Posted By Shelley L. Meyers,
Saturday, June 22, 2013
Some time ago, I wrote this "open letter" to a master's level Marriage and Family Therapy ethics class. I was the teaching assistant at that time and thought that the family crisis I had just experienced would be relevant and applicable to many of the issues discussed in class. I am not sure why, but I never sent the letter. I actually forgot about writing it until recently when I was searching my computer for documents related to my current doctoral course in Medical Family Therapy. My hope is that my story will facilitate discussion about some of these issues and possibly provide some additional insight into the experience of a family dealing with a loved one's terminal illness. I recognize that the events may not be typical or standard procedure and do not wish to imply that they are; this is one person's perspective.
An open letter to the Fall 2011 MFT Ethics Class:
I wanted to share a personal experience with you all that
highlights some of the recent issues you have been studying in class regarding
ethics in general, as well as medical family therapy and end-of-life issues.
Please note that I asked for permission from those mentioned below prior to
sharing this with you and also changed some names.
A little background info… my husband is from Canada, and the
majority of his family live in the province of British Columbia. In early to
mid-October my mother-in-law Heather had some medical tests done as she was
losing a great deal of weight and had little appetite for foods other than
liquids. On October 19th, we were informed that she had cancer but
the exact type was undetermined. It was in her lung, liver and lymph nodes but
the source would need to be determined via biopsy in order to figure out the
course of treatment (you learn a lot about cancer during these times). When we
first learned that she was ill, we planned a visit at Christmas since both my
husband and I would be out of school for break and he would have some time off
from work. When we got information about the extent of her illness, we
purchased tickets to fly out on November 5th. The oncologist told us
that "you might want to come sooner”, which is obviously NOT a very good sign,
and we rushed to fly out on Friday, October 28th.
By this time, Heather has been admitted to the hospital and a
biopsy was done on Thursday the 27th (yes, that’s right…8 days after the diagnosis). We were
told that we were "lucky” that it had been moved up a day earlier to Thursday as
it was originally going to take place on Friday. So, we wait for results that,
honestly, probably wouldn’t matter. At this point, Heather was very ill and any
potential treatment would most likely cause more harm than good. During all of
this, Heather’s family doctor had told her that she had three weeks to live. We
didn’t realize this conversation between the doctor and Heather had taken place
My husband Shayne and I saw Heather in the hospital on
Saturday the 29th. She looked ill and fatigued, but not as sickly as
I had been expecting considering the diagnosis. Shayne’s sister Connie and her
husband were there as well. Connie had been bearing much of the burden of this
situation as she lived in the same town as their mom and was spending time at
doctor’s appointments and at the hospital. She and her husband Andy also have
one adult and two younger children at home and had to manage their normal
family responsibilities. Shayne, Connie and I spent as much time as possible
with Heather at the hospital. Andy, Heather’s sister, and the kids were there
quite often as well. Heather was in a room with another patient who also had
visitors often (and usually loud) which made things awkward at times.
We also had a meeting during that weekend (in the TV lounge,
but at least no one else was in there) with Heather’s family doctor. Obviously we had some questions. One thing I
asked the doctor was why she (the generalist) was the one explaining the
diagnosis and possible outcomes rather than the oncologist (the specialist).
She became very defensive, appeared to be insulted, and said that she was
trying her very best to help Heather, that she was working tirelessly, that she
was here on the weekend to meet with us….etc. etc. Her tone and her
defensiveness surprised and angered me. A few minutes later I felt the need to
excuse myself from the conversation and wander the hospital stairwells,
eventually finding the "Sacred Space” room (similar to a chapel). After some
crying and yelling, I composed myself and returned. By that time, the family doctor
had gone to check on something and I spoke with Connie. Connie told me that she
had asked the doctor a question regarding the biopsy procedure. The doctor
became teary-eyed, then began talking about how horrible it was for her to lose
Heather’s illness began to progress. She was noticeably
weaker and having difficulty with breathing. On Monday the 31st, we
met with the oncologist with Heather at her bedside as well as…in the hallway outside of Heather’s
room. She discussed Heather’s prognosis with us and mentioned the possibility
of hospice care. My husband and I had originally planned to return home to
Pittsburgh the following weekend and asked about the feasibility of coming back
for another visit with my mother-in-law, maybe near the Christmas holiday. The
oncologist looked at me and said, "we’re talking a few days to a few weeks”. Of
course the entire conversation was extremely emotional for the whole family,
but excruciatingly painful for Shayne and Connie. As for me, I felt trapped and
helpless. I have never felt as useless as I did in those moments when I had no
way to "fix” the situation or ease the pain. I also struggled with the
practical questions that came up for me…. had anyone asked Heather about her
plans? What if she did die soon? What would she want? How does all this stuff
happen? Would we have enough time? How do we pay for all of this? Who do we
call? Of course, my stomach churned at the thought of even bringing up any of
So, Monday the 31st was Halloween night. Shayne
and Connie wanted to stay with their mom overnight at the hospital. Andy wanted
to spend as much time as possible there too. The kids went trick-or-treating
that night, so I waited for them at the house until their dad got there. Later
I returned to the hospital and stayed with Shayne and Connie.
By late Monday or early Tuesday, Heather was not able to clearly
communicate. She slept almost constantly, and when she was "awake”, it was
difficult to tell if she was able to understand what was happening around her.
The nurses told us that most likely she had some awareness, so we continued to
talk to her, stroke her gently and hold her hand. They were able to move her to
a private room, which was very helpful.
There’s another twist to the story. Shayne has a 12-year old
son, Brian, who lives about three hours’ drive from this town. Brian has an
older sister, Ariel, who is 17. She is not Shayne’s biological daughter,
however he has always been a father-figure to her. I called their mother
Vanessa to explain the most recent circumstances though she was already aware
that Heather was ill. Vanessa said that
she was allowing the children to make the choice as to whether or not they
wanted to see Heather. She said that they had a very difficult time when her [Vanessa's]
father died from cancer nine years ago. She also said that Brian really didn’t
feel comfortable coming and that Ariel was "on the fence”. I tried very hard to
maintain my composure. I said that I was only relaying the information, however
I would not want anyone to have regrets later should they miss this opportunity
to see her. She said she would call me back. She called a short time later and
said that Ariel would take a bus the next morning and that Vanessa's brother
and sister-in-law would be picking her up as they lived in this town. I made the assumption that Brian was still
not going to be coming. I didn’t ask.
Later in the day on Tuesday we realized that the nurses no
longer came in at regular intervals to check Heather’s vital signs (no, she did
not have the machine that continually monitors them). We made the assumption they were "telling us
without actually telling us” that there was little time left. Shayne and Connie barely left their mother’s
side, even hesitating to go get something to eat. That evening (Tuesday) I went
back to Corinna’s house and gathered some supplies. Most of the immediate
family was jammed into that hospital room…me, Shayne, Connie, Andy, and
Heather’s sister, Aunt Rose. Connie’s oldest son Darrin stayed as well and
fortunately we were able to find friends to watch the younger boys. There was
one recliner-type chair in the room and a couple of regular chairs. I found a
yoga mat in Connie’s linen closet that I brought along with some blankets and
pillows. We tried to sleep at least a little bit. I napped on the yoga mat for
a little while but later went to the TV lounge to sneak some sleep on a sofa.
Aunt Rose went to the lounge too, and everyone else stayed in Heather's room.
Wednesday morning, 3 am, Darrin comes into the lounge. He
said, "She’s gone”. I felt my stomach churn (and actually still do as I write
this) and a sense of panic accompanied by horrible guilt. I so desperately
wanted to support my husband and in the moment he would need me the most I
wasn’t there. Damn! I was so angry with myself and thought about that part in
the Bible where Jesus tells the disciples (my paraphrase), "Geez, couldn’t you
guys stay awake for even an hour???”
I hurried to the room. The sadness was almost tangible; the
crying and wails of despair broke my heart. The guilt I already felt was
intensified by my relief that Heather’s struggle was now over. I had prayed
that if God didn’t see fit to heal her could He at least take her home quickly.
My prayer had been answered. I know now and I even knew then that I did not
"want” her to die, but I still felt awful.
After some time a few of us looked at each other having
absolutely no idea what to do next. I went to the nurse’s station to ask and
was given the necessary information. Eventually we gathered our things and left
Heather’s room, an experience that felt somewhat odd and…. I don’t know…
callous? Disrespectful? We waited for the doctor to arrive and make the
"official” pronouncement. She arrived, spoke with us briefly and then finally,
we all went back to the house. At about 7 am I called Vanessa and gave her the
news. Ariel did not take the bus to her
aunt and uncle’s house at that point. Vanessa asked me to keep her informed
about any memorial plans.
Obviously we now had a lot to do, including planning for a
memorial and other preparations. This is a difficult process in any situation,
but it becomes even more stressful when little has been discussed or prepared
in advance. It’s also a very expensive undertaking. Heather had a very limited
income and a sparse life insurance policy. Of course, none of us have much
extra income either so there was the added stress of figuring out how we were
going to pay for all of this. We finally made the necessary decisions at the
funeral home then worked quickly to prepare a memorial service.
Let me fast-forward a bit. We pulled together a beautiful
service for Heather which was held on Saturday morning, November 5th…coincidentally,
the day we had originally planned to arrive in Canada. After the service, which
in large part was scheduled based on our plans to fly back home that Saturday
night, we had lunch with several family members and friends including Vanessa,
Ariel and Brian. We then had to make a 6-drive back to Seattle, return the
rental car and catch our red-eye flight back to Pittsburgh which included a
lovely layover in New York at JFK.
So, why in the world am I writing all of this (and,
honestly, there is MUCH more but this experience is emotionally exhausting)?
Well, it may sound strange but I thought of your class several times during all
of this. So many issues seemed to arise that were either potential ethical
dilemmas or blatantly obvious ethical mishaps. In addition to the ethical
issues involved, there were numerous times that I shook my head and thought
about how things could have been done differently from a therapeutic standpoint.
How could a MFT have approached the situation in a more helpful way? How could
MFTs help to educate medical personnel so that they might better serve their
patients and their families?
These are some of the questions and thoughts I had and wanted
to share with you. Even if you never "answer" me back, I thought it
would be a rare opportunity for you to enter the world of one particular
client/family and consider the ways in which you might encounter these issues
in your own work. I hope that as you contemplate some of these things you find
How do you feel about giving clients information
about "how much time they have left"? Is it helpful, ethical, honest?
Is it potentially harmful?
How can you respectfully bring up issues such as
terminal illness or funeral arrangements/plans with clients and families?
What is the role of hospital staff when it comes
to providing information to clients and families? If it is "bad
news", should they leave that to a therapist? Where should they talk? With/without
How can hospitals provide more respectful and
compassionate care for families without incurring a great deal of expense?
Think about the dilemmas faced by blended
families. What is the role of the non-parent spouse (me) in this kind of situation?
How involved should this person be regarding communication with their current
How much decision-making power should a parent
give to a child? What are your thoughts about Vanessa's perspective regarding the
children visiting their grandmother?
How would you address the intense feelings of
guilt experienced by someone who lost a loved one, including the "I
should/could have done more" statements?
| Comments (3)
Posted By Golnoush Yektafar-Hooshvar,
Wednesday, November 21, 2012
Updated: Monday, December 10, 2012
As a new doctoral student in Marriage and Family Therapy with a concentration on Medical Family Therapy, I have been expanding my understanding of the social context of illness. I have read about the ways in which Western society has placed an important concern on the medicalization of an illness, emphasizes the biological aspects of the physical malady rather than considering the psychosocial-spiritual impacts of illness on the individual and family, and emphasizes the medical provider as the "expert.”
As I continue to learn from the literature about how social context of health impacts health and collaborative care overall, I am also better understanding my personal experiences and how they relate to these ideas.
From the time that I had the ability to comprehend what being "sick” entailed, I came up with a few observations. I often associated "sickness” with medications of sorts, visits to doctors, and feelings of fatigue and irritability. These were the things that I experienced growing up because my father was diabetic and had chronic cardiovascular disease. Ironically, looking at my father’s appearance, he was the epitome of health. A tall and slender man who enjoyed playing tennis and going for daily runs. To my father’s misfortune, the cause of his poor health was based on genetics. My paternal grandparents had both died from sudden heart attacks, and at the time of their death, their social context was a key contributing factor to their inability to gain access to the appropriate medical attention they needed. Living in Iran, a foreign country where the socioeconomic gap between the rich and poor is a problem that still exists today, it was apparent that the wealthy had more privilege in issues related to healthcare access and advanced technologies. Inevitably, these and other social factors prevented my grandparents and father from gaining knowledge on preventative measures when dealing with chronic illness.
Fast forward to three years ago when my father was admitted to the hospital by his primary care physician who after running numerous tests concluded that congestive heart failure (CHF) was the diagnosis. Since my father had a history of chronic cardiovascular illness and diabetes, the doctor informed my family and me that it would be best for him to remain in the hospital overnight. That evening, the cardiologist came in and poked and prodded my father. After asking a few questions, he concluded that the diagnosis of CHF was correct. As he was writing down notes he informed my family that he would be adding a new medication to my father’s existing medication regimen.
I remember the nurse coming into the room late one night and simply handing my father a cup of water and a small plastic container with about ten different pills. This routine continued for another three days, however the morning of the fourth day was different. As I entered my father’s hospital room I was greeted by a primary physician, a cardiologist, and a nephrologist. They all looked concerned and began their interaction with my family by saying that my father may not be released as early as my family had hoped for. With a panicked look on his face and a trembling in his voice, the primary care physician said that according to recent lab results, my father’s kidneys appeared to not be functioning. A new diagnosis was blurted out; they said it was end-stage renal failure and an immediate procedure had to be done in order to insert a fistula so my father could begin hemodialysis. I remember having a million questions running through my mind, but I could not verbalize a single one. As I muttered out a quiet "Why?” the cardiologist said that the only answer he has is that one of the medications that my father was given to treat the CHF had an adverse effect on the kidneys. Since he was diabetic, he already had under functioning kidneys, but the medication had worsened the existing functioning capabilities of his organs. As the three physicians left the room all I kept thinking and questioning in my mind was how a doctor could not know what medication was contraindicated with another.
As I fast forward to one year after that incident, I have experienced my father not only go through the physical disadvantages that result from chronic illness, but psychological difficulties in dealing with the social context of his illness. The way society perceives him as "ill,” the way our family views him, his role in our family system shifting from breadwinner to someone who is unable to work, and a plethora of other setbacks that had contextual factors that were socially based.
Looking back on this experience as a doctoral student who is interested in medical family therapy, I can clearly see the need for collaborative care between physicians and all those involved with the patients. I have learned firsthand how important it is those nurses, physical therapists, family therapists, and anyone else who interacts with a patient work together in order to provide the patient with the best overall care. My hope is that one day, the social context of illness can be transformed in such a way that all medical professionals work collaboratively with other medical caregivers, patients, and family members in order to best treat the whole patient- mind, body, and soul.
| Comments (0)
Posted By Cheryl Holt,
Thursday, January 26, 2012
are numerous initiatives underway that address the primary care needs
of people with behavioral health disorders. It is heartwarming to see
the silos begin to develop cracks, allowing the primary care folks and
the behavioral health folks to engage in serious conversation about how
they can work TOGETHER to serve this vulnerable population.
isn’t easy for two disparate groups to work together. It takes
considerable planning, patience, and commitment. Despite the fact that
both primary care and behavioral health are healthcare fields, they have
vast differences. Their cultures, funding streams, philosophies, and
overall approaches to treatment vary greatly. Therefore, it is not an
easy task for these two groups to collaborate together to serve
individuals with behavioral health disorders….yet they are doing just
that! The mission is far greater than are the differences! It is
worthwhile to devote the necessary time, energy, resources, and focus to
develop strategies for streamlining the integration process. Whether
the services are provided in the primary care clinic or in the
behavioral health clinic, working collaboratively provides enhanced
For a successful behavioral health – primary care partnership, these eight steps that were adapted from "Strategies to Preserve Public-Private Partnership ‘Best Practices’: Keys to Genuine Collaboration” by Greg Schmieg and Bob Climko, will provide the foundation for success:
· ESTABLISH THE MISSION OF THE PARTNERSHIP
is vital for both organizations to sit down together and create a
shared vision. This will likely require a merging of goals into a
partnership mission statement. This mission statement must be
communicated with everyone
involved in the partnership. The success of the partnership will depend
on frontline champions. They need to be identified and empowered from
the onset. They will provide the energy to motivate other team members.
· IDENTIFY A COMMON LANGUAGE
Care and Behavioral Health speak different languages; therefore, a
common language must be identified. Clarity of communication enhances
mutual understanding of cultures, roles, and expectations. While these
differences might not seem important at the onset, it will become
increasingly important as the partnership progresses. Most likely, each
partner has a different language for many things. There are notable
differences between contract deliverables, medical records, coding,
management structure, procedures, and even the language used in
describing the clients/patients/consumers/members/individuals served.
· MAINTAIN PACING, FLEXIBILITY, AND CAPACITY
is very important to temper expectations within the partnership.
Establishing regular meetings will help to promote ongoing
communication. Mutual goals and disappointments should be continually
communicated so that they can be addressed immediately. The partners
must remain flexible in order to sustain a healthy partnership.
· DEVELOP SHARED SOLUTIONS
decision makers must be open to new ideas and problem solving.
Developing shared solutions maximizes organizational efficiency and
capacity. Everyone must have skin in the game! Compromise is important
· DETERMINE EXPECTATIONS
project should first be piloted to allow for evaluation and for
adjusting expectations to ensure that both partners are on the same
page. Internal conflicts are inevitable and should be discussed openly.
The partners must address differences of opinions on an ongoing basis.
Partnerships create an opportunity for enhanced outcomes through
blending of resources to maximize the capacity of each organization.
· DELEGATE TRUST
meetings are essential for establishing and maintaining trust among
partners. Be sure to focus on building trust at all levels. Face-to-face
time creates a forum for maintaining checks and balances to ensure
fidelity to the mission. Constantly solicit feedback from partners at
· CREATE EMPOWERMENT
is dependent on the involvement of everyone. This requires empowering
champions at all levels to move the mission forward. This empowerment
develops buy-in among staff. Communicating with everyone and soliciting
feedback ensures ongoing focus on the mission. Be sure to create a forum
that allows both positive and negative feedback.
· MEASURE OUTCOMES
the outcomes to be measured early in the project. Be prepared to modify
outcomes as needed. Don’t overlook the benefits of partnership that
include more efficient allocation of resources, less duplication of
services, increased choice among clients, and the synergistic effect of
the partnership resulting in enhancing the lives of those we serve.
these eight steps will assist in bridging the innate differences
between behavioral health and primary care to ensure a successful
partnership. Far too many promising partnerships have been derailed due
to poor communication and lack of planning. Careful preparation at the
onset will ensure a productive partnership that will ensure a focused
mission aimed at addressing health disparities among people with
behavioral health issues.
Cheryl Holt, MA, NCP, BCCP
currently serves as the Director of Training and Technical Assistance
with SAMHSA-HRSA Center for Integrated Health Solutions for the National
Council for Community Behavioral Healthcare. She is moderator of the
Behavioral Health – Primary Care Integration Listserv, manages the Behavioral Health Integration blog, and is active in social media: Twitter, @cherylholt and @BHPCIntegration; and Facebook, Behavioral Health Integration
view expressed in the blogs and comments should be understood as the
personal opinions of the author and do not necessarily reflect the
opinions and views of the Collaborative Family Healthcare Association
(CFHA). No information on this blog will be understood as official. CFHA
offers this blog site for individuals to express their personal and
professional opinions regarding their own independent activities and
| Comments (1)
Posted By Ajantha "AJ"Jayabarathan,
Thursday, January 5, 2012
Kentucky had settled into the month of October in 2010, when I arrived there to attend the 12th annual CFHA conference. It was not only my first visit to Kentucky but also my first attendance at the conference and I was ready for an adventure. I expected to hear, see and learn much that was different from my home city of Halifax Nova Scotia.
People spoke with a distinct drawl that was friendly; the skyscrapers loomed; the city blocks hosted an interesting array of monuments and storefronts; the downtown core was both inviting and somewhat dangerous in its layout; and I plunged into this journey of discovery.
I sat with three hundred and fifty other participants at the conference and happened to be the sole visitor from Canada. The candid, direct styles of the keynote speakers and the bold imagination in their ideas grabbed my interest. The sessions were equally rich and thought provoking. I found myself volunteering my comments, answering questions, getting easily acquainted with other participants and even hosted a lunchtime discussion on Compassion Satisfaction!
The members of the CFHA board and their executive team appeared genuinely interested to make my acquaintance and learn about their sister organization in Canada (National Working group on Shared Mental Health Care). And to top it all off, they invited me to join their membership committee, so that we could work towards strengthening ties between our respective organizations. Before too long, I was invited to write a Blog for the CFHA (V-Forming Healthcare), they joined forces with the planning committee in Halifax which was organizing the 12th Canadian Conference on Collaborative Mental Health Care, an entire month was dedicated to blogs written by Canadian authors and they sent email invitations to their membership, promoting the Halifax conference.
Never before, had I experienced such like-minded dedication to promote, advocate and develop the concepts embedded in Collaborative Mental Health care; and it was happening to benefit both Canadians and Americans.
In Canada, the essence of Collaborative Care is currently being embedded in many provincial re-organized health systems as well as the Mental Health Commission of Canada. It is defined in the newly launched 2011 position paper from the Canadian Psychiatric Association and College of Family Physicians of Canada as Mental Health, addiction and primary care practitioners working together, with people and their family members, to ensure that an individual reaches the services they need, when they need them, with a minimum of inconvenience. It is;
- Built on personal contacts
- Based on mutual respect and trust
- Based on effective practices
- Responsive to changing needs with openness to new ideas
- Shaped by context, culture, local resources, shared goals & local solutions
- Contingent upon five key components – Effective communication, Consultation, Coordination, Co-location and Integration
In Canada, this model of care started with psychiatrists and family physicians working together to provide care differently than established traditional models in the mid-1990s. In 2005, this model was expanded to involve 12 other partners in the work of the CCMHI (Canadian Collaborative Mental Health Initiative); pharmacists, nurses, occupational therapists, social workers, psychologists, dieticians and first voice/consumers/people with lived experience.
Meanwhile, in March of 1993, 15 colleagues from the fields of family medicine and family therapy met to develop a better healthcare paradigm in the USA. This model aimed to address pressing clinical and economic problems.
Naming their vision the "collaborative family healthcare model", they formed an organization to bring together those interested in this innovative approach. In July 1995, CFHA held its first national conference in Washington, D.C. It was well attended and received glowing reviews. The Collaborative Family Healthcare Coalition was up and running.
CFHA is a member-based, member-driven collaborative organization. Collaboration isn't just a word in the organization's name; it defines who we are, how we interact with each other and other organizations. We believe deeply that collaboration is an essential element necessary for re-visioning healthcare, specifically, and society, generally.
CFHA promotes a comprehensive and cost-effective model of healthcare delivery that integrates mind and body, individual and family, patients, providers and communities.CFHA achieves this mission through education, training, partnering, consultation, research and advocacy. We not only host a leading-edge conference every year, we also are active in every other aspect of healthcare change: development, design, delivery and assessment.
October 2011 found me in Philadelphia at the CFHA's 13th annual conference. A new city to discover, new colleagues to hear from, a new set of keynote speakers to present material to evoke and provoke new directions in evolving models of care. I presented the 2011 Canadian position paper alongside Dr. Roger Bland one of the other co-authors, and was one of five Canadians at the conference. The Canadian organization and its work were presented as part of the exhibitors, mirroring CFHA's presence at the Halifax conference earlier in the summer.
Collaborative practice is about how we practice together….how we treat each other….how we benefit from each other's perspective and the partnership that we bring to the table so that people and their families are served to their benefit. It is different from traditional team based approaches. To truly "experience” what it feels like, one has to be open to the ideas and diversity of people involved in this model of care.
Your attendance at the annual CFHA and Canadian conferences could serve as a starting point for you. Robust information and the evidence base for this model of care are available on their websites: cfha.net and shared-care.ca. Consider looking at the material on these sites. Consider attending the conferences. Consider these alternative models of care in your practice of primary care and mental health care, and imagine what it could be like……..and you may find yourself in Vancouver, British Columbia in the summer of 2012 and Austin Texas in the fall of 2012…..ready for an adventure……and return awash with new ideas that have fuelled your hidden passion to work collaboratively….and you will have found what now energizes my daily practice of medicine!
Ajantha Jayabarathan (AJ) is a Family Doctor practicing in Halifax, Nova Scotia. She is well recognized in the Atlantic region of Canada due to her columns on television. She is an Assistant Professor at Dalhousie University and co-chaired the organization of the 12th Canadian Conference on Collaborative Mental Health care in Halifax 2011. She also co-leads the advocacy coalition, Healthynovascotians.com
The view expressed in the blogs and comments should be understood as the personal opinions of the author and do not necessarily reflect the opinions and views of the Collaborative Family Healthcare Association (CFHA). No information on this blog will be understood as official. CFHA offers this blog site for individuals to express their personal and professional opinions regarding their own independent activities and interests.
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Posted By Jennifer Hodgson ,
Thursday, December 1, 2011
Updated: Thursday, December 1, 2011
burgeoning success of integrated care brings with it a complicated
by-product. The diverse range of behavioral and mental health
professionals are stepping up to the plate. Many of these
professionals, trained under the "old guard” as competitors in the
market, are now tasked to re-align in the context of a new paradigm. The
following represents insights from a year-long conversation (tongue in cheek) between two friends and colleagues, one a clinical psychologist
and the other a medical family therapist who are in search of a model of
intra-disciplinary collaboration. Dr. Jodi Polaha, Most Awesome Clinical Psychologist (and humble too):
Last fall, I sat through an uncomfortable board meeting. I was charged to
work with a Clinical Social Worker, Licensed Practicing Counselor, a
Counseling Psychologist, and a Licensed Nurse Practitioner to develop an
integrated care training program as part of a rural workforce
development project. Whose students could provide treatments in
behavioral medicine? Whose students could help develop programming?
Whose students understood research well enough to do program
evaluation? "Ours!” I said, smiling.
So did the other professionals in the room.
I shouted in my mind. I tried to keep my facial expressions in check,
but it was hard. Everyone knows social workers help people get food
stamps and find support groups, right? Everyone knows our counseling
friends deal mostly with life-adjustment issues, right? And everyone
knows that clinical psychologists are superheroes, trained in the
scientist-practitioner model, who REALLY CAN do everything…RIGHT?
was challenged by this conversation, and recognized my long-held,
inaccurate stereotypes of other mental health disciplines, including my
own. Still, some questions made me itch: Can mental health
professionals from various training backgrounds work harmoniously in
integrated care? If so, could their roles be interchangeable? Should
I took my questions to Dr. Jennifer Hodgson. Who would know better
than the president of CFHA? Granted, she is a marriage and family
therapist (or medical family therapist as she calls herself these days),
so she lacks the finely-honed analytical skills of a clinical
psychologist. She can pick out a cute suit, though, so I felt it was
worth a try.Dr. Jennifer Hodgson, Supreme Marriage and Family Therapist:
I would like to say, when Jodi Polaha approached me with questions
about intra-disciplinary collaboration, I had to hide my confusion. Why
would a clinical psychologist be concerned about this? Don’t they mainly
do testing and inpatient work with serious and persistent mental
illness? Isn’t their training mainly in one specific area of health or
mental health? What are they doing in primary care? I would not want a
foot specialist operating on my eye, after all! How does she figure she
is a team player with the likes of medical family therapy, who, we all
know, leads the field in advancing integrated care! I know what is
going to happen, she just wants psychologists to take over the
leadership of this integrated care movement. Arguably, they do have
Medicare in their back pockets, but so do social workers. Does that mean
though that they are better integrated care clinicians?
are so many inaccuracies in how different mental health disciplines are
trained that perpetuate the ideas that others are less well trained
simply because of their degree. Why can’t a social worker, pastoral
counselor, professional counselor, or family therapist (had to get my
field in there somehow) run an integrated care service with a blend of
professions present? Of course we can work harmoniously Jodi, but we
first have to be willing to be vulnerable and willing to learn from one
another in the field.
have gotten to a place where I just want all mental health disciplines
to stop figuring out who is best based on degree and to start taking
classes together, training in the field together, and promoting policy
for parity together. We would be even better together…if only we knew
how to share the space. It is the old adage of those who have power want
to hang on to it and those who want it are working hard to get it. I
tell my students that there is plenty of room in the sandbox so no need
to throw sand to create space.
healthcare professionals just want someone who can do the job and
cannot understand why some mental health providers cannot work together
easily. I go back to how people were trained, Jodi, and I believe
strongly that we can be retrained to learn models of integration that
embrace multiple disciplines in the same location. We can share the
work, divide the responsibilities, and promote one another’s strengths.
We can embrace hiring someone not because of the degree, but because he
or she meets the patient population’s needs and has the core
competencies (to be determined) to provide integrated care services.
starts at the training level and I believe CFHA is the place where we
can drop our labels and learn the core competencies needed for the work.
I know my calling is to train the next generation to behave
differently, but it starts with me and sometimes I struggle with it too.
I want to understand why we cannot just drop the entitlements...but as a
systems thinker I know that change happens slowly, thoughtfully, and
organically (with a smidge of encouragement from associations like
CFHA). Dr. Jodi Polaha
funny, in spite of my reaction to that board meeting last year, this
year in Philadelphia, I had so many positive interactions with
professionals from so many varied disciplines. In that forward-thinking
environment, Jennifer, it was truly effortless to meet the spirit of
your ambition for all of us. I learned from social workers, public
policy people, and physicians. I exchanged cards with a school
psychologist from Florida, with similar research interests to my own.
The energy in this mixed group was incredibly engaging and specific
credentials, training history, and even experience seemed to fade away.
In another week, I am off to a clinical psychology conference and,
reflecting back, I feel I was more among "my people” at CFHA than I will
occurs to me that the mental health professionals involved in
integrated care have so deftly cast off the old guard notions about the
50-minute session, the cozy psychotherapy room, and even the term
"mental health.” I’d like to see your vision become a reality,
Jennifer. Perhaps, the stereotypes and competitive dispositions will be
the next to go.
PhD, is a licensed Marriage and Family Therapist, Associate Professor
in the Departments of Child Development and Family Relations and Family
Medicine at East Carolina University, and outgoing President of CFHA. She has
over 18 years clinical experience and has served on numerous boards and
committees related to healthcare and mental health care issues. She is
co-author to the first doctoral program in medical family therapy in the
|Jodi Polaha, Ph.D. is an Associate Professor in the Department of Psychology at East Tennessee State University where her primary professional interest is research, training, and workforce development in rural integrated practice. In addition to her work, she spends lots of time with her husband and two young boys swimming, biking, and hiking in the surrounding mountains.|
view expressed in the blogs and comments should be understood as the
personal opinions of the author and do not necessarily reflect the
opinions and views of the Collaborative Family Healthcare Association
(CFHA). No information on this blog will be understood as official. CFHA
offers this blog site for individuals to express their personal and
professional opinions regarding their own independent activities and
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Posted By Brian Bonnyman,
Thursday, September 15, 2011
finished my residency in family medicine in 1993, and returned to my
hometown to start work in private practice. My office was located in an
affluent suburb, and my patient population reflected that affluence.
The patients were generally well-educated, insured, and motivated, and I
thoroughly enjoyed caring for them. I had several excellent colleagues
in my practice, but we generally worked as solo practitioners under the
same roof, only consulting each other on occasional cases. I call this
the Lone Ranger model of providing primary care, which is typical for
most private practices, and represents the traditional and time-honored
way of doing things.
15 years of work in this setting, I left that practice and started
working across town, at a large urban community medicine clinic. The
zip code of my office location changed by one digit, from 37922 to
37921, but those sites are worlds apart. Now my practice includes many
homeless people, refugees, recent immigrants, and ex-convicts. The
psychosocial disease burden in this population is astonishing,
especially compared to my prior practice. As one person put it, the
main problem for patients at our clinic is not medical in nature, but
that their lives are broken. I have had to dramatically adjust my
expectations for patient compliance and outcomes, and change the way I
practice medicine. Among the many adaptations I have made in this
transition, one of the most pleasant is working as a member of a team
(rather than as a Lone Ranger), side-by-side with psychologists. In my
old practice, if I thought a patient would benefit from therapy, I would
have to give the patient a phone number of a good therapist. I call
this referral method sending a message in a bottle, given the low
likelihood that the patient would follow through on the recommendation.
I successfully convince the patient of the benefit of seeing a mental
health specialist (which is part of the art of medicine), I can now have
a therapist see the patient in the very same exam room after me. I can
get immediate feedback and additional history from the therapist. For
mental health diagnoses, we collaborate on reaching an assessment, with
appropriate treatment and follow-up plans. With this arrangement, we
estimate that 80% of behavioral cases can be managed without further
consultation. This is not too different than the 90% figure that I
always heard represents the percentage of cases seen in primary care
that can be managed without further consultation.
see a significant improvement in the quality of care that I now
provide, thanks to working in a team environment with behavioral health
specialists. Now, if I have a patient that is non-compliant with
diabetes, for example, I can enlist the help of the behavioralist to
help treat a medical condition. Patients that are ready to address
their substance abuse problems can enroll in a treatment program run by
the psychologists. Likewise, I can get patients easy access to
treatments that I have read for years are beneficial for a variety of
difficult-to-treat conditions, but I could never offer my affluent,
insured patients at my prior practice. Motivational interviewing for
substance abuse and cognitive behavioral therapy for fibromyalgia are
having another person get additional historical information from the
patient can improve quality of care, with little additional cost. Since
about 80% of the data I need to arrive at a diagnosis comes from the
patient’s history, every bit of information helps. For example, a
psychosocial condition unrecognized by me, but detected by the
psychologist, can be the key to getting the correct diagnosis of a
challenging case. The patient with hypertensive crisis who admitted his
cocaine use to the behavioralist (but not to me) comes to mind. Rather
than work him up for some obscure cause of malignant hypertension, we
could concentrate on his substance abuse. To paraphrase the old medical
saw, I have learned that when I hear hoofbeats in the hall, it is more
likely to be a horse with a behavioral problem, rather than a zebra!
a clinician experienced in the ways of the Lone Ranger model, working
in a team setting can be difficult in some ways. In a conservative
field like medicine that has a history of less-than-nurturing
educational methods, teaching an old dog (like me) new tricks can be
hard. At times, the learning process can be a challenge to one’s ego,
as when I find that my assessment of a psychiatric condition is off
base. Recognizing that the correct diagnosis is in everyone’s best
interest (especially the patient’s!), and seeing these moments as
opportunities for learning help minimize potential embarrassment.
Having supportive mental health colleagues is a big plus since their
communication and collaboration skills are miles ahead of many of my MD
friends, who aren’t used to working in teams. I now realize how much of
my medical education revolved around intellectual one-upmanship, and
appreciate the importance of creating a mutually supportive collegial
environment in the office.
though, giving up the Lone Ranger role to work as part of a team makes
sense, both for providers and for patients. Heck, even the Lone Ranger
had a Tonto!
Bonnyman works as a family physician with Cherokee Health Systems in
Knoxville, Tennessee. He enjoys treating patients of different
cultures, who cannot easily obtain care elsewhere. Habla un poquito de
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Posted By Tai J. Mendenhall, Ph.D., LMFT, CFT,
Thursday, June 23, 2011
call for interdisciplinary collaboration in health care is a
longstanding one, and our collective efforts to do this are evolving
across medical- and mental health- training programs and care facilities
today more than they ever have. Recent advancements in the Patient
Centered Medical Home (PCMH) movement are arguably pushing team-based
approaches in continuous and coordinated care toward the middle of the
bell-curve, wherein someday soon our integrated models will represent
the rule (not the exception) to how health care is done.
experiences as a clinician and researcher in this exciting time in
health care have exposed to me to a variety of definitions of what
"integrated”, "collaborative”, or "medical home” sequences looks like,
and efforts by the CFHA and others to standardize and clarify these
characterizations are presently underway. However, while common themes
throughout these descriptions encompass the collaboration between
professionals who represent different disciplines (e.g., a family
physician with a marriage and family therapist) and/or the collaboration
between professionals and patients (i.e., encouraging and facilitating
patients to take active roles in their own health), most hallway
conversations, formal presentations, research studies, professional
literature, and clinical work that I have taken part in (or am aware of)
around the PCMH frame patients as adults.
believe that it is important to extend our call to engage "patients” in
collaborative and integrated care to purposively include children and
adolescents. I support this call on two primary grounds:
First, many of the most prevalent and difficult presentations in health
care today (defined as those that are the most common, most expensive,
and/or most connected to co-morbidities and death) begin early in life.
Diabetes, for example, is highly correlated with cardiovascular diseases
(which represent the #1 cause of death in the United States), kidney
disease, reduced or lost vision, amputations, and depression – and is
directly connected to the rising epidemics of childhood obesity and
sedentary lifestyles of America’s youth. Smoking is similarly correlated
with cardiovascular diseases (as well as asthma, diabetic retinopathy,
optic neuritis, influenza and pneumonia) – and most smokers (up to 90%
of them) begin as teenagers or young adults. Put simply, then, it is
easier to prepare than it is to repair. By engaging patients in
health-related activities early in life, it is more likely that they
will avoid experiencing commonplace troubles later on down the road.
Second, the advancements of the PCMH and parallel efforts in
community-based participatory research (CPBR) bring with them a sharing
of responsibility between providers and patients. While providers
maintain responsibility for learning and appropriately using knowledge
in the prescribing of medications or performing medical procedures, for
example, patients maintain responsibility for managing their diets,
physical activity and other health-related behaviors. This is important
to note because it transcends conventional provider/consumer models in
which passive patients are rendered care (i.e., "fixed”) by
all-knowing/all-powerful providers. And just as adult patients must
assume responsibility for their own health within the PCMH, so to should
children and adolescents. As we encourage and facilitate our youth to
do this, a new generation of active (not passive) patients is born.
I have advanced the call for active engagement of youth in health care
across a variety of formal and informal meetings with colleagues, almost
everyone has agreed that the idea carries a great deal of
face-validity. They add that, too, that oftentimes kids (read:
teenagers) will listen to each other more than they will to an adult,
and that facilitating care sequences and/or supportive interventions
that allows for this may offer a great deal.
it’s when my colleagues ask about evidence of such efforts being
effective that I really light up. Beyond the (admittedly limited)
articles that any of us could find through a literature review regarding
youth-engagement in health, I have been involved in several such
projects since beginning my current position at the University of
Minnesota. In my next blog entry, I will highlight some of these
projects – and the extraordinary work our youth can do as we facilitate
their active participation in care.*This is the first of a two part blog on engaging youth in collaborative and integrative care.
Mendenhall is an Assistant Professor at the University of Minnesota
(UMN) in the Department of Family Medicine and Community Health, the
Associate Director of the UMN’s Citizen Professional Center, and the
co-Director of mental health teams within the UMN’s Academic Health
Center / Office of Emergency Response’s Medical Reserve Corps (MRC). He
is the Coordinator of Behavioral Medicine education at the UMN / St.
John's Family Medicine Residency Program, and holds an adjunct faculty
position in the UMN's Department of Family Social Science. Dr. Mendenhall’s principal
investigative interests center on the use and application of
community-based participatory research (CBPR) methods targeting chronic
illnesses in minority- and under-served patient and family populations.|
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