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.
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.|
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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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Posted By Lisa Zak-Huner,
Wednesday, June 15, 2011
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.
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.
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
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.
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.
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.
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
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.
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