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Growing MedFT and Growing Pains

Posted By Randall Reitz, Monday, December 12, 2011
Updated: Monday, December 12, 2011

I had the great fortune of having Wendy Watson as my doctoral chair at BYU. She and her Canadian colleagues formulated Systemic Belief Therapy. SBT was one of the first family therapy approaches specifically targeted to medical family therapy (although the Canadian nurse triumvirate just cringed at my MedFT reference).

SBT was a great fit with my other favorite postmodern approaches: narrative therapy and solution-focused therapy. Coming out of grad school I thought these models were sufficient for everything I would see in medical clinics. As a post-modern therapist I was:

  • Opposed to psychopathology (that’s not encopresis or schizophrenia, it’s sneaky poo and the in-the-corner lifestyle);
  • Skeptical of psychotropicmedication;
  • Hyper-sensitive to physician privilege and the power of the gaze in "La Clinique”;
  • Convinced that behaviorism was inhumane.

My internship quickly disabused me of these assumptions. Now 11 years later I still follow many of the post-modern assumptions and I teach residents solution-focused therapy. However my day-to-day therapy would make Skinner smile and I model motivational interviewing and CBT for my residents.

All is not lost, however, I am still acutely aware of the influence of families and am often successful at turning individual referrals into systemic interventions. I still draw genograms for my new patients, but haven’t yet figured out how to integrate them into the EMR.

My guess is that my experience is not unique among medical family therapists—especially among MedFTs who were trained before MedFT existed. In some ways family therapy is a perfect fit for medical settings and in some ways it is severely lacking.

Please take a minute and add your thoughts about the family therapy models that caught your fancy in training and on how you’ve had to either adapt them or abandon them to fit within the medical culture. What other models of therapy do you find most helpful?

Randall Reitz is the out-going Executive Director of CFHA and the Behavioral Science Faculty at the St Mary's Family Medicine Residency in Grand Junction, Colorado.  He family therapy at Brigham Young University and Indiana State University.

He is the author of CFHA's CollaboBlog.

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Comments on this post...

Jackie M. Williams Reade says...
Posted Monday, December 12, 2011
So true! I was trained in Narrative Family Therapy and felt so frustrated that I couldn't make it fit well in the quick pacing of integrated care. Solution-focused and MI became my go-to theories. I am reading the Beliefs book now and am looking forward to hearing more about their theory! Thanks for the post!
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Barry J. Jacobs says...
Posted Thursday, December 15, 2011
I went to the doctoral psychology program at Hahnemann University, a hospital-based health professions school in Philadelphia, from 1985-1900. This was in the waning days of the great blossoming of family therapy in the City of Brotherly Love. I trained in structural and strategic family therapy approaches with many of the folks (including Harry Aponte) who had worked side by side with Salvador Minuchin at the Philadephia Child Guidance Clinic before he left town around 1977. At the same time, I trained in psychodynamic approaches to family therapy, especially contextual therapy since Ivan Boszormenyi-Nagy himself was a professor at Hahnemann. In addition, I had an Argentine-born famly therapist named Susanna Bullrich who had just come to Hahnemann from Milan where she had studied Milan Family Therapy with Mara Selvini Palazolli. All these varied mentors gave me a breadth of approaches to draw on.

So what happened when I took my first job on a traumatic brain injury unit at a physical medicine rehabilitation hospital, working with the families of teenagers who'd smashed their fragile cortexes in drunk driving accidents. I quickly found that my varied background was nowhere up to the task of guiding me in my efforts to comfort these severely traumatized family members.

There was no Medical Family Therapy book by McDaniel, Hepworth and Doherty. I wasn't yet aware of the work of John Rolland. Instead, as I searched the stacks at the Hahnemann library looking for something useful, I came upon the work of those two Texan family psychiatrists, now largely forgotten, W. Robert Beavers and Jerry Lewis. These are the guys who'd devised the theories about centripetal and centrifugal forces in family development and family crises. I grasped readily that, during a time of adolescent centrifugal family movement, the advent of a traumatic brain injury was a sudden, strong centripetal force that brought family members up against one another in tightly bonded, anguished knots of despair. It would take months, sometimes years, of neurological and rehabilitative recovery before the adolescent could again start moving away from the family with the blessings of cautious but hopeful parents and siblings..

Later, of course, I learned about agency and communion, concepts that seemed to cut across the structural and psychodynamic approaches that I'd learned. But at first, it was Beavers and Lewis that gave me a clue about providing medical family therapy in this intensely wrenching setting.
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Jennifer Hodgson says...
Posted Friday, December 30, 2011
I recommend all my students read the beliefs book although I would love to see them come out with something reflecting today's healthcare climate.!

Therapists working in medical settings cannot hold tightly onto their 50 minute session idea and need to think about how they can be effective in smaller doses. More of something is not always a good thing (i.e., sugar in tea.....going against Southern Sweet Tea tradition). Being with families in healthcare requires a skill in facilitating a meaningful therapeutic encounter that is focused, coordinated, and realistic to the time. Not every patient encounter should end with a referral to traditional therapy where the real work can begin. We need to learn how to adapt our models to the healthcare setting...some work better than others.

I think gone are the days where we can train students like Jackie in the use of approaches that do not translate well into intergrated healthcare settings. I am a narrative therapist too by training but I have found cognitive-behavioral, solution-focused, and and some structural family therapy to work best in briefer formats. Motivational Interviewing is a wonderful resource for helping patients to move toward health behavior change.

That brings be to another point...we prepare mental health providers to focus on pathology and the billing industry for healthcare requires a mental health diagnosis. However, there are so many opportunities in patient care to help them move toward biopsychosocial health that we need to strengthen the overall skill set in health behavior change.

We need to walk with our healthcare colleagues and find models that adapt well into healthcare culture. What we need are bigger exam rooms with more chairs so we can work with families! Then we can start to design models that work well in these settings...and study the ones we have to see if they hold up to the unique contextual demands of working in a healthcare context.

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Matthew P. Martin says...
Posted Friday, January 6, 2012
This has been a fascinating dialogue to read. As a pre-doctoral medical family therapy intern in New Hampshire, I too have had to adjust my family therapy techniques to the fast-paced rhythm of primary care. However, most of the techniques I use now are more aptly labeled behavioral health or psychology interventions. Like some of you, motivational interviewing, CBT, structural family therapy, and solution focused therapy are all approaches waiting anxiously in my behavioral health consultant tool box.

I have concluded that though some family therapy techniques may not fit necessarily into primary care, a systemic viewpoint (i.e., biopsychosocial) serves me very well in assessing and treating my patients. I can ask questions about how family members impact/are impacted by a health behavior; I can use MI to determine how much a patient is willing/ready to ask a partner to help them with their diabetes; or I can use SFT to help a family member recognize what has worked in the past to get a patient to attend medical appointments. I can even use structural therapy (i.e., enactments) when involving a patient and a provider in a conversation about their relationship. This is where I believe medical family therapy makes a big impact, the purposeful inclusion of systemic thinking.

On a side note, another therapy model that I have recently discovered and found useful (albeit not a family systems approach) is Acceptance and Commitment Therapy. Two terrific books that were written for primary care are based on this model (ACT). "Behavioral Consultation and Primary Care" by Pat Robinson and Jeff Reiter and "Real Behavior Change in Primary Care" by Pat Robinson, Kirk Strosahl, and Debra Gould. Excellent resources on a model that fits well for integrated primary care. Check them out!
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Randall Reitz says...
Posted Monday, January 9, 2012
Matthew, Thanks for your thoughts on this issue. One thing that can be concluded from your comment and the others is that a "generalist" practice is preferable in primary care and (to borrow from my GRE preparations):

Grad School : Theory Loyalty :: Real World Primary Care : Eclecticism
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