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Exploring the Ethical Challenges in Working with Diverse Couples in Primary Care

Posted By Tina Schermer Sellers, Wednesday, September 28, 2016

Tina will host a Masters Lecture at the upcoming 2016 Annual Conference in Charlotte.  


It’s 9 am and you are already behind. Bob, 56, is on your schedule. It’s a follow up for his diabetes and blood-pressure. You have seen Bob, his wife Anne, and their three kids for over ten years. As you walk in, Bob seems anxious. You talk about the local football team, how the kids and Anne are doing, and then about his issues. You ask about how he is doing generally. Bob says he is really slammed at work and has been traveling a lot.


He then says, "Hey doc, we’ve been friends a long time, right?” "Yea, I’ve been seeing you for a long time”, you answer. "Well”, Bob continues, "I need you to keep a secret. I need you to run a little test for me. You see, I have this weird burning sensation when I pee, and I haven’t exactly been faithful. But you can’t tell Anne!” "Holy crap”, you think, "I saw Anne on my schedule for her annual this afternoon!”

In the hamster wheel that is primary care, clinicians master the art of moving and thinking fast - morning until night – except for those precious moments when they give patients their expansive attention. But the expansiveness stops there. If the provider is impacted by an ethical dilemma, where is the time to process this? If there were time, is consultation encouraged in the clinic culture? If it is, who is available to consult?


Dilemmas such as these come in many forms, from patients presenting lifestyles that conflict with the provider’s beliefs and values, to being placed in a triangle. A patient might consent to something that puts their emotional or physical health in danger or a loved one might make a choice for a dying patient that you disagree with, or another family member disagrees with. There are many situations that potentially fall outside the realm of what is clearly defined by a clinician’s guild.

For example, do you know how to deal with the kink couple who has a fetish that involves injury? Would you be able to distinguish this from abuse? What kinds of questions would you ask to be sure consent was being given versus coercion? How do you feel about treating a transgender adolescent? What if their parent is against their transition? How do you feel about treating a gender fluid teen? What if you had a patient with a rare benign brain tumor that went metastatic and now looked like it would be fatal, but she was refusing to tell her teen daughters and forbidding her husband to tell them also?


Do you know how to deal with the kink couple who has a fetish that involves injury? 

Since it is impossible to prepare for all ethical dilemmas that might confront the clinician in primary care, the provider must broaden their awareness of what triggers their reactivity in the face of ethical dilemmas, and closes their curiosity and openness – a kind of provider self-inventory. This is done through two primary avenues. First is to explore key beliefs and values that inform their spirituality or sense of truth, and examine the positive and negative sides of these beliefs with regard to how they influence their work as a clinician.


Second is to stay focused on their concern for the health and well-being of their patient and of the family system. To do this, they ask open-ended questions about how well-being is or is not being maintained, and the potential dilemmas being imposed. Beyond these two avenues, it is important for the clinician to create strategies to support themselves. These kinds of situations take an emotional toll. Strategies both at the clinic, and outside of the clinic, must be in place to restore and renew the provider if they are to thrive as a healer.

Come explore as we unpack the wild and mysterious underbelly of primary care, where the clinician’s heart meets the patient’s autonomy … and they don’t see eye to eye.

Tina Schermer Sellers, Ph.D., LMFT, the director of the Medical Family Therapy Post-graduate Certificate Program in the Department of Marriage and Family Therapy at Seattle Pacific University. She has been a member of the Collaborative Family Healthcare Association (CFHA)since 1993, is a past board member and is currently on the CFHA Advisory Board. She is also a Certified Sex Therapist and Supervisor for AASECT. 

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Naloxone: Prescribing Like a Life Depends on It

Posted By Ryan Jackman, Tuesday, September 20, 2016


I first met Nick (name changed) in May of 2016 in a rural Emergency Department in Western Colorado as I placed a central line into his neck after he had been intubated. Nick, like far too many others, had overdosed on opioids. It was three days until Nick was extubated because of aspiration pneumonia sustained during the episode, and it was three days until I got the entire story – a story that unfortunately is not unique.


Nick had been working on sobriety from prescription opioids and heroin on his own, and had managed to endure withdrawal and cravings for three weeks before a relapse. When he relapsed he returned to taking the same dose of heroin he had previously used. Without the tolerance he had previously developed, his brain was overwhelmed by the heroin and his respiratory drive was compromised to the point that when his aunt found him the next morning and called 911 he was blue, unresponsive, and cold.

Drug overdose is the leading cause of accidental death in the US (having surpassed motor vehicle crashes and firearm related death in 20081,2), with 47,055 lethal drug overdoses in 2014. Opioid addiction is driving this epidemic, with 18,893 overdose deaths related to prescription pain relievers, and 10,574 overdose deaths related to heroin in 2014.3 Even more alarming are the number of non-fatal overdoses, estimated to be 25-30 times greater. These astonishing numbers have led the CDC and Obama Administration to name the current opioid crisis an epidemic and one of the top four epidemics currently facing the U.S. including obesity, heart disease, and cancer.4,5


In addition, these numbers have attracted record media attention with numerous research studies, news stories, and television documentaries all seeking to quantify and characterize the problem; something that Scott Pelley’s recent 60 Minutes monologue summarized well: "After 40 years and a trillion dollars, the nation has little to show for its war on drugs. Prisons are beyond crowded and there’s a new outbreak in the heroin epidemic. If it’s time for a change, it would be now.”6


One way that this change has come is in the form of naloxone, or Narcan®. It is a medication that is well known in the field of medicine, but until relatively recently was not endorsed to be prescribed to the general public; a fact that research is now showing was a fatal mistake. 7,8,9,10,11

Opioids do their most damage during an overdose by decreasing a person’s respiratory rate, which can ultimately produce coma, heart failure, and death from lack of available oxygen. Thus, reversing opioid effects in a timely manner is crucial when an overdose occurs. So crucial, that waiting for EMS to arrive and administer naloxone may be too long. For this reason, a national effort is being made to increase outpatient naloxone prescribing and training.12


At the Center for Dependency, Addiction, and Rehabilitation (CeDAR) in Denver, Colorado, where I work, specific attention is being given to train patients with opioid use disorder and their loved ones on the use of naloxone.13 This training consists of: Didactics on recognizing overdose vs overmedication, the value of naloxone in an overdose, assessing breathing and how to deliver rescue breaths if needed, administering intranasal naloxone, and involvement of emergency services.


Beginning in 2014 CeDAR began training these individuals in the inpatient rehab setting, and has received significant positive feedback from patients, family members, and friends as well as a report of an overdose reversal. Given the success of this program it was quickly expanded to the outpatient setting where it was implemented in an opioid support clinic that has been embedded into a local patient-centered medical home family medicine clinic, complete with integrated mental health services.


 Reversing opioid effects in a timely manner is crucial


This setting, with all of its services and team-based integrated care has not only allowed for this program’s streamline implementation but has also allowed for the program to be improved upon. Some of the ways in which this program was improved upon and patient care was expanded through an integrated care model include:


· The flexibility of performing training in both individual and group settings.

· Recognizing that naloxone training naturally provides multiple intervention/discussion points that are benefited by integrated behavioral health co-visits where the team is able to point out that:

o Naloxone offers patients and loved ones, who often feel powerless, a tool and sense of empowerment in addressing a disease that impacts every component of their lives. Additionally, it empowers the patient to treat an overdose in another person if needed.

o Addiction is a chronic disease with a relapsing-remitting pattern, and prescribing naloxone is evidence of the patient’s commitment to treatment rather than providing a patient permission to relapse.

o A naloxone prescription further invests the patient and his/her support team in his/her care

o Multiple team members available to contribute and lead training which allowed for efficiency, including working with pharmacies to have naloxone prescription available to distribute at the training.

o Continuity and breadth of care which help to increase patient and his/her support team’s buy in.

o Advocacy by members of the team for patients and within the medical community, helping to address misperceptions by other health care providers regarding naloxone and addiction.

The bottom line is that opioids are killing people and destroying social constructs, such as family, that are crucial for health. Naloxone is a tool that has been under-utilized, but that integrated health care is in the perfect position to effectively utilize and increase the number of lives that are saved. Naloxone isn’t the "silver bullet” to the opioid crisis, but like epinephrine in anaphylaxis; naloxone is the life-saving "second chance” that patients like Nick need.


Imagine a scenario where Nick’s aunt had naloxone on hand for immediate treatment and knew the symptoms of overdose to look for. He may not have required the same level and duration of care, and even if he had, the sense of purpose his aunt would have experienced in the moment would be much preferred to the sense of utter helplessness she experienced instead. When I met with Nick before he left the hospital for a rehab intake appointment, a prescription for naloxone in his hand, he said "Thank you. That was eye-opening. I’m glad I got to wake up.”


For additional clinical guidance the following online resources are available:


· SAMHSA Opioid Overdose Toolkit:



1. U.S. Department of Justice Drug Enforcement Administration. (2015). National Drug Threat Assessment Summary (DEA-DCT-DIR-008-16).

2. Rudd, R., Aleshire, N.,Zibbell, J., Gladden, RM. (2016). Increases in Drug and Opioid Overdose Deaths — United States 2000–2014.

3. Center for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System, Mortality File. (2015). Number and Age-Adjusted Rates of Drug-poisoning Deaths Involving Opioid Analgesics and Heroin: United States, 2000–2014. Atlanta, GA: Center for Disease Control and Prevention. 2014.pdf.

4. Center for Disease Control and Prevention. (2016). Injury Prevention and Control: Opioid Overdose.

5. The White House, Office of the Press Secretary. (2016). Fact Sheet: Obama Administration Announces Additional Actions to Address the Prescription Opioid Abuse and Heroin Epidemic [Press release].

6. Pelley, S. (2016, June 5). A new direction on drugs. [Television broadcast]. Fager, J. (Producers), 60 Minutes. New York, CBS Broadcasting.

7. Maxwell, S., Bigg, D., Stanczykiewicz, K., & Carlberg-Racich, S. (2006). Prescribing naloxone to actively injecting heroin users: A program to reduce heroin overdose deaths. Journal of Addictive Diseases, 25(3), 89–96.

8. Piper, T., Rudenstine, S., Stancliff, S., Sherman, S., Nandi, V., Clear, A., Galea, S. (2007). Overdose prevention for injection drug users: Lessons learned from naloxone training and distribution programs in New York City. Harm. Reduct. J., 4,3.

9. Seal, K., Thawley, R., Gee, L., Bamberger,J., Kral, A., Ciccarone, D., Downing, M., Edlin, B. (2005) Naloxone distribution and cardiopulmonary resuscitation training for injection drug users to prevent heroin overdose death: A pilot intervention study. Journal of Urban Health, 82(2), 303-311.

10. Sporer, K., Kral, A. (2007). Prescription naloxone: A novel approach to heroin overdose prevention. Annals of Emergency Medicine, 49(2), 172-177.

11. Tobin, K., Sherman, S., Beilenson, P., Welsh, C., Latkin, C. (2009). Evaluation of Staying Alive programme: Training injection drug users to properly administer naloxone and save lives. International Jouranl of Drug Policy 20:131-136

12. Dowell, D., Haegerich, TM., Chou R. (2016). CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep; 65:1–49

13. Pade, P., Fehling, P., Collins, S., Martin, L. (2016). Opioid Overdose Prevention in a Residential Care Setting: Naloxone Education and Distribution. Subst Abus; 0:0, 1-5. Apr 19:0 [Epub ahead of publishing]

Ryan Jackman, MD is a board certified family physician that is currently completing a one-year addiction medicine fellowship at the University of Colorado, Denver. He recently completed his family medicine residency in Grand Junction, CO. In addition to addiction medicine, his clinical interests include full spectrum medicine, obstetrics, rural medicine, and clinical-based research which currently includes a joint project for STFM-NIDA focused on expanding addiction medicine curriculum in family medicine residencies. He is married with two little girls.

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American Indian Resiliency In the Face of Suicide

Posted By Laurelle Myhra, Thursday, September 15, 2016


American Indians and Alaska Natives (AI/ANs) have the highest prevalence rate of suicide in the nation. Suicide is the second leading cause of death among AI/ANs between age 10 to 34, and 1.5 times higher than the national average for ages 15 to 34 (CDC, 2013, 2011). Risk factors for suicide include mental health disorders, substance abuse, intergenerational trauma, and community-wide issues (Indian Health Services (IHS), 2016). 

Additionally, social ills contribute to risk factors, including experiences of systematic oppression, trauma, racism (e.g., mascot) and historical trauma practices (e.g., boarding school). These impede the potential impact of protective factors and have been linked to the state of public health (e.g., health disparities, chronic disease) among AI/ANs today (Campbell & Evans-Campbell, 2011; Gone & Trimble, 2012; Walters et al., 2011).


Still today, AI/ANs are victimized at the highest rate of any other racial group, twice the rate of other groups, and mostly commonly by strangers or acquaintance (80%) most of which are White (60%; Perry, 2004). Resilience, one’s ability to quickly recover from these traumatic experiences, is based on the quality and number of protective factors at play. Factors that protect AI/ANs against suicidal behavior are a sense of belonging to one's culture, strong friendship,tribal and spiritual bonds, feeling connected tofamily, opportunity to express feelings, and positive emotional health (IHS, 2016).


Unfortunately, my life has not been untouched by grief and loss associated with suicide. As a half Anishinabe and Caucasian woman from Red Lake, MN, I witnessed from an early age mistreatment of AI people. In the education system, this was evidenced by education gaps, and personally being called stupid by a teacher and who then told the class "all Indians are stupid”. My second grade self was angered and knew I should tell my mother.


My mother was my biggest supporter, telling me I could do anything I put my mind to, and although I never knew the outcome on our local education system, my mother went many times to the school to discuss her concerns about how I was being treated. As I grew up incidents such as these persisted, but presented in the form of microaggression, where people would often apologize before saying rude and racist things.


While in the third year of my PhD program, my 22-year-old brother committed suicide. We were devastated. I tried to understand why this young, handsome, bright, kind-hearted, funny and loved person would take his life. He never shared with the family about negative experiences he had, as I had. However, he dropped out of high school and when I would encourage him regarding his education he was irritated with me, and once told me "I’m not smart like you girls are”. I realized many years later that somewhere along his short life he internalized the negative messages he heard regarding AIs.

Great efforts are being made to address the high rates of suicide and heal from trauma in Indian Country. There are a number of tool kits geared toward reducing AI/ANs suicides with community and culturally based curriculum, which can be found at Substance Abuse and Mental Health Services Administration (SAMHSA) Tribal Training and Technical Assistance Center. Northwest Portland Area Indian Health Board (NPAIHB) has launched a anti-suicide media campaign including posters and a fact sheet with the Community is the Healer that Breaks the Silence and has published a Tribal Suicide Action Plan availableto download on their site.


In the Twin Cities, Suzanne Koepplinger, a respected elder, is leading the Catalyst Initiative at the George Family Foundation, to support culturally grounded healing practices and promoting community resilience. In talking with Suzanne Koepplinger, she explained that her goal is to support the use of existing healing practices, done by healers already in place, and through the language of the community. This strength-based approach trusts in the human capacity to heal from trauma by drawing on existing traditional knowledge. Koepplinger believes this healing work will lead to an enhanced sense of wellbeing and deeper family relationships.


George Family Foundation awarded Minnesota Indian Women’s Resource Center (MIWRC) a seed grant to introduce integrative health and healing practices to communities most in need. Elders Linda Eaglespeaker and Donna LaChapelle of MIWRC, have become certified faculty with Center for Mind Body Medicine of Washington D.C., and are working on Pine Ridge Reservation with the Oglala Sioux tribal members to heal from trauma and suicide as a community.


Word of its success is spreading quickly, and other local tribes such as Leech Lake and White Earth are requesting these teachings. Koepplinger emphasized the importance of taking from the trainings what is culturally meaningful and making cultural adaptations were needed. For example, Linda Eaglespeaker, has blended the safe place guided imagery with her traditional Blackfoot teachings to heal both physical and emotional pain.


The loss of my brother taught me that we need to do a better job of understanding and addressing the impact of racism and other traumatic experiences on children. Locally there is a grass roots initiative called Mill City Kids, focused on doing just that, prevention against the effects of racism with both African American and AI/AN children.


Mill City Kids is one of the initiatives selected by Silos to Circles to go through a process of Community Resiliency Planning, in which community members identify goals and take action steps to address them collectively. Efforts such as these are inspiring and provide hope for the future. There is not quick solution to addressing these social ills but acknowledgement is a first step.

Laurelle Myhra, PhD, LMFT is the Director of Health Services at Catholic Charities of St Paul and Minneapolis. Her clinical work and research has focused on families, resiliency, trauma, mental health, substance abuse and integrated care among American Indians. She received her doctorate in Family Social Science/Marriage and Family Therapy from the University of Minnesota. 


Campbell, C. D. & Evans-Campbell, T. (2011). Historical trauma and Native American child development and mental health: An overview. In: Sarche, M., Spicer, P., Farrell, P., Fitzgerald, H. E. (Eds.). American Indian and Alaska Native Children and Mental Health: Development, Context, Prevention, and Treatment (pp. 1–26).Santa Barbara, CA: Praeger.

Centers for Disease Control and Prevention (CDC). Web-based Injury Statistics Query and Reporting System (WISQARS) [Online]. (2013, 2011) National Center for Injury Prevention and Control, CDC (producer). Retrieved from

Gone, J. P. & Trimble, J. E. (2012). American Indian and Alaska Native mental health: Diverse perspectives on enduring disparities.Annual review of clinical psychology, 8, 131–160.

Indian Health Services (IHS; 2016). Suicide Prevention Program. Retrieved from

Perry, S. W. (2004). American Indians and Crime. A BJS Statistical Profile, 1992-2002. U.S. Department of Justice. Office of Justice Programs. Bureau of Justice Statistics. Retrieved from

Substance Abuse and Mental Health Services Administration (SAMHSA, 2016). Suicide Prevention. Tribal Training and Technical Assistance Center. Retrieved from

Walters, K. L., Mohammed, S. A., Evans-Campbell, T., Beltrán, R. E, Chae, D. H., & Duran, B. (2011). Bodies don’t just tell stories, they tell histories.Du Bois Review: Social Science Research on Race,8(1), 179–189.

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It Took A Long Time, But She Did It Her Way

Posted By David Ziobro, Tuesday, August 23, 2016


This blog post is a reprint of an earlier piece. Click here for the original post.

"Well, at least they went quickly and didn’t suffer.” That’s what people say when someone dies. I understand what they mean. But she didn’t go quickly. No, it was a long slow steady decline. Did she suffer? No, with the pain meds, and her loss of memory, she didn’t suffer, but I did. 

When we were told that the cancer had spread to her brain, the clock started to tick. Life went on as much as it could. She was able to do some of the things she enjoyed like reading, crafts, and needlepoint. In time, those activities became impossible, and TV and the two hours a day with her aide became her life. Our aide was a friendly young woman; they would sit and talk about all kinds of things, and they liked to look at our photo albums. Our aide was planning a trip to Disney World, and my wife really enjoyed helping her plan it. The trip ended up being scheduled the week after my wife passed away. Her aide was not able to attend the viewing or the funeral. It was almost like my wife planned it that way. 

As time passed, we entered the beginning-of-the-end dates. When we were given the diagnosis, the doctor simply would not give us a time frame. The internet however gives you lots of information--we were looking at a 16 month time frame, give or take. I was finally able to get the doctors and the hospice nurses to give me a better idea after many conversations. They were all given with reluctance, and usually accompanied by "everyone’s situation is different.” When we hit the beginning of the possible time frame, it got interesting. By this point I had taken the 90 day FMLA leave from work, and I ended up taking another 90 day leave of absence as well.As with most everything in her life, my wife exceeded expectations: she lasted 23 months.


During the final 6 months of her life, we were in the "anytime” zone. Every morning was difficult for me. Was today the day? Remember when you had your first child and, inexperienced and fearful, you would walk into their room at night and listen for them breathing? Well there I was, going into her room in the morning wondering if this would be the day. I would hope upon opening the door she would move in some way so I would know right away. When she didn't I would walk up slowly and listen, a mixture of fear and then relief, followed by disappointment and then guilt. I had six months of that.

In the last year, my wife’s mental capacity diminished to the point where we could no longer really converse. We still talked, but I understood that she was not there, and our conversation would be forgotten as quickly as it started.


The good part was that she was totally unaware of her situation. She knew she was sick, but figured she’d get better and return to work soon. My wife had retired from her position as an elementary music teacher four years earlier. She began to ask about school and I would explain that she had retired. "Oh really, when did that happen…I don’t remember.” We would talk and it would be forgotten. Every night we would go through the routine about how she was retired.


Each morning, we were up early and would go through the same conversation. I had to move her car to her mother’s house around the corner for fear that she would just jump in and drive away. She had not driven since her diagnosis in 2009. Then we had to hide the car keys for all our other cars. Notes on the mirror, on the door, nothing seemed to help. Sometimes she would call the school and arrange to get a sub. The administrative assistant, who knew my wife well, would handle these phone calls with patient understanding. It turns out she enjoyed just talking to her. The rest of the staff were also amazing; they understood and dealt with it. 

Every morning was difficult for me. Was today the day? So when someone says, "well, at least they went quickly and didn't suffer,” understand what suffering is. There are all kinds of suffering. My wife passed away 23 years after her diagnosis of breast cancer. She did better than expected, and did things her way. She once told me "I’m a difficult patient, I know that. It’s my life and I want to know what is going on. I don’t care if they think I’m a bad patient.”


In reality, according to her doctor, she was a good patient. He understood why she was the way she was. When she passed, her doctor told me what a strong person she was. He also told me what a fantastic job I did in taking care of her. I tried the best I could. It was difficult. Her doctor gave me a big hug when he told me that. Men don’t hug usually. It was so special because it gave me the feeling that I did good. The patient is the one being treated; the well spouse is often forgotten. He was telling me I was not forgotten. That was special.


Dave Ziobro, Former Well Spouse

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Lonnie Ali: Our Caregiving Champ

Posted By Barry J. Jacobs, Thursday, July 21, 2016

 This piece was first published by the Huffington Post. Reprinted here with permission. Click here for the original post

During her moving eulogy for her husband, Muhammad Ali, at last month’s memorial service in Louisville, Kentucky, Lonnie Ali, in a face-obscuring bonnet but with a forthright tone, declared, "Muhammad wants young people of every background to see his life as proof that adversity can make you stronger.”

Much the same can be said of the life of this 59-year-old woman, the fourth wife for the past 30 years of the boxing great, civil rights activist and world’s most famous man. From nearly the outset of their marriage, Muhammad showed signs of Parkinson’s disease. As he steadily declined in his capacities to ambulate and speak, their marriage became one between a spousal caregiver and a care recipient. She spent most of her time and energies attending to his increasing needs.

But if our country’s prevailing cultural narrative about family caregiving nowadays is mostly negative—as evidenced by a stream of tragic memoirs and movies depicting caregivers as entrapped, beleaguered and depressed—then Lonnie Ali was an exemplar of positive caregiving. At the same time she played the role of the Champ’s champion, she became our national Caregiver Advocate, especially while working on behalf of Parkinson’s caregivers. By re-reading her interviews with caregiver websites and the general media during her now-completed caregiving years, we can glean lessons for reaping caregiving’s potential rewards.

Love—and like―matter:

The tale of their slowly blooming love has been oft recounted, recently by the New York TimesPeople Magazine, and other major outlets. Lonnie was a 6-year-old, hometown Louisville girl who met Muhammad when he visited his old neighborhood as a 21-year-old heavyweight contender. She was at first scared of his sheer physical size and then enchanted by his playfulness. Later, as an adolescent, she found him to be an excellent confidante and guide whenever he periodically returned home. Her childhood crush on him eventually matured into womanly ardor. That love didn’t die during years of grinding caregiving. Rather, it helped sustain her commitment to caring for him, even during difficult times.

But it is just as evident in a 2010 WAMU interview with Diane Rehm that Lonnie liked and enjoyed her husband. When a caller on the radio show shared an anecdote about Muhammad’s generosity signing autographs and telling jokes, Lonnie said appreciatively, "That’s Muhammad.” She was happy to be with him—to see his mock-angry stare and silly mugging for the camera—and to witness his genuine and unbridled love of people. Liking even a debilitated Muhammad must have helped sustain her caregiving, too.

Practice positive acceptance:

Lonnie wasn’t interested in pity parties for herself or any other family caregiver or even loved ones afflicted with illness. In a 2014 video clip for AARP, she said, "You really have to play the hand that life deals you. Either you can fold and just let it overwhelm you or you can stay in the game.” She clearly was committed to hanging in there every day and doing the best she could. In a 2014 interview with Future of Healthcare News, she said, "When I wake up, I make the decision to speak in a joyous voice, to nurture positive energy, and to make this a good day.”

Gain a sense of mastery:

In numerous publications, Lonnie related how important it was for her to learn about Muhammad’s Parkinson disease and its treatments, as well as to develop good working relationships with physicians with whom she could communicate often and easily. All this gave her knowledge that took some of the uncertainty out of the long, downhill medical course. She told, "[The disease] is not something to be afraid of; the more you know, the more empowered you become.” As with many caregivers, she seems to have gained greater self-confidence over time as she helped her husband manage his Parkinson’s disease and live vitally with it.

Seek support and respite:

Lonnie told Diane Rehm that, however guilty caregivers may feel about reaching out for help, "you need to get someone in there to assist you.” For her, that meant asking her sister to come live with her and Muhammad when they resided in Phoenix. Her sister spelled her at times. At other times, she was just good company for them both.

Find greater purpose and meaning:

Perhaps the most important positive lesson that Lonnie has exemplified is in seeing caregiving in greater moral and spiritual dimensions. According to the New York Times, she "leaned on Ali to become the face of Parkinson’s.” Both he and she spent years collaborating with Michael J. Fox to raise money for Parkinson’s research.

But their faith is what carried them most during these years. She told People Magazine in 1997 that "Parkinson’s has made [Muhammad] a more spiritual person…God gave it to him to bring him to another level, to create another destiny.” The same applied to her. "[God] put me here for a reason,” she said on the AARP video, and added, "He’s not going to let go of my hand.”

Caregiving with love, purpose, mastery, acceptance and support—those are the practices that can bring positive benefits to even long-term caregivers. Lonnie Ali lost her husband but showed us how to gain a richer life.

Barry J. Jacobs, Psy.D. is a clinical psychologist, family therapist and the Director of Behavioral Sciences for the Crozer-Keystone Family Medicine Residency Program in Springfield, PA. He is the co-author (with his wife, Julia L. Mayer, Psy.D.) of AARP Meditations for Caregivers—Practical, Emotional and Spiritual Support for You and Your Family (Da Capo).

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Crossing Over: The View from the Other Side

Posted By Terri Corcoran, Thursday, July 7, 2016

This piece was originally written for the Mainstay Newsletter, a publication from Reprinted here with permission.

When my husband Vince took his last breath at 9:15 p.m. on January 17 of this year, he crossed over into heaven, while I crossed over from "well spouse" to "former well spouse." In that one moment, as my beloved husband was released from the burden of his devastating neurodegenerative illness, I was released from the overwhelming and excruciating burden of caring for all of his needs through the many years of his relentless physical and cognitive deterioration. But while Vince is hopefully at peace in heaven, my trials in this life have not yet ended, and I am left with the heartbreak of his loss and the need to eventually rebuild a whole new life.

I am very gratified that I was able to care for Vince at home until he peacefully passed away in his own bed, with me and his daughter beside him. But I must admit that there were times over the years when the caregiving was so intense and tortuous that part of me would feel some envy for those well spouses who passed over to the "formers" camp. I knew that I would miss Vince horribly were he to die, but the caregiving demands would sometimes feel unbearable.

Suddenly, in that one moment, all the craziness stopped—just stopped. Suddenly there were no more aides camping out in my house; no more incontinence to control or supplies to keep on order; no more meals to purée; no more medications to crush; no more wranglings with the healthcare system, insurance companies and pharmacies; no more daily schedules to maintain; no more research to keep doing on Vince's unusual genetic condition; no more injections, shaves and haircuts to administer; no more coughing to hear; ... and no more Vince ... no more holding his hand; no more reading prayers to him; no more showing him videos on the ipad in bed at night; no more talking to him and crying to him and singing to him, even though he hadn't spoken in years; no more having him next to me at night, somehow giving me peace at the end of a difficult day.

The usual semi-shock that seems to protect us after our spouses pass away and that gets us through the funeral, eventually lifts after a few weeks. Then it is just QUIET. Really QUIET. I realize I no longer have a daily routine, just hours and hours of QUIET. The memories begin to pour into my mind: not memories of the caregiving years, ironically, but memories of Vince when he was whole and healthy (which was mostly before we were married; he was ill for most of our 17 years together). I miss him, and I start to cry at the many triggers of memories of things we did together.


All the pre-grieving I did during the caregiving years and all the imaginings of what life would be like without him did not prepare me for the intense loneliness and lack of a purpose that I feel now. I am fortunate in having many friends to meet for lunch, a loving church community with activities for me to join, children and grandchildren, but there is still a huge hole in my heart which was occupied by the love of my life. I also mourn my lack of closure, since Vince didn't speak for many years before his death, and the communication we had in the earlier years of our marriage was not great because of the creeping brain illness. So, I am not only mourning his death, but I am also mourning the married life we never had.

I know I will heal in time, and I am functioning well, despite the spontaneous crying episodes and the strangeness of the QUIET. I trust that God has a plan for the rest of my life, and I am now trying to concentrate on recovering from the years of traumatic caregiving and loss, living at my own speed and doing what I feel like doing. I have my Former Well Spouse friends to help me along! You just never know what it's like on the other side until you arrive there—and it happens in one moment.

For over 10 years, Terri Corcoran cared for her husband who was severely disabled mentally and physically by Fragile X Tremor Ataxia Syndrome. Before her husband became ill, she worked as a translator, editor and arts reviewer. She is co-editor of the Mainstay newsletter and chair of the Well Spouse Association Public Relations Committee. For more information visit

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The Things I Miss

Posted By Suzanne Mintz, Thursday, June 23, 2016


The things I miss most are the things most folks take for granted.


I miss a walk down the street holding hands.

I miss hugs, real standing up hugs.

I miss snuggling in bed and making love

I miss doing things spontaneously

I miss not having to find out about accessibility everywhere we go

I miss being normal

I hate doing transfers more than anything else. There is always the possibility of a fall.

I hate feeding Steven

I’ve never enjoyed driving and now I have to do it all the time

I hate being "on call” all of the time

I wonder what our lives would have been like if Steven hadn’t been diagnosed with multiple sclerosis in 1974. I wonder what decisions we would have made if we didn’t have the cloud of the diagnosis always hanging over us. Perhaps we wouldn’t have bought our first house. We bought a ranch not knowing if Steven would lose the ability to walk stairs. But if we hadn’t bought it, we never would have met Paul who lived next door and changed my life with his friendship and wise advice. Not having parents nearby Paul acted as a surrogate dad during those early years when I was trying to come to terms with having MS in our lives.


Because of the pre-existing condition clause that existed in health insurance when Steven was diagnosed his career path was pretty much set. He was with the federal government at the time and so with the federal government he stayed for almost 40 years. Who knows what he would have done or where we would be living if he had the flexibility to chart his own course. But they say "God works in strange ways” and so because he was in essence forced to stay "a fed” all those years we are now enjoying the security that comes with a lifetime government pension.


I’ve been a caregiver for so many years now and I anticipate being one for at least another dozen years or so. I wonder if I can do it. I’ve aged and feel its effects. Steven has aged too of course and the MS with the persistence of a dripping faucet keeps degrading his functionality to the point where he can hardly do anything himself. Thank heavens it hasn’t affected his mind.


I really shouldn’t complain. We have a good quality of life because of Steven’s pension and good investments we made over the years. We’ve been able to afford some paid help and high quality equipment. We live in a beautiful neighborhood and in a lovely house that has been renovated for complete accessibility. Our friends and neighbors are very helpful and best of all, our daughter and her family live nearby. They provide support and help and we experience the sheer joy of being part of our granddaughter’s everyday life. We truly are fortunate, and yet I wish I wasn’t a caregiver. I find I am tired most of the time.


But it is because I’ve been a caregiver for most of my adult life that I’ve been able to bring attention to the needs of the millions of other caregivers in our country. When I look back on the progress that has been made since I co-founded the National Family Caregivers Association in 1993 and how we’ve gone from being a nation that had no idea of who caregivers were, what work they did and what struggles they endured to seeing family caregivers being part and parcel of the new patient and family-centered approach to healthcare. I think of my effort in support of family caregivers as the good that has come from the presence of MS in our lives.


I think of the educational materials the organization created and all of the confidence building talks I gave. The letters I received attesting to the positive difference I made in other caregivers’ lives brought me great joy and satisfaction. I know I had, and continue to have, an impact on legislation, and public policy and the lives of individual family caregivers.


And I know that none of this would have happened if Steven didn’t have MS and I didn’t experience what I have as his caregiver. It is impossible to know where life will take us, what direction our lives will take either because of very specific actions on our part or by chance. His having MS has been a mixed blessing. Yes our lives have been harder but more enriched as well. Happenings are rarely black and white.


And yet I am angry because of what the MS has taken from us and I miss what I think a normal life could have been like.


I know I need a vacation from caregiving.


Social entrepreneur, family caregiver thought leader, author, speaker, advocate - 20 years ago she put a face on the issues of family caregiving when they were not recognized outside the aging community. She co-founded the National Family Caregivers Association (now Caregiver Action Network) and led the charge for recognition of family caregivers across the lifespan and as critical players in the delivery of chronic illness care. She retired from the organization in June 2013 and now run her own consultancy: Family Caregiver Advocacy, where she focuses on issues of national importance that affect the health and wellbeing of family caregivers. Ms. Mintz is currently working on the need to have family caregivers identified on medical records, their loved ones’ and their own. Quote: "Family caregivers need to be included as members of their loved ones’ care team, given the education, training, and on-going support they need to bring about better outcomes and their own health and wellbeing.  

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Challenges and Rewards of Fatherhood

Posted By Barry J. Jacobs & Meghana Giridhar, Wednesday, June 15, 2016


This piece is a reprint of a post from on June 14th, 2016. Printed here with permission. Click here for the original publication.

Barry J. Jacobs, Psy.D. is a clinical psychologist, family therapist and the co-author (with his wife, Julia Mayer, Psy.D.) of the book, AARP Meditations for Caregivers—Practical, Emotional, and Spiritual Support for You and Your Family (Da Capo Press, July 2016). His first book, The Emotional Survival Guide for Caregivers—Looking After Yourself and Your Family While Helping an Aging Parent (Guilford, 2006), was named the best book on family caregiving by the popular Ask Amy syndicated newspaper column. Here are his perspectives on fatherhood as we near Father’s Day that will be celebrated on June 19th, 2016.


How significant is Father’s Day for you?

Father’s Day always brings me mixed feelings. Of course I love the cards and well wishes and a little extra attention that I receive from my daughter and son, now in their early-20s. But the death of Morton W. Jacobs, my father, due to brain cancer when I was 15 left a huge void in my life at a time when, as an unruly adolescent, I could have used strong male guidance. Father’s Day, unfortunately, is a reminder to me of his absence today and during those important formative years for me.


How was your relationship with your father as a child?

My father was a strong, sturdy guy--a former college boxer and football player and World War II Air Force sergeant--who had married late in life and didn’t have me, his first born, until he was 37. I can remember thinking as a child that he was so much older than my friends’ fathers and so much more old-fashioned in his dress and attitudes. He could be patient and loving. He spent endless hours teaching my younger brother and me how to play baseball and then rooting loudly for us during our Little League games. But my father also commanded complete obedience. If I horsed around or teased my brother too much when he was in a bad mood, his anger was swift and harsh. He could fly off the handle without much provocation. I loved and admired him but was also intimidated by him.


Did it change as time passed? How so?

When I was 14, I was just beginning to express my own thoughts more readily. I could talk to peers and talk back to teachers but my biggest test would be to stand up against my father’s stern will. At about the same time, however, my father suddenly showed the first symptoms of his brain cancer: He lost the power to converse intelligibly as malignant cells invaded the speech center of the left hemisphere of his brain. There could be no debating him after that. Our relationship had radically changed in an instant. Rather than parrying with him, I was now caring for him as my mother’s deputized assistant caregiver. I’d come home from school and sit in our den watching TV with him. But there was little conversation about the TV shows or his cancer or any burgeoning ideas I might have been having. We were with one another but didn’t talk much from that point forward until his death 10 months later.


How has that influenced your relationship with you children?

With my daughter and son, I’ve attempted to be a different kind of parent than my father was. I’ve kept my own anger in check and have tried to be respectful of and responsive to my children’s viewpoints. But there are many ways that I’m still my father’s son. He was workaholic lawyer. I’m a workaholic psychologist and writer. He was often distracted and irritable when immersed in projects. As my family will attest, the same goes for me. In a similar way that I am critical of my father, my children are critical of me. That’s the right of every young generation reacting to the old.


What is the toughest thing to accept as a son to your father?

That he and I didn’t have the time together for our relationship to grow into one between mutually respectful adults. That he never got to see me become a man. That I never got to see him mellow with age. All got cut short by cancer. But my father is still with me. For the past 40 years, I’ve measured myself against my memories of him as a gentle, furious, complex person. I believe he would be proud of me—but probably not without his own critical asides. During this Father’s Day, as with every other, he and our relationship will be on my mind.


Barry J. Jacobs, Psy.D. is the Director of the Behavioral Sciences for the Crozer-Keystone Family Medicine Residency and the lead faculty member for its super-utilizer program, the Crozer Connections the Health Team, and the Camden-Cooper-Crozer Hot-Spotting and Super-Utilizer Fellowship Program. He is also the author of The Emotional Survival Guide for Caregivers (Guilford, 2006).

Meghana Giridhar serves as Content Manager and is part of eCareDiary's founding team. In her role, she oversees and edits content across all of eCareDiary's media platforms. - See more at:

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One Person Wears the Uniform, but the Whole Family Serves

Posted By Kent Corso, Wednesday, June 1, 2016



Those who volunteer to enter the military are required to make career central to their lives. The military represents one large "unit” for the active duty service member which is then broken down into many smaller units. A very distinct identity develops for the service member first at the level of branch – Army, Navy or Marines and Air Force, then within one’s specialty or occupational code. Finally, identity arises from rank, role within the immediate unit and through contributions to the shared mission of the unit and the larger units. Like members of collectivist cultures, military service members tend to measure their worth in reference to their relationship with the larger group or unit, the entire specialty, rank, or branch. Herein lies an immense source of strength, a factor that emboldens and protects many service members when they deploy, are worn out, or are tired of moving their family every 3 years. It is the constancy of the military unit – the military family which helps them maintain a sense of control, predictability, normalcy and value. But what about the service member’s "actual” family?

It is less often discussed, but families also make the military central to their lives - some willingly, and some with significant reluctance. When children attend school on a military base, it becomes part of their identity – growing up as a military child. When civilian wives or husbands live on or off the military base, it impacts their lives. Service members have demands which extend beyond "normal duty hours”, which means the spouses manage the family and home, sometimes without advanced notice. Yet, the spouses may also have a full time job. Additionally, when there are unit events (pre-deployment gatherings, fundraisers, base community events) spouses are expected to participate. For many of these events, the military provides programming for the children as well. This makes all family members part of the same mission.


Spouses of service members often affiliate and rely on one another. For example, there are deployed spouses groups who meet regularly for socializing, sharing resources, and for mutual support while their loved one is deployed. When a service member moves to a new base, another member’s family is the sponsor. This means that the families of active duty help one another acclimate to the new base. After all, they share many of the same challenges and resources. Ultimately, the unit serves as a source of stability for the family, and the family becomes part of that larger unit.


However, there may be aspects of the unit and this new "family” which are not so stabilizing. For example, there are times when service members are not allowed to deploy if they are undergoing mental health treatment. If the service member cannot deploy, he or she may feel a sense of shame, for letting the unit down. Likewise, the family feels ashamed, while also being spurned by other families and members of the unit. In this way, there is pressure from within the unit and its families to do one’s part in the larger mission.


The culture of the military, which also extends to the family, prides itself in being highly performing. Seeking help – particularly from outside the unit or the unit’s spouses, is aversive. This aversion has persisted because when service members have certain diagnoses or are taking some types of medications, they may be required to surrender their firearm (e.g., military police). If they cannot not do their regular job or they cannot deploy, they are perceived as not high performing and not fulfilling their duty within the larger group. In short, there may be a feared or actual negative impact on their career. For these same reasons, some spouses may also avoid seeking the mental healthcare they need. This is driven by fear that their active duty partner’s commander will discover this, thereby negatively impacting their active duty partner’s career.


Imagine family members who are so dedicated to their active duty spouses and the military, that they will avoid treating legitimate personal or familial medical conditions so that they do not disrupt the homeostasis of the military unit. For better or for worse, this is how central the military becomes to the active duty person and his or her family. It defines their lives. But what happens to service members and their families when service ends?

Only after conducting military cultural competency training to civilian healthcare providers in the years after concluding my military service, did it become clear to me why so many veterans and their families struggle when their service concludes. Consider the two things which define military experiences: the unit and the mission. In the civilian world neither is clear, if present at all. For X years the family, children and service member are indoctrinated into the military – acculturated into its lifestyle and its structures. They learn to rely on these structures and cultural elements to excel professionally, to tolerate the frequent moves, to survive the arduous deployments. And when times are the worst, they may keep in mind that they are not alone; there is a unit. They may remind themselves that all the hardship is not for nothing; there is an important mission they are contributing to.


But, when entering the civilian world, everything changes. The family remains intact, but even it has been removed from its larger military family, which it identified with and relied upon. In essence, the family and service member are on their own. There is no longer a unit. Second, there may not be a clear mission. Few civilian jobs offer the same higher mission as the military - fighting for freedom. Part of what enabled the military families and members to endure the challenges of military life is that they were serving a higher purpose. It is hard for them to identify with and affiliate with careers and communities which are not cohesively revolving around some meaningful higher purpose. No mission equals nopurpose to most service members and families. Even after only few years of service, the absence of mission and unit may be devastating to the family and the member.


We can learn quite a bit from our veteran families and communities. Just imagine what our country would be like if we all insisted on creating communities and pursuing careers which were highly cohesive and oriented around meaningful, service-oriented global missions. This is difficult in the individualistic American society in which we live. But finding a reliable group for affiliation, and a higher mission for accomplishing, in spite of American individualism, is also what would make it so rewarding. Helen Keller once said, "Alone we can do so little, together we can do so much.” I can’t think of a more suitable explanation for the military family mentality.

Kent A. Corso is a licensed clinical health psychologist and board certified behavior analyst. He is an OEF veteran and former Air Force officer having over 15 years of research, teaching and training experience in university and medical settings. Dr. Corso is a subject matter expert for behavioral health re-design and currently holds an adjunct assistant professor position in the Department of Family Medicine at the Uniformed Services University of Health Sciences. As president of NCR Behavioral Health, Dr. Corso leads an international training and consulting group for private and federal healthcare organizations in pursuit of integrated behavioral health programs which improve patients’ health and return the investment to the system. He is the lead author of Integrating Behavioral Health into the Medical Home: A Rapid Implementation Guide, a 2016 book from Greenbranch Publishing. 

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Working With Military Families

Posted By Angela L. Lamson, Meghan H. Lacks, Wednesday, May 25, 2016


There are over 3.5 million military personnel in the U.S., including Department of Defense (DoD) Active Duty, Coast Guard, and Reserve members (DoD, 2014). Along with the active duty population, it is estimated that there are currently over 22 million Veterans in the U.S. (U.S. Census Bureau, 2012). The number of family members- spouses, children, and others-is staggering. While services on military bases and Veterans Affairs clinics or hospitals are available for both mental and physical health care needs, military and veteran families also receive services for their health care in civilian communities. Yet research indicates 87% of civilian clinicians are not equipped to meet the unique needs of military service members (Tanielian et al., 2014).


As such, clinicians must become more involved in professional development that includes a cultural awareness to military and veteran health and healthcare systems, regardless of a clinician’s own healthcare system delivery methods (see list of select training opportunities and books are provided below). Understanding the unique health experiences of military, veterans, and their families is relevant because it is almost inevitable that clinicians and providers will encounter someone who has either served or had a family member who served in the military.


Given the likelihood that most clinicians and providers will care for military personnel, it is important to recognize some unique differences between military and civilian families. For example, service members often marry younger, divorce less, have more young children in the home, and relocate homes more frequently than their civilian counterparts (Clever & Segal, 2013). In addition, the family dynamics of military and veterans differ from civilians, particularly due to child school and peer adjustments because of frequent relocation and family adjustment after parental injury (Hisle-Gorman, Harrington, Nylund, Tercyak, Anthony, & Gorman, 2015). Furthermore, parents in military and veteran families have commonly had to navigate the role of a deployed parent, role of the stateside parent, trustworthy and reliable child care services, family support, and school based support for children.


Differences between branches or reserve components, rank, number of deployments, and experiences with combat are also important to recognize when delivering services or designing research projects. Demographic differences provide only a small piece of a very big picture. For example, what is known about active duty women’s health is often times limited to her reproductive or sexual health matters, (Lacks, 2016), and even less is known about the complexities associated with single parenting, dual military couples, or the health of LGBT couples and their families.


Based on our experiences, our charge to clinicians and researchers is to recognize and honor the diversity of military and veteran families. This is possible when extending care or research programs through a biopsychosocial-spiritual (BPSS) framework (Engel, 1977, 1980; Wright, Watson & Bell, 1996), and attending to the relational dynamics that emerge through common military and veteran health matters. Some of the most common BPSS challenges include: amputations, traumatic brain injury, insomnia, chronic pain, intimate partner violence, military sexual trauma, substance use, and relational distress (Blaisure, Saathoff-Wells, Pereira, MacDermid Wadsworth, & Dombro, 2016; Goff, Crow, Reisbig, & Hamilton, 2007; Mansfield, Kaufman, Marshall, Gaynes, Morrissey, & Engel, 2010; Trump, Lamson, Lewis & Muse, 2015).


In our clinical work, through integrated behavioral health care and traditional therapy sessions, we quickly recognized the complex interaction between physical or behavioral health challenges and relational distress unique to military and veteran lives. There was the civilian husband and his active duty wife, who was preparing for her first deployment. His physical health had begun to decline, resulting in increased weight gain that he attributed to stress about the unknown expectations for his wife’s safety while on deployment. The integrated care team worked with the couple on behavioral health goals for the husband and constructing ways to support one another during the deployment. In another example, a service member in his early 30’s had come into his medical visit reporting back pain that he believed occurred during a training exercise.


This resulted in loss of sleep, limited ability to play with his children, and distress in his marriage due to irritability associated with the pain. The medical provider and family therapist collaborated on a variety of treatment strategies for this patient for both his physical and psychosocial concerns and discussed a treatment plan with the patient including exercises and medications that would not interfere with his job duties. In addition, the therapist provided techniques to reduce relational stress. In a follow up visit, the patient and his wife reported the relational techniques were very helpful for them as a family. The patient reported a lower score on the pain scale. He believed his pain was more manageable because of the medication, exercises, and positive experiences he and his wife had shared through the techniques they learned from his integrated care visit.

However, we have also met with individuals, couples, or families who struggled to imagine a future without the presence of physical, emotional, relational, or spiritual pain. Many of our nation’s heroes fight a battle beyond those in the air, field, or sea; many fight the internal battles of guilt, shame, or confusion that result in suicidal ideation. Some are left with moral injuries, leaving lacerations on the soul and spirit. Service members and veterans are trained to be strong for the unit and strong for the country. Vulnerability is contrary to the mission. Yet, guilt and shame in relation to active duty experiences have emerged as predictive of suicide among military and veteran populations. Military and veteran family members serve by-proxy, and often do not know of or how to navigate life alongside a loved one who is suffering from mental health concerns.


In providing both traditional and integrated behavioral health care to service members and veterans as well as their partners and families, we have come to learn several important lessons: (1) extend a genuine and curious stance to assessment, diagnosis, and treatment with these populations, (2) honor the biospsychosocial-spiritual complexities of health, as most health visits included at least one significant behavioral health concern (primarily challenges with quality sleep and pain management), (3) promote integrated behavioral health care (it was very well received by the patients as well as by the providers), and (4) encourage and deliver couple-centered or family-centered health care visits in medical and mental health venues, particularly when treating complex biopsychosocial-spiritual health issues.



Blaisure, K. R., Saathoff-Wells, T., Pereira, A., MacDermid-Wadsworth, S., & Dombro, A. L., (2016). Serving Military Families (2nd Ed). Florence, GA: Routledge.

Clever, M., & Segal, D. R. (2013). The demographics of military children and families. The Future of Children, 23(2), 13-39. doi:10.1353/foc.2013.0018

Department of Defense (DoD). (2014). Demographics report. Retrieved from Report.pdf

Goff, B. S. N., Crow, J. R., Reisbig, A. M. J., & Hamilton, S. (2007). The impact of individual trauma symptoms of deployed soldiers on relationship satisfaction. Journal of Family Psychology, 21(3), 344-353. doi:10.1037/0893-3200.21.3.344

Hisle-Gorman, E., Harrington, D., Nylund, C. M., Tercyak, K. P., Anthony, B. J., Gorman, G. H. (2015). New research: Impact of parents’ wartime military deployment and injury on young children’s safety and mental health. Journal of the American Academy of Child & Adolescent Psychiatry, 54, 294-301 doi: 10.1016/j.jaac.2014.12.017

Kang, H. K., MA, T. A., Smolenski, D. J., Skopp, N. A., Gahm, G. A., & Reger, M. A. (2015). Suicide risk among 1.3 million veterans who were on active duty during the Iraq and Afghanistan wars. Annals of Epidemiology, 25(2), 96-100. doi:10.1016/j.annepidem.2014.11.020

Lacks, M. H. (2016). The biopsychosocial-spiritual health of active duty women: Service members in need of service. (Unpublished doctoral dissertation). East Carolina University. Greenville, NC.

Mansfield, A. J., Kaufman, J. S., Marshall, S. W., Gaynes, B. N., Morrissey, J. P., & Engel, C. C. (2010). Deployment and the use of mental health services among U.S. Army wives. The New England Journal of Medicine, 362(2), 101–109. doi:10.1056/ NEJMoa0900177.

Tanielian, T., Farris, C., Batka, C., Farmer, C. M., Robinson, E., Engel, C. C. … Jaycox, L. (2014). Ready to serve: Community-based provider capacity to deliver culturally competent, quality mental health care to veterans and their families. Santa Monica, CA: RAND Corporation.

Trump, L. J., Lamson, A. L., Lewis, M. E., & Muse, A. R. (2015). His and hers: The interface of military couples’ biological, psychological, and relational health.Contemporary Family Therapy,37(3), 316-328. doi:10.1007/s10591-015-9344-8

U.S. Census Bureau. (2012). A snapshot of our nations Veterans. Retrieved from


Recommended Resources or Readings

Select Recommended Trainings

1. The Center for Deployment Psychology offers an archive of resources for civilian providers. This website also includes free military culture training modules for healthcare professionals that encourage providers to better understand military culture and its impact on health-related behaviors.

2. The Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury offer free monthly webinars that discusses content on a variety of topics related to military life.

3. The National Center for PTSD offers a large array of resources and training opportunities for providers regarding trauma.


Select Recommended Books

Anderson, W. (2015). Battlefield Doc: Memoirs of a Korean War combat medic. St. Louis, MO: Moonbridge Publications.

Benimoff, R. (2010). Faith under Fire: An Army chaplain's memoir. New York, NY:Three Rivers Press.

Bonsper, D. (2015). Vietnam memoirs: Part 1. AroSage Publishing.

Kyle, T. (2015). American wife: A memoir of love, war, faith, and renewal. New York, NY: Harper Collins Publishers.

Miller, T. & Brotherton, M. (2015). Tough as they come. New York, NY: Convergent Books.

Tillman, M. (2008). Boots on the ground by dusk: My tribute to Pat Tillman. New York, NY: Rodale, Inc.


Dr. Angela Lamson is Associate Dean for Research and Graduate Studies (CHHP) at East Carolina University. 

Dr. Meghan Lacks currently serves as the policy and research analyst for AAMFT where she is responsible for implementing military and Veteran training, research, and policy initiatives for MFTs across the nation.

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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.