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5 Questions with Larry Mauksch

Posted By Randall Reitz, Tuesday, June 12, 2012

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Randall Reitz:  The following is correspondence between Larry Mauksch and me. As with many other collaborative care learners, Larry has been a generous mentor and persuasive advocate for my professional development. Thank you, Larry, for your loving wisdom and prescient vision.

1: What experience in your professional or personal life was most influential in your development as a medical family therapist?

LM: My mother was a nurse practitioner who worked in primary care. My father was a medical sociologist who worked in primary care and studied collaboration between nurses and physicians. I was brought up in an inter-disciplinary home. My college, The Evergreen State College, was interdisciplinary. There were no departments per se. An interdisciplinary team taught all major courses. During my first year I remember reading "The Double Helix”, the story of the discovery of DNA. In the collaborative relationship between Watson and Crick, key discoveries were made in the domains of expertise of the other. This taught me that having a close collaborative relationship with someone operating outside of your worldview is of critical importance.

2: What do you consider your most important contribution to the MedFT field?

LM: From an organizational perspective, perhaps it was some decisions I made while Chair of the CFHA board between 2002 and 2005. Our founding board had not changed its membership since it was formed in the mid 1990s. I learned that "founders syndrome” can kill an organization. I helped develop a policy for board member turnover and I think much of the success of the organization now is due to the vitality and creativity of the new energy of the CFHA board. During the same time we changed the model of our national conference from a traditional program of presenters who share ideas to being more focused on local communities. Academically, I think the work done in Grand Junction, particularly publishing four papers about the transformation of primary care clinic were important contributions. I have spent 32 years practicing and teaching as a family therapist in a primary care environment. This has allowed me to experiment with lots of clinical and educational models.

3:  What does the field of MedFT most need to move into the mainstream of healthcare?

LM: Well, the leaders of one revolution often become the laggards in the next wave of change. I fear that current models of collaboration may become to fixated on behavioral health roles and, to preserve these roles, resist helping other members of the team master skills that every team member should know and use. I am concerned that the focus on the family is not stronger in mainstream primary care. The experimentation with new models of delivery today is exciting. But few people are studying outcomes. We need to measure, to learn. Finally, interdisciplinary approaches to health care need to be appropriately funded by insurers/payers.

4: Early career academics can feel intimidated in their attempts to promote family-based care within large university settings. What was your key to success within the University of Washington School of Medicine?

LM: I have always felt supported by my physician colleagues. It’s always been important to listen to their experiences with patients, to be curious about how they deal with major challenges in caring for families and to offer to help. Some of the most famous researchers in collaborative care come from the University of Washington and Group Health Cooperative of Puget Sound. I have been fortunate to have those folks around as mentors and sources of inspiration. It has been very important to my survival and creativity to have colleagues who shared my interest. The Family in Family Medicine Conference of the Society of Teachers of Family Medicine and later CFHA, provided me with a national support group where I have enjoyed friendships and sources of support for over 25 years. It is important to read the ideas and research of others.

5: Your kids are graduating from college and you seem to be re-adjusting the work/life balance toward "life". What else do you have planned for both work and life in the next decade?

LM: I enjoy a growing practice in consultation and training. I hope to continue to consult but contain it so to leave room for writing and non-professional parts of life. My wife and I love to travel and learn about other cultures. We love the outdoors and exercise. If I am fortunate to keep my health ( I have a new knee) I plan to hike, bike and canoe or kayak in many places around the globe.


Larry Mauksch

Larry Mauksch is a Senior Lecturer in the Department of Family Medicine, University of Washington School of Medicine, in Seattle, Washington and a consultant and trainer for health care system transformation. He has spent the last 26 years training medical students, residents, mental health professionals, practicing physicians and nurses in interviewing skills, team development, and the diagnosis and management of mental disorders. He is a core faculty in the Washington State Department of Health, Medical Home Collaborative, serves on the Society of Teachers of Family Medicine (STFM) program committee and on the Council of Academic Family Medicine Competency Measurement Task Force. He is the past chair of the Collaborative Family Health Care Association and of the STFM Group on Physician Patient Interaction. Mr. Mauksch has provided faculty development on communication training to medical schools and residency programs across the United States. He has developed patient centered communication training programs catered to the needs of specific organization using inside champions as role models and collaborators.


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5 Questions with Jennifer Hodgson

Posted By Dan Marlowe, Tuesday, June 5, 2012

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Dan Marlowe: The following is an interview I conducted with Jennifer Hodgson, PhD, LMFT. Dr. Hodgson is a Professor in the Departments of Child Development and Family Relations and Family Medicine at East Carolina University in Greenville, NC. She was instrumental in developing and starting the first Medical Family Therapy doctoral program in the nation, and continues to be an incredibly passionate supporter of not only MedFT but of collaborative and integrated care in general. On a more personal note, Jennifer has been instrumental in my own professional development from a directionless undergrad with lots of energy, to a master’s student trying to focus that energy to feel competent sitting in the therapy room, and eventually the exam room, to a stubborn doctoral student trying to hone that energy in the right ways to express his views. She was, and continues to be a mentor to me and many of my colleagues. So, without further ado and emotional hemorrhaging, here is my interview with her.

 1: What experiences in your personal/professional life do you feel were most instrumental in your development as a medial family therapist?

JH: A lot of it had to do with experiences around illness in my own family, and my feeling that we (the healthcare system/providers) could be doing a better job at promoting overall health. I think medical family therapy was my way of hoping to address that later on down the road. In the end I saw, in a very personal way, the effect that providers not-talking, not ‘collaborating’ had on how care was delivered, as well as how patients and their families suffered because of that silence.

In terms of my education, even before I started seeing patients, while I was still in training, issues would come up in terms of vignettes or case examples and it seemed like there was more to the story than just the psychosocial. It seemed, at least to me that by compartmentalizing the issues we, as students and eventually clinicians, were missing the larger context and the medical piece was part of that. I/we needed to understand medical language, medical culture, and most importantly for me, I needed to get over my own ‘hero worship’ of physicians and the running thoughts that- "You don’t bother the doctor and…defer…defer…defer.”

When I did my fellowship at The University of Rochester, I realized everything I had been taught in graduate school to this point had to be amended. I stepped into an environment that seemed to be moving at a million miles an hour around me, and I was seemingly standing still. It was an adjustment working in a primary care setting. I describe it like when you first learn to drive and master the city roads. Then, you get on the fast paced highway and learn quickly that just because you have to drive faster doesn’t mean you drive worse. You do need to adjust your reaction times, pay attention to other fast moving things around you, drive smarter and more efficiently, but sooner or later you feel comfortable and ease into cruise control mode. Walking into the world of MedFT gave me the authority to have conversations that would have been previously considered outside of my scope of practice had I just operated off the skillset taught thus far. Getting specialized training in integrated primary care was critical and essential and I am grateful for my time in Rochester with Susan McDaniel, Barbara Gawinski, Dave Seaburn. Nancy Ruddy, Pieter Leroux, Tom Campbell, and many others because of it.


2: What do you feel is your greatest contribution to the field?

JH: I really feel like the Medical Family Therapy doctoral program has been my greatest contribution, thus far. I, and the rest of the faculty at East Carolina University, felt like we needed to fill a gap, and that the best way to go about that was to develop a place where we could train the trainers and develop the researchers. Our goal is to develop professionals who can execute responsible and high-quality research, not just about MedFT, but about how relationships impact health and healthcare delivery. My colleagues and I want our students to be leaders in healthcare, biopsychosocial researchers, and go on to create even better MedFT training programs. That’s what you always want from and for your students, you want them to go out and do it better than you did. Of course none of this would have been possible without the vision of my colleague Mel Markowski (retired), co-authoring of the program with Angela Lamson, and support of many administrators and my talented co-faculty members David Dosser, Damon Rappleyea, Mark White, and Wayne Hill (retired).


3: What do you think MedFT, as a field/orientation, needs in order to move in mainstream healthcare?

JH: We definitely need a louder voice at the advocacy/policy making level, which is hard since we are such a small group at this point. There are all of these panels and committees on healthcare matters springing up nationally, and a lot of organizations are making concerted efforts to place their members on them. It just seems like this is a point in time in healthcare where things are moving so fast, if we do not move at the same pace, we are going to get left behind and consequentially so will all that we stand for and represent: the patient in a family, the systems surrounding them, and the relational aspects of integration. We need to start thinking strategically about how to expose ourselves to the agencies and people making the decisions, as well as the population in general. We need to get more data regarding our work as MedFTs, which we have some of, but that is only half of it and maybe the easier part. The harder part is getting that data to the right people, and that is where I think we have had a rough time so far.


4: What do you think we lack, in terms of training that puts us behind some other fields?

JH: Well, if we are talking strictly about family therapy as a field, and not Medical Family Therapy as an orientation, then, and I know people are going to hate to hear this, we need to require our students to learn how to work in medical settings and adopt more evidence based brief therapy approaches. A lot of healthcare institutions and insurance companies want clinicians to demonstrate use in these types of modalities, and if our students have little to no formal training in them we are at a huge disadvantage. I’m not saying that we abandon traditional family therapy modalities; I am saying that students need exposure to brief models of therapy and augmented models of therapy that have a systemic/relational bent. However, we are talking about an endpoint here, and where we need to start is re-training our faculty to prepare students to work in healthcare settings. We need a national initiative for workforce development like other professional organizations and that takes money.


5: Ideally, where to do see MedFT in the next 10 years?

JH: I agree with many of our colleagues that medical family therapy should not just be about family therapy as a profession. I do, however, feel that family therapists make good trainers regarding MedFT because they’re inculcated with systems and relational thinking from the time they begin their own training. MedFT should be about training/teaching people (regardless of profession) how to think and work systemically not only from a direct care standpoint, but how to think and work in teams from a healthcare system standpoint. I don’t think the name Medical Family Therapy is the problem like some have said: I think it continues to be portrayed as a problem because of the inherent silo’ed thinking of our professions. Medical family therapy is and should be much larger than those who are licensed marriage and family therapists and work in medical settings. I don’t care if you are a psychologist, social worker, nurse, physician, or family therapist, I think in order to call yourself a medical family therapist you need specific training in how to work with couples, families, and larger systems. We get stuck in our dialogue about MedFT when we think about and rely too heavily on the words "family therapy.” What we need is to focus our efforts on the continuum of training that is available for those interested in expanding the system for research and clinical purposes. MedFT may require more or less training in family therapy depending on how one wants to apply it but we all should be mindful that patients leave our offices and go out into the community and to their homes where their interactions in those places are the real determinants of health.


Jennifer Hodgson

Jennifer Hodgson, Ph.D., LMFT is a clinical member of AAMFT, an AAMFT Approved Supervisor, Chair of the Commission on Accreditation for Marriage and Family Therapy Education, Chair of the NC Marriage and Family Licensure Boardand long time member of the Collaborative Family Healthcare Association and Society of Teachers of Family Medicine. She is Immediate Past President of the Collaborative Family Healthcare Association.

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Positive Deviance

Posted By Deepu George, Tuesday, May 29, 2012

Members of the audience stood up in unison to applaud the plenary session given by Dr. Arvind Singhal, a distinguished professor of communication at the University of Texas, El Paso, Texas. He was speaking to all of us at the American Family Therapy Academy (AFTA) annual conference in 2012. With compelling stories to each of his points and almost theatrically perfect oratory skills, Dr. Singhal provoked family therapists to think deeply about social complexity and how contexts often generate positive deviance and generative relationships.

Positive deviance is an approach that enables communities to harness, spread, and leverage existing wisdom to amplify apt solutions. In other words, Positive deviance exemplifies deviant behavior that leads to better, sustainable results to a particular problem. The so-called innovator of this solution manages to create this solution at no extra cost or access to additional resources. Additionally, these solutions are culturally relevant and easily transferrable from one person to the other. Positive Deviance therefore is often behaviors that are not expected from individuals but the performance of such behaviors has a positive influence on the whole system. Singhal and colleagues have been applying positive deviance to a number of health care scenarios, nutrition related issues, and other issues that are embedded in the social narrative.

Positive deviance then occurs within contexts of social complexity. Social complexity consists of roles, privileges, authorities, hierarchies, inequalities, and the various oppressive discourses of our times. It is in this context that a few individuals are able to become deviant in a positive way that dramatically influences certain outcomes. Dr. Singhal recounted two experiences that offer examples of positive deviance that are useful to family therapists in medical settings.
Deepu George
The information contained in simple deviant acts is the "difference that makes a difference".

Incident one was about a pediatric anesthesiologist who treated his son, who due to complications had to remain in the NICU for about the first 2 years of his life. With repeated intrusions by needles and instruments to the baby’s body, he would often tense up and cry when something sharp, cold, or metallic would touch his body. However, things were different when Dr. Virginia Mohl, the pediatric anesthesiologist came in the room before the boy went in for surgery. She would immediately pick up the child, soothe the baby by speaking to the baby, gently caress him while humming and speaking to him. While she engaged the child and as he responded to her warm touch and care, the necessary injections and procedures would be done without the baby bursting into tears and a loud cry. As she would take baby into the operation theater, she would often turn around and tell the parents "Your boy is going to be just fine. I have done this a 1000 times.” Singhal recounted that as parents, they never felt more confident than when Dr. Mohl was in charge.

The second story is about an unassuming doctor in charge of rounds with medical residents. Walt Fairfax, the division chief for hospital medicine would never wear a tie and always was in short sleeves. Dr. Singhal narrated about whenever he came through for rounds with his residents; all of them would have a funny looking folded equipment with them that looked like an umbrella. As soon as they came near Dr. Singhal’s son, they would all open up this umbrella which turned into simple chairs they would sit on. As all of them sat around the baby, they would invite the parents over to their circle for conversation. Their first question was always "Mr. and Mrs. Singhal, how do you think your son is doing?” and then would start a conversation. The parents felt included, respected, and felt confident about the treatment process. All other practitioners who took care of their son all had similar trainings and excellent qualifications. They read the same charts, used the same equipment but did not make a difference to family. Both Dr. Mohl and Dr. Fairfax did make a difference. This apparent aberrant behavior, a behavior that is deviant but made a positive difference is Positive Deviance.

Despite the existing norms of how others in the hospital worked and dealt with patients, both of these doctors were able to bring a different sense of hope and healing to the entire family. It also transformed the particular views of individuals who worked with these two individuals in that hospital. Their relational approach generated a new dynamic between the family and the medical team that was deviant, yet positive. In being deviant from the norm, their behavior improved quality of care with no additional resources or expenses to the overall system.

The positive deviant approach is not much different from what Collaborative Family Healthcare Association is trying to achieve in its overall mission. With the goal to provide "comprehensive and cost-effective model of health care delivery” in working with multi-disciplinary teams, our overall philosophy itself is a deviant from the norm. As the field grows more organized and as rigorous training sets us apart, the question remains how good are we and will we be at detecting positive deviant behavior in our own collaborative teams and environment?

The behavior of positive deviance emanates from everyone, not just experts or people who have been trained. Dr. Singhal speaks of Jasper Palmer, an attending at the Albert Einstein Institute of Medicine whose method or de-robing prevents and contains infections in the hospital setting. With Jasper’s groovy moves, he de-robes himself by squishing his head cap, to gown to gloves and rolls them up in a bundle and gently places it in the dispenser. This method now known as the "Palmer method” reduces contaminations and MRSA, a health care associated infection in hospitals which costs more than $10 billion a year.

Positive deviance is not only an exception in terms of the act of behavior but also has deep and profound connections to the cultural and structural aspects of a system. Building contexts where relationships are generative and collaborative increases the likelihood of positive deviance. In a hospital setting where a MedFT or a nurse feels comfortable enough to tell the chief attending physician that he forgot to wash his hands from a previous appointment is a nurturing context for such deviant behaviors. Settings in which hierarchies and job titles define treatment approach rather than a collaborative setting, positive deviance is not likely to occur.

Gregory Bateson, dedicated learner of the inter-connected nature of human life and the broader ecology spoke of information as "the difference which makes a difference.” The information contained in simple deviant acts is the "difference that makes the difference” for many around them. As medical family therapists and other professionals in the Collaborative Family Healthcare Association continue to make decisive differences to lives of many, let us remember to blaze a deviant (positive) trail in our practice settings that helps us to achieve our mission of delivering comprehensive, cost-effective healthcare to all families and patients we will learn from.


Deepu George is a doctoral student in the Family Therapy program at the University of Georgia. He is interested in social determinants of health, medical family therapy, community development and capacity building. With a Masters Degree in Holistic Psychological Counseling from Bangalore, India, his aim is to continue his passion for applying systems lens in health care, family therapy, community capacity work.

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Taking off the white coat: Putting the soul first and the IV second

Posted By Elizabeth Bailey, Tuesday, May 22, 2012

Editor's Note: For this week's Growing MedFT post, we have invited Elizabeth Bailey to share personal reactions to the commencement address Donald Berwick gave at the 2010 commencement ceremony for the Yale School of Medicine.  The text from Berwick's address is available here.


Donald Berwick is a champion of putting the patient first, in all of his or her fragile, complex humanity, as the only way to improve, indeed save, our failing, fractured healthcare system. As he has said so often, it is only by asking "what will it do for the patient” that we can begin to move towards the care we need rather then the care we currently have.

The title of Berwick’s commencement address "Stepping into Power, Shedding Your White Coat” which he gave to his daughter’s graduating medical school class encapsulates the conflicting forces confronting young doctors as they begin their professional lives. They step into a culture of power and privilege by putting on that white coat of medical authority. The white coat, both in reality and symbolically, distinguishes them from their patients but must not, with its associated rules, language and culture, separate them from their shared humanity. He asks these eager, young graduates to consider that in every human encounter they are always faced with a choice – the choice to put the IV or the soul first in treatment. It is only by metaphorically taking off the white coat that they can truly heal their suffering patients.

Several years ago my Dad went crazy from what turned out to be a cascading series of medication errors and miscommunications. He was hospitalized for almost a month with full-blown steroid induced psychosis. The steroid medication wreaked havoc with not only his mind but also his body by drastically elevating his blood sugar levels. Dad’s previously mild diabetes was now a medical crisis. The first few weeks were focused on bringing his diabetes under control. After being was deemed "medically stable” he was transferred to the psychiatric unit, his psyche proving harder to heal.
Elizabeth Bailey
I wonder if that young resident had taken off her white coat, if only for a moment, she might have seen a frightened, ailing person not a difficult, non-compliant patient.

    -Elizabeth Bailey
An extremely young resident conducted his intake. We told the young doctor about our Dad before his illness because we wanted her to see him as the person he really was in life – an erudite, active, 81 year old former lawyer, not the broken, crazy stranger sitting in a wheelchair in front of her. Too often in the main hospital, Dad’s care seemed impersonal and distracted, his humanity forgotten. We wanted her to know him…at least a little. And we were frightened by his state of mind and unfamiliar with psychiatric units.

We told the young resident that the steroids had seemed to unleash flashbacks of his experience as a young soldier in the Pacific during WWII. As if on cue, he launched into a horrific tale of being trapped by sniper fire on Guam. It was obvious how much Dad was suffering – suffering from the steroids still in his system, suffering from painful memories, suffering because he was a human being who was ill. The young resident listened to him with a blank, stony face.

The next day, we went to visit Dad but he was not in his room. The resident appeared and ushered us into a little side office. She said there had been an "incident” with Dad in the morning, but that he was resting now in the "quiet room” – shackled to a metal gurney, shot full of enough antipsychotic medication to subdue a horse. We would not be allowed to see him then – it was against the rules.

Apparently, Dad had gotten up that morning and decided that he had had enough with hospitals in general; with doctors who looked past him; with too many medications he did not understand. He wanted to leave and go home and read the newspaper. The resident ordered him back to his room. When he refused, security was called.

When Dad saw the guards, he reminded them that he was a Marine and they would never take him alive. They wrestled my eighty-one year old father to the floor. A burly guard sat on his chest while the others put him in restraints. They then carried him to the "quiet room”. She never called us to alert us: that was against hospital rules. We asked her when we would ever have found out if we had not come to visit. She had no answer for us.

When we returned that night, Dad, still heavily drugged, was in his bed in his room, mumbling, "How could they treat me so badly?” The nurses later apologized to Dad about what had happened. The young resident never said anything.

I wonder if that young resident had taken off her white coat, if only for a moment, as Donald Berwick instructed the graduates to whom he spoke, she might have seen a frightened, ailing person not a difficult, non-compliant patient. Might she have found out how much my Dad loves to read, about his favorite hotel in Paris, about how much he misses his wife who died too soon or that he makes a martini that knocks ones’ socks off? By taking off her white coat, might she have seen, as Berwick says, "the dignity in each and every soul ” and in so doing, joined with instead of towering over her patient and become a healer in a world filled with suffering?


About Elizabeth Bailey:  As a producer, director, and vice president of video production for several record labels, Elizabeth Bailey used checklists to oversee hundreds of music videos. While helping family and friends navigate their hospitalizations, she realized how production checklists could be adapted to help patients better manage the complexities of hospital care. She embarked on a career change, working on her book "The Patient's Checklist" for several years and enrolling at Sarah Lawrence College where she is currently completing studies for a Master's in Health Advocacy. She is also working part-time as a Patient Representative at a major teaching hospital in New York City.

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Are We Short-Changing our Patients and Families?

Posted By Dan Marlowe, Tuesday, May 8, 2012

It seems that no matter where we turn, the rising costs of healthcare continue to be an issue for not only governmental agencies and the healthcare profession in general, but is often overlooked (or given a cursory glance at best) in regards to the toll this major stressor takes on individual patients and their families. All of us can recall learning at some point the ‘golden trifecta’ of issues that bring people (couples and families especially) into therapy; money, sex, and parenting. More than once I have worked with a patient/couple/family whose main source of distress stemmed not only from the disease and the associated physical and subsequent role changes, but also the terrifying prospect of losing any hope of a financially secure future.

If MedFT’s emphasis as a field (if it can be called/viewed as that) is about more complete care through systemic conceptualization and collaboration, have we been neglecting discussion about and collaboration with professionals whose expertise is in the area finance. If so, how might we better incorporate these conversations as a fundamental part of our clinical, academic, and research work?

This link is to a NY Times story detailing the financial related distress many families face when coping with illness, as well as the ramifications after the treatments and physician visits have ended.

The marriage and family therapy training program at the University of Georgia has a unique clinic where MFTs work alongside accounting and business graduate students to help couples/families negotiate the financial stresses that often exacerbate and accompany the issues that initially bring them into their clinic- please, any UGA folks reading this feel free to correct me. Perhaps as we, as collaborative professionals (regardless of profession), seek to develop training models around integration and collaboration, we should turn a more watchful eye to explicitly including financial concerns in the laundry list issues our patients and their families need assistance in discussing.


Daniel Marlowe

Dan Marlowe is the co-editor of the Growing MedFT Blog, and the Director of Applied Psychosocial Medicine for the Duke/Southern Regional AHEC Family Medicine Residency Program in Fayetteville, NC. He obtained his MS in Marriage and Family Therapy and PhD in Medical Family Therapy from East Carolina University in Greenville, NC.

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Reality, Hope, and Denial

Posted By Jackie Williams-Reade, Tuesday, May 1, 2012

Hope was the first thing I noticed when, in college, I volunteered at a camp that served adolescents and young adults who were diagnosed with cancer. I walked in expecting to see, at best, moderated sadness, or at worst, utter despair. To me, these seemed like normal responses to a diagnosis of cancer at such a young age. Instead, I was surprised by hope. The campers I met were, on the whole, optimistic about their futures and wore bright smiles most of the day. At times, I was inspired by their joy. In other moments, I felt their hope looked a lot like denial. As I have continued my career working with children and adolescents who have life-threatening or life-limiting conditions, I have become better acquainted with hope and denial and come to realize that there is, indeed, a fine balance of both that is needed to survive the uncertainty associated with serious illness.

For this blog post, I will call reality the objective sense of what actually is the diagnosis, prognosis, and treatment of a disease. (My social construction leanings are well aware that even that reality is subjective, but let’s just leave it at this meaning for now.) Hope is beautifully simple and complex all at the same time. While hope is grounded in an array of values and beliefs and comes in many forms, it is mainly a sense of optimism. This optimism helps a patient or family member cope with the seriousness of their reality. Hope is an adaptive behavior to have in the face of a challenge.

The relationship between
hope and denial is a delicate one.

Denial, on the other hand, has a pathological connotation and is understood as hope gone dangerously awry. An individual or family are "in denial” when they are defensive to hearing new information, become increasingly defensive upon hearing bad news, and begin to block out all new information, which then interferes with proper decision-making and coping with the reality of the situation. Whereas most people would typically agree that hope should be supported when coping with a medical illness, I find that once a patient is labeled as "in denial” their concerns are more often dismissed and we begin to shut out our understanding of and appreciation for the reasons why a patient or family member is not accepting their painful reality. When we consider a person in denial we may very well stop being curious about their situation which severely impacts our capacity to help.

Hope and denial are both normal reactions to a stressful and terrifying diagnosis, and both states of being may actually be necessary and helpful for patients and family members as they face a chronic or critical illness through its various stages and developments. While hope can go too far and lead to unrealistic optimism (which we label denial), this perspective can also lend itself to reducing the terror and excruciating pain associated with the potential loss that is at stake with a serious illness. It is normal to resist bad news, to not want to integrate the new information.

We all have experienced moments of denial when we encounter situations that we want to desperately escape from in our own lives. While I am not espousing that we allow denial to run rampant, I do suggest that we reconsider the role denial plays in a patient and family’s coping process and ask ourselves a few questions. Are we witnessing a family that is still holding on to hope as a positive coping strategy? Does the patient or family have the same understanding of the medical information or experience we are privileged to hold? Have we considered what could result if the family did fully accept their condition and understand the role denial is playing for them? Do we respect that different people need different amounts of time to integrate difficult news? Have we considered how our communication with the family could be influencing their response?

Overall, I have learned that the relationship between hope and denial is a delicate one. When I am tempted to say someone is "in denial” it now triggers me to further ponder the impact that acceptance of their reality would have on themselves and their loved ones which allows me to see more clearly why they are holding onto hope for dear life.

Jackie Williams Reade, PhD is a Postdoctoral Fellow at Johns Hopkins University in Baltimore, MD. She received her Master’s in MFT from Seattle Pacific University and her PhD in Medical Family Therapy at East Carolina University. She is also the administrator of the Medical Family Therapy Group on Facebook.


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Connected by Cancer

Posted By John Rolland, Wednesday, April 25, 2012

John Rolland
CFHA's Growing MedFT blog invited
Dr. John Rolland of the Chicago Center for Family Health to provide his insights and reaction to recent research documenting the connection between a wife's cancer diagnosis and the stress/health of her husband. This
link will take you to the original research report.

This study struck me as important on at least four levels.The findings highlight: 1) the impact of the wives’ cancer on the spouse/partner; 2) the impact of disease status on spouse (here recurrence vs non-recurrence of breast cancer), 3) the impact of perceived stress on the spouse/partner (here measured by immune system status), and 4) the mutual relationship between well and ill spouse emotional and physical wellbeing (and for ill spouse - treatment adherence, and the always interesting question of disease course/outcome).The effects of major illness on the spouse/partner and the unique aspects of the experience for couples remain "neglected edges” in both the general biopsychosocial and broader family literature.

Clearly, spouses are affected by both disease status and perceived stress.This is very consistent with the perceived risk research related to genetic risk, where perception of risk of getting a genetic condition and its course/outcome is more strongly associated with psychological wellbeing than actual genetic risk.With cancer and the possibility of recurrence or a fatal outcome (what I have coined as "anticipatory loss”), the perception of risk and associated level of stress is longterm.I have had patients/families, where even 30 years after initial cancer treatment, they still experience terror that any "unclear” physical symptom may be a recurrence.

The study underscores the vital importance of family/couple-oriented consultation close to the time of diagnosis.Also, it highlights the value of including ongoing periodic consultation with a couple in addition to consultation with the broader family system.As part of that process, I always inquire about sensitizing illness experiences in ones past as well as cultural meanings (cancer, genetics) /illness narratives that are imbedded in levels of stress.For me this is not just looking for sources of vulnerability/stress, but more important stories of resilience and relational growth in the face of adversity.The study authors correctly recommend stress management, relaxation techniques, and self-care for the well spouse/partner.As family and collaborative healthcare advocates, when major health conditions occur, we need to advocate that prevention-oriented couple consultation/psychoeducation and, when appropriate, medically-oriented couple therapy be included in routine care.

Dr. Rolland is internationally recognized for his Family Systems-Illness model, clinical work, and research with families facing serious physical disorders and loss. His book,Families, Illness, and Disability: An Integrative Treatment Model(Basic Books), was nominated for book-of-the-year by the American Medical Writer’s Association. He is currently co-author of a new book, Individuals, Families, and the New Era of Genetics: A Biopsychosocial Perspective(Norton). He has given over 250 national and international presentations on topics related to his work.

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When Family Devotion Leads to Killing: Some Ethical Questions

Posted By Carol Levine and Barry J. Jacobs, Tuesday, April 17, 2012



Part I:
When Family Devotion Leads to Killing: Some Ethical Questions

by Carol Levine


Last October David Brooks, a New York Times columnist, invited readers over the age of 70 to write a brief report about their lives so far as a "gift” to him.

 Among those who responded was Charles Darwin Snelling of Fogelsville, Pa, a small town in the Lehigh Valley, an 81-year-old entrepreneur and recently retired head of the Metropolitan Washington Airports Authority. His long essay, "A Love Story and Redemption,” published online on December 12, 2011, described his successful career and 61-year marriage to his wife Adrienne. With five high-achieving children and 11 grandchildren, two homes, plenty of money, and a variety of interests, they led a "charmed life.”

When Adrienne developed Alzheimer’s disease, six years ago, Snelling made caring for his wife his new life work. He wrote: "We continue to make a life together, living together in the full sense of the word, going about our life, hand in hand, with everyone lending a hand, as though nothing was wrong at all.”

But something was terribly wrong. On March 27, 2012, four months after his essay was published, Snelling killed his wife (no cause of death has been determined) and shot himself. Although rare, this kind of murder-suicide (and that is what it is, despite some attempts to romanticize it), is not unique. Donna Cohen, a researcher at the University of South Florida who studies reported cases like the Snellings, finds that most often it is the elderly husband/caregiver who commits the violence and the wife who is ill.

We will never know what was going on in the Snelling marriage or in Mr. Snelling’s mind. But the incident raises troubling questions. I am not a mental health professional, and I leave that aspect of the commentary to my colleague Barry Jacobs. My views come from my work in medical ethics and my personal and professional experience in family caregiving.

For a start, David Brooks’ response in his column  seems cold and distanced. Rather than expressing some dismay about his own inadvertent role in this drama, he chides Snelling for not "respecting the future.” Brooks says he "bought the arguments that Snelling made in his essay.” How could someone take his "gift” and regift it in this terrible way! He thinks that either Snelling "was so overcome that he lost control of his faculties, or he made a lamentable mistake.”

From my perspective, it was a desperate but entirely thought-out act that can perhaps be explained but not justified legally or ethically. Even an extreme view of autonomy does not include the right to take someone else’s life in addition to one’s own. If he had survived, he should have been charged with a crime, although his status as a pillar of the community might have spared him that indignity. Why is it that so many Americans approve of this kind of violent death but protest withdrawal of treatment from a person in a permanent vegetative state? Why do they refuse to talk about health care proxies and living wills but say that they will rely on a willing relative with pills or a gun?

Some have complained that even to comment on this "family tragedy” violates their privacy. While certainly the surviving family members’ personal privacy should be respected, Snelling took his life story out of the personal realm, first when he wrote his essay and allowed it to be published; and second, when he committed acts of violence that were certain to be reported, investigated, and discussed. These were two very public acts, and he was a man who lived in the public eye.

Nor is this a case of euthanasia, physician-assisted suicide, or that odious phrase "pulling the plug.” The medical community was not involved at all, other than perhaps prescribing medications for Adrienne. (Perhaps some astute clinician might have picked up some clues earlier on.). Refusing unwanted medical treatment is the legal and ethical right of every autonomous person. The facts of this case are not even close to that scenario. There were alternatives. With his resources he could have found a good nursing home with a special dementia program for his wife, visited her as often as he wanted, and found some time for his family and avocations. There is no shame in such a choice, and it should be respected, not criticized as abandonment.

As a person with advanced dementia, Adrienne Snelling did not have the capacity to consent, even if (as seems unlikely), at some point the couple made a verbal pact not to go on living if one partner was terminally ill. Saying, "I wouldn’t want to live without you” is quite different from saying, "Yes, give me that fatal dose of pills today and don’t forget to shoot yourself afterwards.” Nor was this some sort of old-age Romeo and Juliet story. Those who make that connection misremember Shakespeare’s play. In any event, Adrienne was, as far as we know, not imminently dying and not suffering. She might have lived for years in this condition, apparently well cared for (by aides as well as her husband) and happy as long as she could be near him.

And that is probably at the heart of what happened. In rereading Snelling’s essay, I now am struck by the feeling that he was trying to convince himself that this life—a constant caregiver to a person who was and who was no longer his wife—was not only tolerable but good and satisfying. Not a hint of how hard it really was, how diminished he felt, and how difficult it was to imagine the years and years ahead. I have interviewed many caregivers of people with Alzheimer’s; none of them has expressed this kind of total selflessness. The ability to acknowledge one’s losses and limitations is an important asset in surviving caregiving. Friends and family, as well as professionals, should accept and validate these feelings. Perhaps the accolades Snelling received when his essay was published only brought home to him the disjunction between the saintliness ascribed to him and his true feelings.

In the end I feel most deeply for the Snellings’ 11 grandchildren who will live the rest of their lives without the love and pride that is the special contribution of grandparents, but instead with the dark knowledge of violence in their family history.

 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.


Barry Jacobs
Part 2:
Narrative Means to Homicidal Ends

by Barry J. Jacobs, PsyD


What’s your idea of end-of-life redemption? As medical family therapists, we often try to guide our clients—the dying and their family caregivers—to use the last days, weeks and months of life to express love, complete unfinished business, and make reparations—the better to provide healing and lay the groundwork for successful resolution of grief. But do we regard actively trying to end a loved one’s life as a justifiable means of redemption? I believe that’s the crux of how each of us may view the Snelling case.

In the immediate aftermath of the murder-suicide, the Snelling family was reported to have said that its patriarch had acted "out of deep devotion and profound love.” But I agree with my colleague Carol Levine that we can and should make distinctions between ending a loved one’s death’s-door suffering (say, through removal of life-supporting machinery or administering high doses of morphine under hospice guidance) and killing someone with an as yet irreversible disease who is terminal but still viable and who may or may not be suffering.

I also agree with her that Mr. Snelling’s violent acts were probably not the result of a brain addled by depression but of a mind too taken with itself and with its redemptive mission. As Carol points out, cases like these are rare but not unique. A decade ago, I wrote an essay on a similar case (please see "Instructions to the Jury,” Families, Systems & Health, Vol. 20, 2002, 101-104) in which a husband-caregiver was clearly desperate and severely depressed at the time he put a pillow to the face of his wife of 43 years; he soon afterward was placed in a state psychiatric facility. But there is little of the tone of the tormented depressive in Snelling’s long, meandering essay. Rather it is deliberative and full of gratitude even in its allusions to the grinding work of Alzheimer’s caregiving. We all know about "reaction formation,” Freud’s classic defense mechanism in which people state and do the opposite of how they really feel in order to prevent themselves from being plagued by self-condemnation and anxiety. (Shakespeare’s line from Hamlet-- "The lady doth protest too much, methinks”--captures the same insight.) But there is no telling if Snelling were covering up anger or sadness or anything at all negative with his opaquely self-satisfied essay.

Because that essay was undertaken in response to a prompt to provide a "life report” to New York Times columnist David Brooks, it can be read as a narrative in the clinical sense of noted family therapist Michael White—that is, as a construction or justification for a particular life course. Snelling may even have intended it as explanatory back-story for his children of what he already planned to do. So what do we learn from Charles Darwin Snelling’s narrative? He grew up in a materially rich but emotionally impoverished family in which he was subjected to his prominent father’s unremittingly harsh judgments. He developed into an oppositional, disdainful and willful young man who irritated authority figures but still possessed something of his father’s intelligence and determination. Under the nurturing influence of his wife, he softened somewhat but was still known to their 5 children as a curmudgeon. Then his wife became demented. Others didn’t think he had the capacity for nurturance himself to care for her, but he was determined to prove them wrong. He also saw this as an opportunity to redeem himself—to give back to her some of the love he’d received from her.

It made for a nice story in the Times. But, in my opinion, the postscript to this story reveals that Snelling was not redeemed from his upbringing. We know that childhood neglect often produces narcissistic adults —people of shining public facades but with interior lives marked by feelings of inadequacy, despair and resentment. I consider his writing of an essay for national publication to be a grand-standing effort to make a positive impression and garner prominence. I see in his acts of murder and suicide an application of the harshness, bleakness and willfulness he harbored within. These were sharply negative edges to him that his wife had long blunted until she wasn’t competent enough to have that influence on him any longer. Then he was psychologically on his own. In seeking death, Snelling found the severest form of deliverance for himself and, more especially, for her.

Dr Jacobs is the Director of Behavioral Sciences at the Crozer-Keystone Family Medicine Residency in Springfield, PA.  He has written broadly on family and caregiver issues, including the book, The Emotional Survival Guide for Caregivers—Looking After Yourself and Your Family While Helping an Aging Parent

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Moving from the "Unexpected Visitor" to the "Curbside Consult"

Posted By Cassidy Freitas, MA, MFTI, Tuesday, April 10, 2012
There is a knock at the door. An unexpected visitor has shown up at your doorstep and you already have guests. You are really wishing they would have called ahead of time, but alas, here they are. This unexpected visit is from someone who is important to you, a relationship that you would like to maintain. You are having an important and private conversation though with the guests you are already hosting, and must decide how to balance these two important relationships that are inconveniently colliding. Now imagine that your home is a primary care setting, the unexpected visitor is a physician in need of your consult, and your present guests are a couple you are seeing in therapy. In a nutshell, this has been a common experience for me as a "co-located” therapist. Let me provide a real life example.

My intake becomes quiet and exhales as he looks down at the tissue he has been nervously shredding into little bits and pieces. His body language changes and I sense him trying to formulate the words he is about to say when there is a knock. He tenses up as we both look at the door, and the moment for him to speak quickly fades away. I excuse myself as I open the door and see a look on my colleague's face that I know all to well. My colleague is a resident physician in our clinic, and the look on her face is "Help."

I turn back to my patient and explain to him that we are experiencing one of those special circumstances where I must make myself available. I step into my colleague’s office and she shares a quick summary of a patient she is currently treating, a new mom being seen with her husband who had become tearful during their visit and expressed some suicidal thoughts. My colleague is concerned and is hoping I can provide some consult on how to effectively and efficiently assess for postpartum mood disorders and this patient's safety. After some thought and a few brief assessment questions, I make the clinical decision to join my colleague in her visit with this patient. I am already feeling uncomfortable about leaving my patient at such a vulnerable moment, but in an effort to be collaborative, these are the clinical judgments that need to be made.

These interactions between behavioral health clinicians (BHCs) and physicians are an integral and special piece of collaborative care. I share the above scenario because it reflects the challenges I had faced in a "co-located” primary care setting. While Hunter and colleagues (2009) reinforce that physicians are more likely to use a BHC who is responsive and easily accessible, and that BHCs working within the primary care setting must make themselves available at all times, my above scenario is not the ideal.

Cassidy Freitas
Constructive, supportive, didactic, opportunistic, and at times inconvenient. For me, all of these words described my experience with the unexpected knock on my door.
 The beauty of co-location is that we as BHCs are available to physicians when needed, and that our presence contributes to the care of the whole person. Specifically, I believe that Medical Family Therapists are particularly well-suited for this position because our training emphasizes two content areas that are underdeveloped within many healthcare environments, 1) a systemic relational perspective of illness and the illness experience, and 2) the inclusion of the relational system around the patient.

While co-location is definitely heading in the right direction, it is clinically not the perfect scenario. At the UCSD Department of Family and Preventive Medicine we are moving in the direction of many other clinics by utilizinga system in which "floating” therapists are available to the physicians when these consults are desired. Our new clinic system, coined T-CARE, follows the mission of the Primary Care Behavioral Health model in that it provides educational and systemic changes that improve the primary care system’s ability to provide care (Robinson & Reiter, 2006).

Constructive, supportive, didactic, opportunistic, and at times inconvenient. For me, all of these words described my experience with the unexpected knock on my door. As a "co-located” BHC I was constantly doing what I could to balance the needs of my patients, the physicians, and the physician’s patients that were driving these unexpected consults. While our clinic moves from co-location to collaborative integration, I am becoming more aware of the marked distinctions that exist between these two models. The exchanges and consults that are so central to collaborative care are still occurring, but the unexpected visitor is no longer knocking on my door when the circumstance is clinically inopportune.

Above all, I believe that these exchanges have allowed me to build key relationships with the primary care staff in my clinic (convenient or not), and in the end, I wholeheartedly believe that these connections and interactions are at the heart of collaborative care.

Now I must ask, what has your experience been of the curbside consult? How do these interactions take place at your clinic? And have you ever had to make a tough clinical decision such as the one I described above?



Hunter, C.L., Goodie, J. L., Oordt, M.S., & Dobmeyer, A.C. (2009). Building an Integrated Primary Care Service. Integrated behavioral health in primary care: Step-by-step guidance for assessment and intervention (pp. 11-20). Washington, DC: American Psychological Association.

Robinson, P. & Reiter, J. (2006). A mission and a job description. In 1st edition, Behavioral consultation and primary care: A guide to integrating services (pp. 29-58). New York: Springer-Verlag.


Cassidy Freitas is an MFT Intern practicing at the UCSD Department of Family and Preventive Medicine. She is a recent graduate from the University of San Diego, and is in the process of pursuing MFT doctoral programs.

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Seaburn comments...

Posted By David Seaburn, Wednesday, April 4, 2012

I read the AARP document with great interest since it so closely states the position of Med Family Therapy as a discipline. Even more impressive that it comes from one of the most powerful political organizations in the country. If AARP can't make a change in this area, then no one can. It is clearly important for CFHA to make alliances with this organization.

I must add, though, that it is interesting that it has taken so long for AARP to officially take this position since we have known for decades the role that family plays in the lives of older adults. I understand the historic difficulty involved in convincing insurers, policy-makers and most providers that involvement of family is often integral to good and effective care and not just a nice thing to do when time allows. But it seems like an obvious and critical postion for an organization like AARP to take.  I am pleased that they have finally done so.

The road ahead for Med FTs is still a challenging one. I think that the political/cultural wars over individuality vs. mutuality, pulling onself up by the bootstraps vs. social safety networks has created an atmosphere in which the idea of collaboration and working together is not prized in the way it was been in the not-to-distant past.

It is incumbent upon Med FTs and others to press the argument that such divisions in healthcare make little or no sense. Instead we must argue for both individual autonomy and interpersonal responsibility. We are, afterall, persons because of our connections with other persons.


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CFHA is a member-based, 501(c)(3) non-profit organization dedicated to making integrated behavioral and physical health the standard of care nationally. CFHA achieves this by organizing the integrated care community, providing expert technical assistance and producing educational content.