Print Page | Your Cart | Sign In
Families and Health
Blog Home All Blogs

 

Search all posts for:   

 

Top tags: cancer  caregiving  chronic illness  collaborative care  integrated care  medical family therapy  collaboration  communication  dementia  nutrition  Parkinson's Disease  provider patient relationship  research outcomes  resident wellness  self-care 

Hello World! Are there opportunities out there for us, MedFTs?

Posted By Tania Riosvelasco, Tuesday, February 28, 2012
Before our very eyes, the world of Medical Family Therapy is growing, extending its reach to the far corners of the country, patiently and steadily solidifying its foundation as a cornerstone of what an exceptional & enriching healthcare service should be. The more I learn about MedFT, the more I feel compelled to get involved in it. While there are a lot of opportunities to do that within the US (it is after all, the birth place of Medical Family Therapy), they are lacking abroad. As a self-described ‘international MFT’, seeking to practice outside the United States, I’m left wondering, "What opportunities exist abroad for those of us who want to work in the field of medical family therapy?”

My personal experience with Medical Family Therapy, although relatively short, has been very enriching and is deeply rooted in my own life. Coming from a medical family I had a lot of insight into the medical world and developed an interest in the medical profession early on (I tried medical school in Mexico, but decided that I was better off without a scalpel in my hand!). I followed the mental health route and had no doubts when choosing an MFT program with an emphasis in Medical Family Therapy. And when it was time to choose a practicum site, I immediately focused my efforts on getting into the only collaborative care program, offered at UCSD Family Medicine.

Through my practicum year and my time afterwards as an intern, I gained invaluable knowledge of the medical world & how it intersects with the world of family therapy. How a family medicine clinic operates, the busy and unpredictable schedule of physicians, the myriad of health problems that patients present with, the prevalence of mental illness, and how family & social dynamics can positively or negatively impact patients’ health and motivation to adhere to their treatment regimen.
Tania Riosvelasco

"Individually we are one drop.

Together, we are an ocean.”

~Ryunosuke Sator

Throughout all of this, the most valuable lesson I learned was the importance of being able to collaborate and work as a team with other healthcare providers to seek and ensure the best quality of service for a patient.

The seed of Medical Family Therapy has planted deep roots in me and recently relocating to Germany, I seek to find opportunities to practice and continue my growth within the field of medical family therapy.

I also learned, while presenting at the IFTA 2011 conference in Amsterdam, about several programs in Europe where mental health clinicians are seeking to incorporate psychotherapy services, specifically family therapy, into hospitals (Norway). And about two specific projects: one where family therapy is being incorporated into a clinic specializing in obsessive compulsive disorders (The Netherlands), and another in a clinic where mental health treatment alongside family therapy is required by law (Germany).

Talking to the presenters, I got a general sense of the challenges of trying to incorporate collaborative & integrative care in Europe, as the field of family therapy is still struggling to make a stance, and the field of medical family therapy is small. In Germany for example, insurance will not cover family therapy services, so for psychotherapists trained under MFT models it is a challenge to pursue a career only providing psychotherapy services within a family therapy perspective and building a self-paying client base.

So it can be a little scary, to go out of the comfort zone that I feel the US provides, where medical family therapy is seemingly everywhere! Just take a look around the CFHA (and Google) and you’ll find a network of colleagues, research, information & links invested in furthering this field. But if we step outside these boundaries, what is there abroad?

Recently, the CFHA started an international sub-committee headed by AJ Jayabarathan (Canada) with colleagues from Spain, Hong Kong & Germany, which will seek to expand the reach of medical family therapy on a global scale. I hope this helps create opportunities for international family therapists & other mental health providers that want to continue working in this field. Although I don’t mean to imply that the field of MedFT is non-existent outside the US, it does seem to be lagging, and I think there should be more involvement and interest in creating and strengthening a global network to ensure that the advances made within the US are shared and implemented on an international level as well.

For colleagues out there, how have you done it? Are there opportunities for MedFTs on the global field? Or did you have to create them? Let’s share & grow!


A few links:

International Society of Behavioral Medicine (http://www.isbm.info/)

European Family Therapy Association (http://www.europeanfamilytherapy.eu/)

International Family Therapy Association (http://www.ifta-congress.org/)

The German Association for Systemic Therapy, Counseling, & Family Therapy (http://dgsf.org/)

Asociación Mexicana de Terapia Familiar (http://www.amtf.com.mx/)

Instituto de la Familia A.C. (http://www.ifac.edu.mx/)


Tania Riosvelasco, from Mexico, received her Master’s in MFT from the University of San Diego and worked as an intern at the Family Medicine Division of the University of California at San Diego. She has recently relocated to Germany and seeks to continue working in the field of MedFT. She also works as a translator (English-Spanish) specializing in psychotherapy & mental health translations.

This post has not been tagged.

Share |
PermalinkComments (1)
 

Adult Eating Disorders, Primary Care, and the MedFT

Posted By Lisa Zak-Hunter, Tuesday, February 21, 2012
Hmmmm…

During my faculty/resident lunch lecture on diagnosing and treating eating disorders (EDs) in primary care, I was asked the following question "I was wondering how well an appetite stimulant would work with someone who is restricting?” Heads around the room nod and there are a few approving looks toward the inquiring physician.

I affirm the suggestion: "Well, that seems to make sense. When I’m hungry, I look for something to eat. So, if someone’s appetite was stimulated, wouldn’t that increase eating behaviors? Not necessarily with someone who has an ED. EDs aren’t generally about food. They involve complicated feelings about control, self-worth, body image, stress, anxiety, attachment concerns, and many others. Food restriction, purging, and binging all become vehicles of self expression. People who restrict are familiar with hunger pains. However, the hunger has come to represent different things. For some, it is a sign of success, for others it is an annoying side effect they have gotten used to or put up with, and to others it may indicate they are losing control. Increasing appetite would likely only serve to increase these feelings and could actually spiral someone further into the ED.”

I’m met with looks of surprise, confusion, and understanding. At this point there are 15 minutes left, and I’m beginning to wish I’d signed up to do the whole week’s worth of lunch seminars. I’m struck by how little education there is on EDs in primary care and the importance of increasing physician awareness.

Eating Disorders in Adulthood

The Canadian and United States’ Eating Disorder Awareness weeks both occur in February, making this an appropriate time to address adult EDs and the role of medical family therapists in helping to raise awareness within the healthcare community. Eating disorders include anorexia nervosa, bulimia nervosa, and binge eating disorder (currently being considered as a separate diagnosis for the DSM-V).

Although EDs are often considered adolescent concerns, within the past decade there has been a significant increase in the number of early to middle aged women presenting for treatment.* Many of them are coupled and/or have children. Some have developed their first ED as adults, and others have struggled for years and never sought help or have relapsed.

Eating Diorders aren’t generally about food. They involve complicated feelings about control, self-worth, body image, stress, anxiety, attachment concerns, and many others. Food restriction, purging, and binging all become vehicles of self expression.
The reasons for developing or exacerbating ED behaviors in midlife are varied: job stress/loss, increased social pressure to maintain youthful body image ideals, pregnancy and a desire to regain pre-partum figure, couple conflict, menopause, sexual intimacy issues, distancing from or loss of parents, conflict with children, etc.  Symptoms in adults can be more severe than in adolescents, increasing the need for immediate action. Without treatment, approximately 10% of women with anorexia will die within 10 years, making it one of the most lethal psychological disorders. The systemic impact of adult EDs uniquely affects partners, children, parents, employers, and healthcare systems- all of which are underprepared and undereducated to appropriately respond.

Eating Disorders and Primary Care

As with most psychosocial concerns, ED or body image concerns are often first presented to a primary care provider. Many do not have sufficient knowledge or resources to ask the right questions, run the right labs, or make the right referrals. During my lecture, the well-intentioned physicians were also surprised to learn that EDs can develop at any age and that there has been an increase in adult diagnoses. With the increased focus on obesity, primary care providers often do not suspect or understand pathogenic weight control-especially in adults. Lack of understanding EDs in general complicates obtaining appropriate and immediate care for suffering adults. Based on the statistics I mentioned above, if a woman has already suffered for 10+ years without treatment prior to presenting to her primary care provider, time is of the essence. Enter the MedFT.

Working With and Educating The Physician

Many MedFTs are integrated to some degree within a larger healthcare practice such as a residency training program, medical center, or hospital. They are in a prime position to educate others, treat adult EDs from a systemic perspective, and offer collaborative care. The MedFT can improve patient care by facilitating communication between patient and provider, inform the provider if a patient has an ED and discuss how to address this in treatment, suggest what types of labs to run to monitor physical well-being, offer to run a lecture/discussion or grand rounds about diagnosing EDs in primary care, warning signs, and the importance of/how to discuss positive body image with patients- even adults.

They can encourage providers (and themselves) to inquire about current and past body image and dieting practices in their patients of all ages and discuss eating behaviors as a reaction to or coping mechanism for the presenting problem (if it is not an ED). A former colleague of mine (physician) contacted me after discussing weight management strategies with a new obese patient in her mid 40s. He wanted my opinion and further suggestions for how to handle the case. He had first explored the patient’s past dieting behaviors and exercise. He was surprised to learn the patient had a history of anorexia and became concerned about how to help the patient lose weight without triggering an ED. He decided the patient would need to attend counseling while on weight loss medication in case any ED behaviors resurfaced. The patient was unhappy with his decision, but I agreed with the physician. Proceeding in this manner could prevent a relapse and provided more responsive care.

Providing Treatment

Because of the systemic focus of their training, MedFTs can bring that perspective to consults with the provider and therapy sessions. Often, patients with EDs will deny or minimize the severity of the ED. Circular questioning is an excellent way to gather more relational information and assess severity (e.g., how would your partner say your eating practices affect your couple relationship? What would your children say you’ve taught them about food and body image?).

Lastly, the MedFT can increase collaborative care. The most effective ED treatment attends to the biopsychosocial-spiritual nature of the individual by combining individual, group, and family therapies, psychiatric care, nutrition counseling, weight and health management, and expressive therapies such as art, equine, or yoga therapy. MedFTs are well-trained in this theoretical perspective, so they can help coordinate communication among care providers and provide couple or family work (both of which are less commonly addressed in adult ED treatment). Not every family therapist may feel prepared to work with an ED and the patient may need more intense care such as a day program or in-patient therapy. Knowing local resources- especially those that are able to treat adult EDs- is key.

These ideas are meant to inspire, not serve as an exhaustive list of ways to increase consciousness or attend to adult EDs as a MedFT. Some are appropriate for working with adolescents as well. Overall, if you’ve walked away from this with a newfound awareness of adult EDs and a few ideas of how to address them with care providers in your practice, I’ve done my job.


ED resources for mental health professionals, physicians:

http://www.nationaleatingdisorders.org/information-resources/general-information.php

ED resources for patients, families/friends, others:

http://www.nationaleatingdisorders.org/information-resources/index.php

ED treatment referral sites:

http://www.something-fishy.org/treatmentfinder/

http://www.edreferral.com/

*Eating disorders are thought to affect approximately 1 million men and 10 million women in the US alone. Because of this disparity, there is less research on male eating disorders, especially in adulthood. Please note that my blog focuses on findings for adult women, simply due to lack of research on adult men.


Lisa Zak-Hunter, MS is a doctoral candidate specializing in family therapy at the University of Georgia. She is currently completing a behavioral medicine internship with the Department of Family Medicine and Community Health at the University of Minnesota. Her main clinical, teaching, and research interests lie in the realms of collaborative health care and increasing biopsychosocial understanding of mental and medical health conditions. She has a particular interest in adult eating disorders.

This post has not been tagged.

Share |
PermalinkComments (0)
 

Conversing about Conversation: What is MedFT?

Posted By Dan Marlowe, Tuesday, February 14, 2012
Since this is my first foray into the blog-o-sphere, I would like to start off by issuing a big THANK YOU (see, it’s big!) to Barry Jacobs, Jennifer Hodgson, and Randall Reitz for allowing me to help with and contribute to the Growing MedFT blog. Secondly, I want to give an even bigger THANK YOU to all of you who have posted, are willing to post, are contemplating about posting, and/or contemplating about contemplating about posting- your thoughts and ideas are incredibly important, appreciated, and essential to growing this "thing” that we are all passionate about. With that said, let’s dive right in….What is MedFT?

Now, before the hairs on the back of your neck stand-up and you ready yourself for an intellectual boxing match with the rest of my post, know that this has nothing do to with actually defining anything. It is my attempt to highlight the importance of our commitment to the on-going conversation about MedFT in general, how we have had that conversation so far, and why now more than ever, it is important for us to keep that conversation going.

What is MedFT? I remember being asked that daily in my doctoral program. In fact, my ability to accurately describe what it was that I was doing and my professional place in the world was a rather large part of my education- "doctoral” and "indoctrination” rhyme for a reason. Is it an approach, is it a sub-specialty, is it an orientation, is it an entirely new field, is it the answer to who actually shot JR (yes, I am old enough to remember Dallas)?
Dan Marlowe
What is MedFT?
In the end the most important part of that question (for me anyway) has little to do with the answer itself, but the conversations we have along the way in search of that answer.

These were questions that I struggled with and argued about for the better part of three years- even writing my competency manuscript on the subject. However, only after graduation did I realize that I had completely missed the most important part of those conversations/arguments.

What is MedFT? We have a lot of great descriptions of MedFT as a construct: we have the seminal work of Susan McDaniel, Jeri Hepworth, and Bill Doherty (1992), the work of John Rolland (1994), Linville, Hertlein, and Prouty-Lyness’s (2007) attempt to synthesize a description from the literature at that time, and even a Delphi study whose purpose was to provide a systematic description of MedFT through interviewing experts in the area (Tyndall et al., 2010). Let’s not leave out the other angles we have used to describe MedFT as well: we write about cases where we see it in play, we present models of care that purport to utilize it, we point to effectiveness research (not enough of it as Tai Mendenhall points out in an earlier blog post- check it out!), we even have specific training programs dedicated to MedFT and yet the conversation about exactly ‘what’ it is persists. I know I have left out a lot of examples here, but my point being that we have been trying to define MedFT for the better part of 20 years! So, should we just give up? Is the lack of consensus a tell-tale sign that our search for the ‘truth’ about MedFT, is ultimately as fruitless as counting how many licks it takes to get to the tootsie roll center of a tootsie pop?

What is MedFT? In the end the most important part of that question (for me anyway) has little to do with the answer itself, but the conversations we have along the way in search of that answer. The fact remains that what MedFT is or is not will be shaped by a number of forces beyond research, academics, and training (e.g., state/nation health policy, insurance companies, popular opinion, state laws), and even then what it becomes will always be up for negotiation- just look at how our own professional homes are in a constant state of flux. We attempt to define the nature of things (especially professions) by any all means necessary, we make laws, we research, we debate, we theorize, we practice; however, all of these things are impermanent, they are always changing, moving and evolving with those involved in their pursuit. In the end, what matters most is not that we ‘find’ the answer in that classical EUREKA!! moment, but that we are always ready and open to keep the conversation going about what that answer might look like if we ever came upon it.

In that vein of thought then: research, practice, develop models, post a blog (wink wink), or even have an old fashioned debate. All of these things embody the conversation about what MedFT is, what it is not, and what it can be. In the end, ladies and gentlemen, MedFT lives or dies on our words, thoughts, and actions in our pursuit of its practice and development. If MedFT is something we consider to be a passion, then the responsibility falls to all of us to keep that conversation going- if not us, then whom?

Now, remember at the beginning when I said I was not going to offer a definition of MedFT- I lied. Here is my stab, albeit a short one, at my understanding of what I do:

Before I start, I ask you to remember that the answer to a question is always bound by the way in which the question is asked. So, medical family therapy, for me, is the extension of an existing epistemology (there’s a 60 point Words With Friends word for you), or a way of thinking, into a specific venue or context (Marlowe, 2011). Now, the systemic/relational thinking indicative of MedFT is not isolated to a particular person or group of people, but it is, I argue, found as a rallying point in particular fields- and one of those fields would be family therapy (I know, I know- on the boxing gloves go). Now, I will be the first to tell you that not all family therapists think relationally, and that there are plenty of psychologists/social workers/physicians/nurses who are incredibly relational in their thinking and practice. However, I am not talking about individuals here (this is where I think we get stuck in these conversations); I am talking about fields of study and practice. As a field, family therapy was built on relational/systemic theory originating from biological, mathematical, and anthropological foundations. Even if we look back at Engel’s original 1977 article (admittedly not about family therapy), he quotes Margaret Meade, and utilizes the ideas of recursion, punctuation, context, frame of reference, and double description as foundations for his argument. It is important for me to point out that while I feel MedFT (as a profession) is indeed a sub-specialty of family therapy, it is not the same as its practice, or the patterns of thinking that define/inform that practice.

When we talk about medical family therapy, depending on the context, we are talking about it in three interlocking ways: as thinking, as practice, and as profession. Our practice of something does not mean that we belong to the profession that defines that practice- pulling a tooth does not make me a dentist. However, our allegiance to a profession, and subsequent practice of the techniques associated with it does not mean we align with its underlying way of thinking either- how many times have you said, "Wow, you don’t think/act like a physician.” My point being, that while practitioners might utilize the relational thinking and techniques associated with MedFT, as a profession, it finds its roots in the foundational epistemology of family therapy and the biopsychosocial model- a model that too attributes much of its roots to systems/cybernetic theory.


So, those are my thoughts. Now it’s your turn…..what is MedFT?


The search for the truth is more precious than its possession.

Albert Einstein


References:

Engel, G. L. (1977). The need for a new medical model: A challenge for biomedicine. Science, 196(4286), 129-136.

Linville, D., Hertlein, K. M., & Lyness, A. M. P. (2007). Medical family therapy: Reflecting on the necessity of collaborative healthcare research. Families, Systems, & Health, 25(1), 85-97.

Marlowe, D. (2011), Bridging Conversations: Discussing the Intra-professional Relationship between Medical Family Therapy and Family Therapy. Journal of Family Therapy. doi:10.1111/j.1467-6427.2011.00553.x

McDaniel, S. H., Hepworth, J., & Doherty, W. J. (1992). Medical family therapy: A biopsychosocial approach to families with health problems. New York, NY: Basic Books.

Rolland, J. S. (1994). Families, illness, and disability: An integrative treatment model. New York, NY: Basic Books.

Tyndall, L., Hodgson, J., Lamson, A., Knight, S., & White, M. (2010). The state of medical family therapy: A modified Delphi analysis. Unpublished doctoral dissertation, East Carolina University, Greenville.


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.


This post has not been tagged.

Share |
PermalinkComments (0)
 

Providing a Witness to the Experience of Our Colleagues

Posted By Lindsey Lawson, Wednesday, February 8, 2012

It has been so exciting to see the Growing MedFT blog take root over the last several months (Unbearably cheesy? Just go with it.)! Especially of interest to me are the stories of personal connection to Medical Family Therapy that the last several writers have shared... isn’t that what attracts many of us to this work in the first place? Understanding what people have been through and how this connects with who they are today? In her post on staying compassionate and open in a field where our tendency is to want to protect ourselves, Jackie questions whether or not we give enough attention to "recounting... health history and its impact on ourselves and our loved ones.” These illness narratives, as they are called, really matter.

I first began thinking about these issues before I went into the field of therapy, when I was working as a nurse at a small hospital in Oregon. During this time, my mom and brother were hit by a drunk driver in a collision that caused my mom to be permanently crippled in one foot. Our family reorganized completely, with me taking several weeks off of work to be with my mom while she underwent multiple reconstructive surgeries. What a strange feeling that was, to be on the other side of the healthcare system. We, the family, were essentially unnoticed by the medical teams and although our friends offered support (especially during those first few weeks), I remember feeling very much alone.

This is what illness does: It causes us to retreat inside of ourselves, believing that only we can tolerate the ugliness of our diseases and the darkness of our hopelessness. In her article "Witnessing, Wonder, and Hope” Kathy Weingarten (2000) writes of her life post-chemotherapy, "My life was bleak and lonely because I lived in silence, certain that no one could bear to hear the feelings and thoughts I had following my year of treatment; unwilling to find out if I was right; certain that I needed to protect people from my experience; and failing in those few times I tried to put into words the chaos of my emotions and the terror that lived in my flesh.” Lindsey Lawson
"Our ability to be witnesses to these experiences, to sit with physicians and nurses in their moments of pain, and to acknowledge what they have lost generates hope: the greatest gift that we can give."

Somehow we’ve come to see healthcare providers as being immune to these experiences. They are seen as the unaffected givers of care; not out of choice, but out of necessity. In our medical simulation lab at Loma Linda University, we have piloted a reflecting team approach to providing feedback to residents who work at creating compassionate ways of giving bad news to patients’ families. It has not been unusual to see the doctors and nurses fight back tears. Memories of their own losses surface and they reflect back on these as they review their reactions to the actors whose "family member” is dying. They report that no one has ever really taken notice or appreciated the care with which they try to face the implications of this all to frequent occurrence.

What is our job as Medical Family Therapists in all of this? To begin, we must start to address the intersection of healthcare professionals’ own experiences with illness and the burden of providing constant care to others. One of the physicians I work with says, "I just wish people would recognize that this isn’t easy... I go home some days and can hardly face coming back. No one seems to know that emotionally, this work is really difficult.” Addressing what is often un-recognized must be more than a passing thought for us; it is our responsibility. Our ability to be witnesses to these experiences, to sit with physicians and nurses in their moments of pain, and to acknowledge what they have lost generates hope: the greatest gift that we can give.


Lindsey Lawson is a second-year PhD MFT student at Loma Linda University and works at the Loma Linda Medical Center as a Medical Family Therapist. She has spent the last year working on a qualitative, grounded theory study in which she is interviewing nurses and nursing students about their personal experiences with illness and the way that these experiences impact their views of family-focused healthcare and wellness.

This post has not been tagged.

Share |
PermalinkComments (0)
 

What Brought Me Here?: Self-of-(Medical Family) Therapist Exploration

Posted By Jackie Williams Reade, Tuesday, January 31, 2012
Last week's Growing MedFT blog by StephanieTrudeau-Hern reinforced my sense that the self-of-therapist in the MedFT realm is an important conversation that we need to have more often. As a MedFT in pediatric palliative care, I am often asked about why I chose this field and how I can stay in a job where I daily encounter children and their families struggling with life-and-death issues. My reason for entering the field is clear as I was profoundly impacted by witnessing my paternal grandfather dying of pancreatic cancer while I was in college. For me, it was a lived experience in how consuming and lonely the illness and death of a loved one can be and that experience became the foundation of my career as I now seek to help others navigate their own illness.

As to my reason for how I can stay in this job? Not just stay physically in the job, but rather stay compassionate, open, able to think outside of my own grief and assist where needed, and maintain capacity to love and grow in my personal life is the more difficult question to answer. I find a common response to how to stay in this kind of job is to disconnect, distance, and protect yourself. While part of me agrees that these ways of coping are needed at times, I think the more effective way to work in challenging healthcare settings is to do the opposite, which is: connect, get closer, and be vulnerable with yourself in terms of how these experiences are affecting you.

To be compassionately present to the suffering of patients, their family members, and the healthcare team members we work with we need to understand our experiences of suffering, illness, and the healthcare system. We need to pay attention to what happens when we’re suffering, afraid, angry, or feel out of control - what happens in our body and mind - so we aren’t unconsciously causing harm to the healing process of another or ourselves.   While personal healthcare
"What brought me here?” is a good question to ask ourselves when we find we are stifled, overwhelmed, numb, scared, or angry as we interact with a patient, family member, or healthcare team member.
 experiences (good and bad) of ourselves, loved ones, and individuals with whom we work can be our most powerful generators of passion, empathy, and resilience, they can also be the first things that get in our way when we are working in the healthcare system.

While many of us spend months in Master’s programs discussing our assumptions, biases, and family of origin issues as they relate to our typical family therapy cases, I find we do not give the same quality or quantity of time to discussing these same concepts in terms of how they relate to working in healthcare. Do we recount the health history and its impact on ourselves and our loved ones? Do we discuss our reactions to the power dynamics and hierarchy that is often found in the medical setting? Are we exploring our own feelings of burnout, vicarious trauma, and compassion fatigue with safe colleagues and mentors? Being a MedFT is not just applying my skills in the medical setting, but rather it requires learning an entirely new system that requires re-evaluation of our beliefs and values as we sit with patients and caregivers who are often suffering in each area of the biopsychosocial-spiritual framework. Not to mention our attunement to our colleagues who are experiencing their own suffering. As MedFTs it can be an overwhelming challenge to assimilate all of these experiences.

I have now been working in pediatric palliative care and pediatric oncology for the past 15 years and the first 5 years were the most difficult by far as I struggled to make sense of the tragedy of childhood cancer and figure out my own dance (as Stephanie so eloquently refers to it) of engaging, distancing, crying, yelling, coping, and building my capacity for the significant burden of the work. I have read many books along the way that have helped me with some of this exploration, but a recent read I want to recommend to you is: "Beliefs” by Lorraine M. Wright, Wendy L. Watson, and Janice M. Bell. It is a wonderful resource to continue your thinking about the power of illness experiences and their impact on our beliefs and those of our clients.

"What brought me here?” is a good question to ask ourselves when we find we are stifled, overwhelmed, numb, scared, or angry as we interact with a patient, family member, or healthcare team member. Examining the events in our lives that are influencing our responses in the healthcare context is worthwhile work. While it’s not fair to assume we won’t ever be afraid, angry, or vying to control the outcome when faced with a situation that is challenging, what we can do is explore and recognize those experiences that impact our clinical capacity in the healthcare arena and continue our self-of-(medical family)-therapist work.

So… What brought you here? Why are you a Medical Family Therapist and how has that shaped your current practice?


Jackie Williams Reade, PhD is a Postdoctoral Fellow at Johns Hopkins University in Baltimore, MD. She received her Master’s in MFT from Seattle Pacific University and her PhD in Medical Family Therapy at East Carolina University. She is also the administrator of the Medical Family Therapy Group on Facebook.



This post has not been tagged.

Share |
PermalinkComments (1)
 

Cancer as an Educator

Posted By Stephanie Trudeau-Hern, Tuesday, January 24, 2012

A familiar piano melody begins on the radio, then comes the guitar, and then the mellow voice of Garth Brooks sings to me about "The Dance” of life. I am somewhere on the interstate, half paying attention, but mostly crying. Not the attractive crying that you see in the movies, the "I can’t breathe, snot running down my face, need my inhaler” type of crying.

I pull off the interstate in order to compose myself. As I sit in the car I wish I could rewind the song, I don’t want to lose this feeling. An intense discharge of emotion washes over me, and wow, does it ever feel good. I wanted to drive back home; did I hug my kids long enough? Did I memorize their perfect little faces? Did I tell them they are going to be amazing human beings because they do so effortlessly what I struggle with - to love and to feel?

I chose oncology because it is what I know. I have lost an unusually high number of family members to cancer; I have experienced cancer as the unwelcome visitor, the family secret, and the disruptor of emotional and physical balance. I have been determined to figure out a way to help families stay connected and "healthy”. This is why I sought out my internship site; I wanted to be immersed with the families who are dealing with a diagnosis of cancer.

My internship site is a rural Minnesota oncology clinic and also the location where I conducted my master’s thesis. While researching caregivers of cancer patients, I recognized the need for integration of emotional support for family members. With the help of the director, we piloted a MedFT internship that provides therapy for patients and families who are coping with a diagnosis of cancer. What a better way to feed my research mind, to be privileged enough to hear first hand the struggles and the triumphs of these families. Another reason I chose oncology was my ability to disconnect, to be able to be around illness, and death, and to not have it affect me.

Or so I thought.

The emotional revelation I experienced in the car was after my second full day of patients and families. There were two patients weighing on my mind. They were young; both were mothers, and wives who were newly diagnosed. Much to my dismay there was transference and counter-transference all over the therapy room. I had prided myself in being able to theoretically conceptualize, to validate, and reflect feelings, all the things a novice therapist is taught. As I’m doing the mental dance, self-reflection of my physical responses while staying connected to their narratives, I begin to feel this burning in my throat. Are you serious?! I have tears in my eyes! I quickly shut it off, back to being emotionally available to them, the patients, the ones who needed me.

That night I cried for a myriad of reasons. Everything I knew about myself had been challenged. I felt energized by my patients’ determination and optimism, is this how "normal” people handle cancer? And why was I not able to be more stoic in the therapy room? Why did I cry? Have I not resolved the emotions of my past traumatic experiences? How am I going to be able to do this? Have I gotten in over my head?

I have decidedly begun another quest for knowledge, what does "self of the practitioner” look like? As the only therapist on-site, I began to ask the oncology staff, "how do you do this day in and day out without it affecting you”? The overwhelming response I have received is that you have to disconnect a little bit if you are going to deal with this setting, you will get used to it. I am immediately compelled to go into defense mode, I wanted to shout, but don’t you know I have to connect to my patients? In order to facilitate healing, I become part of their process! In trying to make sense of this I cannot help but to reflect on the perceptions of Maturana and Verela’s, "we do not see that we do not see”. It appears to me that I have made a quick judgment, could this simply be a gap in professional training?

In order to be an effective therapist, I am coming to terms with my new professional identity. I no longer have to stuff the emotions that are transparent during the therapeutic process. My outlets have become; crying in the bathroom between patients, journaling mad scribbles, listening to sappy love songs followed by angry heavy metal, and cursing the makers of Dove chocolates for personalizing their quotes to me. Feeling, connecting, and loving make me a better therapist. It is the dance that I choose to do, sometimes it may look like the "African Anteater Ritual”, while other times it may be an elegant ballet; but it is mine and I believe it is how I will be an agent of change within my clinical setting and most importantly for my families.



Stephanie Trudeau-Hern, MS is a doctoral candidate specializing in medical family therapy at the University of Minnesota. She is currently in a behavioral medicine internship with the Coborn Cancer Center in St. Cloud, MN in collaboration with the Department of Family Medicine and Community Health at the University of Minnesota.  She is a student member of CFHA, a collector of books, an enthusiast of John Hughes movies, and a sponge for knowledge with her most influential teachers being her 6 and 3-year-old children, and her patients.

This post has not been tagged.

Share |
PermalinkComments (1)
 

Trauma History: ACE in the Hole or Futile Family Fact?

Posted By Randall Reitz, Tuesday, January 17, 2012
Updated: Friday, January 20, 2012

At this point in my education I am not easily awed, much less shocked. Discovering the Adverse Childhood Experience research was a shock and awe campaign to my clinical sensibilities.

For the uninitiated, the ACE study was n=17,000 research sponsored by the CDC. It looks at the effects of childhood trauma on adult health and behavior. Each research participant completed a 10-item childhood trauma screen. They also provided a thorough health and behavior history. The participants were stratified by trauma history ("ACE Score”) to assess whether it was predictive of health outcomes. Their data proved statistically significant to a degree rarely seen in the human sciences.

In each of the graphs below the numbers on the X-axis are ACE Scores (i.e. how many of the 10 traumas the person endured as a child) and the Y-axis is the percentage of participants with a particular health outcome as an adult. I apologize for the low quality of the graphs.

 

 

 

 

 

 

2 Conclusions:

  1. Negative early childhood experiences, especially those involving family members and other caregivers, have a profoundly detrimental effect on adult health.
  2. People with low ACE scores are amazingly free of these problems.

Fine.

No, that's a poor word choice. It is not fine, it's horrible.

Let's try that again, inspired from a song my kids love, but I hate: "whatever, it doesn't matter, oh well”.

No, that's not right either. It does matter. It matters deeply. BUT, as it relates to my adult patients who are already demonstrating the health sequelae of childhood traumas, I haven't been able to identify anything I can do with these data.

Knowing the fact that horrible parenting or a chaotic childhood placed the patient on a nearly inexorable path toward health destruction is diagnostic, but not therapeutic.

How do I intervene?

How do I make it better?

How do I advise my medical and nursing colleagues?

I have attempted 3 (inadequate) responses so that at least I feel like I'm not being callous:

1. Normalize their Experience: I can say: "I'm sorry, you've been through horrible experiences in your life, and unfortunately, science and my own clinical practice has shown us that these experiences help to explain many of your health problems”. This might assist the patient in piecing together a different health narrative, and the empathy that it implies might fortify our therapeutic relationship. But, I've never seen it go very far.

2. Protect the Innocent: I haven't had occasion to do so, but I've often imagined that a reasonable MedFT intervention would be to go through the ACE research with an abusive parent. These data might be the missing piece to dissuading him from passing along this horrible family legacy to his children. After all, this is exactly what we do with pre-contemplative smokers (i.e. "Were you aware that 2nd-hand smoke can cause more frequent illness, asthma episodes, and perhaps even lung cancer in your children?"). So, yes, this might help the next generation, but it doesn't turn back the clock for the abusive parent in the room who is already addled with her own health problems from her parents' abuse.

3. Educate the Clinicians: Patients who were traumatized as children are some of the least rewarding for healthcare providers. They come to the room with intractable health problems and behavior which looks like an Axis 2 diagnosis. These are the patients who quickly get labeled and often get fired from a practice. Perhaps having the patient complete an ACE screen will assist the clinician in having more compassion and in passing less judgment to the patient. If so, that would be wonderful.

OK, there might be some clinical advantage to screening for childhood traumas. However, I remain unconvinced that it is a clinically relevant tool. The ACE score should NOT be the 6th vital sign (or the 7th or 8th, or however many there are now that we therapists keep adding our soft scales to the hard science of checking patients-in). Perhaps I will continue to bust out an ACE 1-2 times per year, but it's not about to join the PHQ9, GAD7, and Vanderbilt in the pantheon of primary care screens.

There, I said it.

Now you say it:  Do you like the ACE screen? Do you use it in primary care settings? How have you made it clinically relevant?

 

Randall Reitz is the Director of Social Media for CFHA and the Behavioral Science Faculty at the St Mary's Family Medicine Residency in Grand Junction, Colorado. He studied family therapy at Brigham Young University and Indiana State University.

He is the author of CFHA's
CollaboBlog.

This post has not been tagged.

Share |
PermalinkComments (3)
 

Earning our Place at the Healthcare Table: A Call for Research in Medical Family Therapy

Posted By Tai Mendenhall, Tuesday, January 10, 2012
Anybody who listens to the radio or watches television nowadays knows that "healthcare” in this country – however it is defined – is undergoing a dynamic and messy evolution influenced by a myriad of competing interests and constituencies. One of the positive things rising out of (or perhaps enduring despite) all of the political wrangling that makes it to NPR’s "All Things Considered” or ABC’s "World News” is that the calls for integrated care are stronger now than they have ever been. Whether physicians are working with therapists to help a patient for his/her own sake or if it’s to offset forthcoming medical costs associated with a(nother) hospitalization if they do not, really doesn’t matter. What matters is that providers across a variety of disciplines are increasingly working together because, somehow, everybody wins: patients are healthier, providers are more effective, administrators are less overwhelmed, and payers’ funds are more secure.

As our training sites across different mental health fields prepare future healers to enter these complex work environments, we are seeing many of yesterday’s interdisciplinary tensions regarding who is "better” (e.g., Psychology vs. MFT vs. Social Work) change to contemporary mutual respect and valuing of our colleagues’ contributions to a whole that is more than the sum of its parts. This shift is likely, at least in part, a reflection of how we are no longer working within the comfort of private practices that are isolated (or at least insulated) from the biopsychosocial/spiritual realities of the worlds that our patients and families reside in. We are working on a common ground that is not claimed by any single mental health discipline. We are on Medicine’s turf now, wherein most of us – whether we identify personally as a "family therapist,” "psychologist,” "social worker,” or "counselor” – are seen by everyone else as a "mental health clinician,” "behavioral medicine practitioner”, or "shrink.”

Defining and Proving the Profession

Within the trenches of day-to-day practice, many would argue that our medical colleagues, patients and families, and other treatment team members do not care what discipline us mental health providers were originally trained in. And I would, in many cases, agree with them as long as key facets and processes of what I espouse to be essential to good collaborative care are advanced (e.g., biopsychosocial/spiritual sensitivity to the systemic nature of patients’/families’ presentations, active efforts to promote agency and communion). However, from the 1000-foot view of health care policy and 3rd party payer systems, the disciplinary home-base of mental health providers is in fact VERY important. Psychology, for example (with its uncompromising efforts to advance – and deep pockets to support – research, political advocacy, and lobbying for preferential coverage), has long been able to keep other mental health fields from sitting at the healthcare table and/or drawing equally from available funds for service.

As a medical family therapist, it would be easy to demonize Psychology’s efforts to establish itself so well at the head of this table (to the detriment of me, my own specialty, or professional home). However, doing so without challenging MedFT’s contribution to this imbalance would be irresponsible. For example, Tyndall’s (2010) recent review of almost two decades of literature found only 65 articles about Medical Family Therapy, almost all of which are focused on the history, development, and/or application of clinical skills and processes – i.e., NOT on the evaluation of MedFT’s effectiveness or efficacy. In my opinion, we must compare this paucity of published work to the hundreds (if not thousands) of articles that highlight interventions housed within Psychology – or even Social Work – and ask, "Where are the MedFT researchers?”, "What are they doing?” and/or "Who do you think HMOs and other health systems are more likely to pay for, given the available evidence?”

To be sure, it important for all mental health disciplines involved in the evolution of collaborative and integrated healthcare to work hard to produce solid empirical evidence to survive. For MedFT per se, I believe that the first thing we must do toward this goal is to establish and settle-upon what it is we do and how this overlaps with and is distinct from other types of care. Extant literature regarding our efforts to date is very messy in this regard (e.g., defining MedFT inconsistently from one article to the next), and this makes it difficult for researchers to take ensuing steps to assess which components or processes of MedFT contribute to desired outcomes, and/or to evaluate and compare MedFT approaches to standard care alone and other collaborative models.

Drawing from the foundational work of McDaniel, Hepworth, and Doherty (1992), along with writings by Lindville, Hertlein, and Prouty-Lyness (2007) and Tyndall (2010), key components of what MedFT looks like on-the-ground are now coming together. They include: a) a theoretical foundation in MFT and systems theory; 2) biopsychosocial / spiritual sensitivity in care; 3) targeted efforts to empower patients’/families’ active participation and influence in care (i.e., "agency”); 4) purposeful supporting of and attention to emotional connections between patients and family members and other important persons within their immediate social systems (i.e., "communion”), and 5) interdisciplinary collaboration within the contexts of a larger care team and supporting organizational structure.

Asking the Right Questions

Okay, there’s our baseline definition. Now we have to get to work. We must advance research that documents MedFT’s applications/variations from this baseline characterization, and its processes within different teams oriented to different patient and family presentations. Across Peek’s (2008) three worlds of health care, we must evaluate MedFT across clinical, operational, and financial arenas. We can do this through qualitative methods that tap patients’, families’, providers’, and/or administrators’ experiences across different care types and clinical procedures. We can do this through quantitative methods that compare and track disease-related outcomes, cost offset data, and/or inter-member functioning and satisfaction in care teams. We can do this through mixed-methods approaches that simultaneously capture the richness of participants’ experiences alongside objective measures of beneficent change. Wherever we choose to start, and whatever we choose to do, we will be advancing MedFT – because at the present time our specialty is so novel that there are more "gaps” in what we know than there are empirically supported areas of what we do.

I am not advocating that we set out to "prove” MedFT’s universal superiority over any other discipline, nor have I ever found inter-departmental squabbling over whose field or approach is "best” to be very helpful as it relates to clinical work. I believe that graduate students within any discipline do better when they are exposed to each other’s fields and learn how their own and other’s respective efforts contribute to a larger mosaic of high quality and effective care. Just as there are some tasks in which a hammer is more appropriate than a screwdriver (and visa versa), there will be some scenarios in which MedFT is a better fit than a straightforward psychological assessment or intervention (and visa versa). But in order for MedFT to have a stable place at the healthcare table, it (we) must catch-up and establish our right and our worth be there.

And so, let’s get started. Now.



References

Lindville, D., Hertlein, K. & Prouty-Lyness, A. (2007). Medical family therapy: Reflecting on the necessity of collaborative healthcare research. Families, Systems and Health, 25, 85-97.

McDaniel, S., Hepworth, J., & Doherty, W. (1992). Medical family therapy: A biopsychosocial approach to families with health problems. New York: Basic Books.

Peek, C. (2008). Planning care in the clinical, operational, and financial worlds. In R.

Kessler & D. Stafford (Eds.), Collaborative medicine case studies (pp. 25–38). New York: Springer.

Tyndall, L. (2010). Medical family therapy: Conceptual clarification and consensus for an emerging profession. Unpublished doctoral dissertation. East Carolina University.


Tai Mendenhall

Tai Mendenhall is an Assistant Professor at the University of Minnesota (UMN) in the Department of Family Medicine and Community Health, the Associate Director of the UMN’s Citizen Professional Center, and the co-Director of mental health teams within the UMN’s Academic Health Center. He holds an adjunct faculty position in the UMN's Department of Family Social Science and mentors doctoral students who are completing the UMN’s Preparing Future Faculty series in college-level teaching. Dr. Mendenhall’s principal investigative interests center on the use and application of community-based participatory research (CBPR) methods targeting chronic illnesses in minority- and under-served patient and family populations.


This post has not been tagged.

Share |
PermalinkComments (0)
 

Real-Time MedFT Case Consultation: What Would You Do Next Week?

Posted By Randall Reitz, Tuesday, January 3, 2012

Fall 2011

Natalia and Norberto* attended my clinic's diabetes group medical appointment for the first time. They are both immigrants from a Spanish-speaking country who reside in a small town in western Colorado. Natalia has very limited English ability and Norberto knows just enough English to speak for her and to correct the interpreter. Both of them are 5'3” tall. His BMI is 41; hers is 55. Both have diabetes, chronic pain, and numerous other chronic conditions that are caused by or exacerbated by their weights

The topic for the group appointment was "sexual health with diabetes” and the patients were asked to submit anonymous questions to a panel that included a family physician, a family therapist (me), and a resident physician. Despite the promises of confidentiality, few patients submitted questions. We received a question about Viagra, a question about female Viagra alternatives, and a question about how diabetes can affect sexual performance. Natalia submitted a very detailed question which roughly translated to "My husband is now unable to ever have sex with me. He cannot maintain an erection. I am sexually unfulfilled and am not sure what I can do. What do you recommend?”

The panel attempted to maintain confidentiality with this question, but about 1 minute into the discussion Natalia interjected to clarify her question. Norberto then provided a rejoinder, and the couple started a sexual repartee in front of the group. The panelists redirected the discussion, but failed to fully respond to the question.

At the end of the group all participants set a self-management goal for themselves, which they report out to everyone. When it was Natalia's turn, Norberto stated that she needed to drink less soda. Natalia clarified that she only drinks 1-2 diet sodas per day. Norberto stated that it was at least 3-4. Their dialogue continued for about 5 minutes at which point Natalia stated "Why aren't you more worried about your 4-5 beers per night and less worried about my diet soda?” Norberto didn't respond and a silence fell over the room.

Four Months Later

I was precepting residents as they come out of exam rooms and report on their cases. A first year resident was seeing Natalia (and Norberto) so I joined the presentation along with the attending physician. The resident informed us that Natalia has end-stage renal failure and has been referred to hospice. As I knew the couple and have reasonably good medical Spanish I was asked to interpret for the last portion of the visit. The goal was to clarify what the couple understood and to answer any questions they might have.

After greeting the patients and explaining my role, I assumed my customary interpreter's position, slightly behind and to one side of the patient. The resident asked Natalia if she understood why she had received a visit from a hospice social worker. Natalia stated that when the person first came she didn't know she was going to die. She was in her home with Norberto and their adult children when she was told that she would probably only live for 6 to 12 months. At first she was shocked and everyone started crying. In the 2-3 weeks since then she has come to greatly appreciate hospice's home-based care. She credits them with helping to manager her pain and for being very responsive to her calls. She is very pleased to be receiving her care in-home and hopes not to leave.

During our visit Natalia and Norberto reprised their previous interaction of speaking over and contradicting each other. At one point he called her a "masoquista” and she often struggled to speak with the resident, as her husband continued over her. She reported that she has been sleepwalking and he has installed an alarm on their bedroom door so he will know if she is at-risk during a sleepwalking spell.

The resident seeing the patient that day was due to invite a patient or family to "Psych Day”. So, I suggested that she invite Natalia, Norberto, and their children to come. I will attend this visit along with a 2nd resident. I will assist with the patient's care and the 2nd resident will observe and provide feedback.

Now

If you had 45 minutes to work with a family in this setting, what would you want to accomplish? How would you focus the discussion?

Have you ever provided a family conference such as this? If so, what was the outcome?

 

*The patients' names and identifying information have been changed. Additionally, the content of this blog post was approved by my hospital's risk management department and the patients provided verbal consent to have it published online.

 


Randall Reitz is the Director of Social Media for CFHA and the Behavioral Science Faculty at the St Mary's Family Medicine Residency in Grand Junction, Colorado. He studied family therapy at Brigham Young University and Indiana State University.

He is the author of CFHA's
CollaboBlog.



 

This post has not been tagged.

Share |
PermalinkComments (3)
 

Money, Money, Money, Money

Posted By Barry J. Jacobs, Tuesday, January 3, 2012

Happy New Year and welcome to a once-in-a-decade opportunity to promote the growth of Medical Family Therapy. On January 1, new Medicare rules for hospital payments took effect and are a veritable game-changer.

In the past, if a 70-year-old man was admitted to a hospital with, say, a COPD exacerbation, he'd be pumped full of steroids and given breathing treatments for 3 days and then sent home; the hospital would be paid by Medicare for those 3 days of intensive care. If, once home, the guy started smoking heavily again and then suffered another COPD exacerbation a week later, he'd be readmitted to the hospital—jocularly called a "bounce-back”--and the hospital would again be paid by Medicare for another 3 days of care. The guy could keep going in and out of the hospital and the hospital could keep reaping the profits from its ultimately futile treatments for up to 100 days a year that the gentleman was hospitalized.

No longer. Under the new regulations, hospitals will not be paid by Medicare for patient re-admissions within 30 days of hospital discharge. That means the hospital will be paid for the first admission for our 70-year-old smoker but for none of the re-admissions thereafter if the guy bounces back too quickly. In other words, hospitals will have to eat the cost of the care it provides—the steroids, the breathing treatments, the food, the linens, etc.--during those bounce-backs. Medicare will no longer incentivize hospitals to provide inadequate care that doesn't keep patients out of hospitals.

This has spooked hospital administrators. Nearly every VP of Clinical Integration in the country is now scrambling to find ways to decrease hospital bounce-backs and thereby save their institutions money. They are looking at "care transitions”—i.e., how to make sure patients follow up with their primary care doctors, get the proper medications, and receive necessary home-based services. They are also turning their attention to something we know is obvious—the conditions in patients' home environments that affect their health.

Here's MedFT's golden opportunity. We have the know-how and techniques to understand the impact that patients' family members have, for example, on treatment compliance and to foster good health habits to keep patients ensconced at home.

For instance, please take a look at this presentation by Carol Levine, MA, a MacArthur Award-winning ethicist, director of the Families and Health Care Project of the United Hospital Fund of New York, and a major figure in the family caregiving movement (as well as a former CFHA conference plenary speaker)-- http://www.uhfnyc.org/publications/880807?tr=y&auid=10030107. The presentation, given during October 2011 at the National Health Policy Forum in Washington, DC, has a simple premise: If we better support all family caregivers in their work with chronically ill patients, then they will keep those patients from being re-hospitalied.

Then consider combining this approach with that of the "hot spotter” or "super-utilizer” emphasis propoundeded by Jeff Brenner, MD, a family physician and plenary speaker at the CFHA Philadelphia conference in 2011. Dr. Brenner has been highly successful using data to identify those patients within Camden, NJ who have the highest health cost expenditures and then lowering their hospital and emergency room usage by providing them with team-based primary care instead. For an eloquent description of Dr. Brenner's work, see this New Yorker magazine profile--http://www.newyorker.com/reporting/2011/01/24/110124fa_fact_gawande

At the Crozer-Keystone Health System in suburban Philadelphia where I work, we are now trying to decrease hospital bounce-backs by using a "super-utilizer” approach that focuses on family factors. For example, we identified a brittle diabetic man who was hospitalized 20 times in 12 months for diabetic complications, creating hospital bills in excess of $500,000. What simple method worked to decrease his rate of hospital re-admissions? We engaged the man's wife and convinced her to provide greater supervision for his diabetic regimen. To cite another example, a middle-aged, somaticizing woman who was frequently hospitalized for syncope ran up hospital and ER bills of over $700,000 over a 5-year period. What changed this pattern for her? We engaged her husband to help us convince the patient that her symptoms were more stress-related than neurologically based.

Money always talks. Under the new Medicare rules, hospitals will quickly get out of the revolving-door, bounce-back business. Working effectively with patients' families will be the key. We hold that key.

 

Barry J. Jacobs, Psy.D. is a clinical psychologist, family therapist and the author of the book, The Emotional Survival Guide for Caregivers—Looking After Yourself and Your Family While Helping an Aging Parent. He is the Director of Behavioral Sciences for the Crozer-Keystone Family Medicine Residency Program in Springrfield, PA and has had adjunct faculty positions with the Temple University School of Medicine, University of Pennsylvania School of Nursing and the Institute for Clinical Psychology of Widener University. He is on the board of directors of the Collaborative Family Healthcare Association. He lives with his wife and two children in Swarthmore, PA and maintains a website—www.emotionalsurvivalguide.com.

This post has not been tagged.

Share |
PermalinkComments (11)
 
Page 19 of 20
 |<   <<   <  14  |  15  |  16  |  17  |  18  |  19  |  20

Contact Us

P. O. Box 23980,
Rochester, New York
14692-3980 USA
info@CFHA.net

What We Do

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