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A View from the Other Side: One MFT's Story of Family, Illness and Loss

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 until later.

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 her dad.

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 these issues.

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 it useful.

· 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 the "patient"?

· 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 spouse's ex?

· 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?

Tags:  family medicine  family therapy  oncology  primary care  terminal illness 

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The Need for Collaborative Care

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.

Tags:  collaboration  family medicine  family therapy  Integrated Health 

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INTRA-Disciplinary Care: Can Mental Health Professionals Work Together in Primary Care?

Posted By Jennifer Hodgson , Thursday, December 1, 2011
Updated: Thursday, December 1, 2011
The 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.

"NOT!” 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?

I 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 they be?

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:

First, 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?

There 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.

I 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.

Most 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.

It 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

It’s 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 be there.

It 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.


Jennifer Hodgson, 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 nation.


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.


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.


Tags:  CFHA  family medicine  family therapy  Philadelphia 

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A Call to Engage Youth in Collaborative and Integrated Care: Part 2

Posted By Tai J. Mendenhall, Ph.D., LMFT, CFT, Thursday, June 30, 2011
Last week In my previous blog entry, I advanced a call to purposively engage youth in our efforts in collaborative and integrated care. As I have spoken-up regarding this topic across a variety of forums with colleagues, most have initially responded with a strong sense of enthusiasm, followed by a want for evidence that such efforts can be effective.

I have been involved in several community-based participatory research (CBPR) projects in health since beginning my current position at the University of Minnesota, and have seen time-and-again how professionals and patients learn new ways of working together that are different from conventional top-down/service-delivery models of care-provision (i.e., wherein professionals learn to function as citizens of the research process (vs. rigid leaders of it), and patients learn to not instinctively look to professionals for leadership or answers (and to instead work to tap resources within themselves and their communities that have heretofore not been tapped)). Generally this process evolves over several months as a new project begins and/or for new members to orient and function within CBPR-principles. However, I have noted that young persons appear to learn and adopt these principles very quickly (usually faster than adults), and they do extraordinary work.

The SANTA project (Students Against Nicotine & Tobacco Addiction), for example, is a health initiative that engages local medical and mental health providers in partnership with students, teachers, and administrators in a Job Corps training site/community to reduce on-campus smoking. The project has endeavored to better understand the causes of students’ smoking behaviors; change the campus environment in ways facilitative to stress-management and boredom-reduction; revise the manners in which smoking cessation and support services are conducted; and establish the project as a sustainable and stalwart presence on-campus. Every facet of SANTA’s efforts is owned-and-operated by its students, which is a driving force behind its sustainability and integration into campus culture. Since its establishment in 2005, campus-wide smoking (including new and established students) has decreased from almost 60% to 36%, and evaluations across several cohorts of students show that smoking rates decrease significantly with prolonged exposure to SANTA interventions (Mendenhall, Harper, Stephenson et al., 2011; Mendenhall, Whipple, Harper et al., 2008).

The ANGELS project (A Neighbor Giving Encouragement, Love & Support) is a health initiative through which adolescents and their parents who have lived experience with diabetes (called "support partners”) are connected with other families (called "members”) who are struggling with the illness. These efforts begin at the time of diagnosis, which occurs almost universally in the context of an emergency hospitalization. It is during this time that the initiative’s teens maintain that they want the ANGELS to connect with members, because the motivation to adopt healthy lifestyles is the highest at a time of crisis. Support partners and members meet in a variety of combinations (e.g., adolescents with adolescents, parents with parents, families with families), and they continue to meet off hospital grounds (or via telephone, e-mail, internet discussion boards) after initial hospitalization. Sometimes members simply need a pep talk; other times ongoing support is offered for several months (Mendenhall & Doherty, 2007; Mendenhall & Doherty, 2005).

Other arenas that I and my colleagues have worked in to engage youth in health care include physical activity, obesity, teen pregnancy, and interpersonal violence. Across all of these initiatives, our youth have risen to the challenge of taking an active part in their own health (Berge, Mendenhall & Doherty, 2009; Doherty, Mendenhall & Berge, 2010; Mendenhall, Berge, Harper et al., 2010; Mendenhall, Doherty, Baird et al., 2008; Doherty, Mendenhall, & Berge, 2010).

So why is it that teenagers appear to have less difficulty in learning how to work with providers in the PCMH and/or in CBPR? Is it because they have not yet been socialized into the conventionally passive patient-roles that are so consistent with conventional Western health care and/or "standard” education? Is it because they have not yet been socialized to presume that "real change” (however defined) takes a long time?

Honestly, I am not sure that it matters. What is important is that we not leave our youth on the sidelines as we advance our efforts in collaborative and integrative care. As we work to engage them, we will bestow in our youth the honor and confidence that they can take responsibility for their health and well-being. Their voice(s) and involvement represent an essential piece to a larger puzzle, and they are up for the task.

References:

Berge, J., Mendenhall, T., Doherty, W. (2009). Targeting health disparities though community-based participatory research. Family Relations, 58, 475-488.

Doherty, W., Mendenhall, T., Berge, J. (2010). The Families & Democracy and Citizen Health Care Project. Journal of Marital and Family Therapy, 36, 389-402.

Mendenhall, T., Berge, J., Harper, P., GreenCrow, B., LittleWalker, N., WhiteEagle, S., BrownOwl, S. (2010). The Family Education Diabetes Series (FEDS): Community-based participatory research with a Midwestern American Indian community. Nursing Inquiry, 17, 359-372.

Mendenhall, T., Doherty, W. (2007). The ANGELS (A Neighbor Giving Encouragement, Love and Support): A collaborative project for teens with diabetes. In D. Linville and K. Hertlein (Eds.), The Therapist’s Notebook for Family Healthcare (pp. 91-101). New York: Hayworth Press.

Mendenhall, T., Doherty, W. J. (2005). Action research methods in family therapy. In F.
Piercy, D. Sprenkle (Eds.), Research Methods in Family Therapy (2nd Edition) (pp. 100-118). New York: Guilford Press.

Mendenhall, T., Doherty, W., Baird, M., Berge, J. (2008). Citizen Health Care: Engaging patients, families and communities as co-producers of health. Minnesota Physician, 21(#12), pp. 1, 12-13.

Mendenhall, T., Harper, P., Stephenson, H., Haas, S. (2011). The SANTA Project (Students Against Nicotine and Tobacco Addiction): Using community-based participatory research to improve health in a high-risk young adult population. Action Research, 9, 199-213.

Mendenhall, T., Whipple, H., Harper, P., Haas, S. (2008). Students Against Nicotine and Tobacco Addiction (S.A.N.T.A.): Developing novel interventions in smoking cessation through community-based participatory research. Families, Systems & Health, 26, 225-231.



Tai 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.

Tags:  Behavioral Health  family therapy  medical 

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Medical Family Therapy Intern Part II: How do I Help?

Posted By Lisa Zak-Huner, Wednesday, June 15, 2011
November 2010:

It’s a typically non-typical day at the family medicine primary care clinic. ALL my morning patients show up. That must be a record! More often than not, my patients no-show. That’s just one of the changes I’m getting used to working here. As I’m working to fulfill my university’s graduation requirements for clinical hours, I sometimes feel stressed when patients do not show. Other times, I am quite relieved to have some time to write case notes, consult with other providers, process, and maybe catch a bite to eat. It feels like a roller coaster.

After this morning, my head is as full as my caseload. At maximum, I have about 5 minutes between sessions to digest what just occurred with one patient and prepare for the next. This particular day, I’ve switched therapy rooms twice- conducting therapy in two of the faculty physicians’ offices. The clinic serves a very high needs population- low income, immigrant, severe psychosocial stressors, complex health concerns (diabetes, chronic pain, GI problems, renal failure, obesity etc), non-English speaking, severe mental health issues (PTSD, severe depression, severe anxiety problems) etc. So, I sometimes pray for the days in grad school where a couple’s ‘only’ problem was infidelity.

In the past four hours, I have worked with someone who has severe depression, anxiety, and alcoholism. The depression is so severe that we mostly sit in silence. The patient struggles to make eye contact and stutters out a few short sentences while staring out the window. The safest topics to discuss include children, the weather, sports, and plans for the weekend. I feel like it’s a combination of an interview and an awkward conversation with a stranger. I wonder how this has been helpful for the past 5 weeks. My head tells me this must be or the patient would probably not keep coming. Regardless, I feel uneasy. Even with all my knowledge of projection, transference, and counter transference, I can’t help but feel depressed and anxious as we leave the office.

Another patient is struggling with chronic pain from an old injury. She retells the same story about medical mismanagement of her pain. I can almost recite the ten year history with her. Most of session is spent validating feelings of mistrust, deceit, hurt, and skepticism. I think back to Arthur Kleinman’s book Illness Narratives. Conceptualizing her story from this perspective helps guide our sessions, my suggestions to her physician, and my sense of competence. The anxiety and depression from session one has waned. Instead, I want to feel comfortable with the repetition and make sense of it. I come back to the same question. Am I helping? How? It certainly doesn’t feel like I’m pulling much from the different models of family therapy I learned that are supposed to guide my interventions. No time to process that- the next patient is here.

I spend the next two hours in another crash course on Hmong culture. One patient’s depression and suicidality have decreased, but perhaps only me and her primary physician notice. The depression remains severe. I go with my gut on this one. Teach me about your culture, I ask. If I don’t understand what guides your interpretation of past and present experiences, therapy won’t be the most effective. The patient’s normally flat affect disappears a little and I see a small amount of brightness. Even though we’re working through an interpreter, (which normally seems to slow down the process) the session flies by. I’m soaking up everything I’m learning, and the patient is very interactive. I’ve gone from feeling uncertain and somewhat uncomfortable about the first two sessions to feeling like I’m on track.

The next patient is new and not really sure what I do and how I can help. It ironically parallels my own general feelings this fall. We talk (again through an interpreter) about what the primary physician recommended for treatment and how she’s described my role. The patient is not very clear, and my explanation does not seem to clarify anything. However, since the physician has said I can help, she is more than willing to keep returning for future sessions. Right now, I’m not sure where to head with her case either.

The rest of the day flies by. I try to make sense of what happened during the morning. Over lunch I balance supervision, food, case notes, and more spontaneous consultations with other clinic staff. During the afternoon, I switch gears. I’ve gone from provider to teacher. I walk into the precepting room to see which resident I have not shadowed and evaluated. I ask one if I can tag along for the afternoon to help him get his patient-centered evaluations out of the way. We don’t know each other well since our time at the clinic hasn’t overlapped much. I don’t know what to expect or how he might view a mental health intern serving as a mental health preceptor for the afternoon. I’m acutely aware of the power dynamics- I am younger, female, an intern, and a mental health professional. I’m also still learning what I can offer in the world of medicine and how to do it. Everything I’ve learned in theory is being tested. In all, we see about ten patients ranging from well-child checks to chronic pain, tension headaches, and diabetes management. By the end of the day I am exhausted. I’ve gone up and down, riding a roller coaster of stress, emotions, and feelings of incompetence versus competence.


Today:
This blog feels long, overwhelming, pressured, and too detailed. Perhaps it’s the perfect way to communicate my experience. I can’t edit these days. They occur in full force- fast, detailed, and sometimes overwhelming. I’ve learned how to ride the roller coaster a bit better. I’m far from being comfortable, but I know how to hold on and not get sick. And every now and again when it takes an unexpected turn, I get excited. I don’t panic. I hold on tighter, lean into the curve, and look around. Just as the roller coaster drops, I relax a little. Through this, I see how I can help and am reminded of why I enjoy this work.


Lisa Zak-Hunter, MS is a doctoral candidate specializing in family therapy at the University of Georgia. She is currently completing a behavioral medicine internship with the Department of Family Medicine and Community Health at the University of Minnesota. Her main clinical, teaching, and research interests lie in the realms of collaborative health care and increasing biopsychosocial understanding of mental and medical health conditions. She has a particular interest in adult eating disorders.

Tags:  family therapy  medical 

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