Posted By Carol Levine,
Wednesday, April 20, 2016
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"England and America are two countries separated by the same
language.” So said Oscar Wilde or George
Bernard Shaw, or maybe both. Our
countries use different terms for the same thing (‘trainers” for "sneakers”)
and the same term for different things (‘football”). Still, in the realm of
health and social policy, both countries face similar challenges in supporting
an aging population. In both countries the people who provide most of the care
are family members and friends. In the United Kingdom, that person is called a
"carer.” In the United States, the most
common designation is "family caregiver,” with "family” interpreted broadly.
The differences go deeper than terminology. In the UK, there
is a Minister for Social Care and Community responsible for implementing a
National Carers Strategy. In the US, no one is in charge of a national family
caregiving strategy, because there isn’t any. State governments may have their
own strategies, but they mostly focus on "long-term services and supports” available
primarily to Medicaid beneficiaries, for which states pay a big portion of the
It is difficult to compare national policies without
examining their history, demographics, economic context, and other critical
factors. In the UK medical care is
provided largely through the National Health Service; carers’ services are in
the realm of social care, that is, nonmedical support. In the US, despite recent efforts to bring
these two worlds together, the effort is hampered by fragmentation at all levels.
Big picture differences aside, it is instructive to compare
the recently released UK Department of Health’s online
survey for carers and the professionals who support them, and a similar survey from Carers UK,
a leading advocacy organization, and to note some differences with the US
experience. More than just underscoring
the need for information to guide policy on the US side, the UK surveys suggest
some opportunities in the US to obtain standardized information from family
caregivers and to create an impetus for a national strategy.
Caregiver surveys are tools that give policy makers
important information about the diversity of the population, the range of their contributions
to the health care and well-being of the people they care for, the challenges
they face, and their unmet needs. Surveys are also one way to give family
caregivers a voice in policy development and implementation. Because in the UK
there is a defined locus of responsibility for meeting carers’ needs, the
survey findings can be more easily incorporated into planning than in the US,
where accountability is diffuse and elusive.
UK Department of Health Survey
In preparation for a new Carers’ Strategy, the UK Department
of Health has issued a "call for evidence” and is seeking views from carers and
their families, and from professionals who work with them, on what more should
be done to provide support. Unlike US caregiver surveys, mostly conducted by
nonprofit organizations, academic institutions, and some federal agencies, all
with different definitions, purposes, and populations, the most distinctive
feature of the UK government survey is its emphasis on "young carers” (under
the age of 18). Several sections are
specifically devoted to them, and throughout questions are phrased so that
there is an option for young carers to reply. With the exception of one national survey devoted to
young caregivers in the US, published in 2005, all national surveys include
only caregivers over the age of 18. (An
increasing number of caregivers fall into the "millennial” category, ages 18-34.)
Just as in the UK, there are many children and teenagers under 18 in the US who
are caregivers, but we don’t count them, identify their needs, and (except for
a few pioneering programs) support them.
One issue raised by the UK survey is also common in the US:
identifying people as carers. The survey
asks whether the respondents received help to identify themselves as carers and
whether that was important. It also provides space to suggest specific ways to
help carers recognize that they are not just daughters, sons, or spouses, but
The UK Carers Act of 2014 requires local governments (known
as "authorities”) to provide a range of information and advice services to
carers, including an opportunity for an assessment of their needs, which is their
legal right. Carers over 16 may be eligible to receive a Carer’s Allowance of £62.10
a week ($89.19) if they provide over 35 hours of care a week and earn less than
£100 ($143.62) a week. The survey asks about carers’ experiences obtaining this
Similar to US surveys, the government survey asks about physical
and mental health problems and difficulties balancing paid employment with
caring responsibilities. It also asks about "ensuring a life outside caring,”
which in US surveys is usually phrased less elegantly as "quality of life.”
Carers UK Survey
Every year Carers UK surveys carers and others about what
they do, gaps in services, and other items.
Like the government survey, this advocacy organization survey has many
boxes for respondents to tell their stories, suggest changes, and upload
reports or documents. This online survey
asks the type of care or support provided, including "arranging/coordinating
care and support, medical appointments and other help” and "helping with
medication (e.g., making sure he/she takes pills, giving injections, changing
dressings”). One section is devoted to
transition from a hospital stay. This is a greater level of specificity than in
the government survey. It also suggests
that carers’ responsibilities fall into both the medical and social categories.
Housing receives considerable attention in the Carers UK
survey, but not in the government survey, nor generally in US surveys, other
than a question asking whether the care recipient lives with the caregiver. The Carers UK survey asks about the
respondents’ current housing situation, including the option of renting a home
from a local authority, and whether the current home is adequate for the ill
person and the carer’s needs. Several
questions in this survey suggest that waiting lists for services are a problem;
one option on the housing question is "Our home is not appropriate and we are on
the waiting list for local authority housing.” Another question concerns home
adaptations, and one option is "We have qualified for adaptations to be made by
the local authority and have been waiting for these to be made for more than 18
Technology is another important area in the Carers UK
survey. The survey acknowledges that it
is an advocacy tool, noting, "We’re gathering evidence…to make the case for
Government, public service professionals and technology providers to open up
access to these important technologies.” The survey questions ask about current
use of technology, such as a fall detector or personal alarms; and it further
asks about the impact on the carer’s life, including positive and negative
Other domains include finances, community supports, and
Implications for the US
It would be difficult to replicate the UK experience, and
surveys alone will not reach the full range of American caregivers. The surveys
are long and in English only. Neither UK survey is a representative sample; the
responses come from already identified carers and service providers. Online
surveys limit respondents to computer users.
At a minimum, the Centers for Disease Control and Prevention
(CDC) could make additional use of its public health surveillance system called
the Behavioral Risk Factor Surveillance System (BRFSS). All states are required
to ask a representative sample of residents a series of core questions; they
can include some optional modules; and they can ask questions that they want
answered. The optional modules add costs to the states. The questions are
administered by phone (landline and cell phone). The eight-question caregiver
module is optional. In 2015 24 states chose this option, and others could
be given incentives to include the caregiver questions, or the module could be
made part of the core questions. Although the information gathered is minimal,
it could form the basis for a national strategy. Further, states should move
beyond Medicaid to look at middle-income families who are struggling to provide
care, maintain jobs, take care of children, and fulfill all the other
responsibilities they have.
Carers and caregivers may be divided by language, as Wilde
and Shaw observed, but they share similar needs. For the future, caregivers
need a coherent national strategy, implemented by states to reflect local needs. As the well-known American philosopher Yogi
Berra said, "You’ve got to be very careful if you don’t know where you are
going, because you might not get there.”
|Carol Levine directs the Families and Health Care Project at
the United Hospital Fund in New York City.
She is the editor of Living in the
Land of Limbo: Fiction and Poetry about Family Caregiving (Vanderbilt
University Press, 2014). |
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Posted By Suzanne Mintz,
Monday, April 11, 2016
Updated: Monday, April 11, 2016
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This piece is a reprint from March 2015. Click here for original post.
In the past few months my husband Steven has added two more doctors to his alphabet soup of medical professionals, a pulmonologist and a rheumatologist. He now has eight physicians in charge of various parts of his body.
We share a family doc, but Steven also has a neurologist for his MS, an orthopedist for his osteoporosis, a physiatrist who focuses on his functioning, an ophthalmologistwho keeps a watch on his optic nerve since MS can affect eyesight, a urologist to deal with his neurogenic bladder and accompanying bladder stones, a physical therapist who comes to the house twice a week, an occasional visit to a podiatrist to deal with cracking between his toes, and of course the usual bi-annual visit to the dentist.
The recent addition of the pulmonologist and the rheumatologist has really scared us because their specialties deal with hidden problems that are caused by the pernicious degradation of his body. Everyone focuses so intently on the visible aspects of his disability, the fact that he is in a wheelchair, his increasing inability to feed himself and to push the computer keys, but it is the hidden degeneration of his body that is most worrisome to us. Sometimes it really gets us down, but then we remember how lucky we are to have each other, live near our daughter, have the funds to purchase the items and services we need and overall a good quality of life.
Steven’s neck has been stiff for a long time, and a MRI, the first he’s had since early on in the course of his disease, has shown the existence of osteoarthritis. It explains the intense neck pain he feels, its poor range of motion, and the dull ache in the lower back of his head. Apparently there isn’t all that much that can be done about it; "Take ibuprophen” the rheumatologist said. "It will reduce some of the inflammation and the associated pain, but it might also cause stomach problems. If so you’ll need to add an antacid to your medication regimen”. He also suggested that Steven get a soft collar for his neck to help relieve the pressure that accompanies each movement.
|In the past few months, Steven has added two more doctors to his alphabet soup of medical professionals|
Steven went to the pulmonologist at the suggestion of our primary care doc who said he thought Steven’s voice had been getting softer. With pneumonia often being the cause of death for people with MS, he wanted to make sure Steven’s lungs were functioning properly. It turns out they aren’t. The breathing tests Steven underwent showed how abnormal his lung function actually is. One of the biggest problems is his inability to expel all of the carbon dioxide from his lungs. The pulmonologist scheduled a sleep study. He thought it would show sleep apnea and therefore point to the need for Steven to get a continuous pulmonary air pressure machine, generally referred to by its initials, CPAP. Because the machine forces constant air into your lungs through a tube connected to nose "pillows”, soft rubbery nasal inserts, it ensures the proper flow of gases in and gases out.
Steven was diagnosed with MS in 1974 when he was 31. He turned 71 this past summer so we’ve been dealing with MS for 40 years now. The heavy duty caregiving began about 20 years ago when he got his first wheelchair, and it’s been downhill ever since.
The neurologist surprised us recently when he said Steven may not actually have MS, that there is some thought in the medical community that primary progressive MS, which is Steven’s diagnosis, may not be MS at all because the only things it seems to have in common with classic MS is that it attacks the body early in one’s adulthood and causes the breakdown of myelin and the consequent scar tissue. Steven’s disease, whatever it is, only attacks the nerves in the spinal cord, not those in the brain and it isn’t characterized by relapses and remissions, but is rather a slow but steady degeneration. Fortunately it doesn’t show any cognitive impact: Three cheers for that!
|What matters is that he is losing more and more function|
In the long run, whether Steven has MS or something that looks like MS doesn’t really matter. What matters is that he is losing more and more function, inside and out, and there isn’t much we can do about it. Coupled with the normal changes that come with aging, our abnormal life is continually becoming more so.
Despite the difficulty we refuse to let all-of-this stop us from living as full a life as possible. Steven has been retired for three and a half years and I for one year, so we have more time and flexibility regarding what things we can do and when we can do them. Why battle weekend crowds at the movies when we can go on a weekday afternoon? We recently got back from a vacation to Newport RI. It’s a short flight to Providence from where we live and we were able to rent an accessible minivan for the 40 minute drive down to Newport. Once there we "walked” to as many places as we could and had a grand time. The concierge at our hotel found out about a boat that could handle Steven’s wheelchair and we took a lovely tour around the harbor. We went to visit the extraordinarily ostentatious Vanderbilt summer "cottage” and walked along the cliff. We ate lobster and saw fabulous sunsets. We were always back in our room by 9:30 completely worn out from the day’s activities. We slept in taking our time to get started the next day, doing everything at our own pace.
To be fully involved in living or to let MS control our lives, that is the question. For us the answer is simple: Do as much as you can with what you’ve got and enjoy life as much as possible. This summer we hope to go to Santa Fe, one of our favorite places.
|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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Posted By Laura Sudano, Jennifer Miller, Elizabeth Skidmore,
Thursday, March 24, 2016
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Annoyed by the lack of new and innovative ways for keeping children in bed, parents of young children have started to explore techniques for getting little ones to sleep by themselves. "All of these researchers are trying to help us, we know. But we had enough,” said one frustrated parent of a four year-old sleepless child. "These kids have a sixth sense about them – they know when I am deep in REM sleep and come and wake me up.” Parents across America are losing sleep and have attempted to keep their children in bed. One father shared his failed attempts to keep his child in his room, "I have tried Avengers-themed bed straps and padlocks, and ice cream laced Benadryl. Nothing works. He finds his way to my room like a candy bar finds its way into my mouth. It just knows the way.”
Despite these struggles, one researcher has found a solution. Connie Schnoes, a mother of six and director of National Behavioral Health Dissemination at the Boys Town Center for Behavioral Health in Boys Town, Nebraska, created the "Bedtime Pass.” The National Public Radio (NPR) article which highlighted this research describes how it works: Every night, parents give their child a five-by-seven card that is the bedtime pass. They explain to their child that the pass is good for one excused departure from the bedroom per night, whether that's to use the bathroom, get one more hug, report a scary dream, whatever. After the pass is used, the child may not leave the bedroom again, and the parents are not to answer if they call out. (NPR, 2015). Schnoes’ study was published in October 1999 in the Archives of Pediatrics and Adolescent Medicine.
My (JM) initial reaction to the bedtime pass was "it can't be that easy” because like most things, if it were an easy fix we wouldn't be having this discussion. Behavioral insomnia is not an uncommon phenomenon and occurs in 10-30% of children. As noted by the American Academy of Family Physicians (AAFP), this condition is typically the result of a child refusing to sleep without certain conditions or limit-setting types. Instead of relying on the "Band-Aid” that is the bedtime pass, we should embrace that the best treatment is prevention. As noted in the 2014 AAFP journal (Carter, Hathaway, & Lettieri, 2014), physicians should encourage good sleep hygiene including setting boundaries and consistent sleep times. Previous studies (Anders & Keener, 1985; Goodlin-Jones et al., 2001) show that infants who are placed in the crib awake versus asleep are more likely to become self-soothers. By setting a routine we create expectations and a reliable foundation, which I believe is better than a temporary fix.
We, as family medicine physicians, forget that giving advice is hard and getting a parent to consider advice from a physician without children is sometimes harder. I (JM) think we also forget that not only are these sleep issues affecting the children, but advice we give the parents affects their sleep as well. We may recommend that parents keep to a sleep schedule and facilitate optimal sleep hygiene. Advice or recommendations sound great, but execution is tough. For example, I (JM) met a single parent who works third shift while her oldest daughter, in college, helps with the kids at home. It is one thing to give advice to the parent, who implements changes at home. In this case, one may seem almost guilty to pass along the advice knowing that more burden is placed on the eldest child, who is already dealing with college responsibilities and now has another added task. Patient in context is important.
Similar to JM, "It can't be that easy," was my (ES) initial reaction to this allegedly revolutionary "Bedtime Pass." I have visions of walls reverberating with screams and the magical pass reaching its untimely demise in shreds scattered over the ground. However, my pessimistic stance stems from perceived and not personal frustration with this problem, as I listen sympathetically to the parents of my young patients as they describe the bedtime woes, offer some vague supportive advice, and leave the room with a good-luck pat on the shoulder as I head home for a quiet evening in a kid-less house. As a family medicine physician, I advise sleep deprived parents of young children to ignore the unwanted behavior and reward the desired behavior with positive attention.
Research suggests that a contributing factor to children’s behavioral problems is negative (i.e., harsh discipline) parenting behavior (McKee et al., 2007). The "Bedtime Pass” may work for parents and children because of the respect for children’s agency, creates a balance between limits and latitude, and allows children to regulate their emotions to a certain degree. For example, the child who is given a "Bedtime Pass” may choose when and where to use it, without a negative consequence for their actions. A child’s freedom to make choices and mistakes within limits is a main tenant of parenting techniques such as Love and Logic (Fay, Cline, & Fay, 2015). Considering the difficulty of tackling the philosophy of parental discipline in a quick clinic visit, the "Bedtime Pass" is quite attractive given the simplicity of the idea and a concrete plan that is easy to prescribe for at least a trial run.
I want to first disclose that I (LS) am not a parent. And what I say to those parents who are patients in my practice is, "I know that you probably hear more parenting advice from those who do not have children. So, bear with me.” I hope you, the reader, bear with me as well. Before sending this to our CFHA blog editor, Dr. Matt Martin, I thought the article was cold blooded! It reminded me of the Ferber Method… let the child cry it out. I think the "Bedtime Pass” has some credibility but I would be hesitant to direct my sleep deprived parents of young children to use this method. Instead, I would want to ask a few questions to figure out which method may fit to solve their child’s sleep issues. You know, because we are patient-centered. I would first want to understand the parent-child relationship and how the parent interacts with the child. For example, how does the parent respond to the child if the child becomes upset? Teaching a child how to self-soothe is important as it leads to positive outcomes for building resilience (Buckner, Mezzacappa, & Bearslee, 2003), good interpersonal relationships (Rubin, Coplan, Fox, & Calkins, 1995) and reduced risk for developing depression and anxiety (Alvord & Grados, 2004). If the parent is anxious or misreads the child's cues, then I (LS) would focus on the parent first and coach them in session. Or if a child is anxious, I use breathing techniques to help them self-regulate. I think the "Bedtime Pass,” as my colleagues have mentioned, may not be addressing the core issue – the problem could be a behavioral issue which can be a result of an emotional regulation or attachment issue. This is, of course, in my (non parent) clinical opinion.
When it comes to getting more sleep, our position is that people will try anything and everything. We would do anything it takes to get more sleep if it were us in the position of having young children who didn’t stay in their room. Our recommendation, however, is to remember the patient in context and be patient-centered in your approach to help sleep-deprived parents get more sleep.
Alvord, M. K., & Grados, J. J. (2005) Enhancing resilience in children: A proactive approach. Professional Psychology: Research and Practice, 36, 238-245. doi: 0.1037/0735-7028.36.3.238
Anders, T. F., & Keener, M. (1985). Developmental course of nighttime sleep-wake patterns in full-term and premature infants during the first year of life. Sleep, 8, 173-192.
Buckner, J. C., Mezzacappa, E., & Beardslee, W. R. (2003). Characteristics of resilient youths living in poverty: The role of self-regulatory process. Development and Psychopathology, 15, 139–162. doi: 10.1017.S0954579403000087
Carter, K. A., Hathaway, N. E., & Lettieri, C. F. (2014). Common sleep disorders in children. American Academy of Family Physicians, 89, 368-377.
Fay, J., Cline, F. W., & Fay, C. (2015). https://www.loveandlogic.com/about/bios. Accessed January 6th, 2016.
Goodlin-Jones, B. L., Burnham, M. M., Gaylor, E. E., & Anders, T. F. (2001). Night walking, sleep-wake organization, and self-soothing in the first year of life. Journal of Developmental & Behavioral Pediatrics, 22, 226-233.
McKee, L., Roland, E., Coffelt, N., Olson, A. L., & Forehand, R. (2007). Harsh discipline and child problem behaviors: The roles of positive parenting and gender. Journal of Family Violence, 22, 187-196. doi: 10.1007/s10896-007-9070-6
Rubin, K. H., Coplan, R. J., Fox, N. A., & Calkins, S. D. (1995). Emotionality, emotional regulation, and preschoolers' social adaptation. Development and Psychopathology, 7, 49–62. doi: 10.1017/S0954579400006337
Wendy Mitman Clarke (September 18, 2015). The bedtime pass helps parents and kids skip the sleep struggles. http://www.npr.org/sections/health-shots/2015/09/18/441492810/the-bedtime-pass-helps-parents-and-kids-skip-the-sleep-struggles. Accessed September 18th, 2015.
|Dr. Jennifer Miller is a third year Family Medicine Resident at Wake Forest. She graduated from Florida State University College of Medicine with an interest in sports medicine. Moving forward she hopes to practice in an integrated care model with a focus on community awareness of preventative health measures.|
|Dr. Elizabeth Skidmore is a second year Family Medicine Resident at Wake Forest Family Medicine. She looks forward to being a general practitioner after completion of residency, and enjoys opportunities to combine an interest in writing with her interest in medicine.|
|Laura Sudano is an Assistant Professor and the Director of Behavioral Science at Wake Forest Family Medicine Residency. Her interest is in the application of integrated care in different medical settings, residency training, and interprofessional education/training. She enjoys collaborating with different departments in the institution to provide comprehensive, integrated care services to patients in the Wake Health system.|
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Posted By Sarah Woods,
Thursday, March 10, 2016
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I have an almost 2-year-old. One afternoon this summer, I turned the TV on "just to catch some news” (and a parenting breather) and Disney’s Ratatouille was on. So, I thought I would break all of AAP’s (revised) rules and allow her to watch some of the movie.
The message of Ratatouille, and the movie’s conscience, Chef Gusteau, is that "anyone can cook!” While characters in the movie struggle with issues of identity, confidence, and social support (as a therapist, naturally I overanalyzed the whole thing), the conclusion is that, while "not everyone can become a great artist – a great artist cancome from anywhere.” This message replayed in my head, over and over. If anyone can cook, and the truly fearless can be great – doesn’t that hold true for MedFT?
I am a MedFT, but train family therapists in a MS/PhD Family Therapy program. Not all of my students are interested, or knowledgeable (yet) in medical family therapy or integrated care. My emphasis is always on how to train general, new MFTs on how to do quality collaboration, especially with systems they are not embedded in (e.g., PCPs located outside their own mental health system). At times I myself have struggled with this identity. If I am a "true” MedFT, shouldn’t I be teaching and training in a MedFT program? Shouldn’t I be identifying only with that group of fabulous people, teaching in a family medicine residency, getting specialized training in fully integrated models, working clinically in medical settings? I recently had a former student ask me, "So, when are you going to get back to MedFT?” I almost didn’t understand what she meant, because that’s who I am at my core. But, her question was about whether I was ever going to practice in a medical home again, because, to her, that’s what a MedFT does. Only, and solely, in one defined area of family therapy.
But, here’s the thing: ALLfamily therapists need to understand the core tenets of MedFT, the skills and techniques of collaborative care, the importance of the biological domain, and the language of medical systems. Whether my students "grow up” to practice in a hospital, or in community mental health does not matter. It’s critical that they use a biopsychosocial approach, and that they advocate for their families to recognize the biological dimension of what they face and for other providers to consider the psychosocial aspects of their shared patients. Please understand, I do not mean that anyone and everyone takes a biopsychosocial approach to care, and that all therapists are also MedFTs. Instead, as Chef Gusteau suggests, "greatness in cooking can come from anywhere.” Any therapist who adopts a biopsychosocial approach and "wants to take seriously the health and relational aspects of their patients’ lives” (McDaniel, Doherty & Hepworth, 2014, p. 8) can be a MedFT. My students have equal opportunity to pursue education, training, and practice in this approach, and must be pushed to think outside their psychosocial cookbook.
As the movie suggests, family therapists may only be limited by their soul, not by where they come from; MFTs interested in thinking about larger, medical systems "must be imaginative, strong-hearted.” Further, "you must try things that may not work, and you must not let anyone define your limits because of where you come from.” The only limit, for a family therapist from general MFT origins, is whether they adopt a biopsychosocial approach, prioritize collaborating with medical professionals, and seek to consider healthcare providers and systems in their clinical work. Regardless of training background, a philosophical orientation to families and working with them is key. As I teach my family therapy students – educate yourselves about chronic illness, be brave and approach physicians to share care, read literature outside family therapy-only journals, and include the biological dimension in your treatment plans. They’re capable, just not quite as confident as perhaps students coming from MedFT-specific training programs. Which, I suppose, says something about me too: as a MedFT educating family therapists who may or may not be interested in my obsession, it’s important I train for confidence as well as skill, and model confidence in my own self-knowledge and professional identity.
Although I made sure to turn the TV off after 20 minutes of co-viewing…Chef Gusteau’s mantra stayed with me. Not everyone will become a Medical Family Therapist, but a great MedFT can come from anywhere.
McDaniel, S. H., Doherty, W. J., & Hepworth, J. (2014). Medical family therapy and integrated care(2nd ed.). Upper Saddle River, NJ: Pearson Merrill Prentice Hall.
Sarah Woods, PhD, LMFT-Supervisor is an Assistant Professor and Program Coordinator of the Family Therapy program at Texas Woman’s University in Denton, TX. She graduated with her MS in MFT from the University of Rochester, and PhD in MFT from The Florida State University. Her research focuses on the connections between family relationships and physical health outcomes, especially for underrepresented adult populations.
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Posted By Alexandra E. Schmidt, Alicia L. Adams, Paul D. Simmons, & Elvira R. Whiteford ,
Monday, February 29, 2016
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I do not speak their language, and most of them do not speak mine. Still, I have great hope that the care I receive in this country will be better for me and my baby than what I can get at home. I am here because my husband found work here, but I do not know many people. I come to appointments on my own because my husband has to work. The doctor, earnest and nice, and I struggle to communicate. She knows a few phrases of my language, which I find endearing and for which I am grateful. But most of our visit together is done with the help of an interpreter on the phone. I hope the interpreter is getting it right, and I’m sure my doctor feels the same way. When we listen to my baby’s heartbeat, we smile at each other – we share that moment in common, even if we use different words.
But I am afraid. I am afraid of the hospital when the time comes to have my baby – it is so big, so clean and white, full of strange machines. I am afraid of the pain and that I won’t understand what they are doing to me. What if there are problems? Will they be able to explain to me what is going on? My mother told me about when she had me and how scary that first baby can be – but she was surrounded by family and a midwife who had known her for years! I will be in a foreign place, with people who don’t look like me, don’t know me, and don’t understand me. I live in this country, of course, and go to the grocery store and gas station and post office. I’m able to manage most things in this foreign place. But having a baby is different! So, yes, I am afraid.
Pregnancy is often a time of mixed emotions: joyful celebration of new life, hope for the family’s future legacy, and fear of the unknown. These emotions become magnified for mothers who find themselves in a foreign medical system with unfamiliar language barriers. Around the world, pregnancy is understood as a time of increased risk for health complications for women. Although developed countries tend to have lower rates of maternal deaths than less developed countries, a recent report showed that the number of maternal deaths in the United States actually increased from 1990 to 2013, whereas maternal deaths in less developed countries have declined (Erickson, 2015). There are likely a number of factors to explain this curious finding, including the increased provision of prenatal care for pregnant women in less developed countries. However, this discovery presents a reminder that pregnant women in developed countries are not immune to potentially life-threatening complications such as cardiovascular disease, infection, and diabetes. Women with high stress levels and low social support are at an even greater risk for complications.
Family-oriented care during pregnancy and childbirth encourages clinicians to consider all aspects of maternal care, including those that extend beyond the borders of traditional medicine. The transition to motherhood includes challenges such as couples’ adjustment to parenting roles, decisions to be made about lifestyle changes (e.g. smoking cessation), and building a support system to adequately manage stress. For mothers who have traveled to another country to give birth, there are additional challenges related to acculturation. A collaborative treatment team, including a medical family therapist, can provide comprehensive, culturally informed clinical care to support mothers in reducing risks of medical complications by following physicians’ recommendations, increasing social support, and engaging in positive health behaviors. This blog presents two physicians’ perspectives regarding the importance of comprehensive care to promote maternal health and reduce the risk of negative outcomes for biomedical and psychosocial health.
[AA] A few months ago, I was part of a delivery during an OB rotation that I will not soon forget. This first-time mother was very young and new to this country. Speaking virtually no English, she had fled her country to escape political violence and somehow settled in our small town. She delivered her baby in silence and did not want to hold him. When I spoke with her the next morning using the translator telephone line, she said she was not in any real pain despite her significant lacerations from delivery and begged to go home. Her baby was in the nurse’s station, and she still had not held him. Imagining the difficulty of delivering a baby in a foreign medical system, I wanted to insist that she stay longer to heal and adjust to this new role as mother. She had recovered well, however, so I hesitatingly agreed to discharge her.
Reflecting back on this case, I could not shake my desire to offer her more care beyond ensuring a safe delivery. I thought of the trauma she had experienced in her home country, the many unsavory things that could have led to pregnancy at such a young age, and the discomfort she undoubtedly experienced in a small town of people who do not look, act, or speak like her. I yearned for her to be a patient in my own clinic so I could connect her with a behavioral health provider to help her prepare for this new phase of life. Recognizing her need for a safe community and ongoing support, I aspire to provide these resources for my future patients.
[EW] At our family medicine residency practice, we have offered group prenatal care for Spanish-speaking-only patients for the last seven years. A key aspect of our clinic’s mission is to provide comprehensive care for the most vulnerable and marginalized populations, which often includes pregnant women without legal status. These women are frequently fleeing traumatic situations, or they have moved away from the only culture, support system and world they knew in hopes of better opportunities for their families. Often, these women speak rudimentary English and only qualify for emergency Medicaid. As this insurance only covers basic costs for the delivery, but not for prenatal care, both the mother and baby are at increased risk for negative health outcomes. As a family physician leading this group, I sought out Dr. Randall Reitz, a medical family therapist, to help blend obstetrical care with family support, cultural sensitivity, and counseling in a group setting. We enthusiastically collaborated to create this group for our Latina obstetrics patients. This teamwork empowered us to create a dynamic group that has provided patients with benefits such as increased education and safety throughout pregnancy and newborn care, life-long friendships started in the group, and partnership with family members who also attend. We, too, as providers, have been moved by these women’s courageous sharing of their stories and are inspired to continue refining this group to address the evolving health needs of pregnant women and their families.
Erickson, F. (2015, November 18). Maternal health around the world [Infographic]. Retrieved January 1,
2016 from https://online.nursing.georgetown.edu/maternal-health-around-the-world-infographic/
Alex Schmidt, MS, LMFT-A is a Medical Family Therapy Fellow at St. Mary’s Family Medicine Residency in Grand Junction, CO. She is a Ph.D. Candidate in Marriage and Family Therapy at Texas Tech University and holds a M.S. in Family Therapy from Texas Woman’s University and a B.A. in Psychology from Baylor University. Her research and clinical interests include adults with type 1 diabetes, couples facing reproductive losses, and integrated care training in rural primary care.
Alicia Adams, MD is a first year resident at St. Mary's Family Medicine Residency in Grand Junction, CO. She completed her undergraduate education at Brown University and attended Rush University for medical school. She is passionate about providing care to the underserved and has special interests in maternal and child health.
Paul Simmons, MD received his B.A. in History at Baylor University. He received his medical degree from the University of Colorado in 1999 and completed a family medicine residency in 2002 at North Colorado Family Medicine Residency in Greeley. He has practiced the full scope of rural medicine (including endoscopy, obstetrics and sleep medicine) in western Wisconsin and eastern Colorado. He moved to Grand Junction, CO in 2010 to train family medicine residents at St. Mary’s Family Medicine Residency Program.
Elvira Whiteford, MD pursued her medical degree in California at Loma Linda University Medical Center and then completed an Obstetrical Fellowship at Arrowhead Regional Medical Center. She has been a part of the faculty at St. Mary’s Family Medicine Residents since 2007 and has greatly enjoyed educating the residents and medical staff about a variety of Family Medicine topics, but she has special interest in Maternal Care.
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Posted By Lisa Zak-Hunter,
Thursday, February 18, 2016
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I overheard a family physician lament about the unraveling of family practice. It was after a long day of seeing single parent families, grandparents raising children, and endless single pregnant women. The statement was something along the lines of “A single mother and her baby are not a family. This is not why I went into practice.” I sensed frustration and disillusionment from someone who idealized caring for mom, dad, kids, and grandma and grandpa. I put my initial feelings aside and tried stepping into his shoes. A theme I kept coming back to was: how do provider definitions of ‘family’ or the ‘ideal family’ impact patient care and provider wellbeing?
Within the past few years, there has been increased discussion about both how to define family and who defines family. The Syrian refugee crisis has reignited debate over the laws that govern and programs that service immigrant, refugee, and undocumented families. It has also highlighted how families are torn apart in times of war and conflict, leaving them grappling to redefine themselves. Gay marriage has also been legalized in our country more recently, and there continue to be discussions about its legality and morality. Family structures have changed in other ways as well. Births to older women are on the rise and overall birth rates are low (Howe, 2015; Matthews & Hamilton, 2014). Statistics also indicate that approximately 60% of children live in a family with married parents where at least one works. The other 40% live with single parents, grandparents, a parent and their significant other, or other situations (Council on Contemporary Families, 2012). In 2012, the chances that two children selected at random would share the same family constellation was just under 50%, compared to about 80% in 1960 (Council on Contemporary Families, 2012). In other situations and within certain cultures, family members may not be blood relatives but close friends. At this point, it is challenging to identify the ‘typical American family’ because there is no dominant family form (Council on Contemporary Families, 2012).
If there is no dominant family form, how do we provide family healthcare? How family is legally defined in healthcare influences treatment. We are reminded of this as non-legal significant others or non-legal parents have a more difficult time obtaining information and making treatment decisions for minor patients or unresponsive loved ones. They are not considered next of kin, and proper paper work needs to be in place to ensure communication with healthcare providers. How we address these ethical and legal issues could be a blog post in itself!
Perhaps most relevant to the physician’s comment… how much do providers’ personal definitions of family influence care? In February 2015, a news story came out about a pediatrician who declined to treat a lesbian couple’s baby. According to the note the physician sent the couple, she feared she would not be able to establish a good doctor-patient relationship the way she normally does. She did not elaborate whether this was due to the couple’s sexual orientation, but many believed it did. The story raised questions about how the physician handled the manner, and whether it was appropriate, moral, and legal. Assuming the concern was over the morality of their family structure, what would have happened if the pediatrician HAD chosen to work with that family? How could her beliefs influence care? What about the family physician I overheard who was frustrated that the families he treated did not fit his definition of family? Did he take a subtle tone of frustration or disapproval into the room? Did he spend less time with those patients?
Conversely, did he spend more time out of possibly misplaced fear about children’s well-being in a ‘broken home’? Sometimes a provider views the family as ‘un-whole’ or ‘broken’ and may treat members with pity or attribute their concerns to their ‘brokenness’. At that point, the provider has decided to define the family’s value based on personal biases and assumptions instead of the patient’s perspective and circumstances. If a single mother chooses to be single because she can keep her children safe or hold a higher paying job, the family may not need pity or additional resources. A well-intentioned provider may react without knowing the family’s story or integrating the family’s perspective into treatment.
One way to address assumptions and biases is during training. Across the nation, medical students and residents learn algorithms, evidence-based medicine, procedures, and standards of care. They learn how to assess, diagnose, and treat. Self-reflection becomes secondary, tertiary, or non-existent. Especially for those who plan to work with families, reflection ought to be structured into their training. Providers should be able to identify ways to address family concerns or structures they find questionable and be aware of how their treatment of these families may be subtly different. At the very least, there should be a willingness to be open and vulnerable and to wrestle with these questions. There should be safe places built into curriculum for this exploration. Practitioners are human. They hold a variety of beliefs and definitions of family. They are also accountable for providing quality family-centered care.
At the end of my day, I heard something that made me smile. A resident who was opposed to premarital sex visited with a scared, newly pregnant, unwed teenage couple. In both her check-out with the preceptor and in the room with the patients, she remained respectful, family-centered, and encouraging. The physician said to the couple “A baby doesn’t see teenage parents. Baby sees mom and dad. Be that mom and dad.”
||Lisa Zak-Hunter, PhD, LMFT is Behavioral Science Educator/Clinical Assistant Professor at the University of Kansas School of Medicine-Wichita at Via Christi Family Medicine Residency. Her main clinical, teaching, and research interests lie in the realms of collaborative health care, increasing biopsychosocial understanding of mental and medical health conditions, and practitioner self-care. She has a particular interest in adult eating disorders. Within CFHA, she co-edits the Families and Health Blog and serves as Social Media Director.
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Posted By Marianne McPherson,
Thursday, February 4, 2016
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100 Million Healthier Lives is an unprecedented collaboration of change agents across sectors who are pursuing an unprecedented result: Mission: 100 million people living healthier lives by 2020. Our vision is to fundamentally transform the way the world thinks and acts to improve health, well-being and equity to get to breakthrough results. Together, we are systematically creating a community of solutions to the most intractable challenges that stand in the way of achieving health, wellbeing and equity across the globe. Our theory of change follows:
Unprecedented collaboration + innovative improvement + systems change to remove barriers = 100 million people living healthier lives by 2020.
Our 700+ members have signed on because we believe the time is right for a major leap forward in the creation of health, wellbeing and equity. The rising tide of chronic disease, an aging population, structural inequity in health outcomes (despite advances in health care), and technology demand a fundamentally different approach, one which brings us together across sectors to address the physical, social and behavioral contributors to health together.
What’s more, all members of 100 Million Healthier Lives agree to adopt five following core principles in our work together. Several of those resonate strongly with the founding principles of CFHA of collaboration and family-centered care:
- Partner deeply and respectfully in the process of creating change with people, organizations, and communities.
- Promote equity, justice, strength, and wholeness in the process of creating health.
- Adopt a humble posture of learning and improvement that acknowledges the importance of both stories metrics that matter.
- Intentionally work to remove barriers in critical areas (e.g., payment reform, spread of good ideas) through intentional collaboration with traditional and nontraditional partners.
- Make the way we work an example of what’s possible.
We set an audacious goal of 100 million healthier lives precisely so that there was a goal so big that no one organization or community or stream of work could achieve it alone.
A key priority in the movement to is to shift culture and mindset to one of partnership, co-design, and wellbeing. Some examples:
· Partnership means that, for example, we have shared leadership and decision making at every level of the initiative. We believe that everyone holds a unique and important piece of the puzzle in creating health. We are committed to seeing how those pieces fit in different combinations, letting go of the pieces we hold to combine them in innovative ways.
· Co-design means that we are working with rather than for communities. We are working to create 1000 “communities of solution” around the world, believing that sustainable change for health, wellbeing, and equity, will come when communities, themselves are full partners in the work, when they set meaningful goals rather than having goals set for them. The 61 communities in the SCALE and Pathway to Pacesetter initiatives are working in multi-sector teams and using improvement science techniques to test and learn their way into their community’s health goals.
Wellbeing means that we define and measure health as broader than physical health to include physical, mental, social, and spiritual wellbeing. The importance of integrating mental health into primary care resonates deeply with our work and goals, including a stream of work aimed to “make mental health everybody’s job.”
We have organized work by focusing on the following “9 Whats and 9 Hows":
- Close equity gaps – this is “the “price of admission” in 100 Million Healthier Lives
- Help veterans to thrive
- Address and improve social determinants across the continuum
- Improve wellbeing of indigenous communities
- Help all kids have a great start to life
- Make mental health everybody’s job and take a prevention approach
- Engage people in their own health (nutrition, exercise, sleep, stress, food security)
- Improve employee health and wellbeing
- Create wellbeing in the elder years and end of life
- Shift culture and mindset to one of partnership, co-design, and wellbeing.
- Develop the health workforce
- Elevate peer to peer approaches
- Build improvement capability at the community level
- Use chronic diseases and risk factors to build the health continuum
- Improve high quality primary health care access for all
- Integrate data across siloes (health care, community, public health, social services)
- Create new financing strategies
- Transform health care to be great at health and great at care
The movement is more than words and ideas, it is coming to life around the world in everyday action. The story below is from the online community—anyone is free to join the community and share stories about a recent success partnering with high school youth in Algoma, Wisconsin, shared by Teal Vanlanen:
Through the recognition of our Live Algoma work, our local high school received a $5000.00 Hands-Only CPR kit from the American Heart Association and Bellin Health. The students were tasked with "being creative" in using this kits - I think they went above and beyond creativity!
The students decided to partner with Live Algoma because "Live Algoma is by us and for us," they said. As a result, we presented our Driver Diagram, our AIM, and how to complete a PDSA [improvement science tools]. The students were thrilled. We told them to start small and SCALE up in the community.
For their first small scale test, the students wanted to train Hands Only CPR to members of our community at two local basketball games (basketball is a huge draw in our community). They were aiming for to train a minimum of 20 people per game; they trained 130!
How are they planning on SCALING up in our community? Wait until you hear this: next semester they are developing a class where they can go out to local businesses and train all of the employees on Hands Only CPR. Then, they will meet with the local government, school administrators, and local business owners to share their data and convince them to make system and policy changes within their organizations to require all employees and students (grades 7-12) to be trained in Hands Only CPR each year.
Thank you for the opportunity to share our voices on your blog. We invite you to join with us via www.100mlives.org; you can join the movement, register for monthly momentum calls, visit our map of the movement, and share your stories. Thank you for all you do to improve health and wellbeing!
Marianne McPherson, PhD, MS, is Director, 100 Million Healthier Lives Implementation at the Institute for Healthcare Improvement. Her responsibilities include developing and implementing new programs; building external partnerships; and supporting a culture of unprecedented collaboration, innovative improvement and system transformation to support 100 million people worldwide leading healthier lives by 2020. Marianne received her MS in Public Health from Harvard School of Public Health, her MA in Women’s and Gender Studies from Brandeis University, and her PhD in Social Policy from the Heller School at Brandeis University. Connect with her directly at firstname.lastname@example.org (email), www.100mlives.org (web), or @MariannePhD (Twitter).
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Posted By Thekla Brumder Ross,
Monday, January 25, 2016
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As I look out over the Arizona desert at Saguaro cacti glistening in the crisp morning sun, I ponder the life of a desert caballero. Of course I have my own set of assumptions about what a desert cowboy might look like with his/her sun-painted leather skin, blue jeans, bolo tie, silk neck scarf and felt cowboy hat. These images are based on what I have been exposed to in my life or absorbed in our media-cluttered world; they are my stereotypes. My husband and I fantasize about the cowboy’s “simple life” on horseback as we both attempt to tackle the challenges of integrated care in our work lives back home in Colorado. However, this imaginary cowboy dream got me thinking: Do I really know what it is like to be a caballero? Do I truly comprehend the ins and outs of a cowboy’s day?
Contemplating how stereotypes impact my thoughts, feelings and behavior, I am reminded of the Providers Share Workshops created by Jane A. Hassinger, Lisa H. Harris, Lisa A. Martin and Michelle Debbink at The University of Michigan to help explore the experiences of people around the world who provide safe abortion services.1 The Provider Share Workshop was designed to both support and study the experiences of abortion providers and to lessen the burdens of stigma for providers.
Sadly, we live in a world today where stereotypes and stigma not only shape our perceptions, but also strongly influence the national healthcare dialogue. Abortion providers are one example of a highly stigmatized group silenced by stereotypes and judgment. Abortion providers live in a world of harassment, hate mail, and violent language surrounding the care they provide. The most recent shootings that occurred outside of a Colorado Springs Planned Parenthood clinic this past November highlights the ongoing threat of violence focused on abortion providers. It has been over 40 years since the Supreme Court’s decision to legalized abortion in Roe vs. Wade, yet abortion providers often still work in a cloud of silence.
As a facilitator of Provider Share Workshops I learned about how abortion providers rarely feel comfortable disclosing their professional reproductive health work to neighbors, friends and even family. In order to keep at it--providing the high quality comprehensive reproductive healthcare in a safe and supportive environments-- many abortion providers report “a walling off” from fellow colleagues, family and friends. Their silence is associated with disproportionally higher rates of attrition (compared to their primary care counterparts) despite decades of stable abortion rates. Additionally, the number of abortion providers has declined in the US because fewer and fewer hospitals provide abortion care.2 Harris et al. explain these dynamics as the “legitimacy paradox”.3 One would think that because we don’t talk about abortion that it is rare, when in fact about half of American women will have an unintended pregnancy, and nearly 3 in 10 will have an abortion, by age 45.4-5
Jane A. Hassinger, Lisa H. Harris, Lisa A. Martin and Michelle Debbink at The University of Michigan have referred to abortion care as a kind of socially stigmatized ‘dirty work‘ that can both positively and negatively impact providers. In facilitating Provider Share Workshops in North and South America I have been given a snap shot of the palpable stigma that harms the future of safe reproductive care in our society. The stigma of abortion doesn’t just impact the women who seek care, but it impacts the lives of the courageous providers who show up to work daily to ensure that reproductive healthcare is accessible to all. While facilitating these workshops I have witnessed the processes by which stigma, prejudice, discrimination, criminalization and misrepresentation of reproductive healthcare providers are acknowledged, deconstructed, and resisted. By creating a safe space for sharing and exploring abortion provider experiences, this type of provider support acts as a form of stigma management. Like most support groups, the Provider Share Workshop fosters interpersonal connections that help alleviate many of the burdens of abortion stigma.
What makes Provider Share Workshop unique is that it provides a space to develop hope for silenced providers through different medium then transactional daily interactions. The activities in the workshop collage-making, sharing stories of memorable patients, and exploring the challenges of disclosure create a vehicle of expression for the men and women who provide safe abortion care. The space created by the artistic expression of these exercises gives voice to the individual and collective silence surrounding abortion care. As a facilitator of these workshops I am honored to support abortion providers, and I am humbled by the courage they demonstrate daily to provide safe and high quality care. I am also challenged to envision other ways in which we can fight stigma and silence.
As my cowboy dream fades away while watching the desert shadows move in the morning light, I am reminded that we have a long ride ahead in our efforts to breakdown the stereotypes and stigma which plague reproductive healthcare providers. I invite CFHA readers to explore their own internalized stigma regarding abortion care and contemplate how these stereotypes may impact the care of their patients and collaboration with fellow reproductive healthcare providers. Take a moment and imagine if we lived in a world where abortion providers were given as much respect as surgeons, oncologist and family medicine providers; maybe our patients would experience fewer stigmas and more opportunity to access safe reproductive care. Abortion is in fact one of the safest common surgical procedures for women in the United States.2 Maybe abortion services would take their rightful place on the continuum of reproductive choices and reproductive health services for women around the world.
To learn more click here: An Overview of Abortion in the United States. January 2014
Thekla Brumder Ross, PsyD is a bilingual Behavioral Health Clinician at Kaiser Permanente’s Care Management Institute and Northern California’s Division of Research. She has worked for the Care Management Institute since 2014 and Northern California since 2009. Prior to joining Kaiser Permanente in 2009, she received a Bachelor of Arts in psychology from Colorado College in Colorado Springs, CO and her Master and Doctorate degrees from the California School of Professional Psychology in San Francisco, California. She has also completed additional training in integrated behavioral health consultation and management from the University of Massachusetts Medical School. Dr. Ross facilitates Provider Share Workshops domestically and internationally in collaboration with Planned Parenthood Federation and The University of Michigan.
1. Dynamics of stigma in abortion work: findings from a pilot study of the providers share workshop. Soc Sci Med. 2011;73:1062–1070(]
2. Guttmacher Institute. An Overview of Abortion in the United States. January 2014
3. Physicians, abortion provision and the legitimacy paradox. Lisa H. Harris; Lisa Martin; Michelle Debbink; Jane Hassinger. Contraception. 2013;87(1):11-16
4. Henshaw SK, Unintended pregnancy in the United States, Family Planning Perspectives, 1998, 30(1):24–29 & 46.
5. Jones RK and Kavanaugh ML, Changes in abortion rates between 2000 and 2008 and lifetime incidence of abortion, Obstetrics & Gynecology, 2011, 117( 6):1358–1366
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Posted By Administration,
Monday, December 14, 2015
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As the New Year lurks around the corner, we’d like to take an opportunity to announce the Families and Health Interest Group (FHIG)’s plans for the coming year and introduce the new leadership.
Grow and Diversify our Membership. Leadership is committed to recruiting our colleagues in medical professions and non-family therapy behavioral health providers. We are performing targeted outreach to specific professionals we know share our value of families in healthcare. In tandem with this, the editors of the Families and Health Blog have made plans to include more bio-medically oriented authors. We encourage our SIG members and readership to also reach out to non-behavioral health providers. Dr. Froude has a recruitment letter, if that would be helpful.
CFHA 2016 Conference. Similar to 2015, the FHIG is dedicated to putting the family at the center of healthcare and are working towards including this in the 2016 CFHA conference. We have identified specific ways to highlight families for the 2016 conference, including family centered themes and calls for proposals/posters.
Website Improvements. Our intention is for the website to be more useful and resource-full. Therefore, we are compiling lists of family-oriented research and clinical tools. We ask that members submit them so we can have a wonderful resource page. Additionally, we want to promote increased collaboration among members and further mentorship for our early career professionals. We ask that each member submit a short bio, as well as clinical and research interests. If you know of good tools or are submitting a bio, please send them to Drs. Zak-Hunter and Lynch for inclusion on the website. The deadline for everything is Jan 22nd, 2016.
Webinars. We are hosting 2 webinars this year- one in February and one in June.
Early Career Membership Mentoring. We recognize that our early career professional membership is growing. To address this need, we are working to update our website with internship and mentorship opportunities in addition to the other website improvements.
Interested in Joining Us in 2016?
Open calls: 3rd Friday of the month, quarterly. 10am PT/1pm ET.
Maureen Davey, PhD, LMFT is a family researcher, licensed marriage and family therapist, AAMFT approved supervisor, and an associate professor at Drexel University’s Department of Couple and Family Therapy in the College of Nursing and Health Profession. My work focuses on helping children, couples, and families cope with illness. I am currently developing and evaluating couple and family prevention programs for diverse populations who are coping with parental illness (e.g., African Americans families coping with parental cancer), and illness in a partner/spouse (e.g., cancer treatment and survivorship in a partner/spouse).
Laura Lynch, PhD is the Collaborative Healthcare Clinical Practice Educator in the Department of Couple and Family Therapy at Drexel University. She completed the Families, Illness, and Collaborative Healthcare Fellowship under Dr. John Rolland at the Chicago Center for Family Health, and recently co-authored the book, Helping Children and Families Cope with Parental Illness: A Clinician’s Guide. Her research focuses on the development of systemic interventions to help couples and families cope with chronic illness.
Immediate Past Chair
Kaitlin Leckie, PhD, LMFT is the Director of Behavioral Health Education at Southern Kaitlin Leckie, PhD, LMFT is the Director of Behavioral Health Education at Southern Colorado Family Medicine Residency. She earned an Advanced Specialization in Medical Family Therapy, co-sponsored by the University of Colorado School of Medicine and St. Mary’s Family Medicine Residency in Grand Junction, Colorado. She obtained her doctorate and Master’s of Science in Marriage and Family Therapy from Texas Tech University. She is a founding leader of CFHA’s Families and Health Special Interest Group and is a Clinical Fellow of the American Association for Marriage and Family Therapy. Dr. Leckie has conducted research on the multifaceted relationships between health activation, social support, overall functioning, and the use of healthcare services among high-risk patients. Her many interests include Adverse Childhood Experience (ACE) assessment and intervention, self-care and wellness among clinicians, and family-centered health care.
Lisa Zak-Hunter, PhD, LMFT is Behavioral Science Educator/Clinical Assistant Professor at the University of Kansas School of Medicine-Wichita at Via Christi Family Medicine Residency. Her main clinical, teaching, and research interests lie in the realms of collaborative health care, increasing biopsychosocial understanding of mental and medical health conditions, and practitioner self-care. She has a particular interest in adult eating disorders. Within CFHA, she co-edits the Families and Health Blog and serves as Social Media Director.
Early Career Representative
Cameron Froude, PhD is a postdoctoral medical family therapy fellow at St. Mary’s Family Medicine Residency in Grand Junction, CO. Cameron is a licensed marriage and family therapist and recent graduate of the University of Connecticut’s doctoral program in human development and family studies. Her clinical interests include working with individuals diagnosed with chronic health conditions and their family members. As a psychosocial health researcher, Cameron’s focus is on understanding the role of medical and social support systems in individuals’ recovery from chronic illness.
CFHA Board Member
Randall Reitz PhD is the Director of Behavioral Sciences at the St Mary's Family Medicine Residency in Grand Junction, CO. In this role he trains medical residents and medical family therapy fellows. His roles with CFHA have included Executive Director, Board Member, and Founding Chair of the Families and Health Interest Group. His professional interests include professional development, mentorship, and trans-disciplinary training.
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Posted By Rachel L. Hughes,
Monday, November 23, 2015
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Would you believe that I’m starting my second year as a Medical Family Therapy (MedFT) doctoral student and the first time I heard of MedFT was a little over two years ago? During my very first practicum class, a second year doctoral student enthusiastically recounted some of her experiences as a medical family therapy volunteer in the Health Resource Center (HRC), a free community clinic managed by medical students. I immediately volunteered hoping to get my first taste of what medical family therapy meant.
Knowing little more about integrated health care than the name, I dove headfirst into a collaborative experience with medical students also trying to learn about integrated health. When I first started volunteering, the HRC was set up with medical care, optometry, physical therapy, nutrition, and mental health services (clinical psychology and medical family therapy), sharing little but a location amongst them. Now, MedFT is a part of lead student professional planning meetings, preceptor meetings before clinics, and an active voice in the future direction of the HRC. Getting to this point was not an organic, natural, or even comfortable process to start but was well worth the blood, sweat, and tears put into it.
What Wasn’t Working
· Mental health professionals were pigeonholed, specifically with social work at this site. Medical family therapy volunteers had defined their home as in the social work office because 1) the social worker was an amazingly kind woman and 2) medical students looked at the volunteers as though they had three heads when attempting interaction.
· Different screening forms were used with different mental health professionals. Because psychology and medical family therapy alternated weekends at the HRC, the medical students in charge of the intake paperwork at the clinic had to switch between sets of mental health screening forms (and really struggled with remembering which forms for which professionals).
· The lead medical students in charge of the clinic could barely recognize the medical family therapy volunteers, let alone describe the span of services provided. Most bruising to my new professional ego was the fact that I would enter the clinic week after week, check in with the lead medical student of the day, and be met with a blank, unrecognizing face.
What Has Changed For the Better
The increase in integration was not because of the singular effort of medical family therapy, which would have been near impossible since the clinic was first and foremost a medical clinic. Because the medical student leads pass the torch to new leads every March, being involved from the very beginning with the new leads really helped increase the buy-in to MedFT services.
· Increasing proximity to medical students. Instead of limiting location to the social work office, MedFT volunteers make more noticeable appearances by attending preceptor meetings and giving elevator speeches reminding medical students of the services offered. In lulls at the clinic, MedFT volunteers often socialize with the medical students, checking in on how the medical students and patients are doing. Social conversations have often opened the door for medical students to ask more in depth questions about MedFT services.
· Collaboration of mental health services to create a shared intake form. To reduce the confusion of front desk volunteers, psychology and medical family therapy has reevaluated the efficiency of two discrete forms and were able to work together and create a shared screening form that was effective for both services.
· Welcoming the new leads and efficiently disseminating information about medical family therapy services. You catch more flies with honey than vinegar. This was also true in the integration process. Being friendly and sociable with the leads allowed for receptive ears when speedily describing the services medical family therapy volunteers could offer. Focusing on how medical family therapy were also invested in the physical health of the patients at the clinic even further increased receptivity of the leads.
· Creation of an interdisciplinary "lead” board. To address the lack of communication between different services, a group of lead students from each profession in the Health Resource Center was established. The board communicates about difficulties in disseminating services, brainstorms about ideas that might increase collaboration, and shares in the successes of the Health Resource Center.
What Might Not Change (and That’s Okay!)
· Lack of direct referrals from the medical students. As lovely as it would be to have an eager medical student walk up and say, "I think I have a patient that could benefit from your services,” this is probably a lofty goal at best and unrealistic. Since medical student turnover at the clinic is so high (few students come for more than two weeks a semester) and the current structure of the clinic does not allow for unplanned MedFT visits, the focus of intervention has and will continue to be with the lead medical students that are at the HRC regularly.
· Cohabitation of medical family therapy and psychology. Even though both groups of volunteers offer different services, the space in the clinic is so limited that an office exclusively for one set of mental health volunteers is not guaranteed. To make both services accessible to the community, medical family therapy and psychology collaborate on scheduling and alternate weekends in the clinic.
Despite being a complete novice in the field of collaborative care, I have seen (and advocate for) a huge shift towards greater integration at the Health Resource Center in a single year. I have learned to celebrate the successes and not to sweat the things that didn’t turn out exactly how we were hoping. Not every healthcare system is meant to be fully collaborative because certain parameters (e.g., high employee turnover or space constraints) simply will not allow for it, but level of collaboration is not necessarily a measure of effectiveness. Mental health and medical professionals should not be discouraged by imperfect collaboration. Take it from a total amateur, the smallest changes can make a world of difference in how we practice together.
||Rachel L. Hughes, MA, PLMFT is a medical family therapy doctoral student at Saint Louis University. She received her MA from Appalachian State University in Marriage and Family Therapy and graduate certificates in expressive arts therapy and addictions counseling. Her current research interests are medical outcomes of foster children, utilizing play therapy in medical settings, and adverse childhood experiences.
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