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Sending helpful and healthful messages within families

Posted By Katharine Wickel, Monday, July 15, 2013

This blog post is the third in a month-long series about the bi-directional relationship of family systems and nutrition.

It seems like we are constantly being bombarded with "health” messages by various forms of media. There are commercials, billboards, Internet advertisements, and whole television shows dedicated to weight loss. Magazines, for both women and men, have monthly articles addressing new diets, exercise routines, super-foods, foods to avoid, and other ways to make one’s body look better. Most of this is done to promote the illusive ideal of a perfect body, and much of it is done in the name of "health.” We are also not completely off the hook either; we fully participate, not only by the media we consume, but what we choose to pass on through social media. This takes various forms of sharing information about our latest physical activity, healthy recipe, etc. Some of this promotes health and some does not.

To be sure, not all media coverage and social media activity that is related to weight loss is negative, but with so much information being available and shared, one question that arises is: what is helpful? How do we know what we should talk about? As professionals, how can we actively help families be able to not only be wise consumers of health media, but also how to have conversations about health. Answering these questions fully, would most likely take several years of research to really understand the nuances of conversations for both men and women of various ages, cultures, ethnicities, and socioeconomic statuses and is beyond what I can adequately address in a blog post. However, I will address discussions about weight versus health and our role in these conversations as providers.

Families have a great characteristic going for them; they are a family!
First, think about the context that exists for our patients. Most, if not all, are surrounded by important people in their life; often this comes in the form of family. Basic systems theory suggests that each person in this group is constantly influencing each other. Research has found that social support plays an important role in changing behavior, and this is true of health and nutrition habits also. Families have a great characteristic going for them; they are a family. This may sound too simplistic, but think about it. They are an already-formed group of people, who have investment in each other. Families can support and influence each other in what they’re consuming (i.e., food and media). Health and nutrition work has to happen within (not against) this context if we are to have any hope of creating long-term, sustainable change. The ways in which families communicate about nutrition is important. 

In recent years, studies have consistently found that when parents focus on "healthy messages” such as, ‘eat your fruits and vegetables to have a strong body’ instead of messages that focus on a child’s weight or size such as, ‘you need to eat more fruits and vegetables to lose weight’ adolescents are more likely to have healthy behaviors such as fewer disordered eating behaviors, eating more healthful foods (i.e., fruits and vegetables) and lower weight status(1). This can become a difficult task for families to deal with if there are concerns about family members being overweight or obese. Many people are familiar with health risks associated with obesity but are unsure how to address this.

This was reinforced again and again for me this spring as I worked on a study funded by the Healthy Foods, Healthy Lives Institute called UMatter. Drs. Jerica M. Berge and Dianne Neummark-Sztainer are the co-principle investigators of the study. The main aim of UMatter is to prevent adolescent obesity by working with adolescent girls and their parents in a primary care setting. The parents had many questions about how to have these conversations with their daughters about weight and healthy eating and were genuinely interested in how to best help their daughters navigate these difficult topics. Parents want to be helpful, but may not have the understanding of how to be helpful.

In thinking about the contexts in which our patients live and the influential ways they can communicate with each other, there is an additional role for healthcare providers: promoting helpful conversations and healthy changes by starting small. When working with a family to make healthy changes, it is our professional responsibility to help the family work together, and provide them with skills and ideas of how to do so. Health is such an abstract term, and each family member may have a different idea of what it means to be healthy. As a behavioral health provider, I’ve worked with several patients to help them change their habits to become healthier. I have found that an essential piece of the conversation is to define small behaviors that the patient understands and is willing to implement (i.e. eat one whole piece of fruit a day, measure portion sizes, add a vegetable to every dinner, etc.). The blanket statement of "You should eat more healthy food” has little meaning and can be difficult to understand (let alone implement). You may be intending that the patient change small behaviors, but he or she may hear "I have to change everything about the way I eat. I can’t eat any desserts or candy.” This type of idea is extreme. Such a dramatic change would probably be overwhelming, and the likelihood of the patient sticking with it is very low. It is much more effective to have smaller conversations about having one less soda, or an alternative for a snack that is slightly healthier than before. These small changes can build confidence and lead to more small changes, which in turn grows to larger healthier habits.
Define small behaviors that the patient understands and is willing to implement

Thinking of family as social support for healthy habit formation, changing conversations from weight to health, and making small changes that add up to big changes, are all important steps forward in moving toward treating overweightness and obesity. These concepts may not be new to providers, but can be for the families with whom we work. Ideally, this helps empower and educate our patients and promotes long-term and sustainable systemic changes in their nutrition and health. Nutrition and health can provoke a lot of anxiety, and families may not know where to start. We as providers, can start within the family, promote conversations about health rather than weight, and start with small goals that patients can build into big changes. 


1. Berge, J.M., MacLehose, R., Loth. K., Eisenberg, M., Bucchianeri, M.M., & Neumark-Sztainer, D.N. (2013). Parent conversations about healthful eating and weight: Associations with disordered eating behaviors. JAMA Pediatrics. (Epub ahead of print).

Katharine Wickel, MS, LAMFT, is a doctoral student in Couple and Family Therapy Program within the University of Minnesota’s Department of Family Social Science. She is currently working on several research projects that address health disparities within different communities in the Twin Cities Area; these projects address Obesity and Type II Diabetes in the context of family and culture. She is also currently working on her dissertation proposal which looks at implications of discordance in family reporting on family and health variables on adolescent disordered eating habits. In addition to her research she also works as a Behavioral Health Intern at Broadway Family Medicine, a primary care clinic that is part of the University of Minnesota’s residency training program.


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Strengthening parents’ skills for shaping home environments and helping children build healthy habits

Posted By Kate Dickin, Tuesday, July 9, 2013

This blog post is the second in a month-long series about the bi-directional relationship of family systems and nutrition.

How can you get kids to eat their veggies? It’s been a stumbling block on the road to parenting healthy children, even before the "obesity epidemic” focused extra attention on parents’ influence on what kids eat. In my work with Cornell Cooperative Extension providing nutrition education to low-income families, I hear about many hurdles that well-intentioned parents face.

He picks out asparagus, and it’s not really something [chuckle] I want to try. I’m like hmm, "Yeah it’s really good,” and then he tried it, and he liked it but I didn’t. How do you get around telling them it’s good for them and you don’t like it yourself? So that’s challenging for me.

With increasing public health concerns about childhood overweight and obesity, parents are being bombarded with advice -- on how to feed the kids, turn off the tv, get active – even on how to be a good parent. Sometimes the implication is that parents are to blame for unhealthy weight gain in children. Even parents of overweight children tend to view other parents of overweight children as neglectful or unhealthy role models(1). The stigma is unproductive and harmful. Moreover, it’s just wrong. While parents influence children in many important ways, we also know that the environments where kids live, learn, and play create many challenges.

It’s hard to make healthy choices while surrounded by cheap, tasty, calorie-laden foods. Most parents will tell you that time constraints, food preferences, and family dynamics impact their best efforts to model healthy habits, set limits, and encourage good choices. And very few children, regardless of weight, eat according to the Dietary Guidelines(2). Disadvantaged neighborhoods offer limited access to healthy food and safe play spaces(3) and low-income parents struggle to make ends meet, pay for housing, food, and medical bills – all the while trying to protect the kids from the stress.

It’s just... going to be hard. The main reason that we get the big things of iced tea is because it'll last us throughout the month. You know, so by the time the end of the month comes and we have nothing, we at least have the iced tea. That's the main reason we get it, so the kids will at least have something to drink.

After they eat, they’ve still got to do their homework, get cleaned up and ready for bed. During the week it's hard for me to get to the store, so it's hard to keep fresh [produce] on hand. It’s got to be something I can buy on the weekend that's going to last.

At Cooperative Extension, we support families through nutrition education programs funded by the US Department of Agriculture and delivered by paraprofessional community nutrition educators (CNEs) who are connected to local communities and serve as supportive role-models. Healthy Children, Healthy Families: Parents Making a Difference! (HCHF) is a curriculum aimed at helping low-income parents not only learn about healthy eating and activity, but also develop parenting skills to influence kids and create healthy home environments(4).  HCHF is for parents of 3-11 year-olds, not just overweight children. And it’s part of a larger initiative to expand nutrition education beyond individual behavior change to also focus on creating healthful community environments(5).
It’s hard to make healthy choices while surrounded by cheap, tasty, calorie-laden foods.

HCHF promotes recommendations linked to healthy weight and reduced chronic disease risk: replacing sugar-sweetened beverages with water and low fat milk, reducing energy-dense foods, increasing vegetables and fruits, playing actively, and eating only when hungry. While these recommendations are made by countless health professionals every day, HCHF’s hands-on workshops provide time to engage in discussion, develop practical skills, set goals, and support each other’s progress. Selected parenting skills are integrated into the curriculum: teaching by example, building supportive relationships with positive feedback and respect, giving children choices within limits, and creating home environments that make healthy choices easier. The overall theme is to support parents’ efforts to "help make healthy habits happen,” a slogan created by one of the CNEs.

But research evidence on links to child health does not necessarily identify practices that work in real life for low-income families. To learn about acceptability and feasibility of HCHF nutrition and parenting behaviors, we conducted "Trials of Improved Practices” in which parents chose and tried new behaviors, then reported on their experiences(6). The small group of low-income parents we interviewed faced many challenges in their lives, but were motivated enough to enroll in and complete HCHF.

Parents reported success with specific strategies such as offering limited healthy options and they appreciated the value of helping children learn to make decisions on their own.

What I try is, just give them two choices. If I don't want them to have iced tea, I'll just give them a choice of milk or water and I mean, it works... Sometimes they'll throw a fit for a little bit, but I just keep telling them, "These are your only choices,” and it works.

Can-do, that’s like, giving her, giving her choices right? Can do is good because she gets to learn about choosing and decision making.

Most of the recommendations were feasible and acceptable to at least some families and parents saw that despite the challenges, effective parenting strategies were worth the effort.

It's not the easiest thing to be consistent because you know that they don't really want to and you feel bad, but you know what? In the long run it's going to pay off. We've used consistency not just with food -- with his behaviors and his attitudes and his school and with everything. We've learned that you have to be consistent because if you don't you just have chaos.

There were also challenges. Parents were practical and insightful about trade-offs made in the face of conflicting priorities and limited resources. Parents expressed a strong drive to keep kids fed and happy – a drive that could outweigh the health information they received. 

It’s hard... we were always indulged with food. Growing up, it was always "eat it, it's there, eat it.” We never had to worry about food. My wife didn’t grow up with cabinets full of food, so she hates to have them empty. I can see some parents, they didn’t have it when they were growing up and they want their kids to have it. Regardless if somebody says it's no good for them or not.

Even when success was not immediate (so often the case with those vegetables!) many parents demonstrated a willingness to communicate and work with their children over time. Food preferences and time constraints were some of the biggest barriers to behavior change. Food costs, insecure living situations and chronic health problems were mentioned by some families. Other adults in the home were sometimes facilitators, sometimes barriers.

 He’ll be like, "You and this health thing. Don’t try to… convert me, manipulate me, with your ‘nutrition knowledge’. You go to this class and all of a sudden you come back with this foolishness.” [laughing]

Parents come to HCHF with many good practices in place, yet they also report learning a lot and making positive changes at home. We think HCHF is useful for families –the information provided is not that different from what parents hear in the media and from health professionals, but the focus is on application. Community programs like HCHF offer opportunities to follow up professional consultations with hands-on, accessible programming to help put recommendations into practice. Such programs may exist in your community but be underutilized. Stronger referral relationships with family health professionals would benefit everyone.

What have we learned from parents in HCHF? Parents are trying hard. It’s about health, not weight – all kids need healthy diets. Acceptability and feasibility of practices varies by family – what gets labeled as indulgence from the outside may just look like love inside a family. Parents can enhance behavior change by choosing which recommendations to try. And finally, environments matter. Multifactorial public health problems like childhood obesity require multifactorial solutions. It just may "take a village” to get kids to eat their vegetables. You can be sure that blaming and shaming won’t do the trick.


  1. Kalinowski A, Krause K, Berdejo C, Harrell K, Rosenblum K, Lumeng JC. Beliefs about the role of parenting in feeding and childhood obesity among mothers of lower socioeconomic status. J Nutr Educ Behav. 2011.
  2. U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2010. 7th Edition ed. Washington, DC: U.S. Government Printing Office; 2010.
  3. Kumanyika S, Grier S. Targeting interventions for ethnic minority and low-income populations. Future Child. 2006;16(1):187-207.
  4. Lent M, Hill TF, Dollahite JS, Wolfe WS, Dickin KL. Healthy children, healthy families: Parents making a difference! A curriculum integrating key nutrition, physical activity, and parenting practices to help prevent childhood obesity. J Nutr Educ Behav. 2012;44(1):90-92.
  5. Food and Nutrition Education in Communities. Collaboration for Health, Activity, and Nutrition in Children’s Environments (CHANCE).2011; Accessed December 12, 2012.
  6. Dickin K, Seim G. Adapting the trials of improved practices (tips) approach to explore the acceptability and feasibility of nutrition and parenting recommendations: What works for low-income families? Maternal & Child Nutrition. (in press)

Kate Dickin, PhD, is a Research Scientist in the Division of Nutritional Sciences at Cornell University. She conducts translational research on child nutrition and parental feeding practices, food security, micronutrient supplementation, and interventions to reduce health disparities in the US and globally. A particular research focus is the interface between programs and communities, exploring factors that influence the motivations, behaviors, and interactions of practitioners and families.

Tags:  nutrition 

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It’s Not (All) About the Food, It’s (Also) About the Process of Feeding

Posted By Keeley Pratt, Wednesday, July 3, 2013

This blog post is the first in a month-long series about the bi-directional relationship of family systems and nutrition.
I recall from my family therapy training hearing a particular supervisor continually repeat the phrase, "It’s not about the content; it’s all about the process.” I employ the readers of this post to apply that same understanding to the topic of family systems and nutrition, for the purpose of this post is to consider the process of feeding and dining together, not the content of the food itself.

Statistically speaking, more than one-third (35.7%) of adults reading this post (located in the United States) are obese;1 for those readers who have children, 31.8% of them struggle with being overweight, and 16.9% are obese.2 I note these statistics because every single person reading this post can either relate personally to these statistics or loves someone who can. Food is not only meant to be life-sustaining, but also should be enjoyed and experienced socially.

Think back to the last time you had your favorite food served to you… your ultimate favorite food in the world. Think back to how the food looked on your plate. Was it served hot or cold? Was there steam coming off of it? What did the presentation look like? Who cooked it for you? How did it smell? Could you smell it cooking in the kitchen? Does the smell remind you of any warm memories when this same dish was served? Now, recall getting ready to take the first bite of your favorite food. Who was with you when you were served the dish? Did you have to use a knife to cut it? Did you scoop it with a spoon? Remember how all your senses were preparing to taste this food, your favorite food.

Finally, you take a bite, slowly allowing the flavors to absorb into your taste buds, remembering the familiar texture of the food in your mouth. Then you swallow, and smile knowing that there is more where that bite came from. You look around at the other(s) with you, expecting their reaction to be as blissful as your own – to enjoy in the experience of sharing this meal together. Our family and community in many ways determine which foods are purchased, how they are prepared and served, and the dining atmosphere where food consumption takes place. All of these elements employ family systems theory and elements of process that can ultimately impact the experience of feeding and eating.

The purpose of this post is to briefly introduce the dynamics around the process of feeding. This blog is not to discuss "food” itself, or to blame anyone for their (mis)use of food. Additionally, I want to be mindful that our friends and colleagues in Nutrition and Food Science are better equipped to talk about the "content” or nutrient density of food.

1. Food is meant to be enjoyed WITH others: A family that eats together, stays together

The process of eating is meant to be a social experience where family members can join together not only to eat, but also to commune about how their day went. This is a time, set aside routinely, that can serve as a touch point for parents and children, romantic partners, extended family, and others to communicate about their daily ups and downs. In fact, we know that the benefits of family meals include decreased chances of developing, substance abuse, depression, eating disorders, and obesity. Specifically, youth who participate in family dinners with their parents have better overall academic performance, higher self-esteem, a lower risk of teen pregnancy, and greater sense of resilience.

2. Food ≠ love, Feeding = LOVE

We have been taught by our parents, and our parents-parents that love is often shown through the foods we serve at meals. Love motivates us to prepare food for our family, often cooking for hours before it’s served, so that the final product can be enjoyed by all. This can become a challenge in families when a child or partner may refuse to eat a food, critique how a food is prepared, or simply may not be hungry. It’s not hard to imagine how upsetting it could be when a family member refuses to eat or critiques the food that is prepared, lovingly, perhaps for hours-on-end on top of a long workday.

It’s important to remember that the process of feeding is still employed even when food consumption may not take place as smoothly as expected. For example, if your school-age child states, "I hate when you cook green beans!” or your partner remarks, "This chicken is a little burnt this time.” These aren’t personal insults or an indication about how much they love the person who prepared the food for them. We need to encourage our clients and patients to not get caught in a trap where a fight over food might take place. The time we get to socialize with our families every day is limited by busy schedules and demands, and although feelings can get hurt when the effort put into the food preparation may not be acknowledged, family time shouldn’t be taken up by "food fights”.

In order to stay focused on the process of feeding, we should expand from thinking about the content of the food being served (or what is "rejected”) to the process of what is going on with the family at dinner. For example, a child could be having a bad day overall, and the refusal of food is just an indication of something upsetting that happened at school. If a partner makes a comment about the quality of the food, clients and patients can use the opportunity to have a conversation about how the feedback makes them feel. Ideally, conversation should shift over family dinners from food or what is being served to the day’s events.

Other meal-time process considerations include:

  • How are individuals making eye contact during the meal?
  • Is everyone participating in the conversation during the meal?
  • What kind of tone are individuals using during conversation?
  • Does everyone get up at the same time?
  • How are second servings asked for?
  • What kind of thanks is given to the person who prepared the meal?
  • What kinds of topics are brought up during the meal, and how does each person respond?

Keeley J. Pratt, PhD, IMFT, is an assistant professor in the couples and family therapy program in the department of Human Sciences at The Ohio State University, an independently licensed marriage and family therapist, and an AAMFT approved supervisor. Her research focuses on family-based factors that contribute to or are modifiable in the treatment of child/adolescent obesity. She has over 50 presentations at local, national, and international conferences and has authored over 25 manuscripts and book chapters about child and adolescent family-based or integrated obesity treatment, medical family therapy, and supervision in healthcare settings. Currently, Dr. Pratt is working to expand family therapy education to include clinician training on systemic weight-related behaviors (including feeding) and working with clients who are struggling with overweight and obesity.

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What to Wish For

Posted By Barry Jacobs, Wednesday, June 26, 2013

When he became my step-father when I was 17, he and I never made eye contact. We resented each other’s presence in the house and tried to avoid one another as much as possible. He wanted my mother all to himself. I resented the fact that he was taking my deceased father’s place. We passed each other in the narrow hallways with heads down, barely grunting in recognition. If I’d never looked at him again after I reached college age and moved out, it would have been all right by me.

Now, 37 years later, each time I visit him in the dementia unit in the nursing home, I find myself staring at him, gawking at his transformation. His body is now all jutting bones and red sores. His face is a stiff, gaunt mask covered with flaking skin. He gazes back at me just as intensely. I wonder what his blue eyes see as they stare at me, what is going on in the shrunken brain behind them. But his eyes quickly go vacant—unfocused and uncomprehending—with too-narrow pupils. It is clear he no longer recognizes me. In his severely demented and diminished state, I no longer recognize him

What should I wish for him? It only embarrasses me a little that I’ve spent most of my life hating him and wishing him dead. Now that dementia is slowly draining all life from him, I’m ambivalent about what I want to occur. Part of it has to do with my mother’s feelings. During her three-times-a-week visits to the dementia unit’s crowded day room, she still takes small pleasure if she can coax him to eat everything on his lunch tray, as if he were some stubborn toddler. If he also babbles to her—mostly random words and sentence fragments without meaning--she is thrilled for the rest of the day. Even though she has signed nursing home orders to let nature take its course in the event he becomes seriously ill, rather than having him sent to the hospital, my mother isn’t ready to let him go. Caring for him still gives her purpose. Without him, she will feel utterly alone. In deference to her, I don’t want him to die just yet.
How many of us resolve all remaining issues with the dying? How many of us are left with regrets?

But part of my ambivalence also has to do with my unsettled relationship with him. How many of us resolve all remaining issues with the dying, especially those with whom we’ve clashed and whom we then demonized? How many of us are left with regrets? As a teenager and young adult, my step-father served as the example of all I didn’t want to emulate—the Anti-Mentor. Where he was jokey and false, I would sanctimoniously try to be straight and true. Where he was manipulative and self-serving, I would attempt to be above board and serve others. In my mind, he was my foil, my moral counterpoint. But using him in this way to help define myself also connected him to me psychically. It gave him a role of some importance in my development. Even as an older and supposedly wiser middle-aged adult, I never bothered to get to know him beyond the caricature of rival and villain.

Last week, my mother learned that the nursing home staff members have been unable to heal my step-father’s persistent bed sores. It’s a sign that dementia is sapping his recuperative powers and that his end isn’t far off. The nurse who called my mother suggested hospice services for him. My mother asked me what she should do. I recommended that she agree to hospice. She was sad but acquiesced.

I’m feeling conflicted. Part of me regards this matter-of-factly as the right thing to do. Part of me feels a little sad, too, about his likely death in the next few weeks or months. Who was this guy? I’m reluctantly coming to the realization that I wish I knew.

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 Out for Yourself and Your Family While Helping an Aging Parent" (Guilford, 2006). Please see the book’s website—

Tags:  caregiving  dementia 

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Watch Your Mouth

Posted By Stephanie Trudeau-Hern, Tuesday, June 4, 2013

I am going to use this blog post to write about something that is very dear to my heart. The topic is how we communicate about illness: the rhetoric, dialects, and metaphors that riddle the conversations we have with and about a person who is diagnosed with a chronic illness. I will share with you a story, an analogy, some history, and finally a call to action. Some of my words are supported by research and literature, and all are based off of real conversations I've had with patients and family members impacted by a diagnosis of cancer. 

The Story:

"Stephanie, the reason you have felt sick is because your body has been lacking in proper defenses and your immune system has been taken over.  Cancer cells have invaded your body and have colonized into a tumor. Our plan of attack is to excise the mass and begin an aggressive regimen of chemotherapy and radiation. It is very important that you remain positive and keep fighting so you have a better chance at defeating this.” 

From this moment on, I am a woman with cancer. I am a cancer patient. My identity will be wrapped up in a culture of metaphors that feel terrifying and abrasive. I am now at war with my body. It appears that I only have two options: I can stay positive and fight for my life in the hopes of becoming a survivor, or I can fall victim to my disease. I wonder if in my eulogy they will say I fought a good fight…

An Analogy:

Truth be told, I've never had cancer, but a great deal of people close to me have. I have heard these words resonate in the halls, the exam rooms, and in the infusion rooms of the oncology center where I provide behavioral health services. I have met with enough people who have been diagnosed with cancer, and their loved ones, to know that the war-laden language of cancer has an impact, and from what I am hearing it may no longer be a positive one.

During my quest to explore the dialect of cancer I was honored to have a conversation with family scholar Dr. Jay Mancini. I shared with him a conceptual paper I’d been working on regarding this very topic. When we met, he didn’t want to talk about cancer. He wanted to talk about tomato blight. Tomato blight, he stated, was a common yet annoying problem for gardeners. Tomato blight is a rapidly spreading plant disease characterized by a rotting of the leaves and foliage. For decades frustrated gardeners accepted this as a consequence of humid weather. Eventually it was discovered that watering the tomato plant from the wrong direction causes tomato blight. When a gardener waters from the top of the plant, the force of the water causes dirt to splash back up onto the leaves, therefore spreading the organism that causes blight. By changing how the water was delivered, watering at the base of the plant, this annoying issue with tomato plants occurred less often.

He asked me if I understood his point. I didn’t, but he patiently allowed me to chew on it for a couple minutes. Then I got it; it made perfect sense. Maybe what we have been doing all along, which was to do what we knew how to do (watering from the top), was the very thing that was causing harm to our patients (the plants).  Maybe the main thing we need to do instead is to change the delivery of the language (water at the base).  Maybe we have been inadvertently and unknowingly harming our patients by the way we talk about their illness. 

The History:

In 1978 Susan Sontag wrote Illness as Metaphor. She posed questions about the benefits of war-laden language that had been attached to cancer. The metaphors of war had been used to communicate about tuberculosis. Now that the etiology of TB is understood, war metaphors have been transferred onto cancer and other illnesses. She discussed how using these metaphors created norms throughout society that may not have been beneficial to the individuals with the disease. By attaching war language to a physical illness, it is implying one either fights, or dies. One either survives or fails to thrive; that essentially only the strong survive.  

Prior to Sontag’s book, a political movement had started in 1969 with an advertisement to the Washington Post presenting a plea to President Nixon to reduce the secrecy of cancer and to put forth exposure on the veracity of the disease. In 1970 the "Moon Shot” campaign was launched. A large amount of government money was put into creating cancer research dream teams. It was like NASA for the cancer research community. The political call for answers and release of money to find a cure had solidified the rhetoric for the "war on cancer”. The 1970’s became the generation that no longer secretly whispered about cancer.

Sontag’s hope for the future was a movement beyond the limited language that had been created for cancer to include a broadened scope of actual patient experience. This was in 1978; 35 years later we are still using the same winner/loser language. 

So What?

While conducting a qualitative interview, I asked a widowed husband about his experience with his wife’s cancer. He recalled, "People say the dumbest things. When they would say, ‘keep fighting’ or ‘she’s a fighter’, I wanted to scream, ‘What do you think she is doing?!’ … To me it was as though they were implying that she was not fighting hard enough, that if she fought a little harder she should be able to beat this. I wanted them all to know that if cancer was something one could beat by sheer will and toughness, she would have been the one to do it. She did not fail to fight hard enough. Cancer was just better; cancer won.” He then said, "Still to this day when I hear the words, ‘stay positive’, or ‘keep fighting’, it makes me want to jump out of my skin.”

When an individual’s identity becomes rooted in metaphor, the metaphors themselves become the basis of communication within their social system. Metaphors are critical to our sense of meaning making. It helps us assign something we are familiar with and gives language to what we cannot explain. I have sat with many women who are breast cancer "survivors”. I hear from them that the war metaphors have become emotionally grating. I’ve had women tell me that they do not feel that they deserve all that comes with the "survivorship badge.” One woman in her early 30’s stated that she would rather be called a "thriver” or an "overcomer”. When it came to her illness and the treatment she received, she felt she did what she had to do. Nothing she did was superhuman; it was the luck of the draw that she no longer has cancer, when others around her died from cancer. She didn’t want to be seen as something special, being labeled a survivor was too much for her. She didn’t feel that she fit in the same category as all the other women who take ownerships of their survivorship badge. 

We have yet to develop a broader and more helpful way to communicate about one of the most feared diseases of our time. As clinicians and providers we are often the ones who begin the communication around a diagnosis.  We are the ones who introduce the language, the metaphors, and the rhetoric to patients and their families. I say let’s do better; let’s ask the ones with the diagnosis what language and metaphors work for them. Let’s start watering from the bottom!


Diedrich, L. (2007). Treatments: language, politics, and the culture of illness. University of Minnesota Press: Minnesota.

Ehrenreich, B. (2009). Bright-sided: how positive thinking is undermining America. Picador: New York.

Mukherjee, S. (2010). The emperor of all maladies. Scribner: New York. 

Sontag, S. (1988) Illness as Metaphor and AIDS and Its Metaphors. Picador: New York.

Stephanie Trudeau-Hern, MS, is a doctoral student at the University of Minnesota in the Department of Family Social Science - Couple and Family Therapy Program. Her clinical and research interests include caregiver well-being, family coping with chronic illness, end-of-life issues, and provider self-care within collaborative health care teams. She credits her two little monkeys for being the most influential teachers of life, love, play, and well-being.

Tags:  cancer  communication 

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Treating the Patient

Posted By Grace Wilson, Tuesday, May 28, 2013

"The good physician treats the disease.  The great physician treats the patient who has the disease.”

William Osler, 1849-1919


Rachel is scared.  At 55 years old, she’s faced a lot in her life, and has managed pretty well to this point.  She worked in a local factory until she was laid off 5 years ago.  Although she’s been struggling financially since then, she figures that leaving the physically demanding job has probably been better for her health, and she and her husband Daniel manage to get by on his monthly disability check.  With the help of her physician, Dr. Andrews, her Type II Diabetes has been mostly well controlled since her diagnosis 15 years ago.  Now, though, a bigger medical problem looms on the horizon – she found a lump in her breast last week.  Rachel is very familiar with the realities of what this could mean, because her mother died of breast cancer when she was Rachel’s age.  Daniel is a big emotional support for her, but he doesn’t have much knowledge of medical issues, and she is afraid to burden him with her fears because he is struggling with his own health concerns.  Now, Rachel and Daniel are sitting in an exam room waiting for Dr. Andrews to come in to discuss the results of Rachel’s mammogram and consider what her options for further diagnosis and treatment will be.

Dr. Andrews has treated Daniel and Rachel for over 20 years.  He is familiar with Rachel’s medical history, her family situation, and her fondness for baking pies every Christmas to share with the office.  Now, he has the results of her mammogram.  Although she’s going to need a biopsy to confirm the presence of cancer, the film is not looking good.   As he walks into the room, he sees the mix of hope and fear on Rachel and Daniel’s faces, and he knows that the relationship he has with them will be an important part of her quality of life – both medically and personally – in the days to come.


What can be done to foster a positive provider-patient relationship?
The provider-patient relationship can be a rich source of support and healing for patients who are facing stress related to health and illness.  It is built on trust, knowledge, and, increasingly, collaboration.  In the IOM 2001 report "Crossing the Quality Chasm,” six aims for healthcare are presented – among them, patient-centered care, which emphasizes the relationship between patient and provider.  The authors posit that the best healthcare is based on a continuous, healing relationship that is customized on patient needs and values, with safety, transparency, and the free flow of ideas. 

Research has shown that attention to the provider-patient relationship is beneficial for both parties.  Patients with chronic disease have improved quality of life, functional, and emotional status when doctor-patient communication is functioning well (Theofilou, 2011).  Patients who have limited agency and are unable to speak for themselves may be given a voice through a healthy relationship with a provider who cares (Shannon, 2009).  In turn, providers who spend time reflecting on provider-patient relationships tend to have lower stress and increased levels of empathy (Battegay et al., 1991).  Both Rachel and Dr. Andrews benefit from his attention to their relationship.

What can be done to foster a positive provider-patient relationship?  One of the keys is maintaining a patient-centered outlook with good communication (Fong Ha & Longnecker, 2010).   Collaborative communication, which integrates the patient’s perspectives and input, and conflict resolution are particularly important.  Patients report that the extent to which they feel their provider is listening to them is also a key determinant of relationship quality (Jagosh, Boudreau, Steinert, MacDonald, & Ingram, 2011).  In other words, if Rachel feels that Dr. Andrews is really listening to her, and actively communicating with her to increase her sense of agency surrounding her care, she will feel cared for and experience the benefits of a strong doctor-patient relationship.

How can you determine how the provider-patient relationship is going?  First, do a self-check.  To what extent do you feel like you understand your patients as "a whole person” rather than a diagnosis or a disease?  How often are you using active listening skills, such as reflective statements and clarifying questions?  What does your gut tell you about the relationships you maintain with your patients?  All of these questions are important – remember that relationships are always a reciprocal two-way street.  The way you feel about your relationship with your patients can tell you a lot about the state they are in.  More formal assessments are also available.  In 2012, a systematic review of 19 instruments assessing the doctor-patient relationship was published (Eveleigh et al., 2012).  Appendix 2 in the article provides a concise table summarizing the characteristics of the different measures.  While many of these measures are primarily utilized for research purposes, providers may find clinical utility in a more formalized assessment of the provider-patient relationship.
How can you determine how the provider-patient relationship is going?  

Most – if not all – providers would agree that maintaining effective communication with their patients is important, but even when the desire is there, barriers still exist to making this relationship a primary focus of treatment.  First, the pressure to see more patients in a shorter amount of time, coupled with patients’ increasingly complex presentations, can leave providers wondering how they could possibly fit more into their already packed encounters.  Second, opening oneself up to patients’ physical, emotional, and spiritual pain requires vulnerability on the part of the provider and risk of personal hurt or burnout. 

A few suggestions can help with these concerns:

• Simple strategies like making eye contact with patients and repeating patients’ words back to them can help with feelings of connection without increased time on the providers’ part.

 At a policy level, alternative payment structures should be explored to address the broader system issue of providers’ time.  

 To help with the potential burden of vulnerability, providers should engage in self-care and build strong professional and personal support systems from whom they may draw strength.  

 Providers who work in collaborative health care are uniquely posed to strengthen patient care while simultaneously diffusing the personal burden to be "all things to all people.”  Share the care!! 


Battegay, M., Weber, R., Willi, J., Eich, D., Siegenthaler, W., & Luthy, R. (1991). Exploring the doctor-patient relationship reduces staff stress and enhances empathy when caring for AIDS patients. Psychotherapy & Psychosomatics, 56(3), 167-173.  doi: 10.1159/000288551

Eveleigh, R.M., Muskens, E., van Ravesteijn, H., van Dijk, I., van Rijswijk, E., & Lucassen, P. (2012). An overview of 19 instruments assessing the doctor-patient relationship: Different models or concepts are used. Journal of Clinical Epidemiology, 65, 10-15.  doi:10.1016/j.jclinepi.2011.05.011

Fong Ha, J., & Longnecker, N. (2010) Doctor-patient communication: A review. The Ochsner Journal, 10, 38-43.

Jagosh, J., Boudreau, J.D., Steinert, Y., MacDonald, M.E., & Ingram, L. (2011).  The importance of physican listening from the patients’ perspective: Enhancing diagnosis, healing, and the doctor-patient relationship. Patient Education and Counseling, 85, 369-374. doi:10.1016/j.pec.2011.01.028

Theofilou, P. (2011). Improved quality of life, functional and emotional status: The doctor patient relationship. Primary Health Care: Open Access, 1(1). Accessed online.  doi:10.4172/phcoa.1000e101

Grace Wilson is a PhD candidate at East Carolina University in Greenville, NC.  She currently works as a behavioral health provider at a rural FQHC, and she will begin her doctoral internship in Oklahoma in August.  Her research is on couples, the childbearing experience, and the doctor-patient relationship.

Tags:  provider patient relationship 

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Special Patterns: A Story About Parkinson's Disease

Posted By Roberta Winters and Sylvia McCreary, Tuesday, May 21, 2013
Updated: Wednesday, May 15, 2013
"How incessant and great are the ills with which a prolonged old age is replete.”
- C. S. Lewis

This process of aging intrigues me, and has so for much of my time here.  Our human bodies begin tiny and frail, grow strong, create grand things, and then slowly decrease in energy, size, and (sometimes) ability.   Not so different from the trees outside my window, trees that stand tall, that sway and dance, and eventually fall.  But as I stare out my window at all those trees, some of them stand out to me.  These ones are different in some way.  They are not tall and strong; some of them don’t sway and dance.  No, these are different.  They have some special pattern about them, some uniqueness that both stunts their growth and produces a special character.  Limbs are twisted, contorted into interesting shapes and designs.  These ones cause us to pause. 

Parkinson’s Disease (PD) is one of many neurodegenerative diseases, and among the most common.  It is progressive and results from degeneration of neurons in an area of the brain that controls movement.  Any chronic illness will be a test to the will and determination of the patient, as well as a test to family and friend relationships.  But when PD patients develop within family and friend relationships that are nourishing, this can provide the patient with resources that help with their ability to cope and manage with the progressive symptoms.  

I have had the distinct pleasure to meet one exceptional lady, Sylvia, who is one of those trees with a "special pattern.”  She has taught me that chronic illness is a relational illness, and that the persistence and stability of those relationships surrounding one with PD will help to shape the patterns of healthy coping that emerge.  "You have to have an advocate.  You have to have good instincts as to who to trust and who not to trust [regarding medical care].”  Sylvia discussed with me how difficult it has been for her and her family to find support.  And the costs that come with any chronic illness are staggering.  Costs for prescription medications required for PD patients are high, and often these medications are not paid for by insurance companies (including Medicare).  Insurance companies would rather pay for generic brands that sometimes are not as effective.  

"The worst is not knowing what to expect, and knowing it gets worse,” says Sylvia.  "And being alone.”  Loneliness is a theme that repeatedly comes up with PD patients.  You have to include family members in the illness process, Sylvia noted.  She told me that one of the most helpful things she did was to hold a family meeting, and let her children know what she was facing, and how is was affecting her.  Sylvia said that her children now call her regularly, knowing that this little gesture will help their mother manage with difficult days, and times of loneliness.  

"Friendship is unnecessary, like philosophy, like art... It has no survival value; rather it is one of those things that give value to survival.”
- C. S. Lewis

"Friends don’t know what to do, so they do nothing.  It’s a loss.”  One of the most difficult things for PD patients to adjust to is the retreating of friends.  "I understand it,” Sylvia says.  "I certainly understand it.”  But this doesn’t ease the loss, or the pain of isolation.  Care takers of patients with PD can suffer isolation as well.  I have heard care takers say that they just can’t leave their dear one alone, just for a moment even; for fear that their loved one will need them.  Some of the care takers I have met have told me that they didn’t get out much… and that friends eventually stop coming by.  I glance around Sylvia’s kitchen.  Her refrigerator is covered with family photos; her children, their children, someone else’s children.  There are a lot of family photos.  I supposed it reminds her that they are all still there, even when they must go to work and school and busy themselves with life.  

"For after all, the best thing one can do when it is raining is let it rain.” 
- Henry Wadsworth Longfellow

I asked Sylvia, "How long did it take you to accept your illness?”  Sylvia thought, "Ten years.”  The acceptance started when she began to write.  She kept an online journal, and there she would write how she really felt about the illness.  She knew that she could get it all out safely, where no one else would see.  "Art is important,” Sylvia says to me.  She says it helps her to relax.  I look again around her kitchen, walls covered with art.  And little water colors, here and there.  A table sits in the corner, housing brushes that had been dipped in water colors; tools for coping.  She usually has her entire dining table covered in art work, she tells me.  But today, (maybe because I was visiting?) her tools sit in the corner, laid out on a table.  

I’m thinking again about the tress outside my window.  Yes, most of them are tall and strong, waving and dancing.  But today they no longer interest me.  How difficult can it be, to wave and dance, when you are tall and strong.  But to wave and dance when you’re not tall and strong, but seated in a wheelchair, and surrounded by photos of family and pieces of water colors, these things make "special patterns.” Those twists and turns that are embedded into the core, they draw our attention.  

Parkinson’s Disease is a relational disease.  It shows up, unexpectedly, in one person’s body, and somehow manages to spread into the whole family system.  It sometimes causes friends to disappear.  But as Sylvia reminds us, "They don’t know what to do, so they do nothing.”  And it is the loneliness that is left.  What are the pieces of a progressive chronic disease, and how do these pieces fit together?  It will benefit us as providers to see these larger system connections, and to know, while one may carry the disease, the effects ripple outward through the system.  We must always think of such illnesses as relational, and remember that the whole is greater than the sum of its parts.  

"Nana, I wish I could have Parkinson’s Disease, and you can run and play.” 
-Sylvia’s 4 yr old grandson

Roberta is a recent graduate of the Marriage & Family Therapy Master's program at East Carolina University (ECU), and presently enrolled in the Medical Family Therapy doctoral program, also at ECU.  Her research interests include gerontology (biopsychosocial & spiritual issues in aging), and health disparities in the Latino communities.

After being diagnosed with Parkinson's disease 18 years ago, Sylvia McCreary co-founded the Eastern North Carolina Parkinson's support group. As the disease progressed she lost her ability to play the organ and piano, but discovered the joys of painting with watercolors.  She has since produced an annual calendar featuring primarily her artwork. A portion of the proceeds goes toward the support of patients with PD. 

Tags:  chronic illness  Parkinson's Disease 

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A Collaborative Cure for Cancer

Posted By Joshua Fowler, Wednesday, May 15, 2013
Curing cancer, from a biomedical standpoint, is now possible, argues TIME Magazine writer Bill Saporito (2013), and is born from our philosophical beliefs about health care and from the practice of team-based, collaborative care. A bold claim, to be sure, but the truth of his claim depends on the meaning of the word "cure”. There are actually multiple meanings for the word "cure”. Saporito posits this: a cure for cancer is available, but is not simple to produce, nor easy to obtain. Still, it is possible, he says, and what makes it so is the harnessing of a collaborative approach by medical professionals from multiple disciplines.

In Saporito’s article, he writes that cancer "dream teams” can now effectively target and treat cancer, resulting in better and faster results that with more traditional biomedical care may not occur. What lays at the heart of these dream teams is collaborative care. Teams consist of professionals from various disciplines, all working together to help patients in a focused and targeted way. Each member has a purpose and a place and no corners are cut if it means even a chance at a slightly less favorable outcome for the patient. Saporito points out in his article the need to "upend tradition” in order to improve health care overall, not just for cancer. Today, people are living longer and chronic diseases (e.g., asthma, diabetes) are more common than infectious diseases (e.g., influenza, pneumonia). Traditional care that was focused on curing and removing disease may not be adequate for the long, drawn-out battles of chronic disease management. The need to change the way we treat diseases is growing, and it is time, as Saporito states, to part ways with traditional care that is only biomedical.

Perhaps there is something to glean from these cancer "dream teams”. Behavioral health care professionals, who offer biopsychosocial-spiritual care, are uniquely positioned to work alongside other health professionals in support of treatment. Teams of support professionals that work as well as the direct patient care teams that Saporito writes about already exist. At Duke University Hospital, Dr. Cheyenne Corbett, Director of The Duke Cancer Patient Support Program (DSPSP), leads a team of professionals from various disciplines. Though Dr. Corbett’s team is built to provide support rather than direct treatment for cancer, she and her staff take the same approach to health that the dream teams Saporito writes about use.
The need to change the way we treat diseases is growing

Recently, I had the opportunity to co-present with Dr. Corbett at a doctoral class of mine on childhood and adolescent cancers during which Dr. Corbett augmented my presentation with information on adult cancers, the main focus of the DCPSP. Further, she provided our class with an in-depth look at her team, how she operates, and why the DCPSP is accomplishing its mission "to create a humanistic environment for adults with cancer, as well as their family members, during the stress entailed in diagnosis, treatment, and after-care.”

Dr. Corbett, a trained marriage and family therapist, has a unique understanding of what it takes to support cancer patients to produce better outcomes for them. She and her team have the primary responsibility of acting as liaisons between patients and medical staff, providing hospitality to patients and families in exam rooms, and advocating for patients by helping them understand the resources available to them, including all of the services the DCPSP provides. If a patient wants family involved or a close friend to be nearby to provide support, the team works to make it happen. Professionals work as a team and check in with one another to ensure good care for patients. They look for gaps in patient care and work to close those gaps. The DCPSP is set up to take advantage of the collaborative view of problem-solving. Family is incorporated at every step along the way, and services such as family therapy are provided as part of care. Duke has a new cancer treatment center where the DCPSP is housed and even the building design was made to keep families together and to keep patients at the center of treatment.

Collaborative care, as Saporito writes, is becoming a vital part of healthcare not only between professionals but between patients and providers. As biopsychosocial providers, we should consider taking a look at how are we are encouraging family involvement and cross-disciplinary collaboration in our respective settings. If you are a patient or a family member, you may want to consider how you can advocate for cross-discipline collaboration in your treatment or the treatment of your loved one, and how you can stay involved in the overall treatment and support of your family member or friend who is a patient. These considerations allow us to examine if we are working in a way that is actually collaborative.

Saporito, B. (2013). The conspiracy to end cancer. April 1st, 2013, TIME Magazine. Retrieved from

Joshua Fowler is a recent graduate of the marriage and family therapy masters program at East Carolina University.

Tags:  cancer  collaborative care 

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Be Conscious of What the Big Rocks Are in Your Life

Posted By Julie Schirmer, Tuesday, May 7, 2013
This piece is a reprint of a post from the STFM blog, a regular blog produced by members of the Society of Teachers of Family Medicine ( Reprinted with permission.

Although we should do this every day, periods of transition beckon us to examine what’s important to us as we ask ourselves, "Is this really what we want to do? Are we really living our values?” Medical students will soon move to residency programs and graduating residents will be off to their first jobs in medicine. At the recent STFM Annual Conference in early May relatively new faculty began one of the STFM fellowship programs to enhance their skills as leaders or as new behavioral science/family systems faculty.

At times like this, I am reminded of the "jar of rocks” story that I’ve come across in leadership courses and have used in teaching: A philosophy professor enters her classroom with a large, wide-mouthed glass jar and several bags of items. She asks for a student volunteer to fill the jar, who then places one to two inch rocks into the jar to the very top of the brim. The professor then asks the students if it is full. The students agree that it is full.

She asks another student to pour a bag of small pebbles up to the top of the jar. They flow between the open spaces between the rocks. She again asks the class if the jar is full. The students agree.

She then pours sand between the spaces, always finding more spaces to fill up the jar. She then states, "This jar represents your life, the large rocks represent everything that is most important to you, such as work, play, family, and love. The smaller rocks are necessary but of lesser importance. Everything else is just sand. The important thing is to be conscious of what the ‘big rocks’ are in your life. Make sure you fit them into your jar before placing anything else in, or they won’t fit. Take time to nurture, support and develop the ‘big rock’ areas, then the ‘smaller rocks’ before putting anything else in your jar.” To this original story, I have added the professor recruiting students to help her. For with helpers around, the rocks don’t seem so heavy and the process has the potential for being more fun.

I am in transition myself and wonder how I am going to fit new responsibilities into an already full life and schedule. Starting May first, I begin my journey as the new Director of the STFM Behavioral Science Family Systems Educator Fellowship (BFEF) Program, along with the 15 new educator fellows from family medicine residency programs all around the country. The fellowship is one of my "big rocks.” At this later stage in my career, it’s important to nurture and support the next generation of behavioral science faculty leaders in family medicine. It’s that "generativity” thing! I am helped by a large community of able colleagues, including STFM staff and seasoned behavioral science and family medicine educators who serve as mentors, fellowship faculty and steering committee members. This prevents me from feeling overwhelmed as to everything that I have to do for the fellowship on top of my other work and life responsibilities.

Medicine is a continually changing field, which can be exciting and overwhelming - often at the same time. Wherever you are in your life or career, take time to routinely visit and examine the ‘big rocks’ in your life and strive towards valued living. Listen to your body, mind and spirit. If you are feeling "off balance”, make sure the rocks are in their right places. Recruit colleagues and other members of your "team” to help lift the weight off your shoulders and to create a better world.

I welcome others' stories about recommendations for living the most vital and meaningful life and about maintaining balance in this fast-paced, internet-heavy world.

Julie Schirmer, LCSW is Director of Behavioral Health at the Family Medicine Department of Maine Medical Center and Assistant Director of the Family Medicine Clerkship at Tufts/Maine Medical Center School of Medicine. She is Co-chair of the North East Regional Integrated Care Learning Community, Past President of the Family Medicine Education Consortium, and Director of the Behavioral Science/Family Systems Educator Fellowship of the Society of Teachers of Family Medicine. She is author and co-editor of Behavioral Health in Primary Care: A Global Perspective (Radcliffe, 2010).

Tags:  self-care 

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

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

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

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

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

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

Does this sound like
a revolution to you?

A paradigm shift?

I hope so.

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

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

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

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

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


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


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

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