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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

5 Questions logo

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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5 Questions with Jennifer Hodgson

Posted By Dan Marlowe, Tuesday, June 5, 2012

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Dan Marlowe: The following is an interview I conducted with Jennifer Hodgson, PhD, LMFT. Dr. Hodgson is a Professor in the Departments of Child Development and Family Relations and Family Medicine at East Carolina University in Greenville, NC. She was instrumental in developing and starting the first Medical Family Therapy doctoral program in the nation, and continues to be an incredibly passionate supporter of not only MedFT but of collaborative and integrated care in general. On a more personal note, Jennifer has been instrumental in my own professional development from a directionless undergrad with lots of energy, to a master’s student trying to focus that energy to feel competent sitting in the therapy room, and eventually the exam room, to a stubborn doctoral student trying to hone that energy in the right ways to express his views. She was, and continues to be a mentor to me and many of my colleagues. So, without further ado and emotional hemorrhaging, here is my interview with her.
 

 1: What experiences in your personal/professional life do you feel were most instrumental in your development as a medial family therapist?

JH: A lot of it had to do with experiences around illness in my own family, and my feeling that we (the healthcare system/providers) could be doing a better job at promoting overall health. I think medical family therapy was my way of hoping to address that later on down the road. In the end I saw, in a very personal way, the effect that providers not-talking, not ‘collaborating’ had on how care was delivered, as well as how patients and their families suffered because of that silence.

In terms of my education, even before I started seeing patients, while I was still in training, issues would come up in terms of vignettes or case examples and it seemed like there was more to the story than just the psychosocial. It seemed, at least to me that by compartmentalizing the issues we, as students and eventually clinicians, were missing the larger context and the medical piece was part of that. I/we needed to understand medical language, medical culture, and most importantly for me, I needed to get over my own ‘hero worship’ of physicians and the running thoughts that- "You don’t bother the doctor and…defer…defer…defer.”

When I did my fellowship at The University of Rochester, I realized everything I had been taught in graduate school to this point had to be amended. I stepped into an environment that seemed to be moving at a million miles an hour around me, and I was seemingly standing still. It was an adjustment working in a primary care setting. I describe it like when you first learn to drive and master the city roads. Then, you get on the fast paced highway and learn quickly that just because you have to drive faster doesn’t mean you drive worse. You do need to adjust your reaction times, pay attention to other fast moving things around you, drive smarter and more efficiently, but sooner or later you feel comfortable and ease into cruise control mode. Walking into the world of MedFT gave me the authority to have conversations that would have been previously considered outside of my scope of practice had I just operated off the skillset taught thus far. Getting specialized training in integrated primary care was critical and essential and I am grateful for my time in Rochester with Susan McDaniel, Barbara Gawinski, Dave Seaburn. Nancy Ruddy, Pieter Leroux, Tom Campbell, and many others because of it.

 

2: What do you feel is your greatest contribution to the field?

JH: I really feel like the Medical Family Therapy doctoral program has been my greatest contribution, thus far. I, and the rest of the faculty at East Carolina University, felt like we needed to fill a gap, and that the best way to go about that was to develop a place where we could train the trainers and develop the researchers. Our goal is to develop professionals who can execute responsible and high-quality research, not just about MedFT, but about how relationships impact health and healthcare delivery. My colleagues and I want our students to be leaders in healthcare, biopsychosocial researchers, and go on to create even better MedFT training programs. That’s what you always want from and for your students, you want them to go out and do it better than you did. Of course none of this would have been possible without the vision of my colleague Mel Markowski (retired), co-authoring of the program with Angela Lamson, and support of many administrators and my talented co-faculty members David Dosser, Damon Rappleyea, Mark White, and Wayne Hill (retired).

 

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

JH: We definitely need a louder voice at the advocacy/policy making level, which is hard since we are such a small group at this point. There are all of these panels and committees on healthcare matters springing up nationally, and a lot of organizations are making concerted efforts to place their members on them. It just seems like this is a point in time in healthcare where things are moving so fast, if we do not move at the same pace, we are going to get left behind and consequentially so will all that we stand for and represent: the patient in a family, the systems surrounding them, and the relational aspects of integration. We need to start thinking strategically about how to expose ourselves to the agencies and people making the decisions, as well as the population in general. We need to get more data regarding our work as MedFTs, which we have some of, but that is only half of it and maybe the easier part. The harder part is getting that data to the right people, and that is where I think we have had a rough time so far.

 

4: What do you think we lack, in terms of training that puts us behind some other fields?

JH: Well, if we are talking strictly about family therapy as a field, and not Medical Family Therapy as an orientation, then, and I know people are going to hate to hear this, we need to require our students to learn how to work in medical settings and adopt more evidence based brief therapy approaches. A lot of healthcare institutions and insurance companies want clinicians to demonstrate use in these types of modalities, and if our students have little to no formal training in them we are at a huge disadvantage. I’m not saying that we abandon traditional family therapy modalities; I am saying that students need exposure to brief models of therapy and augmented models of therapy that have a systemic/relational bent. However, we are talking about an endpoint here, and where we need to start is re-training our faculty to prepare students to work in healthcare settings. We need a national initiative for workforce development like other professional organizations and that takes money.

 

5: Ideally, where to do see MedFT in the next 10 years?

JH: I agree with many of our colleagues that medical family therapy should not just be about family therapy as a profession. I do, however, feel that family therapists make good trainers regarding MedFT because they’re inculcated with systems and relational thinking from the time they begin their own training. MedFT should be about training/teaching people (regardless of profession) how to think and work systemically not only from a direct care standpoint, but how to think and work in teams from a healthcare system standpoint. I don’t think the name Medical Family Therapy is the problem like some have said: I think it continues to be portrayed as a problem because of the inherent silo’ed thinking of our professions. Medical family therapy is and should be much larger than those who are licensed marriage and family therapists and work in medical settings. I don’t care if you are a psychologist, social worker, nurse, physician, or family therapist, I think in order to call yourself a medical family therapist you need specific training in how to work with couples, families, and larger systems. We get stuck in our dialogue about MedFT when we think about and rely too heavily on the words "family therapy.” What we need is to focus our efforts on the continuum of training that is available for those interested in expanding the system for research and clinical purposes. MedFT may require more or less training in family therapy depending on how one wants to apply it but we all should be mindful that patients leave our offices and go out into the community and to their homes where their interactions in those places are the real determinants of health.

 

Jennifer Hodgson

Jennifer Hodgson, Ph.D., LMFT is a clinical member of AAMFT, an AAMFT Approved Supervisor, Chair of the Commission on Accreditation for Marriage and Family Therapy Education, Chair of the NC Marriage and Family Licensure Boardand long time member of the Collaborative Family Healthcare Association and Society of Teachers of Family Medicine. She is Immediate Past President of the Collaborative Family Healthcare Association.

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Positive Deviance

Posted By Deepu George, Tuesday, May 29, 2012

Members of the audience stood up in unison to applaud the plenary session given by Dr. Arvind Singhal, a distinguished professor of communication at the University of Texas, El Paso, Texas. He was speaking to all of us at the American Family Therapy Academy (AFTA) annual conference in 2012. With compelling stories to each of his points and almost theatrically perfect oratory skills, Dr. Singhal provoked family therapists to think deeply about social complexity and how contexts often generate positive deviance and generative relationships.

Positive deviance is an approach that enables communities to harness, spread, and leverage existing wisdom to amplify apt solutions. In other words, Positive deviance exemplifies deviant behavior that leads to better, sustainable results to a particular problem. The so-called innovator of this solution manages to create this solution at no extra cost or access to additional resources. Additionally, these solutions are culturally relevant and easily transferrable from one person to the other. Positive Deviance therefore is often behaviors that are not expected from individuals but the performance of such behaviors has a positive influence on the whole system. Singhal and colleagues have been applying positive deviance to a number of health care scenarios, nutrition related issues, and other issues that are embedded in the social narrative.

Positive deviance then occurs within contexts of social complexity. Social complexity consists of roles, privileges, authorities, hierarchies, inequalities, and the various oppressive discourses of our times. It is in this context that a few individuals are able to become deviant in a positive way that dramatically influences certain outcomes. Dr. Singhal recounted two experiences that offer examples of positive deviance that are useful to family therapists in medical settings.
Deepu George
The information contained in simple deviant acts is the "difference that makes a difference".

Incident one was about a pediatric anesthesiologist who treated his son, who due to complications had to remain in the NICU for about the first 2 years of his life. With repeated intrusions by needles and instruments to the baby’s body, he would often tense up and cry when something sharp, cold, or metallic would touch his body. However, things were different when Dr. Virginia Mohl, the pediatric anesthesiologist came in the room before the boy went in for surgery. She would immediately pick up the child, soothe the baby by speaking to the baby, gently caress him while humming and speaking to him. While she engaged the child and as he responded to her warm touch and care, the necessary injections and procedures would be done without the baby bursting into tears and a loud cry. As she would take baby into the operation theater, she would often turn around and tell the parents "Your boy is going to be just fine. I have done this a 1000 times.” Singhal recounted that as parents, they never felt more confident than when Dr. Mohl was in charge.

The second story is about an unassuming doctor in charge of rounds with medical residents. Walt Fairfax, the division chief for hospital medicine would never wear a tie and always was in short sleeves. Dr. Singhal narrated about whenever he came through for rounds with his residents; all of them would have a funny looking folded equipment with them that looked like an umbrella. As soon as they came near Dr. Singhal’s son, they would all open up this umbrella which turned into simple chairs they would sit on. As all of them sat around the baby, they would invite the parents over to their circle for conversation. Their first question was always "Mr. and Mrs. Singhal, how do you think your son is doing?” and then would start a conversation. The parents felt included, respected, and felt confident about the treatment process. All other practitioners who took care of their son all had similar trainings and excellent qualifications. They read the same charts, used the same equipment but did not make a difference to family. Both Dr. Mohl and Dr. Fairfax did make a difference. This apparent aberrant behavior, a behavior that is deviant but made a positive difference is Positive Deviance.

Despite the existing norms of how others in the hospital worked and dealt with patients, both of these doctors were able to bring a different sense of hope and healing to the entire family. It also transformed the particular views of individuals who worked with these two individuals in that hospital. Their relational approach generated a new dynamic between the family and the medical team that was deviant, yet positive. In being deviant from the norm, their behavior improved quality of care with no additional resources or expenses to the overall system.

The positive deviant approach is not much different from what Collaborative Family Healthcare Association is trying to achieve in its overall mission. With the goal to provide "comprehensive and cost-effective model of health care delivery” in working with multi-disciplinary teams, our overall philosophy itself is a deviant from the norm. As the field grows more organized and as rigorous training sets us apart, the question remains how good are we and will we be at detecting positive deviant behavior in our own collaborative teams and environment?

The behavior of positive deviance emanates from everyone, not just experts or people who have been trained. Dr. Singhal speaks of Jasper Palmer, an attending at the Albert Einstein Institute of Medicine whose method or de-robing prevents and contains infections in the hospital setting. With Jasper’s groovy moves, he de-robes himself by squishing his head cap, to gown to gloves and rolls them up in a bundle and gently places it in the dispenser. This method now known as the "Palmer method” reduces contaminations and MRSA, a health care associated infection in hospitals which costs more than $10 billion a year.

Positive deviance is not only an exception in terms of the act of behavior but also has deep and profound connections to the cultural and structural aspects of a system. Building contexts where relationships are generative and collaborative increases the likelihood of positive deviance. In a hospital setting where a MedFT or a nurse feels comfortable enough to tell the chief attending physician that he forgot to wash his hands from a previous appointment is a nurturing context for such deviant behaviors. Settings in which hierarchies and job titles define treatment approach rather than a collaborative setting, positive deviance is not likely to occur.

Gregory Bateson, dedicated learner of the inter-connected nature of human life and the broader ecology spoke of information as "the difference which makes a difference.” The information contained in simple deviant acts is the "difference that makes the difference” for many around them. As medical family therapists and other professionals in the Collaborative Family Healthcare Association continue to make decisive differences to lives of many, let us remember to blaze a deviant (positive) trail in our practice settings that helps us to achieve our mission of delivering comprehensive, cost-effective healthcare to all families and patients we will learn from.

 

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 Masters Degree in Holistic Psychological Counseling from Bangalore, India, his aim is to continue his passion for applying systems lens in health care, family therapy, community capacity work.

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Taking off the white coat: Putting the soul first and the IV second

Posted By Elizabeth Bailey, Tuesday, May 22, 2012

Editor's Note: For this week's Growing MedFT post, we have invited Elizabeth Bailey to share personal reactions to the commencement address Donald Berwick gave at the 2010 commencement ceremony for the Yale School of Medicine.  The text from Berwick's address is available here.

 

Donald Berwick is a champion of putting the patient first, in all of his or her fragile, complex humanity, as the only way to improve, indeed save, our failing, fractured healthcare system. As he has said so often, it is only by asking "what will it do for the patient” that we can begin to move towards the care we need rather then the care we currently have.

The title of Berwick’s commencement address "Stepping into Power, Shedding Your White Coat” which he gave to his daughter’s graduating medical school class encapsulates the conflicting forces confronting young doctors as they begin their professional lives. They step into a culture of power and privilege by putting on that white coat of medical authority. The white coat, both in reality and symbolically, distinguishes them from their patients but must not, with its associated rules, language and culture, separate them from their shared humanity. He asks these eager, young graduates to consider that in every human encounter they are always faced with a choice – the choice to put the IV or the soul first in treatment. It is only by metaphorically taking off the white coat that they can truly heal their suffering patients.

Several years ago my Dad went crazy from what turned out to be a cascading series of medication errors and miscommunications. He was hospitalized for almost a month with full-blown steroid induced psychosis. The steroid medication wreaked havoc with not only his mind but also his body by drastically elevating his blood sugar levels. Dad’s previously mild diabetes was now a medical crisis. The first few weeks were focused on bringing his diabetes under control. After being was deemed "medically stable” he was transferred to the psychiatric unit, his psyche proving harder to heal.
Elizabeth Bailey
I wonder if that young resident had taken off her white coat, if only for a moment, she might have seen a frightened, ailing person not a difficult, non-compliant patient.

    -Elizabeth Bailey
An extremely young resident conducted his intake. We told the young doctor about our Dad before his illness because we wanted her to see him as the person he really was in life – an erudite, active, 81 year old former lawyer, not the broken, crazy stranger sitting in a wheelchair in front of her. Too often in the main hospital, Dad’s care seemed impersonal and distracted, his humanity forgotten. We wanted her to know him…at least a little. And we were frightened by his state of mind and unfamiliar with psychiatric units.

We told the young resident that the steroids had seemed to unleash flashbacks of his experience as a young soldier in the Pacific during WWII. As if on cue, he launched into a horrific tale of being trapped by sniper fire on Guam. It was obvious how much Dad was suffering – suffering from the steroids still in his system, suffering from painful memories, suffering because he was a human being who was ill. The young resident listened to him with a blank, stony face.

The next day, we went to visit Dad but he was not in his room. The resident appeared and ushered us into a little side office. She said there had been an "incident” with Dad in the morning, but that he was resting now in the "quiet room” – shackled to a metal gurney, shot full of enough antipsychotic medication to subdue a horse. We would not be allowed to see him then – it was against the rules.

Apparently, Dad had gotten up that morning and decided that he had had enough with hospitals in general; with doctors who looked past him; with too many medications he did not understand. He wanted to leave and go home and read the newspaper. The resident ordered him back to his room. When he refused, security was called.

When Dad saw the guards, he reminded them that he was a Marine and they would never take him alive. They wrestled my eighty-one year old father to the floor. A burly guard sat on his chest while the others put him in restraints. They then carried him to the "quiet room”. She never called us to alert us: that was against hospital rules. We asked her when we would ever have found out if we had not come to visit. She had no answer for us.

When we returned that night, Dad, still heavily drugged, was in his bed in his room, mumbling, "How could they treat me so badly?” The nurses later apologized to Dad about what had happened. The young resident never said anything.

I wonder if that young resident had taken off her white coat, if only for a moment, as Donald Berwick instructed the graduates to whom he spoke, she might have seen a frightened, ailing person not a difficult, non-compliant patient. Might she have found out how much my Dad loves to read, about his favorite hotel in Paris, about how much he misses his wife who died too soon or that he makes a martini that knocks ones’ socks off? By taking off her white coat, might she have seen, as Berwick says, "the dignity in each and every soul ” and in so doing, joined with instead of towering over her patient and become a healer in a world filled with suffering?

 

About Elizabeth Bailey:  As a producer, director, and vice president of video production for several record labels, Elizabeth Bailey used checklists to oversee hundreds of music videos. While helping family and friends navigate their hospitalizations, she realized how production checklists could be adapted to help patients better manage the complexities of hospital care. She embarked on a career change, working on her book "The Patient's Checklist" for several years and enrolling at Sarah Lawrence College where she is currently completing studies for a Master's in Health Advocacy. She is also working part-time as a Patient Representative at a major teaching hospital in New York City.

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Are We Short-Changing our Patients and Families?

Posted By Dan Marlowe, Tuesday, May 8, 2012

It seems that no matter where we turn, the rising costs of healthcare continue to be an issue for not only governmental agencies and the healthcare profession in general, but is often overlooked (or given a cursory glance at best) in regards to the toll this major stressor takes on individual patients and their families. All of us can recall learning at some point the ‘golden trifecta’ of issues that bring people (couples and families especially) into therapy; money, sex, and parenting. More than once I have worked with a patient/couple/family whose main source of distress stemmed not only from the disease and the associated physical and subsequent role changes, but also the terrifying prospect of losing any hope of a financially secure future.

If MedFT’s emphasis as a field (if it can be called/viewed as that) is about more complete care through systemic conceptualization and collaboration, have we been neglecting discussion about and collaboration with professionals whose expertise is in the area finance. If so, how might we better incorporate these conversations as a fundamental part of our clinical, academic, and research work?

This link is to a NY Times story detailing the financial related distress many families face when coping with illness, as well as the ramifications after the treatments and physician visits have ended.

The marriage and family therapy training program at the University of Georgia has a unique clinic where MFTs work alongside accounting and business graduate students to help couples/families negotiate the financial stresses that often exacerbate and accompany the issues that initially bring them into their clinic- please, any UGA folks reading this feel free to correct me. Perhaps as we, as collaborative professionals (regardless of profession), seek to develop training models around integration and collaboration, we should turn a more watchful eye to explicitly including financial concerns in the laundry list issues our patients and their families need assistance in discussing.


 

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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