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Caring for the system: The importance of integrated care for patients and loved ones

Posted By Aubry N. Koehler, Tuesday, April 30, 2013

This past fall, the European Heart Journal published an article on the increased risk of depression, anxiety, and suicide for spouses of partners who had suffered heart attack within the past year, when compared to spouses of partners with other hospitalizations (Fosbøl et al., 2012)

To family-oriented clinicians, this comes as little surprise. The burden of medical crisis is carried not only by patients but also by their families and communities, especially when need for caregiving requires shifts in household and occupational roles. Beyond the biological and logistical components, patients and families must also cope with accompanying emotional, psychological, social, and spiritual ramifications of crisis which can manifest as feelings of confusion, hopelessness, fear, and isolation. And, as Fosbøl and colleagues suggest, there may be something particularly distressing about a loved one’s heart failing him or her.

While we have been trained to look at the systemic impact of health and illness, the medical contexts in which we work are just beginning to adopt this lens. The rise in the popularity of patient-centered medical homes where patients can receive their medical and behavioral health treatment from collaborating providers under one roof is a move towards health care that considers the biopsychosocial needs of the patient.

However, even adoption of a systemic lens in health care is taking place within an individualist paradigm. Electronic health records are not set up for charting relational cases and insurance companies require providers to bill under a single identified patient.

Does this sound like
a revolution to you?

A paradigm shift?

I hope so.

 But let us not scapegoat the medical context. The individualist paradigm pervades the majority of US institutions and is a paradigm that we and the public generally endorse and enact in our day-to-day lives. As consumers, I believe we are not only subject to institutional constructs, we also have a hand in how institutions are constructed and adapted. We all have some degree of agency—albeit, less or more depending on our socioeconomic power and privilege—in changing health care through the policies we support, the health care resources for which we advocate, and the ways in which we access these resources.

The fact that national media reported Fosbøl and colleagues’ findings is perhaps an indication that this is news to the public. Consumers may not consider the ways in which medical crises in family members can impact their physical and emotional wellbeing. Without structures in place to offer relational treatment, consumers may not think to request family support. Further, even if they do recognize a need for behavioral health support, it is unlikely that family members of ill loved ones will have the energy or time to advocate for themselves in the midst of crisis.

So, what can we do as practitioners to help patients and families access medical and behavioral health support? We can start by continuing to carry our own systemic lens into all of our encounters with patients, families, providers, and medical staff. We can educate patients and families about the relational impact of illness in a loved one and connect them with resources, as needed. We can also be a part of advocating for changes in medical and behavioral health care delivery at the administrative level in the medical contexts where we work and on the level of the state and federal policies that will best support these changes.

We still have a great deal of work to do in substantiating our relational approach to health care. While the merits of this approach may seem obvious to us and others within our field, we need to show everyone—from policy makers and insurance company executives to the general public— how needed this kind of approach is and the positive health care outcomes to which it can and does contribute.

Does this sound like a revolution to you? A paradigm shift? I hope so. Imagine a world in which our medical contexts are set up to treat the family as a whole. Where family members are educated about the relational impact of illness in a loved one on their own wellbeing and not only have resources available to them, but feel comfortable reaching out and accessing those resources. Better yet, imagine a world in which those resources are offered automatically to families experiencing medical crisis, so they can then use their agency to opt in or out of receiving them. Let us as practitioners help to envision and evolve a system that reaches out to the whole network of hearts that makes up our world.


Fosbøl, E. L., Peterson, E. D., Weeke, P., Wang, T. Y., Mathews, R., Kober, L., Thomas, L., Gislason, G.H., and Torp-Pedersen, C. (2012). Spousal depression, anxiety, and suicide after myocardial infarction. European Heart Journal, 34, 649-656. doi:10.1093/eurheartj/ehs242


Aubry Koehler, MA, LMFTA, is a first-year Medical Family Therapy doctoral student at East Carolina University in Greenville, NC. She has interned as a behavioral health specialist in integrated care settings over the past two years and is especially interested in the impact of chronic illness on the family system, culturally sensitive care, and closing health disparities. Aubry earned her Master’s of Arts in Marriage and Family Therapy from Antioch University New England in 2012.

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