Working with Couples and Families in Medical Settings

Angela L. Lamson, PhD, LMFT, CLFEAssociate Professor & Director of MFT (MS) and MedFT (PhD) Programs

East Carolina University

Jennifer L. Hodgson, PhD, LMFTAssociate Professor, East Carolina University

Tai J. Mendenhall, PhD, LMFT, CFTAssistant Professor & Coordinator of Behavioral Medicine Education

University of Minnesota Medical School

Collaborative Family Healthcare Association 13th Annual ConferenceOctober 27-29, 2011 Philadelphia, Pennsylvania U.S.A.

Session # D4bOctober 29, 201111:15 AM- Noon

Faculty Disclosure

I/We have not had any relevant financial relationships during the past 12 months.

Need/Practice Gap & Supporting Resources

Despite an overwhelming multidisciplinary body of evidence supporting the vital role that family plays into one another’s healthcare decisions, our healthcare system is not constructed to address much more than the patient’s individual physical and mental domains.

This workshop will be used to provide attendees with fundamental knowledge to successfully transform unipolar practice models into systemic ones.

Working in a medical setting does not mean family therapists should market themselves more as individual therapists, but rather to advance models that include partner and familyinvolvement at the time of the medical visit.

Learning Objectives:

• Participants will be introduced to theories that support a relational approach to health behavior change and endorse comprehensive patient care.

• Participants will recognize that methods of assessment and treatment innovations must be adjusted to best meet the cultural differences within the community they serve.

• Participants will learn several models of care that promote couple and family intervention in a primary care medical encounter.

• Participants will be better able to identify the relevant translational research important to advocating for couple and family work in primary settings.

Couples and Families as Part of Treatment

• Family therapists have an opportunity to become part of the nations’ medical home movement. Their unique training and skills in working with couples and families provide a much needed service to healthcare providers overrun with highly complex cases.

• Inclusion of couples and families in treatment should not be haphazard, but grounded in theory.

Using Family-Based Theories to Ground Practice

• Systems TheoryvonBertalannfy (1968)

• BPSS ApproachEngel (1977, 1980); Wright, Watson &

Bell (1996)

• Three World ViewPeek & Heinrich (1998)

Systems Theory• Systemic thinkers believe that change occurs

through interactions• Language and interactions are systemic • Nonsummativity is a given• Change in one influences change in others

vonBertalannfy, 1968

SYSTEMS HIERARCHY(LEVELS OF ORGANIZATION)

BIOSPHERE↕

SOCIETY – NATION↕

CULTURE – SUBCULTURE↕

COMMUNITY↕

FAMILY↕

TWO-PERSON↕

↕NERVOUS SYSTEM

↕ORGANS / ORGAN SYSTEMS

↕TISSUES

↕CELLS

↕ORGANELLES

↕MOLECULES

↕ATOMS

↕SUBATOMIC PARTICLES

PERSON(experience & behavior)

Engel (1977)

Spiritual influences may contribute perspective and context

Clinical Operational Financial Questions

Object

Process

Outcome

Standard

Relation-ship

Relevant principles

Patients andpopulations

Clinical action

Health goals achieved

Quality

ClinicianPatient

Science, healing, and ethics

What care?High quality?

Systems

Operations

Production

Efficiency

ProviderCustomer

Process and system improvement

How to provide?Well-executed?

Accounting

Bottom line

Price and value

VendorBuyer

Business and financial return

Numbers

Best resource use; A good value?

Three World View

Peek & Heinrich (1998)

Why should we include partners as a part of care?

• Spousal involvement through facilitative communication, responsiveness and support is strongly associated with…– Decreased intensity of pain– Less depressive symptoms– Increased relationship satisfaction

Roberto et al., 2004; Van Lankveld et al., 2004; Zautra et al., 1998

Marital stability and quality affect physical well-being

– immune functioning– endocrine stress hormones– development of illnesses (e.g., hypertension)– disease management (e.g., diabetes)– survival from serious illness(es)– overall health and well-being

e.g., Boss, 2011; Booth & Johnson, 1994; Burman & Margolin, 1992; Doherty & Campbell, 1988House, Landus, & Umberson, 1988; Kiecolt-Glaser & Newton, 2001; Meadows, McLanahan, & BrooksGunn, 2008; Robles & Kiecolt-Glaser, 2003; Umberson et al., 2006; Waite, 1995; Waite & Gallaher, 2000

Physical well-being can be contagious!

• Physical well-being of one spouse affects the physical well-being of the other spouse

e.g., Christakis & Allison, 2006; Falba & Sindelar, 2008; Shaw et al., 1997

Families and Health Outcomes• When family therapy is provided, other medical needs/services are reduced

– For those who are the “focus” of treatment – For those who are not the “focus” of treatment, too

• Costs (total) of care are offset/reversed with increased numbers of participating family members– Research challenges here relate to individual orientation of medical culture

vis-à-vis systemic orientation of family therapy

e.g., Law & Crane, 2000; Law, Crane, & Berge, 2003

Couple Assessments

– Dyadic Adjustment Scale(Spanier & Graham, 1976)

– Kansas Marital Satisfaction Scale(Schumm et al, 1986)

– Marital Adjustment Test(Locke & Wallace, 1959)

– Marital Satisfaction Inventory(Snyder, 1979)

Family Assessments

– Family Assessment Measure(Skinner, 1983)

– Kansas Family Life Satisfaction Scale(Schumm et al., 1986)

– Family Satisfaction Scale (FSS)(Carver et al., 1992)

– PedsQL(Varni & Limbers, 2009)

Core Skills: Engaging Family/Support Persons in Primary Care

– Attend to Family Life Cycle Stages & Normative Stressors– Engage patients’ support persons ethically– Balance voices in room respectfully– Promote cultural sensitivity and competency in working with families – Screen and assess for couple and relational issues (i.e., family, social,

occupational, community)– Make eye contact and acknowledge each person at beginning, middle,

and end– Encourage patients to bring support person(s) in to each visit

Ways to address Family & Health in an Appointment

• 1. Doing a Genogram • 2. Who can you talk to about your health? • 3. Who can come with you to your next appointment? • 4. Set up a Family conference • 5. Refer/consult/collaborate care with Behavioral Health specialist,

someone with couple and family therapy training

Pre-ConferenceWhen preparing for a family conference, the healthcare practitioner and the patient need to be clear about the following:

• Articulate the goal(s) of the family conference: The goal for the family meeting is to strengthen each family member’s individual abilities to act in ways that will promote family health and to explore how the health system can better support the patient and their family.

• Negotiate who will attend and why• Reassure the patient about confidentiality, and establish an

acceptable range of topics for the conference• Consider the primary causes of the problem(s) and strategize

about how to confirm or refute these hypotheses. Include specific questions, observations, or tasks that will facilitate data gathering and help to test any hypotheses or form new ones.

The family conferenceThe family conference can be divided into five phases that generally occur insequence:1 Greet the family members.2 Clarify and further articulate the goals.3 Discuss the challenges to success.4 Acknowledge previous successes and current means of success.5 Make a plan.

* Each phase can take between 2 and 10 minutes, depending on whether the healthcare practitioner has met the family members before, on family members’ conversational abilities, and on the degree of conflict.

Prochaska & DiClemente (1983)

• In the Transtheoretical Model, change is a "process involving progress through a series of stages":– Precontemplation– Contemplation– Preparation– Action– Maintenance

What do MI researchers say?

Concerned Significant Others (CSO) involvement was an option within MI components of treatment in at least three multisite trials:– COMBINE study

(Anton et al., 2006)

– UK Alcohol Treatment Trial(UKATT Research Team, 2005)

– Project MATCH(Babor & Del Boca, 2003)

Speaker Listener Technique• Have them look at one another directly• One person gets to speak. Limit to 2-3 sentences at a time. Use “I”

statements.• Listener summaries/paraphrases• Speaker lets listener know if he or she got it correct and if not repeats the

2-3 sentences until the listener gets it right• Listener gets to be the speaker once

the speaker is done with his or her point. He or she cannot rebut while the Speaker has the floor…only summarize!

• Goal is not solution or agreement but listening!

Circular Questioning

• The simplest way to use "circular questioning" in marital therapy is to ask one partner what the other thinks, or how the other feels about a particular issue.

• These questions help each partner to think the issue through from the other person's perspective.

Examples of Circular Questing• “If I asked your husband, how would he/she describe your

marriage?”• “And how would your children comment on your description?”• “If you were to stop drinking, who else would have to change as

well? And who else would be impacted by those changes?”• “If you changed your behavior in school, who would be delighted

the most? How would that person respond? Who else would respond to that person’s favorable response in a remarkable way? Who might not notice any of those responses?”

What does Research say?

Concerned Significant Others (CSO) involvement was an option within MI components of treatment in at least three multisite trials:– COMBINE study

(Anton et al., 2006)

– UK Alcohol Treatment Trial(UKATT Research Team, 2005)

– Project MATCH(Babor & Del Boca, 2003)

Research, con’t• Marital stability and quality affect physical

well-being – immune functioning– endocrine stress hormones– development of illnesses (e.g., hypertension)– disease management (e.g., diabetes)– survival from serious illness(es)– overall health and well-being

e.g., Burman & Margolin, 1992; House, Landus, & Umberson, 1988; Kiecolt-Glaser & Newton, 2001; Meadows, McLanahan, & Brooks-Gunn, 2008; Robles & Kiecolt-

Glaser, 2003; Umberson et al., 2006; Waite, 1995; Waite & Gallaher, 2000

Research, con’t• Physical well-being affects marital stability and quality

e.g., Boss, 2011; Booth & Johnson, 1994; Doherty & Campbell, 1988

• Physical well-being of one spouse affects the physical well-being of the other spouse

e.g., Christakis & Allison, 2006; Falba & Sindelar, 2008; Shaw et al., 1997

Research, con’t

• When family therapy is provided, other medical needs/services are reduced– For those who are the “focus” of treatment – For those who are not the “focus” of treatment, too

• Costs (total) of care are offset/reversed with increased numbers of participating family members– Research challenges here relate to individual orientation of medical culture

vis-à-vis systemic orientation of family therapy

e.g., Law & Crane, 2000; Law, Crane, & Berge, 2003

ReferencesBooth, A., & Johnson, D. (1994). Declining health and marital quality. Journal of Marriage and the Family, 56,

218-223. Boss, P. (2011). Loving someone who has dementia: How to find hope while coping with stress and grief. New

York: Jossey-Bass Burman, B., & Margolin, G. (1992). Analysis of the association between marital relationships and health

problems: An interactional perspective. Psychological Bulletin, 112, 39-63.Christakis, M., & Allison, P. (2006). Mortality after the hospitalization of a spouse. New England Journal of

Medicine, 354, 719-730.Coyne, J., Rohrbaugh, M., Shoham, V., Sonnega, J., Nicklas, J., & Canford, J. (2001). Prognostic importance of

marital quality for survival of congestive heart failure. American Journal of Cardiology, 88, 526-529. Doherty, W., & Campbell, T. (1988). Families and Health. Beverly Hills, CA: Sage Publications; 1988.Falba, T., & Sindelar, J. (2008). Spousal concordance in health behavior change. Health Services Research, 43,

96-116.House, J., Landus, K., & Umberson, D. (1988). Social relationships and health. Science, 29, 540-545.Kiecolt-Glaser, J., & Newton, T. (2001). Marriage and health: His and hers. Psychological Bulletin, 127, 472-503. Meadows, S., McLanahan, S., & Brooks-Gunn, J. (2008). Stabilty and change in family structure and maternal

health trajectories. American Sociological Review, 73, 314-334.

References, con’t Peek, C.J., & Heinrich, R.L. (1998). Integrating primary care and behavioral health in a health care organization:

From pilot to mainstream. In A. Blount, (Ed.), Integrated primary care: The future of medical and mental health collaboration (pp. 167-202). New York: NortonRobles, T., & Kiecolt-Glaser, J. (2003). The physiology of marriage: pathways to health. Physiological Behavior, 79, 409-416.

Shaw, W., Patterson, T., Semple, S. et al. (1997). Longitudinal analysis of multiple indicators of health decline among spousal caregivers. Annals of Behavioral Medicine, 19, 101-109.

Umberson, D., Williams, K., Powers, D., Liu, H., & Needham, B. (2006). You make me sick: Marital quality and health over the life course. Journal of Health & Social Behavior, 47, 1-16.

Waite, L. (1995). Does marriage matter? Demography, 32, 483-507. Waite, L., & Gallaher, M. (2000) The case for marriage: Why married people are happier, healthier, and better

off financially. New York: Doubleday. Wickrama, A., Frederick, L., Wallace, L., Peiris, L., Conger, R., & Elder, G. (2001). Family influence on physical

health during the middle years: The case of onset of hypertension. Journal of Marital & Family Therapy, 63, 527-539.

Contact Information

Tai Mendenhall, Ph.D.717 Delaware St. SEUniversity of MinnesotaMedical SchoolFamily Medicine &

Community HealthMinneapolis, MN 55414mend0009@umn.edu612-624-3138

Angela Lamson, PhD112 Redditt HouseEast Carolina UniversityChild Development & Family

Relationslamsona@ecu.edu252-737-2042

Jennifer Hodgson, PhD150 Rivers BuildingEast Carolina UniversityChild Development & Family

RelationsGreenville, NC 27858-4353hodgsonj@ecu.edu252-328-1349

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