This is the first in a three-part series on personal stories of caregiving. Come back later for more.
I began as a caretaker for my mother during my adolescence. Although, she was diagnosed with MS some years before, when I was in middle school. Strangely enough there was no conscious or intentional decision for me to become my mother’s caregiver, it just happened. Perhaps it was our close mother-daughter relationship, being the youngest child, and/or a female that made me prime caregiver material. Nonetheless, as her health steadily declined and she loss more functional capacities, my role as her caregiver grew.
Caregiving for my mother has spanned about 3 decades. Initially, I would help with bringing in groceries, which then turned into meal preparation. And over the course of multiple emergency room visits for falls and routine medical appointments I became my mother’s healthcare advocate. I would remember to tell the medical providers about her recent falls, motor declines, and any cognitive or memory changes that occurred between appointments. Through the years my mother was also diagnosed with high blood pressure, high cholesterol, gout, and transient ischemic attacks. I researched her diagnoses, asked questions about her medications, and urged for specific treatments.
Eventually, it was the progression of the neurological disease that took her from walking with many rest breaks, to using a cane then a walker, and now to being fairly wheelchair-bound. With the disease’s progression, I provided greater assistance in the home, helping her with hygiene care and performing other daily living activities. The worsening symptoms morphed my highly active, roller skating, dancing, playful, and energetic mother into a sedentary and at times melancholy version of herself.
Unsurprisingly, there were times of significant stress as a caregiver. One of the most difficult times of caregiving for my mother is when she had knee surgery. She was in such severe pain it was palpable. When she had to use the bathroom it was one of the most excruciatingly distressful experiences of my life. Hearing her shriek in pain and tears running down her face, as a result of the agony that she was enduring evoked simultaneous suffering inside of me. Once she was settled back in bed, I would exit the room, and walk the hospital halls to cry without my mother seeing me.
My mother’s health necessitates a high level of support and care. Attempting to provide much of her care and support led to signs of caregiver fatigue. Particularly, I began to say, “I have nothing left to give.” But what I came to realize through the support of friends and family was that I still had something, actually a lot, to give. But I could only continue to care for my mother, if I decided unapologetically and without introspective judgment to care for myself. This led to me developing greater boundaries and learning how to say “no.” And rather than delegate to other family members, they simply stepped up when I was unable to. I learned that instead of being that adolescent caregiver that quickly jumped into action, I had to slow down. The evidence of positive results provided me with reassurance myself that I could save something for me and my mother’s needs would still be met. Undoubtedly, it still becomes rough and those are the times I have to recalibrate and ask for spiritual, emotional, and physical support; often enlisting my partner, family, and friends. I suppose, I learned how to be cared for, rather than the one always caring for my mother or others. Growing in this way as a caregiver has sustained me.
In turn, this has also helped strengthen and encourage my mother. Now she is more willing and able to endure medical issues that arise. This can range from motor functioning setbacks to autoimmune conditions that develop. Moreover, reliance on the power of our spirituality has allowed us to be more adept at acceptance, tolerance, and flexibility with health issues that arise. For instance, when my mother needed a higher level of care and was transitioning from independent to assisted living. Initially, we both were filled with emotions. My mother with despair, anger, and grief over what this change meant for her sense of autonomy and connection to our family. Whereas, my inner turmoil was a battle between guilt and logic about not being able to be my mother’s sole caregiver. We worked through the emotions and were able make peace with her transitioning to assisted living because it allowed for the care we both needed.
My experience as a caregiver to my mother is a gift. It undoubtedly led me into my current profession within integrated healthcare as a psychologist. Of more worth, I have acquired experiential wealth, in being able to relate to, understand, empathize, and build rapport in some special ways with patients and their families. I feel honored, in being able to act, on some miniscule level, as a healer of sorts. Everyday I am given opportunities to heal (we all are). To act in some way of compassion and helpfulness, coupled with my psychological training, to care for others. In major ways, I've been working ardently to continue applying this inwardly. Ultimately, to be a caregiver for others, I have learned that I have to have great care and compassion for myself.
Lucia J. Stubbs, Ph.D., Licensed Psychologist, currently provides psychological services as a behavioral health consultant at a clinic in Madison, WI. Lucia has a breadth of experience including the provision of psychological assessments, health psychology, and general outpatient psychotherapy with children, adults, and families.
Lost in today’s healthcare headlines about social determinants of health, such as housing, transportation and food insecurity, is greater attention to the original social context of most of our health habits—family. Insurers and health systems are turning toward engaging patients’ family caregivers as another means of decreasing healthcare costs.
It has been a slow turn, to be sure. Despite decades of family systems thinking and clinical approaches, healthcare remains predominantly patient-centric in its policies, practices and research. But the need to reduce hospital readmissions and institutionalization rates are beginning to prod large systems to create more robust family caregiver support programs, especially in geriatric, home medicine, dementia, hospice and palliative care. The logic behind these moves would seem indisputable, given America’s aging population and higher incidence of chronic and serious illnesses and functional deficits. By bolstering the know-how and resilience of family caregivers, insurers and health systems are hoping older adults’ illnesses and disabilities will be better managed at home and therefore require less intensive and expensive services.
Many of these efforts seem to incorporate principles derived from evidence-based dementia caregiver support programs, such as REACH-II and the New York University Caregiver Intervention, during the past 30 years:
A patient- and family-centered care philosophy: There is recognition that spouses and other family members play key roles in communicating with healthcare professionals, picking up medications, buying and cooking healthy foods, and overseeing treatment plans as they are implemented in the real lives of patients in their home settings.
Formal and structured family caregiver support programs: Much of what passes for family intervention in healthcare is still informal and reactive: Physicians or nurses express concern about a troubled or difficult family member and then social workers scramble to make brief interventions. In contrast, the new family caregiver support programs strive to explicitly engage the patients’ family members early on as a normal part of comprehensive care. They use family caregiver navigators—distinct from patient care coordinators—who focus solely on caregiver needs for guidance, support, education and, in some instances, emotional counseling.
Formal and timely caregiver assessment: Like with traditional healthcare, these new programs ask about who’s in the family and solicit questions about the patients’ medical conditions and treatments. But they go beyond that, evaluating family members’ knowledge, abilities and willingness to participate in care, in addition to their degree of emotional distress with instruments such as the Zarit Caregiver Burden Scale, the Benjamin Rose Institute Caregiver Strain Instrument, and the American Medical Association Caregiver Self-Assessment Questionnaire.
Linkage to community-based organizations: To address all social determinants of health, healthcare and social services agencies need to more closely coordinate their helping efforts. For a more family-engaged healthcare, that means hospitals and outpatient clinics make earlier referrals with close follow-up to local Area Agencies on Aging and local chapters of disease-specific organizations such as the Alzheimer’s Association.
So who are the national players in this emerging trend?
--Twenty-six states now have contracted with managed care companies (e.g., United Healthcare and AmeriHealth Caritas) to manage the healthcare services for their Medicaid recipients. That includes so-called “dual eligibles” (older and disabled patients with Medicare and Medicaid) who are receiving Medicaid Long-Term Services and Supports (home- and community-based services and nursing facilities). To hold down costs, some of these managed care insurers have been experimenting with various means of better supporting family caregivers in order to forestall or prevent patients’ hospitalizations and placements in institutions. A November 2017 AARP Public Policy Institute report (see link below) describes some of these innovations, including increased caregiver engagement, assessment, respite and instruction.
--Dementia--unrelenting and without current medical cure—is the costliest of all American diseases despite the fact that over 70% of dementia patients are primarily cared for by unpaid family members. If these family members falter because of the rigors of dementia caregiving, then patients quickly wind up in emergency rooms, hospitals and skilled nursing facilities. It’s no surprise then that dementia caregivers are the target for many enhanced family engagement endeavors. Baylor Scott & White in Texas ran a pilot study that created individual care plans with caregiver supports, including a $750 month stipend for home care services. The results were improved overall functioning and decreased ER and hospital use for both the dementia patients and their family caregivers. Similarly, Alzheimer’s Greater Los Angeles helped create the Dementia Cal MediConnect program for dual eligibles which aims for better detection of patients with dementia, better working relationships between health systems and family caregivers, and better partnerships with dementia-specific community-based organizations.
--Geriatric/palliative medicine and family caregiving go hand in hand. WellMed, a large network of ambulatory facilities in Texas and Florida for Medicare subscribers, has caregiver specialists that reach out to family members at the time patients are admitted to its palliative care program. It offers them home visits, a telephonic support and education group, and an 8-session stress management program that has been found to lower caregiver burden and depression.
--At Dignity Health Central Coast in California, the family caregiver navigator makes an initial home visit to bring a caregiver gift basket and conduct a caregiver assessment before offering a range of services, including care coordination, a stress management program, and referrals to community agencies. She collaborates with promotores or community health workers to provide the caregivers with increased logistical and emotional support. The results: Decreased caregiver depression and reduced patient ER and hospital utilization.
These fledgling programs are noteworthy but rare. Other health systems have yet to follow suit. While Medicare ACOs have proliferated in recent years, few have implemented enhanced family engagement. And even with the existing programs mentioned above, few are employing providers with family systems training, such as medical family therapists.
But as long as America continues aging and value-based care spreads, family caregivers will inevitably play a larger role. It will be no longer adequate for clinicians to marginalize families or take their efforts for granted. The standard of care will require more of everything--education, support, guidance and, most of all, a spirit of partnership.
Barry J. Jacobs, Psy.D. is the author of The Emotional Survival Guide for Caregivers (Guilford, 2006), co-author of AARP Meditations for Caregivers (Da Capo, 2016), and the Director of Behavioral Sciences for the Crozer-Keystone Family Medicine Residency Program in Springfield, PA. In August, he will leave family medicine after nearly 24 years to become a healthcare consultant for Health Management Associates.
Quick! Describe someone with an eating disorder (ED). What characteristics come to mind? Caucasian, female, young, perfectionistic, controlling, secretive, thin? Did you hit the major stereotypes? If so, you’re not alone. However, you’d be missing a bigger part of the picture. Although anorexia is still the most common eating disorder among non-Hispanic Whites, when all three disorders (anorexia, bulimia, and binge eating disorder) are examined together, ethnic differences disappear. EDs are about equally common among White, African American, Asian, and Hispanic groups. While more women still report having an ED, about 1/3 of patients are men (Hudson et al., 2007; Wade et al., 2011). It’s not just a woman’s disease! Additionally, EDs continue to rise in adults, particularly middle aged women. The reasons for developing or worsening a pre-existing illness in adulthood vary: job stress, pregnancy, family conflict, loss of parents, desire to maintain a youthful look, etc. What’s most concerning is that symptoms in adults can be more severe than in adolescents, requiring a keen, attentive assessment and treatment plan.
When EDs are addressed early, outcomes generally are positive, with around 80% of patients achieving remission. However, if an ED is first treated 15 years after symptom onset, which may be true for adult cases, full recovery rates fall to 20%. Importantly, results vary by diagnosis, and the prognosis for binge eating disorder is better than bulimia, and both are better than anorexia. Complete recovery rates for anorexia are low. Many people with EDs will describe them similarly perhaps to someone with substance abuse- the disorder is something you have a relationship with and learn to manage, it never really leaves. The best chance someone with an ED has to be the one in control of that relationship is early detection and multidisciplinary intervention.
A key component is family involvement. Family inclusion in youth eating disorders is so helpful that it is fairly common part of treatment. I doubt many readers would disagree that addressing family concerns /family involvement in general pediatric care is integral. However, care sometimes appears less family oriented in adult patients, with any condition. Think about it, who is most likely to come to the doctor’s office with a family member? Children, the elderly, and those with disabilities-essentially, anyone with a caretaker. Rarely in my primary care clinic do I see an adult patient accompanied by their significant other. Adults come alone-despite having family members who are also impacted by the patient’s functioning and illness, and vice versa.
Similarly to other diseases, intimate relationships offer an important context for eating disorders to fester or improve. On the positive side, patients say that their relationship can help decrease symptoms and give them more motivation to change and seek treatment (Bussolutti, 2002). Negatively, patients fear their partners might misunderstand, reject, or judge them. Sometimes, patients will use their disorder to gain attention and attraction, or protect themselves. So, symptoms might get worse if a patient is feeling neglected (Zak-Hunter& Johnson, 2015, Newton et al., 2006; 2005). Partners generally feel at a loss and struggle with how to provide the best support. They may even develop their own mental health problems. Some early trials of multimodal treatment for anorexia that includes cognitive behavioral couple therapy, are showing improvement in patient symptoms, partner depression/anxiety, treatment drop-out rates, and relationship functioning (Baucom et al., 2017). Essentially, if an adult patient in an intimate relationship has an eating disorder, it’s imperative that we, as healthcare providers recognize the patient needs to have their partner included in treatment.
Consider the following case both without and with family centered care.
Joe is a 45-year old male with binge eating disorder. This was discovered during treatment for his type II diabetes.Joe did not start bingeing until his diabetes diagnosis 5 years ago. He never shared this with anyone because he was ashamed. After 5 years of poorly managed diabetes, blood sugar checks that didn’t always make sense, and medication changes that had little effect, his physician was feeling frustrated and confused. Joe had to be lying about his intake or how he was taking his medicines. Over a few appointments, she asked Joe to explain some of the very high readings. After he couldn’t, she asked him to keep a log. Although Joe had done this in the past, he was tired of hiding and put his binges in. At the follow up appointment the physician asked their behavioral health consultant to step in and help with diagnostic clarification and recommendations. The BHC asked a number of questions related to history, current symptoms, triggers, and Joe’s treatment preferences. They decided to get Joe connected with a local therapist who specialized in binge eating disorder and have him seen by his medical team on a more regular basis. Eventually, Joe’s diabetes numbers began improving. However, they noticed over time that Joe was becoming a little more irritable. He shared that since he was bingeing less, he noticed he didn’t have a good outlet for his marital stress- the bingeing had both distracted him from their conflict and given him much needed alone time away from their home.
It’s not uncommon for a change in one part of the system to impact the rest. Let’s rewind to when it became apparent that Joe may have binge eating disorder. Both the BHC and physician could have asked questions related to how things were going at home, how he thought his bingeing affected his wife or marriage, commented that chronic illness (i.e., his diabetes) disrupts the entire family and asked how he thought everyone was dealing with it or interacting with him because of it. They could have encouraged him to bring her to therapy to help her understand his disease, how to support him, or to address any underlying concerns related to their relationship, his binging, and/or his diabetes.He even could have brought her in to meet his medical team so they could answer any questions she had about his conditions. Using this approach, it may have become apparent earlier that the bingeing had a secondary effect for Joe, and appropriate intervention could have started.
Eating disorders can be tricky to find and tricky to treat. If you detect one in an adult, realize this may not be new, and time is of the essence. Ask questions related to how well they are functioning in their intimate relationship and what role the disorder plays in the relationship. Understand that it is likely they will have better outcomes if their partner is involved. Then, intervene appropriately- make sure that partner is actively involved in treatment. Remember, the whole is always bigger than the sum of its parts.
Lisa Zak-Hunter, PhD, LMFT is Director of Behavioral Health with St. John's Family Medicine Residency at the University of Minnesota. Her interests include provider wellness, family centered care, primary care approaches to adverse experiences and trauma, and adult eating disorders.
This piece was originally published on the Huffington Post. Please click here for the original post. Reprinted here with permission.
The national narrative on family caregiving has been largely negative. Not a week goes by without the publication of a new caregiver memoir about how trying it was to care for a parent with dementia. Not a month elapses without some news item of a caregiver killing his care recipient and then himself somewhere in America. The websites of caregiver advocacy groups add to this negative impression with a steady stream of reports about the effects of caregiver stress among different cultural groups struggling with various kinds of arduous caregiving. It is enough to discourage any family member from taking up the caregiving cudgel or, at the least, to approach it with fear and dread.
But a counter-narrative is starting to emerge. A survey by the AARP Public Policy Institute released in early November (https://www.aarp.org/content/dam/aarp/research/surveys_statistics/ltc/2017/family-caregiving-roles.pdf) found that—though more than half of caregivers are stressed and worried and 40% feel overwhelmed—over 90% of them say they are pleased about helping a loved one and that almost 90% of those loved ones are grateful for their caregivers’ efforts. The survey also pointed out that caregivers who felt better prepared for their caregiving roles tended to handle them much better.
These positive findings fit into a growing pattern. Thirty years of caregiver advocacy and improved services seem to be making a difference. According to a paper to be published in the prestigious academic journal, The Gerontologist, by Johns Hopkins University researcher Jennifer L. Wolff, Ph.D., spousal caregivers in 2015 reported significantly less strain and more use of respite services than those studied in 1999.
That paper is co-written by another Hopkins caregiver researcher, David Roth, Ph.D., who, along with William Haley, Ph.D. of the University of South Florida, has published several articles in recent years which have found that family caregivers are more stressed than non-caregivers but, paradoxically, tend to live longer. In their latest article—to be published in Psychology and Aging and co-authored with Stephanie L. Brown, Ph.D.—caregivers live 16.5% longer, to be exact. Their hypothesis for why this occurs: So-called “pro-social helping behaviors” have a neurohormonal effect on humans that promotes immune system homeostasis. In other words, helping others, especially those we love, may be difficult in many respects but has beneficial effects on our health.
What should we make of these more positive findings? They take nothing away from the fact that caregiving is often hard and that most caregivers report that they find it stressful. There may also be sub-groups of caregivers for whom caregiving is simply nightmarish. But it is a mistake to paint it as wholly deleterious or deadly. It is a more complicated picture than that. As a clinical psychologist specializing in counseling family caregivers and as a former caregiver myself, I conclude the following:
The negative narrative of caregiving has been—and is still—over-sold: I understand the good intentions and political reasons for publicizing the caregivers’ plight. Perhaps we would not have the same level of public funding and support that we do today if family caregiving was not originally depicted as a public health emergency. But we are now beyond that one-dimensional model. It appears increasingly likely that most caregivers find at least something positive in their caregiving experiences and that they grow to some extent personally and spiritually through caregiving. The majority of them, if given a second chance, would still choose to provide care to their loved ones.
It matters how you approach and what you learn from the caregiving experience: I’ve seen caregivers who felt entrapped by caregiving. I’ve seen caregivers who felt entranced by it. The latter works better. According to Hong Kong-based caregiving researcher Sheung-Tak Cheng, Ph.D., guiding caregivers toward identifying caregiving’s positive rewards —such as giving back to someone who has cared well for them or upholding some moral value—helps them avoid depression. I would speculate that finding the silver linings has even greater effects—allowing caregivers to go about their difficult work with more resolve and increased physiological benefit.
The responses of care recipients greatly impact caregivers: If caregivers’ efforts are cherished and not resented by care recipients, then those caregivers are more likely to feel positively about the work that they are doing. Conversely, the caregiver who is, say, preparing meals for a paranoid loved one convinced the food has been poisoned will be more frustrated and downtrodden. The care recipient’s response therefore often shapes the caregiver’s experience which affects the potential health-promoting effects of caregiving.
We are entering a time when a more nuanced and dynamic sense of family caregiving is coming into view. It includes positive aspects, including increased longevity. That may be surprising for some advocates or even some caregivers. But it is not surprising for the majority of people who strive sometimes valiantly, sometimes ambivalently to care for those they love.
Barry Jacobs, PsyD, is the director of behavioral sciences for the Crozer-Keystone Family Medicine Residency Program, the author of The Emotional Survival Guide for Caregivers, and coauthor with Julia Mayer of AARP Meditations for Caregivers. He’s on the Caregiver Advisory Panel and writes a monthly column for AARP.org. Contact: email@example.com
This piece is a reprint of a publication from the American Association of Marriage and Family Therapy. Click here for the original post.
In 2013, a team of field leaders in Medical Family Therapy came together to develop competencies for family therapists working in healthcare settings. They initiated these efforts in response to the increasing number of therapists being sought-out for and placed within such settings, alongside a recognition that clear guidelines regarding knowledge, skills, and abilities for effective engagement in such placements were not yet available. Over the next four years, this team worked across small- and large- group formats to identify key domain areas, associated skillsets, and target indicators relevant to this work. For a thorough description of the steps encompassed in this effort, see American Association for Marriage and Family Therapy (AAMFT; 2018). The following is a summary of core competencies related to scholarship for family therapists in healthcare settings
A marked strength of Marriage/Couple and Family Therapy (M/CFT) programs, particularly among those that are accredited by the Commission on Accreditation for Marriage and Family Therapy (COAMFTE), is the rigor placed on clinical training. Without question, M/CFTs are well prepared to engage in relational screenings and interventions. What is greatly needed, building upon this, is a stronger skillset in scholarship for those at the master’s level and beyond. This becomes even more essential when considering collaboration with healthcare teams and in diverse healthcare contexts. This skill will also make family therapists more competitive for jobs, as the current hiring climate in health care continues to evolve. Behavioral health providers, in addition to providing clinical services, administrative duties, and perhaps supervision/teaching, may be asked to design evaluations, analyze findings, and present on or publish the outcomes from program development and process improvement studies. These types of studies are vital to successfully initiating, growing, and sustaining behavioral health services in a healthcare setting.
M/CFTs conventionally take a class during their master’s program that affords an opportunity to learn about commonly used statistics and/or research methods. However, having competencies in scholarship pertaining to family therapy in healthcare settings is what really makes the clinician a desirable team member. Those who have competencies in scholarship as a family therapist in healthcare have learned to navigate research that honors: (a) systems, (b) biological, psychological, social, and spiritual foci, (c) interdisciplinary collaboration, (d) leadership, (e) ethics, and (f) diversity. This erudition spans across scholars who contribute to the fields of family therapy, medical family therapy, and other healthcare disciplines – and the patient/family/community populations that they study.
Those who were influential in constructing these competencies believe that family therapists who work in healthcare contexts can transcend the roles that have historically bound them. As scholars who are savvy in these competencies, well-trained family therapists are able to effectively contribute to diverse research teams, with an ability to publish in a variety of healthcare journals (mental health, biomedical care, healthcare administration and policy, etc.). This opportunity strengthens the reputation of family therapists in our own field, and beyond our typical readership.
Scholarship Competencies related to General Systems
What is true in the broader family therapy research is also true in the relational facets of healthcare research; family therapists must be at the forefront on studies pertaining to the study of relational health.The door stands open for dyadic, triadic, and familial research (target indicator 1.4a; AAMFT, 2018) in relation to experiences with illness, loss, trauma, and wellness. Thus, family therapists should advocate for research that includes the voice of caregivers, siblings, partners, and providers on the health outcomes of participants.
Scholarship Competencies related to Biopsychosocial-spiritual (BPSS) Systems
Any therapist who works in a healthcare context ought to be a competent consumer of both mental and physical care literature in order to best support the families and teams within their practice setting. For some, the role as a researcher may have a prominent presence in the therapist’s life, including competencies in designing and conducting evaluations or research studies that include BPSS dimensions into interventions and protocols (target indicator 2.4b; AAMFT, 2018). Therapists can strengthen their competency by identifying ways to maximize BPSS data through big data analytics, clinical trials, and dissemination and implementation studies.
Scholarship Competencies related to Collaboration
Likely an easier competency for family therapists to engage in is collaboration within their own research/scholarship endeavors. However, what may sometimes cause a therapist to pause is the hierarchy within medical systems and the perception that their skills are “less-than” compared to other providers. An important element of any interdisciplinary collaboration on clinical, financial, and/or financial outcomes (target indicator 3.4b; AAMFT, 2018) is to have team members who are willing to serve as both experts and learners. Everyone on a team has something to contribute, and this mosaic of different strengths translates into a whole that is more than the sum of its respective parts.
Scholarship Competencies related to Leadership
A skill that requires even more attention among family therapists in healthcare settings is learning how to “serve as a leader in writing, submitting, and implementing grants or contracts on BPSS and relational health and health care” (Knowledge/Abilities/Personal Characteristics 4.4c; AAMFT, 2018). While grant writing may seem like a daunting or intimidating task, many foundations across any state, nation, or providence levels exist that support clinical research aimed at reducing health disparities, increasing best practices, improving healthcare employee productivity, and maximizing value of care services. Both modest- and large- grant sponsors support the systemic and BPSS lenses put forth in proposals led by family therapists.
Scholarship Competencies related to Ethics
Competencies for family therapists in healthcare settings align with the ethics of scholarship that are grounded in AAMFT’s Code of Ethics (2015); these include an awareness of ethics from other disciplines. This understanding is particularly important in healthcare research and grant writing, as the scholar may be accountable to multiple institutional review boards and layers of privacy and protocol requirements. The ethics of family therapy scholars in healthcare contexts must attend to participants, engaging with collaborators, and the role(s) of researchers within the system and/or community. Above all, the researcher must maintain an awareness for the role of sustainability for a program or grant initiated in the healthcare context.
Scholarship Competencies related to Diversity
An area of publishing, presenting, and grant writing that family therapists in healthcare settings must stay especially attuned to is cultural sensitivity, cultural humility, and the ethical implementation of research studies with vulnerable populations and minority groups (target indicators 6.4b and 6.4c; AAMFT, 2018). Upholding these competencies is essential, not just as scholars, but also as professionals whose ethical practice is grounded in interventions that are indicated for a specified family, community, or larger system.
The competencies for scholarship among family therapists working in healthcare settings cut across systems-, biopsychosocial/spiritual-, collaboration-, leadership-, ethics-, and diversity-domains. Crossing primary (e.g., family medicine, pediatrics), secondary (e.g., OBGYN, emergency medicine), tertiary (e.g., hospice care, alcohol and drug treatment), and other scholarly environments (e.g., research institutes, federal organizations), these skillsets are essential for strengthening our contributions in both family therapy and other healthcare literature, research, and scholarly productivity.
Go here to download your free copy: http://www.aamft.org/healthcare
American Association for Marriage and Family Therapy (2018). Competencies for family therapists working in healthcare care settings. Retrieved from www.aamft.org/healthcare
American Association for Marriage and Family Therapy (2015). Code of ethics. Retrieved from http://www.aamft.org/iMIS15/AAMFT/Content/Legal_Ethics/Code_of_Ethics.aspx
This piece is a reprint of a publication from the American Association of Marriage and Family Therapy. Click here for the original post. Check back soon for a post on Core Scholarship Competencies.
Family therapists are well equipped to work in healthcare settings across clinical, training/supervision, management/policy, and scholarship efforts. This blog post is the first in a series (of four) that highlights core competencies across these respective foci. It begins by describing how field leaders worked with AAMFT to identify said competencies, and then highlights those specific to clinical efforts. These efforts are anchored within systems-, biopsychosocial/spiritual-, collaboration-, leadership-, ethics-, and diversity- domains.
Core Clinical Competencies for Family Therapists Working in Healthcare Settings
In 2013, a team of field leaders in Medical Family Therapy came together to develop competencies for family therapists working in healthcare settings. They initiated these efforts in response to the increasing numbers of therapists being sought-out for and placed within such settings, alongside a recognition that clear guidelines regarding knowledge, skills, and abilities for effective engagement in such placements were not yet available. Over the next four years, this team worked across small- and large- group formats to identify key domain areas, associated skillsets, and target indicators relevant to this work. For a thorough description of the steps encompassed in this effort, see American Association for Marriage and Family Therapy [AAMFT] (2018).
Core competencies for family therapists working in healthcare settings are situated in four principal areas: (a) clinical skills; (b) training and supervision; (c) healthcare management and policy; and (d) scholarship. Each of these domains are further anchored in six domains (systems, biopsychosocial/spiritual, collaboration, leadership, ethics, and diversity).
The following is a summary of core competencies related to clinical skills; ensuing blogs on this website will highlight competencies in training and supervision, healthcare management and policy, and scholarship.
As clinicians who are excited about our own work in healthcare contexts, we have been energized by the opportunity to present at AAMFT conferences and publish on our experiences in a variety of healthcare settings. Over the years, a number of family therapists would ask what they need to know in order to work in a healthcare context. First and foremost, we believe that clinical competencies for family therapists in healthcare settings must be grounded in the AAMFT’s Code of Ethics (2015) and MFT Core Competencies (2004). A team of family therapists then united to offer additional competencies uniquely constructed for family therapists in healthcare settings. Leaders in the field agreed that there was a need for additional specialized training and skills in order to maximize employment in and collaboration with healthcare settings and systems. Below is a sample of the clinical competencies via the six domains:
Clinical competencies related to general systems. Family therapists working in healthcare settings must advance clinical efforts in a manner that recognizes and honors multi-level and multi-directional influences between family members (e.g., patients, spouses, parents, children), between healthcare providers (e.g., behavioral, biomedical, pastoral), and between families and healthcare providers (as active participants in team-based care). They are thereby able to engage patients and families in support regarding, processing of, coping with, and effectively managing health crises/conditions/challenges, while at the same time facilitating valuable communication and collaboration between multiple providers involved in their care.
Family therapists in healthcare contexts balance conversations across the continuum from illness to well-being, deficits to resilience, strengths to weaknesses, hope to despair, and acceptance to agency toward change. They maintain competence in explaining literature and implementing practice through best- and systemic- interventions across multiple fields (e.g., Family Therapy, Medicine, Nursing), and through a variety of theories and models as they interface with systemic health concerns (e.g., motivational interviewing with patients who wish to stop smoking, structural family therapy + psychoeducation for adolescents living with diabetes).
Clinical competencies related to biopsychosocial-spiritual (BPSS) systems. Family therapists in healthcare settings consistently work to advance clinical care with clear knowledge regarding the biological components of – and biomedical interventions for – diseases that are customary to the care sites within which they are positioned and how those components interface with psychosocial and spiritual health and beliefs. For example, those working in endocrinology are familiar with metabolic processes, disease management strategies, and medications core to diabetes care as they interface with health behaviors and spiritual practices; those working in oncology are similarly conversant with physiological processes, testing sequences, and care-strategies common in cancer care – particularly as they intersect with relational decision making and mental health comorbidities. They are up-to-date in psychopharmacology (e.g., medication classes, common uses, common side effects), especially regarding drugs most frequently prescribed in their sites. They communicate in manners that demonstrate healthcare literacy across multiple disciplines (e.g., medical- and psychological/psychiatric- terminology, disease- and/or diagnosis- specific nomenclatures), and regularly articulate the manners in which multiple BPSS dimensions interact with each other in the present, across the lifespan, and with consideration of cultural / spiritual beliefs and practices.
Clinical competencies related to collaboration. Connecting the multiple and complex-overlapping dots of systems- and BPSS- sensitive care, family therapists in healthcare settings work hard to employ evidence-based models that promote interdisciplinary collaboration and relational care. They do this in a manner driven by respectful working alliances with patients, families, and other involved professionals working together en route to shared treatment goals. Family therapists in healthcare contexts must know how to navigate collaborative relationships through careful, purposeful, and flexible attention to collaborative efforts that span across workflow time (before, during, and after care encounters) and mediums (verbal, written, electronic, etc.).
Clinical competencies related to leadership. Family therapists in healthcare settings work hard to create and/or promote evidence-based models of integrated behavioral health care in collaboration with patients, families, healthcare team members, supervisees, administrators, community partners, researchers, and policy-makers. They do this through providing education about, modeling, and/or advancing clinical practices that maximize care outcomes, cost efficiency, and/or training and mentoring development. Given the systemic and BPSS training of family therapists in health care contexts, it is not uncommon to be asked to serve in leadership roles such as behavioral health director. Many also secure advanced credentialing and/or certification in leadership and supervision, which further-establishes their integrity as advocates for (and others’ receptivity of) the content and practices that they espouse.
Clinical competencies related to ethics. Family therapists in healthcare settings must demonstrate adherence to ethical practice in all that they do. This is a complex undertaking, however, because it requires practicing with informed knowledge regarding one’s own and other providers’ overlapping and distinct disciplinary guidelines that regulate foci like scope of practice, confidentiality, and billing – alongside appropriate and purposeful problem-solving vis-à-vis commonplace ethical dilemmas. Combined with these baseline knowledge areas and skillsets, these therapists must function in a manner that is consistently receptive to (and seeking of) input and support from colleagues, supervisors, site administrators, and legal counsel.
Clinical competencies related to diversity. Family therapists in healthcare settings must show awareness of, curiosity about, and respect for different biopsychosocial/spiritual beliefs, practices, and traditions across the intersection of social locations (e.g., ability, age, sexual orientation, gender identity). Furthermore, family therapists must be informed of historical marginalization and be aware of how to honor preferred treatment options for diverse populations. These understandings enable unique and/or sacredly-held viewpoints and customs to be effectively carried out, accommodated, and/or integrated into care provision (inside- and outside- of the clinic/hospital). These therapists also regard “diversity” as encompassing attention to social locations, and they work to incorporate sensitivity to these foci across the purposeful design, implementation, and evaluation of treatment plans. They do this with explicit recognition of their own personal biases and beliefs, and openly seek support/training/supervision to process and/or improve their efforts as indicated.
Core clinical competencies for family therapists working in healthcare settings cut across systems-, biopsychosocial/spiritual-, collaboration-, leadership-, ethics-, and diversity- domains. Crossing primary (e.g., family medicine, pediatrics), secondary (e.g., OBGYN, emergency medicine), tertiary (e.g., hospice care, alcohol and drug treatment), and other care environments (e.g., employee assistance programs, military care systems), these skillsets are essential for the effective integration of family therapists into medically-oriented treatment and interdisciplinary care teams.
Note: As outlined in this blog’s introductory text, ensuing installments will highlight other core competencies for family therapists in healthcare settings. These will include attention toward training and supervision, healthcare management and policy, and scholarship.
This piece is a reprint from October 2017. Click here for original publication.
For 58 years, from my birth until her death, my mother and I clashed over money and material values, cents and sensibilities. We were as mismatched as a Hermes scarf atop a Yankees sweatshirt. In my early life, she wrestled me into blue blazers against my will at upscale New York clothiers. In her late life, I berated her for sneaking to Talbot’s with her home health aide to buy wool slacks she didn’t need and couldn’t afford. Our differences made our respective caregiving—her tussling with me as a rebellious child; me struggling with her as a resistant elder—fraught with resentment.
She was a slim, pretty redhead who called herself a princess but came from humble origins. Her parents were poor, uneducated Jewish immigrants from a Polish country village. They and their children spoke Yiddish in their Bronx tenement apartment. Her amiable but careworn father washed storefront windows for a living. Her stern, little mother, trapped as an unhappy wife and homemaker, lashed out at her three children. My mother, the youngest, felt neglected because her disabled brother and popular sister garnered most of the attention. But my mother had unquestioned smarts and drive, excelling at school. She entered City College of New York in 1946 at the age of 16—one of only a handful of women in a class of thousands of war-hardened, returning GI Joes—and became a teacher and an accountant. She benefitted from American meritocracy, escaping the Bronx for Queens and then the suburbs, and later, South Florida, vaulting into the upper middle class and beyond.
These are the things I admired about my mother: her charisma, thirst for new knowledge and experiences, and fierce protectiveness. Wherever she lived, she engaged everyone around her with her warm gaze and intense interest. She then became their leader, energetically running play groups and carpools, PTAs and condo boards. She read incessantly. She called and confronted the parents of the older kids who bullied me on the playground.
But her early years had left her with a gnawing sense of economic and emotional deprivation. This was compounded by real hardships. Her first husband, a boy from down the block, left her for another woman after my mother had supported him through medical school. Her second husband (my father) died from brain cancer when she was only 43. Her third husband was a Korean War vet with PTSD. Despite how far she’d come, her standing in life always felt precarious to her. As time went on, she dressed better and better (designer silk blouses and dress pants), was more coiffed (brightly dyed bouffant hair and polished nails), and bedecked herself with more gold jewelry (necklaces, rings, and earrings)—all means, perhaps, to make herself feel more secure. But she never received all the comfort and distinction she felt she was due.
If life felt like a disappointment to her, then I only added to it. An early Super 8 film shows me as a toddler, chortling with laughter, as I ran away from her in a supermarket and she chased me in anger. I had my own smarts and excelled in school, but never quite conformed to the shining and obedient child she thought she deserved. I was an undiagnosed ADD kid—sloppy and dreamy. Where she thrived in social circles, I was the shy boy who withdrew, much to her irritation. I didn’t aspire to become a physician or a lawyer. I didn’t place family togetherness above all else. I wasn’t thankful enough for all she did for me. We argued a lot during my adolescent years, and then settled into a distant relationship when I went away to college and made my life afterward far away from her.
Nothing about this is unusual for many mother–son relationships. We spent decades seeing each other infrequently and not knowing one another as adults. But then old age hit.
When my mother called me each week from her gated Florida golf community, I noted a growing anxiety in her tone as she complained about my stepfather’s forgetfulness and confusion—early symptoms of Alzheimer’s dementia. I offered my help as an expert on family caregiving, but my mother scoffed at the notion she needed assistance. Then she surprised me by calling me while I was at work one day to ask, “Can you send me $30,000 right away?” I was aghast. They’d enjoyed the high life, travelling the world, leasing new cars every two years. Now the story came out. They’d taken two mortgages on the condo, had run up their credit card balances, and were more than $200,000 in debt. In the struggle to meet her bills, she was depleting her meager savings. I didn’t send her the money but flew down to set her up with a bankruptcy attorney. Their house of cards had collapsed, and she felt humiliated and wronged by misfortune.
Those were the trying circumstances under which my mother, at 80, and me, at 52, began to grapple with one another as adults, and we were often at odds. In her mind, I was supposed to support her exalted view of herself by helping to pay for it, while I was appalled by her disregard for how her overspending affected others, including my family. I couldn’t bring myself to empathize with the small, needy girl behind her outsized desires.
As I helped pack up her condo to move her and my stepfather into an apartment a mile from my Pennsylvania home, I was shocked to find a full rack of expensive blouses and slacks that still bore price tags. But rather than recognize her shopaholism as a symptom of the emptiness she felt, especially caring for a husband with dementia, I lit into her profligacy. Her fall in status and new dependence on me were hard enough, but my condemnation—kicking her when she was down—made her livid. She took her own shots in response. When she arrived in the tidy apartment my wife and I had purchased for them, she pronounced it just like the homely Bronx tenement from which she’d spent most of her life trying to distance herself.
Over the following years, I played the dutiful caregiving son, taking them to doctor’s offices and supermarkets, museums and restaurants. My stepfather eventually went into a nursing home, where he died, and my mother lived in the apartment alone. But there was no joy in being together while living in the same community as her for the first time in more than 30 years. Instead, there was constant underlying tension about money.
My mother would rise late each day and then, with stylish clothes and perfect hair, go into our town’s commercial center to buy lunch for herself and her aide. Later, after I’d found out about that, I’d become aggravated with her for frittering away her scant money. She’d look at me in sour silence. When I’d press her, she’d blurt out, “I gotta live!” as if that were explanation enough. When I’d respond in anger, telling her she was still living in her fantasy world of ease, she’d dismiss me with “I’m too old to change.”
A cousin to whom I described these impasses advised me to resign myself to just letting her spend the way she wanted. I couldn’t bring myself to do it, though. I worried about her bills because she wouldn’t. There was also too much at stake for me emotionally. She may have felt entitled to a grand lifestyle, but I felt entitled to a less solipsistic mother—one who relished, not hated, my help.
We battled in person and behind each other’s backs. I went to her dry cleaners and hairdresser to tell them she was broke and couldn’t afford their services, and I begged the home health agency to stop its aides from lunching with my mother. I found out later that she was hocking her remaining gold jewelry to continue to have pocket cash for clandestine shopping and nice meals. To her, I was a controlling tormentor. To me, she was a selfish ingrate.
If my mother had died at that point, five years into our caregiving journey together, then I’d have been forever bitter toward her. But her continued physical and cognitive decline, which now took a decided turn, created tragedy and opportunity for us. In what seemed a matter of months, she could no longer safely organize her pill box or remember our arguments from one day to the next. She began to fall in her apartment—where her aides would find her splayed on the carpet when they arrived—and in the street, breaking her tailbone and bruising her head. Living was becoming hazardous for her. In 2015, she was hospitalized three times for injuries and changes in mental status. We couldn’t afford to have someone stay with her round-the-clock, and neither she nor I wanted her to move into my house. I felt constantly anxious and guilty.
Then my mother did me a favor that still stuns me: she opted to move into a nursing home. It was a Jewish facility where she could speak Yiddish and eat kosher food like her mother had served. She made it clear that this was her gift to me so I wouldn’t feel so burdened by caring for her any more. A month later, however, she hated the food, the boredom, and the constant din of dementia patients, and wanted to move back into the apartment. Fearful she’d just resume falling, I said no. She fumed. But from that point forward, something changed in our relationship.
Freed from having to police her spending and safeguard her health, I was able to relax and just be her adult son in a way I’d never experienced. Even when she complained about the nursing home in an accusatory tone, I could hear her suffering without feeling responsible and defensive about it and could respond gently. Though her love of jewelry had always struck me as vain, I now found it touching that she wore bracelets and necklaces made of beads she’d strung at an arts-and-crafts session. After three months in the nursing home, she noticed I’d changed and said, “I don’t understand why you’re being so nice to me now.” I answered, “Because you aren’t in a position to defy and hurt me any longer.” She stared at me and slowly nodded.
Every weekend, I drove the hour-and-a-half round trip to the nursing home to lunch with her. There was little substantial conversation—my mother and I never learned to talk deeply with one another—but we sat in her bedroom or the unit sunroom eating sandwiches and then looking at photo albums of her past trips to Thailand, France, and Argentina, or at pictures of my grown kids on my phone. I’d push her in her wheelchair to sit by the flower garden near the back patio or roll along the paths of the lovely grounds. She couldn’t walk, talk, or think the way she wanted, and she was very unhappy. I felt for her. We were both witnessing the spectacle of her dying a little at a time, and it seemed to wipe away our previous conflicts. She took solace from my empathy. One day, while in the elevator on the way back to her room, she suddenly grabbed and squeezed my hand in a small, tender gesture. I took it to mean thank you for being here, but also we’ve been through a lot and have reached a better place, as well as wordless acknowledgement that she was moving toward the end.
A year and a half after the move to the nursing home, I received a call while I was giving a lecture on family caregiving on the other side of the state: my mother was in and out of a coma. As I drove for six hours to be with her, I reflected on our flawed relationship. When I arrived, she was lying in her bed with gaping mouth and eyelids shut. I called to her and she opened her fog-bound eyes briefly before shutting them again. I positioned myself in front of her and called her loudly again. When she opened her eyes and looked at me, seeming to recognize me this time, I told her I forgave her for things she’d done to hurt me and asked for her forgiveness for hurtful things I’d done. I expressed regret that we hadn’t found a way to be closer. She held my gaze a moment longer and then shut her eyes again. A few hours later, she took two last short breaths and died.
I’m troubled by many of my memories of my mother, the mismatch in our styles and convictions, and our inability to understand one another better. But I’m also grateful for the time we had to try, especially through her dementia and dying. Love, I learned, isn’t about agreement. It’s about connecting on that most elemental level: being there, accepting, a nod, a squeeze of the hand.
Barry Jacobs, PsyD, is the director of behavioral sciences for the Crozer-Keystone Family Medicine Residency Program, the author of The Emotional Survival Guide for Caregivers, and coauthor with Julia Mayer of AARP Meditations for Caregivers. He’s on the Caregiver Advisory Panel and writes a monthly column for AARP.org. Contact: firstname.lastname@example.org
Posted By Kaitlin Leckie, Kristine Miller,
Monday, March 12, 2018
This post is a reprint. Click here for the original publication.
During the 2015 CFHA
conference plenary, Vincent Felitti likened poor health behaviors (e.g.,
smoking cigarettes; IV drug use; overeating) to the smoke in a house fire. If
you see the smoke as the problem, and use fans to blow the smoke away, you will
not only fail to put out the fire, you will fan the flames. Treating poor
health behaviors as the primary problem, without attending to the real underlying issue(s), will have a
similar effect, according to Felitti.
Felitti’s analogy reminds
me (KL) of the Process Model of Addiction and Recovery (Harris &
Tabor-Wilkes, 2011), whereby the desire to cope with negative feelings caused
by underlying pain (be it spiritual, emotional, relational, physical, etc.)
drives the decision to adopt an unhealthy or compulsive behavior (e.g.,
hoarding, smoking, IV drug use, alcohol, overeating). While this behavior may
provide an instantaneous but short-lived rush of relief, the resulting feelings
of shame and guilt are longer lasting. This perpetuates the experience of pain,
thereby re-starting the cycle.
The pain that people are
trying to overcome often began in childhood, as a result of what Felitti,
Robert Anda, and their research team (1998) call Adverse Childhood Experiences,
or ACEs. The main categories of these experiences include household
dysfunction, neglect, physical abuse, psychiatric disorder of a parent,
parental substance abuse or incarceration, childhood maltreatment, and sexual
abuse. These experiences can be objectively scored on a questionnaire. Scores
range from zero to ten. Ten indicates that the respondent experienced an event
in each of the ten categories at least once.
An ACE score of four or more (at
least one event in four different ACE categories) correlates strongly with
increased prevalence of chronic disease in adulthood, as well as a high
prevalence of multiple unhealthy lifestyle behaviors, such as smoking, IV drug
use, and promiscuous sex (Felitti et al., 1998). In a sampling of findings from
the longitudinal ACE study, Felitti and Anda (2010) summarize other strong and
significant relationships of ACE scores to biomedical disease, psychiatric
disorders, unhealthy behaviors, and healthcare costs.
During the plenary, Felitti
highlighted that people who are seeking to relieve their pain are mostly
interested in feeling relief as quickly as possible. They typically are not
thinking about the long-term consequences of their choice. Hence the ineffectiveness
of telling a smoker about the likelihood of future lung disease. Instead of
inducing behavior change, the response is akin to: "Smoking provides me relief
right now, which is what I need.” Until the underlying pain is
addressed/treated, the likelihood of people being willing to change an
unhealthy behavior they have adopted to help them cope is pretty slim.
from understanding this truth, successful intervention should rely on a
multi-faceted approach; comprehensive and integrated health care is an ideal
way to address and treat pain from the past. Yet, we can do better than that. Particularly
in primary care/family medicine, we train clinicians to be proactive, not
merely reactive. As such, prevention of ACEs is vital for individual, family,
and population health.
At our primary care
clinic, Southern Colorado Family Medicine (SCFM), the proactive approach we
developed to prevent ACEs for our patients is called SCAN: Score, Connect, and
Nurture. First, we educated our entire
clinic staff about ACEs and then trained our clinicians how to talk to patients
about ACEs. We now assess ACEs in expectant
parents and parents of 0-18 year old patients, focusing our efforts on breaking
the cycle of ACEs often observed across generations. We perform universal
assessments on this targeted population because ACEs affect everyone,
regardless of sociodemographics. We educate parents about what having
experienced ACEs means for their health and what can be done to try to decrease
the risk of their children going through some of the same experiences.
intervention centers on meeting participants where they are. For example, with
parents who have experienced ACEs, the clinician normalizes and explains that
some people feel they have overcome some of their difficult experiences from
childhood but may feel "tripped up” by others. To help meet their specific
needs, all families are offered resources by a family resource specialist, a
social worker embedded in our clinic by a local community resource organization.
Examples of resources offered include parenting education and support with home
visits by a community-based parenting specialist, financial assistance,
children’s books, and mental health treatment referrals.
Of the many success
stories we have had throughout the year, one example that stands out is one of
our first SCAN families. This couple was
expecting their first baby while facing multiple psychosocial concerns. In
addition to having minimal social support, they were being evicted from an
apartment that was later condemned. Of the ten main categories on the Adverse
Childhood Experiences questionnaire, the expectant mom endorsed 9 of them, and
the soon-to-be father had experienced all ten ACE categories, a score of 10 out
Yet, their ACEs scores
and their struggles represent the beginning
of their SCAN story, not the end. Both parents also scored highly on a measure
of resiliency--also part of the SCAN intervention--indicating they were
resourceful and skilled at successfully overcoming challenges. They were scared
and voiced a strong desire to parent their child differently than they
themselves had been parented. They were motivated to get help in order to be the
parents they wanted to be to their child. We provided them with a supportive
and understanding healthcare environment, and our Family Resource Specialist
linked them with several resources to boost their confidence and enhance their
Ultimately, we assisted them in locating safer housing, helped him get
a new job, connected them with mental health services, and enrolled them in a
parenting education and home visiting program for continued support after the
baby was born. The impact of the SCAN intervention, including their perception
of our healthcare environment as safe and accepting, was made evident when,
after a later traumatic event occurred, they returned to our clinic to seek
additional care and support.
The adoption of unhealthy
behaviors is not the only explanation behind the strong connection between ACEs
and later development of chronic disease, as pediatrician Nadine Burke Harris
explains in her TEDMED talk on the profound ways in which the
ACE study changed her clinical practice. Even so, reframing our way of looking
at unhealthy behaviors--not as problems themselves but as adaptive solutions to problems--broadens our
perspective and increases the likelihood with which we are able to intervene
and help patients to adopt healthier behaviors.
Burke-Harris, N. (2014). How childhood trauma
affects health across a lifetime. TEDMED 2014.
Felitti, V. J., & Anda, R.
F. (2010). The relationship of Adverse Childhood Experiences to adult medical
disesae, psychiatric disorders, and sexual behavior: Implications for
healthcare. In The Hidden Epidemic: The Impact of Early Life Trauma on
Health and Disease. Ed. Lanius, R. & Vermetten, E. Cambridge University
Felitti, V. J., et al. (1998). Relationship
of childhood abuse and household dysfunction to many of the leading causes of
death in adults: The Adverse Childhood Experiences Study. American Journal
of Preventive Medicine, 14, 245-258.
Harris, KS, Smock SA, Tabor Wilkes, M. (2011).
Relapse Resilience: A Process Model of Addiction and Recovery. Journal of Family Psychotherapy 22 (3),
Kaitlin Leckie, PhD, LMFT, is the Director of
Behavioral Medicine at the University of Texas Medical Branch’s Department of
Family Medicine in Galveston, Texas.
Kristine Miller, D.O., is a faculty physician in
Pueblo, Colorado, at Southern Colorado Family Medicine Residency, where she
serves as the Clinic Director and Director of Osteopathic Education.
You don't need a family therapist to realize how divided many Americans are today. Whether the conversation is about gun control, health care, globalism, the US military, or even if LeBron James should leave Cleveland, the levels of civility and communication seem to have hit new lows. Tragedies like the senseless violence in Florida magnify these divides leading to more of the same: Americans talking at and past each other.
David Brooks of the New York Times recently commented on this situation in his article "Respect First, Then Gun Control". He argues that issues like gun control become flash points in which we feel and react from strong emotions, often doing more harm than good. But for any progress to be made, he states, there has to be trust and respect first before crucial decisions are made. Hey family therapists out there, does this sound familiar?
Brooks cites the recent work of a group of citizen professionals, David Lapp, David Blankenhorn and prominent family therapist, Bill Doherty, who are using their organization, Better Angels, to bring heavily polarized groups into the same room together for a good dose of reframing and clarifying communication. These long, humbling conversations between people on different ends of the spectrum have lead to some incredible outcomes and may signal one strategy for moving past the "tribal" thinking that seems to dominant the current airwaves.
I reached out to Bill Doherty and asked him some question regarding Better Angels. He responded quickly:
1. What seems to drive polarization within any group or organization?
Loosing sight of the relationships when people differ on viewpoints or emotional stances. In relationships beyond dyads, this is usually associated with forming coalitions--an insider tribe and an outside tribe. Over time, the relationships become more distant, people don't know each other well, and they objectify and stereotype each other. Tribal loyalty replaces commitment to the common good--the overall relationship. At a national level, the big divide is between conservatives and liberals, many of whom view the other tribe as not just wrong-headed but dangerous.
2. How does "Better Angels" attempt to address deep divides between groups? Through red/blue workshops where we bring together 7 people from each side for three hours or a day, in a structured process of coming to understand each other beyond stereotypes and look for common ground. Through skills workshops (for any number of reds and blues) where people learn skills for having cross-partisan conversations. And through Better Angels Alliances (groups of reds and blues) which spring from the red/blue workshops, with the goal of spreading the depolarization work and seeking common ground policy issues to work on (examples thus far: gerrymandering and money in politics). We developed the workshops, took them on the road in two bus tours where we refined them, and now we are training professional around the country to moderate local workshops.
3. What divisions do you think exist in health care that CFHA members might experience? From my frame of mind, CFHA members could view health as involving the civic health of the nation, and thus get involved in Better Angels work. I certainly see it that way, and it's an idea behind being a "citizen professional." I'm also doing a Police and Black Men Project, and that again is about the health of the commonwealth.
If you are interested in supporting Better Angels, you are welcome to donate, pay a $10 subscription per year, or volunteer to help.
Parents of children with autism spectrum disorder (ASD) often experience high stress in the form of psychological problems, marital strain, and/or family interaction difficulties. [1-4] This is especially the case when the child with ASD exhibits challenging behaviors. [5, 6] Mindfulness-based interventions have been found to be beneficial for these parents in many ways, such as decreasing their levels of depression, stress, and emotional reactivity to “aversive stimuli” such as challenging child behaviors.  Additionally, many parents of children with ASD who engage in a mindfulness-based practice see a decrease in their child’s aggression and challenging behaviors and an improvement in the child’s overall functioning. [8, 9] Preliminary evidence suggests that the above benefits may be long-lasting, even months after the mindfulness training has occurred. [10, 11]
The Mechanisms of Mindfulness
Mindfulness has come to be defined as the non-judgmental awareness of the present moment.  When we practice mindfulness, we increase our psychological flexibility—the ability to consider each situation with fresh eyes and to select a response that is consistent with our values. [13, 14] For a parent of a child with ASD, this is the difference between yelling to get a disruptive behavior to stop, and pausing to consider the possible function(s) of the behavior so that he/she can respond intelligently and effectively to the child.The “non-judgmental” aspect of mindfulness means that parents are developing more compassion for themselves instead of feeling like it’s the end of the world when they do yell. Instead, they can mindfully reflect, repair if needed, and try again. 
Mindfulness-Based Interventions for Parents of Kids with ASD
Before discussing interventions, it’s important to understand that mindfulness, in the words of Mindfulness-Based Stress Reduction (MBSR) creator Jon Kabat-Zinn, “isn’t one more cognitive-behavioral technique to be deployed in a behavior change paradigm, but a way of being and a way of seeing that has profound implications for understanding the nature of our own minds and bodies, and for living life as if it really mattered.”
That being said, one way to develop a mindfulness-based skillset is to participate in a structured mindfulness-informed group or curriculum (i.e. Mindfulness-Based Stress Reduction (MBSR), Mindfulness-Based Cognitive Therapy (MBCT), Acceptance and Commitment Therapy (ACT), etc). Tasks common to most mindfulness-based approaches include: making contact with the present moment; exploring breathing techniques; increasing awareness of bodily sensations, mental states and emotions; practicing non-judgmental acceptance and self-compassion; and committing to behavior change.  These above tasks—with the exception of in ACT—are accomplished through the practice of mindfulness meditation, which can be done seated (on a cushion or in a chair), lying down, or walking. However, it’s important to know that any activity can be done with mindfulness, including parenting! [8, 12]
One Minute Counts
Mindfulness meditation is most effective when practiced on a daily basis. That doesn’t necessarily mean that parents need to be folded up in the lotus position for 1-2 hours a day—though they would likely gain benefits from doing so—but it does mean that parents need to be encouraged to schedule intentional time each day for meditation. Parents can be coached to take “breathing breaks” during the day in which their focus would be on taking 5-10 deep breaths with eyes closed or gaze softened. Often parents need help creatively thinking about how they could squeeze in this type of intervention in their busy lives. 
I have found that the image of putting on your own oxygen mask first before assisting your child with theirs resonates with many parents in order to clarify the distinction between self-serving/selfish and self-care/self-sustaining behaviors. I remind parents that they are the foundation of their family, and that it’s not only okay but actually necessary to care for their body, mind, and spirit so that they can be their best selves as parents, and in many cases, as partners to their spouses. For parents who are tech-savvy, there are many good apps on the market (some of which are free) that offer mindfulness-based content and guided meditations. One of my favorites is the app “10% Happier”. Check out the quick guided meditation “1 Minute to Sanity” by Dan Harris.
Practice, practice, practice!
The takeaway is that the biggest benefits from mindfulness come with practice—intentional, consistent, and structured practice—and that this practice doesn’t have to be complicated. I am in the process of adapting a mindfulness-based curriculum for parents of children with ASD for use at my workplace, and I would encourage anyone who is interested in similar endeavors to consult the below references for guidance. As professionals who work with these parents, we are witness to their struggles, and we are best-positioned to assist them in developing a mindfulness practice that can not only sustain them but can allow them to thrive in their experiences as parents, partners, and human beings.
Katy Oberle, MS, IMFT is a family therapist at the Child Development Center (CDC) of Nationwide Children's Hospital. She conducts diagnostic assessments for children and teens with developmental and behavioral health concerns, and she provides systemically-focused therapy services to CDC clients and their families. Her clinical interests include couple relationship enhancement for parents of children with special needs, and systemically-geared mindfulness-based interventions delivered in the context of various healthcare settings.
1.Bitsika, V.S., CF, Stress, anxiety and depression among parents of children with autism spectrum disorder. Australian Journal of Guidance and Counselling, 2004. 14(2): p. 151-161.
2.Gau, S., Chou, M-C, Chiang, H-L, Lee, J-C, Wong, C-C, Chou, W-J, & Wu, Y-Y, Parental adjustment, marital relationship, and family function in families of children with autism. Research in Autism Spectrum Disorders, 2012. 6: p. 263-270.
3.Hartley, S., Barker, ET, Seltzer, MM, Floyd, F, Greenberg, J, Orsmond G & Bolt, D, The relative risk and timing of divorce in families of children with an autism spectrum disorder. Journal of Family Psychology, 2010. 24(4): p. 449-457.
4.Pozo, P., Sarria, E & Brioso, A, Family quality of life and psychological well-being in parents of children with autism spectrum disorders: A double ABCX model. Journal of Intellectual Disability Research, 2014. 58(5): p. 442-458.
5.Estes, A., Munson, J, Dawson, G, Koehler, E, Zhou, XH & Abbott, R, Parenting stress and psychological functioning among mothers of preschool children with autism and developmental delay. Autism, 2009. 13: p. 375-387.
6.Beer, M., Ward, L & Moar, K, The relationship between mindful parenting and distress in parents of children with an autism spectrum disorder. Mindfulness, 2013. 4: p. 102-112.
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What We Do
CFHA is a member-based, 501(c)(3) non-profit organization dedicated to making integrated behavioral and physical health the standard of care nationally. CFHA achieves this by organizing the integrated care community, providing expert technical assistance and producing educational content.