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Looking for Batman in Primary Care

Posted By Patrick McFarlane, Thursday, April 16, 2015

 

GOTHAM ASSISTANCE

"I like batman,” she said

baring her chest to reveal a dishevelment of a tattoo

of the famous Gotham call for assistance

that police commissioner Gordon would shine into the sky.

"I’m really into werewolves too.”

She wears a sweatshirt with the same logo like an echo,

layers of a symbol of the superhero she seeks,

and the superpowers she hopes for.

I asked her why she likes these superheroes,

And she said I don’t know, I just do.

When she tells me how her orbit was fractured

   by an ex-boyfriend,             

and how her mother was an addict who allowed

her using friends into her bedroom as a child

it all made sense.

If, as we are told, 40-70% of all primary care visits are related to underlying psychosocial issues 1 and if the resident physicians are right that 80% of the job is health education and they get to do that only 25% of the time 2, then that leaves 55% of the time that the physician isn't able to respond to which is perhaps the foundation of the patient problem; or to use the metaphor of the opening poem, Batman doesn't show up when called.

Batman is supposed to show up and fix the problem when called. When Batman doesn't show up, or when people don’t know how to call Batman, patients go to the emergency room or urgent care, or get referred to specialty care at great cost both in terms of cost and morbidity.  

Ted Epperly, Former President American Academy of Family Physicians (AAFP) in his plenary at the annual AAFP Program Directors Workshop in March 2015 eloquently described a future of team based care with patient metrics allowing multidisciplinary staff to work at the top of their license responding to patient needs with physician’s concentrating on the most concerning patients and their broad presentations, with incentives for ‘doing what it takes’ to keep people well and out of our emergency system. The technology exists already to electronically interact with patients to determine levels of risk, find the highest risk patients and to educate and connect with patients who are well.  This is Batman stuff.

Arguably, asking patients about what has happened to them, how they think about it impacting their medical needs and what they want is du rigueur, a standard of practice in a patient centered medical home world.  As we move toward a firmer foundation under the expectation that providers inquire in order to address risk in a preventative care model, payment models that support and reward such intervention must be adequately supported. We will know that is the case when providers are able to 100% take the time that each patient requires.

The patient in the poem above is seeking what she failed to get from her family:  a sense of attachment, belonging, and safety.   The medical setting is certainly a poor substitute for what she didn't get, but it can provide a societal foundation for, as Epperly suggests 1, doing what it takes. Part of what it takes is knowing the patient well and diminishing the shame and loneliness that sets up the superhero dynamic. 

By taking time and leveraging the provider relationship with the patient,  we remind the patient that they in fact are their own superhero as a survivor and that preventative care models can be leveraged to improve health outcomes that matter to all of us.   It is a new model of care that disperses with the superhero dynamic and takes the whole patient into account (family, community and environment) which will move the patient toward better health and away from mythic medicine.

 

Patrick McFarlane, MSW, MA, MSN-APRN is Faculty and Director of Behavioral Medicine at the Eastern Maine Medical Center’s Family Medicine Center and Residency Program.   He has worked in integrated health since writing a HRSA Office of Rural Health grant for integrating rural primary care in Western Michigan  in 1998.  He has two boys,  Isaiah and Ben, and loves to Kayak in the cold North Atlantic around Penobscot Bay in Maine and it’s many tributaries.   His research interests including addressing issues of violence and poverty in primary care and reflective practice.  

References 

1. Epperly, Ted (2015) AAFP Program Directors Workshop Conference Plenary.  Kansas City, MO. 

 

2. McFarlane, Patrick (2015)   Resident Focus group in Transition to Office Practice Systems. Bangor, ME. National Ambulatory Medical Survey 2008 Survey Tables.  CDC, Mental Health workgroup  Atlanta, GA.

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Important Lessons for MedFT Trainees to Learn while they are still in School [Part 2 of 2]

Posted By Tai Mendenhall, Stephanie Trudeau, Lisa Trump, Tuesday, April 7, 2015

 

In the first part of this two-part account, we outlined important steps for C/MFT students who are interested in MedFT to take in preparation for clinical work in medical contexts.  In this section (part two), we outline strategies for trainees to follow once they have their foot-in-the-door of a medical facility.  These include functioning as an anthropologist, conducting one’s self sensitively vis-à-vis medical colleagues, using supervision effectively, and aligning your work to fit within the culture of integrated care. 

Function as an Anthropologist

One of the most common mistakes we see new MedFT trainees make is to charge into a healthcare site like a "bull in a china shop”, touting her/his systems-paradigm as a panacea that everyone has heretofore been missing.  This can be off-putting to medical providers, insofar as the turf that trainees are entering is medical (not behavioral).  These contexts are – by design – hierarchical and mental health providers are lower on this hierarchy.  A well-prepared trainee understands and respects this, and is thereby careful to conduct her/himself in a manner that communicates this insight and respect.

God gave you two ears and one mouth for a reason 1.  As a new trainee, then, it is important that you engage with medical colleagues as a person eager to learn more than you want to (or at least show a desire to) teach.  Observing precepting sequences in a medical residency (i.e., consultations between resident learners and faculty supervisors), learning about what types of patient presentations are common to particular sites (e.g., depression and diabetes in primary care, grief and loss in respite care), and asking questions when doing so is not disruptive are excellent ways to do this.  Having already learned medical language (qhs, PRN, b.i.d., etc.) facilitates these processes, alongside equipping you to read/understand patients’ charts, and to write your own notes in the same manner.

Key here, too, is to actively talk with, befriend, and learn from professionals other than physicians (e.g., receptionists, care coordinators, medical assistants, nurses).  These personnel can often describe and translate the structure and care processes of a clinic better than physicians, administrators, or others comparatively "higher up” on the medical hierarchy.  They also tend to know more about patients’ and families’ internal worlds, struggles, and resources.  Insofar as one of the key roles a MedFT plays is in-liaison between respective "parts” of a medical system’s "whole”, lower-ranking (in a hierarchical sense) personnel are essential partners.

And a final word about Medicine’s hierarchy: Yes, behavioral health providers are trumped by medical providers in terms of social/professional status, income, etc.  But there is a difference between honoring this hierarchy (and learning how to function within it) and resigning to the notion that you, as a MedFT, do not have anything to offer (or that what you offer is less important).  Go into these systems with caution.  Listen to and learn from your colleagues.  Gain their respect and regard.  As you do, the care and contributions you offer will evolve, as will the interdisciplinary collaboration that you collectively advance as a team.

Listen to and learn from your colleagues.  Gain their respect and regard 

  

Behave and Conduct Yourself Sensitively

It is important for MedFT trainees to understand what medical providers have been through to secure the positions they have, and to conduct one’s self with sensitivity to this.  Medical education is remarkably difficult (if not straightforwardly abusive).  Residencies cap scheduled education and patient care at 80 hours per week, and include regular on-call sequences that last up to 24 hours at a time.  Patient panels are often in the hundreds, and it is not uncommon for these patients to die.  Extensive research has shown that medical trainees endure higher rates of depression, anxiety, suicidality, substance use, somatic problems, and relationship-dissolution and divorce as compared to other types of graduate learners and/or the general population.  No training program or sequence in C/MFT compares – even closely – with this type of intensity or rigor.

Equipped with this understanding, then, you as a MedFT trainee should be careful to not complain about how exhausted you are after a 10-12 hour day. This type of day is a normal day – if not an "easy” or "light” day – for medical providers.  Similarly, complaining about the intensity of one of your cases, time that you are missing from family, etc., can elicit negative reactions from medical colleagues.  You can be seen as wimpy, entitled, or fitting conventional stereotypes of the isolated private practitioner who works in a comfortable office, sets her/his own hours, and caters to a wealthy clientele.  Once this impression is made, it can be hard to regain your persona as a valuable and engaged member of a healthcare team. 

Strategies for making Supervision Effective

One of the earliest contexts in which MedFT trainees feel a divide between their work and "traditional” C/MFT is within university-based supervision.  As students meet together to discuss cases, MedFTs can feel "out of place” by nature of having higher intensity and/or complex cases.  While your colleagues talk about depression or couple discord, you (as the MedFT) might talk about patients who are struggling with a chronic illness or a family’s (and/or your own) experiences in coping with death.  Because these presentations are not as common with C/MFT students, peers can struggle to effectively brainstorm with and help you.  This can result in your feeling isolated or disconnected from your C/MFT peers, and/or feeling forced to proceed in cases (and manage self-of-therapist issues) with less support.

Participating in dual-supervision facilitates the expansion of your skillsets 

You, then, are charged with finding a champion or on-site supervisor (even if s/he represents a sibling discipline).  Indeed, it is common for MedFT trainees to be supervised at their university while synchronously participating in supervision with a Medical Social Worker or Health Psychologist.  This facilitates a purposeful combining of conventional C/MFT and MedFT training and approaches.  For example, utilizing a long-term insight-oriented therapy modality may be less possible or impactful in MedFT, but its primary tenets (e.g., attachment, poor family-of-origin differentiation) may still be applicable.  Participating in dual-supervision (conventional + MedFT) facilitates the expansion of your skillsets to best fit clinical practices and activities to immediate presentations at-hand.   

 

Other resources and competences specific to MedFT practice include, but are not limited to, motivational interviewing, brief solution focused therapy, conducting PHQ-9 assessments, completing disability or workers’ compensation documents, and assisting physician colleagues with complex citizenship applications and paperwork.  All of these require that you make time to do "extra” homework in skill-development.  Leaning on aforementioned mentors within Medicine can help you navigate this, and further-enable you to assist others who follow (aligning with Medicine’s adage to "Learn one, do one, teach one.”) 

Align your Practice-Patterns to Fit with the Culture of Medicine

For a MedFT to function as a collaborative colleague, s/he must adjust her/his practice patterns away from conventional mental health service models.  The standard "50 minute hour” that you were taught in graduate school is one of the first places to do this.  If medical providers are seeing patients every 15-20 minutes, you (as the MedFT) are not going to be very accessible if you schedule your appointments on-the-hour.  This does not mean that you cannot see some patients/families for this amount of time (indeed, some are best served this way), but – to be clear – you cannot only do this.  

We suggest that you purposively schedule "open” time to shadow, collaborate with, precept, and/or otherwise be available to medical colleagues.  And when you do set up times for 50-minute visits, it is important for collaborators to understand that you are very interrupt-able. Some of our colleagues even hang signs on their office doors that say "Please Disturb”.  This sets a precedent for collaboration: you should always available.  And don’t stress; patients who are being seen by a physician appreciate your ability to step-in and collaborate, and they will similarly appreciate a physician being able to do the same.  

     

 

Conclusion

The steps that your will take as a MedFT student and trainee to gain entry into a medical practice will vary in accord to the practice that you are entering.  Some practices will be familiar with and maintain strong buy-in for MedFTs (e.g., a primary care site that has organized its services to align with contemporary developments in the medical home movement).  Other practices may not have included a MedFT on their team before, but are amenable to trying this out based on a perceived need that systems-informed mental health providers could offer (e.g., a neonatal intensive care unit in which newborn infant deaths and families’ efforts in coping are commonplace).  Conversely, some sites may be resistant to hiring you, for reasons like finances (i.e., not seeing how MedFTs could bring additional revenue) or administrative discomfort with negotiating new territories in referral, scheduling, or billing systems.  Some trainees, then, will be able to get into MedFT placements with relative ease.  For others, this process could be difficult.  However things go – on any place along this continuum – it is our view that the lessons and strategies outlined in this two-part account will help you in the journey. 

References

1.   Diogenes, L. (1901). The lives and opinions of eminent philosophers. London, UK: George Bell & Sons.

 

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Important Lessons for MedFT Trainees to Learn while they are still in School [Part 1 of 2]

Posted By Tai Mendenhall, Stephanie Trudeau, Lisa Trump, Wednesday, April 1, 2015

Clinical practice in healthcare settings is different than the conventional stand-alone mental health clinics and/or private practices that most Couple/Marriage and Family Therapy (C/MFT) programs prepare their students for.  And while some trainees in C/MFT are situated in programs that offer a Medical Family Therapy (MedFT) specialization, there are far more who are not.  As demand for MedFTs continues to rise across both internship- and postgraduate workplace- sites, it is important to consider what trainees can do to: 1) prepare for such opportunities, and 2) effectively adjust and thrive once they are there.  In this two-part account, we describe concrete strategies for students to effectively achieve these goals.

Preparing for Clinical Work within Medical Contexts

Before actually beginning your work as a MedFT trainee, it is important to make a conscious decision about what you are getting into, work through your own personal biases, and develop specific knowledge and skillsets.

Learn What You are Getting Into

Mental health providers who work in healthcare settings encounter stressors and clinical presentations that are often comparatively more complex, intense, and/or acute than "traditional” or conventional therapy settings.  It is important that you understand this, and to ultimately make a personal and professional decision about whether this type of work is a good fit. 

In conventional C/MFT settings, patients and families present with a variety of struggles, including depression, anxiety, parent/child conflict, marital discord, and seeking personal growth (broadly defined).  They come to us, as their primary provider, each week for hour-long visits, wherein we advance clinical interventions through our preferred theory(ies) and approach(es).  We consult with colleagues/supervisors between sessions and try out new angles, ideas, and strategies along the way and in accord to how our patients/families are progressing.  We perceive the conduct of 5-6 (sometimes 7-8) therapy sessions in one day as "a lot” – and we are tired when we go home.
Make a personal and professional decision about whether this type of work is a good fit 

 

In medical settings, patients and families can present with these same straightforward struggles, but those that do are often experienced by MedFTs as our less-complex – or even "easy” – cases.  Most of our work in health care is situated earlier-on in these clinical sequences, such as when a depressed patient first reaches out for help or is imminently suicidal, when sexual abuse is first discovered, or immediately after (or even during) a traumatic loss.  Many of the presentations we see – unlike the ones portrayed in our textbooks – are cases for which there will not be a "cure” or resolution (e.g., patients and families who are coping with serious accidents, chronic illnesses, or death).  We function as part of treatment teams (not as sole providers, and usually from positions of less hierarchal power vis-à-vis our medical colleagues), and we hardly ever see people for hour-long visits.  Seeing 5-6 (or 7-8) patients/families in one day means that we took at least half of the day off.

If you are interested in MedFT, it is important that you expose yourself to, and learn about, the culture and everyday processes of medical care sites.  Many scholars and field leaders in MedFT have contributed to literature regarding these early preparatory steps 1-4.  Common themes in advice here relate to reading first-hand accounts of MedFT on-the-ground 4-6, seminal texts about MedFT tenets and applications 7-10, and/or refereed journals that publish cutting-edge research and accounts of interdisciplinary collaboration (e.g., Annals of Behavioral Medicine; Annals of Family Medicine; Families, Systems, & Health).  You can do this through informational interviewing with MedFTs already working in the field and/or shadowing MedFTs or other similarly-situated behavioral health providers (e.g., Medical Social Workers, Health Psychologists).  Attending grand-rounds presentations at local healthcare facilities and collaborative care conferences/workshops/trainings (e.g., CFHA, STFM) can also be valuable. 

As you do this, we encourage you to take a deep and honest look inward.  Ask "Is this the kind of environment I can thrive in, or will it burn me out?”, "Do I want the predictability and structure of private practice, or would I get bored with that?”  MedFT is a great fit for some C/MFTs.  For others, conventional therapy sites are a great fit.  It is important to figure out for yourself where you will be most fulfilled.

Work through your Personal Biases

You, as a MedFT trainee, have made a conscious decision to work in a healthcare context.  You must, then, behave in a manner that is conducive to this.  There are many biases about Medicine that you might hold, and these biases can hinder your working relationships and ability to collaborate.  Common biases we hear include: physicians are too busy to collaborate; they just don’t "get” what we are talking about; they will not listen to therapy jargon; and/or that they need to be convinced to collaborate with mental health providers.  Biases can go the other way, too (i.e., those that we hold against ourselves); these can include things like: we need to "sell” our potential contributions before they will be valued; we need to maintain a hard external persona (i.e., never show weakness); we cannot talk too much about "warm and fuzzy” emotions and feelings; and/or that we must not speak until spoken to. 

Like any stereotype, we can always find supporting evidence for our biases.  Some physicians are, indeed, very busy and cannot recognize the value in collaborating with a behavioral health provider.  Some therapists do, indeed, work hard to never show vulnerability to medical colleagues.  However, we also know that most stereotypes are unfair (and usually negative) globalizations of a group’s character – and in integrated care environments, holding them will almost invariably sabotage effective teamwork.

Think through and articulate your personal preconceptions about medicine  It is important for you to think through and articulate your personal preconceptions about functioning in a medical context before you get there. You can do this through a combination of individual- and group- exercises and discussions about these preconceptions with colleagues and supervisors familiar with MedFT. Taking the time to do this (because we all have personal biases) enables students to process and allay what could be personal/professional blind-spots later down the road. It also can serve to better equip you with knowledge regarding Medicine’s structure (yes, it is very hierarchal) and how to function effectively within it (which we will address further in the second half of this two-part blog entry). 

 

Develop Specialized Knowledge and Skillsets

Moving beyond the baseline-competencies that any C/MFT is expected to have (i.e., the ones that are advanced by AAMFT regarding admission to treatment, clinical assessment and diagnosis, treatment planning and case management, etc.), MedFTs must develop skillsets specifically targeted to our efforts within medical contexts.  Field-leaders are working hard to articulate and advance shared-understandings regarding these unique competencies 11-13, targeting domains like medical culture/systems, effective interdisciplinary collaboration, theories like the biopsychosocial-spiritual model and three-word view (clinical, operational, financial), self-care, and others.  Competencies within these domains include clinical skills (e.g., promoting patient/family agency and communion, facilitating communication between medical providers and patients/families), alongside skills in training/supervision, policy, and research.  

It is important, too, that you understand the financial world(s) of Medicine, and how mental health services fit into these complex and dynamic structures.  MedFTs are reimbursed in similar and different ways (and at similar and different rates) than their sibling disciplines – and this varies in accord to where you live, the site in which you practice, and the current-day status of the politically-charged debates between local-, State-, and Federal- stakeholders fighting for recognition and market share.  Field-leaders are working hard to articulate and advance shared-understandings of these foci, as well 14-16.

You can begin to develop knowledge and inform these skillsets through aforementioned seminal texts and journals, together with core coursework that – in our view – anyone planning a career in MedFT should (must) take.  These include courses in medical terminology, psychopharmacology, physiology/anatomy, and "special topics” like health policy, healthcare administration, principles of health maintenance organization management, and spirituality and healing.

Concluding Thoughts 

Laying the foundation through the knowledge acquisition and preparatory strategies we have outlined above will prepare you as a C/MFT student to be competitive for clinical opportunities and training in MedFT. As you gain entry into integrated care sites – whether they are facilities that are already established in and conversant with integrated care, or just getting started – the guidelines we will offer in the second half of this two-part account serve to represent strategies and learning we have found to be most helpful. Stay tuned…  

   

 

References

1.Brucker, P., Faulkner, R., Baptist, J., Grames, H., Beckham, L., Walsh, S., & Willert, A. (2005). The internship training experiences in medical family therapy of doctoral-level marriage and family therapy students.American Journal of Family Therapy, 33, 131-146.

2.Gawinski, B., & Rosenberg, T., (2015). Beginning a career in medical family therapy.Family Therapy Magazine, Jan/Feb issue, 36-39.

3.Harkness, J. L., & Nofziger, A. (1998). Medical family therapy casebook training in a collaborative context: What we did not know then… we know now.Families, Systems, & Health, 16, 443-450.

4.Trudeau-Hern, S., Mendenhall, T., & Wong, A. (2014). Self of the medical family therapist: Functioning as a clinician across the multiple worlds of health care. In J. Hodgson, A. Lamson, & T. Mendenhall (Eds.),Medical family therapy: Advanced applications(pp. 55-78). New York: Springer Publications.

5.Mendenhall, T. (2007). Crisis land: A view from inside a behavioral health team.Psychotherapy Networker, May/June, 32-39.

6.Mendenhall, T., & Trudeau-Hern, S. (2014). Using medical genograms in clinical supervision. In R. Bean, S. Davis, and M. Davey (Eds.),Clinical supervision activities for increasing competence and self-awareness(pp. 141-148). Thousand Oaks, CA: Sage Publications.

7.Hodgson, J., Lamson, A., Mendenhall, T., & Crane, R. (Eds.) (2014).Medical family therapy: Advanced applications. New York: Springer.

8.McDaniel, S., Doherty, W., & Hepworth, J. (2014).Medical family therapy and integrated care(2nd ed.). Washington, DC: American Psychological Association.

9.McDaniel, S., Hepworth, J., & Doherty, W. (2009).The shared experience of illness. New York: Basic Books.

10.Seaburn, D., Lorenz, A., Gunn, W., Gawinski, B., & Mauksch, L. (Eds.). (2003).Models of collaboration. New York: Basic Books.

11.Tyndall, L., Hodgson, J., Lamson, A., Knight, S, & White, M. (2010).Medical family therapy: Conceptual clarification and consensus for an emerging profession. (Doctoral dissertation). Retrieved from:http://thescholarship.ecu.edu/handle/10342/2794

12.Tyndall, L., Hodgson, J., Lamson, A., White, M., & Knight, S. (2012). Medical family therapy: Charting a course in competencies.Contemporary Family Therapy, 34, 171-186.

13.Tyndall, L., Hodgson, J., Lamson, A., White, M., & Knight, S. (2014). Medical family therapy: Charting a course in competencies. In J. Hodgson, A. Lamson, T. Mendenhall, & D. Crane (Eds.),Medical family therapy: Advanced applications(pp. 33-53). New York: Springer.

14.Crane, D., & Christenson, J. (2014). A summary report of cost-effectiveness: Recognizing the value of family therapy in health care. In J. Hodgson, A. Lamson, & T. Mendenhall (Eds.),Medical family therapy: Advanced applications(pp. 419-436). New York: Springer Publications.

15.Manchikanti, L., Caraway, D., Parr, A., Fellows, B., & Hirsch, J. (2011). Patient Protection and Affordable Care Act of 2010: Reforming the health care reform for the new decade.Pain Physician, 14, e35-e67.

16. Marlowe, D., Capobianco, J., & Greenberg, C. (2014). Getting reimbursed for MedFT: Financial models toward sustainability. In J. Hodgson, A. Lamson, & T. Mendenhall (Eds.),Medical family therapy: Advanced applications(pp. 437-449). New York: Springer Publications.


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Parents matter: Delaying premature adolescent sexual initiation

Posted By Dan Blocker, Monday, March 23, 2015

 

Researchers and providers recognize that adolescents are having sex. Some professionals and parents recognize it as a part of adolescent identity development. This increased acceptance has resulted in sex education that encourages safe sexual practices and preventing adolescent pregnancy and sexually transmitted infections (STIs). Despite these efforts and the resulting reductions in negative outcomes associated with adolescent sexual intercourse such as teenage pregnancy and sexually transmitted infections (STI), billions are still spent dealing with the ramifications of adolescent sexual intercourse. Adolescents below the age of 16 are especially at-risk for these negative outcomes.

Teenagers below the age of 16 are still developing key cognitive abilities and skills including the ability to fully appreciate and understand the risks associated with sexual intercourse. As such, those who initiate sex before the age of 16 are at a higher risk for pregnancy, sexually transmitted infections, and other negative outcomes. Reports of perceived benefits of sexual intercourse reveal that younger adolescents are seeking sexual relationships for emotional regulation, to maintain a romantic relationship or to increase their sense of worth. 

Adolescent sexual initiation is a systemic issue influenced by multiple factors including race, socio-economic status, friends, parents, and teenager biology and personality. With many of these factors existing outside the parameter of parent control, parents can feel very powerless. However, the parent-child relationship can serve a protective role and increase the likelihood of delayed adolescent sexual initiation. 

Parents remain the primary attachment figures in early adolescence 

  

The presumed operating force behind the impact of the parent-adolescent relationship is Attachment Theory. This theory originally created to understand caretaker-infant relationships proposes that self-worth, emotional regulation, and relationship expectations are influenced by the responsiveness of figures like parents. Despite adolescence being a stage of transition towards peer relationships, parents remain the primary attachment figures in early adolescence and influence adolescent outcomes. There are three factors that can increase the quality of the parent-adolescent relationship and decrease the likelihood of sexual initiation before age 16: parent involvement, parent connection, and parental awareness. 

1.      Parent involvement

Involvement includes engagement in school, day-to-day life, and recreational activities. Increased parent involvement can delay sexual initiation especially in daughters. The emphasis is not about the number of activities, but the quality of the time the parent is engaged with the adolescent. The conversations during this time should not be about information gathering, but about relationship building. When asking about school, it is important for the parent to emphasize things like favorite classes or interesting things learned.

Also, time together should be a cell phone free time for both the adolescent and the parent. Parent(s) can decide a time of the day where all electronic devices are turned off and the family spends time together. Family activities can decrease sexual initiation before age 16. 

 

2.      Parental warmth 

Parental warmth is a willingness to connect, be emotionally open, supportive, and loving with the adolescent. Parental warmth includes behaviors that allow for emotional expression and support through challenges. By providing the emotional support an adolescent needs from her or his family, the adolescent is less likely to initiate sex to meet these needs. Parents can demonstrate warmth by being willing to listen, and to engage the adolescent on his or her terms. Parents should not give love or affection on a conditional basis, but can give love and affection on a regular basis. Parents should use the affection that best matches their adolescent. If the adolescent appreciates physical touch, then the parent could offer hugs. If the adolescent appreciates words of affirmation, then the parent can offer praise and kind words.   

3.      Parental awareness

Parental awareness is made up of three interrelated groups of behaviors including parent solicitation, adolescent openness, and parental knowledge. Within this factor, a sweet zone exists that depends on parents and adolescents. Parental behaviors that are too investigative or too permissive in monitoring the adolescent are associated with increases in adolescent sexual initiation. Similarly, adolescents unwilling to disclose information to parents have higher rates of sexual initiation. Thus, an aware parent is one that is willing to ask an adolescent about their activities with an adolescent willing to share this information. One way to encourage adolescent sharing is to be interested in the adolescent’s activities without casting judgment. Utilizing Ken Hardy’s VCR approach, (validate, challenge, request) found in the book Teens who hurt: Breaking the cycle of adolescent violence (2005), may be the best way to accomplish this end.  The point of this approach is to validate the strengths of the adolescent before challenging the views of the adolescent. 


Sexual initiation before the age of 16 places adolescents at risk for multiple negative outcomes. While parents cannot control all of the factors that influence sexual initiation, they can strengthen the parent-adolescent relationship, which via the tenets of Attachment Theory should delay sexual initiation after age 16. To this end, three parenting behaviors were addressed: parent involvement, parent connection, and parental awareness.

 

Dan Blocker, MS is currently enrolled in the Medical Family Therapy Doctoral program at East Carolina University. He is passionate about integrated care and it’s potential influence in providing whole-person care. He received his masters from Brigham Young University in Marriage and Family Therapy. His current interests include understanding the protective power of relationships on health outcomes, and technology use. 

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To Be or Not to Be

Posted By Suzanne Mintz, Wednesday, March 4, 2015

 

In the past few months my husband Steven has added two more doctors to his alphabet soup of medical professionals, a pulmonologist and a rheumatologist. He now has eight physicians in charge of various parts of his body.

We share a family doc, but Steven also has a neurologist for his MS, an orthopedist for his osteoporosis, a physiatrist who focuses on his functioning, an ophthalmologist who keeps a watch on his optic nerve since MS can affect eyesight, a urologist to deal with his neurogenic bladder and accompanying bladder stones, a physical therapist who comes to the house twice a week, an occasional visit to a podiatrist to deal with cracking between his toes, and of course the usual bi-annual visit to the dentist.

The recent addition of the pulmonologist and the rheumatologist has really scared us because their specialties deal with hidden problems that are caused by the pernicious degradation of his body.  Everyone focuses so intently on the visible aspects of his disability, the fact that he is in a wheelchair, his increasing inability to feed himself and to push the computer keys, but it is the hidden degeneration of his body that is most worrisome to us. Sometimes it really gets us down, but then we remember how lucky we are to have each other, live near our daughter, have the funds to purchase the items and services we need and overall a good quality of life.

Steven’s neck has been stiff for a long time, and a MRI, the first he’s had since early on in the course of his disease, has shown the existence of osteoarthritis. It explains the intense neck pain he feels, its poor range of motion, and the dull ache in the lower back of his head. Apparently there isn’t all that much that can be done about it; “Take ibuprophen” the rheumatologist said.  “It will reduce some of the inflammation and the associated pain, but it might also cause stomach problems. If so you’ll need to add an antacid to your medication regimen”.  He also suggested that Steven get a soft collar for his neck to help relieve the pressure that accompanies each movement.

In the past few months, Steven has added two more doctors to his alphabet soup of medical professionals 

 

Steven went to the pulmonologist at the suggestion of our primary care doc who said he thought Steven’s voice had been getting softer. With pneumonia often being the cause of death for people with MS, he wanted to make sure Steven’s lungs were functioning properly. It turns out they aren’t. The breathing tests Steven underwent showed how abnormal his lung function actually is. One of the biggest problems is his inability to expel all of the carbon dioxide from his lungs. The pulmonologist scheduled a sleep study. He thought it would show sleep apnea and therefore point to the need for Steven to get a continuous pulmonary air pressure machine, generally referred to by its initials, CPAP. Because the machine forces constant air into your lungs through a tube connected to nose “pillows”, soft rubbery nasal inserts, it ensures the proper flow of gases in and gases out.

Steven was diagnosed with MS in 1974 when he was 31. He turned 71 this past summer so we’ve been dealing with MS for 40 years now. The heavy duty caregiving began about 20 years ago when he got his first wheelchair, and it’s been downhill ever since. 

The neurologist surprised us recently when he said Steven may not actually have MS, that there is some thought in the medical community that primary progressive MS, which is Steven’s diagnosis, may not be MS at all because the only things it seems to have in common with classic MS is that it attacks the body early in one’s adulthood and causes the breakdown of myelin and the consequent scar tissue. Steven’s disease, whatever it is, only attacks the nerves in the spinal cord, not those in the brain and it isn’t characterized by relapses and remissions, but is rather a slow but steady degeneration. Fortunately it doesn’t show any cognitive impact: Three cheers for that!


What matters is that he is losing more and more function

In the long run, whether Steven has MS or something that looks like MS doesn’t really matter. What matters is that he is losing more and more function, inside and out, and there isn’t much we can do about it. Coupled with the normal changes that come with aging, our abnormal life is continually becoming more so.

 

Despite the difficulty we refuse to let all-of-this stop us from living as full a life as possible. Steven has been retired for three and a half years and I for one year, so we have more time and flexibility regarding what things we can do and when we can do them. Why battle weekend crowds at the movies when we can go on a weekday afternoon? We recently got back from a vacation to Newport RI. It’s a short flight to Providence from where we live and we were able to rent an accessible minivan for the 40 minute drive down to Newport. Once there we “walked” to as many places as we could and had a grand time. The concierge at our hotel found out about a boat that could handle Steven’s wheelchair and we took a lovely tour around the harbor. We went to visit the extraordinarily ostentatious Vanderbilt summer “cottage” and walked along the cliff. We ate lobster and saw fabulous sunsets. We were always back in our room by 9:30 completely worn out from the day’s activities. We slept in taking our time to get started the next day, doing everything at our own pace.

To be fully involved in living or to let MS control our lives, that is the question. For us the answer is simple: Do as much as you can with what you’ve got and enjoy life as much as possible. This summer we hope to go to Santa Fe, one of our favorite places.  

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

 

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“Amour” Or Love Among The Ruins

Posted By Carol Levine, Tuesday, February 17, 2015

(This post is a reprint of a piece from February 19, 2013. Click here for the original post. Amour is a 2012 French film from Les Films du Losange.) 

 

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 aménage 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?
Amour movie poster
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?

 

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
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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NC Project LAUNCH: A Family-Centered Care Approach

Posted By Matthew P. Martin, Tuesday, February 3, 2015

I recently was introduced to a successful family centered medical home model called NC Project LAUNCH (Linking Actions for Unmet Needs in Children’s Health). Upon hearing the words “family centered”, my ears perked up. Those words are often given little more than lip service in many clinics so I couldn’t help but feel a little skeptical. I soon met a dynamic woman named Martha Kaufman who told me more about the program and offered to stay in touch via email. What I learned since then is very encouraging.

Picture this: a child and her mother come to a pediatric office for a well child visit. The mother fills out some screening questions and then meets a Family Centered Health Navigator (FCHN) who reviews the positive screen and discusses the goals, strengths, and needs of the family. The mother agrees to the service and requests a home visit. A short time later, the FCHN and an Early Childhood Mental Health (ECMH) specialist visit the family to further identity their needs and strengths, prioritize those needs, provide child development psychoeducation, and then develop a family health plan. The health plan coordinates future referrals and consultations, connects the family with online and community resources, and lists the next action steps. The FCHN and ECMH use an approach called the Triple P to suggest specific parenting strategies.

One of the next actions steps is for the FCHN to accompany the parent to school to observe the child and support the parent in communicating the child’s needs to the teacher. Since the school also uses Triple P, there is a shared language and approach that unifies the efforts of both the care team and the school. Later on, the team checks in with the mother by phone to make sure the plan is moving forward, to provide support and further assistance as needed. The mother knows that the team is available to her by phone and at her child’s doctor’s office in the future, and she can just drop by to check in.

NC Project LAUNCH uses an approach called the Triple P

There is much to like about this approach. First, I like that the starting point is the pediatric office. The medical team has an on-site service for psychosocial issues which can facilitate appropriate referrals while reducing the stigma of psychosocial problems. Moreover, some children have chronic medical problems that lead to chronic psychosocial problems. A pediatric office is an ideal place to find these families. Second, the approach is absolutely strength-based. Parents, like most human beings, respond well to positive invitations for help. Third, this approach can do both prevention and intervention work. Some families are surviving but not thriving. The care team can help that family reach a point of thriving. Other families are headed toward disaster which calls for a team-based intervention that includes many helping hands. Fourth, the care team focuses entirely on the family system and not just the child. They discover what the family needs and what they care about and then support the entire family with specific, tailored strategies and tips using an approach backed by decades of research.

For those of you interested in learning more, here are five questions I recently asked Martha, the woman who introduced me to this effective approach:

1. How did you become involved with NC Project Launch?

I had just completed work as a consultant with a project known as Residentially Based Services Reform (RBS), in California, when the NC LAUNCH Project was awarded to the Alamance County Health Department as the State's implementation site. RBS, like all of my previous work, focused on meeting the needs of school-aged children with enduring and complex needs, and their families. After having worked for years in the child and family mental health system, I was excited to have the opportunity to work 'upstream' in a public health and prevention initiative promoting the overall health and wellness of all children 0-8 and their families through integrated care in pediatrics and other activities. 

  I was excited to have the opportunity to work 'upstream' in a public health and prevention initiative

 

2. What do you currently do with the program?

I am the Local Project Director for NC LAUNCH, which includes responsibility to develop and lead implementation of health promotion and prevention services. This includes the development of an innovative Family Centered Medical Home systems model that includes full integration of a 2-person team in two of the largest private pediatric practices in the County, and within the Local Health Department. These 3 full-time teams help ensure that physicians and other practitioners have ready access to comprehensive services and supports for their patients in the practice sites. We have also used a public health approach to help strengthen families through a population-based implementation of the Positive Parenting Program (Triple P), with approximately 200 individuals accredited to help families with everyday (as well as more complex) parenting strategies. The other activities for which I am responsible include the promotion of early childhood best practices in home-visiting services, social-emotional screening for young children and for their caregivers, as well as the development of policy and finance strategies to sustain implementation of NC LAUNCH beyond the period of federal funding by the Substance Abuse Mental Health Services Administration (SAMHSA).

 

3. What do you personally like about the service?

 

I like seeing how our partners in the private pediatric practices have moved to a more comprehensive public health approach, destigmatizing parenting assistance and social-emotional health services by embedding these into familiar and trusted medical settings. I also like the two-person Early Childhood Mental Health Team model, one in which an early childhood mental health specialist works hand in hand with a parent of a child with special health care needs who is specially trained to promote family engagement, address social determinants of health, and actively assist parents/caregivers to develop a health plan that is based on their particular strengths, priorities and needs. This team-work is supported in and beyond the private practices and the health department through a 'common language-common approach' developed through implementation of Triple P in settings across the community, such as in the public school system, pediatric and public health settings, community policing, housing authority, etc. We have also supported the delivery of Triple P parenting supports in the faith community.

 

4. What do physicians like about Project Launch?

The best way I can describe what physicians like about the project is through their own words:


·         “I feel the same about the team as I would if I needed a surgeon and did not have one easily available to me. I feel it’s just as important.”

·         “We rely on the team a lot, and we refer to them a lot earlier than we would before and we use Triple P a lot more.”

·         “Our role is more complete. It gives us more insight into the families we serve and makes us more sensitive to the issues that are going on.”

·         “I feel more comfortable bringing up something myself, because I can do something about it.”

·         “It’s very nice to have a back-up, someone who can take more time and talk to families about normal development.”

 

5. If people are interested in starting Project Launch, what should they do?

 

Feel free to contact me and we can explore: martha.kaufman@alamance-nc.com

 

Martha Kaufman, M.Ed., is currently the local Project Director for NC Project LAUNCH, at the Alamance County Health Department in Burlington, NC. Alamance received designation as is the only implementation site in NC for LAUNCH in 2012 by the NC Division of Public Health, the grantee for the SAMHSA-funded initiative. Prior to this role, Martha worked at the Washington Business Group on Health, NC Division of MH/DD/SAS as State Project Manager for NC’s first three SAMHSA-funded System of Care grants and then as the Chief of the Child and Family Services Section, prior to the initiation of MH Reform. Subsequently she provided consultation in other communities and states to help improve life outcomes for children with complex needs and their families. Martha lives in Durham.

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Dietitians and Mental Health Providers: “Besties" in the Making

Posted By Allison Abrahamson, Tuesday, January 20, 2015


What does it mean to integrate care between psychology and food?

Everywhere we look people are talking about what it means to eat “healthy” and be aware of our food. We hear of “foodies,” new diet trends, and the way students are getting sassy about the First Lady’s school lunch program (#ThanksMichelleObama). We are letting others talk about human behavior and food nutrition in ways that mental health professionals (the experts in human behavior) and dietitians (licensed experts in nutrition) should be running the show. Celebrities help by bringing attention to the issue such as actor Jeff Bridges, NY Times contributor and cook book author Mark Bittman, and a coalition of Food Network’s chefs fighting to end childhood hunger. But in the end, mental health professionals should be more involved in the work that dietitians do and in the food movement in general.

Here’s why:

Poverty is a big issue in American families. Poverty impacts food intake. Food intake impacts human development. 

  • The impact of malnutrition on development is a serious issue as it can limit physical and cognitive growth as well as a child’s ability to fight disease1. Mental health providers working with impoverished families cannot underestimate the impact of malnutrition on children and may need to work with a dietitian to seek appropriate care for the client. Need a lesson about just how draining poverty is on our brain and body? Check out this infographic to put it all in perspective. 
  • Family dinners are not about bringing back June and Ward Cleaver. They’re about something more, such as encouraging good communication, time management skills, togetherness, and cohesion. Eating dinner together as a family has been going out of style for the last century or so for a variety of reasons, including offering fewer home economics classes in schools2. I’ve written about this before in the APA Center for Excellence Newsletter in citing how workplaces can do more to send employees home for dinnertime. Ever wondered what it would be like for psychologists to offer sessions around a dinner table? That’s another story for another time….

  • Dietitians deal with poverty every day because it can go hand in hand with obesity. Obesity can signal a family’s inability to access and afford healthier, more nutritious foods. Check out the movie A Place at the Table for a look at this issue. Furthermore, when I spoke to a clinical psychologist who works in a weight management clinic, she described her job as helping to address barriers to healthier eating, including examining a family’s access to food. Poverty is an aspect of diversity. It is a psychologist’s job to understand all aspects of diversity. 


Some amazing programs already exist that combine food and psychology, sometimes without the steady contribution of dietitians or psychologists. We can do more to research, understand, and create programs to make it easier for dietitians and mental health providers to work together.

  • Using a combination of psychoeducation and experiential learning, a team3 used cooking classes to help clients with diabetes better manage their symptoms. By increasing self-efficacy, clients had a better likelihood of maintaining healthy eating patterns. After all, a diabetes diagnosis can predict frequent health care appointments, often clogging an office’s resources and perhaps suggesting that preventative and psychological care is needed to address motivation and healthy eating4.

  • To increase students’ sense of self-competence and encourage pro-social behavior, schools in Tennessee created a job-training program in food preparation5. To top it all off, the food that is prepared is served at community soup kitchens. That’s a win-win for mental health and the community. 

  • Incarcerated women facing drug related charges in San Francisco can learn how to cook and shop for healthy foods and it may be leading to lower levels of recidivism6

  • The Wall Street Journal recently published a piece about the benefits of cooking and using time in the kitchen towards treating mental health concerns like anxiety and depression by providing an increased capacity towards self soothing and positive thinking7. There’s a reason cooking is considered a coping skill. 

What can mental health providers and dietitians do in the future?

For starters, each field can try harder to understand and utilize each other. When I spoke to two registered dietitians (RDs), they referenced their extreme respect for the field of psychology and the skills psychologists bring to the table. One of them noticed that psychologists in her treatment team are often the least versed in medical issues. The two RDs also felt they had received zero training in how to collaborate their care with other disciplines.

This reveals two suggestions for a future relationship between the two disciplines: provide training to all healthcare disciplines in models of collaborative care and train students in the mental health field about implications of medical diagnoses. For example, educators and training directors in graduate programs can create practicum sites at places where dietitians work or in sites that are more medically oriented. In addition, in some mental health graduate programs, students have the ability to forge relationships with training sites with whom the school had not previously communicated. Students in these programs may have more latitude in creating practica experiences with a patient-centered medical homes (PCMH).


The National Committee for Quality Assurance (NCQA) is the accrediting board for healthcare organizations committed to the model of PCMHs. These models are working and they are becoming more popular8. The goal of a PCMH is for providers to talk to each other so the patient has a better outcome, which should include better nutrition. But how often are dietitians working in these PCMHs and how easy is it for them to do so? For example, the American Association of Diabetes Educators has suggested that dietitians educate themselves in the PCMH model as the first line of advocating for their inclusion in the treatment team9.

Secondly, dietitians who already serve as a member of a diabetes care team are familiar with the integrated style of a PCMH and have received credentialing as a Certified Diabetes Educator (CDE). If dietitians were interested in and in possession of such a CDE, it may be easier to become a member of the PCMH, as their skills in treating diabetes would be highly needed. This could be organized in different ways, such as encouraging PCMHs already in practice to look to how physical medicine rehab teams have already begun integrating dietitians into their treatment teams.


Lastly, psychologists and dietitians can also take a greater stand on policy issues. For example, I recently took myself over to a Philadelphia Food Policy Advisory Council meeting. What’s a food policy council, you ask? It’s a combination of chefs, land use planners, lawyers, politicians, poverty advocates, managers of food banks, urban farmers, etc. that come together to create unique solutions to food systems problems. The Philadelphia council meetings are open to the public and at this meeting in particular, Philadelphia’s Mayor Nutter was in attendance. I was thrilled to briefly introduce myself and discuss the need for psychologists to be involved in the food systems movement.

 

As other attendees introduced themselves, I was surprised that no other dietitian or mental health professional was at the meeting. Afterwards, one attendee approached me, handed me his business card and expressed a desire to learn more about behavior change. I believe that the attendees at these meetings want and need more information from both dietitians and mental health professionals to help solve food systems issues. Go to a meeting. After all, many mental health professionals are trained in the art of systemic thinking and creative problem solving. The food movement is a food system. We have skills to bring to this systems issue.

References

1.      Berk, L. (2012). Infants and children: Prenatal through middle childhood (7th ed.). Boston: Pearson Allyn & Bacon.

2.      Cunningham-Sabo, L. & Simons, A. (2012). Home economics: An old-fashioned answer to a modern day dilemma? Nutrition Today, 47(3), 128-132.

3.      Archuleta, M., VanLeeuwen, D., Halderson, K., Jackson, K., Bock, M., Eastman, W….Wells, L. (2012). Cooking schools improve nutrient intake patterns of people with type 2 diabetes. Journal of Nutrition Education and Behavior. 44(4), 319-325.

4.      Savageau, J., McLoughlin, M., Ursan, A., Bai, Y., Collins, M., & Cashman, S. (2006). Characteristics of frequent attenders at a community health center. The Journal of the American Board of Family Medicine, 19(3), 265-275.

5.      Long, C., Page, J., Hail, B., Davis, T., & Mitchell, L. (2003). Community mental health—in an alternative school, in the public schools, and in the kitchen! Reclaiming Children and Youth, 11(4), 231-235.

6.      Novak, L. (2006, November 13). Not just peeling potatoes. The New York Times, p 20.

7.      Whalen, J. (2014, December 8). A road to mental health through the kitchen: Therapists use cooking to treat depression, anxiety and other psychological problems. The Wall Street Journal. Retrieved from http://www.wsj.com/articles/a-road-to-mental-health-through-the-kitchen-1418059204

8.      Novotney, A. (2014). Psychology’s expanding roles in patient homes. Monitor on Psychology, 45(10), 38-40.

9.    Brown-Riggs, C. (2012). The Patient-Centered Medical Home — The Dietitian’s Role in This Healthcare Model That Improves Diabetes Outcomes. Today’s Dietitian, 14(8). Retrieved from http://www.todaysdietitian.com/newarchives/080112p26.shtml 

Allie Abrahamson, M.S., is a fifth year doctoral student in the Clinical Psychology program at Chestnut Hill College in Philadelphia, Pennsylvania. Mrs. Abrahamson is a graduate of the University of Delaware with her bachelor’s degree in both history and psychology. She began her graduate education eager to develop skills in child and family focused psychology, particularly in systems issues. Allie enjoys finding ways to give back to the community and to the profession. It was an honor for her to co-receive the 2014 American Psychological Association Award for Distinguished Graduate Student in Professional Psychology with her classmate for their work creating a program and partnership between their graduate school and a Philadelphia refugee resettlement agency. Allie is currently serving as the American Psychological Association of Graduate Students (APAGS) member on the Commission on Accreditation (CoA). As a part of CFHA, it has been enlightening and exciting for her to take part in the mentorship program with Dr. Barry Jacobs and to continue to learn more about integrative care approaches and their application to systemic issues.

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ALS: The Uninvited Family Member

Posted By Tara Signs, Tuesday, January 6, 2015
Couples describe the overwhelming feelings of anxiety and the “scariness” of this life-threatening illness

 

Over the last several years, I have worked as a medical family therapy (MedFT) intern at a teaching hospital. I work with families and couples who experience a variety of life-altering illnesses. Within this past year, I have had the opportunity to work onsite at a neurology clinic where I quickly became familiar with the fast paced environment and practice of MedFT in a clinic setting. In this clinic, I see patients who experience amyotrophic lateral sclerosis (ALS), often called Lou Gehrig’s disease, myasthenia gravis, and muscular dystrophy.

Couples who are experiencing ALS are required to adjust and adapt to the demands of this illness, both physically and psychosocially. Muscle weakness and paralysis spread throughout the entire body, leaving individuals with the inability to perform daily activities such as showering, dressing, walking, and getting in and out of bed. As the debilitating illness continues to immobilize the individual, breathing, swallowing, and chewing become severely affected. Often times, individuals grieve the loss of the roles they once had and the inability to use their hands, arms, and legs. Most couples describe the overwhelming feelings of anxiety and the “scariness” of this life-threatening illness, the inability to be independent, and the financial strains it has on the family. The rollercoaster of emotions of depression, anger and guilt are appropriate responses that couples are faced with as they endure this unexpected journey.

Recently, I encountered a couple that reminded me about the beauty of medical family therapy. This was the first time I had seen the couple since I had started at the clinic. The husband was diagnosed with ALS several years ago, and unfortunately it had progressed faster than the couple expected. Given this was our first meeting; I was interested in their story. They described their daily struggles, new roles, and the demands of ALS with their family. The husband described what it was like transitioning from full function of his arms and legs to completely relying on a motorized wheelchair for transportation. He spoke of the unbearable pain he experiences as his muscles began to weaken. The wife spoke of the transition of her husband having to sleep in a hospital bed due to comfort and drastic changes in his body. As she told her story, her face said something different. The toll that illnesses have on caregivers can become emotionally exhausting and painful to experience. The couple described the emotional burden that lies heavy with them as they watch this illness progress. They discussed the anxiety that is instilled in them because of the fear of what the next day may look like. The pressure of wanting to spend adequate time with family members can also increase levels of depression and anxiety. These are appropriate and normal responses as families and couples experience illness.

They described the emotional burden of watching this illness progress

 

Despite the difficulty of talking, the husband tearfully described their young children. It appeared this part of their story was hard to share. It was difficult for the couple to make eye contact as the wife described the most recent crisis in their family. The wife began to cry and grasped on to her husband’s arm as she described her oldest child’s attempt to end her own life. The husband described the recent impulsive behaviors of their other child. The couple began to cry and question what was happening to their family. Their unconditional love for their children poured out as they described what they had done for their family through this journey. A part of my job is to ask tough questions. I sat with this couple and talked about what the children understood about this uninvited family member, the illness. I asked if the family had the opportunity to sit and discuss the scariness of Dad physically changing or not being able to be as active as he used to be with the kids.


As these questions were asked, the couple sat there in tears looking at each other. The wife responded that her husband’s illness was not really discussed. She mentioned the family sit-down about what was wrong with dad, but nothing about the physical changes or that it is a terminal illness. Like with many debilitating illnesses, sometimes the illness takes over the family. The couple was encouraged to talk about how this illness has taken control of the family and their ideas of putting ALS back into its place.

As we sat there for 45 minutes, the couple dialogued with one another about how scared their children must be. In some ways, as the conversation continued, the couple seemed to have a sense of peace about where they were in this process. They discussed that the children probably feel scared to ask what is happening to their Dad because it hasn’t been talked about. At that moment in time, it seemed like a weight had been lifted off of the couple. The couple felt relieved knowing that there was hope to overcome the struggles they were experiencing as a family. It seemed the couple understood that the children felt hidden in the dark with their father’s illness and maybe that these children didn’t know what else to do. The husband voiced the possibility that his children’s behavior might be related to not communicating openly about his illness. The couple also had discussion about a family meeting and what that would look like. At the end of my time with them, I realized the open dialogue the couple had about illness in their family created permission to be vulnerable and open with their children.

As therapists, it is important to elicit each family member’s experience of the illness and to create an atmosphere that feels safe to share. As we guide couples and families to have open communication about their needs, desires, fears, and hopes, they are able to recognize how the illness affects themselves as well as their relationships. This process creates a balance between individual and relationship needs, which is a way to put illness in its place.  Through this specific experience, the couple was able to recognize and understand their fears, emotionally share where they were both at in this process, and collaboratively come up with ideas for each family member to have the opportunity to discuss their own experience and meaning of the illness.


Tara Signs is a doctoral student in marriage and family therapy at Texas Woman's University in Denton, Texas.  

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Happy 3rd Birthday, Families & Health Blog!

Posted By Administration, Tuesday, December 23, 2014

  

The Families & Health Blog is 3 years old this month! And unlike a normal 3 year old, we can actually reminisce about the last year.

There have been many excellent blog posts this past year. A big thanks to all of our writers who generously contribute their time and energy to promoting topics related to families and health care. 

Take a moment this holiday break to re-read or read for the first time some excellent posts from the last twelve months.

If you or someone you know is wrestling with mixed emotions following the loss of a loved one, read Barry Jacobs' post Wooden Box. His story offers a poignant example of the complexity of loss. 

According to Suzanne Mintz, the words we use in health care matter! Her insight and passion are captivating. 

Do you work with couples facing chronic or terminal illness? Read this terrific interview of Evan Imber-Black, who carries a wealth of wisdom and experience for struggling couples (and therapists).

We had excellent posts from some of our first time writers. Noah Gagner wrote about his early experiences as a therapist in training. Wendy Wray provided some excellent information about the growing field of neurobiology. Ruth Nutting made the case for promoting collaborative care to address the health disparities in society. Katie Rootes and Ariel Jones made a persuasive argument for developing cultural attunement in collaborative care work. 

There were also a few pieces specifically targeted toward family-centered care. Read these for some excellent ideas on how to better involve family members in patient care. Leatrice Sherer wrote a fantastic success story in which she worked with the medical team and a care manager to help a Hmong family. Kaitlin Leckie effectively argues for taking integrated care to the next level with more family involvement. Finally, Irina Kolobova and Jennifer Hodgson offered some expert technical assistance on how to actually involve family members in patient care. 

All of the pieces written for Families & Health represent the passion and ingenuity of individuals who care about this work. Stay tuned for more great topics and posts this coming year!

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