Posted By Administration,
Saturday, October 18, 2014
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This is the third in a series of live blog posts for the 2014 CFHA Conference in Washington DC. Check back for more!
Mental Health Promotion and Prevention in Primary Care: An Idea Whose Time Has Come by William Beardslee, MD
October 17th, 8-10 AM
Christine Borst and Laura Sudano: Tag team blogging in style
Christine (CB): A new college student thinks, “Six months ago I didn’t even know what an English major was, and now I are one.”
For so many of us integrated care is just inherent – we have naturally gravitated to it because it made sense. And now we are working to figure out what on Earth we’re doing.
Laura (LS): Dr. Beardslee reflects on his career as in integrating family care for depression and acknowledges that there are many societal challenges, like war, that may get in the way of research; however, there are exciting things that are happening such as government support for research. Dr. Beardslee gives kudos to the speaker Dr. Richard Frank regarding the current healthcare policies implemented to make mental health integration happen.
CB: Dr. Beardslee discussed the good things going on for the world of integrated care – the ACA (with the emphasis on prevention and collaborative care); parity legislation; lots of innovative programs at many levels. “Healthcare is a basic civil right and a basic human right – this is not negotiable. Mental health care is a basic civil right and a basic human right as well”. “Families are the cornerstone of emotional development”. How do we meet the needs of families in healthcare? We need family-centered care.
Amen. We need change. Change!
LS: Mental health care is a basic human right and basic civil right. Participants clap in agreement with his strong statement. Dr. Beardslee notes that we need to disseminate our [members of CFHA] work with proper training and measurements. Family-centered care is key to tackling promotion and prevention of mental health.
CB: Dr. Beardslee discussed the importance of the Triple Aim – improving the experience of care, improving health, reducing cost. Most of the mental adult disorders have early onset – we need a developmental perspective! Need to use this to move towards prevention FROM THE BEGINNING.
I think we are doing our children a disservice if we’re not intervening (preventatively) when it’s most helpful (Honestly, how long will it take before we a) realize early intervention is remarkably important, and b) actually implement it across the board? Family, family, family. No one lives in a vacuum, especially not children.
LS: Dr. Beardslee presents statistics of mental health and calls for a developmental perspective on mental illness. One way to decrease these statistics is to help the parent be an effective parent. Dr. Beardslee presents implementation strategies that include family-based prevention strategies, effectiveness trials, getting the community involved, and to address cultural issues related to pt care.
CB: Dr. Beardslee brought up the importance of cultural sensitivity/humility. A great reminder that it’s so important to not make assumptions based on the dominant culture. “One factor lurks in the background of every discussion of the risks for mental, emotional, and behavioral disorders and antisocial behavior: poverty…We must address poverty.” Specific and general risks for depression. 20% of significant episodes of major depression can be prevented!
“We” ask for so much physical family history (heart disease, cancer, etc) – we really should screen for mental health concerns in the same way across the board and use prevention strategies in the same way. Depression is preventable! What a great opportunity for behavioral health clinicians in primary care.
LS: Dr. Beardslee notes that we need to offer a range of treatment to people as research suggests that people who are offered a range of treatment will tend to get better. Interventions needed to help the family and treatment of parental depression is critical in prevention and treatment.
CB: “Individuals should have informed choices in treatment ‘tools’ that are available to them.” Dr. Beardslee discussed the need for family interventions if we identify a parent who is depressed. Treat the parents, provide help with parenting, and using a two-generational approach.
Parenting is a remarkably intense job. What an incredible opportunity to intervene and be helpful on this subject as clinicians/providers…to help parents be more likely to actually enjoy the job they have.
CB: “A friend, not an apple a day, will keep the doctor away.” Social connectedness.
Eat an apple with a friend maybe…while taking a brisk walk? How’s that for collaborative care?!
LS: Up to this point, Dr. Beardslee discusses the IOM report and multiple studies/papers. He states that a friend once said, “A friend, not an apple, will keep the doctor away.” His point here is that social interaction and relationship is important, and of course, low cost. We need to think about this as clinicians. Dr. Beardslee talks about the difficulty getting reimbursed by insurance, as a psychiatrist, when using preventative interventions with families; however, it appears to be the bread and butter of healthcare. Perhaps this is one way policy should be shaped in the future.
CB: Developing systems that can give two-generational responses to parental depression. Tough for reimbursement because there’s not a diagnosis for the child. Responding to the needs of vulnerable populations, especially low income, culturally and ethnically diverse families. Depression can look different. We need to be educated and aware.
LS: Dr. Beardslee reviews his study of “Family Talk Component” launched in the late 1980s and notes that it is built on principles of risk and resiliency. He acknowledges that his work has been guided by resiliency perspective.
CB: “There is a lack of a payment structure [for preventive/family care].”
Ben Miller, can you fix this too!?
Screen. Treat. Prevent. Save gobs of money. Problem solved!
CB: How can we cultivate openness in our children? This is often lost in households suffering from depression. Dr. Beardslee’s secret to prevention treatment = systemized common sense.
Can you bill for that?
Dr. Beardslee explained that the art of the process is helping the families make sense of depression, eventually seeing the emergence of the healer within. There is also a need for families to “understand depression anew across the development.”
LS: Dr. Beardslee walks through the treatment of depression and notes the first step is psychoeducation with the parent. He states, “Good preventions are systematized common sense.” Dr. Beardslee reviews the six principles for a successful family meeting and interventions with families and depression. He says that he is a “practical person” so the six principles are practical tips for working with families.
CB: Web-based training in Family Talk at ww.fampod.org for free. Parental depression is prevalent in family practice; when recognized and treated can have a multiplier positive affect on the family. Use the PHQ-2/PHQ-9 to screen parents annually. Dr. Beardslee advocated that it is essential to work with parents who are depressed as parents first.
LS: Dr. Beardslee notes that his work with Latino population suggested that the children were curious about the immigration journey of their parents, something that differed from the implementation of this program with the general U.S. population. As such, the use of immigration narrative is important in implementing Family Talk programs.
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Posted By Administration,
Friday, October 17, 2014
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This is the second in a series of live blog posts for the 2014 CFHA Conference in Washington DC. Check back for more!
Economics, Delivery System Reform and Behavioral Health Integration: Don’t Get Left Behind By Richard G. Frank PhD
October 16, 2014 6-8pm
|Stephen Mitchell: blogging like a champion #CFHA14 |
7:00 Dr. Frank opens his talk making the point that placing behavioral health on the same level as general medical care has been shown to be affordable. The Affordable care act fosters parity by “marrying it to a mandate.” Thus, behavioral health is provided on par with general medical care.
7:04 What this means is 30 million people will have behavioral health services at parity. Have you noticed more people getting better behavioral health services at general medical care standards? Folks who are working in the trenches what have you seen?
What’s working? What is not? How does the Affordable Care Act influence these failures and successes?
7:07 Dr. Frank points out healthcare has become incentivized. This is an economic idea influencing medical care. Incentives work theoretically in economics but they can’t factor in the human element. Theoretically incentives bank on everyone “doing the right thing.” Unfortunately not everyone “does the right thing.”
7:11 Patient-centered care in an organization like CFHA means meeting patients where they are. Parity allows patients not to be forced into certain care settings but provides parity across all systems. Thus, no one falls through the cracks. I like this idea but is there another way to motivate all these organizations outside of money? I think we could learn a lesson from the banking industry, the more money available the more incentive to cheat, not do the right thing.
7:17 I like the flipped view Dr. Frank addresses. We have research exploring how behavioral health has been brought to medical care, but we have little evidence on how medical care is brought to behavioral health. I like how this flipped view works against the power dynamics inherent in bringing behavioral health to the medical field (ie. Trying to convince the medical community behavioral health matters).
7:21 Dr. Frank makes a compelling point: Cost-effectiveness does not mean huge savings but quality care and quality services are provided. There are some things that are worth paying for because they enhance quality of life and care. It’s like building a home with high-quality materials rather than cheep materials. The cheap materials make the house more cost-effective in the short-term. Quality materials make the house cost-effective in the long-term. Which would you rather have? Healthcare reforms need to be made for the long-term.
7:25 Dr. Frank returns to his flipped perspective (medical care to specialty behavioral health) and gives some data on what helps this collaboration work.
7:28 You can get a lot of the work of integration done without co-location. Is this statement legit? Can behavioral health needs and medical needs be met without co-location? What needs can be met?
|Ben Miller: Making social media look cool #CFHA14|
Dr. Richard Frank, Assistant Professor for Planning and Evaluation for HHS, our opening speaker today at CFHA. Dr. Frank has done a tremendous amount of work around mental health. For example, consider how Dr. Frank and colleagues were instrumental in bringing about mental health parity. Kicking off this year’s conference is totally appropriate as the majority of Dr. Frank’s work has been focused on evaluation and policy around mental health.
1) Expand overage around behavioral health (e.g. mental health parity)
2) Create new organizational arrangements to advance integration and the like
Dr. Frank opened up his session describing the robust evidence behind integrated behavioral health and primary care. However, he didn’t stop there; in fact, he described how we need to continue to push for delivery reform where we move from volume to value. His brilliant expose on mental health parity, which should the holes (e.g. small employer market).
Dr. Frank then took a bit of a u-turn and got the audience to pay attention to the specialty mental health space. His logic? The recent focus on the patient-centered medical home in primary care has also sparked discussions in the behavioral health community about creating a similar model in specialty behavioral health settings to help meet the health care needs of patients with severe and persistent mental illnesses and substance abuse conditions. SAMHSA has recently published evaluation data on some of these projects.
Throughout his presentation, Dr. Frank reminded us that there is a robust evidence base and principles to follow for integrating care. “We can measure the things that promote this stuff; if we can hold that, we can embed within our accountable systems, those measures so we do not go off the rails.”
Bottom line (from my live blogging): We have the evidence; we have much of the know how; we should scale (for behavioral health in primary care); we still need more evidence for integration in other settings
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Posted By Colleen Fogarty,
Friday, October 17, 2014
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This is the first of several blog posts being written live at the 2014 CFHA Conference. Check back for more!
A group of early career professionals gathered at the session “From Dissertation to Dissemination: An interactive Writing Workshop” organized and led by Lauren DeCaporale-Ryan and Laura Sudano.
After introductions in small groups, and shared reflections on the questions, “why do I write?” and “What do I write?” a panel of speakers addressed key questions of importance to writers and aspiring writers.
Matt Martin reflects on his journey as a blogger, and gives advice from one of his early faculty mentors: “Find a story and tell it.” This advice applies to BOTH creative and scholarly works!
|Randall Reitz takes the podium, and says he’ll talk about collaboration in writing using the names of three people who each need only one name: Mandela, Obama, and Beyonce. Nelson Mandela, leader of the African National Congress, and Barack Obama, current POTUS, both value leadership from behind. They both use strategies of collaboration in their leadership, focusing on consensus building to get a job done. So should writing, says Reitz. He proposes the following strategies for developing writing collaborations: ||Find a story and tell it! |
1. Symbiosis starts at home. Look locally for mentors and collaborators. Who inspires you?
2. Outreach intentionally—Answer the question, “who out there is doing what I want to do?” Develop personal connections and shared contact. Episodic email is a great way to go!
3. Show loyalty to your own peeps! (not the Easter candy….) Advance your careers together with people within your training cohort; you have with them a sense of timeline and shared experience.
4. Pursue non-traditional publications—Randall presents us with a screen shot of a current Google search of images associated with “medical family therapy” and finds luminaries: Susan McDaniel, Jennifer Hodgson and newer/younger folks including Laura Sudano. All of these people have a strong online presence, based on their work, and some of the work is online blogging.
Where does Beyonce fit in? Beyonce, in Randall’s estimation, is the ultimate musical collaborator, and she stays true to her roots and extends her growing beyond it.
Next up, Larry Mauksch and I, facilitating a discussion about barriers to writing. Participants throw out the following examples of barriers:
• Not enough time
• Competing demands on time
• Fear of rejection, or not being good enough.
• Fear of feeling stupid, or worse, actually being stupid!
• Pressure to produce, perfectionism.
• Personal barriers, including, but not limited to, a lack of focus and getting stuck.
|"The reason I write is to find out what I think" ||The major factors break down into psychological factors and time factors. To overcome the psychological barriers, one idea is to use Anne Lamott’s idea of a “shitty first draft.” The only role here is that it get done, then we revise! Larry points out that learning to write well is much like the learning required in any other activity, and requires coaching. I point out that we all need to develop a new relationship with “red ink;” We need to cultivate an open stance towards feedback and not personalize it into something being “wrong” with us as people. |
Next up, Susan McDaniel on writing productivity. She says, “The reason I write is to find out what I think… It’s hard to figure out what one thinks about something. If the writing isn’t clear, the thinking isn’t clear.”
She notes the importance of early mentoring in developing oneself as writer. Lyman Wynne a psychiatrist/psychologist, an exceptionally clear writer, served as an early mentor for Susan. They collaborated on a book about Systems Consultation, shortly before word processing became available. They revised each chapter at LEAST thirty times, each revision requiring hand re-typing of every page.
Susan recommends identifying local mentors and asking for feedback about your writing. She counsels, “When engaging potential collaborators, be careful. It’s like moving in together!... Choose your writing partners carefully!” She especially suggests choosing co-authors who will do their share of the work. When you find good collaborators, notice the dynamics and look for honest feedback to make your work better!
When thinking about why to write, she counsels colleagues that the opportunity to influence people is far greater with writing than with direct teaching; your work can reach across geographic boundaries and develop distant collaborations. Your writing can cultivate a rich opportunity for intellectual exchange!
|She notes that it’s crucial to commit the time to writing and to learn to prioritize and protect the important time for writing! Everyone has the demands of clinical work, trainee precepting, managing interruptions and writers need to learn how to manage this. Don’t schedule anything else during this writing time! Put a do not disturb sign on your door, turn off e-mail. Even if you commit 2 hours per week to your writing, after a year, you will have something! ||Learn to prioritize and protect the important time for writing! |
When you are sitting with a manuscript, thinking, “spare me, I can’t stand this anymore!” Keep at it; the rewards are there though certainly DELAYED! Pay attention to the important, not only the urgent!
Participants began the small group work of a mini-writing seminar. Each group had 2 or 3 participants who had sent in writing ahead for the group to review and critique. Hats off to these folks who showed the courage to share and the faith in the events’ organizers, to make good use of the time and receive feedback on their work.
During the large group debriefing at the end of the session, participants reflected about their experiences in the writing seminars, as both reviewers and authors.
|I am looking forward to the red ink ||On reviewer commented that she could use the feedback that the authors received in her own work. An author noted that she felt the comments drove home Susan McDaniel’s ideas about clarity, saying, “where my reviewers were confused, those were the same spots that I was confused when I wrote it.” Another author reflected that she found that coming together in a group to review helped her get “unstuck” and helped to get her thinking back on track. A third author commented that “Looking forward to the red ink” is something she’s been developing, saying, “The more I do this the better it gets!” |
In closing, groups were tasked to write down a writing goal for the upcoming year and then share the goals within the small group. Goals in my small group included working on a memoir for an hour each week, submitting poetry to a journal, scheduling writing for two hours per week, removing patient appointments during pre-scheduled writing time, and committing to dusting off manuscripts that have languished and prepare them for submission or re-submission.
DeCaporale and Sudano knocked this one out of the park: They included expert tips, facilitated large group discussion, experiential writing/reviewing in a small group setting, and personal/professional reflection and goal-setting. I hope the participants of the session gained as much as I did from participating!
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Posted By Administration,
Tuesday, October 14, 2014
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Don Bloch, MD died on September 18, 2014 at 91 years of age. He founded the Collaborative Family Health Care Association and its affiliate journal, Families, Systems and Health (formerly Family Systems Medicine). He was a funny, creative, authentic human being, one of the original family therapists who saw the importance of applying systemic approaches to healthcare. Don was a generative visionary who found and nurtured new talent and created organizations, journals, even health care movements through recruiting and harvesting the energy of many colleagues.
In this CFHA blog, an interview of Don originally published in 1996 one year after the first CFHA conference, is republished with permission. Don remained heavily involved in CFHA into his early 80s after founding CFHA at the young age of 72.
With gratitude and deep respect for Don,
Larry Mauksch, M.Ed,
Susan McDaniel, PhD.,
and Jeri Hepworth, PhD
An Interview with Donald A. Bloch, M.D. by Eric Weiner, Ph.D., M.S.W.
Families, Systems, & Health 14:95-105, 1996
Prediction is difficult, especially about the future.
Let's begin by having you tell us what you believe is most noteworthy about your career.
I think what I value in myself is having a fairly good early sense of what will be important in the midterm. This meant abandoning psychoanalysis for family therapy in the mid-1950s and recognizing the unfolding importance of systems issues in healthcare in the early 1980s. In connection with the development of each of these fields, family therapy and collaborative family healthcare, I have been the Editor of the two key journals for important periods: I edited Family Process for the volume years 1970-82, thirteen years in all, when family therapy quite literally burgeoned. Similarly, I have edited Family Systems Medicine from its founding in 1983 up to the completion of 1995, again thirteen years, and again I think those were critical years for the early delineation of the field.
Tell us about your early family years.
In many ways, the family I grew up in was typical of the second-generation, Jewish immigrant families that arrived on these shores in the late 1880s. All four of my grandparents immigrated here as youngsters, met here, married and had their four children: two boys and two girls in each instance. Both grandfathers started out as itinerant workers, one a peddlar, the other a painter. They opened small stores, worked heroic hours to hoard up protection against the anxiety and dread that they brought with them from Eastern Europe. They raised their families in the often described atmosphere of gemiitlichkeit, guilt, and ambition that characterized immigrant Jewish families. My father, as oldest son, married a youngest daughter, as did I—twice. He became an attorney and ultimately, after many anxious years and before Alzheimer's struck, walked into the 20-year sunlight of his true vocation as a judge—a role that played to the best of his intrinsically sweet and thoughtful disposition. Truthful, quick sketches of my mother and sister are beyond me. My mother, like countless numbers of her sisters, certainly was an under-utilized woman, and angry and depressed about that—but still with a wonderful capacity for love and humor. My sister Barbara was and is my lifelong friend—at least after I recovered from the dark sense of gloom that attended her arrival when I was five, and the hot Oedipal love affair I was having with our mother was disrupted.
What about college and medical school?
My college years were very turbulent, continuing a pattern that had been established in high school. At the personal level, I was struggling with what I would later come to see as major difficulties in leaving my family of origin. I lived at home and went to college, riding the subway like so many New York City kids—just as I had done for high school. I had a hunger for knowledge and a total inability to conform to the official demands of education because that was what my parents were pushing—an evil combination. My adolescence was often chaotic and painful. Confusion and guilt abounded along with an idealistic yearning to be connected to the great causes of the world. Unfortunately, family therapy had not been invented yet.
It sounds as if politics would have been important to you under these circumstances.
Left-wing politics, with which I became heavily involved as a college student, was God-sent. The Spanish Civil War began in 1936 when I was 14, and the heroic struggle between good and evil—the Loyalists and the Franco Falangists, as transmuted and romanticized through the writings of Hemingway—was the stuff of my adolescent dreams. Heroism and sexuality: an unbeatable combination. Later on in college, I could be so busy selling the Communist newspaper, The Daily Worker, that there was no time for school work—actually I had a goodly number of devices for avoiding school work. The whole enterprise terrified my parents, but they could not do much more than leave me alone and hope for the best. I was frightened myself, but also fascinated and really enjoyed the endless discussions and the political work.
My first serious girl friend was a Young Communist, she later persuaded me to straighten up and become a pre-medical student as a "contribution to the class struggle." She correctly assessed that I could parlay a middle-class background from a working-class school into a rare and much sought after admission to medical school.
When I began to think about going to medical school, I turned into a model student. The possibility of being a doctor wove together a multitude of strands in my life. Physicians were revered in my family and, it seems to me, there was a strong delegation for me to be the physician in my generation of the extended family, which had already had several distinguished doctors in earlier years. More than that, I had been asthmatic as a child and often had severe ear infections—painful and debilitating in the days before antibiotics, when deafness and mastoiditis were not uncommon sequelae. My mother was certainly the best nurse/ mother any child could have, an expert at creating a cozy counterpane world that almost made the extremely painful eardrum lancing for my many middle-ear infections endurable. My mother and I made the tightest of bonds around my illnesses. And, since I was a voracious reader, the romance of medicine and the high adventure of science captured me in a heady swirl.
|My mother and I made the tightest of bonds around my illnesses |
During the war, students were enrolling in the military, either the Army Medical Corps or the Navy V-12 program, so as to avoid being shipped overseas. I was accepted for the more desirable Navy program, very strange and somewhat embarrassing even at this remove because there was so much privilege involved. The intentions were good: not to tie attendance at medical school to the student's financial situation. But, of course, the majority of those admitted had the advantage of education and class background.
You married first at about this time?
I was married just a couple of weeks before medical school started. Natalie and I were just 21 years old. Among other things, she introduced me to psychoanalysis in a form that was understandable, and palatable to me, mostly through the writings of Karen Horney, whose most influential book was The Neurotic Personality of Our Time.
Remember that the 1930s was the decade of the Great Depression. It is almost impossible to convey the impact of this on the lives of ordinary people. To say that one out of four workers was unemployed does not begin to convey the dread people felt. A sense of personal identity and any feeling of self-worth dissolved. Later, when I came to know Nathan Ackerman and to reconstruct some of his history, I learned how much his thinking was molded by the experience of the Depression, not only in his own family but also in his work as a young psychiatrist.
|Psychiatry as a profession began to make sense to me |
The appearance on the scene of the social science oriented psychoanalysts permitted psychoanalysis and my political and social interests to come together, and psychiatry as a profession began to make sense to me. It was also very evident, at the personal level, that I needed some help since I was faced with the stress of leaving home, a new young marriage, and the assault of medical school. Deciding to become a psychiatrist and psychoanalyst legitimized my getting into personal analysis in medical school, and undoubtedly helped keep me somewhere close to sanity.
My first analyst was both a political Marxist and a psychoanalytic radical, Bernard Robbins. As I reconstruct him now in my memory, Robbins had the early intuition of an idea that has dominated my own thinking over the years. At that time, most theory was devoted to considering how personality unfolded from within and was modified by traumatic events. Against this background, it was a major dislocation to think that social responses to individuals played a significant part in maintaining the continuity of personality, and that individuals were active in constructing and modulating these responses.
You trained at Chestnut Lodge, did you not?
Chestnut Lodge Sanitarium, where I went as a first-year resident, was a small, private psychiatric hospital just outside of Washington DC, in Rockville, Maryland. It was then the premier, psychoanalytic hospital for treatment of psychotics and severe behavior disorders. Frieda Fromm- Reichmann, the remarkable refugee psychiatrist who was the central figure in the novel / Never Promised You a Rose Garden, was on the staff and one of my teachers. The brilliant and eccentric American psychiatrist Harry Stack Sullivan, who defined "psychiatry" as the "study of interpersonal relations," was a consultant and taught at the Washington School of Psychiatry where we all were students. It probably seems weird to the reader of today, but this small hospital, in many ways precious and self-involved, was a significant crossover location for the evolving field of what was to become systemic psychiatry.
The "Lodge" had started life in suburban Maryland, just outside of the District of Columbia, as a drying-out place for congressmen and others of their ilk. Somehow, Dexter Bullard, the owner, on inheriting the place from his psychiatrist father had the glorious notion to turn it into a psychoanalytic hospital—just at the time when American psychiatry was being pumped up to previously unimaginable heights by the influx of refugee analysts interacting with the returning young doctor war veterans who were trying to find a place for themselves in a rapidly changing medical world. The residency appealed to me because it provided the opportunity to work intensely with a small number of patients. The custom was to see patients four, five times a week for one-hour analytic sessions; the focus of the work was on examining the interpersonal field constructed in the transference relationship—an effort to bridge interpersonal and classic analysis. I believe a persistent trend was established there, and that it has provided structures supporting the collaborative family healthcare movement some 40 years later.
Why do I give it such importance? This hospital and the Washington School of Psychiatry were committed to understanding and treating psychosis in interpersonal terms. A broader view of this enterprise, and particularly of the idea that the treatment system included the therapist as much as the patient, is so powerful that we are still only at the beginning of understanding its importance— although the idea of collaborative family healthcare captures that notion in action. It provided the logical foundation for the transition from exclusive concern with intrapsychic events to a broader interpersonal and eventually an ecosystemic view of "mental" life.
|[They] were committed to understanding and treating psychosis in interpersonal terms |
The influence of these ideas can best be illustrated by research that went on there—ultimately published in the still interesting book The Mental Hospital by the sociologist Morrie Schwartz and the psychiatrist Alfred Stanton. In what is still a model of research strategy, they attacked the problem of psychotic excitements. These days, heavily medicated patients are not likely to show the fearsome combination of behaviors covered by the term "psychotic upset or excitement"— grueling and dangerous outbreaks for patients and staff. These were patients in extreme psychic pain, restless, disoriented, combative, self-damaging. We did not have any medications available except for chloral hydrate and phenobarbital; Thorazine had not yet come on the market. We used cold, wet-sheet packs to help people quiet down, and we provided a tremendous amount of nursing for patients. But it was still a major source of distress for patients and staff.
In what remains a model of research, Stanton, the psychiatrist, charted the excitements, Schwartz, the sociologist, monitored and charted staff interactions with patients, all of whom were on the closed women's ward, about 20 patients. These records were kept separately and analyzed later. The intriguing finding was that there were disagreements and covert struggles going on between key staff involved with patients and that these preceded the excitement. Let's say that the charge nurse and the patient's analyst might have a major disagreement about how she (the patient) should be dealt with; the covert disagreement would go on for day after day, after which she would go into a psychotic excitement. By independently charting the relationship between the nurses and administrators or individual therapists, and by demonstrating that there would be these hidden wars, it was possible to predict before the patient was going into an excitement that this would happen. Not uncommonly, the episode would end when one of the staff members left the field, by resigning, requesting transfer, or by hospitalization of the staff member for "mental disorder." Family therapists can recognize the isomorphism with patterns that undoubtedly characterized the families from which these patients came.
A number of the people of my generation who went on to become leading innovators were there as residents when I was: Don Jackson and Harold Searles probably being the best known names. The "Lodge" had the quality of a golden land: we were intensely involved in new ideas about the "self." This involvement took us into looking at our own lives, looking at how we fit into what was happening with our patients, what our part was in creating the transference. Transference could no longer be thought of as something that the patient dropped on you like a soggy blanket, but rather something you participated in constructing. The notion of a co-constructed reality—although that was not the language for it then—was alive and well at this hospital in the late 1940s. The years have passed, but I think the early patterns of interest for me were really established at that time.
What happened next?
The intellectual excitement was almost overwhelming at times. We were exploring the territory of the new social sciences and bringing back treasures for our work: linguistics, semiotics, cultural anthropology, sociology, general systems theory, cybernetics: Parsons, Goffman, Wiener, Korzybski, von Bertalanffy, McCulloch, Margaret Mead, Harry Stack Sullivan and, later, Gregory Bateson. Only a few names from a long list whose work we studied and whose ideas we adapted to the clinical problems with which we struggled. Their ideas were exciting in and of themselves, and they were applicable to the human dilemmas with which we were dealing.
|The intellectual excitement was almost overwhelming at times |
I finally had to fulfill some obligated military service because of my deferment during the war. I joined the Public Health Service, was stationed at the National Training School (NTS) for Boys in Washington DC for 2 years, and later at the National Institutes of Health for the same period. NTS was the federal prison for youthful offenders. At NIH, because I was now an expert in delinquency, I was on the planning staff of Bob Felix, the Institute Director. The entire Mental Health Institute was housed in a Quonset hut on the NIH campus in Bethesda—hard to imagine in the light of the Institute's current size. When the Clinical Research Center opened, I was invited to join Fritz Redl in opening the first research unit—improbably studying delinquency by housing a half dozen 10 years olds on a ward in the gleaming glass and steel building. It was an embarrassingly zany effort: the difficult task of getting the government to permit our nurses to wear street clothes on duty was topped only by the problems of the twice-a-day convoy of our kids past the glass-doored laboratories in the hall outside the ward. What kid, delinquent or not, could resist putting an occasional hammer through one of those doors?
I published my first paper in 1952 based on this experience. The paper, "The Delinquent Integration," defined delinquency as an interactive pattern rather than as a personality characteristic. It attempted to identify what there was in the growing-up experience of the to-be-delinquent child, and what adaptive defenses he had to develop to live and minimize anxiety in that experiential world, defenses that would later be known as his character or personality structure. The paper was about the social interactions in which circularity was established so that responses were evoked and made for the reality in which one lived and that had to be dealt with by recycling the same interpersonal patterns. Some years after that I coined the term "portable reality" to describe how the individual, moving through time, evokes from the social fields in which they are moving, a set of responses that in effect create the same reality—so the reality is portable. That has interested me all of my professional life and is a large part of how I look at family and other areas as well.
Then, and perhaps now as well, I was always pushing—out of some inner discontent or restlessness—to the edges of wherever I was at the moment while trying to stay connected to the center. In the early 1950s, having heard dimly of something later called family therapy, I began to record my therapy sessions with analytic patients; this was before the days of taperecorders, and video of course was unheard of. I bought a magnetic wirerecorder that, in those days before transistors, was the size of a large suitcase. You could barely carry it. It would make a magnetic recording on the magnetized wire spool and play it back through what looked like a large radio. The entire project was suspect: analytic colleagues sniffed at your unanalyzed voyeurism. After making recordings for a while, I did something even more outrageous: I began to invite the spouse in when I had patients in analysis. I was intrigued by the notion that I could take a firsthand look at the folks I had been hearing about from their mates and check my impressions directly against what I had heard in the sessions. It also helped ward off analytic boredom, which threatened to descend all too often.
Let me tell a story that I don't tell a lot. I have had only one "successful" suicide of a patient in my entire career. The patient was a woman who came to me for analysis. She was a PhD married to an MD, had two kids, and was pregnant with the third. It was very clear in the first couple of sessions that she was dangerously suicidal. I told her I needed to talk with her husband. She refused, saying that, if I did, she would not work with me. "I have to know that this is confidential," she said. So I didn't contact her husband. She killed herself. She took an overdose, and her husband woke up in bed one morning next to his dead wife. I've regretted that all my life; I know I would do it differently now. At times, the severe limitations of one-on-one, confidentiality oriented psychotherapy were compelling and evident.
How did you happen to go to the Ackerman Institute?
Altogether, I spent 13 years in Washington. My wife and I had our three children there. In 1961 we left Washington DC to move to Northern Vermont for what was to be a one-year sabbatical on a farm, and we ended up staying there for 7 years. I had a research consulting job in New York at the Jewish Board of Guardians, to which I would commute 2 days a week. It seemed as reasonable to commute to New York from Vermont as from the District of Columbia, and we could live on the reduced income under those circumstances. Midway through that period on the farm, around 1965, I began to become actively involved with Nathan Ackerman and the then Family Institute, renamed after Ackerman's death.
Ackerman and I had been lurching toward each other off and on for several years. He fascinated me; I knew I was interested in family work, and a mutual friend, Marjorie Behrens, who was an associate of mine on a research project and a longtime and loyal friend of Nathan's, would talk about him to me a lot. One day, Marge felt it was time for us to get together, and we all had a drink together, which turned into several drinks and finally a night of talk between Ackerman and me. He asked me to come work for him, which I did, first as Research Director, then later as Associate Director.
|I knew I was interested in family work |
Originally called The Family Institute, it was a very part-time enterprise originally run out of Nathan's private office; the staff consisted of Nathan, his secretary, and the wonderfully capable Judy Lieb who was titled administrator but did just about everything. I imagine Nathan paid them out of his private practice income. To say that it was a shoestring operation is to exaggerate. When I joined them in the mid-60s, the Institute had just bought the lovely townhouse on East 78th Street in New York City, which it still occupies. The Board, in those days, was made up mostly of Ackerman's present and past patients. They were just beginning to give the Institute some meaningful financial support, and about 1965 bought the building and finished paying off the mortgage. For the next 25 years this building was the sole capital asset providing, literally, a roof over our heads and the place where teaching and clinical work could go on with some measure of safety.
Nathan Ackerman died suddenly but not unexpectedly in June of 1971. He was only 62 when he died; he had rheumatic heart disease, smoked and drank more than he should. I believe he had made no real effort to prolong his life. There was a way in which he was deeply sad at how things had gone in the world. He had dreamed the dream of family in a way that was rapidly becoming anachronistic since it was deeply rooted in the idealized image of the patriarchal family—not a bad deal when it was going well, but rapidly played out as a goal. Yet family therapy would live on and be incorporated into the newer ecosystemic approaches to human misery. Sometimes students are surprised to hear that there was a man called Ackerman, not only just an institution. That would certainly not have surprised Nathan, but it would have amused him.
I was Associate Director and the logical choice as Director. By 1971 there was a solid core of clinical and teaching talent as well as a fully operating low-cost family clinic that provided our student externs with clinical material. It was worth continuing for the possibility that, with people like Kitty LaPerriere and Peggy Papp, we could carry the ideas and techniques of family therapy into new project areas.
Did some of the activities at the Institute relate to family systems medicine?
Early on, Ackerman and I were involved in two hospital programs. We regularly visited with the head of Orthopedics at New York Hospital—he was a most unusual orthopod who had collected family case histories on a large series of his patients, and who was impressed with the unexpected frequency with which disasters ranging from divorce to homicide had been part of the lives of the families of his patients with severe orthopedic deformities. We also regularly visited the Obstetrics Department at Lenox Hill Hospital to explore the possible benefits of a family intervention early in the lives of vulnerable families. With this in mind, we set up a series of meetings with young families that were observed by professional staff.
I'd also like to mention a project called Family House that I set up in my very early days at the Family Institute—the mid-1960s is the time period involved— because it clearly delineated the ideas that have been enunciated in the collaborative family healthcare paradigm. The Family House project design called for moving a multidiscipline team, built around social and healthcare services, on-site into a housing project building. It would selectively choose for residence those families denied access to more conventional housing projects, denied access because they were alleged to exhibit social or personal pathology too severe to be accommodated in such housing. For all intents and purposes, these were families that 20 years later would be identified as homeless, although that term had no currency then. A central idea of Family House was to deal with the pattern whereby families, as they strengthened themselves and became less "pathological," would move out of the community in which they lived—the housing project, for example. We had the notion of reversing this process and having the professionals "move out," hopefully leaving a vital community behind them.
|The Family House project called for moving a multidiscipline team into a housing project building |
Amazingly, the project was approved for joint funding by both NIH and by the Children's Bureau. But that was in a year when all the funding crashed. So, we got a small amount of money but never got the project really funded. It was approved but never really came to be. Looking back on it now, I think it was laudable but naive and unsophisticated. My guess is that it, like so many similar projects, would have been sustained for a time only by unreasonable inputs of energy and financing. It would have demonstrated one kind of truth, that families can be rehabilitated with those levels of support, and also demonstrated another kind of truth, that such levels are unsustainable. A much more advanced and valuable demonstration of these points was being made around the same time by Dick Auerswald and the Gouverneur Hospital program in a well-funded project where an ecosystemic and family point of view was being applied to a community mental health center, and with outstanding results.
What were your goals for yourself and the Institute when you became Director?
My goal as Director, during the 19 years I held that position, was to have the Ackerman Institute be a flexible and dynamic home for outstanding people and exciting projects. We tried to build these on a first-rate, clinically based, teaching program. I believe doing this well meant setting quality standards, but not pretending to know just where it all would go or what the ultimate model to be promulgated should be. The choice to nail one's flag to the mast of a specific model of therapy has clear tactical advantages if the model works, as almost all do somewhat. The alternative is for an institution to teach clinicians more eclectically, with the best current models available. That way builds institutions along more of an academic model. At the Ackerman Institute we did both, not always without some conflict. Under the star system, it is often hard to persuade others as to what an equitable division of the glory or income should be.
Running the Institute was not always smooth sailing for another kind of reason. Things kept changing in the field, and it was particularly painful to realize that sometimes people had to leave the Institute because they did not fully keep up with these changes. It is not always true that a rising tide lifts all boats. Mercifully, this did not come up too often because the people who had to leave had been my colleagues and friends for years.
How did you start Family Systems Medicine?
My pathway to a closer relation with physical medicine was long and, as I have tried to indicate, goes back to my childhood and my family. More proximately, at the Ackerman Institute I began to feel more and more strongly that our view of our work as family therapists was too limited and partial. Many family therapists still act as if people were disembodied. The comment that the physicians' view of a person stopped at the skin was as true in the opposite direction: family therapists had little to say about things taking place inside the skin. And yet I knew from my clinical, and indeed my personal experience, that this was just not so. People came into therapy for a multitude of reasons related to their biology; endowment, development, disease, aging were all slighted. Later on we learned that they often came into family therapy because they were getting better from some physical disease. So I began to be intrigued by that. It seemed to me that we were not thinking enough about the biological and, as an extension of this, that we were not thinking enough about our relations with physical healthcare providers. Little did I know then how true this would turn out to be.
|We wanted to know more about families in which there is chronic illness |
Somewhere in the early 1980s I had invited Henry Lennard, a medical sociologist, to consult with us on a regular basis, and we spent many long hours discussing healthcare, where it was going, and what might be done to improve things. That began to get the juices flowing. Later, we set up a chronic illness unit under the direction of Robert Simon, with whom Peggy Penn worked so productively. Over the years, many projects at Ackerman have started in just this way: a group of families showing some common pattern of interest—school problems, AIDS, family violence—would be invited to work with us. This involved assembling a small staff group that would systematically observe sessions with these families. In this instance we wanted to know more about families in which there is chronic illness, to look at them really closely, and try to unriddle what relationship there was between the illness and the family. The chronic illness project continued for many years.
In 1982, I had completed my term as Editor of Family Process and was feeling somewhat bereft. Michael Glenn, who earlier had been a student at Ackerman, and whom I valued highly for his intelligence, honesty, and clear views of corrupted systems, approached me for some help on his idea of starting a journal. At that point, Michael had left family therapy (to which he later returned), moved to Boston, and was practicing family medicine. Michael and Barry Dym had been discussing the idea of a new journal, but needed someone with enough credibility with publishers to persuade them to undertake this chancy venture. I seemed to fit the bill, and we set about putting it together. So, Family Systems Medicine was born 13 years ago, with Don Ransom, Michael, and Barry as the initial, core guiding group. Fortunately, we were supported by a generous private donation for the first 3 years of publication and, since then, have gradually built up a readership and group of authors and advisory editors. It is a source of great satisfaction to me to see the journal, renamed Families, Systems & Health, in the competent hands of its new Editors, Susan McDaniel and Tom Campbell, with the leadership of Bill Doherty as Board Chairman. It is the same sense of solid pleasure that I feel when I think of the Ackerman Institute being directed by Peter Steinglass. It is a great tribute to be succeeded by people whom I admire and to whom I can unhesitatingly pledge my own loyalty and support.
And, now you have started the Collaborative Family HealthCare Coalition.
Readers who will have followed the trail I've laid out about my life should not be the least bit puzzled as to my part in starting and building the Collaborative Family HealthCare Coalition (CFHcC). They could indeed say, "What else could the fellow have done given that long-term interest in doctoring, family, and ecosystemics?" In the winter of 1992/3, having left Ackerman almost 2 years earlier, I was occupied with editing the journal and doing a bit of teaching and private practice. I began to obsess over the directions being taken by the professions of psychiatry and family therapy, each of which seemed to be on a downward spiraling course. Psychiatry had long since chosen to define itself as a biological discipline—a decision that filled me with anguish when it first became evident, and then finally left me despairing about any possibility of change in the profession. It was particularly worrisome that family therapy, by defining itself exclusively as a mental health discipline, was condemning itself to eating crumbs from the psychiatric table. And it seemed to me that this was going to be leaner and leaner fare as things moved forward.
There was a tangle of epistemological, clinical, and political issues here as well, which seemed to cry out for some new thinking. Paradigm change toward an ecosystemic model of healthcare (in my view, a somewhat more satisfactory term than George Engel's biopsychosocial model) might just be possible because of the economic and cultural changes that were taking place in the U.S. Certainly, if the holistic vision in healthcare was ever to come to pass, this was the time for it. Difficult as the situation was turning out to be nationally, the turmoil seemed to me to provide opportunities that had not existed before. The essential ingredients for paradigm change seemed to be in place: the prevailing linear epistemology was less and less able to handle the data being generated, and a systemic epistemology was available and more promising; the economic interests of large groups could benefit from a paradigm shift; a work force (mental health providers) and a technology (systemic interventions) were available to implement the operationalization of a new paradigm. It was hard to assess the meta-stability of the present system; the influence of the medical-industrial complex could not be overestimated; there were the enormous problems of redesign and retraining. Since all these issues would have to be dealt with at some point in time, this seemed as good a time as any.
Moreover, it seemed that we were not fully connecting with the natural allies of family therapy—family medicine practitioners. In the course of my years as Editor of Family Systems Medicine, I had come to know many people from family medicine, especially through the Amelia Island meetings of the Task Force on the Family of the Society of Teachers of Family Medicine (STFM). We had been traveling parallel paths, often without fully knowing about each other's work. I had high regard for their ethical and technical excellence. It seemed that this was the appropriate core of a new movement if it were to take place.
|We were not fully connecting with the natural allies of family therapy—family medicine practitioners |
With that in mind, I initiated a planning meeting at the March 1993 Amelia Island meeting of STFM that, by happy accident, Lyman Wynne was able to attend. Lyman's early support for this development was critical; he brings impeccable credentials as a scholar and clinician/researcher, and his indisputable integrity gives a stamp of approval that is priceless. The group was wonderfully lively and wanted to continue the explorations. The Amelia meeting was followed the next January by a meeting at the Johnson Foundation Wingspread Conference Center. Wisconsin in the dead of winter is an unlikely place for buoyant new growth, but that meeting of 50 professionals from many different disciplines ended on a Spring-like note. The Collaborative Family HealthCare Coalition was born and named, and a possible conference was outlined. The ship was sailing even as it was being designed and built.
Do you have any final thoughts you would like to add?
I am particularly conscious of having said almost nothing about my present family: Abby Heyman and our son Lazar. Those who know us know how central they are to my life and how much they are in my heart. My three older children have lived a lifetime with me, and we still care deeply about each other—for which I am endlessly grateful. In addition to Lyman, Carlos Sluzki and Dick Auerswald and I have labored together in all kinds of contexts, and now, at the shank-end of life, are bound by deep ties of friendship, as I am with many other valued old friends. New, younger friends bring me much pleasure and stimulation, and I miss and mourn those who have passed on. I hope I can adequately repay them.
I keep thinking of the line from the play Born Yesterday in which the girl says to the boy, "Tell me the story of your life." To which he replies, "Well, you know, it's a long story—and none of it true." It is a long story—but it is true.
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Posted By Barry Jacobs,
Thursday, October 9, 2014
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Dr. Jacob's post is the third in a 3-part series leading up to the 2014 CFHA Debate at the Conference in Washington DC. The debate will present major issues that have yet to be clearly resolved in the professional literature.
What’s wrong with American healthcare can’t be fixed by office redesigns, personal physicians or other hallmarks of the much-hyped, slow-to-deliver Patient-Centered Medical Home (PCMH). Integrated team-based care is nice--especially if you’re a professional who likes chilling with other professionals--but it hasn’t yet bent the cost curve. New quality improvement systems have made scant difference. It’s because what ails American health is bigger and badder.
It’s the social environment, stupid. And it’s our current blinkered hubris to believe that primping the pods and priming the processes of where most of us work—namely, primary care offices—is going to produce revelatory societal change.
|New quality improvement systems have made scant difference |
That conclusion seemed obvious to public health experts Elizabeth H. Bradley and Lauren A. Taylor in their noted 2013 book, The American Health Care Paradox—Why Spending More is Getting Us Less. They pointed out that the evidence that medical homes save healthcare systems money is nebulous and inconsistent. (To wit, see the May 2014 JAMA review by Friedberg of the three-year results of 32 medical homes that were part of the Southeastern Pennsylvania Chronic Care Initiative; no cost savings and only limited improvements in quality.)
Bradley and Taylor posited instead that it is social causes of human misery—e.g., substandard housing, food deserts, lack of transportation, underemployment, chaotic families, dangerous neighborhoods—that are responsible for our middling healthcare outcomes on nearly every measure because the United States earmarks far less money per capita for basic social supports than do other countries. Poor children who don’t eat well will have poor health regardless of how many EMR-templated flow sheets we use. Hobbled, isolated seniors who can’t easily climb stairs to the medicine cabinets where their medications are located won’t benefit much from office-based medication reconciliation.
|Social causes are responsible for our middling healthcare outcomes|
It is daunting to address our culture’s myriad and complicated social problems. It’s much more comfortable and gratifying for healthcare professionals to target what’s within our easy reach. I’ve worked in the same innovative family medicine office in a socioeconomically mixed Philadelphia suburb for 20 years. We became an NCQA-accredited PCMH in 2009—one of the first on the East Coast. (We were one of the 32 practices in the JAMA study.) I’ve been thrilled by the changes that the PCMH has wrought—more integration, more accountability, more thoughtfulness and passion about every aspect of how we provide care. And we have plenty of improvements in diabetic and other medical indices to point to. But we have no proof as yet that the health of our patients is discernibly changed or that their overall healthcare costs are declining.
We Medical Homebodies need to look out the window upon the greater social world with its much more convoluted ways and processes. Better yet, we need to get out of our insular, cherished offices.
Dr. Jeff Brenner, a 2011 CFHA conference plenary speaker and a bonafide healthcare genius (see his 2013 MacArthur Award), has bolted the office to grapple with the social determinants that are the main drivers of exorbitant healthcare costs. His super-utilizer model of interdisciplinary team-based, intensive care coordination does several things that the PCMH does not:
--It focuses precious clinical and case management resources on the highest utilizers of hospital and emergency room services because addressing the biopsychosocial problems of those individuals is the quickest way to lower their utilization and healthcare expenditures.
--It seeks to forge lasting partnerships between facility-based healthcare providers and community-based social service specialists who are in the best position to marshal community resources for our most complicated cases.
--It embraces trauma-informed care, addictions medicine and patient empowerment as foundational tenets of the care it provides.
--And it addresses patients’ needs in all settings where they find themselves—medical offices, hospitals, sub-acute rehabs, at home, and in homeless shelters—because that is the most effective way to establish reliable healing relationships for those tossed about from one healthcare provider and facility to another.
And where is the gold standard research that Brenner’s super-utilizer model really meets the Triple Aim? It’s on its way. Brenner invited researchers from JPLA, a research group from MIT’s economics department, to do an 18-month, randomized control study of his super-utilizer programs in Camden, New Jersey to prove or disprove that they really lower costs. That study will be completed within the coming year.
An earlier study in Camden looked at the top 35 emergency room super-utilizers who rang up $1.2 million per month in charges in that city’s 3 hospitals. After a year of Brenner’s super utilizer team interventions, the costs for those same patients decreased to $531,000 per month.
|Where is the gold standard research that really meets the Triple Aim? |
Brenner’s work has also inspired other health systems to try their hands at super-utilizer care. A group of five of these systems, including my own Crozer-Keystone Health System, formed the South Central Pennsylvania High Utilizer Learning Collaborative 2 years ago and recently pooled their data. According to a white paper which the group will release in October 2014, the group provided super-utilizer care to a combined 138 patients and decreased their inpatient utilization by 34%.
In truth, I believe that we need the home base of a well-oiled PCMH working in close tandem with nimbly mobile super-utilizer teams to cover the office world and the real world. That’s the only way we can provide the flexibility of care to meet the mundane and complex demands of average and outlying patients. That’s the only way the under-achieving PCMH can possibly live up to its fulsome hype.
Barry J. Jacobs, Psy.D., Director of Behavioral Sciences for the Crozer-Keystone Family Medicine Residency in Springfield, PA, has been the lead faculty member for the past 2 years for the 2 super-utilizer programs that are run out of the residency’s primary family medicine office.
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Posted By Jennifer Ayres,
Thursday, October 2, 2014
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Jennifer Ayres, PhD is a graduate of the Behavioral Science Family Systems Education Fellowship program. If you are interested in applying, please click here.
“What do you know about family medicine?”
It was 07:00 PST and I was participating in a phone interview with the program and associate directors of the family medicine residency in Austin. I had woken up two hours earlier to prepare a brief response to that simple question, so that I sounded simultaneously honest and self-assertive.
“Very little. However, I know a lot about mood disorders, trauma, substance abuse, personality disorders, and family therapy. If you’re wanting someone to treat those issues and teach others to do the same, I know how to do that.”
My first day as a behavioral science educator occurred approximately three months later. The first two years were rough, despite excellent support from the program director and my faculty colleagues. The credentialing process took six to eight months. My predecessor was gifted, experienced, and talented in areas that I was (and am) not. People missed him. It took almost a year to grasp that teaching psychology graduate students and family medicine residents necessitated a different skill set. Thus, most of the labor-intensive power point lectures I wrote were ineffective, despite their excellent research reviews and catchy graphics. Some of the residents were thrilled that I was there, others were suspicious of me and my intentions. Support group attendance was abysmal. One of my first resident evaluations included a comment that I had very little to contribute to his/her resident education because I did not understand what being a physician entailed. In the last half of my second year, we had a leadership change after our program director resigned and our associate director assumed leadership.
|The first two years were rough |
Our new program director and I met to discuss if my chosen amount of clinical care (25-30 scheduled patient hours/week) reflected a deeper issue that needed program support. The truth was obvious to both of us. I still thought and functioned as a practicing clinical psychologist because I had not adopted the mindset of a behavioral science educator. We agreed that I would shift to a weekly caseload of 10-15 scheduled patients within six months and that I would seek mentor(s) to help me with this career transition. Several months later, she forwarded me an email about a new fellowship sponsored by the Society of Teachers of Family Medicine (STFM). The primary objective of this yearlong fellowship was to mentor new behavioral science educators. Four years ago, I was accepted into the inaugural class of STFM’s Behavioral Science/Family Systems Educator Fellowship (BFEF).
My favorite program evaluation question is “What do you think you will remember from this experience in five years?” Here is what I remember about the fellowship and the advice I pass along to my colleagues who are new to this field. It is intended particularly for those who have achieved career success in other areas and are making a professional identity shift from that career to behavioral science education.
(1) There are resources available that will make your job easier.
(2) Teaching residents and teaching mental health students require different strategies and techniques.
(3) There is a wonderful conference every September in Chicago (“The Forum”) and most presentations will be applicable to your work. Attend, if possible.
(4) Other people also struggle(d) to integrate behavioral health into programs that are focused on the medicine aspects of teaching family medicine. Support is available. Reach out.
(5) Be patient. It takes at least three years to have a resident cohort that does not remember the program without you.
(6) Some residents will need several years of professional practice before they realize that behavioral health is a necessary component of family medicine. Keep the labor-intensive power points handy because someday they may shift from ineffective to a desired resource.
(7) Apply for the fellowship and join this community. You will not regret it.
|I was struck by how many people wore gold beads ||The first night of the Forum involves an event known as the “Gathering In.” This event brings together new and experienced behavioral science educators to discuss an issue in our field. I attended for the first time during my fellowship year. We participated in an activity that involved wearing different color beads to indicate our number of years in family medicine education. I was struck by how many people wore gold beads, which indicated greater than 25 years of experience in our field. That number seemed unimaginable to someone in the first month of her fourth year and I could not envision myself attending the Forum in 2031 when I would reach gold bead eligibility. Now I predict that several of us from my BFEF cohort will be there, wearing our beads proudly and welcoming new members to their first Forum. |
Jennifer L. Ayres, Ph.D. is the director of behavioral health services at the University of Texas Southwestern Austin Family Medicine Residency Program. She is a clinical psychologist who completed a postdoctoral fellowship in child abuse and trauma. Prior to her current position, she worked as a trauma psychologist in community mental health centers and was an adjunct professor of psychology. Her interests include trauma in primary care, resident self-reflection and support, supervision of psychology students in integrated behavioral healthcare settings, and palliative care/family medicine collaborations.
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Posted By Andrew Pomerantz,
Thursday, September 25, 2014
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Dr. Pomerantz's post is the second in a 3-part series leading up to the 2014 CFHA Debate at the Conference in Washington DC. The debate will present major issues that have yet to be clearly resolved in the professional literature.
Let’s assume that you managed to find the end of the rainbow and found that elusive pot of gold. Being the good PCMH (Patient Centered Medical Home) fanatic that you are, you decide to spend it all on integrating mental health services into your medical home. Alas, you find the price of gold has dropped and all you have is enough to hire one full time therapist, one and a half nurse care managers OR one measly day per week of a psychiatrist. No one in his or her right mind would choose the latter of those three but I am here to argue on behalf of it anyway; for two reasons:
Reason 1: Past is prologue to the present
First, see Dr. Simmons’s recent blog entry arguing that the leader of the PCMH should be a physician. I won’t repeat the points he made about the depth and breadth of training of family physicians, other than to say that psychiatrists have similar training, encompassing psychological, social, biological and spiritual aspects of human health and well-being (OK, I hear you and will withdraw the claim for the generalization about spiritual – I am one of the lucky ones who has worked intensively with clergy for decades).
From the earliest days of healthcare (shamans, etc), organized societies have identified specific individuals as healers, whether by divine choice or by schooling and training. At times they were treated as slaves to the masses but, thankfully, long before I came around, we were getting a much better deal. Like it or not, our culture still carries the belief that we physicians are the only ones with the depth of knowledge to help them attain or maintain health. The buck stops with us. Do I like that? Not particularly. I’d much rather share the burden but, when it comes to societal norms, third party reimbursement or medicolegal liability, we are “it.”
|Without a psychiatrist, patient outcomes are at risk |
Randomized clinical trials (such as IMPACT and RESPECT) using nurse care managers have clearly demonstrated their value in achieving the triple aim. Patient outcomes are improved, patients like the care and costs are reduced. But care management protocols require a supervising (not consulting) psychiatrist to review cases, make recommendations, do some troubleshooting and identify patients who need more than telephone care. Without a psychiatrist in the mix, costs are still reduced and patients might be happy but outcomes are at risk. Better to have a psychiatrist working in the PCMH and have him or her train primary care nurses to run the protocols. PC nurses often do much better than mental health nurses because they don’t digress into therapy but stick to the protocols.
As for therapists, first let me say that my closest professional colleagues are therapists. Some of my friends as well, though I prefer being around people who don’t do anything like what I do. They are great but usually lack the biological understanding of the mitochondria gone wrong or the demyelination progressing or any one of a number of physiological perturbations that often masquerade as troubles needing therapy. As a consultation psychiatrist I’ve seen too many patients getting treated for panic disorder while their thyroid goes unchecked or patients with early multiple sclerosis being treated for conversion reactions. Behavioral presentations of serious illnesses or drug interactions often get in the way of the PCP evaluation and it’s up to the psychiatrist to sort it all out. Someone has to be looking at the cases before jumping into therapy.
Reason 2: Odysseus
No, not Oedipus. Odysseus, husband of Penelope, son of Laertes and Anticlea and so on. Odysseus faked mental illness in a futile attempt to avoid winding up in what became the Trojan War. Once in the war, he is credited with coming up with the idea of the Trojan Horse. The Greeks presented this hollow wooden horse filled with soldiers and led by a front man to the Trojans and the rest is history (truth be told I have a tough time distinguishing myth from history but after a certain period of time it doesn’t matter). “Beware of Greeks bearing gifts” is a common phrase even today.
Why the digression? Let’s say everyone follows my recommendation in this blog. When all that we are doing to improve healthcare becomes ancient history that one-day-a-week psychiatrist will be known as our front person for a horseload of psychologists, social workers, peers, nurses and others. The psychiatrist, while often maligned by some medical colleagues, is still “one of us” when viewed by the PCP. The MD after the name immediately generates a trust that PHDs, RNs, LPNs, MSWs and others often spend years trying to establish. Get me in the door and after I say for the hundredth time “need someone else to help get that A1C down and get the pain under control,” they’ll be begging for the rest of the team.
Dr. Pomerantz is the National Mental Health Integrated Care director for the Veterans Health Administration and Associate Professor at the Geisel School of Medicine at Dartmouth (which he prefers to think of as the Dr. Seuss School of Medicine). He spent the first 12 years of his career as a PCP carrying his little black bag around the hills of central Vermont before training in psychiatry in hopes that it would make him a better PCP. Unfortunately, he never went back, though he works virtually from an office just down the street from his former practice. If he ever gets broadband at home, he’ll work from where he belongs. He still has his little black bag, just in case.
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Posted By Christina L. Vair,
Tuesday, September 23, 2014
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Christina Vair, PhD, is the 2013 CFHA Fellowship Award recipient. Below is her reflection on her research project.
As the old saying goes, “hindsight is 20/20.”
With the 2014 CFHA conference nearly upon us, I cannot help but think back on last year’s conference, in particular, my receipt of the 2013 CFHA Fellowship Award. In doing so, I have found that oft used phrase referenced above coming to mind regularly. Looking back over the course of this past year, I appreciate how this particular project was inspired by and, in many ways encapsulates, my own professional journey. Though I am certainly excited to present the findings of my study on advanced psychology trainees’ perspectives on preparation for practice in integrated care settings, this forum grants me the unique opportunity to reflect on the process of conducting this research, rather than just the outcome. Through undertaking this project, I have been provided with an opportunity to reflect on my own learning over the last several years and contemplate where I’m headed in the future.
My interest in developing an academic understanding of the primary care psychology trainee perspective is rooted in my own personal training experiences. I first stumbled into the world of integrated care during my last year of graduate school. Though I was quite naïve to the concept of integrated care at that time, I was none-the-less tasked with providing brief assessment and treatment to older adults attending a day heath care program. What might have simply been a one-time, “been there done that” training experience touched off a desire to develop a career as a psychologist in integrated care. This was the first time in my training as a psychologist that I felt as if things really “clicked” for me. The whole person, patient-centered approach to care, the consideration of the interrelationship between mental and physical health, and the dynamic, team-based approach resonated with me on many levels.
From that first experience, I was hooked. I had found my professional “home.” Next came an internship with emphasis in behavioral medicine, then a postdoctoral fellowship focused on primary care-mental health integration with the Department of Veterans Affairs Center for Integrated Healthcare. These increasingly focused opportunities further opened doors that solidified my dedication to integrated care, and in turn, my desire to learn more about what other trainees like me were experiencing in their journeys into primary care psychology. As the intensity of my training increased, I found myself regularly wondering how other trainees found the path to primary care psychology, whether they too intended a career in this field, and what they needed to succeed in this pursuit. These questions set the stage for my research proposal to investigate the trainee perspective, particularly as a review of the literature on training models for behavioral health providers in integrated care appeared to lack this consideration.
|I found myself thinking, "what if I knew then what I know now?" |
Flash forward to a year later. A survey was designed, distributed nationally, piloted along with the Primary Care Behavioral Health Provider Adherence Questionnaire (PPAQ)1, a recently developed measure of fidelity to model adherent behaviors in providing mental and behavioral health care in integrated care settings. Responses from across the country trickled in, and a data set was born. Analyses were undertaken, and various themes emerged. All the while, with each iterative step, I found myself learning new and different things. I found myself thinking often about my own professional path, and wondering, “what if I knew then what I know now?”
One particularly salient response that I found myself pondering in relation to that question was a desire to learn to embrace the inherent challenge of having dual identities. One particular duality that sprang to mind was how to balance being both a clinician and researcher. Though I had been training as a “scientist-practitioner” since graduate school, conducting this study was truly the first time that I authentically felt like a “scientist” thus far in my career. Within scientist-practitioner programs, students are theoretically taught to equally value clinical practice and research, and to appreciate the reciprocal and potentially mutually beneficial relationship between the two. Though internship had helped me feel as if I had developed solid clinical “muscle,” my sense of identity as a scientist was comparatively puny. I found that I had learned to “walk the walk” as a clinician, but was not yet comfortable in my ability to “talk the talk” of a clinical scientist.
Having had several rich opportunities to explore assorted supportive roles on research teams prior, this project represented my first foray into the role of a principal investigator. Up until this point, I had learned the basics of integrated care in a mostly experiential manner, and found my knowledge wanting in regard to the theory behind the practice. Delving headlong into the scholarly literature on training models, core educational components, and the development of competencies for practice in primary care psychology provided a solid foundation for learning the language of integrated care. Understanding and adopting this lexicon has facilitated my ability to not only articulate more thoughtfully and concisely what it is I “do” as a psychologist in primary care, but has also helped me define where I see myself going in the future. Further, exploring and engaging with this literature has also helped me develop an awareness of the gaps in my own training thus far, and presented the opportunity to develop goals to address the areas in which my own competence lags.
|This lexicon helped me define where I see myself in the future |
So where do I go from here? How do I use what I have learned from this experience to move forward, to continue to develop as an integrated scientist and clinician, and help shape the field of primary care psychology? Research is of little use if it’s not disseminated. Then of course every good study has a “Future Directions” section.
As another old saying goes, “the journey of a thousand miles begins with a single step.”
1. Beehler, G. P., Funderburk, J. S., Possemato, K., & Vair, C. L. (2013). Developing a measure of provider adherence to improve the implementation of behavioral health services in primary care: A Delphi study. Implementation Science, 8(19). doi:10.1186/1748-5908-8-19
Christina L. Vair, PhD is a licensed clinical psychologist with the Center for Integrated Healthcare (CIH) at the VA Western New York Healthcare System (VAWNYHCS) in Buffalo, NY. Prior to her current role as a clinical researcher, she completed a two-year postdoctoral fellowship with the VA Advanced Fellowship Program in Mental Illness Research and Treatment (MIRECC) with the CIH that focused on improving the health of veterans through enhancing primary care-mental health integration. During her post-doc and internship with the VAWNYHCS, Dr. Vair provided mental and behavioral health services in primary care, chronic pain management, behavioral medicine, and long-term care. Dr. Vair earned both her MA and PhD in clinical psychology with emphasis in Aging and Geropsychology from the University of Colorado, Colorado Springs. Her research interests including exploring mental health concerns of the aging population within the primary care (PC) medical setting, dementia screening and treatment in PC, and improving the implementation of primary care-mental health integration through provider training, fidelity assessment, and the utilization of measurement in guiding care.
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Posted By Paul Simmons,
Thursday, September 11, 2014
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Dr Simmons’s post is the first in a 3-part series leading up to the 2014 CFHA Debate at the Conference in Washington DC. The debate will present major issues that have yet to be clearly resolved in the professional literature. The question for Dr Simmons’s debate with Dr Susan McDaniel will be “Does the PCMH require that a physician be the team leader?”
The patient-centered medical home (PCMH) is all the rage nowadays, despite recent evidence that the “team-based” model of primary care delivery does not lower service use or total costs, nor does it improve care quality significantly1. Although populated by highly-educated graduate degree holders who should probably know better, PCMH and collaborative care advocacy is often an exercise in cart-before-horse confirmation bias. Advocates want collaborative care teams to work, so they design, execute and publish studies that make them look like they work. Where is the null hypothesis? Where is the study that seeks to show that team-based collaborative care does not work and, much to the researchers’ collective surprise, it actually does? I fear that we’d still be bleeding people if real medical research were done this way. One marvels that a negative study like the one above was published!
Now, some PCMH true believers are advocating that someone, anyone, other than physicians should lead the teams on which the collaborative care approach is based. Nurse practitioners, physician assistants, behavioral health practitioners...one assumes physical therapists, chiropractors and homeopaths are not far behind to accede to the throne. This democratic, egalitarian idea is bad for primary care medicine and for patients. Below, I will explain why.
|This democratic, egalitarian idea is bad for primary care medicine and for patients |
But first, an analogy: I boarded a flight the other day (of course airline analogies are required - all the quality improvement types are in love with medicine-as-airline-industry metaphors) on my way to yet another PCMH conference. As I crossed the threshold, I was greeted by a chipper flight attendant. Looking to my left through the cockpit door, I saw the pilot and co-pilot going through their preflight checklist. About a half hour into the flight, a plume of black smoke emerged from the right side turbine. I looked worriedly from my window up toward the cockpit, where the pilot, co-pilot and two flight attendants were having a team meeting. I could overhear bits of their discussion. To my shock, the pilot and co-pilot were asking one of the flight attendants what they should do! Not usually one to speak up, I raised my trembling hand and politely interrupted, “Er, Captain - shouldn’t you be flying the plane? I mean, you’ve got years of experience, hundreds of hours in simulators dealing with problems like this, and the flight attendant...well, doesn’t (all due respect to him).” The pilot held his hand up to stop me. “Sir, he said, “this is our new passenger-centered, team-based model of flight, and the flight attendant is the team leader today.”
Obviously, this is a ridiculous scenario. Pilots on airliners are in charge because they have the experience, training and expertise - they know the most about the plane, how it works, and how problems should be managed. To switch analogies, the military has not historically advocated team-based operations led by junior enlisted men, and there are very good reasons for this. When lives are on the line and important decisions need to be made, the person with the most experience, training and expertise should make those decisions. Perhaps collaborative care advocates have forgotten that patients’ lives and health are in our hands - perhaps medical care in modern America doesn’t feel like a life-and-death, serious responsibility - but it is. It should be approached with the moral weight it deserves, not as an opportunity for committee-based social experimentation meant, one might suppose, to inflate the perceived importance of certain professional groups.
The possession of a medical doctorate, in the United States, certifies that its holder had completed a certain depth and breadth of training, regardless of what state or graduate school awarded the doctorate. Family physicians (to focus on one specialty) complete 11 years and 21,000 hours of standardized training regulated by one licensing body, the American Board of Family Medicine. Furthermore, though it may seem anachronistic and quaint to cynics, physicians take an oath that has historically defined our profession: to put patient interests always above our own. This oath gives physicians a moral burden of responsibility not shared by others. The ultimate responsibility for our patients’ well-being, like the well-being of troops under a general’s command, falls to us and cannot be transferred to other “team members” when convenient.
However, if advocates of team-based, collaborative models want to stand on a democratic approach, then they should listen to what patients want: “72 percent of American adults prefer physicians to non-physicians when it comes to health care, 90 percent of adults would choose a physician to lead their ‘ideal medical team’ when given the choice, and by a greater than two-to-one margin, adults see physicians and family physicians as more knowledgeable, experienced, trusted and up-to-date on medical advances than non-physicians.”2
|We should listen to what patients want |
So other clinicians want to lead the collaborative care team? This perspective suggests not only a low opinion of physicians, our professionalism and our training, but a low opinion of what it means to work in a team. Is there not nobility and usefulness in performing one’s vital, though limited, role as part of the patient’s care team? Is being designated the “leader” the only viable way to make oneself indispensable and, when it comes down to it, to get paid?
If so, then I have little confidence, as American health care flies toward the mountainside with engines failing, that those who are least qualified to fly the plane will get us safely back home. All parts of the crew are valuable, whether we’re talking air travel or medical care, but not everyone is equally qualified to lead.
1. Friedberg, Mark W., et al. Association between participation in a multipayer medical home intervention and changes in quality, utilization, and costs of care. JAMA 311.8 (2014): 815-825. doi:10.1001/jama.2014.353
2. AAFP 2013 Dec 18, “Americans Want Physicians Handling Their Health Care”. Retrieved from http://www.aafp.org/news/practice-professional-issues/20131218ipsossurvey.html
Dr. Simmons is a faculty physician at St. Mary's Family Medicine Residency. He received his medical doctorate from the University of Colorado, and completed his residency in family medicine in 2002. He practiced full-spectrum family medicine in rural communities in Wisconsin and Colorado before joining the St. Mary's faculty in 2010. He is an advocate of evidence-based medical practice, a merciless critic of wishful thinking, an armchair philosopher, and an avid spoiler of domesticated animals.
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Posted By Jeff Ring,
Thursday, September 4, 2014
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The floor of this cozy office that has served as my professional home for the past nineteen years is littered with folders, charts, articles and books. I pick up a yellowed transparency from my early years of teaching and hold it up to the light. “B is for Background; A is for Affect…”
I catch my own reflection on the shiny plastic…an uncanny vision of the teacher I am today…thinner hair…graying temples. Wiser? Yes. Confident? Thank goodness! I glimpse how far I have evolved from the naïve, tender behavioral scientist who began his integrative care and teaching journey here in 1995, at that time with ‘high tech transparencies!’
Throughout this process, I have been reflecting on an amazing human energetic pull which mystically draws us to a certain profession or avocation, as it has drawn me to collaborative care with physicians. “Calling” is a remarkable human phenomenon. It consists of heeding an internal voice…a tugging on the soul…an illuminated pathway on an otherwise gray and muddled map of life.
When my parents divorced and I felt as if the entire world had broken apart, a therapist provided me with a caring vision of a way forward. She also helped me cope with a mother who was navigating several chronic medical conditions. Later in middle school I realized that learning and speaking Spanish came easily to me. These three threads wove together in a vision of someday providing precious integrated mental health services in Spanish to the underserved Latino/a community of my native Los Angeles.
|"Calling" is a remarkable human phenomenon ||How many people can say that they have lived out their calling as I have, with deep fulfillment, for almost twenty years? I am grateful for the opportunity to serve. I am grateful for how much I have grown in treating patients and in shepherding residents to bloom into exquisite healers (mostly in underserved communities!). I am grateful for program directors and colleagues who have patiently mentored me along the path to become the teacher I am today. I am grateful for the enthusiastic welcoming of my ideas, input and interventions in the shared mission of caring for vulnerable patients with residents on a steep, exhausting learning curve. I pack to leave with great ambivalence and a heavy heart. |
My days are now mostly filled with tearful goodbyes. Moreover, my days are filled with direct, honest conversations about my impact on others and their impact on me. These exchanges happen with residents, patients and colleagues. I swim daily in the humble waters of sadness, appreciation, disappointment, joy and spiny questions about my decision to leave.
Very soon, someone new will sit at this desk, and eventually will gather the courage to walk down the hall and dive into collaborative teams with medical colleagues and learners. What are the pearls of collaborative, integrated care that I carry with me into my next endeavor and which I happily share with my replacement? These include: Gifts, Curiosity, Reflection, and…of course…Transparency.
My mother was a gifted and creative special education teacher, and I have taken her dedication to learning into my work. I hunger to know more and to understand others more deeply. Each patient provides a new challenge of how to help, and how to discover the tools that empower us as a team – physician and psychologist – to bring relief, support, acceptance and change. The joy of working in a collaborative learning relationship is the same joy of attending college as a learner...that of uncertainty, investigation and discovery. To work in a situation where my psychological curiosities interplay with medical colleague’s medical curiosities is to throw rocket fuel on both the learning process as well as on patient care. Diversity of perspective is precisely the propellant that I have found so intellectually invigorating.
James Hillman, the gifted Jungian Analyst, wrote that experience does not become meaningful without essential reflection. Our physician colleagues are incredibly busy, battered by challenging patients, painful narratives, overwhelming documentation demands, and personal burnout potential. A unique role for the Behavioralist is providing a place and space for reflection on one’s work, and self-reflection on one’s internal experience. Moreover, we serve as reminders of, and cheerleaders for, a regular mindful experience of inner reflection. My goal has always been to train outstanding physicians who have a long shelf life, protected from the caregiver burnout inherent in this work. The encouragement of and modeling of reflective practice is an essential nutrient toward this goal, and a rich foundation of the psychological contribution to enhancing care.
|Reflective practice is an essential nutrient and a rich foundation |
Truth be told, there are things that we will never fully comprehend: A mysterious fetal demise. A tumor that disappears without treatment. An unexpected death in a seemingly healthy youth outside of the expected lifecycle. The culture of medicine seeks to determine an answer for every clinical presentation. This attitude is inculcated in blazing Socratic pimping on medical rounds, and boils in the hearts of dedicated doctors who desperately prescribe the optimal cure. The Behavioral Scientist often serves that essential ethical role of reminding colleagues of what cannot be known. Leah Hager Cohen’s aptly titled book ‘I Don’t Know: In Praise of Admitting Ignorance’ reminds us that it may not always be optimal to pretend an understanding that we do not possess. It may be unfair to wear such a mask in front of patients, and we may pay a greater personal price than we realize when we do so. Might there not be value in joining the other in a shared experience of ambiguity. I have strived to work in an honest, transparent way, and to hold the same expectation for honest transparency in return from colleagues and in their work with patients.
Almost twenty years later, ‘B’ still stands for Background and ‘A’ still stands for Affect, even if they now twirl with graceful entrances on Power Point slides or swoop through a Prezi forest! I am grateful for my nineteen years in collaborative medical care and education, and for all the gifts I have received. I am grateful to CFHA for this invitation to transparent reflection in preparing this blog, allowing me the opportunity to move my own wealth of experience into deeper personal meaning.
What’s next for me? I better take a deep breath, bend down, and get this office floor cleaned up to make way for the next behaviorist to take my place. I smile at the remarkable journey that lies ahead for that fortunate individual, and I look back wistfully at a time long ago when I first arrived.
Jeffrey M. Ring, Ph.D. has served as Director of Behavioral Sciences and Cultural Medicine for the past nineteen years at the White Memorial Family Medicine Residency Program in the underserved community of Boyle Heights in Los Angeles. He is Clinical Professor of Family Medicine at the Keck School of Medicine at the University of Southern California. Dr. Ring is the first author of Curriculum for Culturally Responsive Health Care: The Step-by-Step Guide for Cultural Competency Training (Radcliffe Oxford, 2008). In October, he begins as a Principal Consultant for Health Management Associates, assisting organizations in enhanced delivery of integrated health and behavioral care to vulnerable populations.
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