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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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The Assumption

Posted By Lisa Tyndall, Tuesday, November 26, 2013

One beautiful sunny afternoon, my son and I walked in for an appointment with a specialist. This was an appointment that I delayed for quite some time because I was not sure if we really "needed” it, but I finally determined that coming in to talk to the doctor face-to-face was better than continuing to guess and educate myself via the internet. 

When we arrived at this particular appointment, we were greeted and asked to pay the co-pay, which was expected. What was unexpected was the patient coordinator then asking again for my card to pay for the $250 "testing” that was to be done. I said, "But this is our first appointment. I don’t even know if we want the testing. I don’t even know what the testing involves.” She responded, "Well, that is what we normally do for first appointments.” What I wanted to say was, "Not at this first appointment!” Instead I asked, "Well, is it ok for our appointment to just talk to the doctor first to determine our best treatment route? Do we have that option? I just did not plan on spending that kind of money today.” Luckily, she was kind and generous in her response, allowing me the grace to back out of the procedure. Unfortunately, it was too late for her gracious demeanor to completely smooth things over and stop my Medical Family Therapy wheels from turning, because I was already fuming at how this whole process could have occurred for another family, one who was not so bold as to say "Thanks but no thanks.”


Right there in the waiting room it happened, I immediately began ruminating about the importance of patient agency. My son could even tell something was going on, "What’s wrong Mom?” he asked. The injustice of it all, or at least how it seemed, is what disturbed me the most. So many patients may not know that they can speak up for themselves about their own treatment and that they can opt out of an elective expensive procedure. It seemed unethical to me to just assume that a patient wanted and could afford such testing without even an initial consult. 

Now with many more healthcare plans encouraging consumers to pay out of pocket with higher deductibles, instead of the co-pay system, more and more consumers are apt to begin analyzing what is really necessary in terms of medical procedures and appointments. Sounds familiar…the financial world affecting the clinical and operational world, but yet they are still not working together. For those who do not know or who are not so bold as to speak up for what they need, how many will be paying out of pocket for something without informed consent? 

I would imagine that the more empowered and competent consumers feel about their healthcare, the more likely they are to take a more active role in managing their health preventatively. As a consumer, when you respect me and my choices, both inside and outside of your exam room, it translates to reminding me that many of my health behaviors are also choices that either improve or deteriorate my health. Patient agency is one of the founding principles of Medical Family Therapy and it should be a rallying call for all of healthcare. I would argue that we should be encouraging consumers to take an active role in their healthcare. Healthcare providers can help by respecting the rights of consumers to make choices about treatment. Healthcare should be something done with consumers, not something done to consumers. If the healthcare system wants people to be invested in taking care of their health, then it needs to invest in them and the effects of their financial and operational policies.
Patient agency is one of the founding principles of Medical Family Therapy 

We did meet with the doctor that day, and I explained that we just wanted to talk before moving forward on any procedures. He was kind and understanding of my hesitation to move forward with the testing, and largely because of his kindness we will return to his office should we choose to take that route. After it was all said and done, I was reminded of the importance of making my voice heard when it comes to my healthcare choices. We can no longer afford (often literally) to be intimidated by medical lingo, white coats, and sterile surroundings. I am lucky, however, and am grateful for the skills I have learned as a Medical Family Therapist because it is those skills that I can use not only professionally, but also to exercise my voice in all future personal medical appointments. But we must remember that many others have not been privy to this kind of training and may not know how to exercise their rights as a patient. As Medical Family Therapists and as collaborative care professionals we can play an important role in making sure patient’s voices and wallets are respected and heard and these days that is more important than ever.


Lisa Tyndall is the Clinic Director for the East Carolina University (ECU) Family Therapy Clinic in Greenville, NC. She has her license in Marriage and Family Therapy, and received her doctorate in Medical Family Therapy where her dissertation research focused on developing a consensus definition of Medical Family Therapy. She is the beaming mother of two fantastic young boys and adoring wife to her husband, Richard.

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Death to the Caregivers?

Posted By Barry Jacobs, John Rolland, Tuesday, November 12, 2013

It has been the most powerful and durable research finding and rallying cry of the family caregiving movement:  In 1999, the Journal of the American Medical Association published a study by University of Pittsburgh psychologists Richard Schulz and Scott Beach positing that stressed older adults caring for spouses with dementia had a 63% higher mortality rate than non-caregiving peers. That number, alarmingly large, stunned policymakers and politicians. Federal- and state-funded caregiver support programs were quickly developed. Ever since, the idea that family caregivers under duress have higher mortality rates has been an axiom of public health.

Now a new research finding that draws on data from the national REGARDS (Reasons for Geographic and Racial Differences in Stroke) Study challenges all that. In October 2013, the American Journal of Epidemiology e-published a study of over 3,500 stroke caregivers by a multi-institution team led by David Roth of Johns Hopkins that "failed to identify any [caregiver] subgroups [including those who were strained] with increased rates of death. " Quite the contrary: Through the use of a propensity-matched sample of non-caregivers and a proportional hazards model, they found that "caregivers had an 18% reduced rate of death compared with non-caregivers.”

The idea that being a family caregiver would confer some long-term survival advantage boggles the mind. Certainly, there are research and case studies that suggest that many family caregivers find positives, such as personal and spiritual growth, through their arduous work. The large National Alliance for Caregiving survey of caregiver attitudes in 2009 found that only about a third of caregivers described themselves as "highly stressed”; nearly a quarter said that caregiving didn’t stress them at all. But for family-oriented healthcare and social service professionals--as well as for the movie-going public who adored The Notebook, The Savages, and Amour-- the image of the beleaguered, bedraggled and bewildered family caregiver has held sway for so long that it is hard to imagine her in the rosy flush of health, vigor and longevity.

Critics of the Roth study will cast aspersions on its research design and patient selection. They will say that the stroke caregivers who were studied could not have had significant caregiver burden or were not under severe stress. They will say the participants did not caregive for long enough periods of time to be truly worn down. They will seek to launch their own research to disconfirm the hypothesis that caregivers live longer, not shorter, than the rest of us. 

"... caregiving can be a beneficial thing both for caregivers and their care recipients"
If, over time, they prove to be wrong, however, they will have to come to the conclusion that many people—possibly the majority—who make sacrifices to care for a loved one may actually find it an enriching and uplifting endeavor. Wrote University of South Florida psychologist and noted family caregiver researcher William Haley, Ph.D., the Roth study’s second author, in an email to me: "I do hope [our] paper helps the [caregiving] field attain a balance between concerns about caregiver health/well-being (which are legitimate) [and] recognizing that caregiving can be a beneficial thing both for caregivers and their care recipients.”

What would such a balance look like? It would take into account that certain individuals under certain conditions in certain relationships will languish in the caregiver role while others will outdo themselves, soaring above their usual functioning. The broad field of families and health will then need to take a deeper, more nuanced look at who will react positively and who negatively to this increasingly common and normative life task. We’ll be having discussions about the secrets of building caregiver resilience—not just through increased problem-solving and social supports but by ensuring that one has the ability to choose to caregive willingly and know it is making a significant difference to relieve a loved one’s suffering. Our clinical interventions will largely be focused on helping family members derive a larger sense of purpose and meaning as they go about the still difficult, grinding work.

Over the past 30 years, the family caregiving field has reaped attention and funding through its depiction of the dire situations of caregivers. If newer research slowly changes that carefully crafted image of the burnt out family caregiver, will it be the caregiving field that will languish in the future?  Or will the challenge to one of its foundational assumptions bring it new life?


Barry J. Jacobs, Psy.D. is the Director of Behavioral Sciences for the Crozer-Keystone Family Medicine Residency Program, a monthly columnist on family caregiving for AARP.com, and the author of "The Emotional Survival Guide for Caregivers" (Guilford, 2006).

Commentary

As Dr. Jacobs articulately describes, this is a stunning research paper with major public health implications.  Rather than debunking time-honored thinking about caregiver strain consequences, this paper opens up a new avenue of thinking that is more resilience-based.  Going forward, we can better elucidate the individual and family psychosocial factors that promote caregiver wellbeing and relationship growth.  It has always been my belief that we learn more by studying those who thrive in the face of adversity rather than those who falter.  What are the key ingredients that can promote improved prevention and family-oriented psychoeducation?  This in no way undercuts the biopsychosocial risks that caregivers and families face over time.  
We learn more by studying those who thrive in the face of adversity than those who falter

The study authors are clear that their goal is to find a better, more nuanced and balanced understanding of factors that both facilitate growth as well as those that are harbingers of caregiver risk.  They are mindful of the study limitations that require further research.  They note that this study did not distinguish caregivers of those with and without dementia, or severity of cognitive impairment.  These factors have significant implications for caregiver strain over time.  Also, they state that this study did not address caregivers facing end-of-life.  And, it is not an ethnically diverse population (e.g. Latino and Asian populations were not included), leaving many questions related to culture, such as gender roles and expectations and multigenerational traditions. 

Of major significance, beyond marital status, the study did not measure anything regarding couple or family relationship processes or functioning.  Therefore, their "subgroups” did not include family functioning as a variable. This leaves an enormous territory not addressed in this research.  Likewise, this study looked at mortality, not morbidity.  The latter involves myriad health and mental health consequences that may not bear a linear relationship with mortality.

My best hope is that this study energizes and promotes more sophisticated research regarding family caregiving with a greater emphasis on resilience, family functioning variables, and meaning-making and its health protective effects.  In turn, this has major implications for collaborative and integrated care and the vital role CFHA members can play in this area. 


John S. Rolland, M.D., MPH is Professor of Psychiatry and Behavioral Neuroscience, University of Chicago Pritzker School of Medicine; and Executive Co-Director, Chicago Center for Family Health.  He is the author of "Families, Illness, & Disability: An Integrative Treatment Model" (Basic Books, 1994) and forthcoming "Treating Illness and Disability in Families: An Integrative Model" (Guildford).

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Journey to Mindfulness - The Mind-Body Connection to Patient and Practitioner Wellness

Posted By Julia Sayre, Tuesday, November 5, 2013

My office creates a safe meeting place for my clients, and is the meeting ground for many family and individual medical/emotional challenges: cardiological; endocrinological; obstetrical; the effects of infectious disease; after-effects of TBI; alcoholism and codependency; and families overwhelmed by the challenges of their special-needs children, just to name a few. In these and many cases, I work with my clients by incorporating some form of mindfulness meditation to increase self-awareness and reduce stress.

I was first introduced to mindfulness when I returned to Virginia Tech University to work for the program from which I had completed my masters in MFT. Mindfulness was incorporated gradually into the curriculum, eventually through formal classroom instruction. As an intern in that program several years prior, my introduction to working with traumatized clients included what I came to know as a form of mindfulness practice: focusing on how the body feels to learn what is on one’s mind and weighing on one’s heart, and safely process it. Later, I received formal training in Internal Family Systems Therapy™ (IFS), an intervention that uses mindfulness and guided imagery. Eventually, as I trained for my certification in Traumatology, it appeared again, as the training incorporated IFS as well as other mindfulness practices of various sorts, creating further infusion into my training and clinical experience.


Typically, I set goals each year in my professional development, and this year I decided to increase my awareness and skills in working with wounded warriors, through an organization called Warriors at Ease (WAE). They offer a three-part training on the use of mindfulness meditation and yoga as an intervention for PTSD – increasingly referring to it as PTS and dropping "Disorder,” an unhelpful conceptualization of a survival strategy. WAE training has both yoga and mindfulness meditation tracks. As I am not a yoga instructor, I chose the mindfulness track, knowing that I wanted further training in order to lead groups.
Starting this training – I’ve now completed two of three parts – piqued my interest in yoga. I owned a home-practice instructional DVD but kept hearing about the benefits of attending a class. And hey, therapist, heal thyself! I advised many clients to try yoga, but had not yet had a formal class in it. So off I went – and it altered my perspective: you stand like a dancer, but use muscle groups like a world-class weight lifter. And those instructors could teach without breathlessness or breaking a sweat! After each class, I felt…a calm connectedness…

Somewhere in this attitude of learning, this student was increasingly ready for the teacher to appear, and I decided to sign up for a Mindfulness Based Stress Reduction (MBSR) class. Again, my thinking was that it would increase my readiness to take mindfulness-based interventions to group work with wounded warriors – and what a great form of self-care! As I write this, I am about halfway through the 8-week program. I’m creating a formal meditation practice, which is good for me. But it’s also emerging more assuredly in my work with clients.

Meditation lets them dance with their thoughts, then let them go
And so I am able to tell them that meditation lets them dance with their thoughts, then let them go (thanks to my WAE instructor for the concept!). And, I add, dancing instead of wrestling with these thoughts is a vacation from the kind of analysis and rumination that takes up so much of our energy. I am able to normalize for clients that thinking a thousand thoughts a minute during meditation isn’t wrong, yet engaging with the thoughts is unnecessary at that moment. What a relief! I can share with clients that some of their greatest creativity – problem-solving, if that’s their view – will emerge in the moments they have given themselves for that break from wrestling and rumination, and that later they will be able to re-engage with their creativity.

Experientially, mindfulness is the antidote to anxiety. The National Institutes of Health and other sources cite much research support for mindfulness interventions for physical symptom and stress relief. Focus on the breath, or on a sound or an image, improves our chances of wellness in mind and body, in terms of sleep, blood pressure, brain wave and hormonal shifts, and pain management, to name a few. And there is a 2012 study out of the University of Rochester that supports positive effects of mindfulness meditation on physicians: on increasing mindful awareness in interactions with their patients; on self-awareness; and in supportive communication with colleagues.

I have found the formal practice of mindfulness to be a paradigm shift. It has enhanced my experience of being present with clients. I am aware of more fully hearing my colleagues. My need to "jump in and do” with family or friends is tempered with more stillness and waiting. I feel profoundly secure in the knowledge – based on research and clinical experience – that my clients benefit from its practice, as well.


Julia B. Sayre, M.S., LMFT is a licensed Marriage and Family Therapist and Certified Traumatologist in private practice in the Northern VA/Metro Washington, DC area. Julie completed her Masters at Virginia Tech University, Falls Church, VA. Clinical interests include trauma, medical family therapy, and challenges to stepfamilies and families of children with special needs. Email: jbsayreLMFT@aol.com

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MedFT as Flower: Family Caregiving as Forest

Posted By Barry J. Jacobs, Tuesday, September 24, 2013


This is a post in a series of "blasts from the past". These classic posts will highlight issues that are just too important to collect dust in the archives. The series will be off and on for the next several weeks. Enjoy!

(This piece was originally posted on July 24th, 2012)

From that magical moment in the Minnesota hot tub in 1991 when Susan McDaniel, Bill Doherty and Jeri Hepworth coined the term "medical family therapy,” the field has had a slow but steady growth, sending tendrils into curricula for family therapists and other healthcare professionals and blossoming into a dozen or so certificate and degree programs around the country. For this progress, we all should be proud. But MedFT, to me, is like a delicate, hothouse orchid, assiduously watered and trimmed, surrounded by a burgeoning forest of more lush and verdant organic growth. The towering trees nearly blocking out the sun nowadays are the results of a fertile, consumer-initiated movement that took root around the same time as MedFT. That movement—now this country’s chief focus on families and illness--is called "family caregiving.”

Orchids and oaks, you say. Apples and oranges. Family caregiving, you contend, is what devoted family members do for an ill loved one; medical family therapists use systemic expertise to foster that endeavor. But while the term "family caregiving” is used to describe the sacrifices and struggles of over 60 million Americans in their provision of care to ailing relatives and friends each year, it also denotes a multi-disciplinary research, advocacy, and clinical effort with a complex infrastructure of federal, state and local support programs, disease- , relationship- and culture-specific research, and public and private funders and policy mavens.

Orchids and oaks, you say.

Apples and oranges.

All that MedFT is striving to achieve—to better understand how families are buffeted by illness and disability and can continue to develop resiliently—the field of family caregiving has also striven for and has far outgrown us.

Take research, for example. Empirical studies within MedFT are relatively few, are based on small subject groups, and have limited generalizability. In contrast, the research conducted over the past 25 years by psychologists, nurses, social workers, family physicians and others, particularly about dementia caregiving families, has been extensive, broad and deep. The original question those researchers undertook to answer—how family caregivers are affected by caring for someone with Alzheimer’s disease—has long been answered with evidence of increased morbidity (insomnia, depression, musculoskeletal problems; see Schulz & Martire, 2004) and mortality (see Schulz & Beach, 1999). These diverse researchers have also largely answered the next question—what kind of supports better help family caregivers cope (see here)—and are now working on how to translate those findings into effective public programs on the state and local levels.

Then there’s advocacy. MedFT academicians and practitioners have attempted and accomplished little in the policy arena. The powerhouse family caregiver consumer groups (e.g., National Family Caregivers Association, National Alliance for Caregiving, Family Caregiver Alliance) and other larger organizations with a strong interest in family caregiving (e.g., AARP, Alzheimer’s Association) have lobbied for and helped push through landmark federal legislation, including the Family and Medical Leave Act (1993), the National Family Caregiver Support Program (2000), and the Lifespan Respite Act (2006). Family caregiver advocates have made sure politicians know that there’s a growing constituency of Baby Boomers who want more monies earmarked for supporting their aging parents. Even in tight budgetary times, those funds have gradually increased.

The family caregiving movement’s clinical efforts might not be recognized by medical family therapists as "clinical” at all. Largely consisting of psychoeducation, screening for depression and anxiety, and providing respite care, the caregiver support programs are not particularly systemic in orientation, tending to focus on the needs of the primary caregiver. (Here’s where we have something to teach them about better harmonizing the interactions among various family members to produce better outcomes for the patient and family.) But given the widespread availability of caregiver support services, covering every county in this country, the family caregiving movement is meeting more of the basic psychological needs of the vast majority of families dealing with illness than MedFT could ever hope to achieve.

So what should all this mean for medical family therapists? A few thoughts:

  • MedFT should make every effort to become part of the family caregiving movement: That movement has been intensively collaborative, drawing on the strengths of a broad range of healthcare, legal and financial disciplines, as well as family members and patients. Yet because medical family therapists have been toiling in a few relatively isolated outposts, most family caregivers and leaders in the family caregiving field have never even heard of MedFT. I believe that the systemic expertise that we have to offer would greatly enhance the current efforts of family caregiving to roll out effective community-based programs.
  • We need to call our research family caregiving studies, not MedFT studies. Our researchers need to publish in the major journals for family caregiving, such as The Gerontologist and Aging and Mental Health. That’s how our work with be more widely recognized, disseminated and implemented.
  • We should be pitching ourselves clinically to the public and to colleagues from other disciplines on primary and specialty healthcare teams as "family caregiving experts,” not medical family therapists. This will better communicate who we are and what we do than the current identity we have. This is, in fact, truth in advertising—we are family caregiving experts!
  • Our MedFT associations—e.g., the CFHA MedFT work group and the MedFT Facebook group—should be advocating for improved services for family caregivers. We should join with dozens of other healthcare professional associations in the large and powerful coalition known as the National Alliance for Caregiving (www.caregiving.org). NAC is the single strongest voice advocating in Congress and in the academies today for the needs of families struggling with illness and disability.

In short, we need to branch out of the insular hothouse world and roam the forest. We need to cross-fertilize with other disciplines more. We need to pollinate their ideas with our own and improve their systemic understanding and efficacy. We have to trust that who we are and what we do will matter--and not just get lost in the scenery.

References

Schulz, R & Martire, L (2004). Family caregiving of persons with dementia: prevalence, health effects and support strategies, Am J Geri Psychiatry, May-June, 12(3), 240-9

Schulz, R & Beach (1999). Caregiving is a risk factor for mortality: the Caregiver Health Effects Study, JAMA, Dec. 15;282(23):2215-9

 


Barry J. Jacobs, Psy.D., Director of Behavioral Sciences for the Crozer-Keystone Family Medicine Residency Program in Springfield, PA, has long been involved in the family caregiving movement. He is the national spokesperson on family caregiving for the American Heart Association and an honorary board member of the Well Spouse Association. Most recently, he was appointed to the Caregiver Advisory Board of AARP. He has long written the advice column for "Take Care,” the newsletter of the National Family Caregivers Association, and is also the author of The Emotional Survival Guide for Caregivers (Guilford, 2006).



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Do Medical Family Therapists Bring Value to Health Care?

Posted By Joseph Scherger, Tuesday, September 17, 2013


This is a post in a series of "blasts from the past". These classic posts will highlight issues that are just too important to collect dust in the archives. The series will be off and on for the next several weeks. Enjoy!

(This piece was originally posted on October 10th, 2012)

I suspect any family therapist reading this question would quickly say, "Yes, of course we add value to health care”. From a health care policy perspective value is not a simple intuitive concept. Value is quality divided by cost, and today every health care system is focused on becoming value driven.

That the U.S. spends way too much money on health care is well known. Our health outcomes place us low in the world even though we spend twice as much or more on health care as other industrialized countries. Our spending is not sustainable, especially in Medicare with the influx of the Baby Boomer generation. We have to figure out how to spend less money.


A new IOM report indicates that we spend 700 billion dollars in health care every year that is of no benefit to patient care. These include unnecessary tests and procedures, overly expensive drugs when generics would do fine, and excessive treatment, especially at the end of life. Rather than just squeeze this money out of the system, the potential is here for transforming the system to provide value – actually improve the quality of care while we reduce costs."The most important work
of family therapists today
is to make the case for
being vital members of
PCMH practice teams."

Information technology makes much of value driven care possible. For the first time we can look at populations of patients in detail and make proactive strategic decisions to improve their health efficiently. Diabetic patients who are well controlled are much less expensive than ones who are out of control and develop complications. Through internet applications, we can communicate and care for patients at minimal costs compared with face-to-face visits.

So what role do family therapists play in this? We know that psychosocial problems are frequent in health care and usually are masked by physical complaints. Addressing the psychosocial problems early creates great efficiency rather than waiting until every physical evaluation has been done, only to show the patient is "simply” anxious or depressed. Yet this obvious situation remains hidden from the strategic planning to too many health systems.

Regional health systems committed to becoming value-driven are joining the Accountable Care Organization (ACO) movement. Developed by the Centers for Medicare and Medicaid Services (CMS), an ACO is committed to the Triple Aim:

1. Improving the individual experience of care

2. Improving the health of populations

3. Reducing the per capita costs of care for populations

Health systems know the future of health care financing will be directly tied to achieving these aims with their care, and information systems are able to measure it. At the patient care level, teams will operate in ACOs using the principles of the Patient Centered Medical Home (PCMH). PCMH practices have advanced information and communication technologies and are able to provide continuous access to strategic, proactive care rather than the tradition of simply reacting to patient appointments. Patients become activated to play an active role in the own care, ordering desired tests and treatments, according to accepted guidelines.

The most important work of family therapists today is to make the case for being vital members of PCMH practice teams. Working alongside physicians, nurse practitioners, pharmacists and others, family therapists will ensure that patients receive true biopsychosocial care from the beginning. Independent private practice is rapidly becoming a thing of the past. Organized and integrated health systems are the future. Family therapists are not automatically included in this discussion in most settings, so becoming knowledgeable about ACOs and PCMHs is critical today. Assertive inclusion of family therapists in demonstration projects around the country is needed to ensure the proper composition of team practice in the future.

Reference for more detail on ACOs, PCMHs and the Triple Aim:

Edwards TM, Patterson J, Vakili S, Scherger JE. Healthcare Policy in the United States: A Primer for Medical Family Therapists. Comtemp Fam Ther (2012) 34:217-227. 


Joseph E. Scherger, M.D., M.P.H., is Vice President for Primary Care & Academic Affairs at Eisenhower Medicine Center in Rancho Mirage, California. Dr. Scherger is Clinical Professor of Family Medicine at the University of California, San Diego School of Medicine (UCSD), and at the Keck School of Medicine at the University of Southern California (USC). Dr. Scherger’s main focus is on the redesign of office practice using the tools of information technology and quality improvement.

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Exploring The "S" In BPS (BioPsychoSocial)

Posted By Melissa Lewis, Wednesday, September 11, 2013


This is a post in a series of "blasts from the past". These classic posts will highlight issues that are just too important to collect dust in the archives. The series will be off and on for the next several weeks. Enjoy!

(This piece was originally posted on August 7th, 2012)

Engel’s BPS Model has served to guide the discipline of Medical Family Therapy, reminding us to assess, acknowledge and treat each of these systems and specifically not to ignore the psychosocial when working in a medical setting. However, what exactly is encompassed in the ‘social’ realm? For social workers it may include basic living needs or connecting patients to other social service agencies. For chaplains it may be connecting the patient to a religious/spiritual community. For marriage and family therapists, it can include working to improve family relationships. Each of these disciplines is addressing important needs of patients that have been proven to aid in more effective treatment, faster recovery, and increased patient satisfaction.

While these ‘social’ interventions are improving the health and well-being of patients, I would like to take a moment to dig a little deeper. I define the social aspects of life and health as cultural and relational ways of being. With that said, it is clear that ideas surrounding health, illness, cures, and healing will vary by individual and community. Yet we utilize ‘evidence-based’ methods that only allow for one way to see, cause and cure an illness which may be subjugating, and possibly ineffective, for the patient.
Melissa Lewis
What would you do as a MedFT if this were your patient?

Let’s continue the conversation through the comments you make!

Some interventions, such as Motivational Interviewing (MI), allow for patient goals and motivation to be accounted for. Further, Galanti (2004) suggests using the ‘4C’s (1. What do you call the problem/illness? 2. What do you think causedthe problem? 3. How do you cope with the problem? 4. What concerns do you have about the problem?) can help to gain a better understanding of the patient’s view of health and illness. Next, the information gained from this assessment can be incorporated into treatment recommendations which will respect the patient’s health belief system and worldview and, therefore, are more effective.

 

I argue that a deeper and often more difficult intervention is necessary to accompany the above-mentioned techniques. I believe that using cultural humility to interact with patients will allow for some of the best health care outcomes possible. Cultural humility is the constant examination of our own biases and perspective. The regular steps of cultural competence still remain: learning/reading about a particular culture, interacting with that culture, respecting cultures other than your own. However, an additional set of criterion are necessary to become culturally humble:

1) Acknowledge that you are on equal footing as their discussant/patient-There is no better way to conceptualize health (i.e., provider vs. patient beliefs surrounding health).

2) Be aware that the discussant lives their life by a set of rules related to their family, history, and environment, which are individualized, discrete and different from your own (Ethnorelativism).

3) Be aware of how your own personal life history over time effects your thoughts, beliefs and behaviors (strengths andlimitations) in relation to the discussant.

4) Acknowledge that one can never truly know the perspective of another individual or culture and that admitting your limitations opens the door to an honest conversation and does not diminish your legitimacy, credentials, or strengths and skills.

5) Does not search to become culturally competent at some distinct point, instead is continually learning about themselves and others through mutually beneficial conversations.

To demonstrate this point I offer a case example based on a real scenario:

A medical provider and her colleagues have been seeing a patient who has cancer (but has been in remission for 4 years) at 6 month intervals to ensure that the cancer (a rapid and progressive one) does not return. At the end of every visit for 4 years, the provider tells the patient and his family that he continues to be cancer-free and the family wails with joy and tears at the end of every appointment. The provider and her team have become frustrated with this response and do not understand the intense emotional reaction to what seems like a routine check-up that has resulted in the same positive outcome for many years. They hypothesize that there is some psychological trauma that the family has incurred due to this health experience that has resulted in some sort of psychological damage and are planning to refer them to psychiatric services. The patient is being seen at an Indian Health Service (IHS) facility in the Southwest United States and belongs to a Southwest tribe of Native Americans.

What do you think the provider and her team are missing from their assessment of the patient and the family? Using MI, the 4C’s, cultural humility, or your techniques to remain client-centered, what would you do as a MedFT if this were your patient? Let’s continue the conversation through the comments you make!

Reference: Galanti, G.-A. (2004). Caring for patients from different cultures. Third Edition. Anthropology of Consciousness, 15, p.66–67. doi:10.1525/ac.2004.15.2.66

Melissa Lewis is a licensed Marriage and Family Therapist. She received her Master's degree at Arizona State University (MFT) in 2007 and her PhD from East Carolina University (MedFT) in 2012. Her research area broadly encompasses the relationship between stress response and BPSS outcomes. Specifically, she studies the stress transmission model with military couples and is also evaluating integrated care interventions aimed to reduce BPSS health symptoms in both Native American and military populations.

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Dejected Views on Family Hating

Posted By Barry Jacobs, Dave Seaburn, Tuesday, September 3, 2013


This is a post in a series of "blasts from the past". These classic posts will highlight issues that are just too important to collect dust in the archives. The series will be off and on for the next several weeks. Enjoy!

(This piece was originally posted on March 6th, 2012)

 



Dejected Views
on Family-Hating


Barry J. Jacobs



The surreptitious eye-roll is bearable. The low groan is regrettable but not worth reproaching. But what irks me most about the occasional reactions of my family medicine residents to their patients’ relatives is the smug, dismissive, professionally rendered character assassination, complete with technical terminology. "The spouse is in denial,” they point out to their fellow inpatient team members when an overwhelmed and grieving husband or wife is unwilling to change a patient’s code status. "The daughters are being manipulative,” they observe about adult children who are urging their mother to resist physicians’ recommendations to undergo surgery or take a new medication. "They’re over-stepping boundaries,” they claim about family members who call them repeatedly or accost them with concerns in the hospital or office hallway.

It’s not that other healthcare professionals are substantively more family-friendly. For many of my mental health colleagues, hate of (or at least discomfort with) families is a many splendored thing. They focus on individual dynamics and prerogatives, invoking the delicateness of the therapeutic alliance or the sanctity of confidentiality as justifications for eschewing family contact. They cringe at the prospect of family meetings. They regard family systems thinking as a relic of the ‘60s, unsupported by current research or modern expediency.

I’m incredulous at these attitudes; I take them personally. From my teenage years caring for my father with brain cancer to my middle-aged years caring for my aging mother and demented step-father, I know in my gut how families affect patients’ clinical outcomes and how patients’ illnesses affect family caregivers. Others, clearly, don’t share the same visceral conviction. So what do I make of the widespread phenomenon of family-hating? Here are some over-the-top theories:

We operate in evidence-reinforced comfort zones: Much of healthcare practice and consequently research is focused on individual patients. In an era when clinicians are reminded at every turn to treat according to evidence-based principles, family-centered practices—lacking the same degree of empirical support—therefore seems the riskier clinical gamble. This is compounded by the fact that many healthcare professionals do not receive much training in the nuts-and-bolts of working with patients’ family members—e.g., running family meetings, addressing family conflicts. The seemingly prudent and comfortable treatment approach is centered on patients, leaving family members in the wings.

We are rats in templated, encoded mazes: Medical care, especially primary care, is being increasingly shaped by the clinical pathways that are the basis for the templates of our electronic medical records. By clicking through those templates, physicians not only have the assurance of following the so-called highest standards of care but are also working toward completing their progress notes for medical sessions as quickly as possible. It should come as no surprise that those EMR templates reflect bias toward individually-focused treatments. Family-centered healthcare is off-the-templates.

At the same time, clinicians are under enormous pressure to maximize reimbursement for healthcare services. The billing codes—aka CPT codes—they use have a powerful effect on practice. CPT codes for individually-oriented treatments are reimbursed by insurance companies. CPT codes for meeting with patients’ family members are generally not. We follow the money and avoid the family members.

Beaten and bedraggled, we cling to our authority: I don’t need to tell you that every year healthcare providers are worked harder, blamed more for rising healthcare costs, and disparaged more frequently by angry patients and aggressive lawyers. Evoking Rodney Dangerfield, all we want is a little respect. Now comes the dawning age of the patient-centered medical home with its emphasis on team-based care and who wants a place at the decision-making table as partners in care? Family caregivers do. (For example, see this recent AARP Public Policy Institute report). I think it’s tough for us to give up some of our remaining power to family members. When I hear professionals complain that patients’ family members somehow obstruct the treatment plans of the healthcare team, I infer that they don’t want their scant authority challenged any more than it already has been.

We are all adolescents at heart: Many of us give lip service to the importance of family members to patients’ care. But in our own lives, in our heart of hearts, we feel ambivalently about families. We want their support but don’t want them to encroach on the individual’s rights and independence. It reminds me a little of the sentiment captured in the title of the 2002 book on teenager psychology, Get Out of My Life, but First Could You Drive Me and Cheryl to the Mall. We want family members to drive our patients to our offices but then don’t make a fuss in the exam rooms. We want them to help our patients adhere to our treatment plans but not have input into those plans. That’s not family-centered care. That’s not even respectful of what family members know and have to offer. It marginalizes families. It’s reflexively oppositional and hateful.

For more on this general subject, check out the seminal article, "The Trouble withFamilies: Toward an Ethic of Accommodation” by Carol Levine and Connie Zuckerman in theAnnals of Internal Medicine, 1999, vol. 130, pages 148-152.

Also please see "Interacting with Patients’ Family Members During the Office Visit” in the Oct. 1, 2011 issue ofAmerican Family Physician; it’s a tepid, timid approach to incorporating family members into primary care but at least represents some effort to do so. 



I Beg to Differ

David B. Seaburn

 I beg to differ with my good friend Barry Jacobs’ blog posting entitled, "Dejected View on Family-Hating.” Not only is he (uncharacteristically) off-base, but he may not even be on the playing field.

He notes that family-hating is rampant in the medical field as well as in most mental health disciplines. While I don’t espouse family-hatred, I doubt that any well-trained family-oriented mental health professional isn’t at least ambivalent about families from time to time. They are messy and confusing and inconsistent and wonderfully Resilient in their efforts to get us to respect their integrity. Non-family-oriented healthcare professionals are not the only ones to unfairly label families. In moments of frustration, I have considered whether "borderline” might be an apt relational diagnosis, especially when I don’t know what to do with a family.

Which brings me back to Jacobs’ criticism of residents. If as an experienced family therapist (35 years), I, at times, label and very nearly hate a family, what can be expected of residents. Remember---these are medical professionals who have been trained almost exclusively in a paradigm that focuses on the life and death of an individual patient; who have been acculturated to think reductionistically ("Let’s find the single cause of this patient’s symptoms”); who then enter a healthcare system that mitigates against inclusion of families due to time (see what it’s like to care for four or more patients per hour), diagnoses and healthcare reimbursement. If that were my professional background, my professional culture, I would run the other way when I saw a complex, demanding, needy family coming my way, as well.

I was a residency educator for almost twenty years. Early in my tenure I learned that I was a visitor in a different culture and, as such, I needed to enter that culture with respect and an eye to learning as much as I could to be of value. At first I thought I needed to convert the heathens to a family systems paradigm. If they could only become like me! Soon I realized that that wasn’t what was needed. More than anything else, residents needed help with their most difficult patients. As a family systems professional, my help with challenging patients often (but not always) included involvement of the family as a resource to the resident or as an important source for understanding the patient’s problems. Once residents saw that family could be integral to care and that involving family in challenging patient situations made their lives easier, residents often caught the family system’s bug. For me the lesson was---Don’t preach family-systems, just do it. Making it work in the exam room is the best evidenced-based example you can provide.

The challenge for family-oriented residency educators is to be comfortable and creative taking a one down position (yes, even after all these years!) in a system that is slow to accept differences, let alone change. That means wielding power and influence differently, if, at times, not equally. Becoming a recalcitrant adolescent ourselves is not the answer. Instead, we must recognize that as a maturing member of the medical education family, family-oriented healthcare educators must demonstrate the capacity to be systems-oriented in our clinical, research, educational, administrative and policy-making endeavors. We must leave "evidence” of who we are everywhere we go. I think that the better angels of Dr. Jacobs’ nature recognize this.


Barry Jacobs
Dave Seaburn
Barry Jacobs and Dave Seaburn are family medicine educators and long-term collaborators. Barry is the Director of Behavioral Sciences at the Crozer-Keystone Family Medicine Residency in Springfield, PA and the author of The Emotional Survival Guide for Caregivers—Looking After Yourself and Your Family While Helping an Aging Parent. Dave recently retired from a distinguished career as the behavioral science faculty in the University of Rochester Family Medicine Residency and has taken to writing novels, including Charlie No Face.

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