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Words That Matter

Posted By Suzanne Mintz, Tuesday, February 18, 2014
Some of us are numbers people; some of us are word people. I’m definitely one of the latter. Ever since I became an advocate for family caregivers over 20 years ago I’ve been questioning the accepted terminology. It began with the terms formal and informal caregivers, formal referring to home care aides who provide services for a fee; informal referring to me and the millions of other family members/friends who provide care for a loved one and do not get paid.


My skin would bristle every time I heard the phrase and every chance I got I would stand up at meetings and say: "I may not be trained and I’m certainly not paid, but there is nothing informal about the care that I provide. I take it very seriously and give it my all”. I am pleased to say that over the years others have picked up on my words and today the terms family caregiver or family/friend caregiver is in common practice.

There are other common terms or names in health and social policy that make my skin crawl. I will rail against them from time to time, but I haven’t made changing them a crusade, perhaps because they are part of the healthcare lexicon and I know it would be futile. Nevertheless when given the opportunity to be in front of a relevant and thoughtful audience I can’t resist the temptation to try and make some converts to my "what we call things matters” campaign.

Ken Thorpe the highly respected health policy professor and thought leader relates an anecdote about his mom. When telling her about the work he was doing on medical homes, she interrupted him and said: "I’m not going to go into one of those”.  It’s not surprising that someone, especially a senior would react that way. It’s a reasonable assumption that medical home is synonymous with nursing home. 

Those who define a population or create terminology don’t often think about how it will be digested outside their own community, but they should. Words make a difference. Remember ‘death panels’. 

I’ve been thinking lately about the terms ‘patient engagement’ and the ‘engaged patient’. An engagement, according to Merriam-Webster is an appointment, an enlistment, and of course a statement of intent to marry. To be engaged is to be absorbed, enthralled, or immersed. These words aren’t negative in the way informal caregiver is or as misleading as the term medical home can be, but they still rankle. They are more about something that will happen in the future, something that I will be involved in. It’s the ‘in’ that gets to me. I’m absorbed in reading a book; I have an appointment in half an hour, my hands are immersed in water.  I’m engaged in my health care. They seem somewhat passive to me. Words make a difference. Remember 'death panels'?

I act. I am active. These are direct. They are strong. The term patient activation has gained prominence recently, but it is completely off the mark. Human beings can’t be activated, only robots, garage doors, and military units.  Check the dictionary. I did.

Rene Descartes said, "I think therefore I am”. In healthcare I act. I provide information. I ask questions. I (we) should be the center point of all that follows. Patients and family caregivers have always been the objects of healthcare, those whose wishes are often ignored, and those to whom things are done. Now is our time to speak up, to act, to be part of the team. It is time for patients, families and providers to move beyond engagement. It is time for all of us to get married.


Social entrepreneur, family caregiver thought leader, author, speaker, advocate - 20 years ago she put a face on the issues of family caregiving when they were not recognized outside the aging community. She co-founded the National Family Caregivers Association (now Caregiver Action Network) and led the charge for recognition of family caregivers across the lifespan and as critical players in the delivery of chronic illness care. She retired from the organization in June 2013 and now run her own consultancy: Family Caregiver Advocacy, where she focuses on issues of national importance that affect the health and wellbeing of family caregivers. Ms. Mintz is currently working on the need to have family caregivers identified on medical records, their loved ones’ and their own.  Quote: "Family caregivers need to be included as members of their loved ones’ care team, given the education, training, and on-going support they need to bring about better outcomes and their own health and wellbeing.

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Common Ground

Posted By Noah Gagner, Tuesday, February 4, 2014

The walk to the lobby as a first year therapy intern at a local community clinic never seemed to get any easier. Each time I looked at my schedule and saw a new name, I hoped that in some way I was the right person, and that I had the right skills to help. 

On this particular day, Tim (whose real name is changed) stood up and shook my hand. He was a man in his mid- 30s, and despite his large build and heavily tattooed body shook my hand rather limply. He smiled as he greeted me with a head nod and we made our way down the hallway to my office.

Tim’s motivation for coming to therapy was his increasing anxiety, first formally diagnosed during a recent stay in jail, but present in Tim’s life for as far as he could remember.

Tim was on the verge of losing his housing if he did not evict family members who incited constant police presence and conflict at his home. I could tell from the shaking of his head and his furrowed brow that it was a difficult choice between stable housing or family conflict.

When I inquired more about Tim’s family, he explained, "I never knew my father, I have two brothers that were murdered and another is serving life in prison. I’d probably be there too had I not been in jail at the time.”  The tone of his voice sounded like a list he had recited many times before. Perhaps it was a reality so real and common within his community that to belabor the losses meant to be weak, "not a man”, he would later say. 

As a beginning therapist, I knew each question meant the possibility of intense emotions, ambiguity, and further hurt for Tim. Each answer from him carried the potential of making Tim’s life seem more complicated, more real. 

I did not know where to start so I asked Tim what he wanted to focus on in therapy. "Sarah” he said, "I really want to talk about my relationship with my girlfriend.” 

Each week Tim came into therapy and described his girlfriend as a person whose life seemed equally as chaotic as his. He detailed their relationship as one with conflict that at times seemed insurmountable, heightened by the loss of their unborn child some months earlier. However, he also shared the love he had for Sarah and how he hoped to remain in her life. 
As our sessions continued, the barriers to effective therapy seemed to grow

As our sessions continued, the barriers to effective therapy seemed to grow. I learned how hard it is for a former felon to get a job, and that former gang membership meant it was difficult to freely travel around the local community. Each time Tim revealed another aspect of his complex and chaotic environment, I felt increasingly less able to offer any "real” help. Each week of therapy presented a new challenge, from trying to respond to threats from former gang members, or sometimes even basic tasks like where Tim’s next meal was going to come from.  

In class I had learned about grief and loss, self-actualization, helping skills, how cognitions drive emotions, and how to focus on solutions.  However, each week I felt less and less helpful to Tim. My supervisor would remind me that as therapists there are many times that we feel incompetent.  She reassured me that I was doing good work. 

During this process, however, I began to realize what I was struggling with might be something bigger than our sessions together. My motivation for getting into mental health was initially to help people who looked like me, a biracial African American- Native Alaskan man, overcome barriers in their lives. I think Tim and I connected because I looked like him and represented something that he wanted to become: a helper of his people. Me, stuck in my feelings of inadequacy, and Tim, stuck within the complexities of his life. I had never met someone so ready for action, yet so inhibited by their current circumstances. Despite his sometimes strained relationship with Sarah, we continued to discuss it because it gave Tim hope and was a source of connection in his life. 

Sarah was supposed to be the bridge into deeper work. 

Reflecting back, Tim and I had worked hard on his relationship with Sarah leading up to my very last day as an intern. As this day approached, I was looking forward to my termination session with Tim. By then we had worked together for several months, and we had formed a strong therapeutic relationship. 

Tim was early that day. When I walked in, he was pacing, holding his cell phone.  Tim said, "Noah, I cannot meet today. Sarah is in the hospital on life support. The doctors say that she probably won’t make it.  I need to go.” He reached out for my hand, shook it, and then stormed out.  This time his grip was firm.

I never saw him again. 

Our lives forever complex and briefly connected, I think we both gave each other a helping hand. 


Noah Gagner, M.A., is a doctoral student at the University of Minnesota in the Department of Family Social Science’s Couple and Family Therapy (CFT) Program. His clinical and research efforts focus on family- and community- based interventions to address physical and mental health disparities in minority and underserved populations. He currently works as a CFT intern at RS Eden, a residential chemical dependency treatment for men in Minneapolis. 

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Wooden Box

Posted By Barry Jacobs, Tuesday, January 28, 2014

(This is a companion piece to an earlier post from June 26, 2013. Click here to read the first piece.)

On a scorching day at my step-father’s graveside, I stood slightly outside the circle of 20 mourners, present but distant. In my hands, strange to me, was the wooden box.  I wasn’t thinking about its contents of bone cinders and fine ash but of the surprising coolness to the touch of its dark mahogany veneer and polished brass latch.  I listened impassively to my step-sister’s tearful remembrances of her party-boy father and to her cousin’s choked sobs recalling her favorite, most loving uncle. I had promised myself--especially during his decline from dementia--that I wouldn’t speak at his funeral on his behalf. So I stood watching in silence now, holding tight to his box of cremains.


At the time he married my mother when I was 17, he had little interest in me or use for my impudence. For my part, I hated his sullenness when sober and boisterous prejudices when drunk—so unlike my deceased father. We learned to give each other wide berth, maintaining a tepid cordiality punctuated by infrequent clashes. This worked for over 30 years until he started losing his mind. Because I am my mother’s son and a clinician specializing in treating families dealing with illness, I felt it was my duty to assist my mother with the caregiving. That brought me into greater contact with not only him but many difficult feelings. Like many caregivers before me with a history of bad family relationships, I felt with fresh intensity the old resentment I held for the man I was now committed to helping. 

In his last 3 years, I moved my step-father and mother up from Florida to live in an apartment a mile from me and my family. I went about the enervating business of seeing them several times a week for meals and doctor’s appointments. I visited him (irregularly) after he was placed in a nursing home. To deal with caring for someone I’d long detested, I had to shut off all of my feelings. I had to be rigidly self-contained, keeping up the polished veneer of the grimly resolute caregiver to coolly carry out my joyless caregiving efficiently. On the outside, I myself became a kind of wooden box. Inside, though, I felt empty of purpose and energy at times. I burned with anger, at other times, towards the hostile man he’d been and the vexing burden he’d become.

This was exactly what I always counsel family caregiver clients to strive to prevent—to not lose one’s self during caregiving, to not turn wooden and callous just to keep difficult emotions in check. But it seemed so much easier to completely shut off. What possibility could there be for resolving my past feelings with this vague, addled man in life or death? Yet even as I stood there silently on that July day, I felt a bit chagrined. I was in a responsible enough position at this auspicious moment to closely grip his box. Yet, dreamy in the hot sun, I held myself as far away from the unfolding scene as my psyche would allow. 
On the outside, I myself became a kind of wooden box

And then someone suddenly whisked the wooden box from my hands and nestled it into the shallow, open grave. Others cried; I was too shut off to react. As part of the Jewish funeral ritual, a line formed to shovel dirt over the box but I stood there in a daze. I finally snapped to attention when I saw my 17-year-old son grab the long-handled spade. If he could do religious duty for a step-grandfather he hardly knew, so could I. I got into line and went through the motions of helping bury my step-father.

But though his ashes went underground, I didn’t entirely bury him. For too long, I did too good a job of shutting off and not processing what I felt. Six months after his death, I haven’t shaken all the woodenness. Hard as I try to come to terms with my relationship with him and put him to rest and myself at ease, I still find the box sealed. I’ve wound up carrying its weight and burden still. My hands still tightly embrace it.


Barry J. Jacobs, Psy.D. is a clinical psychologist and the Director of Behavioral Sciences for the Crozer-Keystone Family Medicine Residency Program in Springfield, PA. He is the author of The Emotional Survival Guide for Caregivers—Looking After Yourself and Your Family While Helping an Aging Parent (2006, Guilford) and the forthcoming Caregiving Family Stories & Beliefs, a collection of 25 of his previously published essays and case stories on families and illness.

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Partnering with Oncology Providers and their Patients: Lessons Learned

Posted By Laura Lynch, Maureen Davey, Tuesday, January 21, 2014

(This blog post is a follow up to an earlier piece. To read the first post, click here)

We recently described our pilot study which was designed to evaluate an Emotionally Focused Therapy "Hold Me Tight” couple support group that was adapted with Dr. Ting Liu and Dr. Lydia Komarnicky to help couples in which one partner has been diagnosed with cancer. Our study’s design and recruitment strategies have required consistent collaboration with a diverse group of providers embedded in a busy oncology clinic. We believe that the lessons we have learned may be helpful to other medical family therapy researchers who want to help patients and families who are coping with a chronic illness like cancer.

We chose to partner with Drexel University’s Radiation Oncology Clinic for this pilot project for two reasons. Most importantly, this cancer center provides access to the patient population we wanted to study: racially diverse patients who are coping with cancer and their partners. Additionally, we had developed a positive working relationship with the staff and providers through previous oncology support group intervention studies; therefore, we felt we would be able to effectively partner with them again to conduct this study. When we explained the purpose of our pilot study to the staff and providers at several group meetings, and identified how it could benefit their patients, they were more than willing to help us get the word out and recruit patients in their oncology practices.

Due to HIPAA regulations (which protect patients’ rights to keep their cancer diagnoses and treatment private), our research team is not able to directly approach cancer patients about this study. So, our study is first being presented to patients by Drexel Radiation Oncology personnel, including oncology providers, social workers, family therapy interns, nurses, a creative arts therapist, and a nurse navigator. Once patients express an interest in the study and sign a waiver permitting their diagnosis and contact information to be shared with our team, they are contacted and screened for inclusion in the study. Our research team has had to maintain consistent communication with these busy providers who are recruiting for us. We do this through weekly email check-ins and reminders, and in-person meetings. We invite and incorporate feedback from providers as well. For example, we ask how to best support each of them in recruitment (e.g., how and when to best reach out to them for check-ins), and want to hear about cancer patients’ responses to the study when it is presented to them. The challenge of not being able to directly approach oncology patients is that providers are often very busy and study recruitment is not their first priority. Yet, the benefit of partnering with this multidisciplinary team is that patients are able to hear about the intervention study from trusted providers with whom they already have a relationship. In order to build rapport, engage, and join with cancer patients and their partners, the principal investigator (Maureen Davey) makes the first call to all patients after they sign the waiver to be contacted. She stays in contact with cancer patients and their partners by mailing cards, sending emails, calling, and sending text message reminders, based on the patients’ preferences. She also provides them with her contact information and makes herself available for any follow up questions or concerns patients and partners may have.

There are several challenges we have experienced conducting this ongoing study. Many of the patients at the clinic are of lower socioeconomic status, which can make consistent participation in a multi-week intervention study (6 two-hour bi-monthly sessions over a period 12 weeks) a challenge because of financial barriers. Additionally, the cancer and side-effects from treatment (e.g., fatigue, nausea) can interfere with regular participation. Therefore we have made it a priority to remove as many potential barriers as possible and remain flexible. We provide public transit tokens or parking validation for participants, as well as free childcare for participants’ children during the group intervention sessions. We received IRB approval to pay each individual participant 10 dollars ($20 per couple) per session for the 6 sessions, so they are given a small financial remuneration for their time. We also budgeted for food so we that we are able to provide snacks for participants during the sessions; we first ask participants for their food and beverage preferences and do our best to accommodate them. Before each support group begins, we ask all participating couples about their preferences for the days and times of the group (e.g., weekends versus weekday evenings). The scheduling of the group sessions is based on consensus. If a couple misses a session (e.g., the partner with cancer is too ill to attend because of the treatment side effects), we work with the couple’s schedule to do a makeup sessions so that they can continue with their cohort for the remainder of the intervention sessions. We believe that it is essential to warmly join, engage, and collaborate with all participating couples to ensure that we are serving their unique needs as much as possible.
Building successful partnerships will take time, flexibility, and patience

Regarding lessons we learned, we recommend that family therapy researchers who want to partner with medical systems need to first identify one or more medical providers who understand the importance of family therapy interventions and who can be a champion by helping the researchers make connections with other providers who have access to the patient population. Clinical researchers should meet with providers whenever their busy schedules allow and explain how the intervention can benefit both cancer patients and the providers. It is also essential to elicit ongoing feedback from providers in order to make any necessary adjustments to better partner with them. Inviting this ongoing feedback also lets providers know that they are valued stakeholders in the research process. Ultimately, building successful partnerships will take time, flexibility, and patience. As medical family therapy researchers, it is important to demonstrate to providers that you will not abandon them once your study is completed, but rather you will be a long-term partner with the goal of supporting providers and helping to meet the needs of the patients and their families. Before you start planning any study in a medical system, take the time to familiarize yourself with the system so you can understand how patients are assessed at intake and evaluated, as well as any potential barriers to treatment that need to be overcome. If medical family therapy researchers first take these steps and remain patient, flexible, and consistent, then successful collaborations with medical clinics are more likely to be successful and sustained.


Laura Lynch, M.S. is a doctoral candidate in her third year at Drexel University’s Department of Couple and Family Therapy. She received her Master’s degree in Marriage and Family Therapy at the University of Rochester. Laura’s clinical research focuses on developing interventions to help couples and families cope with chronic illness. In collaboration with Dr. Maureen Davey and Dr. Ting Liu, she is currently conducting her dissertation study to adapt and evaluate Hold Me Tight for a diverse sample of couples coping with cancer. She is also completing her doctoral clinical internship at Drexel Medicine’s primary care practice. Her research interests include addressing health disparities by developing culturally sensitive relational interventions, examining how chronic illness affects couple relationships, and children’s experience of parental illness, in particular parental cancer and diabetes.


Dr. Maureen Davey is a licensed marriage and family therapist in the state of Pennsylvania, an AAMFT approved clinical supervisor, and associate professor at Drexel University in the Department of Couple and Family Therapy. Her clinical research examines how different relational and cultural contexts contribute to the experience of health disparities. She has been the PI on several state level foundation intervention grants designed to develop culturally sensitive family interventions for families coping with parental cancer and is now working on securing funding to further develop the intervention with African American families coping with parental cancer. In collaboration with Dr. Ting Liu, Dr. Lydia Komarnicky, and Laura Lynch, she is currently conducting a pilot study to adapt Hold Me Tight for couples coping with cancer.

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Moving Beyond the Hospital: Medical Family Therapy in Fieldwork

Posted By Tai Mendenhall, Tuesday, January 14, 2014

I, like most of us, will never forget September 11, 2001.  As our nation – and, indeed, our world – watched in horror as the day’s events unfolded in New York City and Pennsylvania, I think that my desire to do something to help was both impassioned and commonplace.  We all wanted to help, in whatever ways we were able.  I was a graduate student back then, and when I was asked by one of my professors to join a trauma-response team being mobilized to NYC, I dropped everything and went.  En route (in an otherwise deserted airplane), several of us participated in an intensive just-in-time training regarding Psychological First Aid and Ambiguous Loss.  When we arrived, our team joined a number of other teams and began to do a type of mental health work that I had never done before.  It was one of the most awful, painful, terrible, inspiring, and amazing experiences of my life. I returned a different person.  

I have continued to serve in fieldwork ever since that September.  Today, within the capacity of a faculty role at the University of Minnesota and through the lenses of a trauma responder, trainer/supervisor, and team coordinator, I offer the following as some of the things that I see to be Medical Family Therapy’s (MedFT) principal contributions to this effort:

Creating Meaning

One of the most common questions that people struggle with when they are hurting is "Why?”  When someone is living with depression, he asks "Why do I feel this way?” When relationships are dissolving, couples ask "Why are we fighting like this?”  In conventional therapy, clinicians can work with people who desire such insights by connecting a presenting problem to historical or present-day circumstances that somehow help it "make sense.”

Our efforts to engage those who are suffering to create meaning is importantIn fieldwork, we do not have this luxury (e.g., weekly visits until treatment is defined as "complete”). However, our efforts to engage those who are suffering to create meaning is still important (if not more important). And because MedFTs are comfortable working with multiple people at once, we can support and facilitate conversations and conflict that can be extraordinarily painful and/or newfound narratives that are profound and empowering. For example, a couple I worked with who lost their child to a tornado came to believe that their experience was God’s way of reuniting their extended family after years of emotional cut-offs. A boy I worked with who lost his mother in a hurricane was initially inconsolable because he could not understand how the "all-knowing” and "all-loving” God she raised him to believe in could take her away like this. Normalizing and empathizing with this young man’s pain, while engaging his father and sisters to begin a longer journey with him to make sense of what had happened to (all of) them, helped to ease his acute grief and anger.

Coping with Ambiguous Loss

When there is a mismatch between a loved-one’s physical and psychological presence, families are faced with a complicated type of loss that is not "normal” in the sense that we usually think of when we think about "loss”. In the aftermath of a traumatic event, family members of a missing person often do not know if s/he is still alive (e.g., displaced in an unknown area without cell phone coverage, buried – but still alive – under rubble). And if the person has, indeed, been killed, families may never have tangible confirmation of this fact (e.g., because the body was lost forever to the ocean or vaporized in an explosion). How can families cope or support each other when some members believe that their loved one is still alive while others still believe that s/he is dead?How can they have a funeral without a body?

MedFTs are well-equipped in situations like this to listen to and process family members’ respective views. Sometimes they must agree to disagree.  They may even embrace their ambiguity and ambivalence. Other times families align together in new and co-created narratives to say "goodbye.” For example, several families I worked with after the East-Asian tsunami walked along the beaches during low tide in search of things that the sea had "given back” to them. As they found things that they believed belonged to their loved ones (e.g., clothes, shoes, toys), many found peace in personalizing these things to represent those they had lost. Then they would bury the items in a funeral like they would if the items were human bodies.

Loving and Appreciating Each Other

Oftentimes disasters remind us – albeit too late – that the people who mean the most to us are usually the ones that we tend to take for granted and/or treat the worst. I recall a couple who were planning to have a dinner party one evening. After having agreed to who was going to pick up what after work to get ready, the husband called and asked (told) his wife that he needed to work later, i.e., that she would have to do his errands for him. They escalated in conflict because she was afraid that this would translate into not having enough time to prepare dinner. The husband started yelling at his wife, and finally hung up on her after accusing her of "not being supportive.” On her way home (about 30 minutes later than originally planned), she was killed in a construction accident. I remember a mother who missed her daughter’s piano recital because she, too, wanted to work late. She chastised the daughter’s distress about having her mom miss the performance, maintaining that there would be "plenty more recitals.” The child was murdered the next day in a school shooting.

MedFTs are readily able to facilitate meetings in which surviving victims of trauma review their lives and develop new or enhanced appreciations for the blessings they have. Working in the field across both natural- and human- made disasters, I have talked with many who have expressed overwhelming grief for the dead, alongside great relief for those who are living. They communicate newfound realizations about how physical things like houses and cars – unlike people – are just "things” that can be replaced. They talk about how they understand now that there is so much more to their lives than work. They stop reserving the words "I love you” for when they say goodbye on a telephone call or write well-wishes in an obligatory birthday card; they begin saying it often and every day. And they mean it.  They stop giving each other the silent treatment during conflicts because they understand that no one knows when or how somebody they care about might be taken away from them. 

Reevaluating our Scope(s) of Practice

I often see new professionals struggle to figure out where the overlaps and gaps are between what they can do and what other team members can do in the field. For example, is it alright for a MedFT to assist medical providers in cleaning wounds, drawing up vaccinations, or opening packages of sterile surgical instruments in preparation for emergency procedures? Should a physician provide emotional support if there is a mental health provider on the team? Can a nurse assess for someone’s suicide risk, or chase them if they bolt? Scholars in MedFT and collaborative healthcare have called for purposeful consideration of questions like these in everyday practice; members of interdisciplinary disaster-response teams must do this as well. 

Some situations call for a distinct skill set (e.g., a medical provider to flush tear ducts or set a broken bone), but many do not. And to be clear: working as a MedFT in fieldwork does not mean that you only provide mental health services. I, along with other family therapy colleagues, have indeed cleaned wounds, prepared vaccinations, and assisted medical providers during emergency procedures. So too have we stocked and distributed food and water, raised shelters, organized and run staging areas, and cleared rubble. We have served as greeters at family assistance centers, held off media, reunited family members and pets, and distributed information about local resources and charitable organizations. We have looked through pictures of the dead (e.g., taken before they were buried in mass graves) with families as they search for confirmation of what they hope is not so. We have looked through destroyed homes with survivors in search of treasured photographs and possessions. Physicians, nurses, medical assistants, social workers, psychologists, and lay community volunteers have done all of these things – and many others – as well. 
Working as a MedFT in fieldwork does not mean that you only provide mental health services

Avoiding Compassion Fatigue

Compassion fatigue, as we all know, encompasses a breaking down of our emotional, physical, and even spiritual resources. This is an occupational hazard for any provider in healthcare, but the intense nature of fieldwork is something that can easily push us over the edge. 

MedFT’s systems orientation requires that we, as providers, understand how our own functioning influences the patients and families that we serve. This is important because impaired providers (of any type, representing any discipline) can harm the very people they are supposed to help. Field supervisors thereby work to ensure their team members’ safety by limiting any deployment to two weeks in duration, and we only allow members to work up to three sequential days before taking (at least) a day to recover. We encourage consistent attendance to physical and mental health through regular group processing and debriefing, frequent hydration, snacks, and rest. We organize our teams by twos (i.e., buddy systems) to help ensure this, and we connect members to specialized support during- and after- deployments when and as indicated.

Closing Thoughts

As I intimated earlier, my work in trauma-response teams represents some of the most difficult and rewarding work that I have ever done. Whenever I return from a deployment, my colleagues and students ask what it was like, what I learned, or what experiences I will remember or affected me the most. Answering these questions is difficult because the experiences of "being there” are not well described in words, stories, or pictures. I encourage them to become involved, themselves.  Many have. When they do, they grow to understand.  I similarly encourage you, the reader, to engage in this type of work. Bring to it your skills and talents as a MedFT, and collaborate with colleagues from other disciplines united in the same mission. Then you will know.  And you will never be the same. 


Tai Mendenhall is an Assistant Professor at the University of Minnesota (UMN) in the Department of Family Social Science, the Associate Director of the UMN’s Citizen Professional Center, and the co-Director of mental health teams within the UMN’s Academic Health Center / Office of Emergency Response’s Medical Reserve Corps (MRC). He is the co-Coordinator of Behavioral Medicine education at the UMN / St. John's Family Medicine Residency Program (in which he teaches and supervises doctoral MedFT interns and family practice residents), and holds an adjunct faculty position in the UMN's Department of Family Medicine & Community Health. Dr. Mendenhall’s principal investigative interests center on the use and application of community-based participatory research (CBPR) methods targeting chronic illnesses in minority- and under-served patient and family populations.

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Good Patients, Difficult Patients - Reconsidered

Posted By Karen Kinman, Tuesday, January 7, 2014

This is a response to Dr. Aronson’s article in the New England Journal of Medicine entitled, ""Good” patients and "difficult” patients – rethinking our definitions" (Aronson, 2013). This article will address these definitions, as well as her comments regarding the collaborative process of care, the unspoken rules of medical etiquette and traits of medical culture. I am writing from the systemic perspective of a medical family therapist. 

We know that families have a significant impact on health equal to medical risk factors (Campbell, 2003).  Families are present throughout the development of disease from diagnosis and treatment, to caregiving; each family member affects the biological, emotional, mental and social health and well- being of the others. As Dr. Aronson points out, it is part of the medical culture to see families as something to "deal with” rather than as a significant resource.  She notes that "truly good care” is a collaborative process. However, this collaborative process also means giving back control to patients and families in the management of their disease. 

Control of a patient’s treatment and management of disease, by healthcare providers, in- hospital or outpatient, is a daunting and elusive task. The real paradox is that as healthcare staff relinquishes control to the patient and his/her family, both enjoy a more satisfying and collaborative relationship. Experiencing the other side of medicine, as the daughter of a patient, Dr. Aronson points out how the culture needs to shift to one which welcomes, and perhaps expects patients and families to actively engage in their health care.

The culture needs to shift to one which expects patients and families to actively engage in their health careThis is more needed today than ever before, as healthcare has become more compartmentalized. Looking at healthcare as a system, there are multiple layers which affect the culture of medicine and its challenges which present today. Some of these layers include: a) the role of physicians in their knowledge and expertise regarding treatment and management of disease, b) the development of hospitalists, who are physicians who work solely in the hospital and have no history or relationship with the patient prior to admission, and c) regulations from insurance which come between physician and patient, affecting treatment protocols and time management. Nurses are trained in treating the patient and family holistically, but their time is limited in how much they can do, as well as their limited expertise with mental health issues. When organizing priorities, medication administration, treatments for wound care, and post- operative care come before attending to the psychosocial concerns of a patient.  

Having worked as a nurse for over 30 years, and now as a medical family therapist, I am increasingly convinced that standard care should integrate physicians’ focus on health and disease with the biopsychosocial focus which mental healthcare providers and medical family therapists provide.Medical family therapy is a biopsychosocial approach within a family systems framework, with individuals and families who have medical problems (McDaniel, Hepworth, & Doherty, 1992). Medical family therapists, like other mental healthcare providers, are there for staff as well as patients and families, and can address difficult issues such as noncompliance, denial, and inadequate pain management. They see themselves and the staff joining the family system, and therefore, assess interactional patterns between staff, and between staff and patient/family. This can result in improved staff-patient and staff-staff relationships and broadens the scope of solutions to issues in which traditional intervention may be ineffective. 

I have been in hospital environments which were not nurturing or empowering to patients and families, and environments which very much respected their choices in how they were going to deal with their disease, (whether or not the staff was in agreement with those choices). I am currently  working in an ALS clinic as part of a collaborative team with physician, nurse, social worker, dietician, speech therapist, physical therapist, and a resource person for medical equipment. One salient characteristic of this environment is that we not only have good patient-healthcare provider relationships, but relationships between the staff are more respectful, empowering, collaborative, friendly, and efficient. A medical family therapy perspective facilitates this culture of collaboration and respect.
Medical family therapists, like other mental health care providers, are there for staff as well as patients and families

As Dr. Aronson points out, a "difficult” patient is described by the healthcare team as one who either has mental issues or is not "acquiescing” to staff. Medical family therapists may see what is defined as "difficult”, for example, may be related to: a) unspoken rules or beliefs regarding a disease and its treatment of which the staff is not aware, b) unresolved family problems which emerge in the midst of acute or chronic illness and is deflected on staff, and/or c) staff’s perception which is influenced by their own experiences and meanings of health and illness.

Change in culture happens very slowly. Healthcare providers do recognize the significance of patient/family-centered care, but, such care is a huge shift from traditional practice. It requires support from the top levels of management, structural changes, and a redistribution of power within the system, rather than simply a change in language or more contact with staff. Utilizing and empowering patients and their families gives them responsibility and accountability in managing their health and illness. However, on a deeper level, this hopefully will increase healthcare providers’ awareness of the wisdom and expertise of their patients and families. Perhaps, in this case, if Louise was not a physician, her father may not have made it home.  In Dr. Aronson’s case, "difficult” translated into knowledgeable and competent.

References

Campbell, T. L. (2003). The effectiveness of family interventions for physical disorders. Journal of Marital and Family Therapy, 2, 263-281.

McDaniel, S., Hepworth, J., & Doherty, W. (1992). Medical family therapy: A biopsychosocial approach to families with health problems. New York: Basic Books. 


Karen Kinman, PhD, RN, LMFT-A, is currently working at UT Southwestern Medical Center Family Studies Center where she sees individuals, couples and families. She is a medical family therapist in an ALS clinic, and leads support groups for the Muscular Dystrophy Association. She is currently working on her certification in hypnotherapy, and is a therapeutic touch practitioner. She is adjunct professor at TXWesleyan University in the family therapy department. The majority of her 33 years of experience as a nurse has been in maternal-child health and neonatal ICU. 

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The Case for Identifying Family Caregivers on Medical Records

Posted By Suzanne Mintz, Tuesday, December 31, 2013

(This week’s blog is by Suzanne Mintz, a longtime advocate for family caregiving issues. In April 2012 the CFHA Board unanimously voted to support a chart documentation initiative by Suzanne. This initiative encourages health centers to include family caregiver identification in electronic medical records.)

Across the chronic care continuum there are only two people who are consistently present, a patient and that person’s family caregiver. Family caregivers are acknowledged as the nation’s primary providers of long-term care, but they are not equally acknowledged as primary providers of their loved one’s non-acute healthcare needs.

Family caregivers are like undocumented workers, they have no official status and there is no official record of their existence. There is a significant amount of research about the impact that family caregiving has on the health and wellbeing of family caregivers, most of which is negative unfortunately, but there is very little on the impact that family caregivers make in the lives of their care recipients or on the healthcare system as a whole. 

We know that:

  • Persons with multiple chronic conditions and/or disabilities are the most vulnerable and medically expensive members of society. Their care consumes approximately 75% of all healthcare dollars.
  • Family caregivers provide 80+% of the care for this cohort of the population, most of who reside in the community. 
  • Family caregivers are ill prepared for their "job” as homecare aide/attendant, nurse, advocate, physical therapist, etc. There is no organized mechanism for providing the education, training and support family caregivers need.
  • Family caregivers are not routinely monitored by their own physicians as persons who are at risk for chronic conditions themselves

Medical records are the official documents of the healthcare system. They provide the information on which care plans are developed, insurers pay claims, and the course of an illness is tracked. Yet nowhere on medical records is there a place to record who is and who has a family caregiver. There is a serious disconnect between the day-to-day reality of chronic illness care and traditional healthcare practice and payments. 

The early recommendations for Meaningful Use Stage 3 recognize this and call for giving  all members of the care team access to patient records, including family caregivers (with patient permission). This is a big step forward and implies that caregiver information will be captured. In addition to primary caregiver name and contact information, information about their role in the care process, their own health status and additional responsibilities should also be documented. 
Nowhere on medical records is there a place to record who is and who has a family caregiver
 
Documenting information about family caregivers on medical records is the first step. The bigger issue is how healthcare providers, hospitals, and health systems use the information to improve patient and family caregiver outcomes and quality of life. 

These are not easy questions to answer. The answers will not be the same for each caregiver/patient unit, but finding answers is essential because until there is a place on medical records to document who is and who has a family caregiver, and what their role is:

  • American healthcare will not be able to truly alter the way it provides care for those with chronic conditions
  • Family caregivers will continue to be relegated to the category of nuisance rather than taking their rightful place on their care recipient’s health care team, one who has intimate knowledge of the patient that is not available to any other team member
  • There will be no mandate for providing family caregivers with the education, training, and support they need to both be a more confident and capable care provider and also a responsible steward of their own health.
  • There will be the lost opportunity for research on the impact family caregivers have on their loved one’s health and wellbeing, healthcare costs, the value of different educational and supportive interventions, and caregivers’ own health behaviors.

As we move ever forward toward implementation of electronic medical records and coordinated care it is more important than ever that we address this issue. It is imperative that going forward medical intake forms and official records capture information on who is a family caregiver, who has a family caregiver and what role they play. Without recognition of the chronic care dyad the treatment of those with long-term chronic conditions cannot be as effective and efficient as possible, and equally important, family caregivers will not regularly be evaluated for the healthcare risks to which they are prone. For all the reasons stated above it is time for family caregivers to be given official recognition as full-fledged citizens in chronic illness care. 

On October 25th a diverse group of healthcare professionals, patient/family advocates, NGOs, government agencies and others attended the Summit on Identifying Family Caregivers on Medical Records to discuss the issues outlined above. One of the most intriguing ideas to surface at the meeting was that of providing chronic illness care based on an evolving, coordinated care plan that would include the role of everyone involved in caring for and assisting a chronically ill patient at any given time The meeting was convened by Family Caregiver Advocacy; Booz Allen Hamilton; Kaiser Permanente, and the Coalition to Transform Advanced Care. Here is a link to a meeting summary. http://e-patients.net/archives/2013/11/summit-on-identifying-family-caregivers-on-medical-records-by-suzanne-mintz.html 


Social entrepreneur, family caregiver thought leader, author, speaker, advocate - 20 years ago she put a face on the issues of family caregiving when they were not recognized outside the aging community. She co-founded the National Family Caregivers Association (now Caregiver Action Network) and led the charge for recognition of family caregivers across the lifespan and as critical players in the delivery of chronic illness care. She retired from the organization in June 2013 and now run her own consultancy: Family Caregiver Advocacy, where she focuses on issues of national importance that affect the health and wellbeing of family caregivers. Ms. Mintz is currently working on the need to have family caregivers identified on medical records, their loved ones’ and their own.  Quote: "Family caregivers need to be included as members of their loved ones’ care team, given the education, training, and on-going support they need to bring about better outcomes and their own health and wellbeing. 

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The Health Paradox within Marriage

Posted By Jeremy Yorgason, Tuesday, December 17, 2013

Health problems are generally seen as a stressor to those in committed, couple relationships. That is, when a partner becomes ill, it often puts a strain on the relationship through the ill partner (a) not being able to perform the same level of household chores, (b) losing time at work/earning money, (c) having to pay for doctor bills and prescriptions, (d) having less positive or increased negative mood, and (e) having fewer positive and more negative couple interactions. These stressors associated with poor health within couple relationships have been established in the research literature.

At the same time, there are a number of studies that have indicated paradoxical outcomes within couple relationships in the context of illness. For example, research has shown that some couples suggest that their relationship has become closer in ways because of one partner having diabetes, hearing loss, a disability, or arthritis symptoms. So which is the right answer? Does illness strain couple relationships, does it bring partners closer together, or can couples expect both strain and closeness? The answer may depend on how we view illness.


Our perceptions of illness provide the lens through which we see health challenges. From a health STRESSOR perspective, illness can present difficult challenges for individuals and couples. From a RESILIENCE perspective, some people are strengthened in their relationships when faced with illness challenges. In fact, some couples’ relationships may be stronger than they would have been had they not faced a health challenge together and bonded through that adversity.

Given that not all people respond to illness or health stressors the same way, and that some couples apparently develop stronger relationships through health adversities, what factors might more readily lead to "paradoxical” or beneficial results? Research suggests the following factors likely benefit couples:

- Having a strong marriage relationship prior to illness onset
- Communicating openly about health challenges
- Having empathy for an ailing spouse
- Having resources that can be tapped such as social support and appropriate medical care

Other studies suggest that being over-controlling and overprotective as a caregiving partner has detrimental effects.

Relationship resilience is possible among all couplesThere is so much more that we can learn about the bi-directional relationship between health and couple relationships. Future research ideas include examining partner flexibility in future life planning, relationship history of overcoming past challenges together, and whether healthy partners choose at some point during an illness to be committed to their relationship, to their partner, and to working through whatever may come regardless of the outcome. In short, the mechanisms of health challenges linked with stronger couple relationships are largely unknown.

From a clinical perspective, relationship resilience is possible among all couples wherein one partner or both are faced with health challenges. At the same time, the reality is that health problems are nearly always a stressor on couples. Perhaps the acknowledgement of stress with the willingness to pursue resilience in response to health challenges will provide hope and courage to struggling couples. Perhaps even relationships that are "on the rocks” or experiencing a pile-up of stressors can emerge stronger when faced with health challenges. Clinicians might specifically encourage couples to:

- Communicate regularly about the health problems, and the difficult decisions and topics they may face
- See themselves as collaborators in facing illness, rather than as being alone in the process
- Consider the illness as not being part of the ill person’s identity or the identity of the couple relationship 
- Discuss what is helpful support, and what, if any, types of support might feel overinvolved or controlling to the ill partner
- Try to balance autonomy in the patient, while allowing appropriate dependence or interdependence between partners

Hopefully with the encouragement of healthcare professionals more couples facing serious illness will experience the health paradox within marriage.


Dr. Jeremy Yorgason is an Associate Professor and Director of the Family Studies Center within the School of Family Life at Brigham Young University. He is also a licensed marriage and family therapist in the State of Utah. His research is focused on marriage health in later life, with an emphasis on how couples manage chronic health conditions. His research often involves daily diary surveys as well as information from both spouses in the relationship. He has studied couple relationships in context of various health concerns including osteoarthritis, acquired hearing impairment, diabetes, arthritis, disability, and declines in self-rated health. 

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Childhood Champions

Posted By Victoria Brodersen, Tuesday, December 10, 2013

As a second year Master’s student working toward a degree in Marriage and Family Therapy I am required to complete a year-long internship. In an attempt to become the best therapist I could be I decided to challenge myself. I wanted an internship that would confront everything I thought I knew and inspire me not to give up. Last May I began that internship experience with a Pediatric Hematology/Oncology out-patient clinic in Greenville, NC and so far I have not regretted a second of it. Serving children from birth through college, the Pediatric or "Peds” Clinic is a daily roller coaster of emotions. Families come in and deal with the harsh reality of having a sick child. 

Some come in with multiple sick children while others have one that is terminal. An unfortunate few come in after the parents themselves have beaten cancer just to go home and watch their young child wage the same war with this overwhelming disease. As a staff member you never have a ‘good day’. We have calm days with sparse appointments and no bad news. We celebrate those days. They are the little victories that keep us going but we know they will not last. When you work with hundreds of children, fighting various forms of cancer and blood disorders, you are bound to have days of defeat. There are days when patients are told they have relapsed, their cancer has spread, or they are not responding to the chemotherapy. There are days when children who have been healthy and in remission for years suddenly turn sick and die of unrelated cause. On that same day there can be children fulfilling their Make A Wish requests.
The "Peds" Clinic is a daily roller coaster of emotions

These families have friends that can be counted in the hundreds: nurses that grow attached, front desk staff with welcoming faces, teachers that bring school assignments to their house, and neighbors that offer to drive, cook, and babysit. They also have far more pain than should be allowed. Despite the difficulties these families have, there is overwhelming perseverance and optimism delivered to their door weekly in the form of children that remain playful and strong. If Mount Everest were measured in blood draws and unexpected hospital admissions, the "Peds” Clinic families would all boast having climbed it.

To say that a blood or cancer diagnosis is the worst thing to happen to these families does not give them the credit that is due. Sure for some the news in unbearable, coping is a struggle, and there seems to be no getting back to the way life used to be. But there are families that eventually see the diagnosis as the thing that made them stronger than before, brought them closer together than ever, and re-established their values in a time of fear. To the mother that has seen her teenage daughter with cancer have a stroke and then spend the summer on life support there is nothing more precious than the day that girl acts like a brat. The worst thing to happen would have been to lose that child. Never seeing your daughter healthy enough to have some attitude, some semblance of the child she used to be, would be a devastating blow to these mothers. Not even the best oncologist can predict which families will suffer that fate. 

Because each day together can be like winning the lottery I have seen families at the "Peds” Clinic take very little for granted. They run relays for life and make their wish. They take work leave and accept Ronald McDonald beds. They set up Facebook pages to support their child and share their story. They knit hats for bald heads and take vacations often. Not a moment lost nor a minute is forgotten.

What I have learned over the last seven months in the "Peds” Clinic is that children know no defeat. They have an innate ability to push on so long as there is an opportunity to play. Having a child with this sort of life changing diagnosis transforms every parent into a superhero. You will never see anyone fight so hard, for something so small, as a parent with a chronically ill child.


I am a graduate student getting my Master’s degree in Marriage and Family Therapy at East Carolina University. Originally from Nebraska, I received my Bachelor’s degree in Psychology from Iowa State University and then moved to Greenville, NC to complete my education. After recently becoming engaged and beginning to think about the possibility of having children, I began to see my internship with the Pediatric Clinic in a new light. The impatience of parents sitting in the waiting room became lost on me. More and more I noticed the day-to-day pain of parents that were helpless to improve their child’s circumstances and desperate for any assistance they could get. My biggest fear as a one-day mother is that I might fail my children. My biggest concern is that I might not prove to be a fighter that comes out better because of a challenge like this.

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Helping Couples Cope with Cancer

Posted By Laura Lynch, Maureen Davey, Tuesday, December 3, 2013
In 2013, it is estimated there will be 854,790 new cases of cancer in males and 805,500 new cases in females in the United States (American Cancer Society, 2013).  The implication is that thousands of couples will be affected by the diagnosis and treatment of cancer. Cancer is a chronic and life-threatening illness that affects not only diagnosed patients but also their partners and spouses.  Many suffer from symptoms of depression and relational distress (McClure, Nezu, Nezu, O'Hea, & McMahon, 2012).  Couple clinical intervention studies suggest that it is possible to improve the psychological and relational well-being for couples who are coping with cancer (Badr & Krebs, 2012; Regan et al., 2012). 

In collaboration with Dr. Ting Liu, PhD., LMFT at Drexel University and Dr. Lydia Komarnicky, MD who is an oncologist at Drexel University’s Radiation Oncology clinic, we recently received pilot funding to adapt and evaluate a couple support group intervention, Hold Me Tight (HMT) (Johnson, 2009) with a diverse sample of couples coping with cancer.  The "Hold Me Tight” Couple Intervention Program: Conversations for Connection is grounded in Emotionally Focused Therapy (EFT) and was developed by Dr. Susan Johnson (2009) to help couples "repair, enhance, and continually grow their love relationship” (Johnson, 2009) in small group settings. With permission from Dr. Johnson, we have integrated cancer-relevant examples and reduced the number of HMT sessions from 8 to 6 sessions, and have trained emotionally focused therapists as group facilitators for our 1-year pilot study.  Because most psychosocial couple cancer intervention studies have included primarily white middle-class samples (Badr & Krebs, 2012), we are intentionally evaluating this intervention with an economically, racially, and ethnically diverse sample of couples in Philadelphia, in order to ensure that it is effective cross-culturally.  


Partners are encouraged to connect so they are not fighting the cancer alone
We believe that oncology patients and their partners/spouses can benefit from this type of brief couple support group for the following reasons.  First, couples where one partner is diagnosed with cancer often experience less intimacy, a lack of mutual support and cohesion, and lower relationship satisfaction (Couper et al., 2006). HMT targets these relationship dynamics. Group facilitators are trained to help partners re-secure their relationship connection while coping with cancer. Specifically, therapists have been trained to help partners openly share any concerns related to the cancer diagnosis and treatment, coping, adjustment, and any feelings of loss and fear. By openly addressing their vulnerable feelings with each other, partners are encouraged to increase their connection to each other so they are not fighting the cancer alone, but together as a securely attached and emotionally responsive couple. Second, an association between a cancer diagnosis and elevated symptoms of depression in both cancer patients and their partners was reported (Kolbasovsky, 2008).  There is empirical evidence supporting the effectiveness of EFT in reducing depressive symptoms by strengthening relationship bonds (Denton, Golden, Walsh, 2003; Dessualles & Johnson, 2003). 

Third, sexual issues (e.g., libido, sexual dysfunction, body image) are common among many cancer patients (Kolbasovsky, 2008) but are often not directly addressed by providers. In our adapted 6-session HMT curriculum, one session was designed to facilitate more open communication between partners about any sexual issues. Finally, compared to couple’s therapy which may be emotionally, financially, and physically overwhelming for oncology patients who are navigating tough treatment regimens, a structured short-term support group intervention (6 sessions: 2 hours/each) may not only reduce relationship distress, but also provide social support in a more feasible and acceptable way. 

Cancer is chronic, life-threatening, and often all-consuming for patients and their partners or spouses.  Our hope is that this brief couple support group program, Hold Me Tight, will decrease couples’ distress and help them turn toward each other while coping with cancer. 

References

American Cancer Society (2013). Cancer Facts & Figures 2013. Atlanta: American Cancer Society.

Badr, H. & Krebs, P. (2012). A systematic review and meta-analysis of psychosocial interventions for couples coping with cancer. Psycho-Oncology. DOI: 10.1002/pon.3200 

Couper, J., Bloch, S., Love, A., Macvean, M., Duchesne, G. M., & Kissane, D. (2006). Psychosocial adjustment of   female partners of men with prostate cancer: a review of the literature. Psycho-Oncology, 15(11), 937-953. 

Denton, W. H., Golden, R. N., & Walsh, S. R. (2003). Depression, marital discord, and couple therapy. Current Opinion in Psychiatry, 16(1), 29-34.  

Dessaulles, A., Johnson, S.M. & Denton, W. (2003) The Treatment of Clinical Depression in the Context of Marital Distress. American Journal of Family Therapy, 31, 345-353 

Johnson, S. (2009). The Hold Me Tight Program: Conversations for Connection. International Centre for Excellence in Emotional Focused Therapy: Ontario, Canada 

Johnson, S., & Talitman, E. (1997). Predictors of outcome in emotionally focused marital therapy. Journal of Marital and Family Therapy, 23(2), 135–152.  

Kolbasovsky, A. (2008). Therapist’s Guide to Understanding Common Medical Conditions. New York: W. W. Norton & Company 

McClure, K. S., Nezu, A. M., Nezu, C. M., O'Hea, E. L., & McMahon, C. (2012). Social problem solving and depression in couples coping with cancer. Psycho-Oncology, 21(1), 11-19. doi:10.1002/pon.1856

Regan, T. W., Lambert, S. D., Girgis, A., Kelly, B., Kayser, K., & Turner, J. (2012). Do couple-based interventions make a difference for couples affected by cancer? A systematic review. BMC Cancer, 12(1), 279-279. doi:10.1186/1471-2407-12-279


Laura Lynch, M.S. is a doctoral candidate in her third year at Drexel University’s Department of Couple and Family Therapy.  She received her Master’s degree in Marriage and Family Therapy at the University of Rochester.  Laura’s clinical research focuses on developing interventions to help couples and families cope with chronic illness. In collaboration with Dr. Maureen Davey and Dr. Ting Liu, she is currently conducting her dissertation study to adapt and evaluate Hold Me Tight for a diverse sample of couples coping with cancer.  She is also completing her doctoral clinical internship at Drexel Medicine’s primary care practice.  Her research interests include addressing health disparities by developing culturally sensitive relational interventions, examining how chronic illness affects couple relationships, and children’s experience of parental illness, in particular parental cancer and diabetes.



Dr. Maureen Davey is a licensed marriage and family therapist in the state of Pennsylvania, an AAMFT approved clinical supervisor, and associate professor at Drexel University in the Department of Couple and Family Therapy. Her clinical research examines how different relational and cultural contexts contribute to the experience of health disparities. She has been the PI on several state level foundation intervention grants designed to develop culturally sensitive family interventions for families coping with parental cancer and is now working on securing funding to further develop the intervention with African American families coping with parental cancer. In collaboration with Dr. Ting Liu, Dr. Lydia Komarnicky, and Laura Lynch, she is currently conducting a pilot study to adapt Hold Me Tight for couples coping with cancer.  

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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.