Posted By Elizabeth Patrick,
Tuesday, April 16, 2013
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morning for the past two years, my friend and I have taken our dogs to the
neighborhood park. On those mornings, rain or shine, we share the park with a
Vietnamese couple in their sixties. We have come to expect to see one another
every day and have begun our own unspoken ritual of waving and exchanging a
pleasant "good morning.” The couple comes to the park to exercise and over the
years they have captured my heart and attention because of the apparent love
and care that they have for one another. I have had the privilege to witness
how much this couple values mutual health-positive behaviors.
describe some of the sweet moments I have witnessed from this couple. First,
the husband seems to struggle with a health-related challenge and is in a
wheelchair most of the time. He appears to count on his wife for assistance and
care. I have become familiar with their routine, as I’m sure they have become
with ours. They walk from their home which is about a quarter of a mile away.
Sometimes the wife pushes the husbands’ wheelchair, other times she is
stabilizing him on one side as he walks |
for a short time in a slow and
who face chronic
gender roles and
more mutual or
Once they arrive at the park, they approach a cement bench
that they use as a sort of "home base”. The wife begins to work with the
husband as he gets his physical activity going. He spends about 10-15 minutes
on his feet and while holding onto his
wife, he bends, squats, steps and stretches. His exercise comes first. Once he
has finished, he takes a seat on the bench or in his wheel chair, relaxes, and
begins to encourage and observe his wife as she starts her morning workout. She
has a number of workout courses that she has created at the park, keeping
things relatively new and fresh for herself. She may do some push-ups on an
incline, walk up and down a steep hill, or speed-walk up and down the front of
the park. As she works out, her husband is close by, watching, smiling,
enjoying his wife’s exercise process. Imagine also that this is a couple that
is soft and patient with one another. Never upset, always encouraging.
I recall what I observe every morning I find myself smiling at the couples’
love and care towards one another. However, I also know that when one spouse
becomes sick a lot changes in a relationship. Often the person who gives care
can experience lack of personal health as they put the ill spouse first. However,
the couple at the park has shown me that there can be joy and connection
through a shared experience of health, illness and care. This has been
particularly valuable for me as I am working on research related to a
relational orientation towards illness, in other words, shifting from a "my”
illness to an "our” illness orientation.
& Badr, 2005; Burwell, Templeton, Kennedy,
& Zak-Hunter, 2008; Dankoski & Pais, 2007; McDaniel
& Cole-Kelly, 2003) have highlighted that female spouses easily adapt
to a relational orientation of illness.
As a result, this process has the potential to further burden the female
partner when disparities in power between males and females in the relationship
are not attended to. When females, or
the well partner, take on a greater degree of relational responsibility than
their spouse, it is common for relational strain to increase. Therefore, it is important to recognize and
highlight that a process within the relationship must continually occur so that
each spouse takes a role in the mutual processing of ‘our’ illness experiences (Kayser,
Watson, & Andrade, 2007).
who coped with their chronic illness by confronting challenges and expressing
feelings and experiences openly had greater overall marital satisfaction, as
did their husbands (Badr, 2002; Acitelli & Bahr, 2005). This same "active” coping from the wife is
associated with greater marital satisfaction for ill husbands as well. From a gender lens, this suggests that the
couple is not mutually engaged in an "our” orientation towards illness. Instead,
the illness experience is being shaped by gendered power processes that place
the primary relational burden on the female partner.
couples who face chronic illness, traditional gender roles and processes are
challenged and often redefined, sometimes becoming more mutual or egalitarian (Dankoski
& Pais, 2007). Whether
couples progress to more egalitarian styles of coping or revert to more
traditional gendered patterns, flexibility is a key issue. In fact, Cross et al., (2001) found that
inflexible gender roles often lead to difficulty and distress for couples and
families and can potentially lead to separation or even divorce, especially
when the female partner is the one who becomes ill.
I only see the Vietnamese couple for about an hour each day and only observe
their exercise process, I feel as if I get to witness a
care-giving/care-receiving relationship that is oriented around the couples’ experience of health and
illness. I see flexibility in their gender roles, mutual support, and care. I find
that I look forward to seeing my park friends every morning. I am encouraged by
Acitelli, L. A.,
& Badr, H. J. (2005). My illness or our illness? Attending to the
relationship when one partner is ill. In T. A. Revenson, K. Kayser & G.
Bodenmann (Eds.), Couples coping with
stress: Emerging perspectives on dyadic coping. Washington, DC: American
Badr, H., Carmack, C. L., Kashy, D. A., Cristofanilli, M.,
& Revenson, T. A. (2010).
Dyadic coping in
metastatic breast cancer. Health
Psychology, 29(2), 169-180. doi: 10.1037/a0018165
Burwell, S. R.,
Templeton, B., Kennedy, K. S., & Zak-Hunter, L. (2008). Feminist-informed
medical family therapy principles and techniques across biopsychosocial systems
levels for younger women with breast
cancer and their partners. Journal of
Feminist Family Therapy, 20(2), 99-125.
Dankoski, M. E.,
& Pais, S. (2007). What's love got to do with it? Couples, illness, and
MFT. Journal of Couple & Relationship
Therapy, 6(1), 31-43.
Kayser, K., Watson, L. E., & Andrade, J. T. (2007). Cancer as a
"we-disease": Examining the process of coping from a relational
perspective. Families, Systems, &
Health, 25(4), 404-418. doi: 10.1037/1091-7518.104.22.1684
McDaniel, S. H., & Cole-Kelly, K. (2003). Gender, couples, and
illness: A feminist analysis of medical family therapy. In L. B. Silverstein
& T. J. Goodrich (Eds.), Feminist
family therapy: Empowerment in social context (pp. 267-281). Washington,
DC: American Psychological Association.
|Beth Patrick is a third-year PhD MFT
student at Loma Linda University and has worked at the Loma Linda
Transplantation Institute for the past two years. She has also spent a
year working in Primary Care as a part of an
integrated healthcare team. Her professional interests include medical
family therapy, teaching and mentorship, and socially just/contextual
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Posted By JoAnn Tschanz and Randall Reitz,
Tuesday, April 9, 2013
| Comments (1)
JoAnn Tschanz, psychologist at Utah State University, recently published research connecting specific family caregiver strategies with decreased dementia in their loved ones. Dr Tschanz discusses her groundbreaking study in this interview with Randall Reitz.
Randall Reitz: Your data indicate that people with dementia tend to have better outcomes if their family caregivers use certain coping strategies. The coping strategies that made a difference were: problem-focused coping, counting blessings, seeking social support, and wishful thinking. What are these coping strategies and how do you believe they translate to improved outcomes for people with dementia?
JoAnn Tschanz:These coping strategies are from a larger set of eight strategies in what researchers indicate either address the source of the problem (problem-focused) or seek to manage distress. Counting blessings would be similar to looking at the bright side of things, seeking social support would be akin to talking out your problem with a friend, and wishful thinking would be similar to hoping for the best.
The majority of the strategies did not predict the rate of cognitive or functional decline in the person with dementia. Problem-focused coping and seeks social support predicted slower cognitive decline in dementia participants; problem-focused coping, seeks social support and wishful thinking were associated with slower functional decline. However, because we also saw evidence that use of the coping strategies were associated (e.g., someone who used problem-focused coping may also have a tendency to use the other coping strategies as well), we ran additional statistical models to see which were independent predictors. This is where caregiver problem-focused coping was the strongest predictor of slower cognitive and functional decline in the person with dementia.
Although we do not yet know how problem-focused coping was associated with slower decline, we hypothesize this could reflect a caregiver who is able to adapt flexibly to meeting new challenges and tries to solve problems as the dementia progresses. For example, a troubling behavior (wandering) might emerge. A caregiver using problem-focused strategies might operate under the hypothesis that the patient doesn't recognize their surroundings and so displays, familiar items like family pictures and other decorations that the patient recognizes. Other possibilities include engaging the patient in stimulating activities as other research has found an association between cognitively stimulating activities and slower progression of dementia.
RR:What surprised you most in your analysis?
JT: We hypothesized that problem-focused coping was associated with slower progression and our findings were consistent with that hypothesis. However, we also thought that other coping strategies like Avoidance and Blames Self or Others would be associated with worse outcomes, but this was not the case. These strategies were not associated with rate of cognitive or functional decline.
RR: Your sample comes mostly from one county in rural Utah, do you have any concerns that your data are community-specific?
JT: This is a great question. Although our sample consists of residents of one county in Utah, in some ways our data may actually generalize more broadly to others since the study was based on a population-based sample rather than a clinic-based sample. The latter tend to include individuals who are younger, more highly educated, and those who may have more severe symptoms. That said, the majority of our participants were Caucasian and averaged over 12 years of education, so the results may not generalize to populations with greater ethnic or educational diversity. Studies in other samples are needed to determine whether our results are replicated.
RR: How do you hope your findings will impact the field of collaborative family healthcare?
JS: Many health care providers have not thoroughly looked to the care environment as a place to intervene, other than to help reduce caregiver distress and stress-related illnesses. Our findings suggest that the care environment may be a place to intervene to promote the highest level of functioning in the person with dementia. In this way, caregivers could be trained to problem solve various care management issues that arise, and feel empowered to make a difference in the care of their loved ones.
Rather than looking at dementia as a progressive condition where the caregiver and patient are helpless, ideally, the caregiver and patient could take an active role to work with their health care providers and devise a care management plan. In that plan might be ideas to address challenges that commonly arise for many patients, and likely would include use of formal resources available in the community.
Our findings suggest that the care environment may be a place to intervene to promote the highest level of functioning in the person with dementia.
RR: How do you see your research evolving and in what direction would you like the field to go?
JT: We've found other aspects of the care environment (such as closer relationships and participant engagement in stimulating activities) to be associated with overall better cognitive and functional abilities in dementia. We'd like to follow-up our results to get a better understanding of potential mechanisms and whether they're also predictive of important clinical milestones such as severe disability or institutionalization. Additionally, our results are observational only so we cannot draw cause-effect conclusions.
Ultimately, I'd like to develop an intervention and test that intervention in a study that randomizes treatment to participants and has an appropriate control group so we can draw firmer conclusions from this line of research. I would really like to see the field emphasize non-medical and non-pharmacological approaches to treating all aspects of dementia and really engage the caregiver as a primary source participant in the patient's treatment.
RR: JoAnn, thanks for your contributions to collaborative family healthcare and to the Families and Health blog!
JoAnn Tschanz is Professor in the Department of Psychology and faculty in the Center for Epidemiologic Studies at Utah State University. She is a clinical neuropsychologist and has studied risk factors for Alzheimer's disease and other dementias as well as factors that influence the clinical expression of dementia after disease onset. She has published over 80 papers in scientific journals and books, and is the recipient of grant funding from the National Institute on Aging.
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Posted By Aimee Galick,
Thursday, April 4, 2013
| Comments (2)
I just finished a MedFT clinical internship at the
Loma Linda University Transplantation Institute where I worked with couples in
which one member was severely chronically ill and needed a kidney or liver
transplant. Using SERT as my organizing theory, I have a heightened awareness
of how emotional and tangible support, caregiving, and impact of the illness on
the family typically differs depending on whether the patient is a man or
woman. A recent study by Glantz et al. (2009) affirmed these ideas as it
documented divorce rates in patients diagnosed with a brain tumor, cancer, or
MS and found that 11.9% of marriages ended after the introduction of these
serious illnesses and in 88% of these separations the ill person was the woman,
compared to only 12% of men.
abandonment,” the researcher’s label for the phenomenon, resulted in poorer
health outcomes in patients, more hospitalizations, higher use of
anti-depressants, and less compliance with treatment regimens. This study
supports the notion that relationships are important to both physical and
mental health and it also confirms what I have seen in my practice with severely
ill patients - women are more dedicated to the care of their sick partners. Why
does this happen?
I have been involved in a clinical research group
led by Dr. Carmen Knudson-Martin and Dr. Douglas Huenergardt at Loma Linda
University. The group developed a model of couple’s therapy, Socio-Emotional
Relational Therapy (SERT), which centralizes power in the conceptualization of
influence, responsibility, and support in intimate relationships (Knudson-Martin & Huenergardt,
|Gender is one of the more obvious
sources of power, or lack thereof, but we also look at how culture, SES,
religious beliefs, and the intersection of these social categories influence
power within relationships and of partners in relation to society. We believe
that power differentials between partners prevent them from being able to
actualize mutually supportive relationships and
that dominant ideas about what
it means to be male and female contribute to this imbalance. Looking at the
gender difference in partner abandonment with a
SERT lens I have an idea about
why this occurs.
|I think for most people in our Western society there
is an entitlement to personal happiness over the needs and happiness of others.
So why should anyone suffer to care for a sick person?
I think for most people in our Western society there
is an entitlement to personal happiness over the needs and happiness of others.
So why should anyone suffer to care for a sick person? I have heard things like,
"this isn’t what I signed up for, she/he is not your responsibility, and you
need to do what is best for you.” No one
in this culture wants to be a burden, but I think there is a gender difference.
I frequently hear women who are sick,
say they feel bad for being a burden to their loved ones and this is one of their
greatest sources of stress.
Men, on the other hand, don’t report this as often
and seem to have a sense of entitlement to receive care when they are ill. There
do not appear to be the same societal pressures on men to stay with an ill
partner, but a woman who leaves a sick man? What is wrong with her! What a
terrible person!! These strong messages about male and female responsibilities
often place a heavier burden and more pressure on women. I think men may
abandon their sick partners out of a sense of entitlement to not being bogged
down. I also think that fear about inadequacy around caregiving and their
ability to cope with the level of stress that comes with a loved
one’s serious illness plays a major role.
This fear of inadequacy may play a
larger part than the sense of entitlement, but I think it may be easier for men
to go to the place of "this isn’t what I signed up for” rather than "I am
really scared, I don’t know how to be a caregiver, and I don’t want to get
closer to someone I will likely end up losing.” Another contributing factor is that
when a female partner becomes sick, she
does not have as much time and energy to devote to caring for the relationship
and her partner – so things fall apart.
The couples I see are often in the beginning stages
of adjusting to having a serious illness intrude into their partnerships, which
allows me to intervene often before
the illness has done serious damage. At this crucial point in the illness
trajectory, couples have not yet considered what motivates their behavior in
relationships. I often use my personal and clinical experiences around gender
differences which facilitates the joining and that is crucial for the next
For men, I give voice to what I
think they can’t because it is too vulnerable. I voice the presence of fear, not-knowing, feeling inadequate, and
doubting their abilities to handle this. I also voice how I think they wish they could be in relationship. This
allows us to go to a place where we can discuss ideas in society which have
likely influenced their behaviors, thoughts, and feelings within relationships.
This can take away the shame and guilt they have about being relationally inadequate.
Having a strong therapeutic relationship is key to setting the tone in which
this vulnerable conversation can take place and new possibilities can be
Some people might be asking themselves, what about
the women? How can we help them in this
process? Good question. It would be incongruent with my beliefs about power to
follow this post with suggestions about how to work with women because I don’t
believe they have the same power as men to influence others. I would be happy
to write another post on the issue if there is a demand for it.
Despite the many difficulties couples can encounter,
I often find the introduction of illness can be positive in that it can bring
partners closer than they ever imagined. This happens when instead of one
partner turning toward the illness, both partners turn toward one another. I
feel so privileged to be a part of this amazing process!
If you wish to learn more about SERT and mutually
supportive relationships you can visit our website at equalcouples.com or
contact me at email@example.com.
Knudson-Martin, C., & Huenergardt, D. (2010). A
socio-emotional approach to couple therapy: Linking social context and couple interaction.
Family Process, 49(3), 369-384. doi:
|Aimee Galick, is a doctoral candidate at Loma Linda
University.She identifies as a Feminist Medical Family Therapist. Her
main interest is in how the larger social context affects the
intersection of health and families. Most of her
research has centered on how contextual influences such as gender and
culture affect intimate relationships, the process of therapy, and
experiences with illness.She is passionate about relationships
characterized by mutual attunement, mutual influence, shared
relational responsibility, and shared vulnerability. She administrates a
blog (equalcouples.com) on the topic of mutuality in intimate relationships.|
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Posted By Annie Bao,
Wednesday, March 27, 2013
| Comments (0)
Starting as a
therapist in collaborative healthcare without any formal education or training
in medical family therapy is like going on a blind date, which in
actuality is your first date ever. This is along the same lines of where my
journey began. From what I had heard of the potential for a tremendous
(working) relationship to develop, it appeared to be a good path for me to pave
as a clinician trying to carve out a rewarding career. My third-party knowledge
of the system I was about to meet sounded like the ideal match in core beliefs
and attitudes about how to support patients in their healthcare. I hesitated
about my decision to walk into this situation with little knowledge about the
process, but I was hopeful that there would be longevity in this adventure with
something so innovative.
seeming incompetent coursed through my system and excitement about how this may
impact my future was an electrifying sensation. When I began training as a
marriage and family therapist, most of my perceptions of its practice were
derived from media portrayals (e.g., Frasier, Sopranos, & What About Bob?).
When I was chosen to be a fellow in collaborative healthcare, I again relied on
entertainment depictions (and published research, of course) to guide me
through a general understanding of the environment I was about to immerse
myself in. So armed with the encouragement of family, friends, and mentors
along with my Grey’s Anatomy framework, I…was…ready.
healthcare was the perfect marriage for the pursuit of my aspirations||Something about collaborative healthcare has always intrigued me. Was it that I was the daughter of a physician, who spent my formative years with him, his partner, nurses, and CMAs at their practice? Was it that I myself had ambitions to be a physician that would help alleviate pains of ailing patients like my father could with such humility and grace? Was it my volunteer work at the hospital or with the underserved communities, limited from access to decent healthcare? Or was it having negative encounters with healthcare systems during the care of my loved-ones? Who can say, I’m certain that it is a combination of all of those factors and more. But, I know that passion for medicine and therapy live deep within me and collaborative healthcare was the perfect marriage for the pursuit of my aspirations. |
prior experience or training in collaborative healthcare settings, I was the
least likely candidate to be chosen for a position to work in the field. So, I was
admittedly apprehensive and doubted that I was capable of taking on the role as
a fellow at the Chicago Center for Family Health (CCFH). As an outsider, I was
stricken with feeling like a misfit who simply would not be accepted by this
hierarchical medical system. Fortunately, my director and the other supervisors
at CCFH were willing to take a chance on an eager, naïve, and very green
collaborative healthcare consultant hopeful. They were the gatekeepers that I
needed to grant me access into this specialty and the most unexpected champions
of my abilities for the duration of my time with them. It was not lost on me
that I had accepted a position with the well-respected, John Rolland, so I
resolved to counter my insecurities with positivity and soak up all that I
could from the experience.
collection of practical study of collaborative healthcare, frank process of my challenges,
authentic feedback of my development, and enduring support of everyone
affiliated with my fellowship have culminated into a notably defining time in
my growth as a new medical family therapist. My unconventional introduction
into this work was not a planned career goal, but some of what I learned about
myself in the context of healthcare may seem typical. From my brief immersion,
I developed the following way of being in fulfilling my objective to being an
effective member of a collaborative healthcare team. ||All developing relationships
that are worthwhile take time and commitment|
presents a platform that you can establish genuine connections with those you
will be working with. This will ultimately benefit the patients that you all
want to help.
confident in your expertise: Many times providers do not know what you have
to contribute to the healthcare of their patients until you show that you have
something to contribute to the healthcare of their patients.
humble in what you have to contribute: While you are educated in the psychosocial
elements of an individual and their systems, physicians and nurses are educated
in the biological aspects all the same. Ego has no place in patient healthcare.
collaborative: It is important for physicians and nurses to be transparent with
you about their end of the providing healthcare, but you must also make an
effort to communicate your interaction with the patients and their families.
individually, act collaboratively, and think systemically.
developing relationships that are worthwhile take time and commitment from all
involved to work together. I needed time to define and settle into my role as a
fellow. My supervisors needed time to become acclimated to my personality
(quirky, blunt, & vulnerable) and train someone unacquainted with
collaborative healthcare, with a tendency to ask the most basic of questions. And,
the residents and faculty needed time to visualize and integrate me into their
system in a mutually beneficial manner. Eventually, I found myself busy in our
newborn clinic (I learned how to use a transcutaneous bilirubin tool),
conducting family sessions with multiple healthcare providers in attendance,
and working extensively with physicians as a consultant to the psychosocial
aspects of their patients’ health.
hindsight, this fellowship experience was colored with the most diverse of
personalities and perspectives. The accomplishments of my work with patients was
not mine alone, but was the direct result of intentional collaborative efforts by
all of those I encountered throughout my time at CCFH. One of the most
important lessons I learned was that integration of opposing views is actually
a crucial factor to the success of our care of patients; after all, opposites
oftentimes attract to make for meaningful relationships.
Bao is a licensed marriage and family therapist and a MFT doctoral candidate at
Virginia Tech. As a fellow at the Chicago Center for Family Health, she gained experience
as a healthcare consultant and therapist at the UIC Family Medicine Residency.
She currently supervises MFT graduate students at The Family Institute at
Northwestern and works in the Northwestern University and Advocate Illinois
Masonic healthcare systems. |
medical family therapy
Posted By Tai Mendenhall,
Tuesday, March 19, 2013
| Comments (1)
Providers across the fields of mental health (e.g., Psychology, Medical Family Therapy, Pastoral Counseling, Social work) and biomedical care (e.g., Internal Medicine, Family Practice, Pediatrics) have been increasing their efforts to collaborate with each other since the early 1990s. This movement is, in large part, a natural response to our ever-increasing knowledge about how patients’ respective "parts” – like their minds and their bodies – are more connected than our respective disciplines’ training programs originally prepared us for. As more than 70% of patients attending primary care visits, for example, do so with some kind of psychosocial comorbidity, it is easy to understand how satisfaction with care experiences correlate with the collaborative nature(s) of the services that we provide (Linderman, Koff, Freitag, Min, & Vandivier, 2011; Miller, Kessler, Peek, & Kallenberg, 2010).
This natural (albeit slow) development in our field(s) has evolved in synchrony with our increasing understanding of the strong and reciprocal influences between family functioning (e.g., communication, adaptability, relationship satisfaction) and health (e.g., metabolic control, immune functioning). Indeed, empirical evidence has shown us time-and-again how purposeful attention to families within medical and/or psychotherapeutic interventions can lead to targeted improvements in identified patients’ physiological well-being (e.g., blood pressure, cardiovascular functioning) (Campbell & Patterson, 1995; Tyndall, 2010; Whitney, Murphy, & Landau et al., 2011).
Our efforts to extend collaboration to actively include patients’ families in the care we provide, however, are way out in front of our efforts to evaluate the processes in which families help (or hurt) clinical outcomes. Also lagging are our efforts to understand the impact(s) that our collaborative and integrated care has on families, themselves. While calls to advance empirical support for the work that we do have been made across both local and national/international stages (e.g., Hodgson, Lamson, Mendenhall, & Crane, 2012; Mendenhall, Pratt, Phelps, & Baird, 2012), most research to-date has framed treatment outcomes within individually-oriented frames of dependent variables that are unique to identified patients, alone. A recent review of more than one hundred integrated care studies confirmed this, wherein only a single investigation was recognized for its consideration of family outcomes (Martin, 2012).
Integrating Family- and Relationship- Measures into Healthcare Research
As we work to include patients’ families in the care that we provide, we must also include families in the research that we conduct. In accord with extant literature regarding measures with well-established reliability and validity, the following are instruments that we could begin to integrate into our evaluations of collaborative and integrated care. (Note: In the interests of readability and limited-space, I have not included individual references or studies for each measure described. Literature is robust and easily-found for all instruments identified herein. For more detailed summaries, see Alderfer, Fiese, & Gold et al. (2007) and Walsh (2011)).
Dyadic Relationship Functioning.Our patients’ relationships and social systems are arguably built upon units of two, and it is thereby important to consider ways to assess functioning within the specific unions they maintain. Leading measures evaluating marital and/or romantic-partner relationships include theDyadic Adjustment Scale, the Marital Satisfaction Inventory-Revised, and the Lock-Wallace Marital Adjustment Scale. Collectively these instruments are well-established in their ability to differentiate distressed from non-distressed couples. While paralleling many of the foci evaluated by the aforementioned measures of general family functioning, these tools also tap important dyadic processes related to interpersonal accord and consensus.
Measures with established reliability and validity that evaluate dyadic functioning between parents and children include the Inventory of Parent and Peer Attachment, the Issues Checklist, and the Revised Children’s Report of Parental Behavior Inventory. Key content assessed for by these instruments includes parental acceptance, control and discipline, child attachment, interpersonal trust, communication, alienation, constraining (vs. enabling) interactions, and child discourse changes in reaction to parental responses (i.e., progression vs. regression).
Measures directed toward sibling relationships are still in their infancy, as only one is currently available that for which a compelling empirical base has been developed. The Sibling Relationship Questionnairecaptures interpersonal rivalry, conflict, relative power and status, and warmth/closeness.
Family Relationship Functioning. The most robust group of relational measures in family studies assess for general family functioning. Leading observational instruments (which also encompass clinician-rated interviews) include the Beavers Interactional Scales, the McMaster Clinical Rating Scale, the Iowa Family Interaction Rating Scales, the Circumplex Clinician Rating Scale, and the Mealtime Interaction Coding System. Collectively these measures assess for family phenomena like interpersonal communication, affective responsiveness, problem-solving and adaptability to stress or change, conflict styles and conflict-resolution sequences, organization, and cohesion/relational-closeness. Self-report measures (informed by many of the same guiding family theories) include the Family Assessment Device, the Family Relationship Index of the Family Environment Scale, and the Family Assessment Measure-III. Most researchers advocate the employment of both types of measures (i.e., observational and self-report), insofar as combining and triangulating outsider- and (multiple) insider- perspectives affords a more comprehensive picture of what is going on in families, alongside more confidence in findings ultimately arrived upon.
Relational Functioning vis-à-vis Chronic Illness. Alongside the dyadic- and family- measures outlined above, researchers are beginning to advance relational measures specifically designed to target family functioning within systems living with chronic illness. For example, the Impact on Family Scale, Pediatric Inventory for Parents, and Parents of Children with Disability Inventorycollectively measure family members’ sense of mastery/coping, financial and/or legal burdens, family- and social- relationship satisfaction, personal/emotional stress, respective family members’ roles, and communication sequences with identified patients’ medical teams. The Psychological Adjustment to Illness Scale, while administered to individual patients, includes focused attention to satisfaction with domestic life, sexual relationships, extended family relationships, and social environment(s) and support. Overlapping into arenas of coping per se, the Family Narrative Consortium Coding Scheme, Family Coping Coding System, and the Coping Health Inventory for Parents have all established strong reliability and validity. They assess content areas that include family members’ interpersonal cooperation and coping, social support and psychological stability, and understanding the healthcare system with which they are interacting.
Concluding Thoughts and Next Steps
As we advance research regarding integrated care across clinical, operational, and financial arenas – and as we do this using qualitative, quantitative, and mixed-methods designs – we must remember to include patients’ families within our efforts. Assessing dyadic and/or family functioning alongside dependent variables denoting "success” that are specific to identified patients will better inform how to engage the people that are most important in our patients’ lives to support the very benchmarks that we seek. Conversely, it is important to understand how integrated care that includes family members impacts the family members. Not attending to their needs along the way could translate into a variety of other problems down-the-road if and/or as patients’ support systems erode or fall apart.
The good news here is that we do not have to invent a new wheel. The field of family studies (and within it, Marriage and Family Therapy and – more recently – Medical Family Therapy) has been evolving alongside the field of Collaborative Family Health Care (and within it, Integrated Primary Care and – more recently – the Healthcare Home movement). Established family- and dyadic- measures are already in place, and efforts to integrate these into understanding the intersections of relationships and health have been going on now for quite some time. As we mobilize this natural evolution to bridge advancements in healthcare (i.e., intervening – not just understanding) to tools and instruments in family studies like those outlined herein, we will create new knowledge that further informs the systemically-sensitive and innovative practices that drive us.
Alderfer, M., Fiese, B., Gold, J., Cutuli, J., Holmbeck, G., Goldbeck, L., ... & Patterson, J. (2008). Evidence-based assessment in pediatric psychology: Family measures. Journal of Pediatric Psychology, 33, 1046-1061. doi: 10.1093/jpepsy/jsm083
Campbell, T., & Patterson, J. (1995). The effectiveness of family interventions in the treatment of physical illness. Journal of Marital and Family Therapy, 21, 545-583. doi: 10.1111/j.1752-0606.2003.tb01204.x
Hodgson, J., Lamson, A., Mendenhall, T., & Crane, R. (2012). Medical Family Therapy: Opportunity for workforce development in healthcare. Contemporary Family Therapy, 34, 143-146. doi: 10.1007/s10591-012-9199-1
Linderman, D., Koff, P., Freitag, T., Min, S., & Vandivier, R. (2011). Effect of integrated care on advanced chronic obstructive pulmonary disease in high-mortality rural areas. Archives of Internal Medicine, 171, 2059-2061. doi:10.1001/archinternmed.2011.576
Martin, M. (2012). Integrated primary care: A systematic review of study design and program characteristics.Unpublished Doctoral Dissertation, East Carolina University, Greenville, NC.
Mendenhall, T., Pratt, K., Phelps, K., & Baird, M. (2012). Advancing medical family therapy through research: A consideration of qualitative, quantitative, and mixed methods designs. Contemporary Family Therapy, 34, 187-203. doi: 10.1007/s10591-012-9186-6
Miller, B., Kessler, R., Peek, C., & Kallenberg, G. (2010). Establishing the research agenda for collaborative care. Agency for Healthcare Research and Quality. Retrieved from: http://www.ahrq.gov/research/collaborativecare/collab1.htm
Tyndall, L. (2010). Medical family therapy: Conceptual clarification and consensus of an emerging profession. Unpublished Doctoral Dissertation, East Carolina University, Greenville, NC.
Walsh, F. (Ed.). (2011). Normal family processes: Growing diversity and complexity. Guilford Press.
Whitney, J., Murphy, T., Landau, S., Gavan, K., Todd, G., Whitaker, W., & Treasure, J. (2011). A practical comparison of two types of family intervention: An exploratory RCT of family day workshops and individual family work as a supplement to inpatient care for adults with anorexia nervosa. European Eating Disorders Review, 20, 142-150. doi: 10.1002/erv.1076
|Tai Mendenhall is an Assistant Professor at the University of Minnesota (UMN) in the Department of Family Social Science, the Associate Director of the UMN’s Citizen Professional Center, and the co-Director of mental health teams within the UMN’s Academic Health Center / Office of Emergency Response’s Medical Reserve Corps (MRC). He is the co-Coordinator of Behavioral Medicine education at the UMN / St. John's Family Medicine Residency Program (in which he teaches and supervises doctoral MedFT interns and family practice residents), and holds an adjunct faculty position in the UMN's Department of Family Medicine & Community Health. Dr. Mendenhall’s principal investigative interests center on the use and application of community-based participatory research (CBPR) methods targeting chronic illnesses in minority- and under-served patient and family populations.|
medical family therapy
Posted By David Ziobro,
Tuesday, March 12, 2013
| Comments (0)
This blog post is a reprint of an article from the February/March 2013 (No.105) issue of Mainstay, a regular newsletter produced by the Well Spouse Association (http://www.wellspouse.org/). Reprinted with permission.
"Well, at least they went quickly and didn’t suffer.” That’s what people say when someone dies. I understand what they mean. But she didn’t go quickly. No, it was a long slow steady decline. Did she suffer? No, with the pain meds, and her loss of memory, she didn’t suffer, but I did.
|When we were told that the cancer had spread to her brain, the clock started to tick. Life went on as much as it could. She was able to do some of the things she enjoyed like reading, crafts, and needlepoint. In time, those activities became impossible, and TV and the two hours a day with her aide became her life. Our aide was a friendly young woman; they would sit and talk about all kinds of things, and they liked to look at our photo albums. Our aide was planning a trip to Disney World, and my wife really enjoyed helping her plan it. The trip ended up being scheduled the week after my wife passed away. Her aide was not able to attend the viewing or the funeral. It was almost like my wife planned it that way. |
As time passed, we entered the beginning-of-the-end dates. When we were given the diagnosis, the doctor simply would not give us a time frame. The internet however gives you lots of information--we were looking at a 16 month time frame, give or take. I was finally able to get the doctors and the hospice nurses to give me a better idea after many conversations. They were all given with reluctance, and usually accompanied by "everyone’s situation is different.” When we hit the beginning of the possible time frame, it got interesting. By this point I had taken the 90 day FMLA leave from work, and I ended up taking another 90 day leave of absence as well.
As with most everything in her life, my wife exceeded expectations: she lasted 23 months. During the final 6 months of her life, we were in the "anytime” zone. Every morning was difficult for me. Was today the day? Remember when you had your first child and, inexperienced and fearful, you would walk into their room at night and listen for them breathing? Well there I was, going into her room in the morning wondering if this would be the day. I would hope upon opening the door she would move in some way so I would know right away. When she didn't I would walk up slowly and listen, a mixture of fear and then relief, followed by disappointment and then guilt. I had six months of that.
In the last year, my wife’s mental capacity diminished to the point where we could no longer really converse. We still talked, but I understood that she was not there, and our conversation would be forgotten as quickly as it started.
|The good part was that she was totally unaware of her situation. She knew she was sick, but figured she’d get better and return to work soon. My wife had retired from her position as an elementary music teacher four years earlier. She began to ask about school and I would explain that she had retired. "Oh really, when did that happen…I don’t remember.” We would talk and it would be forgotten. Every night we would go through the routine about how she was retired. Each morning, we were up early and would go through the same conversation. I had to move her car to her mother’s house around the corner for fear that she would just jump in and drive away. She had not driven since her diagnosis in 2009. Then we had to hide the car keys for all our other cars. Notes on the mirror, on the door, nothing seemed to help. Sometimes she would call the school and arrange to get a sub. The administrative assistant, who knew my wife well, would handle these phone calls with patient understanding. It turns out she enjoyed just talking to her. The rest of the staff were also amazing; they understood and dealt with it. ||Every morning was difficult for me. Was today the day?|
So when someone says, "well, at least they went quickly and didn't suffer,” understand what suffering is. There are all kinds of suffering. My wife passed away 23 years after her diagnosis of breast cancer. She did better than expected, and did things her way. She once told me "I’m a difficult patient, I know that. It’s my life and I want to know what is going on. I don’t care if they think I’m a bad patient.” In reality, according to her doctor, she was a good patient. He understood why she was the way she was. When she passed, her doctor told me what a strong person she was. He also told me what a fantastic job I did in taking care of her. I tried the best I could. It was difficult. Her doctor gave me a big hug when he told me that. Men don’t hug usually. It was so special because it gave me the feeling that I did good. The patient is the one being treated; the well spouse is often forgotten. He was telling me I was not forgotten. That was special.
|Dave Ziobro, Former Well Spouse|
Posted By Lauren Guth,
Tuesday, March 5, 2013
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|I’m treading water in the deep end of an Olympic-sized swimming pool, looking up at my lifeguarding instructor, who is standing dry by the side of the pool with a whistle around his neck. There are five other pairs of students in my class, also treading water, listening intently to the instructions: "Remember, when you go to save your partners, make sure you swim behind them before holding them. People that are drowning are terrified and will instinctually grab a hold of you. If you go down, they go down with you.” In the world of healthcare, our providers are often the lifeguards to their drowning patients. They are the people that will listen, teach and guide their patients toward|
a path of wellness.
I was lucky. When looking for a post-doctoral fellowship, I came across an e-mail on a psychology post-doc listserv that described an opening to work in "integrated primary care.” The image of my dream job that I carried around with me in my head always involved working with a multi-disciplinary team, where patients could receive complete, well-rounded "one stop shopping” healthcare. A team of experts at their fingertips, in their community; people they could trust and know who would work collaboratively to keep them or make them well. When I inquired about the position, I had no idea this decision would alter my career path in such a significant and wonderful way. As I treated patients, I watched them form relationships not only with me, but with a team of their providers, nurses, and medical assistants. I watched them connect, trust, and truly become well.
I was hooked. When my time came to an end in my postdoctoral position, I knew I wanted to work in a Family Medicine Residency where a team of experts worked collaboratively in pursuit of patient wellness. I wanted to work in a rich environment that felt more like a family than a workplace and treated patients with warmth and dedication. When I interviewed for my current position, I found what I was looking for. I felt welcomed and included, and I instantly knew I could work collaboratively with everyone here. I knew if I felt this way, certainly the patients would feel the same as well. As a Level-III Patient Centered Medical Home, JFK Family Medicine embodies the values of collaboration, team-work, and complete patient wellness. As a teaching facility, JFK offers well-rounded, quality training to its Family Medicine Residents, preparing them to provide the best possible care to their patients.
|How do providers offer the best care to their patients? Is the power of a collective team stronger than any individual person, or is a team only as strong as its members?|
I became curious. I wondered to myself, "But how? How do providers offer the best care to their patients? Is the power of a collective team stronger than any individual person, or is a team only as strong as its members?” I observed our residents and providers connecting, communicating, laughing and playing. I listened to our residents and providers talk about painting, hiking, exercising, cooking, and relaxing. I realized that patient wellness begins with provider wellness, even though many of us often feel selfish focusing on our own health; it can often be a last priority. After all, we did choose a career path directly related to helping other people. Yet, it is actually quite essential that we focus on our own wellness. As my lifeguard instructor aptly stated, "If you go down, they go down with you.”
I became inspired. Why not apply the same values for our residents that we do for our patients? Our residents and providers need permission and space to self-reflect, connect in a meaningful way, to
laugh and play. They need a place where they can feel heard, where they can trust people are working collaboratively to keep them well. I began to facilitate monthly wellness groups with our residents,
where we connect over difficult patient interactions, discuss ways they have grown personally and professionally since beginning training, and things they miss from their lives since beginning residency. We go outside. We laugh. We relax.
And the answer to my question became clear. The power of a team can most definitely become stronger than any one person, but if each team member is feeling well and knows the team has a commitment to his or her wellness, then the power of the team is enhanced that much further. As we guard the lives of our patients, we also need to remember to guard our own.
|Lauren Guth is a licensed psychologist and currently the Behavioral Scientist at JFK Family Medicine Residency Program in Edison, NJ. She received a Doctorate of Psychology and a Master’s of Education in Human Sexuality from Widener University. Her interests include integrated primary care and resident wellness. |
Posted By Barry J. Jacobs and David Seaburn,
Tuesday, February 26, 2013
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Barry Jacobs: Occasionally, a journal article arrives that knocks the pegs out from under one’s clinical assumptions. "Sorrow: A Therapist’s Reflection on the Inevitable and Unknowable” by renowned narrative and family therapist Kaethe Weingarten, Ph.D., in the current issue of Family Process, is one such essay (click here to access the full-text pdf for free until March 8, 2013).
Written in crystalline, evocative prose, its beauty and heft alone would recommend it. But its topic—helping medically ill clients make peace with ongoing suffering—is essential for medical family therapists to continually grapple with. And Weingarten’s conclusion (following her synthesis of a literature review on "chronic sorrow” and reflections on four individual psychotherapy cases) stuns: Illness may disrupt the self-narrative but the path to peace doesn’t lead toward meaning-making so much as toward tolerance of the incoherence of self and suffering.
|While incoherence is not an unfamiliar state to me, it is not what I usually aim for in my clinical work with family caregivers and ill or disabled care recipients. I’d say I’m looking for silver linings, for the expanded sense of self that can come from increased agency and communion, for the solace of greater appreciation for continued life. Weingarten is having none of this. She ends her essay with a Buddhistic image of sufferers swimming in the ineffability of suffering. She exhorts therapists to accompany but not try to save them.
When confused (or in need of a laugh or even a clever insult), I always turn to the wisest, most sorrowful person I know, Dave Seaburn. I thought that, as one of the early progenitors of both family-centered primary care and medical family therapy, he might have some interesting thoughts about Weingarten’s essay. As an ordained minister as well as a daily practitioner of meditation, he could also reflect on the spiritual implications of Weingarten’s ideas.
Barry Jacobs: Weingarten talks about "chronic sorrow” as a response to the disruption in a person’s sense of self because of chronic illness or disability. How did that strike you?
Dave Seaburn: I like the concept of chronic sorrow and I think it resonates with many people who find that their experience of personal loss (and person loss) is unrelenting and poorly understood/appreciated by others. It is non-pathologizing, which is almost always good because it frees us to see things in greater complexity, something that traditional diagnoses (in the wrong hands) often discourages.
Nevertheless, I thought Weingarten's insistence that this diagnosis was the one and only explanation for each of these cases, also did a disservice to each person’s suffering. I feel certain I saw major depression and maybe character disorders also thrown into the mix without that ever taking away from chronic sorrow as a reasonable, though not all-encompassing,frame. Perhaps her insistence on the exclusivity of this term is because of her own personal experience as a breast cancer survivor (which obviously trumps my lack of similar experience).
BJ: I thought she used several effective metaphors to describe the challenges of living with chronic sorrow. I particularly liked the "boatman’s plight.”
DS: The boatman's plight is excellent. It entails jettisoning all but what is most essential in order to stay afloat in this life. She frames this negatively and I understand why. But in another sense, it is a wonderful metaphor for what we all should address: What would each of us find absolutely essential to keep our personal boats afloat?
BJ: What I’ve struggled most with in trying to understand her essay is this idea that suffering can’t be wrapped in some redeeming meaning—that we can’t lessen the pain through intellectual means.
DS: Her discussion of the "incoherence of suffering” was terrific. It reminded me of those soldiers who debriefed concentration camp victims at the end of WWII; they were the ones who attributed meaning to the inmates’ experience ("noble suffering”) while the inmates themselves could barely speak coherently about what was done to them, let alone attribute some meaning to what they had suffered.
I like the Buddhist notion that "self” is an unreliable concept. As with subatomic structures that can be both "particle” and "wave”, perhaps we are better off to think of the "self” as a wave and not make it so firm that we count on it lasting in a single (dependable and indestructible) form for longer than a day or two. In my case, seconds.
BJ: Her whole tone seemed a bit too negativistic to me—too doom-y. Perhaps I’m still looking for "pink clouds.”
DS: I don’t know. It seems to me that chronic sorrow is something that we should all be experiencing to one degree or another, if we are inclined to look closely at our circumstances. I am not being cynical. I admire those, and I know many of them, who do not operate with much if any insight regarding their life circumstances and yet live happily and often do remarkably good things for those around them. I wish I was part of that majority. But there are also those who recognize that decline is built into life--that we lose dreams and options and paths to follow and physical capacity and spiritual certainty and, finally, time itself. That is the way of things.
I often fantasize that just before birth we understand all of this, but birth itself is so traumatic that we lose that understanding and largely go about our lives not knowing what being here is all about. Consequently, we settle for what we can do and understand--we work, we procreate, we watch the Sixers on TV, we achieve. If we remembered what we knew just before we careened down that canal, I think we'd realize that what we are here to do, more than anything else, is to appreciate this holy mess, with all its constant suffering and occasional brilliance, and to live accordingly.
||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. 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 his latest, Chimney Bluffs, a novel about finding one's way through tragic loss and sorrow.|
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Posted By Carol Levine,
Tuesday, February 19, 2013
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Nominated for five Academy Awards, "Amour” is a film about love and death. (Read no further if you haven’t seen the film and don’t want to know who dies and how.) The setting is Paris, the language French, but any resemblance to a conventional French film about light-hearted romance or a ménage a trois
ends there. The married lovers in the film are in their 80s, as are the main actors (Emmanuelle Riva and Jean-Louis Trintignant). Anne is a retired piano teacher; Georges is retired as well (not clear whether he was also a piano teacher or a musicologist). Their daughter Eva (Isabelle Huppert) is a musician.
"Amour” was directed by Michael Haneke, an Austrian filmmaker whose previous films were, to put it mildly, grim. "The White Ribbon” portrays the abuse and humiliation of children and women in a small German town just before World War I. "The Piano Teacher” is an abusive and self-mutilating woman. "Funny Games” features sadistic serial killers. So it would be unrealistic to expect "Amour” to be cheerful or sentimental in its treatment of old age and illness.
His penchant for violence aside, Haneke is a skilled filmmaker, and this long (very long) film is carefully constructed to achieve an effect. Exactly what effect he had in mind is still unclear to me, and I would have to see the film again (which I have no intention of doing) to figure this out.
|The opening scene of firemen breaking down the door to Anne and Georges’ apartment and then holding their noses because of the smell sets the stage. Anne’s corpse, carefully arranged with flowers at her head, is our first image of her. The film then shifts to a concert hall, where the audience, including Anne and Georges, stares at us-- the movie theater audience--for a long (very long) time before the pianist, who we find out is Anne’s former student, begins to play. Are we meant to be a little uneasy right from the start?
||Could I kill someone |
I love to end that person’s suffering
and mine as well?
Would I want
do this to me?
The couple’s comfortable retirement is abruptly interrupted when Anne has a sudden episode of blanking out. An operation to clear a blocked carotid artery is unsuccessful and she comes home in a wheelchair to be cared for by Georges. Haneke shows the daily routines of caregiving for a partially paralyzed person—bathing, going to the toilet, incontinence, feeding, and range-of-motion exercises. In documenting Anne’s decline, he dwells, almost lovingly, on the ravages to her body and mind. It is a realistic glimpse of the gritty side of caregiving, yet these scenes also turn us into unwitting voyeurs, invaders of Anne’s carefully protected privacy.
At some point in the film the story shifts to Georges. He wants to take care of Anne on his own, but he finally hires nurses for shifts three times a week. (Although the film credits list these roles as l’infirmieres –nurses – they seem more like home care aides, assisting with personal care, not skilled nursing care.) He fires one after she mistreats Anne in some way.
There is no indication of the passing of time in the film. We don’t know whether the illness trajectory is happening over weeks or months. The toll caregiving takes on Georges begins to show in his stooped posture, shuffling walk, and defeated look. He resists Eva’s ineffectual efforts to help and goes so far as to lock Anne’s door when Eva visits. In one scene a pigeon flies into an open window, and Georges chases and finally shoos it out the window.
In his first act of violence, Georges slaps Anne in frustration after she spits her drink in his face. Anne moans in pain (psychic or physical?) until Georges calms her with a story from his childhood. And then, he takes a great big pillow and suffocates her. The scene is predictable but shocking nonetheless. She takes a long (very long) time to die, her leg rising and falling in an odd reminder of the range-of-motion exercise we saw earlier. Her body resists what she has said she wanted to happen.
Georges buys the flowers we saw around Anne’s corpse at the beginning. He catches a second pigeon that has flown in the window, covers it in a blanket, closes the window. He seems to caress the pigeon. He writes a note about letting the pigeon go (but we only see him let the first pigeon go). And then in a dream sequence he and Anne leave the apartment. In the final scene Eva returns alone to the empty apartment and looks squarely at us.
Apart from the exceptional performances of all three leads, what can be said about this film? It is certainly a love story, but a very claustrophobic and exclusive kind of love. There is no room in this couple’s relationship for other people, even their own daughter. Eva seems self-absorbed but neither of her parents express any real interest in her or their grandchildren. Their conversations are the kind that might occur between acquaintances, not close family members. At one point, Eva tells her father she is concerned about him, and he responds, "Your concern is no use to me.” He treats her dismissively, even cruelly. And Anne does not want her daughter to see her in her debilitated state.
If there is no room for Eva, there is even less room for health care professionals. Dr. Bertier, the family doctor, never appears and does not seem to be involved beyond the operation. Once discharged from the hospital, Anne makes Georges promise that she will never go back. She does not want further medical treatment. But in a country with universal health care coverage, there is no indication of home care support other than the aides Georges hires on his own. Hospice or home care with adequate pain and symptom control might have made a difference, although not as dramatic a story. I leave it to clinicians to suggest what interventions might make someone like Georges more responsive to assistance.
And finally what are we supposed to think about Georges’ killing of Anne? She was clearly at the end of life and he was at the end of his ability to cope. Was suffocating her an act of compassion or an act of desperation or possibly both? Whose suffering was greater? What happened to Georges? I think we are meant to understand that he killed himself, after he killed Anne and (maybe) the second pigeon. He certainly disappears from the film.
Perhaps Haneke meant for the audience to ask themselves, Could I kill someone I love to end that person’s suffering and mine as well? Would I want someone to do this to me? Anyone who has seen a family member or friend suffer at the end of life has undoubtedly asked themselves these questions. And many people will see Georges’ act as a final act of love. But saying that you would end someone’s life, violently if that were the only option, is quite different from actually doing it. Most people would stop short. I think that is a good thing.
"Amour” ends and the credits roll. The audience goes home. Maybe they talk about the film, maybe they argue about it. Some say that if Anne were the caregiver, she would never have killed Georges. Some say physician-assisted death is the answer. Some protest that this would not have helped Anne in her demented state. Some appeal to religious or humanistic principles. Some say, "What was up with the pigeons?” Some say, "Come on, it’s just a movie!” Then they move on with their lives, putting aside unpleasant thoughts about illness and death.
If there is a message in this film, let it be that no one should face devastating illness—their own or another person’s--alone.
||Carol Levine directs the Families and Health Care Project and the Next Step in Care campaign at the United Hospital Fund in New York City. She is a Fellow of The Hastings Center, a bioethics institute, and writes frequently about ethical issues in health care. She is editor of the forthcoming anthology Living in the Land of Limbo: Fiction and Poetry about Family Caregiving (Vanderbilt University Press, 2013). Read her previous CFHA blog on a real-life caregiver mureder-suicide here.|
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Posted By Wendy Bradley,
Tuesday, February 12, 2013
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therapists, social workers, and psychologists working in the culture of a primary
care is completely foreign. At Southcentral Foundation (SCF) in Alaska, this is
no exception. SCF is a fully integrated level 3 medical home, so ensuring that a
Behavioral Health Consultant (BHC) is the right fit for the clinic, has a
comprehensive orientation and gets on-going training support is imperative
aspect to the success of the program.
To promote a
systematic approach to BHC recruitment, selection, and development, SCF
documented the BHC role, knowledge, skills, abilities, and qualifications in a
formal BHC job description. BHCs are licensed mental health professionals
qualified to offer services in the full range of conventional counseling
situations, such as depression, substance abuse, family relationships, and
child development, as well as in the behavioral management of medical
conditions, such as diabetes and chronic pain. Requirements include a master’s
degree or doctorate in a mental health field; at least one year of supervised
clinical work experience; and training in behavioral medicine and health
psychology, as well as social systems and familial aspects of psychological and
associated with success include flexibility, resourcefulness, and initiative,
since BHC effectiveness depends on providing prompt access and a focused and
individualized response in order to meet customer-owner and primary care provider
(PCP) needs. A key focus of the BHC interview and selection process is ensuring
that every new hire is a good fit – not only with customer-owners, but also
with all members of the integrated care team (ICT). Of candidates interviewed,
some 20-30 percent demonstrate the combination of characteristics that predict
a good fit: good people skills, team orientation, knowledge and experience in a
variety of situations, good judgment, and the ability to think on one’s
systematic process of |
hiring for fit, orienting new
BHCs and providing on-going
support have been the
foundation for continuity
and consistency in the
the environment for
created a comprehensive set of BHC core competencies. These core competencies
embrace the dual roles of the BHC (behavioral provider and care team
consultant), the required knowledge and skills required (for assessment,
triage, intervention, outcomes analysis and documentation), and best practices
to meet the cultural and age-specific needs of SCF customer-owners. These core
competencies provide the foundation for BHC orientation during the first 12
weeks on the job, as well as ongoing performance evaluation and improvement.
newly hired BHC shadows other BHCs for six weeks, starting the first week with
the clinical supervisor, and then working with the BHC peer mentor. The mentor
is responsible for the BHC’s orientation, training and ongoing support. A new
hire may also be assigned to shadow a PCP in order to gain insight into ways
BHCs interact with medical providers to gain their trust and build their
knowledge. During the last week, the clinical supervisor and BHC mentor, and
then the other BHCs in rotation, shadow the new BHC. During peer shadowing in
the orientation period, the new hire also becomes familiar with SCF’s care
guidelines and documentation practices. This approach to orientation serves as
an active mechanism for knowledge transfer to the new employee, with on-the-job
reinforcement including opportunities to demonstrate learning and get immediate
Performance Management and Improvement
four methods – peer shadowing, chart reviews, peer supervision, and annual work
plans – to ensure that BHCs share best practices while establishing consistency
in the approaches used across the group. All four methods provide opportunities
to review and reinforce the BHC core competencies and fundamental principles of
BHC integration, such as the principle that the primary customer of the BHC is
the PCP and that the primary competency of the BHC is assessment, not therapy.
Since 2009, three BHC mentors work alongside the clinical supervisor to ensure
consistency in the use of these methods.
shadow BHCs on a rotating schedule, using a shadowing checklist to observe and
evaluate the demonstration of competencies in the four phases of a BHC visit.
Representative competencies include refining the reason for referral to the BHC
(Introduction Phase), assessing customer-owner strengths (Assessment Phase),
discussing options (Intervention Phase), providing the PCP with a concise
overview and recommendation (Follow-up Phase), and concluding the interaction –
all within 20 minutes. Although BHCs use the feedback to improve their
knowledge and skills, findings are not used in the formal evaluation
process. BHCs also complete quarterly
chart reviews using a chart review checklist to examine several charts from
each BHC. This approach promotes consistency of documentation.
is a one-on-one discussion and case review facilitated by the clinical
supervisor that supports the delivery of quality behavioral health care,
including clinician self-care. For example, if the customer-owner says
something that triggers issues for the BHC personally, these review
opportunities provide the BHC with an outlet for discussion. Lastly, BHCs work
with their managers and clinical supervisors to design individual BHC work
plans based on the BHC core competencies as well as each BHC’s areas of
interest and potential innovation. These
work plans and agreed-upon goals serve as the basis for the BHC’s annual
performance evaluation follows SCF’s organization-wide performance management
model. It includes an annual meeting of each BHC and supervisor to develop an
individual performance action plan, with goals and timelines, and a year-end
supervisor appraisal of the individual’s performance against the plan. A key
tool in BHC performance planning is the progression checklist, which outlines
the competencies required for promotion (e.g., from BHC I to BHC II), and
provides a tracking mechanism to document training and experience on the job.
systematic process of hiring for fit, orienting new BHCs and providing on-going
support have been the foundation for continuity and consistency in the program and
has created the environment for continued success.
Bradley LPC is clinical improvement advisor at |
in Alaska. She developed and provided clinical oversight to behavior
health integration in primary care--the program has been successfully
established for the past 8 years.
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