4C’s, cultural humility, or your techniques to remain client-centered, what would you do as a MedFT if this were your patient? Let’s continue the conversation through the comments you make!

 

Reference:  Galanti, G.-A. (2004). Caring for patients from different cultures. Third Edition. Anthropology of Consciousness, 15, p.66–67. doi:10.1525/ac.2004.15.2.66

 

Melissa Lewis is a licensed Marriage and Family Therapist in North Carolina. 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 mlewis@alumni.ecu.edu

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Caring for Family Members: In Whose Hands Indeed

Posted By Dan Marlowe, Tuesday, July 31, 2012
The Institute of Medicine released a report earlier this month, as pointed out by Lauren N. DeCaporale in the comment section of Barry Jacobs previous post (check it out), entitled The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?. You can find an abbreviated report, panel recommendations, and even read the full report online here.

In it the panel throws out some interesting figures: 1) the number of adults over age 65 will rise from 40.3 million in 2010 to 72.1 million by 2030- that’s an increase of almost 60%, 2) nearly 1:5 older adults have one or more MH/SU conditions, and 3) none of these figures take into account the elderly who are or will be dealing with a chronic illness (e.g., hypertension, diabetes, COPD, CHF). However, for me, the most concerning part of the report was something that all of us already know, which is how woefully unprepared we are as a workforce to handle the impending influx of patients and their families needing our services. While many of the recommendations were spot on in terms of things like increasing reimbursement coverage for MH specialties, training curriculum redesign , re-credentialing medical/psychosocial providers around caring for the elderly, and methods for making providers more accountable for outcomes, one recommendation stood out to me in particular:

"Recommendation 4: Congress should appropriate funds for the Patient Protec­tion and Affordable Care Act workforce provisions that authorize training, scholarship, and loan forgiveness for individuals who work with or are preparing to work with older adults who have MH/SU conditions. This funding should be targeted to programs with curricula in geriatric MH/SU and directed specifically to the follow­ing types of workers who make a commitment to caring for older adults who have MH/SU conditions:

  • Psychiatrists, psychologists, psychiatric nurses, social workers, MH/SU counselors, and other specialists who require skills and knowledge of both geriatrics and MH/SU.
  • Primary care providers, including geriatricians and other physicians, registered nurses (RNs), advance practice registered nurses (APRNs), and physician assistants.
  • Potential care managers for older adults who have MH/SU conditions, including RNs, APRNs, social workers, physician assistants, and others.
  • Faculty in medicine, nursing, social work, psychology, substance use counseling, and other specialities.
  • Direct care workers and other frontline employees in home health agencies, nursing homes, and assisted living facilities (including personal care attendants not employed by an agency).
  • Family caregivers of older adults with MH/SU conditions."

The last bullet of the fourth recommendation caught my interest because it seemed like a logical way of incentivizing family caregiving by helping recoup some of the lost revenue of providing care- a cost in the billions. Looking at this led me to think about two interrelated and important questions: 1) what other ways can we incentivize family caregiving for not only the elderly but for others regardless of age or disease demographic, and 2) even with the panel's acknowledgement of family caregiving, why does this still seem to be such a low priority in overall workforce development?

So, what do you all think? What other ways can we make family caregiving a more realistic and sustainable endeavor for both patients and their families? In the end it is never enough to only point out a problem without also offering a sensible and systemic alternative.


 

Daniel 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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MedFT as Flower: Family Caregiving as Forest

Posted By Barry J. Jacobs, Tuesday, July 24, 2012

From that magical moment in the Minnesota hot tub in 1991 when Susan McDaniel, Bill Doherty and Jeri Hepworth coined the term "medical family therapy,” the field has had a slow but steady growth, sending tendrils into curricula for family therapists and other healthcare professionals and blossoming into a dozen or so certificate and degree programs around the country. For this progress, we all should be proud. But MedFT, to me, is like a delicate, hothouse orchid, assiduously watered and trimmed, surrounded by a burgeoning forest of more lush and verdant organic growth. The towering trees nearly blocking out the sun nowadays are the results of a fertile, consumer-initiated movement that took root around the same time as MedFT. That movement—now this country’s chief focus on families and illness--is called "family caregiving.”

Orchids and oaks, you say. Apples and oranges. Family caregiving, you contend, is what devoted family members do for an ill loved one; medical family therapists use systemic expertise to foster that endeavor. But while the term "family caregiving” is used to describe the sacrifices and struggles of over 60 million Americans in their provision of care to ailing relatives and friends each year, it also denotes a multi-disciplinary research, advocacy, and clinical effort with a complex infrastructure of federal, state and local support programs, disease- , relationship- and culture-specific research, and public and private funders and policy mavens.
Apples and oranges
Orchids and oaks, you say. 

Apples and oranges.

 

All that MedFT is striving to achieve—to better understand how families are buffeted by illness and disability and can continue to develop resiliently—the field of family caregiving has also striven for and has far outgrown us. 

Take research, for example. Empirical studies within MedFT are relatively few, are based on small subject groups, and have limited generalizability. In contrast, the research conducted over the past 25 years by psychologists, nurses, social workers, family physicians and others, particularly about dementia caregiving families, has been extensive, broad and deep. The original question those researchers undertook to answer—how family caregivers are affected by caring for someone with Alzheimer’s disease—has long been answered with evidence of increased morbidity (insomnia, depression, musculoskeletal problems; see Schulz & Martire, 2004) and mortality (see Schulz & Beach, 1999). These diverse researchers have also largely answered the next question—what kind of supports better help family caregivers cope (see here)—and are now working on how to translate those findings into effective public programs on the state and local levels.

Then there’s advocacy. MedFT academicians and practitioners have attempted and accomplished little in the policy arena. The powerhouse family caregiver consumer groups (e.g., National Family Caregivers Association, National Alliance for Caregiving, Family Caregiver Alliance) and other larger organizations with a strong interest in family caregiving (e.g., AARP, Alzheimer’s Association) have lobbied for and helped push through landmark federal legislation, including the Family and Medical Leave Act (1993), the National Family Caregiver Support Program (2000), and the Lifespan Respite Act (2006). Family caregiver advocates have made sure politicians know that there’s a growing constituency of Baby Boomers who want more monies earmarked for supporting their aging parents. Even in tight budgetary times, those funds have gradually increased.

The family caregiving movement’s clinical efforts might not be recognized by medical family therapists as "clinical” at all. Largely consisting of psychoeducation, screening for depression and anxiety, and providing respite care, the caregiver support programs are not particularly systemic in orientation, tending to focus on the needs of the primary caregiver. (Here’s where we have something to teach them about better harmonizing the interactions among various family members to produce better outcomes for the patient and family.) But given the widespread availability of caregiver support services, covering every county in this country, the family caregiving movement is meeting more of the basic psychological needs of the vast majority of families dealing with illness than MedFT could ever hope to achieve.

So what should all this mean for medical family therapists? A few thoughts:

  • MedFT should make every effort to become part of the family caregiving movement: That movement has been intensively collaborative, drawing on the strengths of a broad range of healthcare, legal and financial disciplines, as well as family members and patients. Yet because medical family therapists have been toiling in a few relatively isolated outposts, most family caregivers and leaders in the family caregiving field have never even heard of MedFT. I believe that the systemic expertise that we have to offer would greatly enhance the current efforts of family caregiving to roll out effective community-based programs.
  • We need to call our research family caregiving studies, not MedFT studies. Our researchers need to publish in the major journals for family caregiving, such as The Gerontologist and Aging and Mental Health. That’s how our work with be more widely recognized, disseminated and implemented.
  • We should be pitching ourselves clinically to the public and to colleagues from other disciplines on primary and specialty healthcare teams as "family caregiving experts,” not medical family therapists. This will better communicate who we are and what we do than the current identity we have. This is, in fact, truth in advertising—we are family caregiving experts!
  • Our MedFT associations—e.g., the CFHA MedFT work group and the MedFT Facebook group—should be advocating for improved services for family caregivers. We should join with dozens of other healthcare professional associations in the large and powerful coalition known as the National Alliance for Caregiving (www.caregiving.org). NAC is the single strongest voice advocating in Congress and in the academies today for the needs of families struggling with illness and disability.

In short, we need to branch out of the insular hothouse world and roam the forest. We need to cross-fertilize with other disciplines more. We need to pollinate their ideas with our own and improve their systemic understanding and efficacy. We have to trust that who we are and what we do will matter--and not just get lost in the scenery.

References

Schulz, R & Martire, L (2004). Family caregiving of persons with dementia: prevalence, health effects and support strategies, Am J Geri Psychiatry, May-June, 12(3), 240-9

Schulz, R & Beach (1999). Caregiving is a risk factor for mortality: the Caregiver Health Effects Study, JAMA, Dec. 15;282(23):2215-9

 

Barry J. Jacobs, Psy.D., Director of Behavioral Sciences for the Crozer-Keystone Family Medicine Residency Program in Springfield, PA, has long been involved in the family caregiving movement. He is the national spokesperson on family caregiving for the American Heart Association and an honorary board member of the Well Spouse Association. Most recently, he was appointed to the Caregiver Advisory Board of AARP. He has long written the advice column for "Take Care,” the newsletter of the National Family Caregivers Association, and is also the author of The Emotional Survival Guide for Caregivers (Guilford, 2006).



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Community in the therapy room: Social networks in therapy

Posted By Deepu George and Kathryn Martin, Wednesday, July 18, 2012

Medhi was a 42-year-old male who sought therapy for "work-related” adjustment issues and to focus on his development within the company. I worked as an on-site psychologist in Bangalore, India where he worked for a Fortune 500 Company. In his 6th year of employment with the company, he felt unsatisfied with the work environment, displeased with his co-workers, and was increasingly frustrated when younger talents acquired higher positions in his department. He contended that, due to his seniority in age, he should be automatically promoted. He refused to interact with his colleagues, who were either in their mid-20’s or early 30’s. He resented them, due to his traditional beliefs that he should be promoted, simply for the time he put in with the company. His morale was further impaired when a younger member of the team was selected as the new team leader and he was expected to report to this individual. With increasing frustrations in his work environment and a negative attitude about his co-workers, he grew more depressed.

He reluctantly approached therapy to address "work dissatisfaction.” As a relational thinker, it was clear to me that Medhi’s relational ties among his colleagues were weak and that his growing dissatisfaction was only symptomatic of long-term patterns he developed before this situation.
Building Community
"We need to place a greater focus on the intersection of the relational, inter-actional, and systemic perspectives to create hybrid innovations in therapeutic healing and community building."

Focusing beyond the psychological process (depression, anxiety, cognitive distortion, etc.), it was easy to conceptualize Medhi’s dissatisfaction as a reflection of the social networks with which he was engaged or, in this case, those networks with which he was not engaged.

One benefit of our clients' social networks (or lack thereof) is that they translate new ideas and behavior from our therapeutic work with them to their real life situations. All clients are members of a larger community and are participating actors in one or more community networks. We can establish lists of these possible communities: from volunteering at food pantries to more formal roles like chairman of a trust or a little league coach. Some examples of such avenues are MeetUp.com groups or circles that developed with the goal of bringing members together. The Meetup.com idea was conceived after 9/11 to facilitate communities to come together to promote better social relations.

Despite the nature of the presenting problem, assuming a broader systemic lens, to include not only family systems, but also the communities in which a client participates, connotes that psychological issues, like anxiety, are "a contract between people” (Haley, 1987). These issues then, are maintained in their immediate life contexts, like family, as we all know, and even community.

The concept of social organization and implications of social networks in creating life experience for its members is closely tied to how family therapy theories define relational issues. Jay Haley (1987) conceptualizes clinical problems as issues rooted in social units. In his words, "A symptom is a label for, a crystallization of, a sequence in a social organization” (p. 2). Therefore in Strategic Family Therapy, successful therapy essentially involved ‘changing the social situation.’ Haley (1987) tells us that the notion of diagnoses, insurance companies, professional colleagues, nurses, and psychiatrists are all part of a problem or the idiosyncratic social organization that maintains the problem.

Implicit in Haley’s definition are implications for – community -- both formal and informal networks. He "assumes a broader perspective” when he understands that the school system may be a part of the problem when a child refuses to return to school rather than it being caused just by a pathological relational system at home. Thus, Strategic Therapy points to social structures in framing the therapist-client relationship, and larger implications of the social organizational structure.

Employing a relational lens with Medhi, he and I explored his relational patterns at work, in his neighborhood, in his child’s school, at the office sports club, and in other associations. Medhi was a solo performer at work and a silent member of his local community. The main interpersonal contact he had was with his wife and his child, and even this was limited to the essentials of daily living. It seemed that he was but a lonely passenger, riding in the backseat of his life. Therapeutically, we looked at interactional patterns with his co-workers and how he behaved with shop owners, vendors, neighbors, etc., to understand a base behavioral pattern. Our work together focused more on social engagement as a treatment outcome rather than altering thoughts or shifting moods. He was also encouraged to maintain a map of relationships, which we developed to help him get more involved.

"Social support" is used as a blanket term in therapy. If we operationalize social support, it translates to meaningful social connections in your life context (family, community, workplace, church etc.,). Therapeutic objectives are rarely informed by this goal. However, if therapists can help a client map out their social connections, we can more clearly define the extent of social support offered to them. When we actually engage formal and informal networks outside the therapeutic system, as well, this support increases. Clinically, the therapist can focus on the web of relationships that the client is involved in to leverage the community context. A lack of a communal perspective isolates the individual stories within the four walls of our offices or clinics.

As Medhi became more engaged within his office, began to have more meaningful interactions with his neighbors and increased his presence as a member in other networks, his complaints about dissatisfaction at work reduced. While this did not immediately guarantee him a promotion, there was a different "sequence in social organization” (Haley, 1987) that mapped his interactions within the same system. In more theoretical terms, Medhi’s issues were seen as a larger issue closely tied to the social ethos of his work-place and his neighborhood. Therefore, understanding social networks is an important part of assuming a systems perspective.

Another pioneer in family therapy who was passionately committed to understanding relational patterns in context was Böszörményi-Nagy. Rightfully, he called his approach Contextual Family Therapy. He said that context is generated by interconnectivity, which is a process of the give and take that transpires between partners. Therefore, inter-connected issues generate the context for growth and development, which becomes a contextual issue. In essence, families or individuals enter a contextual contract with each other; either formal or informal. This contractual, relational agreement can occur between individuals as well as systems and vice versa.

Feminist therapists have been persistent in exposing the linkages between the personal and the communal (Doherty, 1995). Feminist Family Therapy and psychotherapy has accepted that social change is a critical outcome of the therapeutic exchange. While the clinical implications in feminist-oriented therapy do not define informal and formal networks per se, these structures can help us pursue pathways of achieving social change.

Therapists, especially those of us trained in systems thinking, positively affirm the inter-connectedness or inter-dependence in human life and interaction. Engaging the client or the family system with external forces broadens the understanding of inter-dependence. Real life interactions of our clients with their neighbors, colleagues, etc enhance and sustain therapeutic gains. Likewise, Medhi’s assignments to interact with others in his office and neighborhood validated his growth much more effectively than what I could have provided as a therapist.

To quote Mancini & Bowen (2009) "Human beings are innately social” (p. 245). Consequently, relationships with each other are cardinal for personal and community development. The ‘innately social’ tendencies manifest through informal contexts as individuals and families pace through lifecycle challenges. So, informal networks in the community are natural and more real to life than sanitized, controlled settings of the therapy room. Giving a life and voice to these "innately social” tendencies and providing pathways to achieve them in client’s lives awakens community in clinical practice. For example, the duration of therapy sessions usually varies from 50 minutes to 90 minutes, and occur usually once a week. Our clients spend more time in the informal sections of their life than in the therapy room, where life happens. Thus, informal networks are an influential entity in understanding the human condition.

We as family therapists, along with other healthcare professionals are agents of multiple formal networks due to professional identities, ethical guidelines, licensing systems, and sanctions we adhere to from some collective body. As a therapist, we must be aware of this unique position and use our credentials strategically. How can private practitioners better situate our practices within the context of community relations? Doherty and Beaton’s (2000) Levels of Involvement is a clear and concise rubric that I recommend to therapists to define this role precisely. Additionally, the levels represent developmental tasks for therapists as they grow with their practice. Once a therapist finds his or her optimum level of functioning, that professional can decide which level best addresses what type of presenting problems.

Social connections of the past, which mainly transpired through human interaction, have a new skin in the 21st century. With advances in communication technology and the advent of social networking media in every sphere of human life, the quality of informal social connections has become virtual and less intimate. Socially and therapeutically, I think that relationships – human interaction and intimate personal connections – cannot be substituted by virtual and electronic mediums. Psychotherapy is also part of this emerging trend with methods of on-line therapy, associations for the same, and development of ethics for online relationships (e.g. Online Therapy: A Therapists’ guide to Expanding Your Practice by Derring- Palumbo & Zeine.). However, in leveraging the community context in the therapy room, informal networks play a critical role in human transformation, and they mitigate the quality of life within a community. In making this conceptual leap of community in the therapy room, we must also understand that social support is not synonymous with social networks, and we must resist the temptation to assume that larger networks imply stronger social support (McDonald et. al 1998, as cited in Pickens 2003).

Social support is a byproduct of meaningful social connections individuals build with each other, which in sense provides a sense of community for the actors engaged in that relational setting. In today’s terms, a client with 900 facebook friends isn’t necessarily someone with a strong social support network.

In short, literature has identified several clinical areas where social networks play a key dimension in therapeutic endeavors. The most common examples are in the case of elderly, mental illness, domestic violence, violence prevention efforts, addiction treatments etc., (Sluzki, 2000; Todd & Armstrong, 1984; Pickens, 2003). All of these studies come with their specific caveats and strengths, and therefore are specific to the mentioned clinical issues. As the field of family therapy and social networks develops, we as clinicians need to place a greater focus on the intersection of the relational, inter-actional, and systemic perspectives to create hybrid innovations in therapeutic healing and community building. After all, each healthy individual and each healed relationship are signs for a better and stronger society.

References

Haley, J. (1987). Problem-solving Therapy (Second Edition.). San Francisco: Jossey Bass Publishers.

Doherty, W. J. (1995). Soul Searching: Why Psychotherapy Must Promote Moral Responsibility (1st ed.). Basic Books.

Mancini, J. A., & Bowen, G. L. (2009). Community resilience: A social organization theory of action and change. In J. A. Mancini, & K. A. Roberto, (Eds.) Pathways of Human Development: Explorations of Change.( 245-265). Lexington Books.

Doherty, W. J., & Beaton, J. M. (2000). Family therapists, community, and civic renewal. Family Process, 39(2), 149–161.

Pickens, J. M. (2003). Formal and informal social networks of women with serious mental illness. Issues in Mental Health Nursing, 24(2), 109–127.

Sluzki, C. (2000). Social networks and the elderly: Conceptual and clinical issues, and a family consultation. Family Process, 39(3), 271-284.

Todd, D. M., & Armstrong, D. (1984). Support systems of elders in rural communities. Contemporary Family Therapy, 6(2), 82–92.

 

Deepu George
Deepu George is a doctoral student in the Family Therapy program at the University of Georgia. He is interested in social determinants of health, medical family therapy, community development and capacity building. With a Master’s Degree in Holistic Psychological Counseling from Bangalore, India, his aim is to continue his passion for applying systems lens in health care, family therapy, conflict resolution & peace-building, and community capacity work.


Kathryn Martin
Kathryn Martin is a Marriage and Family Therapist Associate in private practice in Austin, Texas. With a Masters in Clinical Psychology from Pepperdine University, Kathryn uses a systemic perspective with her clients through multi-modal treatments including online therapy, movement, and relaxation.


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Getting it Together for High Risk Diabetic Teens

Posted By Harold Starkman, Tuesday, July 10, 2012

Ann, a 15-year-old with Type I diabetes of seven years duration, had multiple admissions to the hospital due to poorly controlled blood sugars. Her diabetes physician and nurse practitioner tried multiple interventions to help Ann and her parents improve regimen adherence--including increasing clinic and phone follow-up and scheduling family diabetes re-education sessions--with limited success. Referral to the hospital social worker and a series of community psychotherapists resulted in a number of short courses of therapy characterized by missed visits and poor communication between the family, diabetes care team and therapist.

At age 18 years, Ann’s medical care was transitioned to an adult diabetes care provider. At her first visit to her new physician, she was told that whether she chose to adhere to her treatment plan and avoid diabetic complications was "totally up to her”. Ann was subsequently lost to medical follow-up until age 34 years when she presented to her local hospital’s emergency department with severe diabetic complications and a history of continued poor blood sugar control.
Harold Starkman
"Being well aware of the difficulty in engaging families in structured psychosocial intervention programs, we decided to take a new tack and ask our high-risk families to become our expert consultants."

  -Harold Starkman

The story above is not atypical for 10-20% of adolescents with diabetes. Often, pediatric diabetes providers feel that they are failing their patients. Their frustration can lead to blaming and shaming the teen and his/her parents. Continued poor blood sugar control frequently results in a mental health referral for individual therapy with the teen becoming the "designated patient” who has issues "dealing with diabetes”. An emphasis on providing first order change (i.e., improved blood sugars. fewer hospitalizations), often moves the therapeutic focus to the teen’s relationship with diabetes and away from relevant family and social issues. This limits therapeutic success and is ineffective in slowing a trajectory towards estrangement of the teen, family and care team and eventual loss to medical follow-up. These youths often re-connect with the medical system in their late 20’s to 30’s, presenting with diabetes complications.

In 2009, at the BD Center for Children & Adolescents of the Goryeb Children’s Hospital in Morristown, NJ, we established our Family Focused High Risk Diabetes Intervention Program to learn more about and provide services to our diabetic adolescents with poor blood sugar control. Being well aware of the difficulty in engaging families in structured psychosocial intervention programs, we decided to take a new tack and ask our high-risk families to become our expert consultants. Family members were invited to participate in a two-hour, videotaped, semi-structured interview, focusing on family strengths, day-to-day diabetes management, and interactions with their diabetes care team. After the initial interview, we offered participating families a short-term therapeutic intervention, at no cost, with the goal of lowering diabetes-related conflict by improving problem-solving and communication skills.

At the same time, we initiated a series of educational conferences focusing on family dynamics for our medical diabetes care team. These sessions included observation of a family therapist conducting a family interview, followed by team discussion. In addition, in order to learn more about the medical provider’s perspective, each team member was asked to participate in a semi-structured, videotaped interview. These interviews focused on the provider’s personal experience with chronic disease and beliefs related to the management of adolescents with sub-optimal blood sugar control.

To date, 20 high-risk families have participated in our program. We are in the process of analyzing our epidemiologic, interview and outcomes data and will be reporting on these in the near future. An invaluable benefit of our study design, however, was the opportunity to observe video interviews showing the dramatically differing perspectives of families, their medical and mental health providers. These differences often evolved into conflict, which in turn impeded collaboration, negatively impacting diabetes care. This effect was particularly notable at times of increased family stress when collaboration is most crucial.

The take-home message is clear: Although their perspectives, language and problem-solving approaches may differ, more effective collaboration between medical and mental health professionals and the families they care for is necessary for improved management of high-risk adolescents with diabetes.

 

Harold Starkman is Director of the BD Diabetes Center at the Goryeb Children’s Hospital in Morristown, New Jersey and Associate Professor of Clinical Pediatrics at the Mount Sinai School of Medicine. He graduated from the Albert Einstein College of Medicine and subsequently completed residency and fellowship training in pediatrics and pediatric endocrinology. More recently, he completed basic training in family dynamics at the Ackerman Institute for the Family.

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I'm Not Her Family Caregiver, I'm Her Husband!

Posted By Theodora Ooms and Jana Staton, Tuesday, July 3, 2012

The title of this blog was inspired by a remark that was made to Susan Stamberg NPR reporter, by a man in his seventies attending an art program designed for Alzheimer’s patients with his wife. Many health care professionals, and family caregiver advocates have heard similar remarks. It raises numerous complex questions for health care.

Too often couplehood is invisible to health care practitioners, and ignored in current health care reform discussions. The spousal/intimate partner relationship is fundamentally different from the relationship between an individual and other family members or close friends who may be providing care. It has unique legal, economic, intimate (emotional and sexual) and social aspects. Theodora Ooma and Jana Staton
Too often couplehood is invisible to health care practitioners, and ignored in current health
care reform discussions.

A growing body of research— gradually becoming better known and getting increasing media attention— demonstrates that the quality of a couple’s relationship can profoundly affect and be affected by the physical and emotional health of each individual over their life span. This research was reviewed by participants at our 2008 conference and they also made numerous recommendations about how to implement a couple focus across all aspects of health care (Staton & Ooms, 2011 & 2012, these links are pdf reports). They agreed that it is in the care of the chronically ill where the pay off of adopting a couple-focus could be most significant in terms of increasing the quality of care and reducing health care costs.

The couple relationship intersects with health care throughout the course of chronic illness, from the moment when the initial diagnosis is received, throughout the often protracted and bumpy course of managing treatment (when the patient is still largely independent). The relationship assumes even more importance at the caregiving stage when the partner’s health is severely compromised, other diseases may co-occur, and assistance from spouse or other caregiver is increasingly required for daily functioning. Spouses and partners indeed function as family caregivers, but they are so much more, and their relationship affects the course of a chronic illness long before "caregiving’ in the current medical sense becomes an issue.

Health care systems need to recognize that at all these stages a strong couple relationship can be the health care professional’s best ally; an unsafe, unstable and emotionally destructive relationship is a major health risk. A systems paradigm maintains that when an individual adult becomes seriously ill or disabled, the couple needs to be viewed as the unit of treatment (if there is no partner, then other family members). What this means in practice will depend on the severity and stage of the illness. Yet the official medical establishment continues to operate within an individualistic paradigm. For example, astonishingly the new Institute of Medicine report on Living Well with Chronic Illness (IOM, 2012) pays no attention to the spousal/partner/or family caregiver’s role.

Changing family demographics—the decline of marriage— is often cited as one of the reasons for ignoring the power of the couple relationship. Yet many chronic illnesses or conditions begin in mid-life—diabetes, MS, heart-disease, cancer, HIV/AIDS—when two thirds of adults are married. A recent Census report provides the numbers: In 2010 70% of men age 55-64 and nearly 71 % over 70 years are married. Women are less likely to be married: 61.2% of 55-64 year, and 41.6% of over 65 year old women are married (U.S. Census Bureau, 2010). If committed cohabiting partners, including GLBT couples, were included the proportion of adults married or with a partner would be even larger. These numbers strongly suggest that health care providers should be aware that it is more likely than not that their chronically ill patient has a spouse. (No national data is available on the marital/partner status of those diagnosed with chronic illness.)

The family caregiving community has made laudable efforts to be inclusive of all those (spouses relatives, friends etc) who provide care to the chronically ill, frail and old. The dominant model of family caregiving is to serve elderly patients, and the majority of these are indeed elderly single women, and for the majority of them their caregiver is an adult child.. In the process however the specific issues that are unique to the large numbers of spouses or committed partners providing increasing levels of assistance to their chronically ill partner are seldom addressed.

Recent trials of psycho-educational interventions designed to improve partner communication and assistance in cancer and other chronic illness are showing promise of improving both patient and partner health (Porter et al. 2011; Baucom, 2012; Scott, Halford & Ward, 2004). Meanwhile numerous innovations are underway to improve the quality and cost effectiveness of health care: for example efforts to improve the management of care transitions, adherence to treatment protocols, coordinate care for those with multiple conditions, prevent unnecessary rehospitalizations (bounce-backs), and establish medical homes.

These innovations offer a window of opportunity to integrate couple relationship information, education and other couple-focused practice and management tools in current reforms and to find out, as seems very likely, whether they do help improve health care quality and reduce costs. Couple-focused approaches should be viewed as complementary to those focused on family caregivers more generally.

We invite readers of this blog to share examples of actual, or proposed practices or system changes in the primary care of chronic illness that exemplify taking a couple perspective. To jump-start this conversation here are a few suggested changes in practice at different stages of chronic illness, but they could be adapted to be used in health care more generally:

  • In the initial medical examinations routinely collect and record information about the spouse/partners and his/her own health status; obtain permission to actively involve the partner in the patient’s care whenever it would be useful.
  • Medicare now reimburses practitioners more if they conduct an Annual Wellness Exam (Center for Medicare & Medicaid Services, 2011) The exam is to include an assessment of the individual’s functioning ability and level of safety in the home. We propose the CMS circular should also require that if they learn that the patient is receiving assistance with medications or ADL, they find out who provides the patient with assistance, and if that person is a spouse/partner (or other relative), and what is the general status of their health.
  • In the treatment and management of chronic or serious illness, routinely invite the spouse/partner to participate in diagnostic discussions, planning for discharge and involve the partner in explanations of post-discharge home-based treatment protocols.
  • Provide the couple with written information (or CDs. DVDs) about how the chronic illness may affect the legal, economic, and intimate aspects of their relationship. Make referrals to additional education and support services designed to address these issues, such as the National MS Relationship Matters program (see Staton & Ooms 2012, pp 15-16).

 References, Links

Baucom, D., H., Porter, L.S., Kirby, J.S., Hudepohl, J. (2012) Couple-Based Interventions for Medical Problems, Behavior Therapy. 43(1):61-76.

Center for Medicare and Medicaid Services. Annual Wellness Visit, Circular MM 7079. Link Here.

Institute of Medicine (2012). Living Well with Chronic Illness: A Call for Public Health Action. http://www.nap.edu/catalog.php?record_id=13272

Porter, L.S., Keefe, F.J., Garst, J., Baucom, D.H., McBride, C.M., McKee, D.C., Sutton, L., Carson, K., Knowles., V., Ruble, M., Scipio, C. (2011) Caregiver-assisted coping skills training for lung cancer: Results of a randomized clinical trial. Cancer, 115 (S18), 4326-4338.http://www.jpsmjournal.com/article/S0885-3924%2810%2900528-2/abstract

Scott, J.L., Halford, K.W., & Keefe, F.J. (2009). A couple-based intervention for female breast cancer. Psycho-oncology,18 (3), 276-83. http://www.ncbi.nlm.nih.gov/pubmed/18702064

Staton, J., Shuy, R., & Byock, I.(2000). A Few Months to Live: Different Paths to Life's End. Washington, D.C., Georgetown University Press. http://www.press.georgetown.edu.

Staton, J., & Ooms, T. (2011). Marriage and Relationship Factors in Health: Implications for Improving Health Care Quality and Reducing Costs. Issue Brief, National Healthy Marriage Resource Center. http://www.healthymarriageinfo.org/resource-detail/index.aspx?rid=3938.

Staton, J., & Ooms, T. (2012). "Something Important is Going on Here!" Making Connections Between Marriage, Relationship Quality and Health: Implications for Research and Healthcare Strategies and Practice. Proceedings Report of the 2008 Wingspread Conference. National Healthy Marriage Resource Center. http://www.healthymarriageinfo.org/resource-detail/index.aspx?rid=3984.

U.S, Census Bureau (2010) Marital Status: 2010 American Community Survey 1-Year Estimates http://factfinder2.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_1

 

Theodora Ooms, a social worker and family therapist has worked for thirty years in Washington DC to integrate a family systems perspective into federal and state policy and programs. She was a participant in the founding CFHA Wingspread conference in 1993 and is very happy to be reconnected.

Jana Staton, has her doctorate in counseling psychology, and currently works as a marriage and family therapist and couples educator in Montana. She is the co-author ofA Few Months to Live: Different Paths to Life’s End.

In 2008 Ooms and Staton coordinated a three day invitational conference at Wingspread designed to critically review the research on the connections between marriage and couple relationships and health, and make recommendations for changes in health care practice and policy.

 

 


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5 Questions with Cleveland Shields

Posted By Keeley Pratt, Tuesday, June 26, 2012

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Keeley Pratt: I met Dr. Shields when I was just a first year doctoral student in East Carolina University’s Medical Family Therapy program. We meet over breakfast, a meeting I anxiously initiated, at one of the annual American Association for Marriage and Family Therapy conferences. I learned of Dr. Shields work from literature I had read on families and health, but also because he worked and lived in Indiana- the state I grew up in. I have to admit looking back I was nervous to meet him; he clearly is an esteemed researcher and educator. However, quickly after meeting Dr. Shields it became evident that we shared a kinship for health and families, research, the Midwest (think cornfields and basketball), and sarcasm. I consider myself extremely fortunate to have had him as professional mentor, at a distance, for close to five years now. I was honored to interview him for the Medical Family Therapy blog series and to have the opportunity to share the pearls of wisdom he has relayed to me over the past five years with current and future Medical Family Therapists whom I’m sure will benefit.



1. What experience in your professional or personal life was most influential in your development as a medical family therapist?

I grew up in a family where we weren’t shielded from older folk’s illnesses. I was lucky to grow up right next to my grandparents. I was involved in taking care of my great-grandmother and an uncle in their last years. My sister, my cousins, and I were never shielded from aging, illness, or death. We were told the truth as it was appropriate to our age at the time. My parents helped us become comfortable the realities of life and death.

I was in the ministry for a few years, so I did a lot of visiting of older folks and some hospital work with ill people. During my time in seminary and church ministry, I learned about caring for people, read a lot of family therapy books, and spent a lot of time with sick people. That piqued my interest in becoming a marriage and family therapist. When I came to grad school (at Purdue), I discovered that I also had the skills to be a researcher.

I had not thought about doing health-oriented research work until I finished my degree at Purdue and started a faculty position at the University of Rochester Medical Center. I worked primarily in Family Medicine, and was immediately thrust into doing therapy with patients with complex medical problems. At the same time, I started conducting research on family relationships and health problems. I became a medical family therapist because of my work context, which involved seeing patients in exam rooms with physicians and having patients come to me who weren’t talking about their marriage. I was trained as an MFT but my patients wanted to talk about their diabetes, why they didn’t like their medication, their cancer, or whatever disease/illness they had. So, I suddenly had to learn about health. I learned by stopping a physician or a nurse practitioner in the hall and saying "What does this mean?” I got educated quickly by colleagues and from extensive reading.

I was at Rochester to build a research program, which because I had not been trained in health, required a huge amount of reading. At Rochester I wrote some papers with Lyman Wynne 1,2,3, worked on publications and book chapters on treating medical illness with Susan McDaniel4 published research with others. It was a great group of people there: Tom Campbell, Susan McDaniel, Barbara Gawinski, Sally Rousseau, Tziporah Rosenberg, David Seaburn5- and all of the physician collaborators and primary care doctors who are great people and great human beings, many who had also been trained as family therapists.

 

2. What do you consider your most important contribution to the medical family therapy field or literature?

When describing what it is I do, I say that I am a family therapist who studies the role of clinical communication in the management of chronic illness and the role of clinical communication in healthcare disparities. Clinical communication is a broad term that includes not just physicians but anyone (such social workers, nurses who give discharge instruction, and family therapists) who interact with patients and their family members. My research is between basic and applied, and I am very interested in turning research into interventions.

Toward the end of my time in Rochester, I started conducting research with Ron Epstein and Kevin Fiscella on physician-patient communication6-10. I have continued this research since coming to Purdue in 2006, and it has been the most fruitful and rewarding collaboration I’ve ever had.

Most of my research has been in relationships and health. I haven’t published much about therapy so I don’t think I contribute directly to the medical family therapy clinical literature. I see myself as doing more basic and applied research on healthcare focused on clinical communication. Now, working through the Purdue Regenstrief Center for Healthcare Engineering, I collaborate with hospitals and physicians in the state. Currently, I am doing a large physician–patient communication study funded by NIH with colleagues at Purdue, the University of Rochester, and Michigan. I am working with colleagues at IU and Duke to develop an intervention study to improve communication between physicians and adolescents about sexuality. I am an MFT, one of us is a communications PhD, and the other is a pediatrician. This is where the fun is, interdisciplinary research; reaching across disciplinary boundaries and expanding knowledge. I’d encourage every MFT to collaborate with people outside their own departments.

I recently became Director of the Center on Poverty and Health Inequities (COPHI). COPHI's mandate is to examine in the US and internationally the effects of socio-economic status, race and ethnicity, national origin, religion, poverty, education, and geography on health care inequities. The Center’s faculty includes scholars from public health, counseling psychology, communication, and consumer sciences. With less than half of our faculty being born in the U.S., our meetings are like a mini UN, which makes our meetings a lot of fun.

Dr. Melissa Franks and I are conducting a study on unnecessary hospital readmissions of patients with Type 2 diabetes. We are examining whether hospital discharge instructions and involvement of family members in discharge planning predicts unnecessary readmission to the hospital. We hope this study could lead to interventions to improve discharge planning, which fits nicely with the recommendations we made in our recent JMFT paper11.

Not everybody needs family therapy, but many families can benefit from family interventions delivered within the healthcare system. Family therapists can devise simple interventions for healthcare providers to involve family members. Interventions can be as simple as encouraging family members to ask questions, encouraging their involvement, and giving them information that will help them provide care adequately.

Clearly there are people who need family therapy, but a lot of people would benefit from psycho-educational interventions that involve the family. So, there is plenty of therapy work to do, but there is also plenty that a healthcare professional with a family-orientation can do to improve healthcare. Family therapist are needed when there is a full-fledged relationship problem that needs intervention, but if you are just trying to get healthcare providers to incorporate the family then we (family therapists) can design programs to do that, but we don’t need to be the ones doing all of it. That’s my position and what we argued in the JMFT article11.

 

3. What does the field of medical family therapy most need to move into the mainstream of healthcare?

From my perspective, we need a research base, its one thing to say we need to do this or that, but we should be plowing ahead and doing research similar to other professions like Health Psychology. I think it is important to establish when it’s important to involve family members and when it’s not; not every problem requires a family member to be intimately involved- lots of individuals can take medication for their bronchitis without a family member reminding them. Major lifestyle changes probably do involve family members, so it is particularly important to develop family oriented interventions to improve the management of chronic diseases. There is a fair amount of basic research on this, but we need to know how to help family members provide needed support12,13.

 

4. What advice do you have for future medical family therapy students or young professionals who are interested in getting into research?

If they want to get into research, they should really know the methodology literature. They should find a mentor, and if they are a marriage and family therapy student and they have to find a mentor in another department, don’t hesitate to do that. They need to find a content expert in their research. They should take advantage of National Institute of Health (NIH) health-focused research conferences. They need to go to research conferences, for example the Society of Behavioral Medicine, because most marriage and family therapy conferences include little research. Find a conference about the health problem they want to study, and go to it. Learn as much about the medical issues involved in their chosen topic. Our focus is around the behavioral issues in managing those diseases, we’re not going to change someone’s medication- we’re not physicians, but we can help change their behaviors such as diet, exercise, medication adherence, and improve family interactions to increase support for changing and maintaining these new behaviors.

We need to be part of interdisciplinary teams. You can’t do research in this area without collaborating with all kinds of people. We need to think that we are bringing a family systems perspective to other areas, but we have just as much to learn from them. We have tons to learn from epidemiology, public health, nutrition science, engineering, economics, and all the other professions involved; and we need to learn to collaborate with them. Every project I am doing is a collaborative project. MFT programs should encourage their new faculty to develop interdisciplinary relationships at their universities.

 

5. What about choosing where to publish: healthcare journals, MFT journals, disease specific journals- How do you decide?

Think about the articles you want to write and see where similar articles have been published. So if you find a really good research article that really speaks to the kind of research you want to do- look at where it was published and then go look that the reference list and see where those papers were published. Your goal is to publish at the highest level possible. Most NIH panels are not going to be familiar with most family therapy journals, so try to publish in non-MFT as well as MFT journals. Publish in disease specific journals. If your area is diabetes, then try to publish in Diabetes Care or Diabetes Educator, which are behaviorally oriented diabetes journals. Finally, new researchers need to learn to write persuasively and scientifically, which is argumentative writing and quite different than describing a new clinical approach.

 

Selected Bibliography

1. CG Shields & LC Wynne. (1997). The strength–vulnerability model of mental health and illness in the elderly. Brunner/Mazel.

2. CG Shields, LC Wynne, SH McDaniel, BA Gawinski. (1994). Conceptual and structural marginalization: Challenges and opportunities for the field of family therapy [A rejoinder to Hardy and Anderson]. Journal of Marital and Family Therapy 20 (3), 297-300.

3. CG Shields & SH McDaniel. (2007). Family Therapy Pioneer, Researcher, and Mentor: Lyman C. Wynne, MD, PhD 1923–2007. Journal of Marital and Family Therapy 33 (2), 132-133.

4. CG Shields & SH McDaniel. (1992). Process differences between male and female therapists in a first family interview. Journal of Marital and Family Therapy 18 (2), 143-151.

5. D Seaburn, B Gawinski, J Harp, S McDaniel, D Waxman, C Shields. (1993). Family systems therapy in a primary care medical setting: The Rochester experience. Journal of Marital and Family Therapy 19 (2), 177-190.

6. CG Shields, CJ Coker, SS Poulsen, JM Doyle, K Fiscella, RM Epstein & JJ Griggs. (2009). Patient-centered communication and prognosis discussions with cancer patients. Patient Education and Counseling, 77, 437–442. doi:10.1016/j.pec.2009.09.006

7. CG Shields, GR Morrow, J Griggs, J Mallinger, J Roscoe, JL Wade, SR Dakhil, S. R., et al. (2004). Decision-making role preferences of patients receiving adjuvant cancer treatment: A University of Rochester Cancer Center community clinical oncology program. Supportive cancer therapy, 1(2), 119–126.

8. CG Shields, KW Ziner, SA Bourff, K Schilling, Q Zhao, P Monahan, G Sledge & V Champion. (2010). An intervention to improve communication between breast cancer survivors and their physicians. Journal of Psychosocial Oncology, 28(6), 610-629. DOI:10.1080/07347332.2010.516811

9. CG Shields, RM Epstein, P Franks, K Fiscella, P Duberstein, SH McDaniel & S Meldrum. (2005) Emotion language in primary care encounters: reliability and validity of an emotion word count coding system Patient Education and Counseling, 57: 232-238

10. RM Epstein, T Hadee, J Carroll, SC Meldrum, J Lardner, CG Shields. Could this be something serious? (2007) Journal of general internal medicine 22 (12), 1731-1739.

11. CG Shields, MA Finley & N Chawla & P Meadors. (2012). Couple and family interventions in health problems. Journal of Marital and Family Therapy, 38(1), 265-280. doi:10.1111/j.1752-0606.2011.00269.x

12. MM Franks, CG Shields, L Sands, E Lim, S Mobley & CJ Boushey. (2012). I will if you will: Similarity in health behavior change of married partners. Health, Education, & Behavior. 39:324-331. DOI: 10.1177/1090198111402824

13. MM Franks, CG Shields, L Sands, E Lim, S Mobley & CJ Boushey. (2012). I will if you will: Similarity in health behavior change of married partners. Health, Education, & Behavior. 39:324-331. DOI: 10.1177/1090198111402824


 

Cleveland Shields

Cleveland Shields, PhD is an Associate Professor in the Department of Human Development and Family Studies at Purdue University in West Layfayette, IN. Dr. Shields’ main research interests include: families and health, couple and family interventions in health, patient-centered care in medical settings, and couples and cancer. He has published extensively in the area of family/patient/physician communication and family/couple intervention development, and has recently been awarded a grant by the National Cancer Institute to examine social and behavioral influences on clinical communication and pain management.


 


 

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5 Questions with Claudia Grauf-Grounds

Posted By Barry Jacobs, Tuesday, June 19, 2012

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Barry J. Jacobs: I had the privilege recently of conducting a phone interview with Claudia Grauf-Grounds, Ph.D., a long-time acquaintance from the CFHA and Society of Teachers of Family Medicine (STFM) conferences. For two decades, she has been an exemplar of the collaborative care champion who has gracefully straddled the family therapy and family medicine worlds, teaching trainees from each about the culture of the other. In workshops and at meetings, I have always been impressed by Claudia’s equanimity and good cheer. Perhaps this reflects her self-assurance about her missions as an educator and clinician, as well as her deep and abiding spirituality.


1: What experiences in your professional or personal life were most influential in your development as a medical family therapist?

In terms of my professional development, I was teaching family therapy at the University of San Diego in the early-‘90s when JoEllen Patterson asked me to apply for a part-time behavioral faculty position at Sharp, a new community-based, family medicine program that was being started by family medicine leader Joe Scherger. After I was hired, along with psychiatrist Steve Groban, we had to figure out what to do. We started going to the STFM Family in Family Medicine conferences, held each year for many years at Amelia Island, Florida, where I met the gang—Jeri Hepworth, Tom Campbell, Susan McDaniel, Dave Seaburn, Alan Lorenz. All of these were very competent professionals and wonderful people who wanted to address families and suffering but could also talk in the same paragraph about their own families. They were all mentoring me. I met Tina Schermer Sellers at Amelia Island at the same time I was applying for my current position at Seattle Pacific University. I shared her vision to work with families and illness and we hit it off. Tina had worked for years as a family therapist in oncology and she had had the idea independent of me to start a certificate program in MedFT at SPU. In 2001, we started a MedFT certificate program for our masters and post-masters family therapy programs.

The personal experience that has informed my career was that my son was born with transposition of the greater heart vessels that meant there were no connections between his lungs, heart and body. He was suffocating at birth. During his two open heart operations and subsequent hospitalization, my husband and I basically lived at the Children’s Hospital in San Diego. We coped not only because of the amazing hospital professionals who supported us but also because of our faith community at that time. That experience has led me to think a lot about internal and external resources of healing. That’s how I train my students and work with my clients—evaluating the kinds of internal and external resources that clients use. My son, by the way, is now 23 and is doing great. His internist at University of Washington wrote about him in an academic journal because he is the only person with that congenital cardiac condition who later went on to compete in Division II track.

 

2: What do you consider your most important contribution to the MedFT field?

In my role as department chair, I’ve been able to facilitate Tina’s dream to start a university-based MedFT certificate—one that isn’t affiliated with one hospital or residency program. Instead, we put students in multiple healthcare settings where they get an overall picture of how families can be involved in medical care. But we also ask each student to focus during training on one illness—fibromyalgia, cancer, diabetes, etc.

I’ve also worked to expand George Engels’ biopsychosocial model to one that is biopsychosocial-spiritual by presenting consistently at CFHA and STFM conferences on spirituality and by collaborating with other trainers on this topic and by introducing a core course on Spirituality & Health in our MedFT course curriculum.

 

3: What do you think MedFT, as a field/orientation, needs in order to move into mainstream healthcare?

I think there are situations now that prompt people to think about their own families and illness situations—e.g., dealing with aging parents, wounded warriors in military families. People understand intuitively that it’s important for healthcare to be family-based. But we’re still using a fee-for-service, individually oriented reimbursement model. Families want to be engaged in healthcare but realize that they will have to pay for it out of pocket. Our field must advocate for a more family-based reimbursement system.

 

4: What do you think our training models lack that puts us behind some other fields?

I like the hubs of MedFT training that I’m seeing in different contexts. The difference is that we’re still an interdisciplinary group and interdisciplinary groups have difficult getting traction politically. Things like writing blogs will help us because that’s where real people live.

 

5: Ideally, where would you like to see MedFT in the next 10 years?

NAMI is an integrated whole of families and healthcare professionals devoted to relieving the suffering of families dealing with psychiatric illnesses. I’d love for MedFT to become a kind of professional NAMI—a go-to field that demonstrates the value of working with families with all illnesses and advocates for those families.


 

Claudia Grauf-Grounds

Claudia Grauf-Grounds, Ph.D. is Chair and Professor of the Department of Marriage and Family Therapy in the School of Psychology of Seattle Pacific University. For many years, she also supervised the behavioral science training of family medicine residents at the University of Washington. She is the co-author of Essential Skills in Family Therapy: From the First Interview to Termination (Second Edition) (Guilford, 2009) and has also published extensively on MedFT training, couples treatment, anticipatory loss and spirituality in Families, Systems & Health and other journals. She and her husband, a pastor, have three adult children (ages 23-30) and an 18-year-old dog named Coffee Grounds.


 


 

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5 Questions with Larry Mauksch

Posted By Randall Reitz, Tuesday, June 12, 2012

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Randall Reitz:  The following is correspondence between Larry Mauksch and me. As with many other collaborative care learners, Larry has been a generous mentor and persuasive advocate for my professional development. Thank you, Larry, for your loving wisdom and prescient vision.
 

1: What experience in your professional or personal life was most influential in your development as a medical family therapist?

LM: My mother was a nurse practitioner who worked in primary care. My father was a medical sociologist who worked in primary care and studied collaboration between nurses and physicians. I was brought up in an inter-disciplinary home. My college, The Evergreen State College, was interdisciplinary. There were no departments per se. An interdisciplinary team taught all major courses. During my first year I remember reading "The Double Helix”, the story of the discovery of DNA. In the collaborative relationship between Watson and Crick, key discoveries were made in the domains of expertise of the other. This taught me that having a close collaborative relationship with someone operating outside of your worldview is of critical importance.

2: What do you consider your most important contribution to the MedFT field?

LM: From an organizational perspective, perhaps it was some decisions I made while Chair of the CFHA board between 2002 and 2005. Our founding board had not changed its membership since it was formed in the mid 1990s. I learned that "founders syndrome” can kill an organization. I helped develop a policy for board member turnover and I think much of the success of the organization now is due to the vitality and creativity of the new energy of the CFHA board. During the same time we changed the model of our national conference from a traditional program of presenters who share ideas to being more focused on local communities. Academically, I think the work done in Grand Junction, particularly publishing four papers about the transformation of primary care clinic were important contributions. I have spent 32 years practicing and teaching as a family therapist in a primary care environment. This has allowed me to experiment with lots of clinical and educational models.

3:  What does the field of MedFT most need to move into the mainstream of healthcare?

LM: Well, the leaders of one revolution often become the laggards in the next wave of change. I fear that current models of collaboration may become to fixated on behavioral health roles and, to preserve these roles, resist helping other members of the team master skills that every team member should know and use. I am concerned that the focus on the family is not stronger in mainstream primary care. The experimentation with new models of delivery today is exciting. But few people are studying outcomes. We need to measure, to learn. Finally, interdisciplinary approaches to health care need to be appropriately funded by insurers/payers.

4: Early career academics can feel intimidated in their attempts to promote family-based care within large university settings. What was your key to success within the University of Washington School of Medicine?

LM: I have always felt supported by my physician colleagues. It’s always been important to listen to their experiences with patients, to be curious about how they deal with major challenges in caring for families and to offer to help. Some of the most famous researchers in collaborative care come from the University of Washington and Group Health Cooperative of Puget Sound. I have been fortunate to have those folks around as mentors and sources of inspiration. It has been very important to my survival and creativity to have colleagues who shared my interest. The Family in Family Medicine Conference of the Society of Teachers of Family Medicine and later CFHA, provided me with a national support group where I have enjoyed friendships and sources of support for over 25 years. It is important to read the ideas and research of others.

5: Your kids are graduating from college and you seem to be re-adjusting the work/life balance toward "life". What else do you have planned for both work and life in the next decade?

LM: I enjoy a growing practice in consultation and training. I hope to continue to consult but contain it so to leave room for writing and non-professional parts of life. My wife and I love to travel and learn about other cultures. We love the outdoors and exercise. If I am fortunate to keep my health ( I have a new knee) I plan to hike, bike and canoe or kayak in many places around the globe.

 

Larry Mauksch

Larry Mauksch is a Senior Lecturer in the Department of Family Medicine, University of Washington School of Medicine, in Seattle, Washington and a consultant and trainer for health care system transformation. He has spent the last 26 years training medical students, residents, mental health professionals, practicing physicians and nurses in interviewing skills, team development, and the diagnosis and management of mental disorders. He is a core faculty in the Washington State Department of Health, Medical Home Collaborative, serves on the Society of Teachers of Family Medicine (STFM) program committee and on the Council of Academic Family Medicine Competency Measurement Task Force. He is the past chair of the Collaborative Family Health Care Association and of the STFM Group on Physician Patient Interaction. Mr. Mauksch has provided faculty development on communication training to medical schools and residency programs across the United States. He has developed patient centered communication training programs catered to the needs of specific organization using inside champions as role models and collaborators.


 

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