Medical Family Therapy

My very first client was a transfer who had been coming into therapy for about a year.  It appeared that the client had been previously treated using a Solution-Focused framework.  While I very much subscribe to a Solution-focused ideology--it seemed less appropriate for this case.  One of the biggest critiques of Solution-Focused therapy is that it does not seem to appropriate address real and permanent problems--such as what my client is facing.  Upon discussing this with my practicum, my supervisor suggested (instructed) switching the model to a Medical Family Therapy model.  This was very exciting to me because it is a model we have not studied in our program and because it is something that I find very interesting and would like to go on to a PhD program that has some sort of MedFT program.  These are my findings in my dabblings with Medical Family Therapy.

What is Medical Family Therapy?

The following outline comes from lecture notes by Dr. Katherine Hertilein.

Medical Family Therapy refers to biopsychosocial (biological, psychological, social) treatment of individuals and families who are dealing with medical problems.  It actively encourages collaboration between therapists and other health professions.  It recognizes that there is a relationship with biology and family therapy.

Goals of MedFT

The two primary goals of Medical Family Therapy are increasing agency and communion.

1. Agency

Agency refers to the active involvement in and commitment to one's own care.  A sense of making personal choices in dealing with the illness and the health care system, both of which often contribute to a patient's feeling of passivity and lack of control.  This can involve:

         a. Helping a patient and family set limits on the amount of control an illness or disability has over their lives.  E.g. deciding to proceed with holiday celebrations despite the patients limited participation.

         b. Helping the family to negotiate for more information or better care arrangements with health professionals, hospitals, or insurance providers.

         c.  The therapist can promote agency of the patient in relation to other family members

                     1. Setting boundaries on family members' helpfulness

                     2. Teaching a family member to ask assertively for help

2. Communion

Emotional bonds are often frayed by illness, disability, and contact with the healthcare system.  There needs to be a sense of being cared for, loved, and supported by a community of family members, friends, and professionals.  Serious illness or disability is an existential crisis that can isolate people from those that who care for them, but the quality of the patient's social relationships appears to be the most powerful psychosocial factor in health and illness. One of the reasons for emphasizing medical "family" therapy is that serious illness and disability provide opportunities for resolving old conflicts and for forging new levels of health family bonding.  During the acute phase of an illness, family members may be emotionally available to each other in unaccustomed ways, but during the chronic phase, many families find that their sense of common purpose and common feeling deteriorates. One of the MedFT's important tasks is to help family members join together to cope with an illness, and to do so within the context of allowing the patient maximum feasibility and autonomy.  

Techniques

There are seven major themes to techniques in the MedFT model: 1. Recognize the biological dimension; 2. Solicit the illness story; 3. Respect defenses, remove blame, and accept unacceptable feelings; 4. Maintain communication; 5. Attend to developmental issues; 6. Increase a sense of agency in the patient & family; 7. Leave the door open for future contact.

1. Recognize the biological dimension

• Start with a focus on the patient
• The word "patient" has its own implications and depersonalization issues
• Use a psychoeducational approach to explain the difference between psychotherapy and other medical encounters
• Ask the physician to explain the patient's illness, its prognosis, and its possible course
• When there is ambiguity or disagreement about the diagnosis, maintain an open, exploratory stance
• Maintain humility about the possibility of biological change

2. Solicit the illness story

• Listen empathetically
• Taking a genogram to trace the course of their particular history with illness and loss
• As part of soliciting the illness story I have asked clients to first write a eulogy of their pre-loss life, and then second to write a birth announcement celebrating the new life.
• I suggested a rule to maintain a 3-1 positive to negative ratio (I wanted to keep the 5-1 Gottman ratio, but I wanted it to be hard not damn-near impossible)

3. Respect defenses, remove blame, and accept unacceptable feelings

• Accept Denial
• A common goal that I have seen from clients is to find a way to grieve the old self and accept the new self.  The eulogy/birth announcement previously mentioned helped to work towards this--however it was not enough.  
• After this I created (compiled) a handout about grief--largely from Kubler-Ross's 5 stages of grief.  After this psychoeducation I assigned an art therapy assignment.  At some point  I'll provide an example/template of some sort of this assignment but it consisted of an instruction to take a large sheet of paper (or 4 regular ones taped together) and draw a visual representation of all the things that have been lost as a result of the illness.  (This works well with any loss).  
• It can be a very challenged and powerful assignment.
• Externalize the illness
• I found this to combine very well with soliciting the illness story.  I've found that my client has a lot to say--and it seems of therapeutic importance that there is a chance provided to allow this to happen.  I'm skeptical of pushing clients beyond telling their story and venting frustrations--but this allow a refocus of these discussions into an externalized discussion.  Once the story is told, I believe they move on.
• Remove blame
• Normalize negative feelings

4. Maintain communication

• Between families and medical providers
• Among family members

5. Attend to developmental issues

• Out the illness in its place
• This means acknowledging the demands placed on a family by an illness, but not letting it run your life

6. Increase a sense of agency in the patient/family

• Emphasize the patient's input
• Bracket patient's unhealthy decisions
• Facilitate rather than advise

7. Leave the door open for future contact 

• Recognize the physician's ongoing involvement
• Provide patient follow-up

Along with these 7 techniques, these 9 steps from Patterson (1991) have proven to be very beneficial to me in working with Medical Family Therapy and chronic illness.

1. Balance illness with other family needs
2. Maintain clear boundaries
3. Develop communication and competence
4. Attributing positive meaning to situation
5. Maintaining flexibility
6. Maintaining family cohesiveness
7. Engaging in active coping efforts
8. Maintaining social supports
9. Developing collaborative relationships with professions