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Caring For Our Mothers: A Plea for Action

Posted By Cassidy Freitas, Thursday, February 7, 2013

"I just want to sleep…I just want to go rent a hotel room, and go to sleep.”

"I’m not strong enough for this....”

"I look at my twins and I don’t know them, shouldn’t I feel differently?”

"I’ve never felt so dark and low. Sometimes I wonder if they’d all be better off without me.”

"I can’t stop worrying, I can’t even bathe him. What if I drowned him…”

"I wouldn’t have said anything if my doctor hadn’t asked…”

Fluctuating hormones. Little or no sleep. A fledgling maternal identity filled with self-doubt. These are the experiences of almost all new mothers, not just the ones who experience a Postpartum Mood and Anxiety Disorder (PMAD). Typical statistics regarding the prevalence of PMADs vary anywhere from 10 to 20%, but I don’t believe they capture the full picture. What would happen if we accounted for those mothers that may not meet DSM criteria? What about those mothers that never come forward due to shame or fear? What about those mothers who experience Psychosis? Where do we account for them?

According to the American Pregnancy Association, approximately 6 million pregnancies occur in the U.S. each year (I report the number of pregnancies rather than the number of live births because every postpartum mother is at risk for PMADs despite the outcome of her pregnancy.) While postpartum mental health issues are far more common than gestational diabetes, every woman will get screened for diabetes during her pregnancy and not nearly as many new mothers will get screened for postpartum mental health issues.
Postpartum Health Alliance logo
for Integrated
Care Settings

The University of California San Diego’s (UCSD) Department of Family Medicine has come a long way in addressing these issues. With trailblazers like Dr. Katie Hirst (who teamed up with LMFT Amber Rukaj to found the Maternal Mental Health Clinic at UCSD in 2007), we have implemented screening, educational resources, and interventions that are helping postpartum mothers and their providers. As a Medical Family Therapist Intern at this site, I’ve had the special privilege of working with primary care physicians and psychiatrists who believe in what my presence can offer which affords me the opportunity to work with women and their families during pregnancy, postpartum, and beyond.

While changes in the treatment of maternal/pregnancy/postpartum, etc. are called for, it is also important to consider the financial ramifications of these pressing issues. The U.S. has not really tried to quantify the cost of postpartum mental health disorders, but Australia has. Their nationwide organization Post and Antenatal Depression Association found that perinatal depression alone will cost them an estimated $433 million dollars in 2012. This number includes health care costs, lost productivity and foregone tax. Let’s also note that Australia has a population of 22.6 million people, and we have 311.6 million. Do the math. Not caring for our mothers is costing us, big time.

Whether it’s due to stigma, limited skills and training, a fast paced schedule, or lack of resources, not enough providers are talking to mothers about postpartum mental health risks and disorders. In order to address these important issues, I suggest a collaborative approach between physicians and mental health clinicians to increase detection and treatment.

If you are looking to help this population, a way to begin coordination in this area is to get in contact with your local postpartum health organization. In San Diego we have the Postpartum Health Alliance, an organization whose entire mission is to connect mothers and providers to each other and to the vast array of resources that exist out there. I’ve been lucky enough to serve as one of their warmline volunteers, and through the process have run into some amazing resources that you can find at the bottom of this post.

We know that untreated postpartum mental health issues have long term costs for mothers, their children, and their families. Whether it’s the personal or financial costs that make you cringe, that doesn’t matter to me. What matters to me is that we do something. Let’s amplify the voices of our hurting mothers. Let’s tell them that they’re not alone, that we care, and that we are taking action.


Cassidy Freitas is a Marriage and Family Therapy doctoral student at Loma Linda University as well as an AAMFT Minority Fellow. Along with her PhD she is pursuing a certificate in Medical Family therapy offered by the doctoral program at Loma Linda. She is currently working at the UCSD Department of Family and Preventive Medicine as an MFT Intern.

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Come Disrupt the Status Quo at CFHA 2013

Posted By Laurie Ivey, Friday, February 1, 2013

Disrupting Status Quo

Hi CFHA community,


It’s that time of year again—time for you to help us create the best CFHA conference yet! The conference dates are October 10-12, 2013 in Broomfield, Colorado. Disrupting Status Quo is our theme and we are ready to shake things up. I am one of the co-chairs of the CFHA 2013 conference and with Amy Davis, am leading the program committee to develop an exciting curriculum for presentations next fall. I have attended many CFHA conferences and find them inspiring. I helped out with the planning process when CFHA came to Denver in 2008 and was excited to do so again when Randall Reitz approached me to be a part of the Denver planning team.


We have spent a lot of time as a group talking about how to energize the 2013 conference and how to breathe some fresh air into our days together next fall. We chose the theme "Disrupting Status Quo” because we wanted to highlight the fact that it is time to bring new energy to our conference, particularly for the long-time attendees. We are all facing many disruptions in the workplace, from the institution of electronic health records, the changing demands resulting from the patient centered medical home movement, and from changes imposed by health care reform. Continuing to weave integrated care into this disruption is both challenging and exciting as we find successes and improvements in our delivery systems. Disruption is the norm for many of us right now and we wanted to capitalize on the notion and use it to give momentum to CFHA 2013.


The good news about our conference location is that you’ll be breathing in some good old Colorado Mountain air, as we have chosen a beautiful location in the foothills of Boulder. We are out of the city bustle this year and in the relaxing open space and sky of Broomfield, Colorado, with spectacular views of the Flat Irons of Boulder. The resort-style hotel is situated between Boulder and Denver for those of you who would like to explore both places. We plan to provide transportation to Boulder by bus for our traditional dine-around night. Our hotel is spectacular with outdoor heated pools and hot tubs. There is a beautiful outdoor reception space in which we will showcase a fun, beer tasting fund-raiser to benefit the CFHA scholarship program—Colorado style.


We need your help with fresh, new presentations. Consider being creative this year and bring us new ideas and new presentation formats. Let’s get the audience engaged. We need a few basic presentation that educate new attendees about Integrated care 101, but otherwise, we have an audience of repeating attendees who needs to leave refreshed and ready to go home and shake up their routines and practices with new thoughts about moving integration forward and through the twists and turns of the changing climate of health care. We have also had requests for excellent presentations on clinical topics.

The call for presentations just opened and ends March 15, 2013. So, click here and start typing up your best ideas. We look forward to reading them!


Laurie Ivey
Laurie Ivey is the Director of Behavioral Health for Swedish Family Medicine Residency and The Colorado Health Foundation. She enjoys teaching both family medicine residents and post-doctoral fellows to work and thrive in the integrated primary care environment. She lives in Denver Colorado with her partner and twin sons.

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Home Grown Providers in Rural Integrated Care: The Web of Interconnectedness

Posted By Catherine Jones-Hazledine, Thursday, January 31, 2013
Updated: Monday, February 4, 2013
Rural blog series logo
Cate's blog is the
last post in a
month-long series
on integrated
care in rural settings.

Read the entire
series here.


Much has been written about the advantages of integrated or co-located behavioral health care in rural primary care settings. At this point, most in the field understand the practical benefits of this model, especially in our most rural and underserved areas. There is a growing understanding, as well, that there are many factors to consider in successfully implementing this model. Dr. Joe Evans and Dr. Rachel Valleley wrote very eloquently about some of these in a blog post earlier this month. And they would know. Over the years, they have worked to establish these services in many settings across our 99% rural, and 87% underserved state of Nebraska. I would like to think of myself as one of their success stories.

Almost 9 years ago now, after working with the Munroe-Meyer Institute Rural Outreach Program for two years as an intern, and obtaining my Ph.D. in Psychology, I made the decision to return to my own home area of the state. Dr. Joe Evans and Dr. Jodi Polaha were instrumental in helping make that happen. We originally established three integrated behavioral health clinics within primary care settings in small, isolated communities along Hwy 20 in the far northwestern corner of Nebraska. Our services were well received by the local family physicians and over the next few years the three clinics grew to five, and ultimately turned into a privately-owned network of clinics called Western Nebraska Behavioral Health.

Over these years, as well, we began to take on practicum students and interns from a small nearby college. These students were mostly Nebraska natives, many from the immediate area, who were training to receive a Master’s Degree in Community Counseling. Many of them ended up staying on with the clinic network after graduation, with the result that several of our clinicians, myself included, now find ourselves working in our home communities – a fact that has proven to add many layers to the collaborative care/integrative care model.

How many Master’s or
Ph.D. level clinicians
are dying to move to
Cody, Nebraska,
population 155?

One of the challenges of rural practice highlighted in another blog earlier this month (by Alysia Hoover-Thompson and Natasha Gouge) is the amount of turnover among those who decide to go into the area of rural integrated care. It is an unfortunate fact that many initial placements of clinicians into rural areas across the nation do not last much past the training phase or, as the authors indicated, the loan repayment phase. This obviously happens for many reasons: family obligations, spousal careers, health issues, financial concerns, lack of resources and support. One fact that contributes to the problem, I think, is that most of our training facilities for clinicians – especially doctoral level clinicians – exist in urban (or at least more urban) areas. As a result, individuals can be identified who express rural interest or commitment, but many of them are not actually from, or familiar with, truly rural settings. Even those who are from rural settings end up living for an extended period in the urban area to complete their training, and develop ties there that make it more difficult to jump out to a rural setting when the time comes.

Our real-life rural settings have many advantages: clean air, simplicity of life, wide-open spaces, good people. They also, however, have many peculiarities that make them challenging for those not accustomed to the lifestyle: lack of resources, lack of anonymity and privacy, distrust of outsiders, sometimes a slowness to open to new ideas, etc. Rural individuals exist in a web of interconnectedness that those from larger areas are often simply uncomfortable with. I once attended a meeting of psychologists at which a provider in a larger community was telling about the awkwardness of going to a home improvement store on a weekend, dressed casually and unshowered, only to run into a client. This was a rare event to hear about for many of the providers at the meeting, but our contingent was struck by surprise that it had only happened once to that provider. In our own rural area, it is the case that we rarely leave our homes without seeing a client or member of a client family

We see our clients outside of session more here because the population and communities are so small, and this issue would occur for us regardless of where we were from. Being originally from the area ourselves means that we are also more likely to know our clients or patients before they come to see us, or have some other level of connection to them. This web of connections is not limited to client connections, either.

Several years ago, I was contacted by a local woman who was in the process of getting her degree in community counseling (from the small local college I mentioned) and needed a practicum placement. I recalled that many years before that, when I was a middle school student and she was a precocious preschooler, our families had been next door neighbors. Further, her father (now retired) was my dentist, her older brother and my younger brother were very good friends in high school, her sister-in-law ran a local daycare that my children had attended as infants, and her nephews were in the same grade and school as my own children. None of these connections were close enough that it felt problematic to train the student, and few other options were available to her, and so she ultimately did a practicum placement, a pre-master’s internship, and an advanced training placement to accrue licensing hours within our clinic. Further, she continues on with us to this day - providing services in a clinic just blocks from where she used to run through my yard as a preschooler, pretending to be a horse. Having so many connections locally, she has no plans of living anywhere else. She is also well versed in the challenges of rural life, and very comfortable with that web of interconnectedness.

This clinician’s story is a common one in our clinic at this point, and it definitely raises issues to consider. It frequently occurs that our collaborating physicians refer a patient to us that one or more of our clinicians has some other connection (current or historical) to. This requires careful thought and supervision about the closeness of the connection, and any way in which it might be ethically problematic. A large number of our referrals end up being cases that, were we in an urban area, would be referred to another provider due to the additional connection. There is a fabulous model that we often refer to by Kitchener (1988) that helps us determine which connections are too close to be ethical for us to work with. This is an ongoing area of thoughtfulness in our work.

Some consider these multiple levels of connectedness to be a serious drawback in rural work. I remember hearing in graduate school the recommendation that if you were to work in a rural setting you should not live in the same community. Or, if you did live there, you should refrain from participating in local life (communities, organizations, etc). Being from a rural area myself, this struck me as silly. I remember thinking about most of my rural neighbors growing up, and realizing how they would perceive someone who kept themselves so distant from the community they meant to serve. Now, being in practice here for several years, I can tell you anecdotally that it is often the case that individuals come to see us BECAUSE we are known to them. There are many conservative rural residents who would be unlikely to seek "behavioral health” or "mental health” services (even at their physician’s recommendation) but who end up following through because the identified clinician is "Gene and Carol’s daughter” or was in their brother’s graduating class. We are a known, and therefore often a more trusted, quantity. Because they exist all the time within a closer web of connections, our rural clients are also just naturally more comfortable with the additional connections and casual interactions that occur outside of clinic.

Summarizing all of this thought, then, it seems that another key to the successful establishment of integrated behavioral health in rural settings involves greater recruitment of local individuals, as well as training of these individuals from the beginning within the rural settings they will eventually practice in. Not only does this seem likely to reduce turn-over and offer better preparation for real-life work scenarios, but it also provides additional job opportunities for rural individuals – thereby reducing the problems of de-population, unemployment and poverty in rural settings.

So positive have our experiences been of training locally raised clinicians, that we have recently taken things a step farther. Working with support from BHECN (the Behavioral Health Education Center of Nebraska) we have designed a program to help identify and mentor rural high school students in particularly isolated areas who have an interest in behavioral health careers. By catching them early in their education, we hope to help provide a pathway for them to access the training to eventually provide much-needed services in their home communities –spots that would have considerable difficulty drawing trained providers. How many Master’s or Ph.D. level clinicians, after all, are dying to move to Cody, Nebraska, population 155? It will be some time before we have available data to tell how successful this approach is, but we are excited to find out!


Kitchener, K.S. (1988). Dual role relationships: What makes them so problematic? Journal of Counseling and Development, 67, 217 – 221.

Dr. Catherine Jones-Hazledine is a psychologist and the owner of Western Nebraska Behavioral Health, PC, a network of five integrated behavioral health clinics in rural western Nebraska which are affiliated sites with the University of Nebraska Medical Center’s Munroe-Meyer Institute Rural Outreach Program. She is also adjunct faculty with Chadron State College, in Chadron, Nebraska.


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Integrated Care in Rural Communities: A Psychologist’s Perspective

Posted By James L. Werth, Thursday, January 24, 2013
Rural blog series logo
James's blog is the
fourth post in a
month-long series
on integrated
care in rural settings.

Read the entire
series here.

As the Director of a doctoral program in Counseling Psychology since 2007, I have attempted to keep up with the literature, anecdotal reports, and personal opinions regarding the future of psychology as a profession so that I could help our students be ready when they graduate. I started hearing about "integrated care” almost immediately upon assuming my position but it was not until I served on the American Psychological Association's Committee on Rural Health that I fully appreciated the importance of integrated care for the field, especially for practitioners who would be working in rural areas. My colleagues helped me understand the value of integrated care for the patient, family, medical providers, and psychologists and other behavioral health professionals. As a result, I became convinced that we had to try to provide training opportunities in integrated care settings for our students.

   Fortunately, such an opportunity arose when the Executive Director of two of the local free medical clinics contacted me and asked if we had any students who would want to work alongside their providers who struggled with some of the psychological issues presented by patients. At about the same time I was contacted by the Development Director of a federally qualified health center who wanted to apply for a Rural Workforce Development Grant and hoped to use the grant to expand their provision of behavioral health services.  
These two collaborative efforts have led to a popular advanced practicum placement site at the free clinic and an internship site at the FQHC. Even more, these sites are helping to provide training and experience that our students will be able to take with them as they move into their first jobs while also filling some significant needs in these Health Professional Shortage Areas.

For those of us in rural
areas, the challenge may
especially important to
meet because of the
difficulty recruiting and
retaining professionals
in these communities.

Based on the facts that one of the American Psychological Association's three strategic goals is to expand psychology's role in healthcare, that the Affordable Care Act promotes interprofessional care, and that insurance payments for psychological services are falling in many locations, I am convinced that psychology graduate students must receive the training necessary to work in integrated care settings. I am fully aware of the challenges associated with setting up these types of training sites but I believe faculty will need to be proactive in finding or creating sites in order to ensure their graduates will be employable. This may mean that faculty members will have to go into the community and provide supervision for students at sites that do not have psychologists or other mental health professionals on site. We need to expand the types of sites that we have considered for practicum and internship to include physician offices, emergency rooms, and university health centers.

For those of us in rural areas, the challenge may be especially important to meet because of the difficulty recruiting and retaining professionals in these communities. Even with the National Health Service Corps loan repayment program available for psychologists and other providers, many outlying areas do not have access to sufficient numbers of mental health professionals. However, if we can get trainees into these areas and provide them with learning opportunities, especially on internship, we have a greater chance that they will stay. Setting up a private practice in a rural area may not be feasible but continuing to work at a FQHC or in a community mental health center that has begun to recruit medical personnel or at a VA's community-based outpatient clinic could provide employment options.

On a related note, I have noticed that in our FQHC training sites, where both psychology and social work interns have begun providing primary care-based services, we have uncovered other needs in the community. The most obvious ones are referrals for traditional mental health services and psychological assessment. Our behavioral health providers in these rural clinics have ended up having to move away from the typical brief behavioral approach to more of a blended model where they also provide longer-term sessions on a weekly basis because there are no referral options, or at least no options without a several month waitlist. The need for assessment, especially neuropsychological assessment, is even greater. Without university-based training clinics that operate on sliding scales and sometimes waive fees entirely, many people would not be able to get the testing needed for appropriate care. Thus, appropriately trained behavioral health professionals could collaborate with clinics to provide these additional services.

One final area that has been increasingly on my mind as I have thought about training psychology graduate students for the future and about the needs of rural communities is the contentious matter of prescription privileges for psychologists. The military and Public Health Service as well as the states of New Mexico and Louisiana allow properly trained psychologists to prescribe (or unprescribe) psychotropic medications. This is a hotly contested issue and until I started practicing in a rural area where there are virtually no psychiatrists or psychiatric nurse practitioners, I did not think I would ever be interested in this if it were to become a reality in my state.

However, I have changed my mind and now think that if I and my psychologist-colleagues had the appropriate training and our state law allowed it, we could provide significant help to patients as well as the medical providers who are reluctant to prescribe these medications. In fact, I think that hospitals, FQHCs, free clinics, and other primary care practices would be perfect places for pilot programs because of the collaborative relationships with medical personnel. Thus, I hope that psychology trainees will receive significant training in psychopharmacology and that psychologists and medical providers in rural areas can work together for policy change in order to expand the numbers of trained personnel who can meet the psychiatric needs of underserved individuals.

In conclusion, I hope that we will see more graduate programs in behavioral health preparing their students for practice in integrated care settings. Within some programs, such as psychology, this would also include ensuring sufficient training in psychopharmacology. If this happens, then perhaps at least some of the significant needs of people living in rural areas would be met through collaborative efforts between training programs and health care facilities.


James L. Werth, Jr., Ph.D., ABPP is currently Director of the Psy.D. Program in Counseling Psychology at Radford University (located in Southwest Virginia). For the past several years he has been collaborating with Stone Mountain Health Services, an FQHC in the Westernmost counties of Virginia and is leaving Radford this fall to become Stone Mountain's Psychology Director. He may be reached at

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Necessary components of Integrated BH in Rural Primary Care

Posted By Joe Evans and Rachel Valleley, Thursday, January 17, 2013
Rural blog series logo
Joseph and Rachel's
blog is the third post
in a month-long series
on integrated care in
rural settings.

Read the entire
series here.

Recently, while preparing yet another grant application, I resurrected one of my favorite quotations related to integrated behavioral health care. Dr. David Lambert, of the Rural Health Research Center at the University of Southern Maine, stated, back in 1999, that, "Integrated behavioral health care is a concept that is frequently discussed, but seldom implemented.” Over the years, this quotation has resonated with me and colleagues as we attempt to prepare students to work in integrated pediatric primary care practices. Just what is it that makes an integrated behavioral health clinic in primary care successful? What are the essentials that we need to pass on to our trainees as they enter the field, particularly those who opt to work in rural primary care?

The concept of integrated behavioral health in primary care is certainly far from a "new” idea. Dr. Nick Cummings and his associates have been espousing this notion for over three decades. As noted by Alexander Blount, the integration of physical and mental health care seems to be such an "obvious” and necessary part of the overall health care system that few can argue with its theoretical underpinnings and utility. Why, then, has the implementation of such a beneficial approach to healthcare taken so long in being recognized and implemented. Why have attempts to integrate behavioral and physical health care failed in the past? What makes some practices extremely successful in this venture while others have experienced major difficulties? Are we looking at the essential and necessary components for positively integrating behavioral healthcare and can we learn from successful implementations by others in the field?

Using the approach of "translational research”, Carol Trivette of the Puckett Institute in Morgantown, North Carolina, has emphasized identifying the "kernels, nuggets, and gems” from research findings that are applicable to applied practice. Identification of those characteristics of programs and practices that "stand out” as most important in successful practices is an approach that we, as a field, have not yet applied to integrated behavioral health care, particularly in rural settings. While we all have ideas of what should be involved in an integrated behavioral health practice in primary care, we have not conducted investigations into what factors truly differentiate what makes a practice successful versus unsuccessful in integrated care.

During our Nebraska experiences in implementing integrated behavioral health into 17 rural primary care practices, we have had our share of successes and disappointments.

By way of example, Wolfe and colleagues at the Achievement Place Project in Kansas conducted an analysis of the necessary components of a treatment group home program for delinquent adolescents following an initial "failure” of the program to be replicated. While, initially, it was felt that their well – researched token economy would be the most essential component of the treatment program, further investigation revealed that it was actually the "relationship” and "teaching style” of the group home Teaching Parent staff that was most important in the implementation of the program. Based on this finding, the training component of the program shifted emphasis to development of "teaching skills” with the token economy being a secondary "tool” in the social skills educational process. This program has now been successfully replicated in literally hundreds of agencies in the USA and in foreign countries.

Similarly, in the area of integrating behavioral health into primary care practice, we need to examine some of the parameters that have separated successful versus unsuccessful implementations of the integrated care approach. We may also need to assess whether there are "differences” in the necessary components for Pediatric versus Family Medicine versus Geriatric primary care practice. Our experiences would lead us to propose that there may be significant differences in successful implementation of an integrated behavioral health approach in a Pediatric or Geriatric setting where much of the intervention implementation is mediated by caregivers (parents and nursing staff) versus direct intervention with the patient as is typical in adult Family Medicine integrated MH care.

Some attempts have been made at identifying commonalities of integrated behavioral health care services by examining existing programs. A study funded by the Robert Wood Johnson Foundation, (2007) reviewed 16 programs that, in various ways, identified themselves as providing integrated behavioral health services. Findings suggested that "Integration implementers and goals varied,” and "Integration approaches vary.” Differences in definitions of integrated behavioral health care, a variety of funding mechanisms, and differing target service populations made the task of identifying commonalities difficult to impossible. Additionally, almost all of the programs reviewed operated in major urban areas and focused on "publicly funded” mental health care for severe mental illness.

Examination of components of successful integrated care practice in rural areas may have some distinct advantages due to commonalities found in rural practices. First, the majority of health care in rural areas is provided by Family Medicine or Pediatric primary care physicians. Secondly, there is generally a lack of local "MH specialists” to whom primary care physicians can refer within the immediate area, particularly psychiatrists. Thirdly, most primary care practices in rural areas have a small number of physicians (with an increasing number of Nurse Practitioners and Physician’s Assistants). Fourth, these primary care physicians are expected to address the full range of health problems, with very few having any type of "specialty” clinical practice. Finally, rural primary care physicians generally have a ready "network” of specialists to whom to refer, frequently at University Medical Centers, for various severe conditions. (In the case of behavioral disorders, however, scheduling for appointments can take weeks or months.) Because of these commonalities, finding necessary components of rural integrated care implementations may be more feasible.

During our Nebraska experiences in implementing integrated behavioral health into 17 rural primary care practices, we have had our share of successes and disappointments. The remainder of this blog will discuss some components that we feel are necessary for successful integration of behavioral health into primary care and we will provide some examples of factors that seemed to undermine our attempts. First, a necessary component, in our experience, is the establishment of positive relationships by the behavioral health specialist with not only the primary care physicians but also office staff (nurses, billing clerks, receptionists, etc.). In one of our first replication attempts, some office staff initially viewed our presence as a "burden” and would frequently neglect to notify our behavioral health provider of patients in the waiting room. After "earning her spurs” by successfully treating one of the children of a support staff member, however, relationships improved markedly and staff became some of our greatest supporters. Lesson learned: be sure to develop relationships with staff by chatting, bringing "treats” on occasion, and providing reinforcing comments for cooperation and services provided, no matter how menial. With physicians, reinforcing the "appropriateness” of referrals and information about treatment successes greatly contributes to relationship building.

Secondly, communication with primary care physicians and staff is paramount for establishing a consistent flow of patient referrals when implementing integrated care. In many cases, physicians are unaware of the types of services and skills that are possessed by behavioral health providers. During their training, most primary care doctors receive one to two months of rotations in psychiatry during their residency years. Depending on their experiences during these rotations, primary care physicians frequently place behavioral health providers into a single category, dealing with only the most severe disorders. Communication about the "types” of services that can be offered should occur during the first 6-12 months of program implementation. Noon conferences, presentations to local hospital "rounds,” and "sitting in” on patient sessions can all be forums for providing information to physicians and staff. Recently, by way of example, a family presented in a new clinic with a behavioral concern about "head banging” by their four-year-old child. Following the physician’s citation of the percent of children who engage in this behavior and reassurance that the child would eventually outgrow this activity, our behavioral health professional was able to indicate having some skills in reducing potentially self – injurious behaviors and was able to "solve” this problem in only two sessions using parental differential attention and timeout. Following this episode, the number of "warm handoff referrals” (a la Kirk Strosahl) increased. Other methods for increasing communication include timely intake reports, discussions of combined medical and behavioral plans, notes about when an outside referral needs to be made, offering assistance in behavioral diagnostics, and monitoring of psychotropic medication effects.

It is important to note that communication can best be achieved through physical proximity and seeing patients in examining rooms in the primary care practice. In one instance, an office manager, in an attempt to provide better "clinic space,” assigned a room at the end of the hall to our behavioral health provider. While accommodations were better for seeing patients, contact with physicians, nurses, and office staff was reduced and referrals dropped markedly. Using examination rooms on physicians’ days off allows contact with other doctors as well as providing access to support staff.

A third critical component in implementing Integrated care, in our estimation, relates to the "economics” of primary care practice. Behavioral health providers need to have enough "business acumen” to understand the financial pressures and incentives in primary health care. A number of models of funding for behavioral health reimbursement exist (and may increase with the implementation of the Affordable Care Act). Capitated care, fee for service, Medicaid, co-pays, sliding scale payments, HMOs, and insurance panels are all examples of how behavioral health services can be reimbursed. Providers need to understand the number and "mix” of patients being seen in the primary care practice according to payment source and reimbursement allowed. Negotiating "overhead” costs for space and staff support should also be taken into consideration. These factors help determine estimates of potential income and number of patients that need to be scheduled. Consideration of the economics for primary care providers should also be a point of awareness for integrated behavioral health providers. Initially, we recommend keeping staff demands and supports at a minimum until the overall "value” of integrating behavioral healthcare into primary care physicians’ practices is established. This can be done by the behavioral health provider transcribing his/her own notes, handling return schedules, making reminder calls, and performing billing and collection functions. As the benefit of having behavioral health available in the practice, many of these functions can be absorbed into the day-to-day activities of support staff.

Data that we have collected over the years indicates that primary care pediatricians spend literally double the amount of time on behavioral referrals as compared to acute care episodes or well – child visits. When collectible fees for providing behavioral health services by physicians were analyzed in one of our studies, physicians unable to utilize mental health codes in their billing. This resulted in reimbursements that were only 45% of "typical” collections for acute and well – child care. Following this logic, physicians should be able to be 15-20% more productive with time freed up when a behavior specialist is available to deal with mental and behavioral health issues within the practice. In our experience, once the that physicians recognize the amount of time savings, economic benefit, and improved diagnostic and treatment capacities resulting from having a behavioral professional in the practice, referrals flow steadily and benefit all parties: primary care physicians, behavioral health professionals, and patients.

Finally, and possibly the most important component in preparing behavioral professionals for primary care practice, is knowledge and skills necessary to treat behavioral problems presenting in primary care physicians’ offices. Unfortunately, there is not a direct correspondence between graduate education in many behavioral health graduate training programs and medical practice in the community. Training in addressing the most common behavioral problems presenting in primary care is a necessity. Most psychology training programs are not located in, nor do they collaborate with, colleges of medicine. In integrated pediatric primary care, by way of example, behavioral providers need to be able to accurately assess and treat the most commonly presenting problems of childhood and adolescence.

Specific protocols for diagnosing and providing therapy for sleep disorders, feeding disorders, thumbsucking, nocturnal enuresis, learning disabilities, ADHD, habit disorders, childhood depression, aggression, anxiety, school motivation problems, medical compliance, and the psychological effects of chronic conditions such as diabetes, epilepsy, cystic fibrosis, and genetic conditions should be mastered in order to be successful in integrated pediatric primary care practice. We recently had a student in a pediatric practice in an underserved, high need poverty area. Her training did not include education in many of the behavioral conditions noted above and she spent a good deal of her time doing assessment and then referral out of the practice. This simply added another "layer” of delay between the physician and eventual treating agent. Similarly, we have had students who are well trained in standardized and "manualized” therapeutic programs requiring consistent attendance at 10-12 consecutive sessions. In primary care, this is a practice that is rarely successful and often leads to treatment failure. In our estimation, short – term, evidence – based, protocol driven and prescriptive therapies are the "norm” in pediatric integrated primary care practice.

In summary, as educators of future integrated behavioral health specialists, we are very interested in sharing and hearing the experiences of others, both positive and negative, who have been successful in implementing integrated care programs. We have attempted to share some of our successes and "tales of woe” that will hopefully be of benefit to you in your future endeavors.


Joseph Evans
Dr. Joseph Evans is a Professor at the Munroe-Meyer Institute (MMI) and in the University of Nebraska Medical Center's (UNMC) Department of Pediatrics. He is the Director of the Psychology Department at MMI and the Division Director of Pediatric Psychology in the UNMC College of Medicine. Dr. Evans administers a staff of eleven Psychologists, nine Doctoral Interns, five Post-doctoral Research Associates, four graduate students in Applied Behavior Analysis, and support staff. He is an active clinician and manages the ADHD Clinic conducted at MMI as well as serving as a staff psychologist for the DHHS Children with Special Health Care Needs program.

Rachel Valleley
Rachel J Valleley, Ph.D., is a licensed psychologist in the Department of Psychology at the Munroe-Meyer Institute for Genetics and Rehabilitation and Associate Professor in Pediatrics and the Munroe-Meyer Institute at the University of Nebraska Medical Center.  Her research and clinical interests revolve around behavioral health in primary care. Specifically, she is interested in the impact that behavioral health problems have on primary care, demonstrating the effectiveness of the integrated model on behavioral health, and the unique contributions that behavioral health specialists can have upon primary care. She is currently Coordinator of MMI’s Outreach Behavioral Health Clinics, overseeing 13 rural clinics, 7 Omaha area clinics, and 4 collaborating sites. She has published nearly 20 scientific papers and chapters related to children with behavioral health and academic concerns.

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Stepping It Up: Innovation to the Stepped Care Model to fit Rural Settings

Posted By Jodi Polaha, Thursday, January 10, 2013
Rural blog series logo
Jamie and Jeff's
blog is the second post
in a month-long series
on integrated care in
rural settings.

Read the entire
series here.


Jamie Tedder, M.S.

East Tennessee
State University

I’ve always viewed the stepped care approach (e.g., see Bower & Gilbody, 2005) to mental and behavioral health service delivery as being like a relay race where the participants are various health and mental health providers. The professionals at each stage provide treatment within their area of expertise and within the constraints of their practice before "passing the baton” to the next provider. This was the image I had in mind when I walked into my first external placement; a rural pediatric clinic with a co-located mental health specialty service. I was to practice population-based care -- the first runner on the mental health relay team.

Within a few patient contacts I realized I was more like the Lone Ranger than a relay racer. I felt many of my patients could benefit from more lengthy and frequent treatment than I was able to provide in population-based model, but the co-located service and the community mental health center in town is typically "booked out” about 8 weeks. The nearest "next best” referral source is over 30 miles away. By the end of that first day I was overwhelmed, to say the least.

There are no easy solutions for the challenges, such as this one, that are raised in a rural setting. This year, we are experimenting with a creative solution that builds in technology. Thus, one day each week I travel about 60 miles to the rural clinic described above, in Rogersville, Tennessee, to provide behavioral health consultation services. Three other days a week I (along with my colleague, Jeff) staff a telehealth clinic based out of Johnson City, where we are based, at East Tennessee State University.

Several rural primary care clinics across the state have access to our services through the telehealth clinic, including my site in Rogersville. This allows me greater flexibility to schedule follow-up visits for patients who need more frequent treatment, longer sessions, or who simply can’t make it into the clinic on the day I’m there. I also access supervision and consultation through telehealth as needed. New and innovative treatment modalities such as the one described above give rural behavioral health consultants more options in underserved areas, and decrease the feeling of professional isolation often experienced by practitioners in rural areas.

Jeff Ellison, M.S.

East Tennessee
State University

Through my graduate training, I have had the opportunity to work on-site as a Behavioral Health Consultant (BHC) in two rural Appalachian primary care practices and via telehealth at several others. These experiences have shown me that, while every primary care clinic faces unique challenges (e.g. the types of patients seen, the physical space available, the workflow, etc.), the lacking availability of community resources is a constant challenge among rural practices.

As a BHC in non-rural settings, I have enjoyed my role as a component in a stepped care approach, where more intensive outpatient services are available to patients who do not benefit from brief, problem-focused treatment in the primary care setting. In rural communities, however, I quickly learned that lacking specialty services made such referrals impossible. Thus, in rural practice I feel a pull to treat a much broader spectrum of problem types and severities than would ideally be the case in population based mental/behavioral health care. It is a challenge to navigate this dilemma, allocate clinical time, and prioritize clinical services to make the greatest impact.

Our attempts to make this dilemma more manageable have led us to experiment with a variety of possible solutions, some novel and innovative and others common-sense. One way that we have risen to this challenge has been by developing a telehealth infrastructure in the clinics in which we provide service. This has allowed us to allocate more of our time to clinic coverage (due to reduced travel time to and from these rural clinics) and has reduced the "lone-wolf” feeling when we are providing on-site services (because of the potential to access additional consultation, supervision, and support via video).

We have also experimented with setting aside dedicated time each day for brief appointments with patients requiring longer term management (e.g., specialty services) while making it clear to providers that appointments can be interrupted for consultation and warm handoffs as needed. Although we have had some success with interventions such as these, rural practice as a BHC is a daunting calling and one that begs persistence, flexibility, and creative thinking at each "step.”

Jeff Ellison and Jamie Tedder are advanced students in the doctoral program in Clinical Psychology at East Tennessee State University, which has a focus on rural, integrated care. 


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Growing Vegetable Connoisseurs

Posted By Jodi Polaha, Thursday, January 3, 2013
Rural blog series logo
Natasha and Alysia's
blog is the first post
in a month-long series
on integrated care in
rural settings.

Read the entire
series here.

The following highlights insights from two pre-doctoral interns working in rural, integrated primary care clinics. Their doctoral programs differ in foci of training, but do overlap in their focus on providing care to rural, underserved populations. They are both currently on internship thru a novel "grow your own” model at Stone Mountain Health Services (SMHS).


Natasha Gouge

Natasha Gouge, MA
East Tennessee
State University
Cummings, O’Donohue, and Cummings (2009) put it best: "integrated behavioral/primary care is like a pomegranate: overwhelmingly people say they like it, but few buy it” (pg. 6). I read this statement a few years ago while reviewing literature for a term paper, and these words have been engrained in my mind ever since. The statement, although originally associated to the economic hurdles associated within integrated care, is not limited to health care costs or sustainability.

Within my own graduate training program, which is tailored to train clinicians to work within integrated care settings and/or among rural populations, several individuals "don’t buy it”. Despite the program’s mission offering an appealing training specialty at the onset, as students get exposure to integrated care and working within rural areas their commitment to the model and region often seems to wane. So I might add a similar statement like, "integrated care and working within rural areas are like vegetables: overwhelmingly people recognize they are needed, but few enjoy eating them every day”.

The ideals of integrated care and of offering services to underserved areas are generally supported in theory. However, supporting those ideals and working in the service of those ideals are two very different tasks. And the result? Turnover. Students, interns, post docs, residents—the list goes on, embark on clinical experiences in line with these ideals, only to seek other career opportunities after their initial obligation is over. So after the 9-week rotation, or semester practicum, or yearly internship comes to a close, some individuals decide they no longer have a taste for their vegetables. (Or worse, in the case of rural underserved regions, this realization occurs after an individual has received their loan reimbursement installments!)

Alysia Hoover-Thompson

Alysia Hoover-Thompson, MS

Radford University

My path to liking vegetables was a long one, as I suspect is the case with many other clinicians in integrated care. I had an undergraduate double-major in physics and anthropology (seriously…what was I going to do with that combination?) and worked in IT staffing and boarding school admissions prior to applying to Master’s programs in Counselor Education. I loved my Master’s program, but felt that pursuing a doctoral program that offered more intensive clinical training, as well as the opportunity to conduct research, really appealed to me.

My doctoral training program, which has a focus on rural mental health and additional emphases on cultural diversity, social justice, and evidence-based practice in psychology, is designed to train generalists in rural mental health. During my final year as a practicum student, I had the opportunity to work at a Free Clinic doing integrated care. Beyond coursework and readings, I had limited exposure to the world of integrated care, prior to this opportunity. I vividly remember my first day at this new site - I could work in a fast-paced environment, seeing patients alongside medical providers, doing more than just traditional mental health and someone would eventually pay me for this? Sign me up for a vegetarian diet!

While integrated primary healthcare is right for me, it is certainly not the right fit for everyone. Along the way, I have often been asked- "How can you see someone in 15 minutes?” "Don’t you miss really getting to know your clients?” "How do you work without an office?” Yes, these are very good questions but are easy to answer for someone who fits in this model of care. Do I miss having a cushy couch to nap on over my hour-long lunch break? Yes. Do I wish that I could go home every day and not have blisters on my feet from running around the office in impractical heels? Yes. Would I trade this vegetarian diet for something less PETA friendly? Definitely not.

About Stone Mountain Health Services

The farm that produces our vegetables is SMHS, a Federally Qualified Health Center that consists of 11 primary care clinics in rural, Southwest Virginia. The mission of SMHS is to promote and provide quality primary health care that is accessible, affordable, and community-based for the people of Southwest Virginia. Following from this mission, the organization’s vision is to be the recognized leader in the provision of accessible health care in our communities, through integrity, excellence and diversity of services. Services offered by clinics include: family health care, black lung, assistance in obtaining medication, x-ray and laboratory, dental and behavioral health counseling. In 2011, SMHS, in conjunction with East Tennessee State University and Radford University, created the pre-doctoral internship to address the needs of this patient population.

We both desire to remain working in rural primary care after the completion of our internship. Are we the norm among doctoral trainees? Probably not. Most interns uproot themselves and their families for a 1 year training experience and then move on. To provide consistent, doctoral-level providers, SMHS created a "grow our own” model. Two interns began in August of 2011 and they are now both psychologists within the organization. We began in August of 2012 and hope to also be offered positions to stay on board. To date, we have seen over 300 patient contacts (in addition to all of our hours of supervision and didactic training).

Organizations that wish to train or employ psychologists who enjoy a daily dose of those rural integrated care veggies, have quite the challenge! SMHS recognizes that psychologists who desire working in integrated care can move to a rural region and lose interest in maintaining their position due to a lack of resources professionally (e.g., referral options for their patients) and personally (e.g., academic or extracurricular opportunities for their children); likewise, psychologists who desire serving the underserved, do not necessarily want to work within primary care settings. With internship opportunities, employment, and funding ever in flux, how can a better match between an organization and applicants be found? Well, SMHS has taken a novel approach: seek out the vegetable-friendly professionals already residing in the region and grow them into vegetable connoisseurs.


Alysia Hoover-Thompson is a doctoral candidate at Radford University in the Counseling Psychology PsyD program. She received her MS in Community Counseling from Radford University in 2009. Her research interests include: women’s issues, body image and rural practice.   


Natasha Gouge is a doctoral candidate at East Tennessee State University in the Clinical Psychology PhD program.  She received her MA in Clinical Psychology from ETSU in 2011. Her professional interests include dissemination and implementation science; program development, innovation, and evaluation; primary care, rural practice, and pediatrics.


Cummings, N.A., O’Donohue, T.O., & Cummings, J.L. (2009). The financial dimension of integrated behavioral/primary care. Journal of Clinical Psychology in Medical Settings, 1-9. DOI 10.1007/s10880-008-9139-2

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Geriatric training: Allowing our patients to be our educators

Posted By Lauren DeCaporale, Thursday, December 27, 2012

When I was interviewing for graduate school, I was asked if I thought my dual major as an undergraduate in sociology and psychology would be "detrimental” to my career as a geropsychologist. Evidently, it was the interviewer’s belief that systems had little to do with the individual adult. I have often reflected on that moment and recognized the critical role it played in my professional development. It is difficult for me to imagine working with an older adult and not knowing his or her background, not exploring the interplay between one’s social structure and sense of self, and not integrating families and other professionals into a patient’s care. However, there are many that do not know the benefits of this work or how it can be done, particularly as it pertains to older adults.

As I participated in this year’s CFHA conference, I was surprised by how few people I met expressed interest in geriatrics. In fact, I was alarmed. It was disheartening to hear Doctors Blazer and Martinez report on the "silver tsunami” and the Institute of Medicine’s report on the limited number of workforce prepared to care for this rapidly growing population.

Silver Tsunami

I wondered: how could this be? Is it a lack of funding? A lack of educators? A lack of awareness? And the answer seems to be: All of the above. So how do those of us who are passionate about our work with this population demonstrate that it is a worthwhile endeavor desperately needed in our current culture?

The numbers alone should demand our attention:

  • 72.1 million: the number of older adults projected by 2030 in the US alone (Administration on Aging, 2011).
  • 7 - 8%: the number with severe cognitive impairment (Freedman, Aykan, & Martin, 2001).
  • 5 - 10%: the number of older adults seen in primary care suffering from major depression and dysthymia (Lyness et al., 1999).
  • 20%: the number of older adults with chronic disabilities in the US (Manton & Gu, 2001).
  • 29%: the number of the US population providing care for a chronically ill or older adult family member (National Alliance for Caregiving, 2009).

Though these numbers are powerful, they do not capture the full story of our aging population. There are many families who invite us into their lives to share their experiences of successful and sometimes less than successful aging. Recently, I was meeting with an aging patient and her friend. They both expressed gratitude to me for not shouting and talking down to them as if they were children, noting that this was so often their experience with others. I was reminded during this encounter of the stigma attached to aging. Why is it that we assume we must shout or that an aging individual must be suffering from cognitive impairment? These assumptions are unhelpful.

I am fortunate enough to have learned many lessons on aging from all four of my beloved grandparents and my parents who provided them with much of their care. I was taught to live and breathe the idea of respect for my elders, but it was more than that: it was a message of providing the aging people around me with dignity and a listening ear. It was from them that I learned how to grieve and on some days, how not to. I learned how to be flexible, as they gracefully made transitions and altered their expectations when necessitated by medical and physical need. I learned perseverance as my grandmother insisted she was not old, not ready to die, and kept taking the stairs rather than using an elevator at the age of 90. When I wasn’t learning from them, 30 older adults and their professional caregivers at adult daycare facility were teaching me every summer during my adolescence about the power of gentle touch and laughter as sources of healing.

I recognize that others are not as fortunate as I, who had the wonderful opportunity to know all four of these people until my early adulthood. But I challenge all providers who have not had such opportunity to listen to your older patients, to hear their stories, and to learn from them. Geriatric educational programs might not be accessible to all of us, but these patients are abounding, and ready and willing to teach us. Let us take a moment to be educated through their experiences, their voices, their families, and their lived-wisdom.


Lauren DeCaporale, PhD is a second-year postdoctoral fellow in Primary Care Family Psychology with a specialization in geriatrics/internal medicine at the University of Rochester Medical Center, Institute for the Family, Rochester, NY.



Administration on Aging (2011). Profile of older Americans. Aging statistics. Retrieved from

FreedmanVA, AykanH, MartinLG.Aggregate changes in severe cognitive impairment among older Americans: 1993 and 1998.J Gerontol B Psychol Sci Soc Sci.2001;56:S100-S111.

Lyness JM, Caine ED, King DA, Cox C, Yoediono Z. Psychiatric disorders in older primary care patients. J Gen Intern Med. 1999;14:249–254.

MantonKG, GuX.Changes in the prevalence of chronic disability in the United States black and nonblack population above age 65 from 1982 to 1999.Proc Natl Acad Sci U S A.2001;98:6354-6359.

National Alliance for Caregiving (2009). Caregiving statistics. Who are Family Caregivers?. Retrieved from

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Family Oriented Behavioral Health: An Interview with John Rolland

Posted By Zephon Lister, Thursday, December 20, 2012
Zephon Lister:  What experience in your professional or personal life was most influential in your development as a family-oriented behavioral healthcare practitioner?

John Rolland: Near the end of medical school I debated between family medicine and psychiatry and ultimately decided to go into community psychiatry and public health. There have been both personal and professional experiences that I believe have influenced my development as a family focused practitioner. Personally, I was influenced by two experiences during my psychiatric residency. First, my mom had a stroke, which became one of my first close encounters with how families and the healthcare system interacted. Later in my residency my first wife developed and later died of cancer. I remember there being no advice or support provided to the family. I saw how marginalized the family was, and that there was little effort to reach out to those outside of the "patient”, who were also suffering.

As I reached out to the providers and my professors for insight and understanding, I began to realize that there was no road map given to help individuals, couples, and families, navigate these situations. No one had anything to offer to me in the situation. Almost everything was pathologizing. There was no guidance on whether what I and we as a couple were experiencing was normal or dysfunctional. I remembered how I felt during that experience and knew I wanted to help families not go through what I went through. I also wanted to help providers do a better job of understanding the importance of family and how illness impacts the entire family system.

John Rolland
"I saw how marginalized the family was, and that there was little effort to reach out to those outside of the 'patient', who were also suffering."
 Professionally, some of the experiences that had a significant impact on my career path were my exposure to early system thinkers such as John Weakland and Don Bloch. One of the first papers that excited my interest in family and illness was John Weakland’s, "Family Somatics”- A Neglected Edge” (1977). In addition to my personal family experiences with illness and readings, I was strongly influenced by my primary mentors, Betty Carter in family life cycle and Dan Levinson in individual life cycle development. They informed and inspired my conceptual thinking about how illness, family system, and individual family member’s development interact across time. Don Bloch was another very influential person that led to my focus on health and the family. He had the vision of the field and its potential. I remember how he was able to bring "kindred spirits” together from different disciplines to collaborate around family systems and healthcare. These collaborations led to foundational and lasting contributions to the field of family systems in healthcare especially through the establishment of the journal Family Systems Medicine, now Family, Systems, and Health and the Collaborative Family Healthcare Association (CFHA).


ZL:  What do you consider your most important contribution to the family systems in healthcare field or literature?

JR: I think my most important contribution to the field of family systems in healthcare is the Family Systems Illness model I initially developed during the late 80’s and early 90’s, which ultimately culminated into my book Families, Illness, & Disability: An Integrative Treatment Model published in 1994. It has been gratifying to see how well it has been received among mental health professionals and some healthcare disciplines, such as Family Medicine and Nursing. However, it was also my hope to expose these ideas more to other medical disciplines, especially those who are less familiar with systems thinking in relation to family and illness (i.e. physicians, family educators, healthcare administrators and policy-makers).


ZL:  What do family-oriented behavioral health clinicians most need to move into the mainstream of healthcare?

JR: I would say a greater effort on visibility and marketing. Medical family therapy is not just a discipline but an orientation and way of practice that is not limited to family therapists or providing just family therapy. Personally, in medical settings, I prefer to identify myself as a "family-oriented behavioral health consultant.” Certainly as a psychiatrist, this is more acceptable to patients and their families, who have no prior exposure to mental health professionals. Outside of my practice or a mental health clinic setting, I have always found the term "consultant” an easier entry point to a relationship with patients/families.

Regarding visibility, I believe the family-oriented behavioral healthcare field has done a pretty good job integrating into primary and secondary care settings. The next step, I believe, is expanding the family systems training in current curricula across mental health disciplines to incorporate the skills needed for better integration into tertiary, quarternary, and home/community healthcare environments. My own work has always centered more in this area. To me, there is a huge opportunity for family-oriented behavioral health clinicians to provide services in chronic illness-based and specialty medicine. Some of the areas I think family-oriented clinicians should give increased attention to include: oncology, cardio-vascular disease, diabetes, rehabilitation medicine, pediatrics, obstetrics and gynecology, and palliative care/hospice.

Since it is by definition family-based, the burgeoning field of genomics is particularly well-suited to our skills. Many of these settings have a collaborative team ethos and structure that is just not family-oriented enough and lacks a team member with advanced family-oriented behavioral health skills. Greater access to medical in-patient services would be terrific. It is typically a crisis-point in healthcare, where patients and their families are vulnerable, biomedical providers often need behavioral healthcare support, and all are usually brought into closer physical proximity.

While it is important to continue to develop the field of family-oriented behavioral health practitioners across professional disciplines, in terms of the MFT discipline specifically, I think there is a unique opportunity to train its practitioners to be more integrationist. At this point of the field’s development, instead of focusing energy on describing how different MFT’s are as a discipline and potentially isolating themselves, I would suggest, take the skills that MFTs have cultivated and collaborate more with other healthcare disciplines and environments to demonstrate how MFTs fit into a broad range of multi-disciplinary healthcare teams and healthcare settings.

I think that fields that are ripe for integration with MedFTs would include disease specialties, hospice/palliative care, and genomics. MedFTs should make a more concerted effort to attend and present at professional conferences outside of their discipline (e.g. Psychosocial Oncology, Behavioral Medicine and become more involved in non-guild organizations, such as the American Family Therapy Academy (AFTA) and the National Council on Family Relations (NCFR). They should also write towards journals in other healthcare areas, emphasizing the application and benefits of a family systems perspective and the role of MedFTs within various healthcare contexts and illnesses.

ZL: You have been successful in collaborating with various organizations to promote and implement funded family-centered care approaches, what advice or suggestions would you have for young family-oriented behavioral health clinicians who wish to pursue similar collaborative relationships?

JR: The first step is helping other healthcare professionals understand what family-oriented behavioral health clinicians do and then helping them understand how you can help in their particular healthcare environment. It is important to be able to concisely describe how your presence will benefit the organization in the short and long term in order to get buy in. Often, to gain initial access to a clinical service or organization, it is useful to provide services at a lower cost and intervene with complex cases to demonstrate your effectiveness. I think that a couple underutilized resources are forging relationships with family (e.g. National Family Caregivers Association, Well-Spouse Foundation) and illness-oriented consumer-based organizations (e.g. MS Society, American Diabetes Association). More attention should also be given to the executive team, such as medical directors, administrative leadership of healthcare systems of care, and benefits directors. These are the individuals that have or know how to access financial resources to support integrated care services. Forging an effective relationship with a clinical service’s/center’s medical and nursing directors greatly benefits overall development and implementation of family sensitive service delivery models.

In recent years, I have become increasingly interested in funding for family-centered prevention models of integrated behavioral healthcare. This means both providing family-oriented behavioral healthcare to individuals/families at high risk for a condition, such as diabetes, and families entering the world of chronic illness, such as cancer, cardiovascular disease, or dementia. I have had most success implementing brief family psychoeducation consultations that can be incorporated as a family-oriented behavioral consultation in routine intake protocols, or multi-family groups psychoeducational "modules” (e.g. 4 evening sessions or a weekend ½ - 1 day skills-building format). The latter is very cost-effective, identifies higher-risk families, and networks families facing the same disease. I have found prevention-based models of integrated behavioral healthcare to be more challenging in terms of getting the buy-in needed to access the financial and administrative resources to establish an effective program. Ultimately, I think these types of prevention-oriented initiatives would need support at the government and policy levels if any real impact is going to be made long term.

ZL: What areas do you believe family-oriented clinicians are not taking full advantage of in the areas of research and practice and how could the field improve upon these areas over the next 10 years?

JR: Reflecting on the points made in questions 3 and 4, I think making a deliberate effort to expand into tertiary, quarternary, and home/community healthcare environments as well as being more intentional in integrating into other organizations. I also believe we should place a greater emphasis or both clinical and cost benefit research. While it is difficult to demonstrate how integrated family-oriented care can increase revenue short term, research should seek to identify how the use of our services reduce cost more long term. In general, we need more empirical support for systems-of-care and disease specific family-based interventions.


John Rolland, MD LMFT is internationally recognized for his Family Systems-Illness model, clinical work, and research with families facing serious physical disorders and loss. His book,Families, Illness, and Disability: An Integrative Treatment Model (Basic Books), was nominated for book-of-the-year by the American Medical Writer’s Association. He is currently co-author of a new book, Individuals, Families, and the New Era of Genetics: A Biopsychosocial Perspective (Norton). He has given over 250 national and international presentations on topics related to his work.

Zephon Lister, PhD LMFT earned his doctorate in Marriage & Family Therapy from Loma Linda University with an emphasis in Medical Family Therapy and completed his post-doctoral training at the Chicago Center for Family Health an affiliate of the University of Chicago. His clinical and research interests have focused on the recursive influences of family relationships and chronic health conditions and the integration of behavioral health into health care settings. Dr. Lister is the director of the UCSD family medicine integrative collaborative care program where he facilitates behavioral science training for family medicine residents, supervises MFT clinical training, and facilitates learning groups with medical students.

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Gray Families: An Interview with Sara Honn Qualls

Posted By Barry J. Jacobs, Thursday, December 13, 2012
Updated: Wednesday, December 12, 2012

In the evolution of healthcare, demographics will shape our destiny. On the horizon is the so-called "silver tsunami”—the increasing prevalence of aging Baby Boomers using more and more healthcare resources. But there’s a dearth of American healthcare professionals interested in geriatrics. And there are relatively few collaborative, team-based programs focused on the needs of aging adults.

Psychologist Sara Honn Qualls, Ph.D. has spent her career integrating the evidence-based insights of gerontology with both elegant and pragmatic formulations of family systems thinking. The Kraemer Family Professor of Aging Studies and the director of the Gerontology Center at the University of Colorado, Colorado Springs, she is one of the country’s leading clinicians, writers and educators about families in late-life. Her latest book, Caregiver Family Therapy (co-written by Ashley A. Williams) was recently published by APA Books. It should become a foundational text of not only medical family therapy academic programs but of all family-oriented healthcare training.

Sarah Honn Qualls   Caregiver Family Therapy

I had the privilege of working closely with Dr. Qualls for a year-and-a-half as members of the APA Presidential Task Force that produced the Caregiver Briefcase, a web-based resource on family caregiver research, practice and policy. It was good to hear her quick, incisive voice again as she talked with me about her new book.


BJ: What has led you to focus your career on aging families?

SHQ: My family-of-origin had exposed me to a lot of aging families. Then, while I was an undergraduate during the late-70s and early-80s, I did a workshop in gerontology for which we went out in the field. I was hooked. I just got it. I became interested in the psychology of aging families but there wasn’t much information out there. At the time, however, there was a rich family therapy literature that was mostly based on families with young children. It was fascinating for me to try to translate those early family therapy models into ideas about families of older adults in which there was a lot more ambiguity about what family roles could or should be. When I started working as a psychologist in the aging field, it was clear to me that family is the key social and service context for older adults. Families ought to be key members of the integrated healthcare team but are often considered outside the pale and are left outside team deliberations. 

BJ: Why write the book Caregiver Family Therapy?

SHQ: In the field of gerontology, family caregiving interventions have had a focus on the individual framed mostly in a stress and coping paradigm. But what struck me while talking to caregivers in our clinic is that most of them didn’t seem to think of themselves as individual caregivers dealing with stress so much as they saw themselves as part of families in late-life transition.  

We wrote the book because there was a need to integrate various caregiving interventions into a systemic framework that isn’t addressed in the stress and coping paradigm. How do we help family members walk through an illness trajectory while identifying the transition points that challenge the whole family’s organizational structure. How do we help family members make the transitions they need to make while supporting the development of all family members? All these types of changes require a systems frame to understand and intervene.

BJ: You focus in your book on "naming the problem.” What do you mean by that?

SHQ: Families come into treatment because something isn’t going right for them. Their name for the problem is often not what the healthcare system calls it. That’s a disconnect. For example, caregivers may call me to see their mother for depression when it’s clear to me that their mother also has cognitive changes, possibly dementia. As a professional, I have to gather all the assessment data and integrate it and make sense of it. And then I have to offer that understanding to the family in a way that will be useful to them so that it matches their value system and cultural context and positions them to respond to the practical health and well-being needs of their elder.

BJ: You also focus on what you call "role structuring.” How do you help family caregivers shift into new roles?

SHQ: We have to increase their awareness of the transitions that are required to deal with aging and illness, especially dementia. We then have to figure out the barriers that are keeping them from smoothly making those transitions. In our clinic, we use role plays or imagery exercises to help family members understand what would be a more effective strategy and to make real the risks they run if they insist on playing the same roles they’ve always played.

BJ: You engage family caregivers in problem-solving. What evidence do you have that that kind of cognitive process is effective?

SHQ: Insight is necessary but rarely sufficient, especially when it comes to changing fundamental aspects of our roles across generations. By engaging family members in problem-solving, we are more likely to elicit the real barriers to action or transition—e.g., guilt or fear of conflict with a sibling. The power of change is in helping family members see the problem in a new frame and exploring new resources.

BJ: How can family-oriented healthcare professionals improve their effectiveness with family caregivers?

SHQ: By asking family caregivers to collect clinical data about the patient for us—say, through using reporting scales-- healthcare professionals may become aware of problems that we didn’t even know about. This will lead us to ask ourselves different questions about how to help our aging patients and their devoted family members.

Barry J. Jacobs

Barry J. Jacobs, Psy.D. is the Director of Behavioral Sciences for the Crozer-Keystone Family Medicine Residency Program in Springfield, PA and is the author of The Emotional Survival Guide for Caregivers.

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Rochester, New York
14692-3980 USA

What We Do

CFHA is a member-based, 501(c)(3) non-profit organization dedicated to making integrated behavioral and physical health the standard of care nationally. CFHA achieves this by organizing the integrated care community, providing expert technical assistance and producing educational content.