Posted By Jonathan B. Wilson,
Sunday, July 30, 2017
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This is the second in a two-part series about spirituality and collaborative care. Click here for part 1.
Spiritual Collaboration in Family Centered Health Care
The role of spirituality in healthcare is a constantly evolving topic requiring dedicated time and attention from medical and mental healthcare providers alike. As a whole, Americans are a highly religious people with 89% reported believing in God, 75% indicating that religion is “very important” or “fairly important” in their lives, and 73% saying they try hard to incorporate their religious beliefs into all areas of their lives.1, 2 Furthermore, researchers have demonstrated that religion and spirituality have significant effects on physical and mental health alike.3
Although many Behavioral Healthcare Providers (BHPs) and medical providers ascribe to the practice of incorporating religion and spirituality into their clinical practices, others may not do so as readily. While interdisciplinary teams focus on patients’ spiritual concerns, those most commonly recognized for their specific training in this area are chaplains (also referred to in the literature as “hospital chaplains,” “healthcare chaplains,” and “non-denominational spiritual healers”).4 It is important to understand the services provided by chaplains in order to seek opportunities for collaboration.
Roles and Benefits of the Hospital Chaplain
Chaplains serve in a variety of contexts, often fulfilling numerous roles within those contexts. Chaplains spend time with patients before surgeries and during the disclosure of diagnoses or therapeutic procedures by other healthcare professionals, and may assist in discharge planning and referrals to the faith community.5 Chaplains who serve within hospice settings may provide spiritual care to end-of-life patients and their families, addressing various religious and spiritual concerns that may surface during times of suffering, death, and loss.5-7
The benefits of the services provided by chaplains are noteworthy. Various researchers have linked spiritual well-being to a better quality of life 8, and other health benefits including lower anxiety and depression.9, 10 Flannelly and colleagues11 even linked chaplaincy services to “significantly lower rates of hospital deaths compared to hospitals that did not provide chaplaincy services” (p. 4).
Roles of Chaplains
As discussed in previous CFHA blog entries, behavioral and medical providers should be seeking opportunities to address spirituality with their patients. Although some providers report discomfort or inadequacy regarding addressing spirituality concerns among their patients,6 various opportunities exist for collaboration with other healthcare providers and chaplains.
Chaplains fulfill a variety of roles within the healthcare system. They spend time with patients before medical procedures, assist in discharge planning, and provide referrals to the faith community.5 Chaplains may serve as a neutral professional when discussing diagnoses and treatment options with patients and their families at any point, but most often when addressing significant medical stressors and end-of-life care.5 By assisting patients and their families with coping during difficult experiences, chaplains fill an important role in the medical community.
Chaplains are also able to support staff by providing counseling and spiritual support5 as well as increase provider diversity as members of interdisciplinary healthcare teams. Chaplains who serve as members of interdisciplinary healthcare teams actually report higher satisfaction with communication among team members.12 Furthermore, chaplains may also serve as valuable resources when providing care to patients from multiple religious backgrounds. By informing team members of common beliefs and healthcare practices of various religious groups, BHPs and chaplains alike can increase the quality of patient-provider relationships and establish excellent continuity of care.
While chaplains are important providers of spiritual care services to patients, they are not the only members of healthcare treatment teams that have the ability to do so. Nurses, for instance, observe patients and their families in far greater frequency than chaplains or BHPs. Nurses may very well become aware of the spiritual needs of patients long before a referral to a chaplain is sought. One team of researchers noted that nurses, in fact, refer patients to chaplains more than any other medical discipline.13 In many cases, nurses serve as a link between BHPs, chaplains, attending physicians, and hospital administrators.
Although physicians, therapists, nurses, and clinical pastoral staff alike should receive training on the value of spiritual assessment,14 many providers do not actively implement these assessments into their practices. It is important to continue to seek opportunities to meet the spiritual needs of patients, whether in prayer, spiritual support groups, collaborative scripture reading, ceremonial or individual worship rituals, or other services.
In conclusion, as clinicians and researchers of family centered health care, it is crucial that we continue to look for new ways to meet the spiritual needs of our patients. Collaboration with chaplains and other members of interdisciplinary treatment teams may provide further opportunities to do so. Below are a few electronic resources specifically pertaining to chaplains that may be useful for those future collaboration:
- ACPE Research Network – http://acperesearch.net
- Australian Journal of Pastoral Care and Health - http://www.pastoraljournal.findaus.com/index.php
- Health and Social Care Chaplaincy Journal - https://journals.equinoxpub.com/index.php/HSCC
- Journal of Health Care Chaplaincy - http://www.tandf.co.uk/journals/WHCC
- Plainviews E-Newsletter - www.plainviews.org
1. Curlin FA, Lantos JD, Roach CJ, Sellergren SA, Chin MH. Religious characteristics of US physicians: a national survey. Journal of General Internal Medicine. 2005;20;629-634.
2. Gallup. Religion. http://www.gallup.com/poll/1690/religion.aspx. Accessed July 6, 2017.
3. Oh P, Kim SH. The effects of spiritual interventions in patients with cancer: a meta-analysis. Oncology Nursing Forum. 2014;41;E290-E301.
4. Bulling D, DeKraai M, Abdel-Monem T, et al. Confidentiality and mental health/chaplaincy collaboration. Military Psychology. 2013;25;557.
5. Dell ML. Religious professionals and institutions: untapped resources for clinical care. Child and Adolescent Psychiatric Clinics of North America. 2004;13;85-110.
6. Balboni TA, Vanderwerker LC, Block SD. Religiousness and spiritual support among advanced cancer patients and associations with end-of-life treatment preferences and quality of life. Journal of Clinical Oncology. 2007;25;555-560.
7. Daaleman TP, Frey B. Prevalence and patterns of physician referral to clergy and pastoral care providers. Archives of Family Medicine. 1998;7;548-553.
8. Frost MH, Johnson ME, Atherton, PJ, et al. Spiritual well-being and quality of life of women with ovarian cancer and their spouses. Journal of Supportive Oncology. 2012;10;72-80.
9. Gaston-Johansson F, Haisfield-Wolfe ME, Reddick B, Goldstein N, Lawal TA. The relationships among coping strategies, religious coping, and spirituality in African American women with breast cancer receiving chemotherapy. Oncology Nursing Forum. 2013;40;120-131.
10. Rawdin B, Evans C, & Rabow MW. The relationships among hope, pain, psychological distress, and spiritual well-being in oncology outpatients. Journal of Palliative Medicine. 2013;16;167-172.
11. Flannelly KJ, Emanuel LL, Handzo GF, Galek K, Silton NR, Carlson M. A national study of chaplaincy services and end-of-life outcomes. BMC Palliative Care. 2012;11;10.
12. Clemm S, Jox RJ, Borasio GD, Roser T. The role of chaplains in end-of-life decision making: Results of a pilot survey. Palliative and Supportive Care. 2015;13;45-51.
13. Vanderwerker LC, Flannelly, KJ, Galek K, et al. What do chaplains really do? III. referrals in the New York chaplaincy study. Journal of Health Care Chaplaincy. 2008;14;57-73.
14. Joint Commission on the Accreditation of Healthcare Organizations. Evaluating your spiritual assessment process. 2005. Accessed here July 10, 2017.
Jonathan B. Wilson, PhD, is an Assistant Professor at Oklahoma Baptist University in the Department of Behavioral and Social Sciences. He co-founded Oklahoma’s first advanced clinical training certificate in Medical Family Therapy, and has various publications and presentations in Medical Family Therapy and Integrated Behavioral Health Care. He has held leadership positions for the Oklahoma Association for Marriage and Family Therapy as well. His research interests include intimate partner violence, qualitative research methods, and sexuality in relationships.
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Posted By Stephanie Trudeau,
Tuesday, July 11, 2017
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Reattaching the “S”
How often do you hear the following phrases either clinically, at the holiday dinner table, or streaming across your social media platform: “We are asking for your prayers”; “We know he will remain strong and keep fighting”; “God is good and will grant us a miracle”; “I am granted the strength everyday to get through this”; “If I stay the path, I know I will get better”; and “It’s in God’s hands now”.
These colloquial expressions do more than fill the empty space in conversations with people who are suffering. They constitute the unseen, untouchable, sometimes-mysterious part of illness and disease – a belief in something bigger than themselves.
Patients want to be asked about their spirituality, in fact, upwards of 94% of them do.1 How often are they asked? Not often enough. Ten percent of physician’s and 56% of mental health professionals report asking patients about their spirituality or religious practices.2, 3
For decades now in our clinical and academic work, we have been making strides to “reattach the head to the body”. In this blog post I am attempting to push you a little further: “reattach the S to the BPS-S model”. Part 1 of this 2 part series will offer a quick primer (i.e., background information, research on health outcomes), and a starter guide (i.e., assessments and measures to be used in practice and research). Part 2 will follow up by focusing on collaborative practices with spiritual providers within the healthcare system (e.g., chaplains).
From BioMed to Biopsychosocial-Spiritual
Prior to 1977, illness was generally thought to be influenced by deviations in biological norms. Thus, clinicians relied primarily on the Biomedical Model. Engel4 developed the Biopsychosocial Model (BPS) to expand the picture of illness beyond the biological to include psychological and social dimensions. Wright, Watson and Bell5 later expanded BPS to incorporate Spirituality as an equally important influencer in health and illness. The outcome was the inception of the model that clinicians, academics, and researchers ascribe to as the primary epistemology in the practice of family centered health care - the Biopsychosocial-Spiritual Model (BPS-S).
Spirituality/Religion: and/or & both/and
Due to space restrictions, this post will not fully go into the differences and similarities of spirituality and religion. For a comprehensive review of how these terms are used and researched, refer to Koening.6 Research uses the terms spirituality and religion interchangeably so much so, that there is contamination and confounding constructs in the measures. Given the overlap, religion and spirituality will be used interchangeably and will be identified as “Spirituality” here on out.
Spirituality: Physical Health and Health Behaviors
Research has shown that those who self report higher levels of spirituality have healthier diets, healthier weight, and less risky sexual behaviors. Indirect associations between spirituality and physical health include positive outcomes for the following conditions: coronary heart disease, hypertension, stroke, dementia, immune function, cancer, pain and somatic symptoms, and mortality. How spirituality influences physical health has generally been researched via three pathways, through improved psychological health, increased social involvement, and improved health behaviors.
Spirituality: Mental Health
Levels of spirituality and mental health outcomes have been shown to have a significant inverse relationship. Spirituality has been shown to directly or indirectly influence various mental health pathways such as: use in coping with adversity, positive emotions, well-being/happiness, hope, optimism, meaning and purpose, sense of control, depression, anxiety, suicide, and substance abuse. Overall, spirituality influences mental health through many different mechanisms and has a substantial evidence base supporting its importance. Researchers attribute these impacts via the following mechanisms: spirituality provides resources for coping with stressful events, it provides guidelines for how to live life such as doctrines, and it promotes an altruistic, compassionate stance in life and encourages contact with community.
You Can’t Know If You Don’t Ask
Not too many moons ago I stumbled over how to assess spirituality in the clinical setting. Even with the presence of prompting question on the diagnostic assessment, I still threw out: “you’re religious right?” nodding my head in hopes we wouldn’t have to “go there”. It wasn’t until I was steeped in a family medicine residency program serving a high-risk population (e.g., multiple health disparities, trauma histories) that I made an intentional move to ask more purposeful questions regarding the role of religion and spirituality in my patient’s illness and suffering narratives.
Far too many of my patients would say things such as “if I pray enough God will cure my diabetes” and “I knew I was destined to get this disease, I was not a good person in my early life”. It dawned on me; no matter how many BPS interventions we could produce for these patients, their deeply seeded beliefs - intertwined with spirituality - could be impeding any actual healing. And, we would never know, if we didn’t ask.
First things first, we have to ask ourselves why we are not asking. We need to dive in and assess our own biases. What’s keeping us from asking? It is our own comfortability, our own lack of knowledge, or is it an unfamiliarity in resources and referral pathways? Second, we must recognize it is our requirement to ask. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO)7 sustain that “Physicians, therapists, nurses, and clinical pastoral staff should receive training on the value of spiritual assessment and the tools that should be used to assess a patient’s spirituality” (p. 6).
JCAHO7 “requires organizations to include a spiritual assessment as part of the overall assessment of a patient to determine how the patient’s spiritual outlook can affect his or her care, treatment, and services” (p. 6). It is the clinician who is responsible for doing these initial screeners. If spiritual needs are discovered, a referral to pastoral care is made to further address these needs (stay tuned for Part 2 of this blog series for more information on these transactions). Lastly, a gentle reminder that any assessment of spirituality should be patient and family-centered and patient driven. Coercion is a no-no, and the patient should feel in control of the pace and depth they reveal information pertaining to spirituality.
In conclusion, the impacts of spirituality on health outcomes are becoming more apparent. As clinicians and researchers looking to expand upon the principles of family centered health care, it is essential that we make a purposeful effort to reattach the “S” to the “BPS” model. Below are a list of resources and measures that may be used to assess and measure spirituality.
FICA Spiritual History Tool
HOPE Approach so Spiritual Assessment
The Open Invite Mnemonic Assessment (page 3)
Duke University Religion Index (DUREL)
Spiritual Assessment Inventory (SAI)
Brief Multidimensional Measure of Religiousness and Spirituality (BMMRS)
1. Williams JA, Meltzer D, Arora V, Chung G, Curlin FA. Attention to inpatients’ religious and spiritual concerns: predictors and association with patient satisfaction. Journal of General Internal Medicine. 2011;26;1265-1271.
2. Curlin FA, Chin MH, Sellergren SA, Roach CJ, Lantos JD. The association of physicians’ religious characteristics with their attitudes and self-reported behaviors regarding religion and spirituality in the clinical encounter. Medical Care. 2006;44;5;446-453.
3. Curlin FA, Lawrence RE, Odell S. Religion, spirituality, and medicine: psychiatrists’ and other physicians’ differing observations, interpretations, and clinical approaches. American Journal of Psychiatry. 2007;164;12;1825-1831.
4. Engel GL. The need for a new medical model: a challenge for biomedicine. Science. 1977;196;4286;129-136.
5. Wright LM, Watson WL, Bell JM. Beliefs: The Heart of Healing in Families and Illness. New York, NY: Basic Books; 1996.
6. Koenig HG, George LK, & Titus P. Religion, spirituality, and health in medically ill hospitalized older patients. Journal of the American Geriatrics Society. 2004;52;4;554-562.
7. Joint Commission on the Accreditation of Healthcare Organizations. Evaluating your spiritual assessment process. 2005. http://www.professionalchaplains.org/files/resources/reading_room/ evaluating_your_spiritual_assessment_process.pdf. Accessed July 10, 2017.
Stephanie Trudeau, M.S., LAMFT, is a doctoral candidate at the University of Minnesota in the Department of Family Social Science's Couple and Family Therapy program. Her clinical and research interests include family medicine, family coping with chronic illness and end of life, provider well-being, and integrated behavioral healthcare model design, development, and evaluation. She credits her two little monkeys for being the most influential teachers of life, love, play, and well-being.
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Posted By Nicole Rubin, Deron Ferguson, Linda Franck,
Thursday, June 22, 2017
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This post was originally published on 29 July 2015. Click here for the original post.
Finding a place to stay can be a major stressor for families traveling long distances for their child’s hospitalization. When the necessary specialist pediatric medical care is not available near home, uncertainties about transportation and accommodation become sources of both emotional and financial stress.3 Hospitals can play a greater role in understanding each family’s accommodation needs, before their hospital stay when possible, and can work to ensure these needs are adequately met upon arrival so that the family is able to focus more fully on the child and their care.
Families want to stay together when their child is hospitalized and believe it helps improve their child’s recovery. Families of seriously ill children want to be with their child as he/she receives treatment and do not want to be separated from spouses, partners and other children for extended periods of time. In the first in a series of studies examining the questions of accommodation and proximity, we found that families who stayed together for at least some of their child’s hospitalization believed more strongly that their presence nearby improved their child’s recovery. They also believed that RMH helped their family to stay together. Cultural differences were evident, with Hispanic families believing more strongly that RMH shortened their child’s hospital stay.4
Nearby purpose-built accommodation provides families with much-needed rest while enabling them to stay close to their hospitalized child. In another study5, we measured sleep quantity and quality in parents who stayed in a RMH and those who slept at the child’s bedside. We found that parents who slept in the child’s hospital room had poorer sleep (more awakenings and feeling less rested after a night’s sleep) than parents who slept in the RMH. Nearby family accommodation may facilitate parent-child proximity during a child’s hospitalization while also providing parents with opportunities for essential sleep.
Families who stay in nearby purpose-built accommodation report more positive patient experiences. In our most recent study of 10 hospitals that provide pediatric services across the United States6, the most common accommodation for pediatric inpatient families was at the bedside (76.8%) and for neonatal intensive care families was in their own home or the home of a relative or friend (47.2%). Yet those families who stayed in a RMH reported significantly higher overall experience scores for their child’s hospital stay, were more likely to recommend the hospital and were more likely to view their accommodation as being helpful to staying involved in their child’s care than parents who stayed at the child’s bedside or their own homes. This study highlights how nearby accommodation that includes family peer-to-peer and other support services helped improve the quality of the hospital experience for these families.
Hospital leaders worldwide understand that meeting the accommodation needs of families is an important part of enabling family-centered care. While hospitals are appropriately focused on providing excellent medical care to those they serve, an international survey of hospital leaders also demonstrates an understanding that caring for the whole family allows better care for pediatric patients.7 Hospital leaders reported positive opinions about the contributions of their RMH affiliation to their ability to serve seriously-ill children and their families. This included such important outcomes as increasing family integrity and family participation in care decisions; and decreasing psychosocial stress and hospital social work resource burdens associated with lodging, food, transportation and sibling support.
What is it about the family accommodation program that makes such a positive impact on families and their hospital stay overall? It is not just proximity, lodging or a reduced financial burden. The program is designed to provide comfort, care and support to families through a shared experience with other families facing similar challenges, through activities and meals designed to provide a break from the stresses of daily caregiving, and through a comfortable and uninterrupted night’s sleep.
Future research is needed to understand what can be done for all families with hospitalized children. It is important that further research aim to understand how to better support families who are not traveling long distances to help provide more of the benefits that seem to be associated with an RMH stay. Psychosocial support, a community of families facing similar challenges and forced separation from the chores and expectations when one is at home may be important factors to consider.
1. Kuo DZ, Houtrow AJ, Arango P, Kuhlthau KA, Simmons JM, Neff JM. Family-centered care: Current applications and future directions in pediatric health care. Maternal and Child Health Journal 2012;16(2):297-305.
2. Kuhlthau KA, Bloom S, VanCleave J, Knapp AA, et al. Evidence for family-centered care for children with special health care needs: A systematic review. Academic Pediatrics 2011; 11(2):136-143.
3. Daniel G, Wakefield CE, Ryan B, Fleming CAK, Levett N, Cohn RJ. Accommodation in pediatric oncology: Parental experiences, preferences and unmet needs. Rural and Remote Health 2013;13(2):2005.
4. Franck LS, Gay CL, Rubin N. Accommodating families during a child's hospital stay: Implications for family experience and perceptions of outcomes. Families, Systems and Health. 2013;31(3):294-306.
5. Franck LS, Wray J, Gay C, Dearmun AK, Alsberge I, Lee KA. Where do parents sleep best when children are hospitalized? A pilot comparison study. Behavor Sleep Med 2014;12:307-316.
6. Franck LS, Ferguson D, Fryda S and Rubin N. The child and family experience: Is it influenced by family Accommodation? Medical Care Research and Review 2015 [Epub ahead of print] pii:1077558715579667
7. Lantz PM, Rubin N, Mauery DR. Hospital leadership perspectives on the contributions of Ronald McDonald Houses: Results from an international survey. Journal of Health Organization and Management 2015;29(3):3881-392.
||Nicole Rubin, MHSA, is the Founder and Principal of Impact Solutions, LLC, where she works with nonprofits on strategic planning and assessing impact. She formerly served in a variety of leadership roles for organizations such as Ronald McDonald House Charities of Southern California, Susan G. Komen for the Cure Greater New York City Affiliate and Methodist Health Care System in Houston, Texas.
Deron Ferguson, PhD, is the Director of Analytics at Qualis Health. Qualis Health is one of the nation's leading population health management organizations. He most recently served as Senior Director of Research and Analytics for the National Research Corporation.
Dr. Linda S Franck, RN, PhD is Professor and Jack & Elaine Koehn Endowed Chair in Pediatric Nursing at the University of California San Francisco School of Nursing. Her research program includes investigation of patient and family experience of health care and engagement of parents and children as partners in pain management and in research to improve quality of care and quality of life.
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Posted By Barry J. Jacobs,
Wednesday, May 31, 2017
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This piece is a reprint originally published on 15 May 2017. Please click here for the original post. Reprinted with permission.
On April 26, 2017, while lying motionless in her nursing home bed with closed eyelids and a gaping mouth, my 86-year-old mother took two last short breaths before peacefully going still. Her death from complications of dementia and kidney failure brought to a close a nearly 7-year, sometimes rancorous period of family caregiving after my wife and I moved her up from Florida to live near us. We then gradually took over every aspect of her life.
That wasn’t our intention, of course. We tried to preserve her independence for as long as we could. But as she became confused about her pills, fell more often, and wandered at times, we responded by commandeering her pill box, making her use a walker, and hiring legions of home health aides. With nearly every change, she fought us. That made a sad, deteriorating situation more difficult. Living in a nursing home during her last year-and-a-half gave her the supports she needed and allowed us to finally stop battling with her.
As a clinical psychologist specializing in helping families struggling with illness, I thought I had some idea of what I was getting into. But, looking back, I did only partially. Real-life caregiving for my mom was much more personal and perturbing, complex and challenging, gratifying and vexing than my clinical work or academic reading could have prepared me for. Like all family caregivers, I suffered growing pains but learned a great deal. Here are some of the lessons I gleaned along the way:
There’s no magic other than the caregiver’s creativity: There are dozens of helpful caregiver websites and books offering information on diseases, treatments, healthcare systems; insurance and financial management; stress, dread and joy. (Hey, I’ve written many online articles and two of the books.) But because each caregiving family’s situation is so unique in its history, dynamics, and resources, no self-help blueprint can address each pressing crisis. Ultimately, it’s the primary caregiver who has to trust herself to devise solutions for her family’s particular cast of quirky characters and their problems. As my mother’s condition worsened and my own anxiety-level rose, I think I was too reliant on the pat answers that a nurse or case manager might suggest. I needed to be bolder and more decisive. She was my mother. This was our family.
Professionals came through—except when they didn’t: Perhaps because I’ve worked in various medical settings for nearly 30 years and teach communication skills to family medicine residents, I had high expectations for my professional colleagues. Mostly, they were wonderful—empathetic, knowledgeable, responsive. My mother’s internist—like her, a Jewish kid from the Bronx—was a warm balm to her pain and an effective advocate for me. But there were glaring and infuriating examples of professionals failing at even the most basic courtesies for caregivers. To the nurses who talked down to me as if I didn’t know anything about my mother’s condition, I say that you need to assess not just the patient but the level of understanding and ability of her caregivers. To the emergency room physician who failed to call me for many hours to inform me that my mother had been found down in the street and brought to the hospital by ambulance, I say that you do patients a disservice by marginalizing the family members who have pertinent information and a large stake in the medical outcome. To the home health agency administrator who lied to me on multiple occasions about sending a new home health aide for my mother, I say that I only wish I’d fired your agency sooner.
Anger is an unfortunate way to avoid sadness: Given that my mother and I had an ingrained propensity for arguing with one another, it was unpleasant but too easy for us to lock horns over whether, say, she needed a home health aide on Saturdays or required financial supervision. The big picture of her decline was too sad and frightening to talk about so we avoided it by getting angry over caregiving’s small details. The few instances in the nursing home when we were sad together about her progressing dementia made me feel closer to her than I did at any other time. In retrospect, I wish we’d communed more and fought less.
Adversity creates gratitude: The caregiving went on longer and was harder than I expected. But I have few regrets about having been my mother’s primary caregiver. I learned more about her stubbornly independent character as she faced unremitting loss. I learned something about my own character to just as stubbornly work to ensure her safety and comfort. I’m grateful to my wife for sharing the caregiving with me and for our children for supporting us. I’m grateful to my brother and cousins for pitching in. It was a test for all of us as a family. I believe we passed. No victory lap here; my mother’s dead. But our family endures as one that values caring for one another.
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Posted By Katy Oberle,
Thursday, May 11, 2017
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Approximately 1 in every 68 children is diagnosed with autism spectrum disorder (ASD). Although myriad diagnostic- and treatment-related resources are available for these children, few resources exist to help their families accept and adjust to the diagnosis, deal with various treatment challenges, and cope with the impact of ASD on the family.
Parent training can be very beneficial in decreasing problem behaviors in children with ASD. However, because it generally does not address family functioning, additional family-based work may be needed and can be done simultaneously with other ASD interventions. Sometimes family issues need to be addressed before parent training so that parents can have the emotional resources necessary to successfully implement behavioral interventions.
In my position at a community-based, hospital-run multidisciplinary autism and child development center, I assess children at-risk for ASD and other developmental disabilities, and I provide psychotherapy services for their families. Most parents are relieved to learn about the availability of family-based support since they often experience feelings of isolation, depression, and anxiety. This support offers a space to discuss family issues that are often pushed to the back burner and helps mitigate some of the stress of caring for children with ASD.
While engaged with a family, I collaborate with the other providers involved in the patient’s care. Whenever possible, I co-facilitate family sessions with the patient’s individual therapist from our autism center next door. Oftentimes this clinician has a better sense than I do of the patient’s behavioral and emotional patterns and can, when needed, help deescalate the patient during a session. Through our collaboration, the therapist gathers valuable information about family interactions to inform his/her own work with the patient, and the patient benefits from having an ally in the room.
This was the case for Derrick, a teenager with ADHD and ASD. Derrick struggled with emotional regulation, anger, and aggression, primarily at home. Derrick’s individual therapist was often present in my family sessions. As session progressed with Derrick, his adoptive parents, and his younger brother, the parents realized that as co-parenting was improving, their martial relationship was decompensating. It became important to balance marital and co-parenting roles so the couple could effectively address Derrick’s behaviors while taking good care of their marriage. During couples sessions, Derrick’s parents processed their romantic relationship and families of origin. They became more mindful of how their patterns of interaction impacted each other and how they were affecting the children. In subsequent couple and family sessions I coached parents to engage in mindful listening and communication with each other and with their sons.
It was determined that trauma was a factor at play in the palpable tension and angry exchanges in the relationship between Derrick and his father, Tom; both had experienced abuse in their childhoods. During one session, Derrick explained that when he disclosed to Tom his suicidal feelings the day before, Tom responded in a dismissive manner which angered Derrick to the point of becoming physical with Tom. When I asked Derrick more about this, Derrick confirmed that Tom’s response triggered a memory from Derrick’s time in foster care in which he had felt vulnerable and dismissed. His aggression towards Tom, although unhealthy, was self-protective.
With my coaching, Tom informed Derrick that when he heard Derrick’s suicidal talk, a memory from his own traumatic past was triggered, and he just wanted to “shut it down.” I praised the two for their honesty and resilience, and I imparted to them that being trauma survivors has the potential to deepen their bond. Since then, Tom has been more self-aware and has been working on responding mindfully rather than reacting, especially regarding Derrick. Derrick continues to struggle with emotional regulation, but the foundation for a more positive relationship with his family has been laid.
Family-based work adds important value to any team that participates in the diagnosis or treatment of children with ASD or other developmental disabilities. Child behavior in ASD and family functioning are interconnected, and treating them together can have a synergistic effect. As Doherty et al (1994) states, “all therapeutic issues involve complex systems dynamics at biological, psychological, interpersonal, institutional, and community levels” (p. 34). When we as providers appreciate this phenomenon and create interventions designed to address various systemic dynamics in the lives of our patients, we are truly living into our value of integrated care.
References/ Recommended reading:
Bearss, K., Burrell, T.L., Stewart, L., & Scahill, L. (2015). Parent training in autism spectrum disorder: What’s in a name? Clinical Child and Family Psychology Review, 18, 170-182.
Cridland, E.K., Jones, S.C., Magee, C.A., & Caputi, P. (2014). Family-focused autism spectrum disorder research: A review of the utility of family systems approaches. Autism, 18(3), 213-222.
Ramisch, J. (2012). Marriage and family therapists working with couples who have children with autism. Journal of Marital and Family Therapy, 38(2), 306-316.
Neely, J, Amatea, E.S., Echevarria-Doan, S., & Tannen, T. (2011). Working with families living with autism: potential contributions of marriage and family therapists. Journal of Marital and Family Thearpy, 38, 1, 211-226.
Patterson, S.Y., Smith, V., & Mirenda, P. (2011). A systematic review of training programs for parents of children with autism spectrum disorders: Single subject contributions. Autism, 16(5), 498-522.
Hock, R.M., Timm, T.M., & Ramisch, J.L. (2012). Parenting children with autism spectrum disorder: a crucible for couple relationships. Child and Family Social Work, 17, 406-415.
Garcia-Lopez, C., Sarria, E., Pozo, P., & Recio, P. (2016). Supportive dyadic coping and psychological adaptation in couples parenting children with autism spectrum disorder: the role of relationship satisfaction. Journal of Autism and Developmental Disorders, 46(11), 3434-3447
Hayes, S. A. & Watson, S. L. (2013). The impact of parenting stress: a meta-analysis of studies comparing the experience of parenting stress in parents of children with and without autism spectrum disorder. Journal of Autism and Developmental Disorders, 43(3), 629-642.
Gau, S. S., Chou, M. C., Chiang, H. L., Lee, J. C., Wong. C. C., Chou, W. J. et al (2012). Parental adjustment, marital relationship, and family function in families of children with autism. Research in Autism Spectrum Disorders, 6, 253-270.
Katy Oberle, MS, IMFT is a family therapist at the Child Development Center (CDC) of Nationwide Children's Hospital. She conducts diagnostic assessments for children and teens with developmental and behavioral health concerns, and she provides systemically-focused therapy services to CDC clients and their families. She also serves as the treasurer of the Ohio Association for Marriage and Family Therapy. Her clinical interests include couple relationship enhancement for parents of children with special needs, and systemically-geared mindfulness-based interventions delivered in the context of various healthcare settings.
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Posted By David Haralson,
Tuesday, April 25, 2017
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Children and adolescents are a common sight in primary care, making up approximately 16% of all doctor’s visits (CDC, 2012a). Of those visits, approximately half were problem-focused visits (i.e., child comes in for an earache) and half were routine child checkups (CDC, 2012b). It is important that doctors, behavioral health specialists, and other healthcare providers are competent in relating to and communicating with children. One of the most effective ways to communicate and relate with children is through the use of play. Play can be defined as any fun or enjoyable activity that allows us to creatively express who we are (Association for Play Therapy, 2016) and is one of the primary means by which young children communicate (Landreth, 2012).
Why Play is Important in Primary Care Settings
Although play is as essential to our well-being as love and work are, it is often disregarded in primary care settings. This is understandable as play is generally seen as a time-consuming and non-directive process, two characteristics that seem almost incompatible to the fast-paced, provider-directed culture of primary care. As a medical family therapist who has seen first-hand the healing power of play, I have worked to figure out simple, yet creative ways that we can more effectively use play while working with children in primary care settings. Here are a couple of suggestions for behavioral health specialists or other healthcare providers who wish to use play in primary care.
● Paper with a blank gingerbread person
● Small box of crayons
1. Tell the child that the gingerbread person represents their body.
2. Ask the child to choose their favorite crayon.
3. Ask them to color or draw where in their body they feel pain or discomfort.
4. Ask them if they want to use another crayon or draw anything else on their gingerbread.
5. Ask them if they would like to draw what is going to make them feel better on the margins of their gingerbread person
6. Ask follow up questions on their drawing like, “Can you tell me what you drew? What is that you drew in the margins?” “I notice a lot of red. If you don’t mind me asking, did you choose red for a reason?”
7. Follow-up with parents if you have any additional questions.
Doctor's Toy Kit
● Doctor’s toy kit
● Smooth surface (table, chair, etc.)
1. Hold the bag up and tell the child that in the bag there are a few things that the doctor might use to make sure their body is feeling OK.
2. Spread the toys out on a smooth surface and ask the child if he or she would like to play.
3. Observe them play and reflect what you see: “You are using the stethoscope on mommy.”
4. After a few minutes, ask the child if it would be OK if you demonstrated what some of these toys are used for.
5. Demonstrate how the doctor might use these toys with the child. Observe and reflect on their reactions.
6. Ask them if they have any questions and let the family know the doctor will be in shortly.
● Mini-play dough
1. Ask the child to create what they believe is making them feel yucky or have pain.
2. Explore with the child what item they chose to create and why they chose that item.
3. Let them know that part of the doctor’s job is to help them get rid of the pain or yuckiness. In order to do this, though, sometimes this means having to do scary things like having a look in their mouth, their ears, or having a shot.
4. Let the child know that if they start to feel scared or stressed, they can smash or squeeze this play dough in any way they want to.
● Your favorite book on nutrition, exercise, or some other topic
1. Show the family that you have a book that you like to read to each child that comes in for their first visit with their doctor.
2. Ask the parents to look through the book to make sure they agree with everything presented.
3. Read the book out loud to the parent and child.
4. Ask the child follow-up questions about what they learned and how they feel they are doing with keeping their body healthy.
5. Set a goal with the family about eating healthier, exercising more, etc.
Drawing with Teenagers
● Plain white piece of paper
● Pencils or color pencils
1. Use traditional screening tools for family and individual struggles (i.e., family conflict, depression, etc.)
2. After discussing their results, tell them that many people feel more comfortable drawing how they feel or what they are struggling with then talking about it.
3. Ask them to draw the problem, the pain, or the struggle that has brought them into the clinic that day.
4. Validate and listen to their concerns.
5. Ask them what has helped them overcome this pain, problem, or struggle.
6. If willing, set a goal with them based on their answers from the previous step.
There are also many cell phone apps that can be used for self-care or for the management of difficult thoughts or emotions. Some of my favorites to use with patients are Breathe2Relax, PTSD Coach, or Bliss. If possible, download the app with the patient and practice one or two of the exercises together.
Tying it all Together
These strategies are, by no means, exhaustive. The strategies are endless! These are only a few, simple ways that we, as healthcare providers, could more fully use play in primary care. Remember, it is important that we do our best to learn the language of those whom we serve. And play is one of the primary languages of children!
David Haralson is a Ph.D. student in Medical Family Therapy at East Carolina University. For nearly four years he has worked as a bi-lingual medical family therapist in a variety of primary care settings. In particular, he enjoys helping families who struggle with substance misuse or other life-altering health conditions (such as cancer or MS). He often uses play therapy in his day-to-day work with children, adults, and their families. He is currently on the path to becoming a licensed marriage and family therapist and AAMFT approved supervisor.
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Posted By Barry J. Jacobs,
Wednesday, March 15, 2017
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This piece originally appeared on the Huffington Post. Posted here with permission.
“You are treating her like she’s a piece of meat,” Tony was shouting angrily at me. I hadn’t the power to change the care his 62-year-old wife was receiving in my hospital’s intensive care unit—for the past two years, I had been their psychologist, not nephrologist—but, for the moment, I became the embodiment of all Medical Authority. “She just lies there, unconscious and horribly swollen. You don’t do anything for her except stick her with more needles.” The look on his face then shifted slightly from accusatory to imploring. But I couldn’t save her.
His wife, Elena, had been bedbound in their tiny apartment in suburban Philadelphia for at least five years because of chronic, severe back and knee pain. She’d become confined there as the result of a series of personal and medical missteps—or, put another way, lack of steps. Once she’d entered middle age and her girth thickened, her joints had started aching because of the increased weight they supported and she consequently walked less. As she’d walked less and took to her “sick” bed more often, she burned fewer calories but never adjusted her diet and consequently gained more and more weight. Taking handfuls of pain pills every day didn’t relieve her joints and propel her off the mattress; instead, they only sedated her into a supine stupor in front of the TV. And the long-term narcotic use gradually took its toll: Her kidneys and other organ systems were now shutting down.
Tony was her devoted enabler. He’d waited on her slavishly, bringing her favorite foods, sitting bedside with her every day for hours to watch TV and listen to her steady complaints. He owed her, he felt, because she had stuck with him through his wild drinking years until he finally sobered up. He’d paid her back by sticking with her through her retreat from the world and now he was still sticking with her in the hospital, like he thought he was supposed to do. He would plead with the doctors to make her whole. He would utter lengthy beseeching prayers during sleepless nights in the armchair in Elena’s ICU room. But he could see that none of it was working. He was frightened for her life. He was afraid he was letting her down.
My job, it seemed to me, was not to try to persuade her medical specialists to make hail-Mary efforts for Tony’s sake. Neither dialysis nor multiple meds were working. My job was to convince him that Elena’s condition had taken a discernible turn. Family psychiatrist John Rolland of the Chicago Center for Family Health has written compellingly about the phases of illness—acute, chronic, terminal—and how hard it is for patients and families to switch their expectations and actions from one phase to another. We all believe at first that our ailments have a cure until some professional tells us that our condition is chronic and that we will have to learn to live with managing the symptoms. We are all lulled into believing that life with that chronic condition will go on and on until the end hits us shockingly like a sucker punch. This is the hard stop on hope.
“Tony, I’m worried that Elena won’t make it,” I said quietly. He stiffened and said, “No,” but the word sounded more resigned than forceful as if he knew that protesting wouldn’t change anything. We’d worked together for two years and he trusted me. By stating the inevitable first, I was giving him permission to begin thinking about the possibility of her death without feeling guilty. “You’ve been a very good husband to her for a long time,” I went on. And then to suggest a way he could continue to be good to her, I said, “I think it’s time to talk with her doctors about considering hospice.”
“Yeah, well, we’ll see,” he said gruffly. Over the next few days he continued to push her physicians to try new interventions as if defying what I’d said. But our short exchange had a started a process. He didn’t want to accept that she was in the terminal phase but he now knew it. When the doctors themselves approached him with the suggestion of taking her off of life supports, he acquiesced. She died a day later.
In our initial meetings in the months afterwards, he was still angry at her doctors and at what he saw as an uncaring world. But time passed and anger abated and he began to allow himself to feel relieved of the burden of caring for her without also feeling guilt for getting rid of her. “You were a good husband,” I kept telling him. With time, he came to see that that didn’t mean preserving her life, but accompanying her through its vicissitudes, termination included.
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Posted By Kaitlin Leckie, Kristine Miller,
Wednesday, February 15, 2017
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During the 2015 CFHA
conference plenary, Vincent Felitti likened poor health behaviors (e.g.,
smoking cigarettes; IV drug use; overeating) to the smoke in a house fire. If
you see the smoke as the problem, and use fans to blow the smoke away, you will
not only fail to put out the fire, you will fan the flames. Treating poor
health behaviors as the primary problem, without attending to the real underlying issue(s), will have a
similar effect, according to Felitti.
Felitti’s analogy reminds
me (KL) of the Process Model of Addiction and Recovery (Harris &
Tabor-Wilkes, 2011), whereby the desire to cope with negative feelings caused
by underlying pain (be it spiritual, emotional, relational, physical, etc.)
drives the decision to adopt an unhealthy or compulsive behavior (e.g.,
hoarding, smoking, IV drug use, alcohol, overeating). While this behavior may
provide an instantaneous but short-lived rush of relief, the resulting feelings
of shame and guilt are longer lasting. This perpetuates the experience of pain,
thereby re-starting the cycle.
The pain that people are
trying to overcome often began in childhood, as a result of what Felitti,
Robert Anda, and their research team (1998) call Adverse Childhood Experiences,
or ACEs. The main categories of these experiences include household
dysfunction, neglect, physical abuse, psychiatric disorder of a parent,
parental substance abuse or incarceration, childhood maltreatment, and sexual
abuse. These experiences can be objectively scored on a questionnaire. Scores
range from zero to ten. Ten indicates that the respondent experienced an event
in each of the ten categories at least once.
An ACE score of four or more (at
least one event in four different ACE categories) correlates strongly with
increased prevalence of chronic disease in adulthood, as well as a high
prevalence of multiple unhealthy lifestyle behaviors, such as smoking, IV drug
use, and promiscuous sex (Felitti et al., 1998). In a sampling of findings from
the longitudinal ACE study, Felitti and Anda (2010) summarize other strong and
significant relationships of ACE scores to biomedical disease, psychiatric
disorders, unhealthy behaviors, and healthcare costs.
During the plenary, Felitti
highlighted that people who are seeking to relieve their pain are mostly
interested in feeling relief as quickly as possible. They typically are not
thinking about the long-term consequences of their choice. Hence the ineffectiveness
of telling a smoker about the likelihood of future lung disease. Instead of
inducing behavior change, the response is akin to: "Smoking provides me relief
right now, which is what I need.” Until the underlying pain is
addressed/treated, the likelihood of people being willing to change an
unhealthy behavior they have adopted to help them cope is pretty slim.
from understanding this truth, successful intervention should rely on a
multi-faceted approach; comprehensive and integrated health care is an ideal
way to address and treat pain from the past. Yet, we can do better than that. Particularly
in primary care/family medicine, we train clinicians to be proactive, not
merely reactive. As such, prevention of ACEs is vital for individual, family,
and population health.
At our primary care
clinic, Southern Colorado Family Medicine (SCFM), the proactive approach we
developed to prevent ACEs for our patients is called SCAN: Score, Connect, and
Nurture. First, we educated our entire
clinic staff about ACEs and then trained our clinicians how to talk to patients
about ACEs. We now assess ACEs in expectant
parents and parents of 0-18 year old patients, focusing our efforts on breaking
the cycle of ACEs often observed across generations. We perform universal
assessments on this targeted population because ACEs affect everyone,
regardless of sociodemographics. We educate parents about what having
experienced ACEs means for their health and what can be done to try to decrease
the risk of their children going through some of the same experiences.
intervention centers on meeting participants where they are. For example, with
parents who have experienced ACEs, the clinician normalizes and explains that
some people feel they have overcome some of their difficult experiences from
childhood but may feel "tripped up” by others. To help meet their specific
needs, all families are offered resources by a family resource specialist, a
social worker embedded in our clinic by a local community resource organization.
Examples of resources offered include parenting education and support with home
visits by a community-based parenting specialist, financial assistance,
children’s books, and mental health treatment referrals.
Of the many success
stories we have had throughout the year, one example that stands out is one of
our first SCAN families. This couple was
expecting their first baby while facing multiple psychosocial concerns. In
addition to having minimal social support, they were being evicted from an
apartment that was later condemned. Of the ten main categories on the Adverse
Childhood Experiences questionnaire, the expectant mom endorsed 9 of them, and
the soon-to-be father had experienced all ten ACE categories, a score of 10 out
Yet, their ACEs scores
and their struggles represent the beginning
of their SCAN story, not the end. Both parents also scored highly on a measure
of resiliency--also part of the SCAN intervention--indicating they were
resourceful and skilled at successfully overcoming challenges. They were scared
and voiced a strong desire to parent their child differently than they
themselves had been parented. They were motivated to get help in order to be the
parents they wanted to be to their child. We provided them with a supportive
and understanding healthcare environment, and our Family Resource Specialist
linked them with several resources to boost their confidence and enhance their
Ultimately, we assisted them in locating safer housing, helped him get
a new job, connected them with mental health services, and enrolled them in a
parenting education and home visiting program for continued support after the
baby was born. The impact of the SCAN intervention, including their perception
of our healthcare environment as safe and accepting, was made evident when,
after a later traumatic event occurred, they returned to our clinic to seek
additional care and support.
The adoption of unhealthy
behaviors is not the only explanation behind the strong connection between ACEs
and later development of chronic disease, as pediatrician Nadine Burke Harris
explains in her TEDMED talk on the profound ways in which the
ACE study changed her clinical practice. Even so, reframing our way of looking
at unhealthy behaviors--not as problems themselves but as adaptive solutions to problems--broadens our
perspective and increases the likelihood with which we are able to intervene
and help patients to adopt healthier behaviors.
References and suggested
Burke-Harris, N. (2014). How childhood trauma
affects health across a lifetime. TEDMED 2014.
Felitti, V. J., & Anda, R.
F. (2010). The relationship of Adverse Childhood Experiences to adult medical
disesae, psychiatric disorders, and sexual behavior: Implications for
healthcare. In The Hidden Epidemic: The Impact of Early Life Trauma on
Health and Disease. Ed. Lanius, R. & Vermetten, E. Cambridge University
Felitti, V. J., et al. (1998). Relationship
of childhood abuse and household dysfunction to many of the leading causes of
death in adults: The Adverse Childhood Experiences Study. American Journal
of Preventive Medicine, 14, 245-258.
Harris, KS, Smock SA, Tabor Wilkes, M. (2011).
Relapse Resilience: A Process Model of Addiction and Recovery. Journal of Family Psychotherapy 22 (3),
|Kaitlin Leckie, PhD, LMFT, is the Director of
Behavioral Medicine at the University of Texas Medical Branch’s Department of
Family Medicine in Galveston, Texas. |
|Kristine Miller, D.O., is a faculty physician in
Pueblo, Colorado, at Southern Colorado Family Medicine Residency, where she
serves as the Clinic Director and Director of Osteopathic Education. |
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Posted By Matthew P. Martin,
Tuesday, January 10, 2017
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According to the U.S. Census, 87% of Americans live with a
family member. That’s 8.7 out of 10 human beings in the U.S. living with a
loved one. That’s huge! Let that sink into your brain for a moment. That means
that most of us are sharing a house, a condo, an apartment, or other dwelling
with someone we consider to be "family”, however you define it. In the words of
Joe Biden, "That’s a big … deal”. My goal is to convince you that the family
should be at the heart of our health care system but that evil forces are
conspiring to kick it to the curb in favor of "population health” and
"community” (I’m dramatically using both of my hands to make these air quotes).
Family relationships impact your health. Did you know that family
dynamics can even lower glycated hemoglobin levels and increase knowledge of chronic
disease like diabetes? It can even predict
the body mass index of youth! Imagine a doctor prescribing family time like
a drug. "And one more thing, Mr. Martin. I’m prescribing you 20 mg of quality
communication with your wife. There may be some side effects like loss of
football knowledge and increased libido but you should be okay.”
Despite this evidence, family-centered care is much more the
exception than the norm. Even though many medical clinics emblazon the words
"family care” on their door sign, you would be hard pressed to find physicians
who encourage bringing family members to an appointment or who even ask how
family life is affecting your health. Usually "family care” means that the
physician can treat anyone in your family; just don’t expect the doctor to ask
a patient what his wife thinks about his smoking.
It wasn’t always this way. In the famous painting "The
Doctor” by Sir Luke Fildes (1891), a general practitioner sits all night with
parents whose daughter is sick from an infection. Sure it’s a romanticized
ideal, but house calls in the past probably included a conversation with the
rest of the family. An astute doctor making a house call would collect more
health information in 30 seconds than in three medical appointments. Fun fact:
in 1949, this painting was used by the American Medical Association in a
campaign against a proposal for nationalized medical care put forth by
President Harry S. Truman. How times have changed!
House calls aside, we have lost our way in this post-family 21st
century of self-driving cars and 3-D printers. The family has been cast aside
in favor of the greater neighborhood and community. Public health officials and
policy wonks dream of a health care machine that looks beyond the tight-knit
relationships of family units to broader systems of "population health”. This
globalist view maligns the bi-directional influence of family dynamics and
health and supplants it with a broad focus on systems that are too big for any
medical exam room.
It’s time to bring health back to the family! Imagine a
health care system in which nurses inquire about blood pressure as well as
marital pressure. Imagine a system in which physicians ask how the newly
diagnosed diabetes is affecting family meals or how the adult children can help
the patient manage stress better. That is the kind of system that will make
family great again and lower health care utilization and costs. That is the
system that leads to winning, so much winning that you may get tired of it and
say to your physician, "Doctor, please, we’re tired of all this winning”. And
she’s going to say, "I’m sorry but we have to keep winning”.
Now, a word of caution: the other side will attempt to
convince you that the family is passé and that the future is the "population”,
the "community”. They will cleverly concede that the family was instrumental in
helping our pre-industrial progenitors but that now is the time for the
physician to look beyond the family and into a patient’s "community”. They
believe that it takes a village to care for your sickly grandfather and not the
adult children. They believe your neighborhood is going to give you a hug and
encourage you to cut back on your drinking. They believe in population health,
not family health. Little do they know, the family is the basic unit of any
population. Strong families lead to a strong population. It’s a beautiful
thing, am I right? Of course I’m right.
Here are two ways to make the family great again in our
healthcare system. First, family caregivers need more support and attention. Most
patients want to stay at home and be cared for by a loved one, but this
presents financial and medical challenges for caregivers. Insurance companies
should make it easier for caregivers to be trained and compensated for their
time. Not only does this save money for society, it improves the patient’s
quality of life.
Second, researchers need to determine the best practices of
family-centered care and educators need to teach these practices to healthcare
professionals. Right now, we have a strong group of cheerleaders championing family-centered
care but no clinical competencies and evidence-based teaching strategies. We
need family champions, but we also need a big, beautiful wall of evidence that
family-centered care works.
We need to drain the swamp of public health and policy
centers everywhere and get "Big Data” out of the healthcare system. If not now,
then when? If not us, then who? Please join with me in bringing health back to
the family, back to the basic unit of society. Thank you and God bless.
Martin, PhD, LMFT, serves as the Director of Behavioral Medicine at Southern
Regional AHEC in Fayetteville, NC. He is the CFHA Blog Editor. |
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Posted By Lisa Zak-Hunter,
Wednesday, December 14, 2016
| Comments (0)
NOTE: in an
earlier blog, I
addressed how personal definitions of family impact care (explicit biases).
Therefore, this blog focuses only on implicit biases.
A physician was in disbelief. He anchored
himself in the belief that people were not inherently better or worse than
others based on factors such as gender, race, disability, sexual orientation,
religion etc. Yet here he sat, faced with his online score on the Implicit
(IAT) hosted by Harvard University. It read: strong preference for light skin over
dark skin. He struggled to comprehend what this meant. Deep down, was he
racist? He so firmly believed otherwise, that he didn’t understand how to
comprehend the results and what it meant for how he practiced.
Stereotypes surround us. They are the
learned associations between a characteristic and a social group. They may be
true at a group level but inaccurate individually. For example, most people in
Kansas City are Royals fans but some may be Cardinals fans. Although some
stereotypes are benign, there are a number of stereotypes that are more
contentious and have implications related to power, equity, safety, and legal
concerns. Explicit bias refers to the stereotypes one readily acknowledges that
they hold. "I believe women are more nurturing than men”.
implicit bias refers to the stereotypes or associations that occur
unconsciously or outside of conscious control. They develop early based on
reinforced social stereotypes. For example, implicit beliefs about race are
established in childhood whereas explicit beliefs change with age1. By definition we are ignorant
to our implicit biases and not immune to their power. Simply knowing a
stereotype can distort information processes, despite self-reported beliefs.
For example, college students’ implicit race bias did not impact self-reported
egalitarianism, but did predict friendliness towards Black students.2 Students who thought they
felt Blacks and Whites should be treated equally, were not, in fact, as
friendly to Black students.
What are the implications for healthcare
delivery? The literature on bias and physician decision making reveals that
even when physicians endorse no explicit negativity to various groups, they
still hold a number of implicit biases such as: Blacks were associated with
being uncooperative, especially regarding procedures, Whites were linked with
greater compliance, and obese persons were correlated with negative words such
as lazy, stupid, or worthless.3-5 If physicians have these biases but don’t
realize it, what impact does that have? It’s hard to completely tell, but
we do see that patients view physicians more negatively, and physicians make
different assessments and treatment choices.
For instance, even if physicians
think they hold little race bias but have high implicit race bias, Black
patients rate them as less team-oriented, friendly, and warm.6 If patients have negative
perceptions about their physician or their ability to establish a relationship
with their physician, how likely are they to adhere to treatment regimens or
return for follow-up appointments? Other examples indicate that elderly
patients are offered less treatment than younger patients for depression and
suicidality, or women are less likely than men to receive knee arthroplasty when
indicated. These findings have led some to propose that implicit biases are a
contributing factor to health disparities.7
An area of research that has yet to be
explored is family composition or constellation bias. This is a term I coined
to refer to the type of bias about who makes up a family or who is ‘in’ a
family. Nuclear family bias has been examined in stepfamily research, but this
term fails to address parental sexual orientation. Traditionally, the preferred
family is a heterosexual married couple with children.
Based on the research of
other forms of bias in healthcare, it would not be surprising if provider
implicit bias about who should be in a family would impact how they work with
that family. I argue this could have important implications for relationship
building, treatment adherence, assessment, and treatment choice- similar to
what the literature indicates with other implicit biases. Even providers who
ascribe to the notion ‘the patient defines their family’, may have some strong
implicit biases that negatively impact their care.
are some ways to address this?
Accept your implicit biases. Respect they impact your work. Understand
they come from reinforced stereotypes. The more you see a stereotype- in the
clinic, on the news, with friends, at the movies etc, it reinforces the
Address the source of implicit biases: stereotypes.
Be mindful when you encounter a stereotype and call it
out as such. There is power in making the implicit explicit, moving the
unconscious to conscious.
Commit to learning.
Read the research. For example, what ARE the outcomes for
children raised by gay or lesbian parents?
Get connected with local community centers, churches,
organizations that support different forms of family. Have a liaison speak to
Stay humble and curious. Don’t assume. Always ask about personal
you don’t already, try letting the patient define who is ‘family’. Ask
how family members should be included in care. This may get tricky with legal
concerns, documentation, or space concerns (how many people can we
realistically cram into an exam or labor and delivery room?).
Be careful about venting. Venting has the tendency to reinforce
stereotypes and feed implicit biases.
Do your own work or provide a space for others to do theirs.
Make your own genogram complete with all the relationship
connections- many a genogram look like a defensive coordinator’s playbook.
Examine how your experiences shape your understanding about family.
Think about the types of families you encountered growing up. What
were your impressions of them/how were they discussed? How did that inform your
thoughts about ‘family’? Where did you learn what makes a ‘preferred family’
vs. a ‘non-preferred family’?
you work in a training facility, consider a lecture or didactic on this
1. Baron AS, Banaji MR.
The development of implicit attitudes. Evidence of race evaluations from ages 6
and 10 and adulthood. Psychol Sci. 2006;17(1):53–8.
2. Dovidio JF, Kawakami
K, Gaertner SL. Implicit and explicit prejudice and interracial
interaction. J Pers
Soc Psychol. 2002; 82(1):62–8.
3. Green AR, Carney DR,
Pallin DJ, Ngo LH, Raymond KL, Iezzoni LI, et al. Implicit bias among
physicians and its prediction of thrombolysis decisions for black and white
patients. J Gen Intern Med. 2007;22(9):1231–8.
4. Sabin JA, Rivara FP, Greenwald AG. Physician
implicit attitudes and stereotypes about race and quality of medical care. Med
Schwartz MB, Chambliss HO, Brownell KD, Blair SN, Billington C. Weight bias
among health professionals specializing in obesity. Obes Res.
Penner LA, Dovidio JF, West TV, Gaertner SL, Albrecht TL, Dailey RK, et al.
Aversive racism and medical interactions with Black patients: a field study. J
Exp Soc Psychol. 2010;46(2):436–40.
Chapman, EN, Kaatz, A, Carnes, M. Physicians and implicit bias: How doctors may
unwittingly perpetuate healt care disparities. J. Gen Intern Med. 2013 28(11)
Zak-Hunter, PhD, LMFT is Assistant Professor and Coordinator of Behavioral
Science at St. John’s Family Medicine Residency at the University of Minnesota
Department of Family Medicine and Community Health. Her interests include
family healthcare, practitioner wellness, resident education, and the impact of
trauma and adverse events on health outcomes and point of care interventions to
address these. Within CFHA, she co-edits the Families and Health Blog and
serves as Social Media Director.
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