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Heroic Measures

Posted By Patrick Allen, Tuesday, June 9, 2015

It was harvest – a time that I have grown to respect after moving to the fertile plains of Kansas three years ago for residency. During this time, a family would learn whether the year of hard labor had reaped financial stability.  Harvest had a heightened importance in the Sahel. Located on the edge of the unforgiving Sahara, it has some of the worst poverty on Earth. One month of rains were the only chance for income and food for most of the Hausa people I was there serving.  Harvest and its hard work brought hope that perhaps fewer children would starve this year.


It was poor timing for a "70” year old man to become so short of breath that walking was no longer possible. Convention was to guesstimate ages to the nearest decade, so his true age was unknown. He had breathing problems and swelling in his legs for "a while,” but he had lacked the finances, time, and hope needed to seek out medical care. 


This time, however, it could not be ignored.  His two sons gathered the money from a few relatives, borrowed a small motorcycle from yet another, and sandwiched their father’s weak body between theirs. They left their millet fields and children, and journeyed towards the hospital.  Both sons were needed, as most of their father’s care at the hospital, even food and water, would depend on them.


His diagnosis of severe heart failure was readily apparent, and his low oxygen and labored breathing made me worry that he would not survive.  But this man was not yet on any medications. I convinced myself that this might be one of the dying patients I could save.  I started the most aggressive therapy we had available and waited.


By the next morning he was even worse than when he arrived.  He was now unable to lie down in his hospital cot lest fluid accumulate in his lungs and suffocate him.  His sons began taking shifts – sitting behind their father with a leg straddled on either side of his, arms gripped backwards around the cot’s frame to support the weight of their father’s frail body on their chest. 


Back home I worked part-time at a hospice.  I was accustomed to coaching families through the last days.  I was used to families enduring all the appointments, the tests, the ICU’s, the battles with insurance companies, the mixed messages, and the roller coaster of expectations, all fueled by a burning hope that "we can get dad better”. Eventually, that hope yielded to an acceptance that this just might be "his time to go.”  Through compassionate communication, I would elicit the family’s true goals of care (comfort, dignity, meaning) and help arrange for those to be met as the end approached.


Among the Hausa, however, death is well accepted, even in children.  Yet these young men endured anyways.   Why?  For days these two sons propped themselves upright on the colorful woven cot, patiently bearing their father’s weight in order to help him to breathe.  As I saw them each morning, unmoved, I myself was moved to tears.  I owed them my best. Though recovery seemed less likely each day, I would ask their permission to try something else, to give it one more day.  Maybe we could turn this around.  As I informed them of my thoughts and presented them with options, their response was always the same – nothing.  "Just tell them what to do,” my translator would tell me.  There was never a hint of frustration, tiredness, or impatience.

I came to accept that their endurance was not fueled by hope for a miraculous recovery.  I think, rather, that they were fueled by unquestionable respect for their father, the man who taught them how to live and work, what it means to be Hausa. In fact, they recognized and accepted the end a few days before I did.  When I recommended that they disconnect his oxygen and carry their father homeward, they simply accepted with a stoic nod of understanding. 


We talk a lot about heroic measures in our healthcare system. By this we imply resources:  medicines, monitors, tubes, consultations, procedures, devices, etc. 


However, the most heroic care, the care that I will desire when my time comes, has little to do with payer source or access to resources:

Respect.  Compassion.  Physical presence.  Physical touch.  Tenderness.  Sacrifice.  Patience. 


I think these sons, and their father, reaped a more meaningful harvest than grain this season.

  Patrick L Allen, MD, studied at Texas A&M University, then the University of Texas Medical School at Houston before completing his Family Medicine residency at Via Christi Hospitals through the University of Kansas - Wichita.  His interest in Global Health and Tropical Medicine led him to pursue a one year International Family Medicine Fellowship, which included 5 months of intensive service in Niger.  He is also passionate about primary care medical education, both domestically and abroad. 

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What is Family? The Harry Potter Case Study

Posted By Randall Reitz; Kaitlin Leckie, Friday, June 5, 2015


In recent decades few words have become more politicized than "family”.  Some groups would limit a family to a man married to a woman and their naturally born children.  Others would expand the definition beyond any recognition or legal application.  The Harry Potter series written by J. K. Rowling presents an interesting case study on the diverse manifestations and implications of family.

Caveat:  If you’re a muggle who’s never read Harry Potter, you will require magical intervention to understand this blog post and will be frightened by myriad plot spoilers. Read the series and then return to this research.  And, no, watching the movies is wholly insufficient.

Biological Family of Origin

Harry is the only child of James and Lily Potter.  His parents were killed by Tom Riddle (a.k.a. Voldemort) when Harry was still an infant.  Despite this early loss, Harry’s parents play a vital role throughout his life.  

While Harry can track much of his greatness to their courage and smarts, his parents—especially his father—weren’t always good role models for Harry.  Fortunately, the parents seem to have matured by the time they conceived Harry—both of them becoming aurors and founding members of the Order of the Phoenix during the first war with Voldemort.  Like his father, Harry has a mischievous streak and occasionally breaks school rules, such as sneaking around the hallways after bedtime in his invisibility cloak. However, his trouble-making does not cross the line into bullying, as his father’s did. Instead, his behavior toward his peers, muggles, and magical creatures reflects his mother’s compassionate nature. In developing his own identity, Harry balances qualities of both his parents.

Harry’s deceased parents visit him in three different settings, at crucial times in his development and heroics.  In Book 1, during a particularly difficult time when Harry feels alone and questions his place in the world, he is able to see his parents through the Mirror of Erised. He is immediately struck by how closely he resembles his father’s unkempt appearance and how he shares his mother’s emerald eyes.  It is the first-time that Harry feels the loving gaze and unconditional acceptance of family.  He becomes so absorbed in his family’s love that he risks wasting away in front of the mirror.

In Book 4, as Harry duels Voldemort, his wand locks with Voldemort’s and his ethereal parents emerge from Voldemort’s wand (the wand that had killed them) and provide encouragement and counsel to Harry. Similarly, in Book 7 James and Lily emerge from the Resurrection Stone, along with their friends (and Harry’s deceased mentors) Lupin and Sirius.  They provide enlightenment and promise to accompany him as he accepts the fate of his own mortal sacrifice:

"He knew they would not tell him to go, that it would have to be his decision.

‘You’ll stay with me?’

‘Until the very end,’ said James.

‘They won’t be able to see you?’ asked Harry.

‘We are part of you,’ said Sirius. ‘Invisible to anyone else.’

Harry looked at his mother.

‘Stay close to me,’ he said quietly.

 And he set off.”


Adoptive Family

The only family Harry knows in his first eleven years is his maternal aunt, uncle, and cousin, the Dursleys. Though related by blood, Harry is as opposite from this biological family as disengagement is from enmeshment. The Dursleys perpetuate his role of scapegoat and parentified child by forcing him to cook and clean and by berating him whenever possible. Yet, Nature wins out. Harry maintains his innocent character despite being under the roof of the materialistic and tyrannical Dursleys. Although he has an understandable right to be angry at their maltreatment, Harry is kind, appreciative, open-minded, and pure of heart.

While the Dursleys have legal status as Harry’s caretakers, the very first pages of Book 1 foreshadow the characters who will be the adoptive parents of Harry’s heart.  Albus Dumbledore and Minerva McGonagall place Harry at the Dursleys’ doorstep after his parents are murdered.  Their love and commitment are already apparent in their anxiety at leaving Harry in the hands of his narrow-minded, contrary biological family. 

This parental connection develops throughout Harry’s years at Hogwarts, as Dumbledore is the school’s headmaster and McGonagall is head of Harry’s house, Hogwart’s deputy headmistress, and eventually headmistress.  Dumbledore is the wizard whom Harry most admires and the person who pushes Harry to fulfill his destiny as The Boy Who Lived.  As with most children, Harry experiences shock and loss when he discovers that Dumbledore isn’t the perfect parent-figure he had idolized. For her part, McGonagall watches over Harry: correcting him sternly when required but also advocating for him throughout the series.  While Dumbledore and McGonagall are not husband and wife and don’t always agree, they are both committed to raising Harry for greatness and goodness.

Summer visits to the Weasleys’ Burrow are the closest experiences Harry has to a traditional home life.  The Weasley parents love Harry like a son and initiate him to family traditions that the Dursleys had deprived him. 

Quasi Family


Harry benefits from a large community of loved ones who fill family-like roles.  James and Lily chose Sirius Black to be his godfather, a role he fills with deathly seriousness. Harry’s close Hogwarts friends who join him in Dumbledore’s Army are the siblings that Harry never had: Ron, Hermione, Neville, Luna, Fred, George, Cho, and Lee.  Hermione would be upset if we called Dobby Harry's pet, so we'll instead consider him a doting, awkward younger brother. Harry is never able to overcome the family and wizarding lore that creates a wall of acrimony between Snape and him.  However, it is easy to compare Snape to a begrudging step-father who steps in to raise the child of the woman he loves.  Tonks and Lupin are his favorite aunt and uncle; Hagrid is obviously the crazy uncle. 




Family of Creation


When Harry has the chance to create his own home, he intentionally brings together the best aspects of all his v


gnificant family-figures: James Sirius, Albus Severus, and Lily Luna.  He pursues the same career as his parents, and his children continue the Potter/Weasley tradition of attending Hogwarts—although we’re left not knowing if they are sorted into Gryffindor or Slytherin.

How Does This Apply in the Muggle World of Collaborative Family Healthcare?

At this point, our research proffers few answers and far more questions for future studies:

·         Who should we consider family when intervening in integrated care?

·         How can we best assess the positive and negative contributions of family?

·         What supports and resources should we draw on in supporting patients and families?

·         How can we incorporate family beliefs—both magical and spiritual—regarding the influence of family in this life and beyond?


Randall Reitz, PhD is the Director of Behavioral Sciences at St Mary’s Family Medicine Residency and Medical Family Therapy Fellowship.  He has read the entire series 3 times and has blogged on Harry Potter previously.  Like Hermione, his patronus is an otter.


  Kaitlin Leckie, PhD is the Director of Behavioral Health Education at Southern Colorado Family Medicine Residency. She has been studying/appreciating Harry Potter for decades and recently took a pilgrimage to the Mecca of Harry Potter at Universal Studios Orlando. Her Patronus is an ocelot. 


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Typology of Romantic Music: A Highly Scientific Thematic Analysis

Posted By Randall Reitz, Kaitlin Leckie, Friday, May 15, 2015


 We conducted a survey of popular music. Full disclosure: no factor analyses or structural equations were hurt in this study. Rather, we created our typology by plumbing our memories of high school and trolling the radio presets on a drive to work.  We then googled the song lyrics and consulted websites that use crowd-sourcing to explain lyric meanings.  We can neither confirm nor deny that Urban Dictionary informed our findings.



We’ve concluded that the relationships described in all popular music fit neatly into 1 or more of the following 5 categories:

·         Co-dependent: 25%

·         Over-sexed / Rapey: 25%

·         Unsustainably sappy: 25%

·         Bitter / Emotionally cut-off  20%

·         Healthily committed: 5%



Lady Antebellum is still clearly the gold standard:


"It’s a quarter after one, I’m a little drunk and I need you now.

Said I wouldn’t call, but I’ve lost all control and I need you now.

And I don’t know how I can do without, I just need you now.

Oh, whoa, guess I’d rather hurt than feel nothing at all.”



Over-sexed / Rapey

Yes, "Blurred Lines” is the obvious song to define this category, but we’ll keep things fresh by highlighting every middle schooler’s favorite Maroon 5 song:

"Baby I’m preying on you tonight

Hunt you down eat you alive

Just like animals, animals, like animals-mals”



Unsustainably sappy

Dido’s "Thank You” would have gone thankfully unnoticed were it not picked up by Eminem and sampled into his hit "Stan”:


"I drank too much last night, got bills to pay

My head just feels in pain

I missed the bus and there’ll be hell today

I’m late for work again

And even if I’m there,

They’ll all imply that I might not last the day

And then you call me and it’s not so bad

It’s not so bad and

I want to thank you for giving me the best day of my life

Oh, just to be with you is having the best day of my life”


"Stan” also has the notoriety of turning obsessive jealousy into a sing-along homophobic anthem.



Bitter / Emotionally cut-off

While we applaud female artists who have expanded the definitions of feminism to include self-empowered sexuality and masculine bravado, sometimes these songs aspire for Angelouian lyricism but their Icarusian arc drops to petty trash talking.  Beyoncé to wit:

"You must not know ‘bout me

You must not know ‘bout me

I could have another you in a minute

Matter fact he’ll be here in a minute, baby


"You must not know ‘bout me

You must not know ‘bout me

So don’t you ever for a second get

To thinking you’re irreplaceable”




The Trifecta

Leave it to the 50 Shades of Gray soundtrack to offer an ear worm that exalts 3 categories simultaneously (spoiler alert: co-dependence, over-sex, and sap are nearly always followed by bitterness).

"Fading in, fading out
On the edge of paradise
Every inch of your skin is a holy grail I've got to find
Only you can set my heart on fire
Yeah, I'll let you set the pace
Cause I'm not thinking straight
My head spinning around I can't see clear no more
What are you waiting for?”



Why are we drawn to songs about unhealthy relationships?
Why are songs about loving, normal, enduring couples reserved for wedding days and anniversaries?

We assert 2 reasons:

1) Healthy relationships are artistically dreadful. Boring. No one wants to hear a song detailing the work required to sustain such a relationship—the patience everyday compromises, tradeoffs of action movies with rom-coms, and biting your tongue when your partner loads the dishwasher wrong AGAIN. In contrast to this tedium, the tension and discomforting images of the unhealthy relationship songs provide a captivating edge.

2) We identify with the unhealthy lyrics. Our selves and our relationships reflect the dysfunction of our popular songs. We’ve all been there at a quarter after one (+/- the alcohol) yearning for the affection of someone whom we know is bad for us. We’ve all found healing in dissing the person we had hitherto deified. Few, if any, of us have relationships as idyllic as an Air Supply chorus. We identify with the unhealthy lyrics.

That said, in our clinical work, the couples with whom we work struggle with levels of dysfunction that threaten the survival of the relationship. Healthy song lyrics (especially ones that tell a narrative of resilience) can play the same role as bibliotherapy and youtube clips. Here are a few recommendations for therapeutic songs that are both artistically alluring and therapeutically relevant:

Power of Two and Prince of Darkness by Indigo Girls
Same Love by Macklemore and Ryan Lewis
The Middle by Jimmy Eat World
Remember When by Alan Jackson
Unpretty by TLC
Umbrella by Rihanna and Jay-Z
Forever by Ben Harper
Stuck in a Moment by U2
Til Kingdom Come by Coldplay




What do you think? Is our typology complete? Do you recommend music to patients? If so, what are your favorites? 

  Randall Reitz, PhD is the Director of Behavioral Sciences at St Mary’s Family Medicine Residency and Medical Family Therapy Fellowship. His tastes in unhealthy lyrics vary from Queen to Avett Brothers to Lady Gaga.


  Kaitlin Leckie, PhD is the Director of Behavioral Health Education at Southern Colorado Family Medicine Residency. Her Pandora radio is constantly shuffling between alternative, rock, rap, and everything in between.


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6 Tips for Helping Families Talk about Eating Disorders

Posted By Brittney France, Thursday, April 30, 2015

"When I is replaced with WE, even ILLness becomes WELLness

My first experience working with the eating disorder (ED) population was as a milieu therapist in an inpatient eating disorder unit. As milieu therapist I led groups, supported meals, and managed the unit throughout daily activities. Through spending 8 to 16 hours a day with patients over the course of weeks or months, trust began to develop and I was privileged to hear their stories. I began to view EDs as a coping tool, an escape, and as protection. They do not develop solely because someone wanted to look better in jeans or because they saw a skinny model on a magazine; they are complex biopsychosocial diseases and steps toward recovery are often tedious.

Through observation and listening I began to notice a pattern among the adults and children on the unit- the revolving door effect. Often, once patients entered their life outside the unit, symptoms reappeared and patients re-entered treatment. As a new treatment provider, I did not understand the complexity of this process. I knew these individuals had the skills, insight, and strength to take the necessary steps toward overcoming their illness. However, recovery is not a straightforward path. Studies estimate that 50-55% of adults recover within 6-8 years, and this is often marked by periods of relapse.1, 2

Therefore, something is different outside the treatment walls.  On the inside, the program offered twenty-four hour structure, meal plans and support, as well as groups with the other patients on the unit. Outside the walls were relationships, stressful experiences, triggers, social pressures, gender imbalances, injustice, and pain.  EDs cannot be viewed outside of relationships and the environment in which the person lives.  What I experienced on the inpatient unit sparked a passion that lead to pursuing my PhD, with a focus on understanding and serving this population.

Currently I work in a private practice specializing in the wide spectrum of eating disorders. Whether I’m working with a 65 year old male with binge eating disorder, or a 13 year old female with anorexia, one treatment goal remains the same: help the client build a support network. While many programs are beginning to include family and support systems into adult ED treatment, research is needed to better understand the impact of including carers in their treatment.3 There is limited research on adolescent EDs and family treatment as well.4 However, of the eight randomized control trials that have included children and adolescents, seven include a family element. Those that were outpatient-based and had parental intervention were more effective than comparison treatments.4

With this in mind, I receive phone calls and emails from family members thinking someone they love has an eating disorder, yet they do not know how to talk about it. Family members often want to help but do not feel equipped to do so. Why are eating disorders still so hard to talk about? I believe stigma and lack of education around eating disorders continue to hold many people back from seeking the support they truly need. Eating disorders are not a choice, they occur in both males and females, and all forms of eating disorders are serious.5 There are some common myths around eating disorders, and in this powerful video, ED expert Cynthia Bulik powerfully tackles some of them. Medical and mental health professionals need to be equipped to dispel these false claims and facilitate supportive conversations for individuals and family members.

The following are 6 tips for encouraging positive family conversations about EDs.

1. Take an open stance to the conversation: Do not have an agenda or certain point you feel your loved one needs to understand by the end of the conversation, ask open ended questions. Be open to both their and your own reactions.

Example Questions: What is it like for you to have an eating disorder?, What has it been like for you to see me struggle with an eating disorder?,

How can I be a support? How can we continue to talk about the eating disorder?

2. Do not give advice:Speak from a place of concern. Many times we want to give advice out of love and trying to "fix” a situation. However, if the behavior was not helping the individual in some way, they would not be engaging in it. Advice such as "Just eat more” or "Try to exercise” can invalidate struggles and perpetuate symptomology.

Example Question: How can we work together to reach the treatment goals?,

3. Validate feelings:Eating disorders are complicated. Those who overeat or binge do not "lack will power” and those who restrict food intake or over exercise are not vain. When someone with an eating disorder does open up it is important they feel the environment is safe. Validation and support can go a long way. However often those with eating disorders have a difficult time expressing their needs or emotions. Simply acknowledging their challenges and efforts can both help them identify these needs and emotions and express an understanding for the difficult process.

4. Avoid demanding changes: Recovery is a long process. Avoid ultimatums (If you don’t change then I will…) and instead express support throughout the process.

5. Do not feel blamed for the illness: You are not to blame for your loved ones struggle. In the end the individual with the eating disorder needs to do the work. However you can learn ways of communicating and supporting their needs that can help in this process.

6. Do not push the conversation: If a loved one is resistant or denying the presences of a problem do not push this issue on your own. Encourage the individual to speak with the trusted physician or mental health provider. These conversations are difficult and can take time to open up to. 

Whether working in family practice, pediatrics, or specialty settings you will most likely encounter someone with an eating disorder and a concerned family member or spouse. Relationships are complicated. Stressors, such as illness, often magnify worries and fears. Through sharing these tips you can help promote communication and a reduction of stigma around eating disorders. I hope these help you as providers feel confident and guided in facilitating/encouraging these conversations in your patients/clients. 


1.      Eckert, E.  D., Halmi, K.  A., Marchi, P., Grove, W., & Crosby, R.(1995).  Ten-year follow-up of anorexia nervosa: Clinical course and outcome.  Psychological Medicine, 25, 143-156. 

2.      Fichter, M. & Quadflieg, N. (2007). Long-term stability of eating disorder diagnoses. International Journal of Eating Disorders,40(S3), S61-S66

3.      Le Grange, D., Lock, J., Loeb, K., & Nicholls, D. (2010). Academy for eating disorders position paper: The role of the family in eating disorders. International Journal of Eating Disorders43(1), 1-5.

4.      Lock, J. (2011). Evaluation of family treatment models for eating disorders. Current Opinion in Psychiatry24(4), 274-279.

5.      NEDA Toolkit for Educators. (n.d.). Retrieved April 28, 2015, from


Brittney France, MA, MFTI currently lives and works in San Diego, CA. She has completed her classwork for her Ph.D. in Marriage and Family Therapy with a concentration in Families, Systems, and Health. She currently divides her time between writing her dissertation with a focus on families and eating disorders, working in a practice specializing in eating disorders, and teaching a class of masters students. She hopes her research will continue to bridge the gap between Medical Family Therapy and eating disorders research.

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Caregiving, Dementia, and Sex

Posted By Matt Martin, Cathy Hudgins, Barry J. Jacobs, Wednesday, April 22, 2015


On April 7th, the Washington Post reported on a case involving Henry Rayhons, a former member of the Iowa House of Representatives, and criminal charges of third-degree sexual abuse. State prosecutors charged Mr. Rayhons for having sex with his wife, Donna Lou Rayhons, in August 2014 while she was incapacitated by dementia and living in a care facility. Jury deliberations began on Monday April 20th, 2015.

Henry and Donna Lou married after their longtime spouses had died. A few years into the marriage, Donna Lou was diagnosed with dementia. In May 2014, two of Donna Lou’s daughters met with care facility staff members to create a care plan for their mother. They, along with a doctor, decided that mom was no longer able to consent to sex. Henry was informed of this decision.

Donna Lou died in a nursing home in August 2014 after a four-year battle with Alzheimer’s. Henry was arrested and charged with sexual abuse a week later. According to law experts, this is the first case of its kind regarding capacity and dementia. At what point in dementia does a spouse or partner lose the right to say yes? Cathy Hudgins and Barry J. Jacobs provide commentary below. Click here for another viewpoint on this case.

CATHY HUDGINSAfter reading this article and accompanying documents, I had more questions than I had answers. Early in my career as a Marriage and Family Therapist, I practiced at an adult day services center that served participants with various types of dementia and cognitive impairment. In working with these older adults and their families, I gained an appreciation for the extreme feelings of loss and confusion related to how to proceed with relationships and basic life issues. I worked with many family members and caregivers who had little guidance or experience prior to the onset of the disease.  I remember giving these folks some room to learn and make small mistakes as they navigated the decline of their loved one. However, we taught our families that there were lines that no one would be allowed to cross, and those lines were drawn by the state’s definition of elder abuse.

Mrs. Rayhon’s disease progression was determined by the provider team, which included her family, at the facility through a validated screening tool and through the expertise of the providers and staff. As a way to educate and draw the line for Mr. Rayhon, it was conveyed overtly that she would no longer be able to consent to sex. From what Mr. Rahyon’s family wrote in rebuttal to his case, they believe (and I assume in concert with his belief and actions) that there should be no such restrictions to protect patients in a nursing home – even those that score a 0 on a dementia assessment. It is this kind of thinking that actually initiated protective services for vulnerable populations many years ago. The bottom line is that Mr. Rayhon knew that she could not consent, and he decided that his right to have sex with his wife trumped the law and the boundaries drawn for her based on an assessment of her capacity.


I do have several questions about this case, however. Does Mr. Rayhon have some type of cognitive decline or mental health problem that would make someone in his position as a law-maker disregard the law? While it does not sound like he had time with her prior to the sexual encounter to interpret her ability to consent at that time (I have seen several patients with dementia experience short windows of clarity), did he interpret something she did as consent? 

Finally, I am not sure what Dr. Pearson meant by "at what point in dementia do you lose the right to say yes?” In my opinion, the ability to consent, if even possible at her stage of the disease, is transient, and the limitations associated with those moments of clarity are inconsistent at best. This fact is why the line must be drawn to protect vulnerable individuals, even from those who love them. There is no doubt that physical closeness can be curative and comforting. Nevertheless, there are other ways to satisfy this human need in lieu of an act that requires consent. 

BARRY J. JACOBSSome landmarks cases—whether legal or clinical—help us forge ahead into new territories of understanding and knowledge. Others, like signposts at the edge of frontiers, delineate the outer edge of the known world beyond which we are lost in cloudbanks and quicksand. The Rayhons case—about marriage, dementia and sexual consent—catapults us into a wilderness of clinical fuzziness, moral ambiguities, and legal murk.

We are all in agreement that sex should be consensual between intellectually capable adults. But determining exactly the point at which a person with a progressive dementia loses the capacity for informed sexual consent is not scientific at this point. It’s often clinical guesswork, based on wildly inappropriate measures (e.g., using memory test results to calculate degree of sexual understanding). The "line” that my colleague, Dr. Hudgins, refers to is not so clear; it is a legal construct, based on clinical impressions, extrapolations and opinions. This idea of a "line” is sometimes used to prevent people in nursing homes from engaging in sex, as if they lose that right once they enter the institution. The "line” was used in this case as a weapon by step-daughters in a power struggle with their step-father for control over their mother’s last months.

That is quite familiar in this family-and-illness drama (at least in the more detailed Bloomberg news story). Mr. Rayhons wanted to take care of his wife with dementia at home. Her daughters from her first marriage decided that he was in denial about her degree of impairment and, with the collusion of a family physician, placed her in a nursing home one day against Rayhons’ wishes while he was at a state legislative session 30 miles away. (As her husband, he should have had the legal right to make decisions about where she would reside. How did her daughters usurp that right?) After that, it appears that they sniped at one another and struggled over details of Mrs. Rayhons’ care at the nursing home. When the daughters took steps to protect their mother through limiting the privacy that their step-father would have with her, he responded by flouting the rules they set up. Seen from this perspective, his alleged act of having intercourse with his wife was, as much as anything else, a gesture of defiance toward his step-daughters.


A family-oriented professional could have helped these warring parties find some compromises and accommodations before the story’s climax (so to speak). Unfortunately, the professionals seem to have banded together to demonize the husband. He may have acted rashly or even naively but I don’t believe he’s a demon. And I don’t think an Iowa jury will determine he’s a criminal—just a lost and angry man who wandered into the poorly charted landscape of dementia and the law. 


Matt Martin, PhD, LMFT, is Blog Editor for the Collaborative Family Healthcare Association. When he is not blogging or editing he teaches behavioral science to family medicine residents at the Duke/SR-AHEC residency program. Interested in writing for the blogs? Email Matt at 

Cathy Hudgins, PhD, LMFT, is the Director of the Center of Excellence for Integrated Care under the North Carolina Foundation for Advanced Health Programs. Dr. Hudgins has experience in Integrated Care management and development, crisis assessment and intervention, community-based and college-based outpatient counseling, in-patient assessment and intervention, and community mental health consulting. She has practiced in community mental health agencies, hospital and healthcare settings, as well as in private practice. She has also held a variety of posts in higher education administration and student affairs. She is an active member of the Collaborative Family Health Association and AAMFT and presents locally and nationally on Integrated Care. 

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).

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Looking for Batman in Primary Care

Posted By Patrick McFarlane, Thursday, April 16, 2015



"I like batman,” she said

baring her chest to reveal a dishevelment of a tattoo

of the famous Gotham call for assistance

that police commissioner Gordon would shine into the sky.

"I’m really into werewolves too.”

She wears a sweatshirt with the same logo like an echo,

layers of a symbol of the superhero she seeks,

and the superpowers she hopes for.

I asked her why she likes these superheroes,

And she said I don’t know, I just do.

When she tells me how her orbit was fractured

   by an ex-boyfriend,             

and how her mother was an addict who allowed

her using friends into her bedroom as a child

it all made sense.

If, as we are told, 40-70% of all primary care visits are related to underlying psychosocial issues 1 and if the resident physicians are right that 80% of the job is health education and they get to do that only 25% of the time 2, then that leaves 55% of the time that the physician isn't able to respond to which is perhaps the foundation of the patient problem; or to use the metaphor of the opening poem, Batman doesn't show up when called.

Batman is supposed to show up and fix the problem when called. When Batman doesn't show up, or when people don’t know how to call Batman, patients go to the emergency room or urgent care, or get referred to specialty care at great cost both in terms of cost and morbidity.  

Ted Epperly, Former President American Academy of Family Physicians (AAFP) in his plenary at the annual AAFP Program Directors Workshop in March 2015 eloquently described a future of team based care with patient metrics allowing multidisciplinary staff to work at the top of their license responding to patient needs with physician’s concentrating on the most concerning patients and their broad presentations, with incentives for ‘doing what it takes’ to keep people well and out of our emergency system. The technology exists already to electronically interact with patients to determine levels of risk, find the highest risk patients and to educate and connect with patients who are well.  This is Batman stuff.

Arguably, asking patients about what has happened to them, how they think about it impacting their medical needs and what they want is du rigueur, a standard of practice in a patient centered medical home world.  As we move toward a firmer foundation under the expectation that providers inquire in order to address risk in a preventative care model, payment models that support and reward such intervention must be adequately supported. We will know that is the case when providers are able to 100% take the time that each patient requires.

The patient in the poem above is seeking what she failed to get from her family:  a sense of attachment, belonging, and safety.   The medical setting is certainly a poor substitute for what she didn't get, but it can provide a societal foundation for, as Epperly suggests 1, doing what it takes. Part of what it takes is knowing the patient well and diminishing the shame and loneliness that sets up the superhero dynamic. 

By taking time and leveraging the provider relationship with the patient,  we remind the patient that they in fact are their own superhero as a survivor and that preventative care models can be leveraged to improve health outcomes that matter to all of us.   It is a new model of care that disperses with the superhero dynamic and takes the whole patient into account (family, community and environment) which will move the patient toward better health and away from mythic medicine.


Patrick McFarlane, MSW, MA, MSN-APRN is Faculty and Director of Behavioral Medicine at the Eastern Maine Medical Center’s Family Medicine Center and Residency Program.   He has worked in integrated health since writing a HRSA Office of Rural Health grant for integrating rural primary care in Western Michigan  in 1998.  He has two boys,  Isaiah and Ben, and loves to Kayak in the cold North Atlantic around Penobscot Bay in Maine and it’s many tributaries.   His research interests including addressing issues of violence and poverty in primary care and reflective practice.  


1. Epperly, Ted (2015) AAFP Program Directors Workshop Conference Plenary.  Kansas City, MO. 


2. McFarlane, Patrick (2015)   Resident Focus group in Transition to Office Practice Systems. Bangor, ME. National Ambulatory Medical Survey 2008 Survey Tables.  CDC, Mental Health workgroup  Atlanta, GA.

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Important Lessons for MedFT Trainees to Learn while they are still in School [Part 2 of 2]

Posted By Tai Mendenhall, Stephanie Trudeau, Lisa Trump, Tuesday, April 7, 2015


In the first part of this two-part account, we outlined important steps for C/MFT students who are interested in MedFT to take in preparation for clinical work in medical contexts.  In this section (part two), we outline strategies for trainees to follow once they have their foot-in-the-door of a medical facility.  These include functioning as an anthropologist, conducting one’s self sensitively vis-à-vis medical colleagues, using supervision effectively, and aligning your work to fit within the culture of integrated care. 

Function as an Anthropologist

One of the most common mistakes we see new MedFT trainees make is to charge into a healthcare site like a "bull in a china shop”, touting her/his systems-paradigm as a panacea that everyone has heretofore been missing.  This can be off-putting to medical providers, insofar as the turf that trainees are entering is medical (not behavioral).  These contexts are – by design – hierarchical and mental health providers are lower on this hierarchy.  A well-prepared trainee understands and respects this, and is thereby careful to conduct her/himself in a manner that communicates this insight and respect.

God gave you two ears and one mouth for a reason 1.  As a new trainee, then, it is important that you engage with medical colleagues as a person eager to learn more than you want to (or at least show a desire to) teach.  Observing precepting sequences in a medical residency (i.e., consultations between resident learners and faculty supervisors), learning about what types of patient presentations are common to particular sites (e.g., depression and diabetes in primary care, grief and loss in respite care), and asking questions when doing so is not disruptive are excellent ways to do this.  Having already learned medical language (qhs, PRN, b.i.d., etc.) facilitates these processes, alongside equipping you to read/understand patients’ charts, and to write your own notes in the same manner.

Key here, too, is to actively talk with, befriend, and learn from professionals other than physicians (e.g., receptionists, care coordinators, medical assistants, nurses).  These personnel can often describe and translate the structure and care processes of a clinic better than physicians, administrators, or others comparatively "higher up” on the medical hierarchy.  They also tend to know more about patients’ and families’ internal worlds, struggles, and resources.  Insofar as one of the key roles a MedFT plays is in-liaison between respective "parts” of a medical system’s "whole”, lower-ranking (in a hierarchical sense) personnel are essential partners.

And a final word about Medicine’s hierarchy: Yes, behavioral health providers are trumped by medical providers in terms of social/professional status, income, etc.  But there is a difference between honoring this hierarchy (and learning how to function within it) and resigning to the notion that you, as a MedFT, do not have anything to offer (or that what you offer is less important).  Go into these systems with caution.  Listen to and learn from your colleagues.  Gain their respect and regard.  As you do, the care and contributions you offer will evolve, as will the interdisciplinary collaboration that you collectively advance as a team.

Listen to and learn from your colleagues.  Gain their respect and regard 


Behave and Conduct Yourself Sensitively

It is important for MedFT trainees to understand what medical providers have been through to secure the positions they have, and to conduct one’s self with sensitivity to this.  Medical education is remarkably difficult (if not straightforwardly abusive).  Residencies cap scheduled education and patient care at 80 hours per week, and include regular on-call sequences that last up to 24 hours at a time.  Patient panels are often in the hundreds, and it is not uncommon for these patients to die.  Extensive research has shown that medical trainees endure higher rates of depression, anxiety, suicidality, substance use, somatic problems, and relationship-dissolution and divorce as compared to other types of graduate learners and/or the general population.  No training program or sequence in C/MFT compares – even closely – with this type of intensity or rigor.

Equipped with this understanding, then, you as a MedFT trainee should be careful to not complain about how exhausted you are after a 10-12 hour day. This type of day is a normal day – if not an "easy” or "light” day – for medical providers.  Similarly, complaining about the intensity of one of your cases, time that you are missing from family, etc., can elicit negative reactions from medical colleagues.  You can be seen as wimpy, entitled, or fitting conventional stereotypes of the isolated private practitioner who works in a comfortable office, sets her/his own hours, and caters to a wealthy clientele.  Once this impression is made, it can be hard to regain your persona as a valuable and engaged member of a healthcare team. 

Strategies for making Supervision Effective

One of the earliest contexts in which MedFT trainees feel a divide between their work and "traditional” C/MFT is within university-based supervision.  As students meet together to discuss cases, MedFTs can feel "out of place” by nature of having higher intensity and/or complex cases.  While your colleagues talk about depression or couple discord, you (as the MedFT) might talk about patients who are struggling with a chronic illness or a family’s (and/or your own) experiences in coping with death.  Because these presentations are not as common with C/MFT students, peers can struggle to effectively brainstorm with and help you.  This can result in your feeling isolated or disconnected from your C/MFT peers, and/or feeling forced to proceed in cases (and manage self-of-therapist issues) with less support.

Participating in dual-supervision facilitates the expansion of your skillsets 

You, then, are charged with finding a champion or on-site supervisor (even if s/he represents a sibling discipline).  Indeed, it is common for MedFT trainees to be supervised at their university while synchronously participating in supervision with a Medical Social Worker or Health Psychologist.  This facilitates a purposeful combining of conventional C/MFT and MedFT training and approaches.  For example, utilizing a long-term insight-oriented therapy modality may be less possible or impactful in MedFT, but its primary tenets (e.g., attachment, poor family-of-origin differentiation) may still be applicable.  Participating in dual-supervision (conventional + MedFT) facilitates the expansion of your skillsets to best fit clinical practices and activities to immediate presentations at-hand.   


Other resources and competences specific to MedFT practice include, but are not limited to, motivational interviewing, brief solution focused therapy, conducting PHQ-9 assessments, completing disability or workers’ compensation documents, and assisting physician colleagues with complex citizenship applications and paperwork.  All of these require that you make time to do "extra” homework in skill-development.  Leaning on aforementioned mentors within Medicine can help you navigate this, and further-enable you to assist others who follow (aligning with Medicine’s adage to "Learn one, do one, teach one.”) 

Align your Practice-Patterns to Fit with the Culture of Medicine

For a MedFT to function as a collaborative colleague, s/he must adjust her/his practice patterns away from conventional mental health service models.  The standard "50 minute hour” that you were taught in graduate school is one of the first places to do this.  If medical providers are seeing patients every 15-20 minutes, you (as the MedFT) are not going to be very accessible if you schedule your appointments on-the-hour.  This does not mean that you cannot see some patients/families for this amount of time (indeed, some are best served this way), but – to be clear – you cannot only do this.  

We suggest that you purposively schedule "open” time to shadow, collaborate with, precept, and/or otherwise be available to medical colleagues.  And when you do set up times for 50-minute visits, it is important for collaborators to understand that you are very interrupt-able. Some of our colleagues even hang signs on their office doors that say "Please Disturb”.  This sets a precedent for collaboration: you should always available.  And don’t stress; patients who are being seen by a physician appreciate your ability to step-in and collaborate, and they will similarly appreciate a physician being able to do the same.  




The steps that your will take as a MedFT student and trainee to gain entry into a medical practice will vary in accord to the practice that you are entering.  Some practices will be familiar with and maintain strong buy-in for MedFTs (e.g., a primary care site that has organized its services to align with contemporary developments in the medical home movement).  Other practices may not have included a MedFT on their team before, but are amenable to trying this out based on a perceived need that systems-informed mental health providers could offer (e.g., a neonatal intensive care unit in which newborn infant deaths and families’ efforts in coping are commonplace).  Conversely, some sites may be resistant to hiring you, for reasons like finances (i.e., not seeing how MedFTs could bring additional revenue) or administrative discomfort with negotiating new territories in referral, scheduling, or billing systems.  Some trainees, then, will be able to get into MedFT placements with relative ease.  For others, this process could be difficult.  However things go – on any place along this continuum – it is our view that the lessons and strategies outlined in this two-part account will help you in the journey. 


1.   Diogenes, L. (1901). The lives and opinions of eminent philosophers. London, UK: George Bell & Sons.


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Important Lessons for MedFT Trainees to Learn while they are still in School [Part 1 of 2]

Posted By Tai Mendenhall, Stephanie Trudeau, Lisa Trump, Wednesday, April 1, 2015

Clinical practice in healthcare settings is different than the conventional stand-alone mental health clinics and/or private practices that most Couple/Marriage and Family Therapy (C/MFT) programs prepare their students for.  And while some trainees in C/MFT are situated in programs that offer a Medical Family Therapy (MedFT) specialization, there are far more who are not.  As demand for MedFTs continues to rise across both internship- and postgraduate workplace- sites, it is important to consider what trainees can do to: 1) prepare for such opportunities, and 2) effectively adjust and thrive once they are there.  In this two-part account, we describe concrete strategies for students to effectively achieve these goals.

Preparing for Clinical Work within Medical Contexts

Before actually beginning your work as a MedFT trainee, it is important to make a conscious decision about what you are getting into, work through your own personal biases, and develop specific knowledge and skillsets.

Learn What You are Getting Into

Mental health providers who work in healthcare settings encounter stressors and clinical presentations that are often comparatively more complex, intense, and/or acute than "traditional” or conventional therapy settings.  It is important that you understand this, and to ultimately make a personal and professional decision about whether this type of work is a good fit. 

In conventional C/MFT settings, patients and families present with a variety of struggles, including depression, anxiety, parent/child conflict, marital discord, and seeking personal growth (broadly defined).  They come to us, as their primary provider, each week for hour-long visits, wherein we advance clinical interventions through our preferred theory(ies) and approach(es).  We consult with colleagues/supervisors between sessions and try out new angles, ideas, and strategies along the way and in accord to how our patients/families are progressing.  We perceive the conduct of 5-6 (sometimes 7-8) therapy sessions in one day as "a lot” – and we are tired when we go home.
Make a personal and professional decision about whether this type of work is a good fit 


In medical settings, patients and families can present with these same straightforward struggles, but those that do are often experienced by MedFTs as our less-complex – or even "easy” – cases.  Most of our work in health care is situated earlier-on in these clinical sequences, such as when a depressed patient first reaches out for help or is imminently suicidal, when sexual abuse is first discovered, or immediately after (or even during) a traumatic loss.  Many of the presentations we see – unlike the ones portrayed in our textbooks – are cases for which there will not be a "cure” or resolution (e.g., patients and families who are coping with serious accidents, chronic illnesses, or death).  We function as part of treatment teams (not as sole providers, and usually from positions of less hierarchal power vis-à-vis our medical colleagues), and we hardly ever see people for hour-long visits.  Seeing 5-6 (or 7-8) patients/families in one day means that we took at least half of the day off.

If you are interested in MedFT, it is important that you expose yourself to, and learn about, the culture and everyday processes of medical care sites.  Many scholars and field leaders in MedFT have contributed to literature regarding these early preparatory steps 1-4.  Common themes in advice here relate to reading first-hand accounts of MedFT on-the-ground 4-6, seminal texts about MedFT tenets and applications 7-10, and/or refereed journals that publish cutting-edge research and accounts of interdisciplinary collaboration (e.g., Annals of Behavioral Medicine; Annals of Family Medicine; Families, Systems, & Health).  You can do this through informational interviewing with MedFTs already working in the field and/or shadowing MedFTs or other similarly-situated behavioral health providers (e.g., Medical Social Workers, Health Psychologists).  Attending grand-rounds presentations at local healthcare facilities and collaborative care conferences/workshops/trainings (e.g., CFHA, STFM) can also be valuable. 

As you do this, we encourage you to take a deep and honest look inward.  Ask "Is this the kind of environment I can thrive in, or will it burn me out?”, "Do I want the predictability and structure of private practice, or would I get bored with that?”  MedFT is a great fit for some C/MFTs.  For others, conventional therapy sites are a great fit.  It is important to figure out for yourself where you will be most fulfilled.

Work through your Personal Biases

You, as a MedFT trainee, have made a conscious decision to work in a healthcare context.  You must, then, behave in a manner that is conducive to this.  There are many biases about Medicine that you might hold, and these biases can hinder your working relationships and ability to collaborate.  Common biases we hear include: physicians are too busy to collaborate; they just don’t "get” what we are talking about; they will not listen to therapy jargon; and/or that they need to be convinced to collaborate with mental health providers.  Biases can go the other way, too (i.e., those that we hold against ourselves); these can include things like: we need to "sell” our potential contributions before they will be valued; we need to maintain a hard external persona (i.e., never show weakness); we cannot talk too much about "warm and fuzzy” emotions and feelings; and/or that we must not speak until spoken to. 

Like any stereotype, we can always find supporting evidence for our biases.  Some physicians are, indeed, very busy and cannot recognize the value in collaborating with a behavioral health provider.  Some therapists do, indeed, work hard to never show vulnerability to medical colleagues.  However, we also know that most stereotypes are unfair (and usually negative) globalizations of a group’s character – and in integrated care environments, holding them will almost invariably sabotage effective teamwork.

Think through and articulate your personal preconceptions about medicine  It is important for you to think through and articulate your personal preconceptions about functioning in a medical context before you get there. You can do this through a combination of individual- and group- exercises and discussions about these preconceptions with colleagues and supervisors familiar with MedFT. Taking the time to do this (because we all have personal biases) enables students to process and allay what could be personal/professional blind-spots later down the road. It also can serve to better equip you with knowledge regarding Medicine’s structure (yes, it is very hierarchal) and how to function effectively within it (which we will address further in the second half of this two-part blog entry). 


Develop Specialized Knowledge and Skillsets

Moving beyond the baseline-competencies that any C/MFT is expected to have (i.e., the ones that are advanced by AAMFT regarding admission to treatment, clinical assessment and diagnosis, treatment planning and case management, etc.), MedFTs must develop skillsets specifically targeted to our efforts within medical contexts.  Field-leaders are working hard to articulate and advance shared-understandings regarding these unique competencies 11-13, targeting domains like medical culture/systems, effective interdisciplinary collaboration, theories like the biopsychosocial-spiritual model and three-word view (clinical, operational, financial), self-care, and others.  Competencies within these domains include clinical skills (e.g., promoting patient/family agency and communion, facilitating communication between medical providers and patients/families), alongside skills in training/supervision, policy, and research.  

It is important, too, that you understand the financial world(s) of Medicine, and how mental health services fit into these complex and dynamic structures.  MedFTs are reimbursed in similar and different ways (and at similar and different rates) than their sibling disciplines – and this varies in accord to where you live, the site in which you practice, and the current-day status of the politically-charged debates between local-, State-, and Federal- stakeholders fighting for recognition and market share.  Field-leaders are working hard to articulate and advance shared-understandings of these foci, as well 14-16.

You can begin to develop knowledge and inform these skillsets through aforementioned seminal texts and journals, together with core coursework that – in our view – anyone planning a career in MedFT should (must) take.  These include courses in medical terminology, psychopharmacology, physiology/anatomy, and "special topics” like health policy, healthcare administration, principles of health maintenance organization management, and spirituality and healing.

Concluding Thoughts 

Laying the foundation through the knowledge acquisition and preparatory strategies we have outlined above will prepare you as a C/MFT student to be competitive for clinical opportunities and training in MedFT. As you gain entry into integrated care sites – whether they are facilities that are already established in and conversant with integrated care, or just getting started – the guidelines we will offer in the second half of this two-part account serve to represent strategies and learning we have found to be most helpful. Stay tuned…  




1.Brucker, P., Faulkner, R., Baptist, J., Grames, H., Beckham, L., Walsh, S., & Willert, A. (2005). The internship training experiences in medical family therapy of doctoral-level marriage and family therapy students.American Journal of Family Therapy, 33, 131-146.

2.Gawinski, B., & Rosenberg, T., (2015). Beginning a career in medical family therapy.Family Therapy Magazine, Jan/Feb issue, 36-39.

3.Harkness, J. L., & Nofziger, A. (1998). Medical family therapy casebook training in a collaborative context: What we did not know then… we know now.Families, Systems, & Health, 16, 443-450.

4.Trudeau-Hern, S., Mendenhall, T., & Wong, A. (2014). Self of the medical family therapist: Functioning as a clinician across the multiple worlds of health care. In J. Hodgson, A. Lamson, & T. Mendenhall (Eds.),Medical family therapy: Advanced applications(pp. 55-78). New York: Springer Publications.

5.Mendenhall, T. (2007). Crisis land: A view from inside a behavioral health team.Psychotherapy Networker, May/June, 32-39.

6.Mendenhall, T., & Trudeau-Hern, S. (2014). Using medical genograms in clinical supervision. In R. Bean, S. Davis, and M. Davey (Eds.),Clinical supervision activities for increasing competence and self-awareness(pp. 141-148). Thousand Oaks, CA: Sage Publications.

7.Hodgson, J., Lamson, A., Mendenhall, T., & Crane, R. (Eds.) (2014).Medical family therapy: Advanced applications. New York: Springer.

8.McDaniel, S., Doherty, W., & Hepworth, J. (2014).Medical family therapy and integrated care(2nd ed.). Washington, DC: American Psychological Association.

9.McDaniel, S., Hepworth, J., & Doherty, W. (2009).The shared experience of illness. New York: Basic Books.

10.Seaburn, D., Lorenz, A., Gunn, W., Gawinski, B., & Mauksch, L. (Eds.). (2003).Models of collaboration. New York: Basic Books.

11.Tyndall, L., Hodgson, J., Lamson, A., Knight, S, & White, M. (2010).Medical family therapy: Conceptual clarification and consensus for an emerging profession. (Doctoral dissertation). Retrieved from:

12.Tyndall, L., Hodgson, J., Lamson, A., White, M., & Knight, S. (2012). Medical family therapy: Charting a course in competencies.Contemporary Family Therapy, 34, 171-186.

13.Tyndall, L., Hodgson, J., Lamson, A., White, M., & Knight, S. (2014). Medical family therapy: Charting a course in competencies. In J. Hodgson, A. Lamson, T. Mendenhall, & D. Crane (Eds.),Medical family therapy: Advanced applications(pp. 33-53). New York: Springer.

14.Crane, D., & Christenson, J. (2014). A summary report of cost-effectiveness: Recognizing the value of family therapy in health care. In J. Hodgson, A. Lamson, & T. Mendenhall (Eds.),Medical family therapy: Advanced applications(pp. 419-436). New York: Springer Publications.

15.Manchikanti, L., Caraway, D., Parr, A., Fellows, B., & Hirsch, J. (2011). Patient Protection and Affordable Care Act of 2010: Reforming the health care reform for the new decade.Pain Physician, 14, e35-e67.

16. Marlowe, D., Capobianco, J., & Greenberg, C. (2014). Getting reimbursed for MedFT: Financial models toward sustainability. In J. Hodgson, A. Lamson, & T. Mendenhall (Eds.),Medical family therapy: Advanced applications(pp. 437-449). New York: Springer Publications.

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Parents matter: Delaying premature adolescent sexual initiation

Posted By Dan Blocker, Monday, March 23, 2015


Researchers and providers recognize that adolescents are having sex. Some professionals and parents recognize it as a part of adolescent identity development. This increased acceptance has resulted in sex education that encourages safe sexual practices and preventing adolescent pregnancy and sexually transmitted infections (STIs). Despite these efforts and the resulting reductions in negative outcomes associated with adolescent sexual intercourse such as teenage pregnancy and sexually transmitted infections (STI), billions are still spent dealing with the ramifications of adolescent sexual intercourse. Adolescents below the age of 16 are especially at-risk for these negative outcomes.

Teenagers below the age of 16 are still developing key cognitive abilities and skills including the ability to fully appreciate and understand the risks associated with sexual intercourse. As such, those who initiate sex before the age of 16 are at a higher risk for pregnancy, sexually transmitted infections, and other negative outcomes. Reports of perceived benefits of sexual intercourse reveal that younger adolescents are seeking sexual relationships for emotional regulation, to maintain a romantic relationship or to increase their sense of worth. 

Adolescent sexual initiation is a systemic issue influenced by multiple factors including race, socio-economic status, friends, parents, and teenager biology and personality. With many of these factors existing outside the parameter of parent control, parents can feel very powerless. However, the parent-child relationship can serve a protective role and increase the likelihood of delayed adolescent sexual initiation. 

Parents remain the primary attachment figures in early adolescence 


The presumed operating force behind the impact of the parent-adolescent relationship is Attachment Theory. This theory originally created to understand caretaker-infant relationships proposes that self-worth, emotional regulation, and relationship expectations are influenced by the responsiveness of figures like parents. Despite adolescence being a stage of transition towards peer relationships, parents remain the primary attachment figures in early adolescence and influence adolescent outcomes. There are three factors that can increase the quality of the parent-adolescent relationship and decrease the likelihood of sexual initiation before age 16: parent involvement, parent connection, and parental awareness. 

1.      Parent involvement

Involvement includes engagement in school, day-to-day life, and recreational activities. Increased parent involvement can delay sexual initiation especially in daughters. The emphasis is not about the number of activities, but the quality of the time the parent is engaged with the adolescent. The conversations during this time should not be about information gathering, but about relationship building. When asking about school, it is important for the parent to emphasize things like favorite classes or interesting things learned.

Also, time together should be a cell phone free time for both the adolescent and the parent. Parent(s) can decide a time of the day where all electronic devices are turned off and the family spends time together. Family activities can decrease sexual initiation before age 16. 


2.      Parental warmth 

Parental warmth is a willingness to connect, be emotionally open, supportive, and loving with the adolescent. Parental warmth includes behaviors that allow for emotional expression and support through challenges. By providing the emotional support an adolescent needs from her or his family, the adolescent is less likely to initiate sex to meet these needs. Parents can demonstrate warmth by being willing to listen, and to engage the adolescent on his or her terms. Parents should not give love or affection on a conditional basis, but can give love and affection on a regular basis. Parents should use the affection that best matches their adolescent. If the adolescent appreciates physical touch, then the parent could offer hugs. If the adolescent appreciates words of affirmation, then the parent can offer praise and kind words.   

3.      Parental awareness

Parental awareness is made up of three interrelated groups of behaviors including parent solicitation, adolescent openness, and parental knowledge. Within this factor, a sweet zone exists that depends on parents and adolescents. Parental behaviors that are too investigative or too permissive in monitoring the adolescent are associated with increases in adolescent sexual initiation. Similarly, adolescents unwilling to disclose information to parents have higher rates of sexual initiation. Thus, an aware parent is one that is willing to ask an adolescent about their activities with an adolescent willing to share this information. One way to encourage adolescent sharing is to be interested in the adolescent’s activities without casting judgment. Utilizing Ken Hardy’s VCR approach, (validate, challenge, request) found in the book Teens who hurt: Breaking the cycle of adolescent violence (2005), may be the best way to accomplish this end.  The point of this approach is to validate the strengths of the adolescent before challenging the views of the adolescent. 

Sexual initiation before the age of 16 places adolescents at risk for multiple negative outcomes. While parents cannot control all of the factors that influence sexual initiation, they can strengthen the parent-adolescent relationship, which via the tenets of Attachment Theory should delay sexual initiation after age 16. To this end, three parenting behaviors were addressed: parent involvement, parent connection, and parental awareness.


Dan Blocker, MS is currently enrolled in the Medical Family Therapy Doctoral program at East Carolina University. He is passionate about integrated care and it’s potential influence in providing whole-person care. He received his masters from Brigham Young University in Marriage and Family Therapy. His current interests include understanding the protective power of relationships on health outcomes, and technology use. 

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To Be or Not to Be

Posted By Suzanne Mintz, Wednesday, March 4, 2015


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 ophthalmologist who 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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