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“Amour” Or Love Among The Ruins

Posted By Carol Levine, Tuesday, February 17, 2015

(This post is a reprint of a piece from February 19, 2013. Click here for the original post. Amour is a 2012 French film from Les Films du Losange.) 


Nominated for five Academy Awards, "Amour” is a film about love and death. (Read no further if you haven’t seen the film and don’t want to know who dies and how.) The setting is Paris, the language French, but any resemblance to a conventional French film about light-hearted romance or aménage a trois ends there. The married lovers in the film are in their 80s, as are the main actors (Emmanuelle Riva and Jean-Louis Trintignant). Anne is a retired piano teacher; Georges is retired as well (not clear whether he was also a piano teacher or a musicologist). Their daughter Eva (Isabelle Huppert) is a musician.

"Amour” was directed by Michael Haneke, an Austrian filmmaker whose previous films were, to put it mildly, grim. "The White Ribbon” portrays the abuse and humiliation of children and women in a small German town just before World War I. "The Piano Teacher” is an abusive and self-mutilating woman. "Funny Games” features sadistic serial killers. So it would be unrealistic to expect "Amour” to be cheerful or sentimental in its treatment of old age and illness.

His penchant for violence aside, Haneke is a skilled filmmaker, and this long (very long) film is carefully constructed to achieve an effect. Exactly what effect he had in mind is still unclear to me, and I would have to see the film again (which I have no intention of doing) to figure this out.

The opening scene of firemen breaking down the door to Anne and Georges’ apartment and then holding their noses because of the smell sets the stage. Anne’s corpse, carefully arranged with flowers at her head, is our first image of her. The film then shifts to a concert hall, where the audience, including Anne and Georges, stares at us-- the movie theater audience--for a long (very long) time before the pianist, who we find out is Anne’s former student, begins to play. Are we meant to be a little uneasy right from the start?
Amour movie poster
Could I kill someone
I love to end that person’s suffering
and mine as well?

Would I want
someone to
do this to me?


The couple’s comfortable retirement is abruptly interrupted when Anne has a sudden episode of blanking out. An operation to clear a blocked carotid artery is unsuccessful and she comes home in a wheelchair to be cared for by Georges. Haneke shows the daily routines of caregiving for a partially paralyzed person—bathing, going to the toilet, incontinence, feeding, and range-of-motion exercises. In documenting Anne’s decline, he dwells, almost lovingly, on the ravages to her body and mind. It is a realistic glimpse of the gritty side of caregiving, yet these scenes also turn us into unwitting voyeurs, invaders of Anne’s carefully protected privacy.

At some point in the film the story shifts to Georges. He wants to take care of Anne on his own, but he finally hires nurses for shifts three times a week. (Although the film credits list these roles as l’infirmieres –nurses – they seem more like home care aides, assisting with personal care, not skilled nursing care.) He fires one after she mistreats Anne in some way.

There is no indication of the passing of time in the film. We don’t know whether the illness trajectory is happening over weeks or months. The toll caregiving takes on Georges begins to show in his stooped posture, shuffling walk, and defeated look. He resists Eva’s ineffectual efforts to help and goes so far as to lock Anne’s door when Eva visits. In one scene a pigeon flies into an open window, and Georges chases and finally shoos it out the window.

In his first act of violence, Georges slaps Anne in frustration after she spits her drink in his face. Anne moans in pain (psychic or physical?) until Georges calms her with a story from his childhood. And then, he takes a great big pillow and suffocates her. The scene is predictable but shocking nonetheless. She takes a long (very long) time to die, her leg rising and falling in an odd reminder of the range-of-motion exercise we saw earlier. Her body resists what she has said she wanted to happen.

Georges buys the flowers we saw around Anne’s corpse at the beginning. He catches a second pigeon that has flown in the window, covers it in a blanket, closes the window. He seems to caress the pigeon. He writes a note about letting the pigeon go (but we only see him let the first pigeon go). And then in a dream sequence he and Anne leave the apartment. In the final scene Eva returns alone to the empty apartment and looks squarely at us.

Apart from the exceptional performances of all three leads, what can be said about this film? It is certainly a love story, but a very claustrophobic and exclusive kind of love. There is no room in this couple’s relationship for other people, even their own daughter. Eva seems self-absorbed but neither of her parents express any real interest in her or their grandchildren. Their conversations are the kind that might occur between acquaintances, not close family members. At one point, Eva tells her father she is concerned about him, and he responds, "Your concern is no use to me.” He treats her dismissively, even cruelly. And Anne does not want her daughter to see her in her debilitated state.  

If there is no room for Eva, there is even less room for health care professionals. Dr. Bertier, the family doctor, never appears and does not seem to be involved beyond the operation. Once discharged from the hospital, Anne makes Georges promise that she will never go back. She does not want further medical treatment. But in a country with universal health care coverage, there is no indication of home care support other than the aides Georges hires on his own. Hospice or home care with adequate pain and symptom control might have made a difference, although not as dramatic a story. I leave it to clinicians to suggest what interventions might make someone like Georges more responsive to assistance.

And finally what are we supposed to think about Georges’ killing of Anne? She was clearly at the end of life and he was at the end of his ability to cope. Was suffocating her an act of compassion or an act of desperation or possibly both? Whose suffering was greater? What happened to Georges? I think we are meant to understand that he killed himself, after he killed Anne and (maybe) the second pigeon. He certainly disappears from the film.

Perhaps Haneke meant for the audience to ask themselves, Could I kill someone I love to end that person’s suffering and mine as well? Would I want someone to do this to me? Anyone who has seen a family member or friend suffer at the end of life has undoubtedly asked themselves these questions. And many people will see Georges’ act as a final act of love. But saying that you would end someone’s life, violently if that were the only option, is quite different from actually doing it. Most people would stop short. I think that is a good thing.

"Amour” ends and the credits roll. The audience goes home. Maybe they talk about the film, maybe they argue about it. Some say that if Anne were the caregiver, she would never have killed Georges. Some say physician-assisted death is the answer. Some protest that this would not have helped Anne in her demented state. Some appeal to religious or humanistic principles. Some say, "What was up with the pigeons?” Some say, "Come on, it’s just a movie!” Then they move on with their lives, putting aside unpleasant thoughts about illness and death.

If there is a message in this film, let it be that no one should face devastating illness—their own or another person’s--alone.

Carol Levine
Carol Levine directs the Families and Health Care Project and the Next Step in Care campaign at the United Hospital Fund in New York City. She is a Fellow of The Hastings Center, a bioethics institute, and writes frequently about ethical issues in health care. She is editor of the forthcoming anthology Living in the Land of Limbo: Fiction and Poetry about Family Caregiving (Vanderbilt University Press, 2013).  Read her previous CFHA blog on a real-life caregiver mureder-suicide here.


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NC Project LAUNCH: A Family-Centered Care Approach

Posted By Matthew P. Martin, Tuesday, February 3, 2015

I recently was introduced to a successful family centered medical home model called NC Project LAUNCH (Linking Actions for Unmet Needs in Children’s Health). Upon hearing the words “family centered”, my ears perked up. Those words are often given little more than lip service in many clinics so I couldn’t help but feel a little skeptical. I soon met a dynamic woman named Martha Kaufman who told me more about the program and offered to stay in touch via email. What I learned since then is very encouraging.

Picture this: a child and her mother come to a pediatric office for a well child visit. The mother fills out some screening questions and then meets a Family Centered Health Navigator (FCHN) who reviews the positive screen and discusses the goals, strengths, and needs of the family. The mother agrees to the service and requests a home visit. A short time later, the FCHN and an Early Childhood Mental Health (ECMH) specialist visit the family to further identity their needs and strengths, prioritize those needs, provide child development psychoeducation, and then develop a family health plan. The health plan coordinates future referrals and consultations, connects the family with online and community resources, and lists the next action steps. The FCHN and ECMH use an approach called the Triple P to suggest specific parenting strategies.

One of the next actions steps is for the FCHN to accompany the parent to school to observe the child and support the parent in communicating the child’s needs to the teacher. Since the school also uses Triple P, there is a shared language and approach that unifies the efforts of both the care team and the school. Later on, the team checks in with the mother by phone to make sure the plan is moving forward, to provide support and further assistance as needed. The mother knows that the team is available to her by phone and at her child’s doctor’s office in the future, and she can just drop by to check in.

NC Project LAUNCH uses an approach called the Triple P

There is much to like about this approach. First, I like that the starting point is the pediatric office. The medical team has an on-site service for psychosocial issues which can facilitate appropriate referrals while reducing the stigma of psychosocial problems. Moreover, some children have chronic medical problems that lead to chronic psychosocial problems. A pediatric office is an ideal place to find these families. Second, the approach is absolutely strength-based. Parents, like most human beings, respond well to positive invitations for help. Third, this approach can do both prevention and intervention work. Some families are surviving but not thriving. The care team can help that family reach a point of thriving. Other families are headed toward disaster which calls for a team-based intervention that includes many helping hands. Fourth, the care team focuses entirely on the family system and not just the child. They discover what the family needs and what they care about and then support the entire family with specific, tailored strategies and tips using an approach backed by decades of research.

For those of you interested in learning more, here are five questions I recently asked Martha, the woman who introduced me to this effective approach:

1. How did you become involved with NC Project Launch?

I had just completed work as a consultant with a project known as Residentially Based Services Reform (RBS), in California, when the NC LAUNCH Project was awarded to the Alamance County Health Department as the State's implementation site. RBS, like all of my previous work, focused on meeting the needs of school-aged children with enduring and complex needs, and their families. After having worked for years in the child and family mental health system, I was excited to have the opportunity to work 'upstream' in a public health and prevention initiative promoting the overall health and wellness of all children 0-8 and their families through integrated care in pediatrics and other activities. 

  I was excited to have the opportunity to work 'upstream' in a public health and prevention initiative


2. What do you currently do with the program?

I am the Local Project Director for NC LAUNCH, which includes responsibility to develop and lead implementation of health promotion and prevention services. This includes the development of an innovative Family Centered Medical Home systems model that includes full integration of a 2-person team in two of the largest private pediatric practices in the County, and within the Local Health Department. These 3 full-time teams help ensure that physicians and other practitioners have ready access to comprehensive services and supports for their patients in the practice sites. We have also used a public health approach to help strengthen families through a population-based implementation of the Positive Parenting Program (Triple P), with approximately 200 individuals accredited to help families with everyday (as well as more complex) parenting strategies. The other activities for which I am responsible include the promotion of early childhood best practices in home-visiting services, social-emotional screening for young children and for their caregivers, as well as the development of policy and finance strategies to sustain implementation of NC LAUNCH beyond the period of federal funding by the Substance Abuse Mental Health Services Administration (SAMHSA).


3. What do you personally like about the service?


I like seeing how our partners in the private pediatric practices have moved to a more comprehensive public health approach, destigmatizing parenting assistance and social-emotional health services by embedding these into familiar and trusted medical settings. I also like the two-person Early Childhood Mental Health Team model, one in which an early childhood mental health specialist works hand in hand with a parent of a child with special health care needs who is specially trained to promote family engagement, address social determinants of health, and actively assist parents/caregivers to develop a health plan that is based on their particular strengths, priorities and needs. This team-work is supported in and beyond the private practices and the health department through a 'common language-common approach' developed through implementation of Triple P in settings across the community, such as in the public school system, pediatric and public health settings, community policing, housing authority, etc. We have also supported the delivery of Triple P parenting supports in the faith community.


4. What do physicians like about Project Launch?

The best way I can describe what physicians like about the project is through their own words:

·         “I feel the same about the team as I would if I needed a surgeon and did not have one easily available to me. I feel it’s just as important.”

·         “We rely on the team a lot, and we refer to them a lot earlier than we would before and we use Triple P a lot more.”

·         “Our role is more complete. It gives us more insight into the families we serve and makes us more sensitive to the issues that are going on.”

·         “I feel more comfortable bringing up something myself, because I can do something about it.”

·         “It’s very nice to have a back-up, someone who can take more time and talk to families about normal development.”


5. If people are interested in starting Project Launch, what should they do?


Feel free to contact me and we can explore:


Martha Kaufman, M.Ed., is currently the local Project Director for NC Project LAUNCH, at the Alamance County Health Department in Burlington, NC. Alamance received designation as is the only implementation site in NC for LAUNCH in 2012 by the NC Division of Public Health, the grantee for the SAMHSA-funded initiative. Prior to this role, Martha worked at the Washington Business Group on Health, NC Division of MH/DD/SAS as State Project Manager for NC’s first three SAMHSA-funded System of Care grants and then as the Chief of the Child and Family Services Section, prior to the initiation of MH Reform. Subsequently she provided consultation in other communities and states to help improve life outcomes for children with complex needs and their families. Martha lives in Durham.

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Dietitians and Mental Health Providers: “Besties" in the Making

Posted By Allison Abrahamson, Tuesday, January 20, 2015

What does it mean to integrate care between psychology and food?

Everywhere we look people are talking about what it means to eat “healthy” and be aware of our food. We hear of “foodies,” new diet trends, and the way students are getting sassy about the First Lady’s school lunch program (#ThanksMichelleObama). We are letting others talk about human behavior and food nutrition in ways that mental health professionals (the experts in human behavior) and dietitians (licensed experts in nutrition) should be running the show. Celebrities help by bringing attention to the issue such as actor Jeff Bridges, NY Times contributor and cook book author Mark Bittman, and a coalition of Food Network’s chefs fighting to end childhood hunger. But in the end, mental health professionals should be more involved in the work that dietitians do and in the food movement in general.

Here’s why:

Poverty is a big issue in American families. Poverty impacts food intake. Food intake impacts human development. 

  • The impact of malnutrition on development is a serious issue as it can limit physical and cognitive growth as well as a child’s ability to fight disease1. Mental health providers working with impoverished families cannot underestimate the impact of malnutrition on children and may need to work with a dietitian to seek appropriate care for the client. Need a lesson about just how draining poverty is on our brain and body? Check out this infographic to put it all in perspective. 
  • Family dinners are not about bringing back June and Ward Cleaver. They’re about something more, such as encouraging good communication, time management skills, togetherness, and cohesion. Eating dinner together as a family has been going out of style for the last century or so for a variety of reasons, including offering fewer home economics classes in schools2. I’ve written about this before in the APA Center for Excellence Newsletter in citing how workplaces can do more to send employees home for dinnertime. Ever wondered what it would be like for psychologists to offer sessions around a dinner table? That’s another story for another time….

  • Dietitians deal with poverty every day because it can go hand in hand with obesity. Obesity can signal a family’s inability to access and afford healthier, more nutritious foods. Check out the movie A Place at the Table for a look at this issue. Furthermore, when I spoke to a clinical psychologist who works in a weight management clinic, she described her job as helping to address barriers to healthier eating, including examining a family’s access to food. Poverty is an aspect of diversity. It is a psychologist’s job to understand all aspects of diversity. 

Some amazing programs already exist that combine food and psychology, sometimes without the steady contribution of dietitians or psychologists. We can do more to research, understand, and create programs to make it easier for dietitians and mental health providers to work together.

  • Using a combination of psychoeducation and experiential learning, a team3 used cooking classes to help clients with diabetes better manage their symptoms. By increasing self-efficacy, clients had a better likelihood of maintaining healthy eating patterns. After all, a diabetes diagnosis can predict frequent health care appointments, often clogging an office’s resources and perhaps suggesting that preventative and psychological care is needed to address motivation and healthy eating4.

  • To increase students’ sense of self-competence and encourage pro-social behavior, schools in Tennessee created a job-training program in food preparation5. To top it all off, the food that is prepared is served at community soup kitchens. That’s a win-win for mental health and the community. 

  • Incarcerated women facing drug related charges in San Francisco can learn how to cook and shop for healthy foods and it may be leading to lower levels of recidivism6

  • The Wall Street Journal recently published a piece about the benefits of cooking and using time in the kitchen towards treating mental health concerns like anxiety and depression by providing an increased capacity towards self soothing and positive thinking7. There’s a reason cooking is considered a coping skill. 

What can mental health providers and dietitians do in the future?

For starters, each field can try harder to understand and utilize each other. When I spoke to two registered dietitians (RDs), they referenced their extreme respect for the field of psychology and the skills psychologists bring to the table. One of them noticed that psychologists in her treatment team are often the least versed in medical issues. The two RDs also felt they had received zero training in how to collaborate their care with other disciplines.

This reveals two suggestions for a future relationship between the two disciplines: provide training to all healthcare disciplines in models of collaborative care and train students in the mental health field about implications of medical diagnoses. For example, educators and training directors in graduate programs can create practicum sites at places where dietitians work or in sites that are more medically oriented. In addition, in some mental health graduate programs, students have the ability to forge relationships with training sites with whom the school had not previously communicated. Students in these programs may have more latitude in creating practica experiences with a patient-centered medical homes (PCMH).

The National Committee for Quality Assurance (NCQA) is the accrediting board for healthcare organizations committed to the model of PCMHs. These models are working and they are becoming more popular8. The goal of a PCMH is for providers to talk to each other so the patient has a better outcome, which should include better nutrition. But how often are dietitians working in these PCMHs and how easy is it for them to do so? For example, the American Association of Diabetes Educators has suggested that dietitians educate themselves in the PCMH model as the first line of advocating for their inclusion in the treatment team9.

Secondly, dietitians who already serve as a member of a diabetes care team are familiar with the integrated style of a PCMH and have received credentialing as a Certified Diabetes Educator (CDE). If dietitians were interested in and in possession of such a CDE, it may be easier to become a member of the PCMH, as their skills in treating diabetes would be highly needed. This could be organized in different ways, such as encouraging PCMHs already in practice to look to how physical medicine rehab teams have already begun integrating dietitians into their treatment teams.

Lastly, psychologists and dietitians can also take a greater stand on policy issues. For example, I recently took myself over to a Philadelphia Food Policy Advisory Council meeting. What’s a food policy council, you ask? It’s a combination of chefs, land use planners, lawyers, politicians, poverty advocates, managers of food banks, urban farmers, etc. that come together to create unique solutions to food systems problems. The Philadelphia council meetings are open to the public and at this meeting in particular, Philadelphia’s Mayor Nutter was in attendance. I was thrilled to briefly introduce myself and discuss the need for psychologists to be involved in the food systems movement.


As other attendees introduced themselves, I was surprised that no other dietitian or mental health professional was at the meeting. Afterwards, one attendee approached me, handed me his business card and expressed a desire to learn more about behavior change. I believe that the attendees at these meetings want and need more information from both dietitians and mental health professionals to help solve food systems issues. Go to a meeting. After all, many mental health professionals are trained in the art of systemic thinking and creative problem solving. The food movement is a food system. We have skills to bring to this systems issue.


1.      Berk, L. (2012). Infants and children: Prenatal through middle childhood (7th ed.). Boston: Pearson Allyn & Bacon.

2.      Cunningham-Sabo, L. & Simons, A. (2012). Home economics: An old-fashioned answer to a modern day dilemma? Nutrition Today, 47(3), 128-132.

3.      Archuleta, M., VanLeeuwen, D., Halderson, K., Jackson, K., Bock, M., Eastman, W….Wells, L. (2012). Cooking schools improve nutrient intake patterns of people with type 2 diabetes. Journal of Nutrition Education and Behavior. 44(4), 319-325.

4.      Savageau, J., McLoughlin, M., Ursan, A., Bai, Y., Collins, M., & Cashman, S. (2006). Characteristics of frequent attenders at a community health center. The Journal of the American Board of Family Medicine, 19(3), 265-275.

5.      Long, C., Page, J., Hail, B., Davis, T., & Mitchell, L. (2003). Community mental health—in an alternative school, in the public schools, and in the kitchen! Reclaiming Children and Youth, 11(4), 231-235.

6.      Novak, L. (2006, November 13). Not just peeling potatoes. The New York Times, p 20.

7.      Whalen, J. (2014, December 8). A road to mental health through the kitchen: Therapists use cooking to treat depression, anxiety and other psychological problems. The Wall Street Journal. Retrieved from

8.      Novotney, A. (2014). Psychology’s expanding roles in patient homes. Monitor on Psychology, 45(10), 38-40.

9.    Brown-Riggs, C. (2012). The Patient-Centered Medical Home — The Dietitian’s Role in This Healthcare Model That Improves Diabetes Outcomes. Today’s Dietitian, 14(8). Retrieved from 

Allie Abrahamson, M.S., is a fifth year doctoral student in the Clinical Psychology program at Chestnut Hill College in Philadelphia, Pennsylvania. Mrs. Abrahamson is a graduate of the University of Delaware with her bachelor’s degree in both history and psychology. She began her graduate education eager to develop skills in child and family focused psychology, particularly in systems issues. Allie enjoys finding ways to give back to the community and to the profession. It was an honor for her to co-receive the 2014 American Psychological Association Award for Distinguished Graduate Student in Professional Psychology with her classmate for their work creating a program and partnership between their graduate school and a Philadelphia refugee resettlement agency. Allie is currently serving as the American Psychological Association of Graduate Students (APAGS) member on the Commission on Accreditation (CoA). As a part of CFHA, it has been enlightening and exciting for her to take part in the mentorship program with Dr. Barry Jacobs and to continue to learn more about integrative care approaches and their application to systemic issues.

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ALS: The Uninvited Family Member

Posted By Tara Signs, Tuesday, January 6, 2015
Couples describe the overwhelming feelings of anxiety and the “scariness” of this life-threatening illness


Over the last several years, I have worked as a medical family therapy (MedFT) intern at a teaching hospital. I work with families and couples who experience a variety of life-altering illnesses. Within this past year, I have had the opportunity to work onsite at a neurology clinic where I quickly became familiar with the fast paced environment and practice of MedFT in a clinic setting. In this clinic, I see patients who experience amyotrophic lateral sclerosis (ALS), often called Lou Gehrig’s disease, myasthenia gravis, and muscular dystrophy.

Couples who are experiencing ALS are required to adjust and adapt to the demands of this illness, both physically and psychosocially. Muscle weakness and paralysis spread throughout the entire body, leaving individuals with the inability to perform daily activities such as showering, dressing, walking, and getting in and out of bed. As the debilitating illness continues to immobilize the individual, breathing, swallowing, and chewing become severely affected. Often times, individuals grieve the loss of the roles they once had and the inability to use their hands, arms, and legs. Most couples describe the overwhelming feelings of anxiety and the “scariness” of this life-threatening illness, the inability to be independent, and the financial strains it has on the family. The rollercoaster of emotions of depression, anger and guilt are appropriate responses that couples are faced with as they endure this unexpected journey.

Recently, I encountered a couple that reminded me about the beauty of medical family therapy. This was the first time I had seen the couple since I had started at the clinic. The husband was diagnosed with ALS several years ago, and unfortunately it had progressed faster than the couple expected. Given this was our first meeting; I was interested in their story. They described their daily struggles, new roles, and the demands of ALS with their family. The husband described what it was like transitioning from full function of his arms and legs to completely relying on a motorized wheelchair for transportation. He spoke of the unbearable pain he experiences as his muscles began to weaken. The wife spoke of the transition of her husband having to sleep in a hospital bed due to comfort and drastic changes in his body. As she told her story, her face said something different. The toll that illnesses have on caregivers can become emotionally exhausting and painful to experience. The couple described the emotional burden that lies heavy with them as they watch this illness progress. They discussed the anxiety that is instilled in them because of the fear of what the next day may look like. The pressure of wanting to spend adequate time with family members can also increase levels of depression and anxiety. These are appropriate and normal responses as families and couples experience illness.

They described the emotional burden of watching this illness progress


Despite the difficulty of talking, the husband tearfully described their young children. It appeared this part of their story was hard to share. It was difficult for the couple to make eye contact as the wife described the most recent crisis in their family. The wife began to cry and grasped on to her husband’s arm as she described her oldest child’s attempt to end her own life. The husband described the recent impulsive behaviors of their other child. The couple began to cry and question what was happening to their family. Their unconditional love for their children poured out as they described what they had done for their family through this journey. A part of my job is to ask tough questions. I sat with this couple and talked about what the children understood about this uninvited family member, the illness. I asked if the family had the opportunity to sit and discuss the scariness of Dad physically changing or not being able to be as active as he used to be with the kids.

As these questions were asked, the couple sat there in tears looking at each other. The wife responded that her husband’s illness was not really discussed. She mentioned the family sit-down about what was wrong with dad, but nothing about the physical changes or that it is a terminal illness. Like with many debilitating illnesses, sometimes the illness takes over the family. The couple was encouraged to talk about how this illness has taken control of the family and their ideas of putting ALS back into its place.

As we sat there for 45 minutes, the couple dialogued with one another about how scared their children must be. In some ways, as the conversation continued, the couple seemed to have a sense of peace about where they were in this process. They discussed that the children probably feel scared to ask what is happening to their Dad because it hasn’t been talked about. At that moment in time, it seemed like a weight had been lifted off of the couple. The couple felt relieved knowing that there was hope to overcome the struggles they were experiencing as a family. It seemed the couple understood that the children felt hidden in the dark with their father’s illness and maybe that these children didn’t know what else to do. The husband voiced the possibility that his children’s behavior might be related to not communicating openly about his illness. The couple also had discussion about a family meeting and what that would look like. At the end of my time with them, I realized the open dialogue the couple had about illness in their family created permission to be vulnerable and open with their children.

As therapists, it is important to elicit each family member’s experience of the illness and to create an atmosphere that feels safe to share. As we guide couples and families to have open communication about their needs, desires, fears, and hopes, they are able to recognize how the illness affects themselves as well as their relationships. This process creates a balance between individual and relationship needs, which is a way to put illness in its place.  Through this specific experience, the couple was able to recognize and understand their fears, emotionally share where they were both at in this process, and collaboratively come up with ideas for each family member to have the opportunity to discuss their own experience and meaning of the illness.

Tara Signs is a doctoral student in marriage and family therapy at Texas Woman's University in Denton, Texas.  

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Happy 3rd Birthday, Families & Health Blog!

Posted By Administration, Tuesday, December 23, 2014


The Families & Health Blog is 3 years old this month! And unlike a normal 3 year old, we can actually reminisce about the last year.

There have been many excellent blog posts this past year. A big thanks to all of our writers who generously contribute their time and energy to promoting topics related to families and health care. 

Take a moment this holiday break to re-read or read for the first time some excellent posts from the last twelve months.

If you or someone you know is wrestling with mixed emotions following the loss of a loved one, read Barry Jacobs' post Wooden Box. His story offers a poignant example of the complexity of loss. 

According to Suzanne Mintz, the words we use in health care matter! Her insight and passion are captivating. 

Do you work with couples facing chronic or terminal illness? Read this terrific interview of Evan Imber-Black, who carries a wealth of wisdom and experience for struggling couples (and therapists).

We had excellent posts from some of our first time writers. Noah Gagner wrote about his early experiences as a therapist in training. Wendy Wray provided some excellent information about the growing field of neurobiology. Ruth Nutting made the case for promoting collaborative care to address the health disparities in society. Katie Rootes and Ariel Jones made a persuasive argument for developing cultural attunement in collaborative care work. 

There were also a few pieces specifically targeted toward family-centered care. Read these for some excellent ideas on how to better involve family members in patient care. Leatrice Sherer wrote a fantastic success story in which she worked with the medical team and a care manager to help a Hmong family. Kaitlin Leckie effectively argues for taking integrated care to the next level with more family involvement. Finally, Irina Kolobova and Jennifer Hodgson offered some expert technical assistance on how to actually involve family members in patient care. 

All of the pieces written for Families & Health represent the passion and ingenuity of individuals who care about this work. Stay tuned for more great topics and posts this coming year!

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Attachment Theory and Primary Care: Jumping off the Porch Hand in Hand

Posted By Stephen Mitchell, Tuesday, December 9, 2014

My son, Leeds, looks at me with a spark of daring in his eyes and instinctively lifts his hand in search of mine. The ten-fingered connection is made and simultaneously he throws his body off the front porch.  He lands safely on the grassy terrain below and scampers off to the next adventure. Leeds likes to jump off of any object that rises two feet or more above the ground, any object as long as I am near offering a hand to stabilize his free falling body. When I am physically close and attentive to his needs as a budding daredevil, my son feels safe and willing to explore new things.  These moments bolster his belief that he can trust his decisions and trust I will be available to help him if needed.

A fundamental tenet of attachment theory is that a caregiver who is physically close and emotionally responsive to their child’s needs helps them believe and feel that relationships are safe1. Safety and trust facilitate the formation of an attachment bond between an attachment figure and child. An attachment figure is a person with whom a child can develop a “warm, intimate, and continuous relationship.”2

Safety and trust facilitate the formation of attachment bonds

Bartholomew and Horowitzrecognized that attachment processes continue into adulthood and developed a four-category model of adult attachment.  The four categories of adult attachment are: secure, dismissing, preoccupied, and fearful4. Each category describes how an individual perceives self and other, based on early attachment experiences.  Part of healthy self-development is the experience of making decisions, holding beliefs, and feeling certain emotions that are acknowledged and validated by others.  When this happens we come to believe that we exist. Daniel Siegeldescribes this as “feeling felt.” We feel that the other person across from us gets us and is open to us being our self. 


This is the experience Leeds hopefully had when he jumped off our porch. He felt a spirit of daring, decided to jump off the porch, and looked to me to validate his decision by taking his hand and helping (granted if I felt his decision was unsafe I would have intervened, but even in intervening I am still acknowledging him and trying to work towards a shared understanding of how to act).

Caring for patients in a primary care setting is at its core a relational endeavor. Thus, a theory about how interpersonal styles of relating develop from childhood to adulthood and influence perceptions of self and other, seems pertinent in an integrated care setting. Just as caregivers function as attachment figures for children, doctors can be seen as attachment figures for patients. Patients will relate to their doctor in the same ways they learned to interact with attachment figures. Understanding patient’s relational styles informs patient care. 

Four-Category Model of Adult Attachment

A securely attached adult has a positive view of self and other. This leads to a sense of self-worth and belief that others can be trusted.6 Dismissing adults have a positive view of self and negative view of others that originates from repeated experiences of rejection.7 Preoccupied adults have a negative view of self and positive view of others due to experiences of inconsistent levels of responsiveness from caregivers. This inconsistency results in a tendency to be “excessively vigilant of attachment relationships and emotionally dependent on others’ approval…often to the point of being ‘clingy.’”8
Fearfully attached adults experienced caregiving that was harsh, abusive, and frightening. Thus, fearfully attached adults have a negative view of self and others9.

Attachment and Integrated Care

Dr. Herbert Walker was my primary care doctor growing up. He was kind, smiled when he saw me, and when I sat on the examining room table I felt like I mattered. My feelings of “being felt” in Dr. Walker’s presence helped me believe in his medical advice and prescriptions. I spent ten years of my life attaching to Dr. Walker and as I write this I feel a strong affinity for him. 

Doctors are attachment figures. How patients respond to medical advice directly correlates to how strong their bond is with their doctor. If a patient feels safe with their doctor then they just might listen to what he or she says. For example, a “warm hand-off” from a trusted doctor can soften a patient’s anxiety about seeing a therapist like me. Doctors that are trusted by their patients are also able to broach hard topics with patients. So, a man who is struggling with depression and increasing his alcohol intake may more readily listen to his doctor when he expresses concern about his behavior. If the patient did not feel safe with his doctor he may feel threatened by his inquiries about his drinking and tune the doctor out. A safe relationship allows challenging issues to be addressed.

Awareness of a patient’s style of relating can help doctors facilitate building safe relationships. Research has shown that preoccupied patients are prone to report more symptoms compared to other attachment styles10. The higher rates of somatization could be an explanation for high-utilizers’ frequent emergency room visits and outpatient visits. Perhaps a preoccupied patient is transferring the anxiety they feel about inconsistent levels of responsiveness from caregivers to the healthcare community

Dismissing patients report higher rates of non-adherence to medication regimens, dietary restrictions, and exercise plans.11 This is a reasonable finding considering dismissive patients tend to be self-reliant.  Trusting a doctor and their recommendations is a challenge for these patients. 

Understanding a patient’s style of relating can be useful in crafting interpersonal interactions that soothe anxieties and increase overall wellness. Perhaps a preoccupied patient could have more frequent nurse visits for routine health maintenance. Frequent visits may assuage the patient’s fear of inconsistent care and actually reduce doctor visits by strengthening their relationship with doctors and clinic staff.     

Dismissing patients might benefit from routine calls from a doctor to check-in on adherence to medication, diet plans, or exercise routines. These calls could help establish a feeling of close and responsive attention to the patient’s needs. They do not require the patient to come into the clinic but help them know the doctor is thinking about them and concerned about their health. 

Each of these small interventions requires more personal contact from a doctor. There may be more work upfront but as trust grows the patient’s anxiety will decrease likely leading to a healthier patient. Dr. Walker understood that if he wanted a patient to jump off the porch with him they needed to trust him first. The integrated world would do well to heed his example.


[1] Bowlby, J.  (1982).  Attachment (2nd ed. Vol. 1).  New York: BasicBooks. 

[2] Bowlby, J.  (1973).  Separation: Anxiety and Anger (Vol. 2).  New York: BasicBooks. 

[3] Bartholomew, K.  & Horowitz, L.  (1991).  Attachment styles among young adults: A test of a four-category model.  Journal of Personality and Social

Psychology, 61(2), 226-244. 

[4] Ibid 

[5] Siegel, D. J.  (2012).  The Developing Mind: How Relationships and the Brain Interact to Shape Who We Are (2nd ed).  New York: Guilford.

[6] Ciechanowski, P. S., Walker, E. A., Katon, W. J., & Russo, J. E.  (2002). Attachment theory: A model for health care utilization and somatization.  Psychosomatic Medicine, 64, 660-667.  doi: 10.1097/01.PSY.0000021948.90613.76 

[7] (Ciechanowski et al. 2002; Bartholomew& Horowitz, 1991) 

[8] Ciechanowski, P. S., Walker, E. A., Katon, W. J., & Russo, J. E.  (2002). Attachment theory: A model for health care utilization and somatization. Psychosomatic Medicine, 64, 660-667.  doi: 10.1097/01.PSY.0000021948.90613.76 

[9] Ibid 

[10] Bennet, J. K., Fuertes, J. N., Keitel, M., & Phillips, R.  (2011).  The role ofpatient attachment and working alliance on patient adherence, satisfaction, and health-related quality of life in lupus treatment.  Patent Education and Counseling, 85, 53-59.  doi: 10.1016/j.pec.2010.08.005

[11] Ibid


Stephen Mitchell, Mdiv, MA, LPC is a doctoral student in Saint Louis University’s Medical Family Therapy Program.  He currently is a Medical Family Therapy Fellow at St. Mary’s Family Medicine Residency in Grand Junction, CO.  He is a Licensed Professional Counselor in both Missouri and Colorado and spends most of his days listening to patient’s stories, writing a dissertation, and wishing he had his own DIY Network series.  His research interests are loss and grief particularly in regards to infertility, miscarriage, pregnancy, and birth.  Additionally, he is interested in the connection between attachment and leadership development in pastors and doctors.  His son, Leeds, has not sustained any grave injuries jumping off of stuff in the last two weeks. 

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Retirement: It's Not Just the Money

Posted By Matthew P. Martin, Tuesday, November 11, 2014


Several years ago, a friend of mine went to see her primary care physician for her blood pressure. After reading her vital signs, the physician was concerned and began asking my friend about exercise and eating habits. “Yes, I exercise regularly and watch what I eat” my friend said. “Well, your blood pressure is much higher than usual. What else is going on in your life right now?” “Nothing much. My husband and I are planning a trip but that’s about it”.

The physician thought for a moment and then asked “Isn’t your retirement coming up?” That question shook my friend like a Polaroid picture. She suddenly realized how worried she was about retiring from a job that meant so much to her. “Yes, it is! And I am so scared to stop working.” She and the physician discussed some options for preparing for retirement and then ended the visit. My friend eventually retired not just once, but three times in total. She loved working so much it took several down shifts for her to become fully retired.

Retirement involves the loss of two characteristics: Income and status 

Retirement is a double-edged sword: it can be absolutely exciting or just plain terrifying for older adults. Most people think retirement, and all the devilish details that come with it, is all about money. People who think that way are either financial advisors or too young to vote. It’s more than just about the Benjamins. Retirement involves the loss of two very important work characteristics: income and status. Can both of these losses affect health? You bet. 


Now, please fasten your seatbelt. I am about to throw down some fast facts on retirement. 

Did you know?

The average American works 90,000 hours during a lifetime but spends 10 hours planning for retirement1

The over-85 age group is the fastest-growing segment of the population2

About 40% of Americans between 51-60 years of age have no pension income other than Social Security3

The median age of retirement is 60.6 years3

Those with poorer health retire earlier, especially African American men3

Unhealthy women tend to work longer because of inadequate income3

One out of four men aged 60-65 return to work after retiring3

Retirement is a relatively new concept. Before 1935, when Social Security was inaugurated, retirement was rarely considered by most Americans. In 1950, 45% of Americans 65 and older were working. Today, about 20% in that age group are working4. Even though retirement is more common today, it is NOT common for individuals and couples to be physically and mentally prepared for it. It’s even rarer for health professionals to inquire about a patient’s readiness for or adjustment to retirement. When is the last time a doctor asked you if you were emotionally prepared to give up your identity as a full-time worker for retirement?



Retirement is a many-splendored thing, fraught with opportunities and challenges. Some of the challenges include real health risks like increases in illness conditions (e.g., blood pressure, diabetes, and congestive heart failure), difficulty with activities of daily living, and a decline in mental health5. Some of these are attributed to the lifestyle changes that accompany swapping an office chair for a beach chair (i.e., decreased activity, fewer social interactions) and because many people retire DUE to health reasons. 

There are also several psychosocial challenges that come with getting off the work treadmill including identity change, questions of self-worth, limited social activity, asynchronous retirements in marriage, and more6. Here are some things you might hear an individual say:

“I was a supervisor for almost thirty years but now I’m fiddling around in the garage all day”

“My last job was creating new chemical solvents for Texaco Chemical. Retirement has left me without much purpose”

“I’ve enjoyed my retirement for the past two years by traveling and learning to paint. Now what do I do?”

“All of my friends are still working. Can I still spend time with them?”

Here are some things you might hear a spouse or partner say:

“She doesn’t have time to enjoy my retirement with me”

“I have things of my own to do but he just follows me around all day”

“I love having him home but now he tries to tell me how to do the laundry”

Delaying retirement age may lessen or postpone poor health outcomes 

Retirement is especially challenging when it’s unexpected due to health, family, or work pressures because then retirement becomes a necessity instead of a celebration. Moreover, retiring early is not always ideal. Delaying retirement age may lessen or postpone poor health outcomes, improve wellbeing, and reduce health care utilization7. Several protective factors can help individuals smooth the transition into those golden years including marriage, social support, physical activity, and part-time work7. 



Is money important for retirement? Without a doubt. AND (notice the absence of “but”) so is health including emotional and social wellbeing. Should a patient invest in a nest egg? Yes! Should she also mentally prepare for the huge changes in identity, status, and social activity? Absolutely. AND (I seem to have misplaced that word “but”) health professionals can play a big role.

Here are 7 things health professionals can do to support patients planning for or adjusting to retirement:

1.      Ask about retirement plans

What are your plans for retirement?

What have you and your family discussed or decided?

What concerns you about retirement?

What excites you about retirement?

2.      Ask about retirement adjustment

How are you adjusting to retirement?

What has gone well? What has not gone well?

How can I help you adjust even better?

3.      Collaborate with family friends, and other health professionals

4.      Conduct a thorough assessment of health risks, social support, and mental health

5.      Suggest a self-help book

What Color is Your Parachute?

How to Love Your Retirement

6.      Refer to financial advisor or life coach

7.      Watch out for unexpected retirements. These are the patients who may need the most attention. Love them, support them, and connect them with resources.


1.      Cavanaugh, J. (1997). Adult Development and Aging. Albany, NY: Brooks/Cole Publishing Company.

2.      The Center for Mature Consumer Studies.

3.      Foos, P.W., & Clark, M.C. (2008). Human Aging. Boston, MA: Allyn and Bacon

4.      U.S. Department of Labor, Bureau of Labor Statistics

5.      Dave, D., Rashad, I., & Spasojevic, J. (2007). The effects of retirement on physical and mental health outcomes. Andrew Young School of Policy Studies: Research Paper Series, October(2007), 1-47.

6.      Cox, H., Parks, T., Hammonds, A., & Sekhon, G.(2001). Work/retirement choices and lifestyle patterns of older Americans. Journal of Applied Sociology, 18(1), 131-149.

7.      Dave, D., Rashad, I., & Spasojevic, J. (2007). The effects of retirement on physical and mental health outcomes. Andrew Young School of Policy Studies: Research Paper Series, October(2007), 1-47.

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

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Finding a Rhythm Where There is None: Medical Family Therapy in a Pediatric Intensive Care Unit (PICU)

Posted By Alex Schmidt, Tuesday, October 28, 2014

Last year, I began working as a medical family therapy (MedFT) intern in a pediatric intensive care unit (PICU). During my master’s program, I worked as part of a collaborative treatment team in a clinic serving patients with neuromuscular disorders. I loved the steady, consistent pace of this bustling clinic and the team with whom I worked. Although many of my skills in designing behavioral health interventions transferred to this new setting in the PICU, I quickly realized there were significant differences between an outpatient adult neurology clinic and this pediatric intensive care setting.



In the PICU, there are more frequent changes of physicians and nurses as shifts rotate, no opening and closing hours, and an expansive variety of injuries and diseases being treated. In the past year, I have worked with patients and their families facing diabetes, cerebral palsy, hydrocephaly, seizure disorders, rare neuro-genetic disorders, leukemia, and accidental and non-accidental injuries including suicide attempts. This vast array of illnesses provides me the freedom to be curious and briefly research many different types of diseases. However, this has also presented a substantial challenge to my ability to accumulate a great deal of knowledge quickly. 

In the early weeks on the job, I felt like I was trying to grasp onto a rhythm when the genre and pace of the music kept changing. At the same time, I was also very aware that I was the first MedFT intern to join this multidisciplinary PICU team. This meant that a significant part of my job has included educating medical providers about how I, as a medical family therapist, can improve patients’ experiences by helping meet essential needs of their families. As a supportive team member, I also serve as an outlet for the staff to process the social, emotional, and mental stresses inherent in this type of work.  

I was trying to grasp onto a rhythm when the genre and pace of the music kept changing 

By now, it seems cliché to say that working in a medical setting requires a great deal of flexibility. What may be cliché is also powerfully true, as I have seen in my experiences. There is simply no way to predict with certainty when a patient might develop an infection, when parents’ bosses may tire of being patient and demand a return to work, or, in the most devastating of cases, when a patient might die after an unexpected complication from treatment. As a MedFT intern, I have become accustomed to receiving calls for consults during weekends, holidays, and evenings since, not surprisingly, illness does not operate on a schedule. Whether you are a patient, a parent, or a provider in the PICU, you learn to expect the unexpected. 



I receive consults from charge nurses, hospitalists, and intensivists for a variety of reasons, including: patients with a history of treatment noncompliance, families experiencing significant emotional difficulties due to a devastating diagnosis, families struggling to elicit social support from others, and families appearing hesitant to answer questions from the medical providers. Whereas physicians carry a large case load of patients and are responsible for managing a great deal of information, I have the luxury of time and the training to sit a with a family in uncertainty for as long as they need – sometimes 15-20 minutes, and sometimes upwards of an hour in crisis situations. In sessions, I typically aim to meet several goals

·         Elicit the family’s illness story beyond simply tracking physical symptoms,

·         Assess for emotional, relational, spiritual, and physical needs that can be met during the family’s hospital stay,

·         Identify any barriers to meeting these needs and creating a plan of action, and

·         Identify the family’s level of satisfaction with and comfort with making requests for more information or additional support from the treatment team. 

In alignment with family-centered care principles, I overtly state to family members that I view them as essential partners in providing the highest standards of care for the patient. I make it known that, regardless of the circumstances, I value the wisdom and concern of family members. One of the first things I often say to parents and caregivers is, “I know most people here have probably asked you about how your child is doing, but my job is being aware of how this hospital stay is affecting your entire family. How are you doing?” Usually, this is met with a tired half-smile and “I’m doing ok, now that he’s doing better,” “I feel like I’m losing my mind,” or “You know, I haven’t even stopped to think of that.”

Working in an intensive care unit also requires intensive self-care 


This simple question reinforces for families that we, as a collaborative treatment team, realize that our patients’ lives do not exist in a vacuum only large enough for medical history. Rather, we recognize the importance of our patients’ relationships. Our team extends beyond those of us with clinical experiences in hospitals and degrees after our names to include those who love the patient most and know their innermost dreams and the sounds of their heartbeats.  

I have found it helpful to remind myself that working in the intensive care unit also requires intensive self-care. This work is adventuresome and thought-provoking and invigorating, but there are also days when it is draining. There are days when my heart aches for families who are in so much pain that I break into tears as soon as I get into my car. Caring so deeply for these patients and their families encourages me to care for my own spiritual, emotional, physical, and relational health so that I can continue to give my very best and deepest caring to those with whom I work.                                 

I have found that I am a better dancer when I don’t think too much about finding the rhythm in the music. By following my instincts and trusting in my training, my dance steps become more fluid, more like me, and more in sync with the music. Over time, I have found the same to be true of working as a MedFT in the PICU. By learning to let go of a need for a static job description, unambiguous answers, and a certain structure, I believe I have found my rhythm.


Alex Schmidt is a doctoral student in Marriage and Family Therapy at Texas Tech University. She currently works as a medical family therapy intern at Covenant Women and Children’s Hospital in Lubbock, TX, and she is a Licensed Marriage and Family Therapist-Associate (TX). Her clinical interests include working with patients in intensive care settings and patients with neuromuscular disorders. Her research interests include factors influencing the comfort of therapists in working with patients facing life threatening illnesses, the collaboration experiences of medical family therapists, and families’ experiences of raising an adolescent with diabetes.


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Finding Family at the 2014 CFHA Conference

Posted By Administration, Tuesday, October 14, 2014

The Families and Health Special Interest Group welcomes you to the 2014 annual conference of the Collaborative Family Healthcare Association! We have prepared this document of suggested concurrent education sessions for conference attendees who are interested in a special focus on families and health.


Period 1: Friday, October 17, 2014 10:30am – 12:00pm


A1a: The Case for Utilizing Psycho-educational Multiple Family Groups (MFGs) in Medical Settings: Our 25-Year Experience with the Ackerman Institute MFT Model (Peter Steinglass, MD & Talia Zaider, PhD)

Although MFGs have been enjoying increasing popularity in medical settings, they still remain very much underutilized. To take up this challenge, for the past 25 years we have been implementing a manualized version of an MFG in a wide variety of clinical settings, including community hospitals, a tertiary care cancer center, and out-patient settings. Join us for a whirlwind review of our MFG experiences, and a discussion of why this model can be so effective and has been so positively endorsed by participating families.”   Based on innovative models, this presentation will describe ways that providers can work with families living with diabetes across both community and tertiary care environments. Participants in this interactive session will be able to: 1) describe multiple ways that providers partner with families to better manage health, 2) identify how these collaborative efforts can lower diabetes-related health care costs, and 3) apply these skills in their own professional and community networks to target a broad range of chronic health conditions.” 


Period 2: Friday, October 17, 2014  1:30pm – 3:00pm


D2a: Integrated Treatment of Child Obesity and Overweight in the Primary Care Pediatric Setting (Timothy Marean, MD, & Jennifer Fontaine, PsyD)


“The Healthy Kids Program at Evans Army Community Hospital is a fully integrated, evidence-based, collaborative approach to treating childhood obesity and overweight that includes a pediatrician, a psychologist, the patient, family members, and a dietician. The team works together to identify, assess, educate, and motivate children and families to develop healthy lifestyle behaviors that lead to improved health outcomes, currently tracked and measured in our clinic through an ongoing performance improvement research project. The program combines current American Academy of Pediatrics (AAP) recommendations for medical treatment of obesity, as well as several evidence based behavioral interventions (including motivational interviewing), eventually leading to improved patient outcomes.”  


Period 3: Friday, October 17, 2014  3:30pm – 5:00pm


D3a: What Do I Do with this Family? Healthcare Innovations Using a Relational Lens (Tai Mendenhall, PhD & Jennifer Hodgson, PhD)


  This interactive workshop will offer a synthesis of contemporary advancements in healthcare using a relational lens through medical family therapy (MedFT) training, research, policy, and financial models. Presenters will highlight and draw from their recentlypublished text, Medical Family Therapy: Advanced Applications, wherein established and rising leaders across multiple disciplines have contributed cutting-edge knowledge about how to make the Triple Aim a reality in the ways that we prepare for, organize, practice, fund, and sustain care. From new trainees to seasoned practitioners, educators, administrators, and policy makers, participants will walk away with newfound energy and resources to take part in this exciting evolution. 


G3a: Beyond the Exam Room: Leveraging Perinatal Data to Increase Father Involvement and Improve Maternal-Child Health Outcomes (Mark Thomas, PhD)


With the proliferation of electronic medical records (EMRs), providers have increased opportunities to leverage EMR data to improve health outcomes among the populations for whom they care. This presentation will describe the results of research that examined perinatal health data to identify predictors of low father involvement, which is often associated with poor maternal-child health outcomes. Participants will learn how the perinatal data contained in an EMR can be leveraged to proactively identify and intervene with at-risk populations.   


Period 4: Saturday, October 18, 2014 10:30am – 12:00pm


A4a: What’s Next? Advancing Healthcare from Provider-centered to Patient-centered to Family-centered. (Kaitlin Leckie, MS, Randall Reitz, PhD, Peter Fifield, MA, & Keith Dickerson, MD)


  With equal parts real-life application and hopeful idealism, this session presents the recent history and near future of healthcare's evolution. We outline the strengths and limitations of the paradigm shift toward patient-centeredness, and make the case that the full vision of "moving from fragmentation to integration" will only be achieved in a model that places family at its core. Direct application to care planning, care coordination, and health information technology provide take-home value. 


A4b: Putting Family at the Heart of the Collaborative Healthcare Team (Barry Jacobs, PsyD)


Family caregivers play essential roles as hands-on care providers, care coordinators and treatment effect observers for America's burgeoning numbers of chronically ill patients. Yet few collaborative care models embrace patients' family members as full-fledged team members. In this workshop, we will outline five ways for family members to be effectively integrated into healthcare and social service interventions from gaining recognition in the patient chart to granting access to professionals' treatment notes to practicing shared decision-making.   


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Doctors, Therapists, & Moms

Posted By Katharine Sileo, Tuesday, September 30, 2014

9-16% of new mothers experience some form of post-partum depression. As my friends started to have children I noticed how they were changing after childbirth. My first thought was that being a parent is hard and they’re just going through a transition period. However, I started to notice some friends were becoming extremely depressed, displaying OCD like symptoms or expressing hopelessness. I began to wonder why my friends were reacting to this life change so powerfully and why it was going unnoticed.



I started asking questions. The most informative and moving answer I received was “being a new mother is hard, but feeling like you should be happy, and not feeling happy, is even harder.” This conversation sparked my interest in post-partum depression and other perinatal mood disorders.

For many women, childbirth brings about feelings of extreme anxiety, depression and OCD tendencies. When mothers are experiencing these symptoms, they often feel lost and alone. When mothers struggle, the whole family struggles. Under these circumstances children are less likely to form secure attachments, marriages experience more difficulties and men begin to experience similar symptoms of depression and hopelessness.

As a clinician I am interested in the relationship between these symptoms, the tendency to ask for help, and the availability of that help. I explored the relationship between perinatal mood disorders, new mothers and their doctors. I was interested in whether or not the doctors identified their symptoms before they became harder to manage and if doctors were able to assist them in finding help. Beyond this, I was interested in whether or not the doctor and therapist were able to work collaboratively with the mother to discover the most beneficial treatment plan.  

Because of her perinatal mood disorder she experienced postpartum psychosis

To research this I met with a few mothers who experienced postpartum depression and listened to their personal stories. These women differed in many ways, from how many children they had to what post-partum symptoms they experienced. One of the women I had the pleasure of speaking with has four children under eight years old and is a full time working mom. She experienced post-partum depression after all of her children except the first. Her OBGYN suggested that she may be “having a hard time” and began prescribing anti-depressants, with no referral to a therapist. While this was a good catch on the part of the doctor, I wonder what would have happened if she was also referred to therapy. Her last episode of post-partum depression landed her in the UNC inpatient hospital. One of the other mothers that I spoke to reported that, with the help of anti-depressants, but no therapist, she lost custody of her daughter. Her perinatal mood disorder became so severe that she experienced postpartum psychosis and attempted suicide. While we cannot be sure, we can presume that with the help of therapy these women may have experienced different outcomes. I believe that this is evidence for greater collaborative between doctors and therapists. 


My goal in writing this blog post is to not only normalize the concept of postpartum depression and perinatal mood disorders but to inform mothers, fathers, doctors and therapists that there is a need for collaborative care in mental health. Providers can take the first step in officering collaborative care by encouraging their clients to sign releases allowing providers to share information. Ideally, collaborative care teams would consist of therapists, OBGYN’s and primary care doctors or pediatricians. They would collaborate on treatment plans, medication management and any changes that the client is experiencing.  Some barriers to collaborative care are the time that it takes for busy professionals to collaborate, as well as, the fact that many clients may refuse to sign releases allowing doctors to share information.

While there are many positive outcomes to be achieved if collaborative care became standard practice, we are far away from this being the standard. As the arena of mental health continues to gain recognition in the media and reduces its stigma, both patients and clients alike will feel more comfortable with collaborative care techniques.  It is becoming increasingly important to understand mental illness and figure out ways in which we can enhance awareness and help people have access to more resources; collaborative care is a promising first step. 


Katharine Sileo, MA, LMFTA is the co-owner of Mathews & Sileo Therapy Services in Cary, NC. Katharine completed her undergraduate degree in Psychology from North Carolina State University. She graduated at the top of her class from Pfeiffer University and received her Masters Degree in Marriage and Family Therapy. Katharine fell in love with Medical Family Therapy after interning at Duke Cancer Patient Support Program. 


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