Print Page | Your Cart | Sign In
Families and Health
Blog Home All Blogs


Search all posts for:   


Top tags: cancer  caregiving  chronic illness  collaborative care  integrated care  medical family therapy  collaboration  communication  dementia  nutrition  Parkinson's Disease  provider patient relationship  research outcomes  resident wellness  self-care 

Including the Family in Research Evaluating Integrated Care: A Call for Expanding Investigators’ Scope beyond Single-Person Measures

Posted By Tai Mendenhall, Tuesday, March 19, 2013

Providers across the fields of mental health (e.g., Psychology, Medical Family Therapy, Pastoral Counseling, Social work) and biomedical care (e.g., Internal Medicine, Family Practice, Pediatrics) have been increasing their efforts to collaborate with each other since the early 1990s. This movement is, in large part, a natural response to our ever-increasing knowledge about how patients’ respective "parts” – like their minds and their bodies – are more connected than our respective disciplines’ training programs originally prepared us for. As more than 70% of patients attending primary care visits, for example, do so with some kind of psychosocial comorbidity, it is easy to understand how satisfaction with care experiences correlate with the collaborative nature(s) of the services that we provide (Linderman, Koff, Freitag, Min, & Vandivier, 2011; Miller, Kessler, Peek, & Kallenberg, 2010).

This natural (albeit slow) development in our field(s) has evolved in synchrony with our increasing understanding of the strong and reciprocal influences between family functioning (e.g., communication, adaptability, relationship satisfaction) and health (e.g., metabolic control, immune functioning). Indeed, empirical evidence has shown us time-and-again how purposeful attention to families within medical and/or psychotherapeutic interventions can lead to targeted improvements in identified patients’ physiological well-being (e.g., blood pressure, cardiovascular functioning) (Campbell & Patterson, 1995; Tyndall, 2010; Whitney, Murphy, & Landau et al., 2011).

Our efforts to extend collaboration to actively include patients’ families in the care we provide, however, are way out in front of our efforts to evaluate the processes in which families help (or hurt) clinical outcomes. Also lagging are our efforts to understand the impact(s) that our collaborative and integrated care has on families, themselves. While calls to advance empirical support for the work that we do have been made across both local and national/international stages (e.g., Hodgson, Lamson, Mendenhall, & Crane, 2012; Mendenhall, Pratt, Phelps, & Baird, 2012), most research to-date has framed treatment outcomes within individually-oriented frames of dependent variables that are unique to identified patients, alone. A recent review of more than one hundred integrated care studies confirmed this, wherein only a single investigation was recognized for its consideration of family outcomes (Martin, 2012).

Integrating Family- and Relationship- Measures into Healthcare Research

As we work to include patients’ families in the care that we provide, we must also include families in the research that we conduct. In accord with extant literature regarding measures with well-established reliability and validity, the following are instruments that we could begin to integrate into our evaluations of collaborative and integrated care. (Note: In the interests of readability and limited-space, I have not included individual references or studies for each measure described. Literature is robust and easily-found for all instruments identified herein. For more detailed summaries, see Alderfer, Fiese, & Gold et al. (2007) and Walsh (2011)).

Dyadic Relationship Functioning.Our patients’ relationships and social systems are arguably built upon units of two, and it is thereby important to consider ways to assess functioning within the specific unions they maintain. Leading measures evaluating marital and/or romantic-partner relationships include theDyadic Adjustment Scale, the Marital Satisfaction Inventory-Revised, and the Lock-Wallace Marital Adjustment Scale. Collectively these instruments are well-established in their ability to differentiate distressed from non-distressed couples. While paralleling many of the foci evaluated by the aforementioned measures of general family functioning, these tools also tap important dyadic processes related to interpersonal accord and consensus.

Measures with established reliability and validity that evaluate dyadic functioning between parents and children include the Inventory of Parent and Peer Attachment, the Issues Checklist, and the Revised Children’s Report of Parental Behavior Inventory. Key content assessed for by these instruments includes parental acceptance, control and discipline, child attachment, interpersonal trust, communication, alienation, constraining (vs. enabling) interactions, and child discourse changes in reaction to parental responses (i.e., progression vs. regression).

Measures directed toward sibling relationships are still in their infancy, as only one is currently available that for which a compelling empirical base has been developed. The Sibling Relationship Questionnairecaptures interpersonal rivalry, conflict, relative power and status, and warmth/closeness.

Family Relationship Functioning. The most robust group of relational measures in family studies assess for general family functioning. Leading observational instruments (which also encompass clinician-rated interviews) include the Beavers Interactional Scales, the McMaster Clinical Rating Scale, the Iowa Family Interaction Rating Scales, the Circumplex Clinician Rating Scale, and the Mealtime Interaction Coding System. Collectively these measures assess for family phenomena like interpersonal communication, affective responsiveness, problem-solving and adaptability to stress or change, conflict styles and conflict-resolution sequences, organization, and cohesion/relational-closeness. Self-report measures (informed by many of the same guiding family theories) include the Family Assessment Device, the Family Relationship Index of the Family Environment Scale, and the Family Assessment Measure-III. Most researchers advocate the employment of both types of measures (i.e., observational and self-report), insofar as combining and triangulating outsider- and (multiple) insider- perspectives affords a more comprehensive picture of what is going on in families, alongside more confidence in findings ultimately arrived upon.

Relational Functioning vis-à-vis Chronic Illness. Alongside the dyadic- and family- measures outlined above, researchers are beginning to advance relational measures specifically designed to target family functioning within systems living with chronic illness. For example, the Impact on Family Scale, Pediatric Inventory for Parents, and Parents of Children with Disability Inventorycollectively measure family members’ sense of mastery/coping, financial and/or legal burdens, family- and social- relationship satisfaction, personal/emotional stress, respective family members’ roles, and communication sequences with identified patients’ medical teams. The Psychological Adjustment to Illness Scale, while administered to individual patients, includes focused attention to satisfaction with domestic life, sexual relationships, extended family relationships, and social environment(s) and support. Overlapping into arenas of coping per se, the Family Narrative Consortium Coding Scheme, Family Coping Coding System, and the Coping Health Inventory for Parents have all established strong reliability and validity. They assess content areas that include family members’ interpersonal cooperation and coping, social support and psychological stability, and understanding the healthcare system with which they are interacting.

Concluding Thoughts and Next Steps

As we advance research regarding integrated care across clinical, operational, and financial arenas – and as we do this using qualitative, quantitative, and mixed-methods designs – we must remember to include patients’ families within our efforts. Assessing dyadic and/or family functioning alongside dependent variables denoting "success” that are specific to identified patients will better inform how to engage the people that are most important in our patients’ lives to support the very benchmarks that we seek. Conversely, it is important to understand how integrated care that includes family members impacts the family members. Not attending to their needs along the way could translate into a variety of other problems down-the-road if and/or as patients’ support systems erode or fall apart.

The good news here is that we do not have to invent a new wheel. The field of family studies (and within it, Marriage and Family Therapy and – more recently – Medical Family Therapy) has been evolving alongside the field of Collaborative Family Health Care (and within it, Integrated Primary Care and – more recently – the Healthcare Home movement). Established family- and dyadic- measures are already in place, and efforts to integrate these into understanding the intersections of relationships and health have been going on now for quite some time. As we mobilize this natural evolution to bridge advancements in healthcare (i.e., intervening – not just understanding) to tools and instruments in family studies like those outlined herein, we will create new knowledge that further informs the systemically-sensitive and innovative practices that drive us.


Alderfer, M., Fiese, B., Gold, J., Cutuli, J., Holmbeck, G., Goldbeck, L., ... & Patterson, J. (2008). Evidence-based assessment in pediatric psychology: Family measures. Journal of Pediatric Psychology, 33, 1046-1061. doi: 10.1093/jpepsy/jsm083

Campbell, T., & Patterson, J. (1995). The effectiveness of family interventions in the treatment of physical illness. Journal of Marital and Family Therapy, 21, 545-583. doi: 10.1111/j.1752-0606.2003.tb01204.x

Hodgson, J., Lamson, A., Mendenhall, T., & Crane, R. (2012). Medical Family Therapy: Opportunity for workforce development in healthcare. Contemporary Family Therapy, 34, 143-146. doi: 10.1007/s10591-012-9199-1

Linderman, D., Koff, P., Freitag, T., Min, S., & Vandivier, R. (2011). Effect of integrated care on advanced chronic obstructive pulmonary disease in high-mortality rural areas. Archives of Internal Medicine, 171, 2059-2061. doi:10.1001/archinternmed.2011.576

Martin, M. (2012). Integrated primary care: A systematic review of study design and program characteristics.Unpublished Doctoral Dissertation, East Carolina University, Greenville, NC.

Mendenhall, T., Pratt, K., Phelps, K., & Baird, M. (2012). Advancing medical family therapy through research: A consideration of qualitative, quantitative, and mixed methods designs. Contemporary Family Therapy, 34, 187-203. doi: 10.1007/s10591-012-9186-6

Miller, B., Kessler, R., Peek, C., & Kallenberg, G. (2010). Establishing the research agenda for collaborative care. Agency for Healthcare Research and Quality. Retrieved from:

Tyndall, L. (2010). Medical family therapy: Conceptual clarification and consensus of an emerging profession. Unpublished Doctoral Dissertation, East Carolina University, Greenville, NC.

Walsh, F. (Ed.). (2011). Normal family processes: Growing diversity and complexity. Guilford Press.

Whitney, J., Murphy, T., Landau, S., Gavan, K., Todd, G., Whitaker, W., & Treasure, J. (2011). A practical comparison of two types of family intervention: An exploratory RCT of family day workshops and individual family work as a supplement to inpatient care for adults with anorexia nervosa. European Eating Disorders Review, 20, 142-150. doi: 10.1002/erv.1076

Tai Mendenhall is an Assistant Professor at the University of Minnesota (UMN) in the Department of Family Social Science, the Associate Director of the UMN’s Citizen Professional Center, and the co-Director of mental health teams within the UMN’s Academic Health Center / Office of Emergency Response’s Medical Reserve Corps (MRC). He is the co-Coordinator of Behavioral Medicine education at the UMN / St. John's Family Medicine Residency Program (in which he teaches and supervises doctoral MedFT interns and family practice residents), and holds an adjunct faculty position in the UMN's Department of Family Medicine & Community Health. Dr. Mendenhall’s principal investigative interests center on the use and application of community-based participatory research (CBPR) methods targeting chronic illnesses in minority- and under-served patient and family populations.

Tags:  integrated care  medical family therapy  research outcomes 

Share |
PermalinkComments (1)

Guarding Lives

Posted By Lauren Guth, Tuesday, March 5, 2013
I’m treading water in the deep end of an Olympic-sized swimming pool, looking up at my lifeguarding instructor, who is standing dry by the side of the pool with a whistle around his neck. There are five other pairs of students in my class, also treading water, listening intently to the instructions: "Remember, when you go to save your partners, make sure you swim behind them before holding them. People that are drowning are terrified and will instinctually grab a hold of you. If you go down, they go down with you.” In the world of healthcare, our providers are often the lifeguards to their drowning patients. They are the people that will listen, teach and guide their patients toward
a path of wellness.

I was lucky. When looking for a post-doctoral fellowship, I came across an e-mail on a psychology post-doc listserv that described an opening to work in "integrated primary care.” The image of my dream job that I carried around with me in my head always involved working with a multi-disciplinary team, where patients could receive complete, well-rounded "one stop shopping” healthcare. A team of experts at their fingertips, in their community; people they could trust and know who would work collaboratively to keep them or make them well. When I inquired about the position, I had no idea this decision would alter my career path in such a significant and wonderful way. As I treated patients, I watched them form relationships not only with me, but with a team of their providers, nurses, and medical assistants. I watched them connect, trust, and truly become well.

I was hooked. When my time came to an end in my postdoctoral position, I knew I wanted to work in a Family Medicine Residency where a team of experts worked collaboratively in pursuit of patient wellness. I wanted to work in a rich environment that felt more like a family than a workplace and treated patients with warmth and dedication. When I interviewed for my current position, I found what I was looking for. I felt welcomed and included, and I instantly knew I could work collaboratively with everyone here. I knew if I felt this way, certainly the patients would feel the same as well. As a Level-III Patient Centered Medical Home, JFK Family Medicine embodies the values of collaboration, team-work, and complete patient wellness. As a teaching facility, JFK offers well-rounded, quality training to its Family Medicine Residents, preparing them to provide the best possible care to their patients.

How do providers offer the best care to their patients? Is the power of a collective team stronger than any individual person, or is a team only as strong as its members?

I became curious. I wondered to myself, "But how? How do providers offer the best care to their patients? Is the power of a collective team stronger than any individual person, or is a team only as strong as its members?” I observed our residents and providers connecting, communicating, laughing and playing. I listened to our residents and providers talk about painting, hiking, exercising, cooking, and relaxing. I realized that patient wellness begins with provider wellness, even though many of us often feel selfish focusing on our own health; it can often be a last priority. After all, we did choose a career path directly related to helping other people. Yet, it is actually quite essential that we focus on our own wellness. As my lifeguard instructor aptly stated, "If you go down, they go down with you.”

I became inspired. Why not apply the same values for our residents that we do for our patients? Our residents and providers need permission and space to self-reflect, connect in a meaningful way, to
laugh and play. They need a place where they can feel heard, where they can trust people are working collaboratively to keep them well. I began to facilitate monthly wellness groups with our residents,
where we connect over difficult patient interactions, discuss ways they have grown personally and professionally since beginning training, and things they miss from their lives since beginning residency. We go outside. We laugh. We relax.

And the answer to my question became clear. The power of a team can most definitely become stronger than any one person, but if each team member is feeling well and knows the team has a commitment to his or her wellness, then the power of the team is enhanced that much further. As we guard the lives of our patients, we also need to remember to guard our own.

Lauren Guth is a licensed psychologist and currently the Behavioral Scientist at JFK Family Medicine Residency Program in Edison, NJ. She received a Doctorate of Psychology and a Master’s of Education in Human Sexuality from Widener University. Her interests include integrated primary care and resident wellness.

Tags:  collaboration  integrated care  resident wellness 

Share |
PermalinkComments (1)

Contact Us

P. O. Box 23980,
Rochester, New York
14692-3980 USA

What We Do

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.